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Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: Pt is ___ year old with HTN, afib on apixaban, diastolic CHF, valvular heart disease, and left cavernous sinus lesion who presented to cardiology clinic for routine appointment and was found to be in AFib with RVR and respiratory distress. Per ED records: Family states for 3 days pt has been coughing, having generalized weakness. The patient and family cannot provide more specific history at this time as family present do not primarily care for pt or live with her and pt is altered. Family report that weight has decreased. Family deny history of fever or chest pain. Per referral: ___ year old female with chief complaint of congestion, AF with RVR, HTN. Came in for a routine cardiology ___, was lying on exam table, make gurgling, wet sounds, O2 sats 91%, HR 140, BP 151/111. Did respond to her daughter speaking with her, opened eyes when asked, made eye contact and smiled. Has been like this for at least 3 days per family, almost no PO intake. In the ED, initial VS were: 0 97.1 135 143/94 36 96% 4L NC Exam notable for: Tachypneic, accessory muscle use Confused JVP elevated Diffuse rhonchi bilaterally Bilateral ___ edema Labs showed: BNP 15000, up from 3000 before. Trop 0.02. No MB. Hgb 16.4 Imaging showed: CXR w/ Marked cardiomegaly again noted. Subtle opacity abutting the right heart border, question early right lower lobe pneumonia. No overt signs of edema. Consults: None Patient received: ___ 17:35 IV Piperacillin-Tazobactam ___ 18:29 IV Vancomycin ___ 18:40 IV Furosemide 20 mg ___ 01:12 IV Furosemide 20 mg ___ 01:12 IV Metoprolol Tartrate 2.5 mg ___ 02:02 IV Metoprolol Tartrate 2.5 mg ___ 03:45 PO/NG Apixaban 2.5 mg ___ 03:45 PO Metoprolol Succinate XL 100 mg ___ 04:33 IV Metoprolol Tartrate 5 mg Transfer VS were: 97.4 ___ 24 98% RA On arrival to the floor, patient is alert but breathing heavily with course breath sounds. Interview with interpreter deferred as she would not be able to speak on the phone at this time. REVIEW OF SYSTEMS: Unable to obtain Past Medical History: Hypertension Atrial Fibrillation Congestive Heart Failure Pulmonary Hypertension Osteopenia DJD Social History: ___ Family History: Both parents died at the age of ___; they were prosecuted due to the fact that they were ___ in ___. She has five brothers and sisters; the three sisters passed away from unknown reasons. She has 12 children, one of whom passed away from a presumed stroke. No family history of known hypertension, dyslipidemia, early coronary artery disease, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.3 PO 165 / 114 R Lying 123 22 95 ra GENERAL: Alert, lying in bed, wet respiratory sounds, not coughing HEENT: AT/NC, anicteric sclera, pink conjunctiva, NC in place NECK: supple, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Coarse breath sounds diffusely, heard without auscultation. Rapid respiratory sounds. ABDOMEN: nondistended, soft, nontender in all quadrants EXTREMITIES: 2+ edema NEURO: A&Ox3 SKIN: warm DISCHARGE PHYSICAL EXAM: ======================== GENERAL: Alert, laying in bed, NAD HEENT: AT/NC, anicteric sclera, pink conjunctiva, dobhoff tube in place NECK: supple HEART: irregularly irregular, S1 + S2 present, no mrg LUNGS: Coarse breath sounds diffusely with expiratory wheezing. ABDOMEN: Soft, NT, ND, no rebound or guarding EXTREMITIES: Warm and well perfused lower extremities, palpable pulses, trace edema bilaterally NEURO: A&Ox2 (oriented to self and place) Pertinent Results: ADMISSION LABS: =============== ___ 05:12PM BLOOD WBC-7.2 RBC-5.16 Hgb-16.4* Hct-49.5* MCV-96 MCH-31.8 MCHC-33.1 RDW-15.8* RDWSD-54.9* Plt ___ ___ 05:12PM BLOOD Neuts-77.8* Lymphs-9.7* Monos-11.7 Eos-0.0* Baso-0.1 NRBC-0.4* Im ___ AbsNeut-5.61 AbsLymp-0.70* AbsMono-0.84* AbsEos-0.00* AbsBaso-0.01 ___ 05:12PM BLOOD ___ PTT-38.0* ___ ___ 05:12PM BLOOD Glucose-193* UreaN-46* Creat-1.3* Na-142 K-4.9 Cl-101 HCO3-26 AnGap-15 ___ 05:12PM BLOOD ALT-20 AST-41* AlkPhos-79 TotBili-3.3* ___ 05:12PM BLOOD ___ ___ 05:12PM BLOOD cTropnT-0.02* ___ 05:12PM BLOOD Calcium-9.5 Phos-5.1* Mg-2.4 ___ 05:16PM BLOOD ___ pO2-34* pCO2-57* pH-7.35 calTCO2-33* Base XS-3 Intubat-NOT INTUBA ___ 05:16PM BLOOD Lactate-3.8* ___ 07:00PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 07:00PM URINE Blood-TR* Nitrite-NEG Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 07:00PM URINE RBC-2 WBC-2 Bacteri-MANY* Yeast-NONE Epi-1 ___ 07:00PM URINE CastHy-21* ___ 07:00PM URINE AmorphX-RARE* ___ 07:00PM URINE Mucous-FEW* INTERVAL PERTINENT EVENTS: ========================== ___ 06:15AM BLOOD CK-MB-3 cTropnT-0.03* ___ 06:15AM BLOOD TSH-1.0 ___ 06:34AM BLOOD ___ pO2-98 pCO2-39 pH-7.43 calTCO2-27 Base XS-1 Comment-GREEN TOP ___ 09:41AM BLOOD ___ pO2-128* pCO2-43 pH-7.39 calTCO2-27 Base XS-1 Comment-GREEN TOP ___ 01:11PM BLOOD ___ pO2-62* pCO2-55* pH-7.34* calTCO2-31* Base XS-1 ___ 06:34AM BLOOD Lactate-2.5* ___ 09:41AM BLOOD Lactate-3.3* ___ 01:11PM BLOOD Lactate-2.6* ___ 10:06PM BLOOD Lactate-2.3* DISCHARGE LABS: =============== ___ 05:21AM BLOOD WBC-11.6* RBC-4.42 Hgb-13.7 Hct-41.9 MCV-95 MCH-31.0 MCHC-32.7 RDW-15.6* RDWSD-52.4* Plt ___ ___ 05:21AM BLOOD Glucose-115* UreaN-27* Creat-0.7 Na-146 K-4.8 Cl-101 HCO3-34* AnGap-11 ___ 05:26AM BLOOD ALT-29 AST-44* LD(LDH)-282* AlkPhos-87 TotBili-1.0 DirBili-0.5* IndBili-0.5 ___ 05:21AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.3 MICROBIOLOGY: ============= ___ 7:00 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Time Taken Not Noted Log-In Date/Time: ___ 4:28 am URINE **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. ___ 04:28AM URINE Streptococcus pneumoniae Antigen Detection- Detected A ___ 07:54PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 10:08 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 10:08 am SPUTUM Source: Expectorated. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. IMAGING ======================== ___ Imaging CHEST (PORTABLE AP) IMPRESSION: In comparison with the study of ___, there is an placement of a Dobhoff tube that extends at least to the lower stomach, were crosses the inferior margin of the image. Huge enlargement of the cardiac silhouette without appreciable vascular congestion is unchanged. The questioned opacification at the right baseon the previous study is not appreciated on this examination. ___ Cardiovascular TTE Report LVEF>75% IMPRESSION: Adequate image quality. Moderate symmetric left ventricular hypertrophy with small chamber size and hyperdynamic left ventricular systolic function. Moderate-severe tricuspid regurgitation. Mild mitral regurgitation. Mild aortic regurgitation. At least moderate pulmonary artery systolic hypertension. Small to moderate pericardial effusion without echocardiographic evidence of hemodynamic compromise. Compared with the prior TTE ___, the severity of mitral regurgitation is now lower. ___ Imaging CHEST PORT. LINE PLACEM IMPRESSION: The tip of the right PICC line projects over the cavoatrial junction. No pneumothorax. Nodular appearing opacity along the periphery of the right lower lung for which attention on follow-up imaging is recommended. If there is no subsequent evolution of the lesion, further evaluation with a dedicated CT chest is recommended to exclude malignancy. ___ Imaging CHEST (PORTABLE AP) IMPRESSION: Increasing patchy right lung base consolidation, suspicious for pneumonia. Unchanged marked enlargement of the cardiac silhouette. ___ Imaging CHEST (PORTABLE AP) IMPRESSION: Marked cardiomegaly again noted. Subtle opacity abutting the right heart border, question early right lower lobe pneumonia. No overt signs of edema. Brief Hospital Course: Ms. ___ is ___ year old with HTN, Afib on Apixaban, dCHF, valvular heart disease, and left cavernous sinus lesion who presented to cardiology clinic for routine appointment and was found to be in AFib with RVR and respiratory distress. ACUTE ISSUES: ============= #Hypoxic respiratory distress: Likely from RLL PNA, started on Vancomycin/Cefepime/Azithromycin at admission. Also with mild hypervolemia on initial exam, therefore, was initially received diuresis. History from family of poor swallowing and thus there was concern for aspiration. Speech/swallow evaluated and recommended a feeding tube for aspiration risk. A dobhuff was initially placed for tube feeds. Patient self discontinued this and patient and family declined replacement (see goals of care below). She received PNA treatment during admission as below, chest ___, and nebs/Muccinex. #Pnemonia Identified RLL opacity concerning for early aspiration (given poor swallowing) vs CAP. Patient remained afebrile. Strep PNA Ag positive. Flu and legionella negative. She received Vanc/Zosyn initially and was transitioned to augmentin for 10 day course, last day ___. #Recurrent Aspirations Patient with high risk of aspiration. She was evaluated by speech and swallow who initially recommended NPO status and a dobhoff was placed for tube feeds. Pt pulled out her dobhoff tube and along with her family expressed to the medical team she would not like another NG tube to be replaced. After discussion with patient and her family we advanced her diet to puree and nectar thick liquids, with meds crushed in apple sauce. Please see below for speech and swallow final recommendations. # ___ Family meeting was held with the medical team and palliative care to further facilitate clarification of goals of care, long term treatment plan and code status. We reviewed family's understanding of her active medical conditions which is very good and discussed in depth the main ongoing issues including ongoing silent aspiration, risk of recurrent pneumonias, severe life threatening aspiration, malnutrition, dehydration risk with inadequate oral intake. We explained that while aspiration risk can not be eliminated it could be reduced with peg-tube feeds. Family re-expressed their and the patient's strong preference for allowing PO nutrition despite the risks and for going home. They also expressed their understanding and acceptance of patient's guarded prognosis and that serious complications may be inevitable given her age and medical condition. #HFpEF: Pro-BNP elevated on admission with CXR w/congestion with mild volume overload on exam that was likely triggered by PNA. Patient received IV Lasix diuresis with good effect. Lisinopril held due to ___. Home metoprolol was fractionated. Patient subsequently remained euvolemic on exam and maintained normal BP's off lisinopril which continued to be held at discharge. Given low oral fluid intake, oral furosamide continued to be held at discharge. ___: Her baseline Cr 0.7-0.9 with admission Cr 1.3. Likely in setting of PNA vs cardiorenal given elevated BNP. Her home Lisinopril was held during this admission. Renal function improved after holding diuretics and receiving IVF. We will continue to hold lisinopril at d/c as BP's well controlled in house without it. Patient will get repeat chem10 on ___. She will get BP monitoring by ___. #Afib w/RVR: On admission had HRs in 120-130's in setting of respiratory distress from CHF and PNA. Home diltiazem, Metoprolol and apixiban were continued. #Pericardial effusion: TTE (___) shows small-moderate pericardial effusion with no evidence of tamponade. Patient remained hemodynamically stable throughout hospitalization. Repeated TTE showed stable effusion. #UTI: UCx grew K.pneumo that is sensitive to Cefepime (start ___. The patient was asymptomatic, afebrile, without leukocytosis throughout this admission. She received antibiotics as above. #Erythrocytosis: Elevated HgB noted on admission. Baseline HgB ___ although has been as high as 16 in the past. Was likely slightly hemoconcentrated in the setting of infection, diuresis, and poor po intake. #Hypernatremia. Initially concerning for hypovolemia in setting of elevated BUNC/Cr and lactate. She received additional free water and sodium normalized. #Troponinemia: Likely secondary to RVR and ___. No chest pain. Troponins mildly elevated and plateau(0.02->0.03) with flat MB #HTN: Patient had elevated BP (130-160's/100's)on admission but improved with improvement in HR's due to AFib w/RVR. Her home Lisinopril was held iso of ___. Patient continued on home Metoprolol and diltiazem. TRANSITIONAL ISSUES =================== [ ] ___ visits for weight and fluid status monitoring, BP monitoring, home ___. [ ] ___ should monitor O2 sats. Home O2 PRN comfort [ ] ___ with out patient PCP and cardiologist [ ] Consider repeat interval TTE by outpatient cardiology [ ] CBC and Chem 10 on ___ for PCP/cardiologist ___ [ ] ___ with outpatient palliative care service at ___ [ ] Furosemide, lisinopril held at d/c as per above for outpatient provider ___. [ ] Speech and swallow recs: -PO Diet: Accepting risks of an aspiration event and for quality of life purposes, recommend to continue with puree solids and nectar thick liquids. Meds crushed -TID Oral care -Aspiration Precautions: -- 1:1 supervision for all meals -- Upright for all meals -- Feed only when awake/alert -- Small bites/sips. No straws -- Slow rate - Pt may benefit from continued home SLP home services to provide further educations re: dysphagia/safe swallow strategies. #CODE: Full (presumed) #CONTACT: ___ (son) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 30 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Diltiazem Extended-Release 120 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Apixaban 2.5 mg PO BID 6. Potassium Chloride 20 mEq PO DAILY Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. Apixaban 2.5 mg PO BID 4. Diltiazem Extended-Release 120 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. HELD- Furosemide 40 mg PO DAILY This medication was held. Do not restart Furosemide until you see your outpatient cardiologist 7. HELD- Lisinopril 30 mg PO DAILY This medication was held. Do not restart Lisinopril until you are seen by your cardiologist 8. HELD- Potassium Chloride 20 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until until you see your outpatient cardiologist 9.Rolling ___ Diagnosis: Pneumonia Prognosis: Good ___: 13 months 10.Oxygen ___ DOB: ___ Diagnosis: Chronic Aspiration Length of Need: Ongoing Concentrator and portable Via N/C ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary ======== Pneumonia Urinary tract infection Atrial fibrillation Dysphagia Acute kidney injury Secondary ========= Heart failure Pericardial Effusion 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 caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were here because you had trouble breathing. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received antibiotics to treat for an infection. - You received a tube and tube feeds to keep up with your nutrition when you had trouble swallowing. - The speech and swallow team evaluated your ability to swallow. They determined that you were at risk of choking. We discussed this with your family and worked with the speech/swallow team to create a safer eating/diet plan for you. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "J690", "I5033", "N179", "N390", "I313", "E870", "I110", "I083", "I4891", "R1310", "R0603", "R0902", "E861", "B961", "I2720", "D751", "K761", "N200", "D320", "R197", "E8809", "R791", "Z7902" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: Pt is [MASKED] year old with HTN, afib on apixaban, diastolic CHF, valvular heart disease, and left cavernous sinus lesion who presented to cardiology clinic for routine appointment and was found to be in AFib with RVR and respiratory distress. Per ED records: Family states for 3 days pt has been coughing, having generalized weakness. The patient and family cannot provide more specific history at this time as family present do not primarily care for pt or live with her and pt is altered. Family report that weight has decreased. Family deny history of fever or chest pain. Per referral: [MASKED] year old female with chief complaint of congestion, AF with RVR, HTN. Came in for a routine cardiology [MASKED], was lying on exam table, make gurgling, wet sounds, O2 sats 91%, HR 140, BP 151/111. Did respond to her daughter speaking with her, opened eyes when asked, made eye contact and smiled. Has been like this for at least 3 days per family, almost no PO intake. In the ED, initial VS were: 0 97.1 135 143/94 36 96% 4L NC Exam notable for: Tachypneic, accessory muscle use Confused JVP elevated Diffuse rhonchi bilaterally Bilateral [MASKED] edema Labs showed: BNP 15000, up from 3000 before. Trop 0.02. No MB. Hgb 16.4 Imaging showed: CXR w/ Marked cardiomegaly again noted. Subtle opacity abutting the right heart border, question early right lower lobe pneumonia. No overt signs of edema. Consults: None Patient received: [MASKED] 17:35 IV Piperacillin-Tazobactam [MASKED] 18:29 IV Vancomycin [MASKED] 18:40 IV Furosemide 20 mg [MASKED] 01:12 IV Furosemide 20 mg [MASKED] 01:12 IV Metoprolol Tartrate 2.5 mg [MASKED] 02:02 IV Metoprolol Tartrate 2.5 mg [MASKED] 03:45 PO/NG Apixaban 2.5 mg [MASKED] 03:45 PO Metoprolol Succinate XL 100 mg [MASKED] 04:33 IV Metoprolol Tartrate 5 mg Transfer VS were: 97.4 [MASKED] 24 98% RA On arrival to the floor, patient is alert but breathing heavily with course breath sounds. Interview with interpreter deferred as she would not be able to speak on the phone at this time. REVIEW OF SYSTEMS: Unable to obtain Past Medical History: Hypertension Atrial Fibrillation Congestive Heart Failure Pulmonary Hypertension Osteopenia DJD Social History: [MASKED] Family History: Both parents died at the age of [MASKED]; they were prosecuted due to the fact that they were [MASKED] in [MASKED]. She has five brothers and sisters; the three sisters passed away from unknown reasons. She has 12 children, one of whom passed away from a presumed stroke. No family history of known hypertension, dyslipidemia, early coronary artery disease, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: 97.3 PO 165 / 114 R Lying 123 22 95 ra GENERAL: Alert, lying in bed, wet respiratory sounds, not coughing HEENT: AT/NC, anicteric sclera, pink conjunctiva, NC in place NECK: supple, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: Coarse breath sounds diffusely, heard without auscultation. Rapid respiratory sounds. ABDOMEN: nondistended, soft, nontender in all quadrants EXTREMITIES: 2+ edema NEURO: A&Ox3 SKIN: warm DISCHARGE PHYSICAL EXAM: ======================== GENERAL: Alert, laying in bed, NAD HEENT: AT/NC, anicteric sclera, pink conjunctiva, dobhoff tube in place NECK: supple HEART: irregularly irregular, S1 + S2 present, no mrg LUNGS: Coarse breath sounds diffusely with expiratory wheezing. ABDOMEN: Soft, NT, ND, no rebound or guarding EXTREMITIES: Warm and well perfused lower extremities, palpable pulses, trace edema bilaterally NEURO: A&Ox2 (oriented to self and place) Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:12PM BLOOD WBC-7.2 RBC-5.16 Hgb-16.4* Hct-49.5* MCV-96 MCH-31.8 MCHC-33.1 RDW-15.8* RDWSD-54.9* Plt [MASKED] [MASKED] 05:12PM BLOOD Neuts-77.8* Lymphs-9.7* Monos-11.7 Eos-0.0* Baso-0.1 NRBC-0.4* Im [MASKED] AbsNeut-5.61 AbsLymp-0.70* AbsMono-0.84* AbsEos-0.00* AbsBaso-0.01 [MASKED] 05:12PM BLOOD [MASKED] PTT-38.0* [MASKED] [MASKED] 05:12PM BLOOD Glucose-193* UreaN-46* Creat-1.3* Na-142 K-4.9 Cl-101 HCO3-26 AnGap-15 [MASKED] 05:12PM BLOOD ALT-20 AST-41* AlkPhos-79 TotBili-3.3* [MASKED] 05:12PM BLOOD [MASKED] [MASKED] 05:12PM BLOOD cTropnT-0.02* [MASKED] 05:12PM BLOOD Calcium-9.5 Phos-5.1* Mg-2.4 [MASKED] 05:16PM BLOOD [MASKED] pO2-34* pCO2-57* pH-7.35 calTCO2-33* Base XS-3 Intubat-NOT INTUBA [MASKED] 05:16PM BLOOD Lactate-3.8* [MASKED] 07:00PM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 07:00PM URINE Blood-TR* Nitrite-NEG Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 07:00PM URINE RBC-2 WBC-2 Bacteri-MANY* Yeast-NONE Epi-1 [MASKED] 07:00PM URINE CastHy-21* [MASKED] 07:00PM URINE AmorphX-RARE* [MASKED] 07:00PM URINE Mucous-FEW* INTERVAL PERTINENT EVENTS: ========================== [MASKED] 06:15AM BLOOD CK-MB-3 cTropnT-0.03* [MASKED] 06:15AM BLOOD TSH-1.0 [MASKED] 06:34AM BLOOD [MASKED] pO2-98 pCO2-39 pH-7.43 calTCO2-27 Base XS-1 Comment-GREEN TOP [MASKED] 09:41AM BLOOD [MASKED] pO2-128* pCO2-43 pH-7.39 calTCO2-27 Base XS-1 Comment-GREEN TOP [MASKED] 01:11PM BLOOD [MASKED] pO2-62* pCO2-55* pH-7.34* calTCO2-31* Base XS-1 [MASKED] 06:34AM BLOOD Lactate-2.5* [MASKED] 09:41AM BLOOD Lactate-3.3* [MASKED] 01:11PM BLOOD Lactate-2.6* [MASKED] 10:06PM BLOOD Lactate-2.3* DISCHARGE LABS: =============== [MASKED] 05:21AM BLOOD WBC-11.6* RBC-4.42 Hgb-13.7 Hct-41.9 MCV-95 MCH-31.0 MCHC-32.7 RDW-15.6* RDWSD-52.4* Plt [MASKED] [MASKED] 05:21AM BLOOD Glucose-115* UreaN-27* Creat-0.7 Na-146 K-4.8 Cl-101 HCO3-34* AnGap-11 [MASKED] 05:26AM BLOOD ALT-29 AST-44* LD(LDH)-282* AlkPhos-87 TotBili-1.0 DirBili-0.5* IndBili-0.5 [MASKED] 05:21AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.3 MICROBIOLOGY: ============= [MASKED] 7:00 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Time Taken Not Noted Log-In Date/Time: [MASKED] 4:28 am URINE **FINAL REPORT [MASKED] Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [MASKED] 04:28AM URINE Streptococcus pneumoniae Antigen Detection- Detected A [MASKED] 07:54PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 10:08 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. [MASKED] 10:08 am SPUTUM Source: Expectorated. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. IMAGING ======================== [MASKED] Imaging CHEST (PORTABLE AP) IMPRESSION: In comparison with the study of [MASKED], there is an placement of a Dobhoff tube that extends at least to the lower stomach, were crosses the inferior margin of the image. Huge enlargement of the cardiac silhouette without appreciable vascular congestion is unchanged. The questioned opacification at the right baseon the previous study is not appreciated on this examination. [MASKED] Cardiovascular TTE Report LVEF>75% IMPRESSION: Adequate image quality. Moderate symmetric left ventricular hypertrophy with small chamber size and hyperdynamic left ventricular systolic function. Moderate-severe tricuspid regurgitation. Mild mitral regurgitation. Mild aortic regurgitation. At least moderate pulmonary artery systolic hypertension. Small to moderate pericardial effusion without echocardiographic evidence of hemodynamic compromise. Compared with the prior TTE [MASKED], the severity of mitral regurgitation is now lower. [MASKED] Imaging CHEST PORT. LINE PLACEM IMPRESSION: The tip of the right PICC line projects over the cavoatrial junction. No pneumothorax. Nodular appearing opacity along the periphery of the right lower lung for which attention on follow-up imaging is recommended. If there is no subsequent evolution of the lesion, further evaluation with a dedicated CT chest is recommended to exclude malignancy. [MASKED] Imaging CHEST (PORTABLE AP) IMPRESSION: Increasing patchy right lung base consolidation, suspicious for pneumonia. Unchanged marked enlargement of the cardiac silhouette. [MASKED] Imaging CHEST (PORTABLE AP) IMPRESSION: Marked cardiomegaly again noted. Subtle opacity abutting the right heart border, question early right lower lobe pneumonia. No overt signs of edema. Brief Hospital Course: Ms. [MASKED] is [MASKED] year old with HTN, Afib on Apixaban, dCHF, valvular heart disease, and left cavernous sinus lesion who presented to cardiology clinic for routine appointment and was found to be in AFib with RVR and respiratory distress. ACUTE ISSUES: ============= #Hypoxic respiratory distress: Likely from RLL PNA, started on Vancomycin/Cefepime/Azithromycin at admission. Also with mild hypervolemia on initial exam, therefore, was initially received diuresis. History from family of poor swallowing and thus there was concern for aspiration. Speech/swallow evaluated and recommended a feeding tube for aspiration risk. A dobhuff was initially placed for tube feeds. Patient self discontinued this and patient and family declined replacement (see goals of care below). She received PNA treatment during admission as below, chest [MASKED], and nebs/Muccinex. #Pnemonia Identified RLL opacity concerning for early aspiration (given poor swallowing) vs CAP. Patient remained afebrile. Strep PNA Ag positive. Flu and legionella negative. She received Vanc/Zosyn initially and was transitioned to augmentin for 10 day course, last day [MASKED]. #Recurrent Aspirations Patient with high risk of aspiration. She was evaluated by speech and swallow who initially recommended NPO status and a dobhoff was placed for tube feeds. Pt pulled out her dobhoff tube and along with her family expressed to the medical team she would not like another NG tube to be replaced. After discussion with patient and her family we advanced her diet to puree and nectar thick liquids, with meds crushed in apple sauce. Please see below for speech and swallow final recommendations. # [MASKED] Family meeting was held with the medical team and palliative care to further facilitate clarification of goals of care, long term treatment plan and code status. We reviewed family's understanding of her active medical conditions which is very good and discussed in depth the main ongoing issues including ongoing silent aspiration, risk of recurrent pneumonias, severe life threatening aspiration, malnutrition, dehydration risk with inadequate oral intake. We explained that while aspiration risk can not be eliminated it could be reduced with peg-tube feeds. Family re-expressed their and the patient's strong preference for allowing PO nutrition despite the risks and for going home. They also expressed their understanding and acceptance of patient's guarded prognosis and that serious complications may be inevitable given her age and medical condition. #HFpEF: Pro-BNP elevated on admission with CXR w/congestion with mild volume overload on exam that was likely triggered by PNA. Patient received IV Lasix diuresis with good effect. Lisinopril held due to [MASKED]. Home metoprolol was fractionated. Patient subsequently remained euvolemic on exam and maintained normal BP's off lisinopril which continued to be held at discharge. Given low oral fluid intake, oral furosamide continued to be held at discharge. [MASKED]: Her baseline Cr 0.7-0.9 with admission Cr 1.3. Likely in setting of PNA vs cardiorenal given elevated BNP. Her home Lisinopril was held during this admission. Renal function improved after holding diuretics and receiving IVF. We will continue to hold lisinopril at d/c as BP's well controlled in house without it. Patient will get repeat chem10 on [MASKED]. She will get BP monitoring by [MASKED]. #Afib w/RVR: On admission had HRs in 120-130's in setting of respiratory distress from CHF and PNA. Home diltiazem, Metoprolol and apixiban were continued. #Pericardial effusion: TTE ([MASKED]) shows small-moderate pericardial effusion with no evidence of tamponade. Patient remained hemodynamically stable throughout hospitalization. Repeated TTE showed stable effusion. #UTI: UCx grew K.pneumo that is sensitive to Cefepime (start [MASKED]. The patient was asymptomatic, afebrile, without leukocytosis throughout this admission. She received antibiotics as above. #Erythrocytosis: Elevated HgB noted on admission. Baseline HgB [MASKED] although has been as high as 16 in the past. Was likely slightly hemoconcentrated in the setting of infection, diuresis, and poor po intake. #Hypernatremia. Initially concerning for hypovolemia in setting of elevated BUNC/Cr and lactate. She received additional free water and sodium normalized. #Troponinemia: Likely secondary to RVR and [MASKED]. No chest pain. Troponins mildly elevated and plateau(0.02->0.03) with flat MB #HTN: Patient had elevated BP (130-160's/100's)on admission but improved with improvement in HR's due to AFib w/RVR. Her home Lisinopril was held iso of [MASKED]. Patient continued on home Metoprolol and diltiazem. TRANSITIONAL ISSUES =================== [ ] [MASKED] visits for weight and fluid status monitoring, BP monitoring, home [MASKED]. [ ] [MASKED] should monitor O2 sats. Home O2 PRN comfort [ ] [MASKED] with out patient PCP and cardiologist [ ] Consider repeat interval TTE by outpatient cardiology [ ] CBC and Chem 10 on [MASKED] for PCP/cardiologist [MASKED] [ ] [MASKED] with outpatient palliative care service at [MASKED] [ ] Furosemide, lisinopril held at d/c as per above for outpatient provider [MASKED]. [ ] Speech and swallow recs: -PO Diet: Accepting risks of an aspiration event and for quality of life purposes, recommend to continue with puree solids and nectar thick liquids. Meds crushed -TID Oral care -Aspiration Precautions: -- 1:1 supervision for all meals -- Upright for all meals -- Feed only when awake/alert -- Small bites/sips. No straws -- Slow rate - Pt may benefit from continued home SLP home services to provide further educations re: dysphagia/safe swallow strategies. #CODE: Full (presumed) #CONTACT: [MASKED] (son) [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 30 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Diltiazem Extended-Release 120 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Apixaban 2.5 mg PO BID 6. Potassium Chloride 20 mEq PO DAILY Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. Apixaban 2.5 mg PO BID 4. Diltiazem Extended-Release 120 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY 6. HELD- Furosemide 40 mg PO DAILY This medication was held. Do not restart Furosemide until you see your outpatient cardiologist 7. HELD- Lisinopril 30 mg PO DAILY This medication was held. Do not restart Lisinopril until you are seen by your cardiologist 8. HELD- Potassium Chloride 20 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until until you see your outpatient cardiologist 9.Rolling [MASKED] Diagnosis: Pneumonia Prognosis: Good [MASKED]: 13 months 10.Oxygen [MASKED] DOB: [MASKED] Diagnosis: Chronic Aspiration Length of Need: Ongoing Concentrator and portable Via N/C [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary ======== Pneumonia Urinary tract infection Atrial fibrillation Dysphagia Acute kidney injury Secondary ========= Heart failure Pericardial Effusion 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 caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were here because you had trouble breathing. WHAT HAPPENED TO ME IN THE HOSPITAL? - You received antibiotics to treat for an infection. - You received a tube and tube feeds to keep up with your nutrition when you had trouble swallowing. - The speech and swallow team evaluated your ability to swallow. They determined that you were at risk of choking. We discussed this with your family and worked with the speech/swallow team to create a safer eating/diet plan for you. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "N390", "I110", "I4891", "Z7902" ]
[ "J690: Pneumonitis due to inhalation of food and vomit", "I5033: Acute on chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "I313: Pericardial effusion (noninflammatory)", "E870: Hyperosmolality and hypernatremia", "I110: Hypertensive heart disease with heart failure", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I4891: Unspecified atrial fibrillation", "R1310: Dysphagia, unspecified", "R0603: Acute respiratory distress", "R0902: Hypoxemia", "E861: Hypovolemia", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "I2720: Pulmonary hypertension, unspecified", "D751: Secondary polycythemia", "K761: Chronic passive congestion of liver", "N200: Calculus of kidney", "D320: Benign neoplasm of cerebral meninges", "R197: Diarrhea, unspecified", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "R791: Abnormal coagulation profile", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,068,843
21,200,388
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Amoxicillin / Ultram / hydrocodone / meloxicam / omnipague 240 Attending: ___. Chief Complaint: left shoulder osteoarthritis/pain Major Surgical or Invasive Procedure: ___: left total shoulder arthroplasty History of Present Illness: ___ year old female w/left shoulder osteoarthritis/pain who failed conservative measures, now admitted for left total shoulder replacement. Past Medical History: dyslipidemia, heart murmur, OSA (remote hx, resolved w/weight loss), migraines, spinal stenosis, vertigo, hypothyroidism, GERD, pancreatic cyst, anemia, depression, s/p B/L TKRs, R TSR (___), tonsillectomy, L hand ___ digit arthrodesis (___) 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 Upper Extremity: * Incision healing well * Scant serosanguinous drainage * ___ strength * SILT, NVI distally * Fingers warm Pertinent Results: ___ 10:00AM BLOOD WBC-8.5 RBC-2.71* Hgb-8.6* Hct-25.8* MCV-95 MCH-31.7 MCHC-33.3 RDW-12.9 RDWSD-44.9 Plt ___ ___ 05:10PM BLOOD WBC-9.3 RBC-2.55* Hgb-8.1* Hct-24.4* MCV-96 MCH-31.8 MCHC-33.2 RDW-13.0 RDWSD-45.6 Plt ___ ___ 07:05AM BLOOD WBC-9.2 RBC-2.88* Hgb-9.1* Hct-27.5* MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt ___ ___ 02:33PM BLOOD Hct-29.5* ___ 10:00AM BLOOD Plt ___ ___ 05:10PM BLOOD Plt ___ ___ 07:05AM BLOOD Plt ___ ___ 05:10PM BLOOD Glucose-86 UreaN-17 Creat-0.8 Na-133 K-3.5 Cl-99 HCO3-25 AnGap-13 ___ 07:05AM BLOOD Glucose-141* UreaN-24* Creat-0.8 Na-131* K-3.8 Cl-97 HCO3-25 AnGap-13 ___ 07:05AM BLOOD estGFR-Using this ___ 05:10PM BLOOD cTropnT-<0.01 proBNP-2461* ___ 07:05AM BLOOD proBNP-675* ___ 05:10PM BLOOD Calcium-8.4 Phos-2.5* Mg-1.7 ___ 02:33PM BLOOD Albumin-3.5 ___ 02:33PM BLOOD VitB12-1053* ___ 02:33PM BLOOD TSH-1.7 Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: On POD#0, she was oliguric and was bloused 500cc NS. On POD #1, she was hypotensive and bloused 1L of NS and continued to be hypotensive. Later in the day she became hypotensive, short of breath, and hypoxic. A CXR was obtained and was unremarkable. A CTA was ordered which was negative for a pulmonary embolism. POD# 2, she continued to have low O2 sats. She was weaned down on her oxygen and respond well when ambulating with physical therapy, but would de-sat upon laying flat. Medicine was consulted which recommended getting a BNP which was mildly elevated, and Tropins which were within normal limits. On POD #3, Her oxygen saturation improved. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin for DVT prophylaxis. 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 non-weight bearing as tolerated on the operative extremity. Ms. ___ is discharged to home in stable condition. Medications on Admission: 1. Estrogens Conjugated 0.625 gm VG 1X/WEEK (MO) 2. FLUoxetine 50 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Simvastatin 20 mg PO QPM 6. Spironolactone 50 mg PO DAILY 7. Acetaminophen ___ mg PO Q6H:PRN pain 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 20 mg PO QPM 4. Vitamin D 1000 UNIT PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Estrogens Conjugated 0.625 gm VG 1X/WEEK (MO) 7. FLUoxetine 50 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain please no driving or drinking alcohol while taking this medication 10. Aspirin EC 325 mg PO DAILY 11. Senna 17.2 mg PO HS 12. TraMADol 25 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: left shoulder osteoarthritis/pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 8. ANTICOAGULATION: Please continue your Aspirin 325 mg daily for two (2) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. 9. WOUND CARE: Please remove your dressing two days after surgery. You may place a dry sterile dressing on the wound if needed. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. ACTIVITY: Non weight bearing on the operative extremity. Physical Therapy: NWB LUE Treatments Frequency: remove dressing in 2 days apply dry sterile dressing if needed Followup Instructions: ___
[ "M19012", "D649", "E871", "S46212A", "X58XXXA", "Y929", "E785", "R42", "E039", "K219", "F329", "R911", "N990", "I9581", "R0902", "Z96653", "Z96611" ]
Allergies: Penicillins / Amoxicillin / Ultram / hydrocodone / meloxicam / omnipague 240 Chief Complaint: left shoulder osteoarthritis/pain Major Surgical or Invasive Procedure: [MASKED]: left total shoulder arthroplasty History of Present Illness: [MASKED] year old female w/left shoulder osteoarthritis/pain who failed conservative measures, now admitted for left total shoulder replacement. Past Medical History: dyslipidemia, heart murmur, OSA (remote hx, resolved w/weight loss), migraines, spinal stenosis, vertigo, hypothyroidism, GERD, pancreatic cyst, anemia, depression, s/p B/L TKRs, R TSR ([MASKED]), tonsillectomy, L hand [MASKED] digit arthrodesis ([MASKED]) Social History: [MASKED] Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Upper Extremity: * Incision healing well * Scant serosanguinous drainage * [MASKED] strength * SILT, NVI distally * Fingers warm Pertinent Results: [MASKED] 10:00AM BLOOD WBC-8.5 RBC-2.71* Hgb-8.6* Hct-25.8* MCV-95 MCH-31.7 MCHC-33.3 RDW-12.9 RDWSD-44.9 Plt [MASKED] [MASKED] 05:10PM BLOOD WBC-9.3 RBC-2.55* Hgb-8.1* Hct-24.4* MCV-96 MCH-31.8 MCHC-33.2 RDW-13.0 RDWSD-45.6 Plt [MASKED] [MASKED] 07:05AM BLOOD WBC-9.2 RBC-2.88* Hgb-9.1* Hct-27.5* MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt [MASKED] [MASKED] 02:33PM BLOOD Hct-29.5* [MASKED] 10:00AM BLOOD Plt [MASKED] [MASKED] 05:10PM BLOOD Plt [MASKED] [MASKED] 07:05AM BLOOD Plt [MASKED] [MASKED] 05:10PM BLOOD Glucose-86 UreaN-17 Creat-0.8 Na-133 K-3.5 Cl-99 HCO3-25 AnGap-13 [MASKED] 07:05AM BLOOD Glucose-141* UreaN-24* Creat-0.8 Na-131* K-3.8 Cl-97 HCO3-25 AnGap-13 [MASKED] 07:05AM BLOOD estGFR-Using this [MASKED] 05:10PM BLOOD cTropnT-<0.01 proBNP-2461* [MASKED] 07:05AM BLOOD proBNP-675* [MASKED] 05:10PM BLOOD Calcium-8.4 Phos-2.5* Mg-1.7 [MASKED] 02:33PM BLOOD Albumin-3.5 [MASKED] 02:33PM BLOOD VitB12-1053* [MASKED] 02:33PM BLOOD TSH-1.7 Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: On POD#0, she was oliguric and was bloused 500cc NS. On POD #1, she was hypotensive and bloused 1L of NS and continued to be hypotensive. Later in the day she became hypotensive, short of breath, and hypoxic. A CXR was obtained and was unremarkable. A CTA was ordered which was negative for a pulmonary embolism. POD# 2, she continued to have low O2 sats. She was weaned down on her oxygen and respond well when ambulating with physical therapy, but would de-sat upon laying flat. Medicine was consulted which recommended getting a BNP which was mildly elevated, and Tropins which were within normal limits. On POD #3, Her oxygen saturation improved. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin for DVT prophylaxis. 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 non-weight bearing as tolerated on the operative extremity. Ms. [MASKED] is discharged to home in stable condition. Medications on Admission: 1. Estrogens Conjugated 0.625 gm VG 1X/WEEK (MO) 2. FLUoxetine 50 mg PO DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Simvastatin 20 mg PO QPM 6. Spironolactone 50 mg PO DAILY 7. Acetaminophen [MASKED] mg PO Q6H:PRN pain 8. Vitamin D 1000 UNIT PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Levothyroxine Sodium 75 mcg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 20 mg PO QPM 4. Vitamin D 1000 UNIT PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Estrogens Conjugated 0.625 gm VG 1X/WEEK (MO) 7. FLUoxetine 50 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain please no driving or drinking alcohol while taking this medication 10. Aspirin EC 325 mg PO DAILY 11. Senna 17.2 mg PO HS 12. TraMADol 25 mg PO Q6H:PRN pain Discharge Disposition: Home Discharge Diagnosis: left shoulder osteoarthritis/pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc). 8. ANTICOAGULATION: Please continue your Aspirin 325 mg daily for two (2) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. 9. WOUND CARE: Please remove your dressing two days after surgery. You may place a dry sterile dressing on the wound if needed. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. ACTIVITY: Non weight bearing on the operative extremity. Physical Therapy: NWB LUE Treatments Frequency: remove dressing in 2 days apply dry sterile dressing if needed Followup Instructions: [MASKED]
[]
[ "D649", "E871", "Y929", "E785", "E039", "K219", "F329" ]
[ "M19012: Primary osteoarthritis, left shoulder", "D649: Anemia, unspecified", "E871: Hypo-osmolality and hyponatremia", "S46212A: Strain of muscle, fascia and tendon of other parts of biceps, left arm, initial encounter", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable", "E785: Hyperlipidemia, unspecified", "R42: Dizziness and giddiness", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "R911: Solitary pulmonary nodule", "N990: Postprocedural (acute) (chronic) kidney failure", "I9581: Postprocedural hypotension", "R0902: Hypoxemia", "Z96653: Presence of artificial knee joint, bilateral", "Z96611: Presence of right artificial shoulder joint" ]
10,069,364
20,403,405
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: Mr. ___ is a ___ man with a history of hypertension & hyperlipidemia, who presents several months of arthralgias, fatigue, and fever of unknown origin. He was at his baseline state of health until ___. At that time, he noticed swollen, painful feet bilaterally, which he attributed to increased exercising. He started swimming, and later realized that the pool was contaminated with Pseudomonas, Staph, and other bacteria. His feet continued to hurt, so he saw a doctor in ___ at that time. He was diagnosed with gout in ___, and prescribed Allopurinol & Colchicine. He had no other symptoms at that time; no fevers, chills, weight loss, other arthralgias, or rashes. Shortly after starting Allopurinol & Colchicine, he developed a rash on the back of his hand. He was diagnosed with eczema, so Allopurinol was stopped. In ___, he was also diagnosed with a superficial clot in a vein in his left arm. No anticoagulation was started. He re-started the Allopurinol again in ___, and developed a horrible rash over his back, arms, chest, and legs 3 days later. Rash spared his palms & soles. At that time, he also had diffuse arthralgias in his shoulders, fingers, ankles, and toes. He was febrile to 101, and had lots of fatigue. He also had sinus congestion. He presented to the ED in ___, where CT torso was normal, and he was discharged. When he got back from ___, he immediately saw his PCP in ___ for this joint pain, weakness, and fevers. CRP was elevated at that visit, but other labs were unrevealing. He felt better on his own without any further treatment. On ___, he developed a clot in his right arm, and was started on Eloquis because he was about to travel to ___. While in ___, 1 week prior to today's presentation, he had another flare of fevers, fatigue, arthralgias, and "bone pain." No sinus symptoms this time. This time, he also developed esophageal spasms & hiccups, which are new symptoms. He was seen in a hospital in ___, where he was admitted. He was discharged, flew home, and presented here. In the ED, initial VS were 99.4 108 106/58 16 99% RA Exam notable for normal neurologic exam, diffuse arthralgias, mild swelling to bilateral hands. Labs showed transaminitis with Na 126, CRP 183 Received 1g PO Tylenol. Transfer VS were 99.2 80 97/57 18 98% RA Decision was made to admit to medicine for further management. On arrival to the floor, patient's main concern is that no on seems to know what is going on. His most bothersome symptoms are his joint pain & his episodes of hiccups, where he feels esophageal spasm. They have been preventing him from sleeping & eating. He has had drenching night sweats, and unintentionally lost 8lbs in the past 6 months. REVIEW OF SYSTEMS: + fevers intermittently since ___ + night sweats, drenching, nightly + 8lb unintentional weight loss + chronic nasal congestion, but no recent change, no nasal polyps + seasonal allergies + decreased hearing + dry mouth + rashes, as described in HPI; also, 2 episodes of ring worm in past several months No dry eyes, lymphadenopathy, cough, chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea, or constipation Past Medical History: PAST MEDICAL AND SURGICAL HISTORY: - Hypertension - Hyperlipidemia - Superficial thrombosis in RUE - Had cardiac cath ___ years ago for dizziness spell, was normal - No history of malignancy, autoimmune disorder SCREENING - Had colonoscopy ___ year ago that was normal Social History: ___ Family History: - Mother died of gastric cancer in her ___ - Father died of an MI in his ___, strong FH of heart disease on his side - No known autoimmune disease in the family Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.5 74 114/68 20 97% ra GEN: well-appearing, nontoxic man, appears younger than stated age NECK: supple, no tenderness CV: rrr, no m/r/g PULM: normal work of breathing on room air, LCAB, no wheezes or crackles ABD: soft, NT/ND, +bs EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, normal speech, moving all 4 extremities with purpose MSK: tenderness to palpation over thumb & forefinger joints in bilateral hands, otherwise joints are non-warm & non-tender PULSES: 2+ DP pulses bilaterally SKIN: no rashes DISCHARGE PHYSICAL EXAM: VS - 98.2-99.1 | ___ | ___ | ___ | 97-100% RA GEN: well-appearing, nontoxic man, appears younger than stated age NECK: supple, no tenderness CV: rrr, no m/r/g PULM: normal work of breathing on room air, LCAB, no wheezes or crackles ABD: soft, NT/ND, +bs EXTREMITIES: no cyanosis, clubbing, or edema; erythema over knuckles NEURO: A&Ox3, normal speech, moving all 4 extremities with purpose SKIN: no rashes on limited exam Pertinent Results: ADMISSION LABS: ====================== ___ 01:30PM BLOOD WBC-6.6 RBC-3.73* Hgb-13.2* Hct-36.3* MCV-97 MCH-35.4* MCHC-36.4 RDW-12.2 RDWSD-43.7 Plt Ct-UNABLE TO ___ 01:30PM BLOOD Neuts-87* Bands-0 Lymphs-6* Monos-3* Eos-1 Baso-0 Atyps-3* ___ Myelos-0 AbsNeut-5.74 AbsLymp-0.59* AbsMono-0.20 AbsEos-0.07 AbsBaso-0.00* ___ 01:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-OCCASIONAL Tear Dr-1+ ___ 01:30PM BLOOD ___ PTT-26.0 ___ ___ 01:30PM BLOOD Glucose-127* UreaN-14 Creat-0.7 Na-126* K-5.2* Cl-92* HCO3-25 AnGap-14 ___ 01:30PM BLOOD ALT-56* AST-57* AlkPhos-81 TotBili-0.4 ___ 01:30PM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.0 Mg-2.1 ___ 01:30PM BLOOD CRP-183.1* OTHER PERTINENT LABS: ====================== [x] Hepatitis serologies: HCV negative, HAV-Ab: Positive [x] CK: 28 [x] LDH: normal [x] uric acid: 2.6 (low) [x] fibrinogen: 493 (high) [x] serum osm: 280 (normal) [x] U/A, UCx: U/A negative [x] C3: C3: 108 normal [x] iron studies: iron normal, ferritin high [x] hapto: high, 276 [x] urine lytes: urine Na low [x] ESR: high, 106 [x] Lyme: negative [x] Parasite smear: neg [x] RUQ U/S: fine [x] CT TORSO: fine [x] HIV: negative [x] Regular smear: 92% neutrophils [/] AFB x3: prelim of 1 neg [ ] Rickettsia: pnd [ ] Erhlichia: pnd [ ] ___: pnd [ ] ANCA: pnd MICRO: ====================== Urine cultures: Blood cultures: IMAGING/STUDIES: ====================== ___ RUQ US: 1. Coarsened hepatic parenchyma. Normal gallbladder and biliary tree. 2. Tortuous and heavily calcified abdominal aorta. 3. Bilateral simple renal cysts measuring up to 8.2 cm on the left. ___ CT CHEST: No evidence of lymphadenopathy. Known malignancy. 1 cm right apical ground-glass nodule needs to be followed by CT in 12 months. RECOMMENDATION: Followup of 10 mm pure ground-glass nodule in 12 months. ___ CT A/P: 1. No acute intra-abdominal or intrapelvic process. No evidence of malignancy in the abdomen or pelvis. DISCHARGE LABS: ====================== ___ 09:30AM BLOOD WBC-4.6 RBC-3.94* Hgb-13.4* Hct-38.8* MCV-99* MCH-34.0* MCHC-34.5 RDW-12.4 RDWSD-44.9 Plt ___ ___ 07:10AM BLOOD Neuts-54.4 ___ Monos-7.9 Eos-0.6* Baso-0.3 Im ___ AbsNeut-1.85 AbsLymp-1.19* AbsMono-0.27 AbsEos-0.02* AbsBaso-0.01 ___ 09:30AM BLOOD Glucose-116* UreaN-19 Creat-0.7 Na-132* K-3.6 Cl-97 HCO3-23 AnGap-16 ___ 07:10AM BLOOD ALT-74* AST-66* LD(___)-148 AlkPhos-60 TotBili-0.5 ___ 09:30AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.___RIEF SUMMARY STATEMENT: ======================== Mr. ___ is a ___ man with a history of hypertension & hyperlipidemia, who presents several months of arthralgias, fatigue, and fever of unknown origin. ACTIVE ISSUES: ============== # POLYMYALGIA RHEUMATICA # FEVER OF UNKNOWN ORIGIN: # WEIGHT LOSS, NIGHT SWEATS: Patient presented with fever of unknown origin, and concerning constitutional symptoms. Initial differential diagnosis included infection v malignancy v autoimmune/inflammatory process. For infection, he was ruled out for tick-borne illness, including Lyme, Rickettsia, & Erhlichia. Urine and blood cultures were with no growth on discharge. CT torso showed no pneumonia, abscess, or other evidence of infection or tumor. He had one AFB smear that was negative, another was pending on discharge, but suspicion was low. HIV was negative, and Hepatitis serologies showed immunization with Hep B and prior exposure to Hep A. For malignancy, his CT torso showed no evidence of malignancy or lymphadenopathy, and his diff/smear showed no evidence of a lymphoma or leukemia. For autoimmune process, ___, ANCA, and complement were within normal limits. Rheumatology was consulted, and suspected that polymyalgia rheumatica could provide a unifying diagnosis - prednisone was started and the patient began to feel better. He will continue prednisone until outpatient follow-up with Rheumatology. # HICCUPS, ESOPHAGEAL SPASM: Patient had episodes of hiccups thought esophageal spasm. DDx included medication effect, but also concerning for an underlying gastric malignancy (in family history) or a dysmotility (CREST syndrome). He was continued on a PPI, and CT torso was unrevealing. GI was consulted with EGD performed, which was unrevealing. There may be an anxiety component to his symptoms. He will follow-up with Neurology who also evaluated him for this issue as an outpatient. # HYPOTENSIVE EPISODE: On ___, patient's blood pressure dropped from 130s systolic to ___. He felt dizzy & lightheaded, so was placed back in bed. He received 2L NS, with appropriate response in blood pressure. He was started briefly on broad spectrum antibiotics (Vanc/Cefepime/Flagyl/Doxy on ___, which were stopped on ___ when he stabilized. # TRANSAMINITIS: Patient presented with AST/ALT of 44/58, with an unclear baseline. He had no abdominal pain. RUQ U/S and CT torso were unrevealing. Hepatitis serologies showed immunization with Hep B and prior exposure to Hep A. These mildly improved before discharge. His statin was stopped for LFT abnormalities. # HYPONATREMIA: Patient presented with hyponatremia of unclear cause. Euvolemic on exam. Urine lytes without evidence of SIADH. He likely was hypovolemic, and PO intake was encouraged. # ELEVATED CRP: Patient had CRP 183 on admission, appears higher than value of 23 at an OSH. Likely related to his Rheum issues as above. # ARTHRALGIAS: He received Tylenol for pain control. CHRONIC STABLE ISSUES: ====================== # RUE CLOT: Had been placed apixaban at an OSH, but he had no evidence of the same here, and his description was consistent with a provoked superficial thrombophlebitis. He was maintained on just HSQ while hospitalized, and discharged off anticoagulation. # HTN: Held home Lisinopril 10mg daily and metoprolol succinate ER 25 mg daily given episode of hypotension, and normotension on discharge. # HLD: Stopped home Simvastatin 10mg daily for transaminitis. # GERD: Stopped Omeprazole 40mg daily as did not have acid reflux, but rather spasm as above. TRANSITIONAL ISSUES: ==================== - Patient has the following labs outstanding at discharge: [ ] ___: pnd [ ] Erhlichia: pnd [ ] parasite smears [ ] PSA [ ] mycolytic blood culture [ ] crypto Antigen [ ] quant gold [ ] Q fever [ ] ds dna [ ] RF [ ] rho [ ] la [ ] rnp [ ] cryoglobulin [ ] upep [ ] urine sediment from first urine in AM [ ] urine protein/cr from first urine in AM [ ] SPEP - Patient was normotensive while in the hospital. Metoprolol XL and Lisinopril were stopped, consider restarting after discharge if again demonstrates hypertension. - For LFT abnormalities, statin medication was stopped while in the hospital. These should be restarted after LFTs are trended as an outpatient. - Patient has solitary Right apical ground-glass nodule that should be followed up by repeat CT in 3mths - If ongoing esophageal spasms after discharge, could consider calcium channel blocker or tricyclic antidepressant for treatment Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Simvastatin 10 mg PO QPM 4. Loratadine 10 mg PO DAILY:PRN allergies 5. Omeprazole 40 mg PO DAILY 6. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) 80-14.2 mg oral TID Discharge Medications: 1. PredniSONE 20 mg PO DAILY RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*28 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Polymyalgia Rheumatica SECONDARY DIAGNOSES Esophageal Spasm Transaminitis Hyponatreamia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you. You were admitted to ___ for fevers, joint pain, sweats, and weakness. While you were here, you had extensive lab testing & imaging performed. You were seen by several specialists and eventually a diagnosis of polymyalgia rheumatica was made. You were prescribed prednisone for this. When you go home, it will be very important to take all of your medicines as prescribed and keep your appointments as below. We wish you all the best in the future! Sincerely, Your ___ Care Team Followup Instructions: ___
[ "M353", "E871", "I959", "I10", "E785", "Z86718", "Z7901", "K219", "K224", "Z85828", "F419", "R911" ]
Allergies: Penicillins Chief Complaint: fever Major Surgical or Invasive Procedure: EGD [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] man with a history of hypertension & hyperlipidemia, who presents several months of arthralgias, fatigue, and fever of unknown origin. He was at his baseline state of health until [MASKED]. At that time, he noticed swollen, painful feet bilaterally, which he attributed to increased exercising. He started swimming, and later realized that the pool was contaminated with Pseudomonas, Staph, and other bacteria. His feet continued to hurt, so he saw a doctor in [MASKED] at that time. He was diagnosed with gout in [MASKED], and prescribed Allopurinol & Colchicine. He had no other symptoms at that time; no fevers, chills, weight loss, other arthralgias, or rashes. Shortly after starting Allopurinol & Colchicine, he developed a rash on the back of his hand. He was diagnosed with eczema, so Allopurinol was stopped. In [MASKED], he was also diagnosed with a superficial clot in a vein in his left arm. No anticoagulation was started. He re-started the Allopurinol again in [MASKED], and developed a horrible rash over his back, arms, chest, and legs 3 days later. Rash spared his palms & soles. At that time, he also had diffuse arthralgias in his shoulders, fingers, ankles, and toes. He was febrile to 101, and had lots of fatigue. He also had sinus congestion. He presented to the ED in [MASKED], where CT torso was normal, and he was discharged. When he got back from [MASKED], he immediately saw his PCP in [MASKED] for this joint pain, weakness, and fevers. CRP was elevated at that visit, but other labs were unrevealing. He felt better on his own without any further treatment. On [MASKED], he developed a clot in his right arm, and was started on Eloquis because he was about to travel to [MASKED]. While in [MASKED], 1 week prior to today's presentation, he had another flare of fevers, fatigue, arthralgias, and "bone pain." No sinus symptoms this time. This time, he also developed esophageal spasms & hiccups, which are new symptoms. He was seen in a hospital in [MASKED], where he was admitted. He was discharged, flew home, and presented here. In the ED, initial VS were 99.4 108 106/58 16 99% RA Exam notable for normal neurologic exam, diffuse arthralgias, mild swelling to bilateral hands. Labs showed transaminitis with Na 126, CRP 183 Received 1g PO Tylenol. Transfer VS were 99.2 80 97/57 18 98% RA Decision was made to admit to medicine for further management. On arrival to the floor, patient's main concern is that no on seems to know what is going on. His most bothersome symptoms are his joint pain & his episodes of hiccups, where he feels esophageal spasm. They have been preventing him from sleeping & eating. He has had drenching night sweats, and unintentionally lost 8lbs in the past 6 months. REVIEW OF SYSTEMS: + fevers intermittently since [MASKED] + night sweats, drenching, nightly + 8lb unintentional weight loss + chronic nasal congestion, but no recent change, no nasal polyps + seasonal allergies + decreased hearing + dry mouth + rashes, as described in HPI; also, 2 episodes of ring worm in past several months No dry eyes, lymphadenopathy, cough, chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea, or constipation Past Medical History: PAST MEDICAL AND SURGICAL HISTORY: - Hypertension - Hyperlipidemia - Superficial thrombosis in RUE - Had cardiac cath [MASKED] years ago for dizziness spell, was normal - No history of malignancy, autoimmune disorder SCREENING - Had colonoscopy [MASKED] year ago that was normal Social History: [MASKED] Family History: - Mother died of gastric cancer in her [MASKED] - Father died of an MI in his [MASKED], strong FH of heart disease on his side - No known autoimmune disease in the family Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.5 74 114/68 20 97% ra GEN: well-appearing, nontoxic man, appears younger than stated age NECK: supple, no tenderness CV: rrr, no m/r/g PULM: normal work of breathing on room air, LCAB, no wheezes or crackles ABD: soft, NT/ND, +bs EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, normal speech, moving all 4 extremities with purpose MSK: tenderness to palpation over thumb & forefinger joints in bilateral hands, otherwise joints are non-warm & non-tender PULSES: 2+ DP pulses bilaterally SKIN: no rashes DISCHARGE PHYSICAL EXAM: VS - 98.2-99.1 | [MASKED] | [MASKED] | [MASKED] | 97-100% RA GEN: well-appearing, nontoxic man, appears younger than stated age NECK: supple, no tenderness CV: rrr, no m/r/g PULM: normal work of breathing on room air, LCAB, no wheezes or crackles ABD: soft, NT/ND, +bs EXTREMITIES: no cyanosis, clubbing, or edema; erythema over knuckles NEURO: A&Ox3, normal speech, moving all 4 extremities with purpose SKIN: no rashes on limited exam Pertinent Results: ADMISSION LABS: ====================== [MASKED] 01:30PM BLOOD WBC-6.6 RBC-3.73* Hgb-13.2* Hct-36.3* MCV-97 MCH-35.4* MCHC-36.4 RDW-12.2 RDWSD-43.7 Plt Ct-UNABLE TO [MASKED] 01:30PM BLOOD Neuts-87* Bands-0 Lymphs-6* Monos-3* Eos-1 Baso-0 Atyps-3* [MASKED] Myelos-0 AbsNeut-5.74 AbsLymp-0.59* AbsMono-0.20 AbsEos-0.07 AbsBaso-0.00* [MASKED] 01:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-OCCASIONAL Tear Dr-1+ [MASKED] 01:30PM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 01:30PM BLOOD Glucose-127* UreaN-14 Creat-0.7 Na-126* K-5.2* Cl-92* HCO3-25 AnGap-14 [MASKED] 01:30PM BLOOD ALT-56* AST-57* AlkPhos-81 TotBili-0.4 [MASKED] 01:30PM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.0 Mg-2.1 [MASKED] 01:30PM BLOOD CRP-183.1* OTHER PERTINENT LABS: ====================== [x] Hepatitis serologies: HCV negative, HAV-Ab: Positive [x] CK: 28 [x] LDH: normal [x] uric acid: 2.6 (low) [x] fibrinogen: 493 (high) [x] serum osm: 280 (normal) [x] U/A, UCx: U/A negative [x] C3: C3: 108 normal [x] iron studies: iron normal, ferritin high [x] hapto: high, 276 [x] urine lytes: urine Na low [x] ESR: high, 106 [x] Lyme: negative [x] Parasite smear: neg [x] RUQ U/S: fine [x] CT TORSO: fine [x] HIV: negative [x] Regular smear: 92% neutrophils [/] AFB x3: prelim of 1 neg [ ] Rickettsia: pnd [ ] Erhlichia: pnd [ ] [MASKED]: pnd [ ] ANCA: pnd MICRO: ====================== Urine cultures: Blood cultures: IMAGING/STUDIES: ====================== [MASKED] RUQ US: 1. Coarsened hepatic parenchyma. Normal gallbladder and biliary tree. 2. Tortuous and heavily calcified abdominal aorta. 3. Bilateral simple renal cysts measuring up to 8.2 cm on the left. [MASKED] CT CHEST: No evidence of lymphadenopathy. Known malignancy. 1 cm right apical ground-glass nodule needs to be followed by CT in 12 months. RECOMMENDATION: Followup of 10 mm pure ground-glass nodule in 12 months. [MASKED] CT A/P: 1. No acute intra-abdominal or intrapelvic process. No evidence of malignancy in the abdomen or pelvis. DISCHARGE LABS: ====================== [MASKED] 09:30AM BLOOD WBC-4.6 RBC-3.94* Hgb-13.4* Hct-38.8* MCV-99* MCH-34.0* MCHC-34.5 RDW-12.4 RDWSD-44.9 Plt [MASKED] [MASKED] 07:10AM BLOOD Neuts-54.4 [MASKED] Monos-7.9 Eos-0.6* Baso-0.3 Im [MASKED] AbsNeut-1.85 AbsLymp-1.19* AbsMono-0.27 AbsEos-0.02* AbsBaso-0.01 [MASKED] 09:30AM BLOOD Glucose-116* UreaN-19 Creat-0.7 Na-132* K-3.6 Cl-97 HCO3-23 AnGap-16 [MASKED] 07:10AM BLOOD ALT-74* AST-66* LD([MASKED])-148 AlkPhos-60 TotBili-0.5 [MASKED] 09:30AM BLOOD Calcium-9.1 Phos-3.0 Mg-2. RIEF SUMMARY STATEMENT: ======================== Mr. [MASKED] is a [MASKED] man with a history of hypertension & hyperlipidemia, who presents several months of arthralgias, fatigue, and fever of unknown origin. ACTIVE ISSUES: ============== # POLYMYALGIA RHEUMATICA # FEVER OF UNKNOWN ORIGIN: # WEIGHT LOSS, NIGHT SWEATS: Patient presented with fever of unknown origin, and concerning constitutional symptoms. Initial differential diagnosis included infection v malignancy v autoimmune/inflammatory process. For infection, he was ruled out for tick-borne illness, including Lyme, Rickettsia, & Erhlichia. Urine and blood cultures were with no growth on discharge. CT torso showed no pneumonia, abscess, or other evidence of infection or tumor. He had one AFB smear that was negative, another was pending on discharge, but suspicion was low. HIV was negative, and Hepatitis serologies showed immunization with Hep B and prior exposure to Hep A. For malignancy, his CT torso showed no evidence of malignancy or lymphadenopathy, and his diff/smear showed no evidence of a lymphoma or leukemia. For autoimmune process, [MASKED], ANCA, and complement were within normal limits. Rheumatology was consulted, and suspected that polymyalgia rheumatica could provide a unifying diagnosis - prednisone was started and the patient began to feel better. He will continue prednisone until outpatient follow-up with Rheumatology. # HICCUPS, ESOPHAGEAL SPASM: Patient had episodes of hiccups thought esophageal spasm. DDx included medication effect, but also concerning for an underlying gastric malignancy (in family history) or a dysmotility (CREST syndrome). He was continued on a PPI, and CT torso was unrevealing. GI was consulted with EGD performed, which was unrevealing. There may be an anxiety component to his symptoms. He will follow-up with Neurology who also evaluated him for this issue as an outpatient. # HYPOTENSIVE EPISODE: On [MASKED], patient's blood pressure dropped from 130s systolic to [MASKED]. He felt dizzy & lightheaded, so was placed back in bed. He received 2L NS, with appropriate response in blood pressure. He was started briefly on broad spectrum antibiotics (Vanc/Cefepime/Flagyl/Doxy on [MASKED], which were stopped on [MASKED] when he stabilized. # TRANSAMINITIS: Patient presented with AST/ALT of 44/58, with an unclear baseline. He had no abdominal pain. RUQ U/S and CT torso were unrevealing. Hepatitis serologies showed immunization with Hep B and prior exposure to Hep A. These mildly improved before discharge. His statin was stopped for LFT abnormalities. # HYPONATREMIA: Patient presented with hyponatremia of unclear cause. Euvolemic on exam. Urine lytes without evidence of SIADH. He likely was hypovolemic, and PO intake was encouraged. # ELEVATED CRP: Patient had CRP 183 on admission, appears higher than value of 23 at an OSH. Likely related to his Rheum issues as above. # ARTHRALGIAS: He received Tylenol for pain control. CHRONIC STABLE ISSUES: ====================== # RUE CLOT: Had been placed apixaban at an OSH, but he had no evidence of the same here, and his description was consistent with a provoked superficial thrombophlebitis. He was maintained on just HSQ while hospitalized, and discharged off anticoagulation. # HTN: Held home Lisinopril 10mg daily and metoprolol succinate ER 25 mg daily given episode of hypotension, and normotension on discharge. # HLD: Stopped home Simvastatin 10mg daily for transaminitis. # GERD: Stopped Omeprazole 40mg daily as did not have acid reflux, but rather spasm as above. TRANSITIONAL ISSUES: ==================== - Patient has the following labs outstanding at discharge: [ ] [MASKED]: pnd [ ] Erhlichia: pnd [ ] parasite smears [ ] PSA [ ] mycolytic blood culture [ ] crypto Antigen [ ] quant gold [ ] Q fever [ ] ds dna [ ] RF [ ] rho [ ] la [ ] rnp [ ] cryoglobulin [ ] upep [ ] urine sediment from first urine in AM [ ] urine protein/cr from first urine in AM [ ] SPEP - Patient was normotensive while in the hospital. Metoprolol XL and Lisinopril were stopped, consider restarting after discharge if again demonstrates hypertension. - For LFT abnormalities, statin medication was stopped while in the hospital. These should be restarted after LFTs are trended as an outpatient. - Patient has solitary Right apical ground-glass nodule that should be followed up by repeat CT in 3mths - If ongoing esophageal spasms after discharge, could consider calcium channel blocker or tricyclic antidepressant for treatment Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Simvastatin 10 mg PO QPM 4. Loratadine 10 mg PO DAILY:PRN allergies 5. Omeprazole 40 mg PO DAILY 6. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum hydrox-magnesium carb) 80-14.2 mg oral TID Discharge Medications: 1. PredniSONE 20 mg PO DAILY RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*28 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Polymyalgia Rheumatica SECONDARY DIAGNOSES Esophageal Spasm Transaminitis Hyponatreamia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you. You were admitted to [MASKED] for fevers, joint pain, sweats, and weakness. While you were here, you had extensive lab testing & imaging performed. You were seen by several specialists and eventually a diagnosis of polymyalgia rheumatica was made. You were prescribed prednisone for this. When you go home, it will be very important to take all of your medicines as prescribed and keep your appointments as below. We wish you all the best in the future! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E871", "I10", "E785", "Z86718", "Z7901", "K219", "F419" ]
[ "M353: Polymyalgia rheumatica", "E871: Hypo-osmolality and hyponatremia", "I959: Hypotension, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "K219: Gastro-esophageal reflux disease without esophagitis", "K224: Dyskinesia of esophagus", "Z85828: Personal history of other malignant neoplasm of skin", "F419: Anxiety disorder, unspecified", "R911: Solitary pulmonary nodule" ]
10,069,637
27,682,379
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: prednisone Attending: ___. Chief Complaint: Scrotal cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ transverse myelitis, indwelling Foley (since ___ for unclear reasons), BPH, who presented from home with scrotal erythema, fever, and hematuria in setting of Foley trauma approximately one week prior to admission. The patient states that his Foley was inadvertently partially pulled out a week ago and had to be replaced. He then developed hematuria, fever, scrotal erythema and pain. His ___ sent him to the ___ ED. ___. ___ were reportedly concerned for possibility of ___ gangrene and gave vancomycin, Zosyn and clindamycin. He had a CT abdomen and pelvis which reportedly showed scrotal cellulitis with no gas. WBC was ___ at the OSH ED. He was transferred to the ___ ED where vitals were: 98.8F, HR 82, BP 154/84, RR 20, 94% on 2L NC (baseline unknown). Scrotal ultrasound was performed (due to lack of availability of OSH CT images), which confirmed scrotal cellulitis and absence of gas. He was seen by urology who recommended admission for IV antibiotics, serial scrotal exams, and exchange of Foley catheter. UA showed WBCs too numerous to count with culture pending. He was given a second dose of Zosyn and admitted to medicine. ROS GEN: denies fevers/chills CARDIAC: denies chest pain or palpitations PULM: denies new dyspnea or cough GI: denies n/v, poor appetite, endorses constipation GU: as per HPI Full 14-system review of systems otherwise negative and non-contributory. Past Medical History: HTN HLD DM (on no meds for this) BPH Incontinence UTIs Lymphedema Morbid obesity Ventral hernia GERD Anxiety and depression PVD and venous stasis ulcers (has Unaboots) Gout Social History: ___ Family History: Patient cannot tell me FH. Physical Exam: ADMISSION EXAM: GEN: obese M in NAD HEENT: EOMI, sclerae anicteric, MMM, OP clear NECK: No LAD, no JVD CARDIAC: RRR, no M/R/G PULM: normal effort, no accessory muscle use, LCAB GI: soft, NT, ND, NABS MSK: No visible joint effusions or deformities. NEURO: AAOx3. No facial droop, moving all extremities. PSYCH: Full range of affect EXTREMITIES: WWP, lymphedema and brawny erythema GU: erythematous scrotum. R epididymis enlarged. DISCHARGE EXAM: VS: 98.7PO 146/75 72 18 92% on RA GEN: obese male in NAD HEENT: EOMI, sclerae anicteric, MMM, OP clear NECK: No LAD, no JVD CARDIAC: RRR, no M/R/G PULM: normal effort, no accessory muscle use, LCAB GI: soft, NT, ND, NABS MSK: No visible joint effusions or deformities. NEURO: AAOx3. No facial droop, moving all extremities. PSYCH: Full range of affect EXTREMITIES: WWP, lymphedema and brawny erythema GU: erythematous scrotum, but much improved with less edema. R epididymis enlarged. No erythema or crepitus of perineum Pertinent Results: ADMISSION LABS -------------- ___ 10:40PM BLOOD WBC-10.5* RBC-3.80* Hgb-12.0* Hct-36.0* MCV-95 MCH-31.6 MCHC-33.3 RDW-14.7 RDWSD-51.3* Plt ___ ___ 10:40PM BLOOD Glucose-124* UreaN-14 Creat-0.9 Na-136 K-3.3 Cl-99 HCO3-24 AnGap-16 ___ 05:03PM BLOOD Type-ART pO2-64* pCO2-37 pH-7.46* calTCO2-27 Base XS-2 ___ 05:03PM BLOOD freeCa-1.15 MICROBIOLOGY ------------ ___ 1:20 am URINE URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). 10,000-100,000 CFU/mL. IMAGING ------- CXR ___ 1. Limited evaluation given beam underpenetration caused by significant softtissue attenuation. Despite this limitation, no evidence of pneumonia. 2. Apparent prominence of the left pulmonary artery may be related totechnique, or pulmonary hypertension. SCROTAL US ___ Right epididymitis with asymmetric, right greater than left scrotal swelling and hyperemia consistent with cellulitis. No evidence of subcutaneous emphysema. DISCHARGE LABS -------------- ___ 07:45AM BLOOD WBC-6.6 RBC-3.87* Hgb-12.3* Hct-36.2* MCV-94 MCH-31.8 MCHC-34.0 RDW-14.5 RDWSD-49.1* Plt ___ ___ 07:45AM BLOOD Glucose-107* UreaN-13 Creat-0.9 Na-143 K-3.8 Cl-104 HCO3-22 AnGap-21* Brief Hospital Course: ___ year old male with transverse myelitis, indwelling Foley catheter, BPH, who present for scrotal cellulitis. # Scrotal cellulitis # Epididymitis: presented with scrotal inflammation and tender right epididymis. He had a WBC count of 19K at the outside hospital, placed on IV vancomycin and ciprofloxacin, and WBC count improved with improvement on exam. There was no spreading of erythema, no perineal involvement and no crepitus noted. He will be on antibiotics, continuing with PO ciprofloxacin, for a total 10 day course. Urology saw the patient and recommended no specific intervention. Patient has a chronic Foley catheter. He will follow up with his PCP within ___ week of discharge. # Anxiety/depression: continue duloxetine 20 mg daily # Gout: continue allopurinol ___ mg daily # Hypertension: continue hydralazine 50 mg TID, doxazosin 8 mg, metoprolol 75 mg BID, amlodipine 10 mg daily # Hyperlipidemia: continue simvastatin 10 mg daily # BPH: Continue doxazosin 8 mg, Proscar 5 mg # Venous stasis: Continue triamcinolone 0.1% TRANSITIONS OF CARE ------------------- # Follow-up: patient will follow up with his PCP within ___ week of discharge. # Code status: full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. nystatin 100,000 unit/gram topical BID:PRN 3. Metoprolol Tartrate 75 mg PO BID 4. Simvastatin 10 mg PO QPM 5. DULoxetine 20 mg PO DAILY 6. HydrALAZINE 50 mg PO TID 7. Doxazosin 8 mg PO DAILY 8. amLODIPine 10 mg PO DAILY 9. Potassium Chloride 10 mEq PO DAILY 10. Finasteride 5 mg PO DAILY 11. Acetaminophen w/Codeine 1 TAB PO DAILY PRN (filled only twice in past year) 12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 13. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*16 Tablet Refills:*0 2. ___ ___ ea topical BID:PRN rash 3. Acetaminophen w/Codeine 1 TAB PO DAILY 4. Allopurinol ___ mg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Doxazosin 8 mg PO DAILY 7. DULoxetine 20 mg PO DAILY 8. Finasteride 5 mg PO DAILY 9. HydrALAZINE 50 mg PO TID 10. Metoprolol Tartrate 75 mg PO BID 11. Potassium Chloride 10 mEq PO DAILY 12. Simvastatin 10 mg PO QPM 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 14. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Scrotal cellulitis Epididymitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you during your recent admission to ___. You came for further evaluation of swelling of your scrotum. You were found to have cellulitis, a skin infection, of the scrotum, and epididymitis. You were initially treated with intravenous antibiotics, and eventually switched to oral antibiotics when you improved. You are now being discharged home. It is important that you continue to take all medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: ___
[ "N492", "G373", "N390", "Z6842", "N451", "E119", "I10", "E785", "K219", "F329", "F419", "M109", "N401", "N39498", "I739", "I878", "E6601" ]
Allergies: prednisone Chief Complaint: Scrotal cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ transverse myelitis, indwelling Foley (since [MASKED] for unclear reasons), BPH, who presented from home with scrotal erythema, fever, and hematuria in setting of Foley trauma approximately one week prior to admission. The patient states that his Foley was inadvertently partially pulled out a week ago and had to be replaced. He then developed hematuria, fever, scrotal erythema and pain. His [MASKED] sent him to the [MASKED] ED. [MASKED]. [MASKED] were reportedly concerned for possibility of [MASKED] gangrene and gave vancomycin, Zosyn and clindamycin. He had a CT abdomen and pelvis which reportedly showed scrotal cellulitis with no gas. WBC was [MASKED] at the OSH ED. He was transferred to the [MASKED] ED where vitals were: 98.8F, HR 82, BP 154/84, RR 20, 94% on 2L NC (baseline unknown). Scrotal ultrasound was performed (due to lack of availability of OSH CT images), which confirmed scrotal cellulitis and absence of gas. He was seen by urology who recommended admission for IV antibiotics, serial scrotal exams, and exchange of Foley catheter. UA showed WBCs too numerous to count with culture pending. He was given a second dose of Zosyn and admitted to medicine. ROS GEN: denies fevers/chills CARDIAC: denies chest pain or palpitations PULM: denies new dyspnea or cough GI: denies n/v, poor appetite, endorses constipation GU: as per HPI Full 14-system review of systems otherwise negative and non-contributory. Past Medical History: HTN HLD DM (on no meds for this) BPH Incontinence UTIs Lymphedema Morbid obesity Ventral hernia GERD Anxiety and depression PVD and venous stasis ulcers (has Unaboots) Gout Social History: [MASKED] Family History: Patient cannot tell me FH. Physical Exam: ADMISSION EXAM: GEN: obese M in NAD HEENT: EOMI, sclerae anicteric, MMM, OP clear NECK: No LAD, no JVD CARDIAC: RRR, no M/R/G PULM: normal effort, no accessory muscle use, LCAB GI: soft, NT, ND, NABS MSK: No visible joint effusions or deformities. NEURO: AAOx3. No facial droop, moving all extremities. PSYCH: Full range of affect EXTREMITIES: WWP, lymphedema and brawny erythema GU: erythematous scrotum. R epididymis enlarged. DISCHARGE EXAM: VS: 98.7PO 146/75 72 18 92% on RA GEN: obese male in NAD HEENT: EOMI, sclerae anicteric, MMM, OP clear NECK: No LAD, no JVD CARDIAC: RRR, no M/R/G PULM: normal effort, no accessory muscle use, LCAB GI: soft, NT, ND, NABS MSK: No visible joint effusions or deformities. NEURO: AAOx3. No facial droop, moving all extremities. PSYCH: Full range of affect EXTREMITIES: WWP, lymphedema and brawny erythema GU: erythematous scrotum, but much improved with less edema. R epididymis enlarged. No erythema or crepitus of perineum Pertinent Results: ADMISSION LABS -------------- [MASKED] 10:40PM BLOOD WBC-10.5* RBC-3.80* Hgb-12.0* Hct-36.0* MCV-95 MCH-31.6 MCHC-33.3 RDW-14.7 RDWSD-51.3* Plt [MASKED] [MASKED] 10:40PM BLOOD Glucose-124* UreaN-14 Creat-0.9 Na-136 K-3.3 Cl-99 HCO3-24 AnGap-16 [MASKED] 05:03PM BLOOD Type-ART pO2-64* pCO2-37 pH-7.46* calTCO2-27 Base XS-2 [MASKED] 05:03PM BLOOD freeCa-1.15 MICROBIOLOGY ------------ [MASKED] 1:20 am URINE URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). 10,000-100,000 CFU/mL. IMAGING ------- CXR [MASKED] 1. Limited evaluation given beam underpenetration caused by significant softtissue attenuation. Despite this limitation, no evidence of pneumonia. 2. Apparent prominence of the left pulmonary artery may be related totechnique, or pulmonary hypertension. SCROTAL US [MASKED] Right epididymitis with asymmetric, right greater than left scrotal swelling and hyperemia consistent with cellulitis. No evidence of subcutaneous emphysema. DISCHARGE LABS -------------- [MASKED] 07:45AM BLOOD WBC-6.6 RBC-3.87* Hgb-12.3* Hct-36.2* MCV-94 MCH-31.8 MCHC-34.0 RDW-14.5 RDWSD-49.1* Plt [MASKED] [MASKED] 07:45AM BLOOD Glucose-107* UreaN-13 Creat-0.9 Na-143 K-3.8 Cl-104 HCO3-22 AnGap-21* Brief Hospital Course: [MASKED] year old male with transverse myelitis, indwelling Foley catheter, BPH, who present for scrotal cellulitis. # Scrotal cellulitis # Epididymitis: presented with scrotal inflammation and tender right epididymis. He had a WBC count of 19K at the outside hospital, placed on IV vancomycin and ciprofloxacin, and WBC count improved with improvement on exam. There was no spreading of erythema, no perineal involvement and no crepitus noted. He will be on antibiotics, continuing with PO ciprofloxacin, for a total 10 day course. Urology saw the patient and recommended no specific intervention. Patient has a chronic Foley catheter. He will follow up with his PCP within [MASKED] week of discharge. # Anxiety/depression: continue duloxetine 20 mg daily # Gout: continue allopurinol [MASKED] mg daily # Hypertension: continue hydralazine 50 mg TID, doxazosin 8 mg, metoprolol 75 mg BID, amlodipine 10 mg daily # Hyperlipidemia: continue simvastatin 10 mg daily # BPH: Continue doxazosin 8 mg, Proscar 5 mg # Venous stasis: Continue triamcinolone 0.1% TRANSITIONS OF CARE ------------------- # Follow-up: patient will follow up with his PCP within [MASKED] week of discharge. # Code status: full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. nystatin 100,000 unit/gram topical BID:PRN 3. Metoprolol Tartrate 75 mg PO BID 4. Simvastatin 10 mg PO QPM 5. DULoxetine 20 mg PO DAILY 6. HydrALAZINE 50 mg PO TID 7. Doxazosin 8 mg PO DAILY 8. amLODIPine 10 mg PO DAILY 9. Potassium Chloride 10 mEq PO DAILY 10. Finasteride 5 mg PO DAILY 11. Acetaminophen w/Codeine 1 TAB PO DAILY PRN (filled only twice in past year) 12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 13. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*16 Tablet Refills:*0 2. [MASKED] [MASKED] ea topical BID:PRN rash 3. Acetaminophen w/Codeine 1 TAB PO DAILY 4. Allopurinol [MASKED] mg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Doxazosin 8 mg PO DAILY 7. DULoxetine 20 mg PO DAILY 8. Finasteride 5 mg PO DAILY 9. HydrALAZINE 50 mg PO TID 10. Metoprolol Tartrate 75 mg PO BID 11. Potassium Chloride 10 mEq PO DAILY 12. Simvastatin 10 mg PO QPM 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 14. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Scrotal cellulitis Epididymitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you during your recent admission to [MASKED]. You came for further evaluation of swelling of your scrotum. You were found to have cellulitis, a skin infection, of the scrotum, and epididymitis. You were initially treated with intravenous antibiotics, and eventually switched to oral antibiotics when you improved. You are now being discharged home. It is important that you continue to take all medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: [MASKED]
[]
[ "N390", "E119", "I10", "E785", "K219", "F329", "F419", "M109" ]
[ "N492: Inflammatory disorders of scrotum", "G373: Acute transverse myelitis in demyelinating disease of central nervous system", "N390: Urinary tract infection, site not specified", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "N451: Epididymitis", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "M109: Gout, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "N39498: Other specified urinary incontinence", "I739: Peripheral vascular disease, unspecified", "I878: Other specified disorders of veins", "E6601: Morbid (severe) obesity due to excess calories" ]
10,069,692
23,743,248
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ ___ woman with no past medical history, s/p right hip hemiarthroplasty on ___, who presents from home with diffuse weakness and bilateral leg swelling. The patient recently suffered a displaced right femoral neck fracture after an unwitnessed fall at home. With respect to the fall, the patient states that she was getting up to go the bathroom when she fell. She cannot recall all of the details about the fall but does not think she lost consciousness. Her daughter heard a thud from the other room, and found her on the floor, conscious. Prior to this fall, the patient lived independently in an apartment in ___ where she was able to walk 2 flights of stairs slowly without shortness of breath or chest pain. She recently moved in with her daughter due to ___ falls since ___, with plans to transition to a nursing facility. She ambulates with a cane but is partially blind in one eye which is thought to contribute to her recent falls. The patient was taken to the OR for right hip hemiarthroplasty, with a post op course complicated by ___ which resolved with hydration PO and IVF. The patient worked with ___ who determined that discharge to rehab was appropriate. She as discharged on Tylenol and oxycodone for pain, a bowel regimen, and SQ heparin. The patient did well at rehab initially, improving in her ambulation and mental status, however she acutely worsened on ___ and ___, becoming increasingly weak and fatigued. She denies focal symptoms, including cough, chest pain, dizziness, lightheadedness, palpitations, n/v/d or urinary symptoms, although her son reports that she did have some episodes of coughing while eating. Past Medical History: None Social History: ___ Family History: Non-contributory Physical Exam: Admission Exam: =============== GENERAL: Cachectic appearing elderly woman. Lying comfortably, flat in bed. No acute distress. HEENT: Healing lesion on the scalp on the left side. Pupils equal, round, and reactive bilaterally, EOMI. NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. Two distinct systolic murmurs: ___ early peaking crescendo-decrescendo murmur hear best at right upper sternal border, radiating to carotids. ___ holosystolic murmur hear best at the apex. LUNGS: Mild inspiratory crackles bibasilarly, otherwise clear without wheezes. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: Warm, well-perfused. No cyanosis, clubbing or edema. Incision on R hip is healing well with staples in place. No sign of erythema, edema, pus or ulceration. No hematoma or creptus. NEUROLOGIC: AAOx1-2 (oriented to self, disoriented to place and date). CN II-XII intact. No signs of focal deficits. ___ strength in ___ and ___. Discharge Exam: ============== Patient expired on ___ See death note dated ___ Pertinent Results: Admission Labs: ============== ___ 03:13PM BLOOD WBC-11.1* RBC-2.09* Hgb-7.2* Hct-21.5* MCV-103* MCH-34.4* MCHC-33.5 RDW-20.0* RDWSD-73.4* Plt ___ ___ 03:13PM BLOOD Neuts-87.0* Lymphs-8.0* Monos-4.1* Eos-0.3* Baso-0.1 Im ___ AbsNeut-9.66* AbsLymp-0.89* AbsMono-0.46 AbsEos-0.03* AbsBaso-0.01 ___ 01:07AM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-2+* Polychr-NORMAL Schisto-OCCASIONAL ___ 10:30AM BLOOD ___ ___ 01:07AM BLOOD Ret Aut-7.5* Abs Ret-0.13* ___ 03:13PM BLOOD Glucose-103* UreaN-23* Creat-0.9 Na-130* K-5.6* Cl-91* HCO3-23 AnGap-16 ___ 08:00AM BLOOD ALT-13 AST-18 AlkPhos-103 TotBili-2.4* DirBili-0.5* IndBili-1.9 ___ 03:13PM BLOOD CK-MB-2 cTropnT-0.06* proBNP-2893* ___ 03:25PM BLOOD Calcium-8.0* Phos-4.2 Mg-2.0 ___ 01:07AM BLOOD calTIBC-155* VitB12-680 Folate-9 ___ Ferritn-677* TRF-119* ___ 06:50AM BLOOD %HbA1c-4.5 eAG-82 ___ 05:35PM BLOOD Lactate-1.2 Cardiac Biomarkers: =================== ___ 03:13PM BLOOD CK-MB-2 cTropnT-0.06* proBNP-2893* ___ 01:07AM BLOOD CK-MB-4 cTropnT-0.08* ___ 08:00AM BLOOD CK-MB-5 cTropnT-0.14* ___ 01:00PM BLOOD CK-MB-7 cTropnT-0.19* ___ 03:25PM BLOOD CK-MB-7 cTropnT-0.22* ___ 06:10AM BLOOD CK-MB-4 cTropnT-0.16* Microbiology: ============= ___ 4:55 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 5:10 pm BLOOD CULTURE Blood Culture, Routine (Pending ___ 12:24 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. Imagining: ========== CXR ___ IMPRESSION: Multifocal patchy ill-defined opacities in the right midlung field and in both lung bases concerning for multifocal pneumonia. Small bilateral pleural effusion and mild pulmonary vascular congestion. CT Abdomen/Pelvis ___ IMPRESSION: 1. Bilateral small nonhemorrhagic pleural effusions, left greater than right with subjacent atelectasis. Additionally, there are ground-glass opacities in the left lower lobe, which could reflect aspiration or pneumonia. 2. Moderate volume ascites is nonspecific, but in combination with anasarca and pleural effusion could be related to volume overload. 3. Status post total right hip arthroplasty with expected postsurgical changes. 4. Compression deformity of the L4 vertebral body is likely chronic, although exact age is indeterminate as there is no prior lumbar spine imaging CT Head without contrast ___: IMPRESSION: No definite acute intracranial abnormality. Scattered subcortical and periventricular white matter hypodensities which are likely sequela of chronic small vessel disease, however there is one new area of hypodensity in the right frontal lobe near the vertex which could represent interval infarct since ___. MRI may offer additional detail regarding chronicity of this finding. ECHO ___: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal for the patient's body size. Overall left ventricular systolic function is normal (LVEF = 70%). The right ventricular free wall is hypertrophied. with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The diameters of aorta at the sinus, ascending and arch levels are normal. There are complex (>4mm) atheroma in the aortic root. There are complex (>4mm) atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The mitral valve leaflets are moderately thickened. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are moderately thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. MRI Head w/out contrast ___: IMPRESSION: 1. Linear band of early subacute infarcts right frontal lobe, in watershed distribution. 2. Advanced brain parenchymal atrophy CTA Chest ___: IMPRESSION: -No evidence of pulmonary embolism. -Scattered peribronchial ground-glass opacities in the bilateral upper lobes compatible with pneumonia. -Small bilateral layering pleural effusions, left greater than right. -Extensive atherosclerotic calcifications involving coronaries as well as the normal caliber thoracic aorta. -15 mm right lobe thyroid nodule. This can be further evaluated via thyroid ultrasound if clinically indicated. -Right heart failure with mainly right atrial enlargement with reflux of contrast into the hepatic veins. Brief Hospital Course: Ms. ___ is a ___ ___ woman with recent right hip hemiarthroplasty in the setting of a traumatic fall (displaced R femoral neck fracture) on ___, who presented with diffuse weakness and altered mental status found to have pneumonia NSTEMI with right heart strain on ECHO as well as recent watershed infarct on MRI. Prior to discharge she had acute hypotension and hemoptysis. Patient was briefly on oxygen therapy and peripheral pressers. The family was notified and declined MICU transfer/ The patient was made CMO and expired on ___ #Anemia: The patient presented with anemia with initial hemoglobin to 7.2 from 9.5 on ___. A CT Abd and pelvis with contrast was performed for concern of intraabdominal bleed which was negative. She did not have dark stools or other evidence of a GI bleed prior to admission or during hospitalization. Iron studies were consistent with anemia of acute inflammation. Folic acid, B12 normal. Haptoglobin normal. Patient received PRBC X2. Her last PRBC was on ___, and blood counts remained stable following this.Prior to discharge she had acute hypotension and hemoptysis. Patient was briefly on oxygen therapy and peripheral pressers. The family was notified and declined MICU transfer/ The patient was made CMO and expired on ___ #NSTEMI II secondary to right heart strain. #Concern for PE #Pulmonary Hypertension #Right heart Strain On admission, the patient was found to have troponin of 0.06 with CK-MB of 2. She has no known cardiac history. EKG showed no signs of ischemic changes and no changes from baseline. The patient did not complain of chest pain. Troponin and CKMB continued to rise, ultimately peaking at 0.22. Repeated EKGs were without change. Cardiology was consulted, and the patient was started on aspirin, statin, and heparin drip. ECHO showed mild MR, AS, and no wall motion abnormality were noted to suggest acute ischemia. ECHO did show significant right heart strain, and pulmonary hypertension. CTA showed no evidence of PE. VQ scan was considered however given the abnormal CXR early in the admission, diagnostic yield was felt to be low. RHC to further elucidate etiology of right heart strain was considered and discussed with health care proxy however was deferred as invasive procedure are not within her goals of care. She remained hemodynamialy stable during her hospitalization. She was discharged on aspirin and statin. She was not continued on therapeutic anticoagulation given no findings of PE. # R frontal lobe stroke Patient admitted with increased lethargy and confusion. A CT head was done, and showed a possible new ischemic stroke since ___. An MRI head was done to further characterize the lesion, and was concerning for a linear band of early subacute infarcts right frontal lobe in a watershed distribution. The patient has no focal neurological findings. Patient was without known acute hypotensive event to explain MRI finding. Neurology was consulted and initially recommended further imaging including CTA head and neck vs carotid ultrasound to workup potential vascular lesion to explain watershed stroke. This was discussed with ___ the patient's son and healthcare proxy. Since surgery and invasive procedures are not within the patients goals, further imaging was deferred given that it would not change management. Patient will continue medical management of stroke with aspirin and atorvastatin. #Pneumonia: #Leukocytosis The patient presented with mild leukocytosis, cough and some history of possible aspiration with CXR concerning for multifocal pneumonia. CT chest preformed to evaluated for PE showed some ground glass opacity in upper lung field bilaterally. She was started on ceftriaxone and azithromycin to cover for pneumonia. During the hospitalization, she remained afebrile and continued to sat well on room air. "\." #Hyponatremia: Patient was noted to have hyponatemia to 130 on admission. Hyponatremia improved to 134 on discharge after patient improved PO intake. Hyponatremia likely in setting of decreased PO intake on days prior to presentation. #Hypertension: Patient with known history of hypertension. SBP 130's-150's while in house, and was not started on new medications. #S/p right hip hemiarthroplasty on ___: Patient was seen by ortho in ED with no changes in management. She continued on heparin SQ for DVT prophylaxis and Tylenol for pain. Patient was discharged on subQ heparin. She will have follow-up with her orthopedic surgeon on ___ ==================== Transitional Issues: ==================== Patient Expired ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D 400 UNIT PO DAILY 2. Acetaminophen 650 mg PO 5X/DAY 3. Docusate Sodium 100 mg PO BID 4. Heparin 5000 UNIT SC BID 5. Multivitamins 1 TAB PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Acetaminophen 650 mg PO 5X/DAY 4. Docusate Sodium 100 mg PO BID 5. Heparin 5000 UNIT SC BID 6. Multivitamins 1 TAB PO DAILY 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 8.6 mg PO BID 9. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Expired Facility: ___ Discharge Diagnosis: Primary Diagnosis: ================== Right frontal lobe CVA NSTEMI II Right Heart Strain Pneumonia Secondary Diagnosis: ==================== Hypertension left hip fracture. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? - Because you were feeling weak What did you receive in the hospital? - We were worried that you were having a small heart attack. We closely monitored your heart and worked with the heart doctors. - We did scans of your head and found that you had a stroke. The neurology team (brain doctors) saw you. We put you on medications to reduce your risk of stroke in the future. - We gave you antibiotics to treat an infection in your lungs. What should you do once you leave the hospital? - Please keep all of your appointments and take your medications as prescribed We wish you the best! Your ___ Care Team Followup Instructions: ___
[ "I21A1", "J189", "I2609", "E43", "I638", "I50811", "I2782", "E871", "I5082", "F05", "R042", "R404", "I951", "Z96641", "Z66", "Z515", "Z9181", "H5461", "D6489", "I081", "E861", "Z6820" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms [MASKED] is a [MASKED] [MASKED] woman with no past medical history, s/p right hip hemiarthroplasty on [MASKED], who presents from home with diffuse weakness and bilateral leg swelling. The patient recently suffered a displaced right femoral neck fracture after an unwitnessed fall at home. With respect to the fall, the patient states that she was getting up to go the bathroom when she fell. She cannot recall all of the details about the fall but does not think she lost consciousness. Her daughter heard a thud from the other room, and found her on the floor, conscious. Prior to this fall, the patient lived independently in an apartment in [MASKED] where she was able to walk 2 flights of stairs slowly without shortness of breath or chest pain. She recently moved in with her daughter due to [MASKED] falls since [MASKED], with plans to transition to a nursing facility. She ambulates with a cane but is partially blind in one eye which is thought to contribute to her recent falls. The patient was taken to the OR for right hip hemiarthroplasty, with a post op course complicated by [MASKED] which resolved with hydration PO and IVF. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. She as discharged on Tylenol and oxycodone for pain, a bowel regimen, and SQ heparin. The patient did well at rehab initially, improving in her ambulation and mental status, however she acutely worsened on [MASKED] and [MASKED], becoming increasingly weak and fatigued. She denies focal symptoms, including cough, chest pain, dizziness, lightheadedness, palpitations, n/v/d or urinary symptoms, although her son reports that she did have some episodes of coughing while eating. Past Medical History: None Social History: [MASKED] Family History: Non-contributory Physical Exam: Admission Exam: =============== GENERAL: Cachectic appearing elderly woman. Lying comfortably, flat in bed. No acute distress. HEENT: Healing lesion on the scalp on the left side. Pupils equal, round, and reactive bilaterally, EOMI. NECK: No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. Two distinct systolic murmurs: [MASKED] early peaking crescendo-decrescendo murmur hear best at right upper sternal border, radiating to carotids. [MASKED] holosystolic murmur hear best at the apex. LUNGS: Mild inspiratory crackles bibasilarly, otherwise clear without wheezes. ABDOMEN: Soft, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: Warm, well-perfused. No cyanosis, clubbing or edema. Incision on R hip is healing well with staples in place. No sign of erythema, edema, pus or ulceration. No hematoma or creptus. NEUROLOGIC: AAOx1-2 (oriented to self, disoriented to place and date). CN II-XII intact. No signs of focal deficits. [MASKED] strength in [MASKED] and [MASKED]. Discharge Exam: ============== Patient expired on [MASKED] See death note dated [MASKED] Pertinent Results: Admission Labs: ============== [MASKED] 03:13PM BLOOD WBC-11.1* RBC-2.09* Hgb-7.2* Hct-21.5* MCV-103* MCH-34.4* MCHC-33.5 RDW-20.0* RDWSD-73.4* Plt [MASKED] [MASKED] 03:13PM BLOOD Neuts-87.0* Lymphs-8.0* Monos-4.1* Eos-0.3* Baso-0.1 Im [MASKED] AbsNeut-9.66* AbsLymp-0.89* AbsMono-0.46 AbsEos-0.03* AbsBaso-0.01 [MASKED] 01:07AM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-2+* Polychr-NORMAL Schisto-OCCASIONAL [MASKED] 10:30AM BLOOD [MASKED] [MASKED] 01:07AM BLOOD Ret Aut-7.5* Abs Ret-0.13* [MASKED] 03:13PM BLOOD Glucose-103* UreaN-23* Creat-0.9 Na-130* K-5.6* Cl-91* HCO3-23 AnGap-16 [MASKED] 08:00AM BLOOD ALT-13 AST-18 AlkPhos-103 TotBili-2.4* DirBili-0.5* IndBili-1.9 [MASKED] 03:13PM BLOOD CK-MB-2 cTropnT-0.06* proBNP-2893* [MASKED] 03:25PM BLOOD Calcium-8.0* Phos-4.2 Mg-2.0 [MASKED] 01:07AM BLOOD calTIBC-155* VitB12-680 Folate-9 [MASKED] Ferritn-677* TRF-119* [MASKED] 06:50AM BLOOD %HbA1c-4.5 eAG-82 [MASKED] 05:35PM BLOOD Lactate-1.2 Cardiac Biomarkers: =================== [MASKED] 03:13PM BLOOD CK-MB-2 cTropnT-0.06* proBNP-2893* [MASKED] 01:07AM BLOOD CK-MB-4 cTropnT-0.08* [MASKED] 08:00AM BLOOD CK-MB-5 cTropnT-0.14* [MASKED] 01:00PM BLOOD CK-MB-7 cTropnT-0.19* [MASKED] 03:25PM BLOOD CK-MB-7 cTropnT-0.22* [MASKED] 06:10AM BLOOD CK-MB-4 cTropnT-0.16* Microbiology: ============= [MASKED] 4:55 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 5:10 pm BLOOD CULTURE Blood Culture, Routine (Pending [MASKED] 12:24 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. Imagining: ========== CXR [MASKED] IMPRESSION: Multifocal patchy ill-defined opacities in the right midlung field and in both lung bases concerning for multifocal pneumonia. Small bilateral pleural effusion and mild pulmonary vascular congestion. CT Abdomen/Pelvis [MASKED] IMPRESSION: 1. Bilateral small nonhemorrhagic pleural effusions, left greater than right with subjacent atelectasis. Additionally, there are ground-glass opacities in the left lower lobe, which could reflect aspiration or pneumonia. 2. Moderate volume ascites is nonspecific, but in combination with anasarca and pleural effusion could be related to volume overload. 3. Status post total right hip arthroplasty with expected postsurgical changes. 4. Compression deformity of the L4 vertebral body is likely chronic, although exact age is indeterminate as there is no prior lumbar spine imaging CT Head without contrast [MASKED]: IMPRESSION: No definite acute intracranial abnormality. Scattered subcortical and periventricular white matter hypodensities which are likely sequela of chronic small vessel disease, however there is one new area of hypodensity in the right frontal lobe near the vertex which could represent interval infarct since [MASKED]. MRI may offer additional detail regarding chronicity of this finding. ECHO [MASKED]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal for the patient's body size. Overall left ventricular systolic function is normal (LVEF = 70%). The right ventricular free wall is hypertrophied. with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The diameters of aorta at the sinus, ascending and arch levels are normal. There are complex (>4mm) atheroma in the aortic root. There are complex (>4mm) atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The mitral valve leaflets are moderately thickened. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are moderately thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. MRI Head w/out contrast [MASKED]: IMPRESSION: 1. Linear band of early subacute infarcts right frontal lobe, in watershed distribution. 2. Advanced brain parenchymal atrophy CTA Chest [MASKED]: IMPRESSION: -No evidence of pulmonary embolism. -Scattered peribronchial ground-glass opacities in the bilateral upper lobes compatible with pneumonia. -Small bilateral layering pleural effusions, left greater than right. -Extensive atherosclerotic calcifications involving coronaries as well as the normal caliber thoracic aorta. -15 mm right lobe thyroid nodule. This can be further evaluated via thyroid ultrasound if clinically indicated. -Right heart failure with mainly right atrial enlargement with reflux of contrast into the hepatic veins. Brief Hospital Course: Ms. [MASKED] is a [MASKED] [MASKED] woman with recent right hip hemiarthroplasty in the setting of a traumatic fall (displaced R femoral neck fracture) on [MASKED], who presented with diffuse weakness and altered mental status found to have pneumonia NSTEMI with right heart strain on ECHO as well as recent watershed infarct on MRI. Prior to discharge she had acute hypotension and hemoptysis. Patient was briefly on oxygen therapy and peripheral pressers. The family was notified and declined MICU transfer/ The patient was made CMO and expired on [MASKED] #Anemia: The patient presented with anemia with initial hemoglobin to 7.2 from 9.5 on [MASKED]. A CT Abd and pelvis with contrast was performed for concern of intraabdominal bleed which was negative. She did not have dark stools or other evidence of a GI bleed prior to admission or during hospitalization. Iron studies were consistent with anemia of acute inflammation. Folic acid, B12 normal. Haptoglobin normal. Patient received PRBC X2. Her last PRBC was on [MASKED], and blood counts remained stable following this.Prior to discharge she had acute hypotension and hemoptysis. Patient was briefly on oxygen therapy and peripheral pressers. The family was notified and declined MICU transfer/ The patient was made CMO and expired on [MASKED] #NSTEMI II secondary to right heart strain. #Concern for PE #Pulmonary Hypertension #Right heart Strain On admission, the patient was found to have troponin of 0.06 with CK-MB of 2. She has no known cardiac history. EKG showed no signs of ischemic changes and no changes from baseline. The patient did not complain of chest pain. Troponin and CKMB continued to rise, ultimately peaking at 0.22. Repeated EKGs were without change. Cardiology was consulted, and the patient was started on aspirin, statin, and heparin drip. ECHO showed mild MR, AS, and no wall motion abnormality were noted to suggest acute ischemia. ECHO did show significant right heart strain, and pulmonary hypertension. CTA showed no evidence of PE. VQ scan was considered however given the abnormal CXR early in the admission, diagnostic yield was felt to be low. RHC to further elucidate etiology of right heart strain was considered and discussed with health care proxy however was deferred as invasive procedure are not within her goals of care. She remained hemodynamialy stable during her hospitalization. She was discharged on aspirin and statin. She was not continued on therapeutic anticoagulation given no findings of PE. # R frontal lobe stroke Patient admitted with increased lethargy and confusion. A CT head was done, and showed a possible new ischemic stroke since [MASKED]. An MRI head was done to further characterize the lesion, and was concerning for a linear band of early subacute infarcts right frontal lobe in a watershed distribution. The patient has no focal neurological findings. Patient was without known acute hypotensive event to explain MRI finding. Neurology was consulted and initially recommended further imaging including CTA head and neck vs carotid ultrasound to workup potential vascular lesion to explain watershed stroke. This was discussed with [MASKED] the patient's son and healthcare proxy. Since surgery and invasive procedures are not within the patients goals, further imaging was deferred given that it would not change management. Patient will continue medical management of stroke with aspirin and atorvastatin. #Pneumonia: #Leukocytosis The patient presented with mild leukocytosis, cough and some history of possible aspiration with CXR concerning for multifocal pneumonia. CT chest preformed to evaluated for PE showed some ground glass opacity in upper lung field bilaterally. She was started on ceftriaxone and azithromycin to cover for pneumonia. During the hospitalization, she remained afebrile and continued to sat well on room air. "\." #Hyponatremia: Patient was noted to have hyponatemia to 130 on admission. Hyponatremia improved to 134 on discharge after patient improved PO intake. Hyponatremia likely in setting of decreased PO intake on days prior to presentation. #Hypertension: Patient with known history of hypertension. SBP 130's-150's while in house, and was not started on new medications. #S/p right hip hemiarthroplasty on [MASKED]: Patient was seen by ortho in ED with no changes in management. She continued on heparin SQ for DVT prophylaxis and Tylenol for pain. Patient was discharged on subQ heparin. She will have follow-up with her orthopedic surgeon on [MASKED] ==================== Transitional Issues: ==================== Patient Expired [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D 400 UNIT PO DAILY 2. Acetaminophen 650 mg PO 5X/DAY 3. Docusate Sodium 100 mg PO BID 4. Heparin 5000 UNIT SC BID 5. Multivitamins 1 TAB PO DAILY 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Acetaminophen 650 mg PO 5X/DAY 4. Docusate Sodium 100 mg PO BID 5. Heparin 5000 UNIT SC BID 6. Multivitamins 1 TAB PO DAILY 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 8.6 mg PO BID 9. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Expired Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: ================== Right frontal lobe CVA NSTEMI II Right Heart Strain Pneumonia Secondary Diagnosis: ==================== Hypertension left hip fracture. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure to care for you at the [MASKED] [MASKED]. Why did you come to the hospital? - Because you were feeling weak What did you receive in the hospital? - We were worried that you were having a small heart attack. We closely monitored your heart and worked with the heart doctors. - We did scans of your head and found that you had a stroke. The neurology team (brain doctors) saw you. We put you on medications to reduce your risk of stroke in the future. - We gave you antibiotics to treat an infection in your lungs. What should you do once you leave the hospital? - Please keep all of your appointments and take your medications as prescribed We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "E871", "Z66", "Z515" ]
[ "I21A1: Myocardial infarction type 2", "J189: Pneumonia, unspecified organism", "I2609: Other pulmonary embolism with acute cor pulmonale", "E43: Unspecified severe protein-calorie malnutrition", "I638: Other cerebral infarction", "I50811: Acute right heart failure", "I2782: Chronic pulmonary embolism", "E871: Hypo-osmolality and hyponatremia", "I5082: Biventricular heart failure", "F05: Delirium due to known physiological condition", "R042: Hemoptysis", "R404: Transient alteration of awareness", "I951: Orthostatic hypotension", "Z96641: Presence of right artificial hip joint", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z9181: History of falling", "H5461: Unqualified visual loss, right eye, normal vision left eye", "D6489: Other specified anemias", "I081: Rheumatic disorders of both mitral and tricuspid valves", "E861: Hypovolemia", "Z6820: Body mass index [BMI] 20.0-20.9, adult" ]
10,069,692
25,846,597
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right Hip Pain Major Surgical or Invasive Procedure: R hip hemiarthroplasty ___, ___. History of Present Illness: ___ with no significant PMH p/w displaced right femoral neck fracture after an unwitnessed mechanical fall at home. The patient is ___ speaking and the history was obtained from her daughter. The patient states that she was getting up to go the bathroom this morning around 6 AM when she fell. She cannot recall all of the details about the fall but does not think she lost consciousness. Her daughter heard a thud from the other room, and found her on the floor, conscious. Patient denies HS/LOC. CT head/Cspine negative in ___ ED. Isolated injury. The patient lived independently in an apartment in ___ until 2 weeks ago. She can walk 2 flights of stairs slowly without shortness of breath according to the patient and her daughter. She recently moved in with her daughter due to frequent falls with plans to move to an assisted living facility on ___. According to her daughter she has fallen between 6 and 8 times since ___. She has seen her PCP for this problem, most recently 1 week ago. She is partially blind in the right eye which is believed to contribute to her falls. She ambulates with a cane at baseline. No medications on a daily basis. Past Medical History: None Social History: ___ Family History: NC Physical Exam: On admission General: Well-appearing female in no acute distress. C-spine: No midline tenderness to palpation Able to rotate head 45 degrees left and right Right lower extremity: - skin intact, leg ___ - No deformity, edema, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM at hip, knee, and ankle - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP On discharge General: Frail-appearing, breathing comfortably CV: Pink and well perfused Abd: Soft, non-tender, and non-distended Lower Extremity: Skin clean & intact; dressing c/d/i No deformity or ecchymosis Unable to examine due to non-cooperation due to dementia Toes warm & well perfused Pertinent Results: ___ 05:05AM BLOOD WBC-6.4 RBC-2.28* Hgb-7.4* Hct-22.8* MCV-100* MCH-32.5* MCHC-32.5 RDW-14.6 RDWSD-52.9* Plt ___ ___ 05:05AM BLOOD Glucose-112* UreaN-37* Creat-1.2* Na-140 K-4.2 Cl-106 HCO3-23 AnGap-11 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right hip 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. On POD1, the patient was found to have a bump in her Creatinine. This resolved with improved hydration via increased PO intake and IV fluids. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID RX *heparin (porcine) 5,000 unit/mL 5000 units SQ twice a day Disp #*56 Vial Refills:*0 4. Multivitamins 1 TAB PO DAILY 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 2.5-5 mg by mouth every four (4) hours PRN Disp #*15 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID 8. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right femoral neck fracture Discharge Condition: Mental Status: Alert but demented at baseline. Level of Consciousness: Minimally 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; Range of motion as tolerated 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 subcutaneous heparin daily for 4 weeks WOUND CARE: - You may shower. Please keep the wound clean and dry. 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 cover the incision with a dry dressing and change it daily. If there is no drainage from the wound, you can leave the incision open to the iar. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB Physical Therapy: Activity: Activity: Activity as tolerated Right lower extremity: Full weight bearing; range of motion as tolerated Encourage turn, cough and deep breathe q2h when awake; Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Call your surgeon's office with any questions. Followup Instructions: ___
[ "S72031A", "F0391", "D62", "W010XXA", "Z9181", "Y92013", "Z781", "R339", "H5440", "R944", "R911", "E042" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right Hip Pain Major Surgical or Invasive Procedure: R hip hemiarthroplasty [MASKED], [MASKED]. History of Present Illness: [MASKED] with no significant PMH p/w displaced right femoral neck fracture after an unwitnessed mechanical fall at home. The patient is [MASKED] speaking and the history was obtained from her daughter. The patient states that she was getting up to go the bathroom this morning around 6 AM when she fell. She cannot recall all of the details about the fall but does not think she lost consciousness. Her daughter heard a thud from the other room, and found her on the floor, conscious. Patient denies HS/LOC. CT head/Cspine negative in [MASKED] ED. Isolated injury. The patient lived independently in an apartment in [MASKED] until 2 weeks ago. She can walk 2 flights of stairs slowly without shortness of breath according to the patient and her daughter. She recently moved in with her daughter due to frequent falls with plans to move to an assisted living facility on [MASKED]. According to her daughter she has fallen between 6 and 8 times since [MASKED]. She has seen her PCP for this problem, most recently 1 week ago. She is partially blind in the right eye which is believed to contribute to her falls. She ambulates with a cane at baseline. No medications on a daily basis. Past Medical History: None Social History: [MASKED] Family History: NC Physical Exam: On admission General: Well-appearing female in no acute distress. C-spine: No midline tenderness to palpation Able to rotate head 45 degrees left and right Right lower extremity: - skin intact, leg [MASKED] - No deformity, edema, ecchymosis, erythema, induration - Soft, non-tender thigh and leg - Full, painless ROM at hip, knee, and ankle - Fires [MASKED] - SILT S/S/SP/DP/T distributions - 1+ [MASKED] pulses, WWP On discharge General: Frail-appearing, breathing comfortably CV: Pink and well perfused Abd: Soft, non-tender, and non-distended Lower Extremity: Skin clean & intact; dressing c/d/i No deformity or ecchymosis Unable to examine due to non-cooperation due to dementia Toes warm & well perfused Pertinent Results: [MASKED] 05:05AM BLOOD WBC-6.4 RBC-2.28* Hgb-7.4* Hct-22.8* MCV-100* MCH-32.5* MCHC-32.5 RDW-14.6 RDWSD-52.9* Plt [MASKED] [MASKED] 05:05AM BLOOD Glucose-112* UreaN-37* Creat-1.2* Na-140 K-4.2 Cl-106 HCO3-23 AnGap-11 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for right hip 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. On POD1, the patient was found to have a bump in her Creatinine. This resolved with improved hydration via increased PO intake and IV fluids. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D Dose is Unknown PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO 5X/DAY 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID RX *heparin (porcine) 5,000 unit/mL 5000 units SQ twice a day Disp #*56 Vial Refills:*0 4. Multivitamins 1 TAB PO DAILY 5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg 2.5-5 mg by mouth every four (4) hours PRN Disp #*15 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 8.6 mg PO BID 8. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Right femoral neck fracture Discharge Condition: Mental Status: Alert but demented at baseline. Level of Consciousness: Minimally 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; Range of motion as tolerated 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 subcutaneous heparin daily for 4 weeks WOUND CARE: - You may shower. Please keep the wound clean and dry. 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 cover the incision with a dry dressing and change it daily. If there is no drainage from the wound, you can leave the incision open to the iar. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB Physical Therapy: Activity: Activity: Activity as tolerated Right lower extremity: Full weight bearing; range of motion as tolerated Encourage turn, cough and deep breathe q2h when awake; Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Call your surgeon's office with any questions. Followup Instructions: [MASKED]
[]
[ "D62" ]
[ "S72031A: Displaced midcervical fracture of right femur, initial encounter for closed fracture", "F0391: Unspecified dementia with behavioral disturbance", "D62: Acute posthemorrhagic anemia", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Z9181: History of falling", "Y92013: Bedroom of single-family (private) house as the place of occurrence of the external cause", "Z781: Physical restraint status", "R339: Retention of urine, unspecified", "H5440: Blindness, one eye, unspecified eye", "R944: Abnormal results of kidney function studies", "R911: Solitary pulmonary nodule", "E042: Nontoxic multinodular goiter" ]
10,069,780
22,777,795
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: asymptomatic high grade stenosis Major Surgical or Invasive Procedure: right carotid endarterectomy History of Present Illness: Mr. ___ is a ___ female smoker who was found to have a high-grade stenosis of the right internal carotid artery. She denies any history of amaurosis fugax, TIAs or stroke-like symptoms. She had a carotid duplex back in ___, which had demonstrated moderate stenosis of the right carotid artery, which has now progressed to 90% stenosis on repeat duplex. Past Medical History: R Carotid stenosis, HTN, Dyslipidemia, obesity, former PPD smoker-quit last month. Social History: ___ Family History: unknown Physical Exam: Vitals: Temp: 98.3 BP: 124/85, HR: 53 RR: 17 sat: 94% CV: S1S2 WOUND: clean, dry, had skin oozing on lower aspect of incision(this was cauterized with silver nitrate) ABD: soft, NT EXTREMITIES: no edema CN II-XII intact b/l Pertinent Results: ___ 04:47AM BLOOD WBC-14.4* RBC-3.95 Hgb-12.7 Hct-38.2 MCV-97 MCH-32.2* MCHC-33.2 RDW-12.9 RDWSD-46.5* Plt ___ ___ 04:47AM BLOOD Glucose-116* UreaN-16 Creat-0.7 Na-145 K-4.2 Cl-108 HCO3-25 AnGap-12 ___ 04:47AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8 Brief Hospital Course: Mr. ___ is a ___ female smoker who was found to have a high-grade stenosis of the right internal carotid artery. She denies any history of amaurosis fugax, TIAs or stroke-like symptoms. She had a carotid duplex back in ___, which had demonstrated moderate stenosis of the right carotid artery, which has now progressed to 90% stenosis on repeat duplex. The risks and benefits of an elective carotid endarterectomy for stroke prevention were discussed with the patient and she elected to procedure with surgical intervention. She underwent a right carotid endarterectomy with bovine patch angioplasty on ___. She tolerated the procedure well. Her post op course was uneventful. Her ___ hospital meds were resumed. She tolerated regular diet and ambulated with out any difficulty. She is discharged with ___ follow up for Blood pressure check on Post op day #2 and Post op day #4. She will see Dr ___ in 1 month with a repeat duplex. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Hydrochlorothiazide 25 mg PO DAILY 7. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right carotid stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms ___, It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after a carotid endarterectomy. This surgery was done to restore proper blood flow to your brain. To perform this procedure, an incision was made in your neck. 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. Carotid Endarterectomy Patient Discharge Instructions WHAT TO EXPECT: Bruising, tenderness, mild swelling, numbness and/or a firm ridge at the incision site is normal. This will improve gradually in the next 2 weeks. You may have a sore throat and or mild hoarseness. Warm tea, throat lozenges, or cool drinks usually help. It is normal to feel tired for ___ weeks after your surgery. MEDICATION INSTRUCTIONS: 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! It is very important that you take Aspirin every day! You should never stop this medication before checking with your surgeon You should take Tylenol ___ every 6 hours, as needed for neck pain. If this is not enough, take your prescription pain medication. You should require less pain medication each day. Do not take more than a daily total of 3000mg of Tylenol. Tylenol is used as an ingredient in some other over-the-counter and prescription medications. Be aware of how much Tylenol you are taking in a day. Narcotic pain medication can be very constipating. If you take narcotics, please also take a stool softener such as Colace. If constipation becomes a problem, your pharmacist can suggest an additional over the counter laxative. CARE OF YOUR NECK INCISION: You may shower 48 hours after your procedure. Avoid direct shower spray to the incision. Let soapy water run over the incision, then rinse and gently pat the area dry. Do not scrub the incision. Your neck incision may be left open to air and uncovered unless you have a small amount of drainage at the site. If drainage is present, place a small sterile gauze over the incision and change the gauze daily. Do not take a bath or go swimming for 2 weeks. ACTIVITY: Do not drive for one week after your procedure. Do not ever drive after taking narcotic pain medication. You should not push, pull, lift or carry anything heavier than 5 pounds for the next 2 weeks. After 2 weeks, you may return to your regular activities including exercise, sexual activitiy and work. DIET: It is normal to have a decreased appetite. Your appetite will return over time. Follow a well-balanced, heart healthy diet, with moderate restriction of salt and fat. SMOKING: If you smoke, it is very important for you to stop. Research has shown that smoking makes vascular disease worse. Talk to your primary care physician about ways to quit smoking. The ___ Smokers' Helpline is a FREE and confidential way to get support and information to help you quit smoking. Call ___ CALLING FOR HELP If you need help, please call us at ___. Remember your doctor, or someone covering for your doctor is available 24 hours a day, 7 days a week. If you call during non-business hours, you will reach someone who can help you reach the vascular surgeon on call. Followup Instructions: ___
[ "I6521", "I10", "E785", "E669", "Z6835", "F17210" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: asymptomatic high grade stenosis Major Surgical or Invasive Procedure: right carotid endarterectomy History of Present Illness: Mr. [MASKED] is a [MASKED] female smoker who was found to have a high-grade stenosis of the right internal carotid artery. She denies any history of amaurosis fugax, TIAs or stroke-like symptoms. She had a carotid duplex back in [MASKED], which had demonstrated moderate stenosis of the right carotid artery, which has now progressed to 90% stenosis on repeat duplex. Past Medical History: R Carotid stenosis, HTN, Dyslipidemia, obesity, former PPD smoker-quit last month. Social History: [MASKED] Family History: unknown Physical Exam: Vitals: Temp: 98.3 BP: 124/85, HR: 53 RR: 17 sat: 94% CV: S1S2 WOUND: clean, dry, had skin oozing on lower aspect of incision(this was cauterized with silver nitrate) ABD: soft, NT EXTREMITIES: no edema CN II-XII intact b/l Pertinent Results: [MASKED] 04:47AM BLOOD WBC-14.4* RBC-3.95 Hgb-12.7 Hct-38.2 MCV-97 MCH-32.2* MCHC-33.2 RDW-12.9 RDWSD-46.5* Plt [MASKED] [MASKED] 04:47AM BLOOD Glucose-116* UreaN-16 Creat-0.7 Na-145 K-4.2 Cl-108 HCO3-25 AnGap-12 [MASKED] 04:47AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8 Brief Hospital Course: Mr. [MASKED] is a [MASKED] female smoker who was found to have a high-grade stenosis of the right internal carotid artery. She denies any history of amaurosis fugax, TIAs or stroke-like symptoms. She had a carotid duplex back in [MASKED], which had demonstrated moderate stenosis of the right carotid artery, which has now progressed to 90% stenosis on repeat duplex. The risks and benefits of an elective carotid endarterectomy for stroke prevention were discussed with the patient and she elected to procedure with surgical intervention. She underwent a right carotid endarterectomy with bovine patch angioplasty on [MASKED]. She tolerated the procedure well. Her post op course was uneventful. Her [MASKED] hospital meds were resumed. She tolerated regular diet and ambulated with out any difficulty. She is discharged with [MASKED] follow up for Blood pressure check on Post op day #2 and Post op day #4. She will see Dr [MASKED] in 1 month with a repeat duplex. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Vitamin D [MASKED] UNIT PO DAILY 5. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Hydrochlorothiazide 25 mg PO DAILY 7. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right carotid stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. You were admitted to the hospital after a carotid endarterectomy. This surgery was done to restore proper blood flow to your brain. To perform this procedure, an incision was made in your neck. 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. Carotid Endarterectomy Patient Discharge Instructions WHAT TO EXPECT: Bruising, tenderness, mild swelling, numbness and/or a firm ridge at the incision site is normal. This will improve gradually in the next 2 weeks. You may have a sore throat and or mild hoarseness. Warm tea, throat lozenges, or cool drinks usually help. It is normal to feel tired for [MASKED] weeks after your surgery. MEDICATION INSTRUCTIONS: 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! It is very important that you take Aspirin every day! You should never stop this medication before checking with your surgeon You should take Tylenol [MASKED] every 6 hours, as needed for neck pain. If this is not enough, take your prescription pain medication. You should require less pain medication each day. Do not take more than a daily total of 3000mg of Tylenol. Tylenol is used as an ingredient in some other over-the-counter and prescription medications. Be aware of how much Tylenol you are taking in a day. Narcotic pain medication can be very constipating. If you take narcotics, please also take a stool softener such as Colace. If constipation becomes a problem, your pharmacist can suggest an additional over the counter laxative. CARE OF YOUR NECK INCISION: You may shower 48 hours after your procedure. Avoid direct shower spray to the incision. Let soapy water run over the incision, then rinse and gently pat the area dry. Do not scrub the incision. Your neck incision may be left open to air and uncovered unless you have a small amount of drainage at the site. If drainage is present, place a small sterile gauze over the incision and change the gauze daily. Do not take a bath or go swimming for 2 weeks. ACTIVITY: Do not drive for one week after your procedure. Do not ever drive after taking narcotic pain medication. You should not push, pull, lift or carry anything heavier than 5 pounds for the next 2 weeks. After 2 weeks, you may return to your regular activities including exercise, sexual activitiy and work. DIET: It is normal to have a decreased appetite. Your appetite will return over time. Follow a well-balanced, heart healthy diet, with moderate restriction of salt and fat. SMOKING: If you smoke, it is very important for you to stop. Research has shown that smoking makes vascular disease worse. Talk to your primary care physician about ways to quit smoking. The [MASKED] Smokers' Helpline is a FREE and confidential way to get support and information to help you quit smoking. Call [MASKED] CALLING FOR HELP If you need help, please call us at [MASKED]. Remember your doctor, or someone covering for your doctor is available 24 hours a day, 7 days a week. If you call during non-business hours, you will reach someone who can help you reach the vascular surgeon on call. Followup Instructions: [MASKED]
[]
[ "I10", "E785", "E669", "F17210" ]
[ "I6521: Occlusion and stenosis of right carotid artery", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,069,864
24,251,829
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: succinylcholine Attending: ___ Chief Complaint: right breast cancer Major Surgical or Invasive Procedure: Right wire localized lumpectomy x 2, right axillary ultrasound localized dissection, right LVB, right oncoplastic reduction and left reduction for symmetry (essentially mastopexies). History of Present Illness: The patient is a ___ year-old woman who presents with breast cancer and symptomatic macromastia. Patient was counseled to undergo bilateral oncoplastic breast reductions. Risks include bleeding, infection, abnormal scarring, difficulty with wound healing, change in sensation, numbness, seromas, change in nipple sensation, loss of nipple-areolar complex, and need for additional surgery. She understands all this and wishes to proceed. The patient was also referred to our service for immediate lymphatic reconstruction given her need for an ALND. The patient understands the risks and benefits and wished to proceed. All risks and benefits of surgery were discussed at length and all questions were answered. In particular, we discussed the possibility for a dye reaction, DVT and lymphedema. These items were also reviewed on the day of surgery, and at this point in time, the patient does wish to proceed. Past Medical History: HTN, Obesity, Hx gestational diabetes Social History: ___ Family History: Father lung cancer ___ (smoker). No other family history of malignancy. No family history of anaphylactic allergic reactions. Physical Exam: ___ 0744 Temp: 98.6 PO BP: 125/83 HR: 77 RR: 18 O2 sat: 96% O2 delivery: RA ___ 0530 Pain Score: ___ ___ Total Intake: 2900ml PO Amt: 300ml IV Amt Infused: 2600ml ___ Total Intake: 1024ml PO Amt: 300ml IV Amt Infused: 724ml ___ Total Output: 525ml Urine Amt: 505ml R axilla JP: 20ml ___ Total Output: 610ml Urine Amt: 565ml R axilla JP: 45ml Weight: 151.01 (Entered in Nursing IPA) BMI: 27.2 Gen: NAD, A&Ox3, lying on stretcher. HEENT: Normocephalic. CV: RRR R: Breathing comfortably on room air. No wheezing. Chest: breasts wrapped in dressing to stay in place for 5 days. No sanguinous staining of wrap. Upper pole of breasts soft without ecchymosis, tension, or fluctuance. R axillary JP with ss fluid. R chest port accessible. Pertinent Results: none Brief Hospital Course: The patient was admitted to the plastic surgery service on ___ after Right wire localized lumpectomy x 2, right axillary ultrasound localized dissection, right LVB, right oncoplastic reduction and left reduction for symmetry (essentially mastopexies). During the case there was no hypotension or high peak ventilator pressures to suggest any anaphylactic type reactions. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received IV pain medication with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. She had a foley catheter during the procedure which was removed POD1 and she voided without issue. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Bilateral breast mounds soft and symmetrical without evidence of hematoma. Incisions intact. Nipples viable. Chest wrap dressing in place. Medications on Admission: see OMR. Antihypertensives and metformin. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*20 Tablet Refills:*0 3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. NIFEdipine (Extended Release) 60 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted on ___ for right breast lumpectomy x 2 and axillary lymph node removal by Dr. ___ lymphovenous bypass and bilateral oncoplastic breast lifting/reduction with Dr. ___. Please follow these discharge instructions. . Personal Care: 1. Leave chest wrap on until follow up with Dr. ___. Call for an appointment in 5 days after surgery (should be ___ or ___. 2. You may sponge bathe only until first follow up appointment. Do not get chest wrap wet. 3. Drain. you will be discharged with a drain in the right axilla. Please empty the drain and record the output at least once a day. Make sure to re-charge (keep on suction) the bulb after you empty it. Visiting nurse can help with this. . Diet/Activity: 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for two weeks after surgery. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. 3. You may take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 4. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: ___
[ "C50411", "C773", "N62", "N6489", "E119", "I10", "Z801" ]
Allergies: succinylcholine Chief Complaint: right breast cancer Major Surgical or Invasive Procedure: Right wire localized lumpectomy x 2, right axillary ultrasound localized dissection, right LVB, right oncoplastic reduction and left reduction for symmetry (essentially mastopexies). History of Present Illness: The patient is a [MASKED] year-old woman who presents with breast cancer and symptomatic macromastia. Patient was counseled to undergo bilateral oncoplastic breast reductions. Risks include bleeding, infection, abnormal scarring, difficulty with wound healing, change in sensation, numbness, seromas, change in nipple sensation, loss of nipple-areolar complex, and need for additional surgery. She understands all this and wishes to proceed. The patient was also referred to our service for immediate lymphatic reconstruction given her need for an ALND. The patient understands the risks and benefits and wished to proceed. All risks and benefits of surgery were discussed at length and all questions were answered. In particular, we discussed the possibility for a dye reaction, DVT and lymphedema. These items were also reviewed on the day of surgery, and at this point in time, the patient does wish to proceed. Past Medical History: HTN, Obesity, Hx gestational diabetes Social History: [MASKED] Family History: Father lung cancer [MASKED] (smoker). No other family history of malignancy. No family history of anaphylactic allergic reactions. Physical Exam: [MASKED] 0744 Temp: 98.6 PO BP: 125/83 HR: 77 RR: 18 O2 sat: 96% O2 delivery: RA [MASKED] 0530 Pain Score: [MASKED] [MASKED] Total Intake: 2900ml PO Amt: 300ml IV Amt Infused: 2600ml [MASKED] Total Intake: 1024ml PO Amt: 300ml IV Amt Infused: 724ml [MASKED] Total Output: 525ml Urine Amt: 505ml R axilla JP: 20ml [MASKED] Total Output: 610ml Urine Amt: 565ml R axilla JP: 45ml Weight: 151.01 (Entered in Nursing IPA) BMI: 27.2 Gen: NAD, A&Ox3, lying on stretcher. HEENT: Normocephalic. CV: RRR R: Breathing comfortably on room air. No wheezing. Chest: breasts wrapped in dressing to stay in place for 5 days. No sanguinous staining of wrap. Upper pole of breasts soft without ecchymosis, tension, or fluctuance. R axillary JP with ss fluid. R chest port accessible. Pertinent Results: none Brief Hospital Course: The patient was admitted to the plastic surgery service on [MASKED] after Right wire localized lumpectomy x 2, right axillary ultrasound localized dissection, right LVB, right oncoplastic reduction and left reduction for symmetry (essentially mastopexies). During the case there was no hypotension or high peak ventilator pressures to suggest any anaphylactic type reactions. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received IV pain medication with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. She had a foley catheter during the procedure which was removed POD1 and she voided without issue. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Bilateral breast mounds soft and symmetrical without evidence of hematoma. Incisions intact. Nipples viable. Chest wrap dressing in place. Medications on Admission: see OMR. Antihypertensives and metformin. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed Disp #*20 Tablet Refills:*0 3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. NIFEdipine (Extended Release) 60 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted on [MASKED] for right breast lumpectomy x 2 and axillary lymph node removal by Dr. [MASKED] lymphovenous bypass and bilateral oncoplastic breast lifting/reduction with Dr. [MASKED]. Please follow these discharge instructions. . Personal Care: 1. Leave chest wrap on until follow up with Dr. [MASKED]. Call for an appointment in 5 days after surgery (should be [MASKED] or [MASKED]. 2. You may sponge bathe only until first follow up appointment. Do not get chest wrap wet. 3. Drain. you will be discharged with a drain in the right axilla. Please empty the drain and record the output at least once a day. Make sure to re-charge (keep on suction) the bulb after you empty it. Visiting nurse can help with this. . Diet/Activity: 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for two weeks after surgery. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. 3. You may take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 4. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: [MASKED]
[]
[ "E119", "I10" ]
[ "C50411: Malignant neoplasm of upper-outer quadrant of right female breast", "C773: Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes", "N62: Hypertrophy of breast", "N6489: Other specified disorders of breast", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung" ]
10,069,864
27,357,732
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: succinylcholine Attending: ___ ___ Complaint: Scheduled for R lumpectomy (for R breast cancer) and ALND with lymphovenous bypass but OR case aborted due to apparent anaphylaxis Major Surgical or Invasive Procedure: OR case aborted. (scheduled for R lumpectomy and ALND) History of Present Illness: Patient is a ___ year old woman with right invasive ductal carcinoma s/p neoadjuvant therapy scheduled for right lumpectomy, axillary lymph node dissection, and lymphovenous bypass. Past Medical History: HTN, Obesity, Hx gestational diabetes Social History: ___ Family History: Father lung cancer ___ (smoker). No other family history of malignancy. No family history of anaphylactic allergic reactions. Physical Exam: VS: 98.3, BP 112/71, HR 68, RR 16, 97% RA GEN: No distress Skin: No apparent flushing at face or extremities. HEENT: NCAT, EOMI, sclera anicteric CV: Regular PULM: Breathing unlabored on room air BREAST: deferred URO/GYN: Foley in place EXT: Warm, well-perfused, no edema, no tenderness. NEURO: no focal neurologic deficits I: 2267 IV. O: ___ UOP Pertinent Results: ___ 06:02AM BLOOD WBC-5.7 RBC-3.56* Hgb-10.1* Hct-30.7* MCV-86 MCH-28.4 MCHC-32.9 RDW-13.2 RDWSD-41.1 Plt ___ ___ 06:02AM BLOOD Neuts-64.1 ___ Monos-8.5 Eos-1.9 Baso-0.4 Im ___ AbsNeut-3.64 AbsLymp-1.41 AbsMono-0.48 AbsEos-0.11 AbsBaso-0.02 ___ 06:02AM BLOOD Plt ___ ___ 06:02AM BLOOD Glucose-86 UreaN-13 Creat-1.0 Na-142 K-4.1 Cl-105 HCO3-22 AnGap-15 Brief Hospital Course: Patient is a ___ year old woman with right invasive ductal carcinoma s/p neoadjuvant therapy scheduled for right lumpectomy, axillary lymph node dissection, and lymphovenous bypass. Patient arrived to pre-op, where she received tylenol, and after standard pre-operative assessment and protocol, the patient was brought to the OR. She was prepared and intubated by anesthesia (received 100mg IV bolus succinylcholine), and the plastic surgery team was preparing for assessment of the lymphatics, having injected up to this point indocyanin dye subcutaneously. Shortly after, the patient was noted to have desaturations, BP dropped to ___, she was tachycardia to 130s, and developed some red flushing at the face and upper extremities. (medications patient received up to that point included tylenol, succinylcholine, benadryl, hydrocortisone, propofol, indocyanin green). Patient was given epinephrine and eventually started on neo-synephrine for BP support. OR case was aborted and patient was sent to the ICU, where she was quickly weaned off of pressors and extubated overnight. The allergy team was consulted and they recommended drawing trypsin lab and CBC with diff. The next day, patient was back to baseline, felt well except for a mild sore throat. She was breathing well on room air and hemodynamically stable. She was discharged in stable condition and set up for outpatient follow up at the ___ ___ for allergen testing in order to determine the causative agent of her adverse reaction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. NIFEdipine (Extended Release) 60 mg PO DAILY 4. Lidocaine-Prilocaine 1 Appl TP ONCE w/ chemo Discharge Medications: 1. Lidocaine-Prilocaine 1 Appl TP ONCE w/ chemo 2. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY 4. NIFEdipine (Extended Release) 60 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right breast cancer s/p neoadjuvant therapy scheduled for Right lumpectomy, ALND, and lymphovenous bypass but with apparent anaphylactic reaction in OR during preparation. Resolved and back to baseline. Discharge Condition: Comfortable, breathing well on room air. Mild sore throat but otherwise back to baseline. Alert and oriented to time place and person. Pleasant and conversant. Ambulating normally. Tolerating PO diet without nausea or vomiting. Discharge Instructions: Please follow up with Allergy Clinic on ___ (see details below). Followup Instructions: ___
[ "T886XXA", "T508X5A", "Y92234", "C50911", "I10", "I952", "E119", "J45909", "Z5309", "Z171", "N62" ]
Allergies: succinylcholine [MASKED] Complaint: Scheduled for R lumpectomy (for R breast cancer) and ALND with lymphovenous bypass but OR case aborted due to apparent anaphylaxis Major Surgical or Invasive Procedure: OR case aborted. (scheduled for R lumpectomy and ALND) History of Present Illness: Patient is a [MASKED] year old woman with right invasive ductal carcinoma s/p neoadjuvant therapy scheduled for right lumpectomy, axillary lymph node dissection, and lymphovenous bypass. Past Medical History: HTN, Obesity, Hx gestational diabetes Social History: [MASKED] Family History: Father lung cancer [MASKED] (smoker). No other family history of malignancy. No family history of anaphylactic allergic reactions. Physical Exam: VS: 98.3, BP 112/71, HR 68, RR 16, 97% RA GEN: No distress Skin: No apparent flushing at face or extremities. HEENT: NCAT, EOMI, sclera anicteric CV: Regular PULM: Breathing unlabored on room air BREAST: deferred URO/GYN: Foley in place EXT: Warm, well-perfused, no edema, no tenderness. NEURO: no focal neurologic deficits I: 2267 IV. O: [MASKED] UOP Pertinent Results: [MASKED] 06:02AM BLOOD WBC-5.7 RBC-3.56* Hgb-10.1* Hct-30.7* MCV-86 MCH-28.4 MCHC-32.9 RDW-13.2 RDWSD-41.1 Plt [MASKED] [MASKED] 06:02AM BLOOD Neuts-64.1 [MASKED] Monos-8.5 Eos-1.9 Baso-0.4 Im [MASKED] AbsNeut-3.64 AbsLymp-1.41 AbsMono-0.48 AbsEos-0.11 AbsBaso-0.02 [MASKED] 06:02AM BLOOD Plt [MASKED] [MASKED] 06:02AM BLOOD Glucose-86 UreaN-13 Creat-1.0 Na-142 K-4.1 Cl-105 HCO3-22 AnGap-15 Brief Hospital Course: Patient is a [MASKED] year old woman with right invasive ductal carcinoma s/p neoadjuvant therapy scheduled for right lumpectomy, axillary lymph node dissection, and lymphovenous bypass. Patient arrived to pre-op, where she received tylenol, and after standard pre-operative assessment and protocol, the patient was brought to the OR. She was prepared and intubated by anesthesia (received 100mg IV bolus succinylcholine), and the plastic surgery team was preparing for assessment of the lymphatics, having injected up to this point indocyanin dye subcutaneously. Shortly after, the patient was noted to have desaturations, BP dropped to [MASKED], she was tachycardia to 130s, and developed some red flushing at the face and upper extremities. (medications patient received up to that point included tylenol, succinylcholine, benadryl, hydrocortisone, propofol, indocyanin green). Patient was given epinephrine and eventually started on neo-synephrine for BP support. OR case was aborted and patient was sent to the ICU, where she was quickly weaned off of pressors and extubated overnight. The allergy team was consulted and they recommended drawing trypsin lab and CBC with diff. The next day, patient was back to baseline, felt well except for a mild sore throat. She was breathing well on room air and hemodynamically stable. She was discharged in stable condition and set up for outpatient follow up at the [MASKED] [MASKED] for allergen testing in order to determine the causative agent of her adverse reaction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. NIFEdipine (Extended Release) 60 mg PO DAILY 4. Lidocaine-Prilocaine 1 Appl TP ONCE w/ chemo Discharge Medications: 1. Lidocaine-Prilocaine 1 Appl TP ONCE w/ chemo 2. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY 4. NIFEdipine (Extended Release) 60 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Right breast cancer s/p neoadjuvant therapy scheduled for Right lumpectomy, ALND, and lymphovenous bypass but with apparent anaphylactic reaction in OR during preparation. Resolved and back to baseline. Discharge Condition: Comfortable, breathing well on room air. Mild sore throat but otherwise back to baseline. Alert and oriented to time place and person. Pleasant and conversant. Ambulating normally. Tolerating PO diet without nausea or vomiting. Discharge Instructions: Please follow up with Allergy Clinic on [MASKED] (see details below). Followup Instructions: [MASKED]
[]
[ "I10", "E119", "J45909" ]
[ "T886XXA: Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, initial encounter", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "C50911: Malignant neoplasm of unspecified site of right female breast", "I10: Essential (primary) hypertension", "I952: Hypotension due to drugs", "E119: Type 2 diabetes mellitus without complications", "J45909: Unspecified asthma, uncomplicated", "Z5309: Procedure and treatment not carried out because of other contraindication", "Z171: Estrogen receptor negative status [ER-]", "N62: Hypertrophy of breast" ]
10,069,871
26,257,265
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Zithromax / Zofran Attending: ___. Chief Complaint: SOB and chest pain, here for ___ opinion surgical evaluation Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o opioid use disorder w/history of injection drug use, currently in remission since ___, with complex history of TV endocarditis, presenting with c/o chest pain, SOB (?fever) 2 days after leaving ___, where she was being treated for recurrent TV endocarditis. Her history is as follows, though some of the timelines are somewhat unclear: In ___, she was admitted to ___ with MSSA bacteremia, TV endocarditis, R hip septic arthritis. Treated with antibiotics (unclear what specifically), washout of the R hip, and ultimately TV bioprosthetic valve replacement in ___. She was subsequently discharged off antibiotics, and reports that about 1.5 weeks later, she began to have fevers, nausea, SOB, chest pain. She may have had another ___ admission after that, but the records are unclear to that point, and indicate that she did get admitted to ___ on ___ with these complaints, and was found to have MSSA and Strep mitis bacteremia and vegetation on the prosthetic valve. She was presumably treated with antibiotics at ___ for an unclear amount of time, then was transferred to ___, where treatment was continued apparently with vanc/gent/rifampin, until she left on ___ and presented to ___. At ___, she was started on cefazolin on ___ based on the MSSA from ___ gent was given for the first two weeks, and RIF was started ___. She had multiple TTE's (details below) showing TV vegetations, as well as a TEE which was not complete due to severe desat during the procedure, but also showed a complex of vegetation at the TV/RA. Subsequent TTEs over time showed decreasing size of the veg; she also was shown to have a PFO. She had a CT chest on ___ which showed multiple pulmonary emboli, ?septic. She left ___ on ___ due to concerns over behavioral issues. She was discharged with Bactrim, rifampin and Augmentin, which she did take. However, on the day of presentation here (___), she suffered a fall and hit her head, was feeling very weak, nauseated, and with significant pleuritic chest pain and shortness of breath. She states that she would like to continue antibiotics longer to "give me a better chance." At ___, she was seen by cardiothoracic surgery, who recommended no surgical intervention until she could show 6 months free of IV drug use. Her prior CT surgeon at ___ was contacted as well. In the ED here, CT chest showed several foci of peripheral parenchymal opacities in the RLL and LLL, with subtle lucent focus adjacent to the RLL consolidation, which may represent early cavitation and given recent history of endocarditis, favor septic emboli. She was initially given a dose of vanco and cipro, but these were stopped on admission to the floor and she was started on Bactrim, augmentin and rifampin. Blood cultures were drawn and have been negative to date. She has had no fevers. Today she reports ongoing nausea and pleuritic chest pain. Past Medical History: Tricuspid valve endocarditis s/p bioprosthetic valve c/b reinfection Opiate use disorder Hepatitis C Right hip septic arthritis s/p wash out Social History: Obtained a GED after dropping out of ___ grade. Went to ___ school. Did hair, makeup and nails. Got married, had 5 kids ___ years old). Got into an unfortunate car accident ___, was prescribed high doses of opioids which started her addiction, switched to IV heroin (reports shes been on IV heroin for only ___ years). Left the 5 kids in ___ with mother in law and moved to ___ to care for her sister in law who suffers from mental illness and to start a new life with her husband. Got sick in ___ with IE with complicated hospital stay. Has been sober since. Was on suboxone, no longer on it. Husband started opioids because wife was on it, has been clean as well for 7 months and currently on suboxone. Both are homeless and she has her luggage with her, prior to this they were living with the sister in law, currently sleeping in parks and shelters, surviving off of food stamps, pan handling. No longer does things for money anymore, did not want to go into detail about what things she use to do. Husband just a new job installing alarm systems in home. Of note, patient has been taking 9 tabs of 2mg hydromorphone a day (about 4mg q6H) buying off the streets. smoker ___ pack since ___, food stamps, money through panhandling and husband just got a job. No drinking, IVDU since ___ Mother was a drug addict- cocaine Brother- poly substance Father- prison for life Family History: maternal grandmother- suicidal, mental illness, strokes paternal grandparents: died, unclear cause Whole family is drug addicts. The rest she is not sure about. Physical Exam: ADMISSION PHYSICAL: VITALS:98.8 PO 137 / 90 L Lying 75 20 100 Ra Wt 81kg, 178lb ___: Alert, oriented, no acute distress, tearfull, itchy HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP 11cm, poor dentition CARDIOVASCULAR: Regular rate and rhythm, tachycardic, normal S1 + S2 with splitting of s2, unable to characterize it due to tachycardia, no murmurs, rubs, gallops LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi, decreased at right base more than left ABDOMEN: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Excoriations and track marks throughout body, most prominent in upper and lower extremity NEURO: Face grossly symmetric. Moving all limbs with purpose against gravity. Pupils equal and reactive, no dysarthria. DISCHARGE EXAM: Vitals: T max 98.1, BP 102/70, HR 64, RR 16, O2 97% RA ___: 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 CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 11:30AM BLOOD WBC-8.3 RBC-4.14 Hgb-9.8*# Hct-33.9* MCV-82 MCH-23.7* MCHC-28.9* RDW-23.3* RDWSD-69.5* Plt ___ ___ 11:30AM BLOOD Neuts-78.1* Lymphs-15.6* Monos-4.0* Eos-1.3 Baso-0.5 Im ___ AbsNeut-6.44* AbsLymp-1.29 AbsMono-0.33 AbsEos-0.11 AbsBaso-0.04 ___ 11:30AM BLOOD ___ PTT-31.3 ___ ___ 11:30AM BLOOD Glucose-91 UreaN-21* Creat-1.1 Na-142 K-4.8 Cl-103 HCO3-21* AnGap-18* ___ 11:30AM BLOOD proBNP-1285* ___ 11:30AM BLOOD D-Dimer-1792* DISCHARGE LABS: ___ 06:25AM BLOOD WBC-3.0* RBC-3.71* Hgb-8.9* Hct-31.0* MCV-84 MCH-24.0* MCHC-28.7* RDW-22.6* RDWSD-69.7* Plt Ct-92* ___ 06:25AM BLOOD Glucose-81 UreaN-30* Creat-0.8 Na-137 K-4.7 Cl-103 HCO3-20* AnGap-14 ___ 06:25AM BLOOD Calcium-9.1 Phos-5.4* Mg-1.7 IMAGING: CTA CHEST (___): 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Several foci of peripheral parenchymal opacities are noted in the right lower lobe and left lower lobe, with subtle lucent focus adjacent to the right lower lobe consolidation, which may represent early cavitation and given recent history of endocarditis, favor septic emboli, though nonspecific infectious or inflammatory conditions remain differential possibilities. 3. Patient is status post tricuspid valve replacement. ECHO (___): The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. A bioprosthetic tricuspid valve is present. The gradients are higher than expected for this type of prosthesis. There is a moderate to large-sized (at least 1 x 1.2) vegetation on the tricuspid prosthesis, with partial destruction of the prosthetic leaflets. There is no evidence of annular abscess. Moderate to severe [3+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Prosthetic tricuspid valve endocarditis. Moderate to severe prosthetic tricuspid regurgitation. Normal biventricular systolic function. No vegetations seen on the other valves. Brief Hospital Course: ___ y/o F w/ h/o IVDU, hepatitis C, infective endocarditis c/b R hip septic arthritis s/p washout and s/p TV replacement (stented bioprosthetic Epic; ___ at ___ c/b reinfection of new bioprosthetic valve who presented with pleuritic chest pain and SOB 2 days after leaving AMA from ___, where she was being treated for recurrent TV endocarditis. She presented to ___ with hopes of being evaluated for candidacy for a TV replacement. During this hospitalization, we obtained a CTA and Echo to evaluate possibly worsening pulmonary emboli or worsening tricuspid vegetations compared to her findings at ___. We determined that both the emboli and vegetations were stable, and determined that she completed an appropriate antibiotic course and no longer needs further antibiotic suppression. Our CT surgery team agreed with the operative plan established at ___ by Dr. ___ (6 months of abstinence from drugs prior to re-evaluation for TV replacement). She was discharged with plans to follow-up with primary care and CT surgery at ___, and with plans to follow-up with a ___ clinic. A more detailed hospital course by problem is outlined below: #MSSA prosthetic tricuspid valve endocarditis: She was recently managed at ___ (left AMA on ___ w/ IV cefazolin/gent (day 1: ___ and rifampin (day 1: ___ with a plan to continue to ___, but since she left AMA she was transitioned to PO meds Augmentin 875 mg BID, Rifampin 300 mg BID, Bactrim 800-160 mg BID, which she did not continue as o/p. Her BCx showed no growth during her entire ___ hospitalization. Dr. ___ surgeon at ___, had agreed to re-evaluate her for a possible TVR in 6 months if the patient remains clean (___). At ___, her BCx continued to show no growth. We obtained a TTE at ___ to evaluate possible progression of endocarditis, and consulted our CT surgery team to see if they would provide a different operative plan from their ___ colleagues. We initially continued Ms. ___ on bactrim, rifampin, and augmentin, then transitioned her to IV cefazolin before stopping all abx at discharge once conferring with our CT surgery team and confirming that pt will follow-up at ___ for a possible future surgery. #Chest pain ___ septic emboli: A CT PE on ___ at ___ showed evolving pulmonary infarcts and pulmonary arterial filling defects. At ___, there was no evidence of thrombotic PE on CTA (___). She had not been managed with any anticoagulation at ___, and we did not initiate anticoagulation here. Her pain was managed with methadone 20mg TID and Ketorolac. #Syncope: There is no clear proximate cause of pt's reported syncope, and it's unclear whether she even syncopized given that her initial story prior to admission is inconsistent with the ___ record. Orthostatics on ___ were negative. #Asymptomatic bacteriuria: ED urine cultures were shown to grow Enterobacter Aerogenes. However, since she has been asymptomatic we decided not to provide abx. #Opioid abuse: Although the patient claims to be clean since ___, track marks on her arms and the history from ___ suggest more recent use. We continued treatment with 20mg methadone TID and transitioned her 30mg BID, ultimately to be on 60mg daily. She was referred to a ___ clinic for follow-up. Her QTc on ___ on a stable amount of methadone was 462. TRANSITIONAL ISSUES: # CODE: Full # CONTACT: Husband, ___ - does not have a phone [ ] MEDICATION CHANGES: - Added: Methadone 60mg PO daily, metoprolol succinate 25mg daily, ASA 81mg daily - Stopped: PO hydromorphone, metoprolol tartrate [ ] METHADONE TREATMENT: - Pt will be followed by the Habit ___ clinic on ___. She will have her next-day dosing on ___. - Her last dose of methadone was 60mg PO. It was given at 0952 on ___. - QTc on ___ was 426 by ECG. [ ] ENDOCARDITIS FOLLOW-UP: - Pt has a follow-up appointment scheduled with Dr. ___ at ___ on ___. A discharge summary will be sent to his office in anticipation of this appointment. - Pt needs close follow-up to ensure adherence to methadone treatment and abstinence from drug use, required 6mo of being clean in order to be evaluated again by ___ CT Surgery (last evaluated ___ next surgical consideration may be ___. - Per previous discharge planning from ___, Pt does not need anticoagulation for her sterile pulmonary emboli. - Per discussions with their team: Pt will be evaluated for a revision of the tricuspid valve after a 6-month period of sobriety. She does not require suppressive antibiotics during this time. [ ] DISCHARGE PLANNING: - Pt provided with resources for shelters at discharge. She is going to be discharged into the care of her sister-in-law for the afternoon/evening of ___. - Her husband ___ lives at the ___, where she can stay in a separate wing of the facility. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate Dose is Unknown PO Frequency is Unknown 2. Aspirin 81 mg PO DAILY 3. FLUoxetine 20 mg PO BID 4. HYDROmorphone (Dilaudid) ___ mg PO ___ PRN Pain - Moderate Discharge Medications: 1. Methadone 60 mg PO DAILY 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. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 4. FLUoxetine 20 mg PO BID RX *fluoxetine 20 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Tricuspid valve endocarditis complicated by septic emboli SECONDARY DIAGNOSES: Septic pulmonary emboli, improved Asymptomatic bacteriuria Opioid use disorder 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 ___. WHY WERE YOU ADMITTED? You were admitted for evaluation and management of chest pain, shortness of breath, and an episode of losing consciousness, in addition to wanting to receive another opinion on management of your tricuspid valve endocarditis. WHAT DID WE DO FOR YOU? - To manage your endocarditis, we continued the antibiotics (Augmentin, Rifampin, and Bactrim) that you had left ___ with. We then switched you to intravenous Cefazolin after speaking with our infectious disease team. Our infectious disease team determined that you had completed your antibiotic course, and did not need other antibiotics at home. - We managed your chest pain with an IV anti-inflammatory drug, and then continued you on methadone to manage both pain and your previous opioid use. You were discharged on a dose of 60mg once daily. The last dose of your methadone was given at 9:52AM on ___. - We obtained an echo image of your heart to evaluate whether surgery (tricuspid valve replacement) would be appropriate at this point. Our cardiac surgery team agreed with your operative plan at ___, that you would need to demonstrate 6 months of not using drugs in order to be re-considered for valve replacement WHAT SHOULD YOU DO FOR FOLLOW-UP? - Set up follow-up with a primary care physician at ___: ___, or online ___/ - Follow up with the ___ clinic (Habit Opco) as scheduled below. - Follow up with Dr. ___ office as scheduled below. - Follow up with our infectious disease team as scheduled below. It was a pleasure taking care of you. We wish you all the best. -Your ___ team Followup Instructions: ___
[ "T826XXA", "I330", "I2690", "F1110", "B9561", "B954", "B1920", "F17210", "R8271", "F609", "Y838", "Y929" ]
Allergies: Zithromax / Zofran Chief Complaint: SOB and chest pain, here for [MASKED] opinion surgical evaluation Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with h/o opioid use disorder w/history of injection drug use, currently in remission since [MASKED], with complex history of TV endocarditis, presenting with c/o chest pain, SOB (?fever) 2 days after leaving [MASKED], where she was being treated for recurrent TV endocarditis. Her history is as follows, though some of the timelines are somewhat unclear: In [MASKED], she was admitted to [MASKED] with MSSA bacteremia, TV endocarditis, R hip septic arthritis. Treated with antibiotics (unclear what specifically), washout of the R hip, and ultimately TV bioprosthetic valve replacement in [MASKED]. She was subsequently discharged off antibiotics, and reports that about 1.5 weeks later, she began to have fevers, nausea, SOB, chest pain. She may have had another [MASKED] admission after that, but the records are unclear to that point, and indicate that she did get admitted to [MASKED] on [MASKED] with these complaints, and was found to have MSSA and Strep mitis bacteremia and vegetation on the prosthetic valve. She was presumably treated with antibiotics at [MASKED] for an unclear amount of time, then was transferred to [MASKED], where treatment was continued apparently with vanc/gent/rifampin, until she left on [MASKED] and presented to [MASKED]. At [MASKED], she was started on cefazolin on [MASKED] based on the MSSA from [MASKED] gent was given for the first two weeks, and RIF was started [MASKED]. She had multiple TTE's (details below) showing TV vegetations, as well as a TEE which was not complete due to severe desat during the procedure, but also showed a complex of vegetation at the TV/RA. Subsequent TTEs over time showed decreasing size of the veg; she also was shown to have a PFO. She had a CT chest on [MASKED] which showed multiple pulmonary emboli, ?septic. She left [MASKED] on [MASKED] due to concerns over behavioral issues. She was discharged with Bactrim, rifampin and Augmentin, which she did take. However, on the day of presentation here ([MASKED]), she suffered a fall and hit her head, was feeling very weak, nauseated, and with significant pleuritic chest pain and shortness of breath. She states that she would like to continue antibiotics longer to "give me a better chance." At [MASKED], she was seen by cardiothoracic surgery, who recommended no surgical intervention until she could show 6 months free of IV drug use. Her prior CT surgeon at [MASKED] was contacted as well. In the ED here, CT chest showed several foci of peripheral parenchymal opacities in the RLL and LLL, with subtle lucent focus adjacent to the RLL consolidation, which may represent early cavitation and given recent history of endocarditis, favor septic emboli. She was initially given a dose of vanco and cipro, but these were stopped on admission to the floor and she was started on Bactrim, augmentin and rifampin. Blood cultures were drawn and have been negative to date. She has had no fevers. Today she reports ongoing nausea and pleuritic chest pain. Past Medical History: Tricuspid valve endocarditis s/p bioprosthetic valve c/b reinfection Opiate use disorder Hepatitis C Right hip septic arthritis s/p wash out Social History: Obtained a GED after dropping out of [MASKED] grade. Went to [MASKED] school. Did hair, makeup and nails. Got married, had 5 kids [MASKED] years old). Got into an unfortunate car accident [MASKED], was prescribed high doses of opioids which started her addiction, switched to IV heroin (reports shes been on IV heroin for only [MASKED] years). Left the 5 kids in [MASKED] with mother in law and moved to [MASKED] to care for her sister in law who suffers from mental illness and to start a new life with her husband. Got sick in [MASKED] with IE with complicated hospital stay. Has been sober since. Was on suboxone, no longer on it. Husband started opioids because wife was on it, has been clean as well for 7 months and currently on suboxone. Both are homeless and she has her luggage with her, prior to this they were living with the sister in law, currently sleeping in parks and shelters, surviving off of food stamps, pan handling. No longer does things for money anymore, did not want to go into detail about what things she use to do. Husband just a new job installing alarm systems in home. Of note, patient has been taking 9 tabs of 2mg hydromorphone a day (about 4mg q6H) buying off the streets. smoker [MASKED] pack since [MASKED], food stamps, money through panhandling and husband just got a job. No drinking, IVDU since [MASKED] Mother was a drug addict- cocaine Brother- poly substance Father- prison for life Family History: maternal grandmother- suicidal, mental illness, strokes paternal grandparents: died, unclear cause Whole family is drug addicts. The rest she is not sure about. Physical Exam: ADMISSION PHYSICAL: VITALS:98.8 PO 137 / 90 L Lying 75 20 100 Ra Wt 81kg, 178lb [MASKED]: Alert, oriented, no acute distress, tearfull, itchy HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP 11cm, poor dentition CARDIOVASCULAR: Regular rate and rhythm, tachycardic, normal S1 + S2 with splitting of s2, unable to characterize it due to tachycardia, no murmurs, rubs, gallops LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi, decreased at right base more than left ABDOMEN: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Excoriations and track marks throughout body, most prominent in upper and lower extremity NEURO: Face grossly symmetric. Moving all limbs with purpose against gravity. Pupils equal and reactive, no dysarthria. DISCHARGE EXAM: Vitals: T max 98.1, BP 102/70, HR 64, RR 16, O2 97% RA [MASKED]: 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 CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 grossly intact, motor function grossly normal Pertinent Results: ADMISSION LABS: [MASKED] 11:30AM BLOOD WBC-8.3 RBC-4.14 Hgb-9.8*# Hct-33.9* MCV-82 MCH-23.7* MCHC-28.9* RDW-23.3* RDWSD-69.5* Plt [MASKED] [MASKED] 11:30AM BLOOD Neuts-78.1* Lymphs-15.6* Monos-4.0* Eos-1.3 Baso-0.5 Im [MASKED] AbsNeut-6.44* AbsLymp-1.29 AbsMono-0.33 AbsEos-0.11 AbsBaso-0.04 [MASKED] 11:30AM BLOOD [MASKED] PTT-31.3 [MASKED] [MASKED] 11:30AM BLOOD Glucose-91 UreaN-21* Creat-1.1 Na-142 K-4.8 Cl-103 HCO3-21* AnGap-18* [MASKED] 11:30AM BLOOD proBNP-1285* [MASKED] 11:30AM BLOOD D-Dimer-1792* DISCHARGE LABS: [MASKED] 06:25AM BLOOD WBC-3.0* RBC-3.71* Hgb-8.9* Hct-31.0* MCV-84 MCH-24.0* MCHC-28.7* RDW-22.6* RDWSD-69.7* Plt Ct-92* [MASKED] 06:25AM BLOOD Glucose-81 UreaN-30* Creat-0.8 Na-137 K-4.7 Cl-103 HCO3-20* AnGap-14 [MASKED] 06:25AM BLOOD Calcium-9.1 Phos-5.4* Mg-1.7 IMAGING: CTA CHEST ([MASKED]): 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Several foci of peripheral parenchymal opacities are noted in the right lower lobe and left lower lobe, with subtle lucent focus adjacent to the right lower lobe consolidation, which may represent early cavitation and given recent history of endocarditis, favor septic emboli, though nonspecific infectious or inflammatory conditions remain differential possibilities. 3. Patient is status post tricuspid valve replacement. ECHO ([MASKED]): The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. A bioprosthetic tricuspid valve is present. The gradients are higher than expected for this type of prosthesis. There is a moderate to large-sized (at least 1 x 1.2) vegetation on the tricuspid prosthesis, with partial destruction of the prosthetic leaflets. There is no evidence of annular abscess. Moderate to severe [3+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Prosthetic tricuspid valve endocarditis. Moderate to severe prosthetic tricuspid regurgitation. Normal biventricular systolic function. No vegetations seen on the other valves. Brief Hospital Course: [MASKED] y/o F w/ h/o IVDU, hepatitis C, infective endocarditis c/b R hip septic arthritis s/p washout and s/p TV replacement (stented bioprosthetic Epic; [MASKED] at [MASKED] c/b reinfection of new bioprosthetic valve who presented with pleuritic chest pain and SOB 2 days after leaving AMA from [MASKED], where she was being treated for recurrent TV endocarditis. She presented to [MASKED] with hopes of being evaluated for candidacy for a TV replacement. During this hospitalization, we obtained a CTA and Echo to evaluate possibly worsening pulmonary emboli or worsening tricuspid vegetations compared to her findings at [MASKED]. We determined that both the emboli and vegetations were stable, and determined that she completed an appropriate antibiotic course and no longer needs further antibiotic suppression. Our CT surgery team agreed with the operative plan established at [MASKED] by Dr. [MASKED] (6 months of abstinence from drugs prior to re-evaluation for TV replacement). She was discharged with plans to follow-up with primary care and CT surgery at [MASKED], and with plans to follow-up with a [MASKED] clinic. A more detailed hospital course by problem is outlined below: #MSSA prosthetic tricuspid valve endocarditis: She was recently managed at [MASKED] (left AMA on [MASKED] w/ IV cefazolin/gent (day 1: [MASKED] and rifampin (day 1: [MASKED] with a plan to continue to [MASKED], but since she left AMA she was transitioned to PO meds Augmentin 875 mg BID, Rifampin 300 mg BID, Bactrim 800-160 mg BID, which she did not continue as o/p. Her BCx showed no growth during her entire [MASKED] hospitalization. Dr. [MASKED] surgeon at [MASKED], had agreed to re-evaluate her for a possible TVR in 6 months if the patient remains clean ([MASKED]). At [MASKED], her BCx continued to show no growth. We obtained a TTE at [MASKED] to evaluate possible progression of endocarditis, and consulted our CT surgery team to see if they would provide a different operative plan from their [MASKED] colleagues. We initially continued Ms. [MASKED] on bactrim, rifampin, and augmentin, then transitioned her to IV cefazolin before stopping all abx at discharge once conferring with our CT surgery team and confirming that pt will follow-up at [MASKED] for a possible future surgery. #Chest pain [MASKED] septic emboli: A CT PE on [MASKED] at [MASKED] showed evolving pulmonary infarcts and pulmonary arterial filling defects. At [MASKED], there was no evidence of thrombotic PE on CTA ([MASKED]). She had not been managed with any anticoagulation at [MASKED], and we did not initiate anticoagulation here. Her pain was managed with methadone 20mg TID and Ketorolac. #Syncope: There is no clear proximate cause of pt's reported syncope, and it's unclear whether she even syncopized given that her initial story prior to admission is inconsistent with the [MASKED] record. Orthostatics on [MASKED] were negative. #Asymptomatic bacteriuria: ED urine cultures were shown to grow Enterobacter Aerogenes. However, since she has been asymptomatic we decided not to provide abx. #Opioid abuse: Although the patient claims to be clean since [MASKED], track marks on her arms and the history from [MASKED] suggest more recent use. We continued treatment with 20mg methadone TID and transitioned her 30mg BID, ultimately to be on 60mg daily. She was referred to a [MASKED] clinic for follow-up. Her QTc on [MASKED] on a stable amount of methadone was 462. TRANSITIONAL ISSUES: # CODE: Full # CONTACT: Husband, [MASKED] - does not have a phone [ ] MEDICATION CHANGES: - Added: Methadone 60mg PO daily, metoprolol succinate 25mg daily, ASA 81mg daily - Stopped: PO hydromorphone, metoprolol tartrate [ ] METHADONE TREATMENT: - Pt will be followed by the Habit [MASKED] clinic on [MASKED]. She will have her next-day dosing on [MASKED]. - Her last dose of methadone was 60mg PO. It was given at 0952 on [MASKED]. - QTc on [MASKED] was 426 by ECG. [ ] ENDOCARDITIS FOLLOW-UP: - Pt has a follow-up appointment scheduled with Dr. [MASKED] at [MASKED] on [MASKED]. A discharge summary will be sent to his office in anticipation of this appointment. - Pt needs close follow-up to ensure adherence to methadone treatment and abstinence from drug use, required 6mo of being clean in order to be evaluated again by [MASKED] CT Surgery (last evaluated [MASKED] next surgical consideration may be [MASKED]. - Per previous discharge planning from [MASKED], Pt does not need anticoagulation for her sterile pulmonary emboli. - Per discussions with their team: Pt will be evaluated for a revision of the tricuspid valve after a 6-month period of sobriety. She does not require suppressive antibiotics during this time. [ ] DISCHARGE PLANNING: - Pt provided with resources for shelters at discharge. She is going to be discharged into the care of her sister-in-law for the afternoon/evening of [MASKED]. - Her husband [MASKED] lives at the [MASKED], where she can stay in a separate wing of the facility. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Tartrate Dose is Unknown PO Frequency is Unknown 2. Aspirin 81 mg PO DAILY 3. FLUoxetine 20 mg PO BID 4. HYDROmorphone (Dilaudid) [MASKED] mg PO [MASKED] PRN Pain - Moderate Discharge Medications: 1. Methadone 60 mg PO DAILY 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. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 4. FLUoxetine 20 mg PO BID RX *fluoxetine 20 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Tricuspid valve endocarditis complicated by septic emboli SECONDARY DIAGNOSES: Septic pulmonary emboli, improved Asymptomatic bacteriuria Opioid use disorder 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]. WHY WERE YOU ADMITTED? You were admitted for evaluation and management of chest pain, shortness of breath, and an episode of losing consciousness, in addition to wanting to receive another opinion on management of your tricuspid valve endocarditis. WHAT DID WE DO FOR YOU? - To manage your endocarditis, we continued the antibiotics (Augmentin, Rifampin, and Bactrim) that you had left [MASKED] with. We then switched you to intravenous Cefazolin after speaking with our infectious disease team. Our infectious disease team determined that you had completed your antibiotic course, and did not need other antibiotics at home. - We managed your chest pain with an IV anti-inflammatory drug, and then continued you on methadone to manage both pain and your previous opioid use. You were discharged on a dose of 60mg once daily. The last dose of your methadone was given at 9:52AM on [MASKED]. - We obtained an echo image of your heart to evaluate whether surgery (tricuspid valve replacement) would be appropriate at this point. Our cardiac surgery team agreed with your operative plan at [MASKED], that you would need to demonstrate 6 months of not using drugs in order to be re-considered for valve replacement WHAT SHOULD YOU DO FOR FOLLOW-UP? - Set up follow-up with a primary care physician at [MASKED]: [MASKED], or online [MASKED]/ - Follow up with the [MASKED] clinic (Habit Opco) as scheduled below. - Follow up with Dr. [MASKED] office as scheduled below. - Follow up with our infectious disease team as scheduled below. It was a pleasure taking care of you. We wish you all the best. -Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "F17210", "Y929" ]
[ "T826XXA: Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter", "I330: Acute and subacute infective endocarditis", "I2690: Septic pulmonary embolism without acute cor pulmonale", "F1110: Opioid abuse, uncomplicated", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "B954: Other streptococcus as the cause of diseases classified elsewhere", "B1920: Unspecified viral hepatitis C without hepatic coma", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R8271: Bacteriuria", "F609: Personality disorder, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]
10,069,992
28,478,673
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: hydrocodone Attending: ___. Chief Complaint: Fever, diarrhea, abdominal pain, dysuria Major Surgical or Invasive Procedure: None History of Present Illness: ___ with multiple medical problems including recurrent C. diff colitis, brittle diabetes mellitus, COPD, history of acute respiratory failure, EtOH abuse, status post tracheostomy and PEG tube in ___, recent DC in ___ for DKA in ___, now transferred to ___ with DKA. Pt reports 2 days of fevers (Tm 103), N/V, diarrhea, abd pain, dysuria. Endorses mild cough, fatigue, decreased PO intake. States has brittle DM, very diff to control FSGs, no recent change in insulin. Denies chest pain, shortness of breath, bleeding, GIB, hematemesis. She states she takes 2 shots brandy daily, has been ongoing for many yrs. At ___, labs notable for WBC 2.2, platelets 85, Na 126, Cl 88, HCO3 20, Cr 1.25, Glu 464 with UA notable for 0.43 ketones. CXR revealed no evidence of acute cardiopulmonary process. Patient was started on an insulin drip and given 500 mg IV meropenem x1 prior to transfer. Patient was last hospitalized in ___ for evaluation of hyperglycemia. She was found to be profoundly volume depleted with dehydration, and marked depletion of electrolytes including a potassium of 2.2 and magnesium of 1.7. She was evaluated to recurrent C. diff colitis and administered fidamoxicin and underwent a fecal transplant and colonoscopy. She was placed on ___ protocol with Ativan due to alcohol abuse history, but had no signs of withdrawal at that time. Her blood sugars were very labile with bouts of marked hypo-and hyperglycemia asked couple of days, ranging from the ___ up to 400, with some difficulty in control due to her varying PO status. She was additionally started KCl 40 mEq BID supplement and Mag-Ox 800 mg twice a day due to persistently low levels. In ED initial VS: 98, 80, 69/45, 16, 99% RA Exam: Hypotensive, RRR, s1/s2, no mgr, clear to ausculatation bilaterally, abdomen is soft, +distended, non-tender, no rebound/guarding, wwp, no lower extremity edema bilaterally EKG: Regular sinus rhythm at a rate of 89 beats per minute, Q waves and flattening of T wave in V1 and V2, STD in V3 through V5 and possibly in II. No prior ECG is available for comparison. On presentation, patient was hypotensive, she was administered 5L (NS -> D5NS with K), continued to still be hypotensive and minimally responsive after 2L, and was placed on a levophed drip. She became hypoglycemic on the insulin gtt, was given 25 gm 50% dextrose, then restarted on an insulin gtt. Lactate 5.5 -> 6.7, c/f mesenteric ischemia - CT abd/pelvis demonstrated 1. Foci of gas at the right anterior aspect of the bladder wall may be extraluminal and raises concern for emphysematous cystitis versus bladder perforation 2. Heterogeneity of the right kidney with surrounding stranding concerning for right pyelonephritis. Delayed bilateral nephrograms as well as mild stranding around the left kidney also raises possibility of bilateral pyelonephritis. 3. Cirrhosis with trace ascites. Labs: WBC 8.9 H/H 9.8/29.0 platelets 65 N:83 Band: 5 Na 131 Cl 93 BUN 22 glucose 49 AGap=21 K 2.7 Bicarb 20 Creatinine 1.1 Ca: 8.4 Mg: 1.4 P: 0.9 ALT: 9 AP: 49 Tbili: 0.8 AST: 25 ___: 14.0 PTT: 26.5 INR: 1.3 UA: WBC 126, bacteria none, no nitrite Trop-T: <0.01 Lactate:6.7 1045 ABG: pH 7.31 pCO2 42 pO2 37 HCO3 22 BaseXS -4 Consults: Urology: CT scan concerning for emphysematous cystitis vs. bladder perf. No mechanism for bladder perf and has severe UTI. Either way, no indication for intervention at this time. Will treat with bladder decompression and IV antibiotics. -upsize foley to ___ -use saline to gently hand irrigate to clear debris in bladder (no CBI) -hold off on further imaging at this time -antibiotics for at least 3 weeks -further care per primary team VS prior to transfer: 92 92/52 19 99% RA On arrival to the MICU, patient reports nausea/vomiting. Denies chest pain, shortness of breath, abdominal pain, diarrhea. Tearful, states she would like a drink of water. Past Medical History: Past medical history: Hypertension, Hyperlipidemia, Type 2 diabetes mellitus maintained on an insulin, very brittle, recurrent episodes of DKA and hypoglycemia COPD, active smoker, degenerative joint disease, anxiety, depression, GERD, urinary incontinence, Etoh abuse, cirrhosis , esophageal varices, alcohol induced pancytopenia, folic acid deficiency, C. difficile colitis, recurrent, indicated for stool transplant, multiple ICU admissions mostly for respiratory failure, status post tracheostomy and gastrostomy ___, malnutrition Past surgical history: Gastrostomy, tracheostomy, tubal ligation Social History: ___ Family History: Father died age ___ coronary artery disease, MI, mother died age ___, COPD Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 100.9, 105, 118/74, 25, 100% RA GENERAL: Alert, oriented, appears uncomfortable, tearful HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, regular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Back: no CVA tenderness EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no significant rashes or lesions NEURO: moves all extremities with purpose, no focal deficits DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: ===================================== ___ 09:14AM BLOOD WBC-8.9 RBC-3.05* Hgb-9.8* Hct-29.0* MCV-95 MCH-32.1* MCHC-33.8 RDW-13.5 RDWSD-46.4* Plt Ct-65* ___ 09:14AM BLOOD Neuts-83* Bands-5 Lymphs-9* Monos-2* Eos-0 Baso-1 ___ Myelos-0 NRBC-1* AbsNeut-7.83* AbsLymp-0.80* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.09* ___ 09:14AM BLOOD ___ PTT-26.5 ___ ___ 09:14AM BLOOD Glucose-49* UreaN-22* Creat-1.1 Na-131* K-2.7* Cl-93* HCO3-20* AnGap-21* ___ 09:14AM BLOOD ALT-9 AST-25 AlkPhos-49 TotBili-0.8 ___ 09:14AM BLOOD Calcium-8.4 Phos-0.9* Mg-1.4* Interim labs ___ 06:40AM BLOOD WBC-6.1 RBC-2.54* Hgb-8.1* Hct-23.8* MCV-94 MCH-31.9 MCHC-34.0 RDW-14.3 RDWSD-47.8* Plt ___ ___:40AM BLOOD Glucose-250* UreaN-6 Creat-0.7 Na-133 K-3.1* Cl-95* HCO3-26 AnGap-15 MICRO: ===================================== URINE CULTURE (Final ___: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R 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 Blood culture ___ NGTD IMAGING: ===================================== CXR ___ FINDINGS: Lungs are well inflated and notable for decreased conspicuity of right lower lobe opacity. No new opacity. No pleural effusion or pneumothorax. Heart size, mediastinal contour, and hila are unremarkable. A new left PICC tip projects over the right atrium. Right IJ CVL tip is in the low SVC. IMPRESSION: 1. Left PICC tip entering into right atrium. Consider withdrawing 1.5 cm for better positioning. 2. Decreased conspicuity of right lower lobe opacity suggestive of atelectasis/resolved pleural effusion. DISCHARGE LABS: ===================================== ___ 06:03AM BLOOD WBC-8.8 RBC-2.72* Hgb-8.6* Hct-26.2* MCV-96 MCH-31.6 MCHC-32.8 RDW-15.1 RDWSD-52.7* Plt ___ ___ 06:03AM BLOOD Glucose-279* UreaN-5* Creat-0.6 Na-133 K-5.0 Cl-98 HCO3-24 AnGap-16 ___ 06:03AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.4* ___ 04:57AM BLOOD ___ ___ 03:13PM BLOOD Ret Aut-3.6* Abs Ret-0.10 ___ 03:13PM BLOOD ___ Ferritn-253* ___ 04:57AM BLOOD Hapto-201* ___ 06:03AM BLOOD Glucose-279* UreaN-5* Creat-0.6 Na-133 K-5.0 Cl-98 HCO3-24 AnGap-16 ___ 07:50PM BLOOD K-5.0 ___ 01:30PM BLOOD Glucose-134* UreaN-5* Creat-0.6 Na-132* K-5.7* Cl-96 HCO3-26 AnGap-16 ___ 03:13PM BLOOD Glucose-252* UreaN-5* Creat-0.6 Na-136 K-3.6 Cl-98 HCO3-27 AnGap-15 ___ 06:45AM BLOOD Glucose-66* UreaN-7 Creat-0.7 Na-140 K-3.3 Cl-101 HCO3-27 AnGap-15 ___ 07:00PM BLOOD Glucose-143* UreaN-9 Creat-0.7 Na-134 K-2.9* Cl-100 HCO3-23 AnGap-___ with multiple medical problems including recurrent C. diff colitis, brittle diabetes mellitus, COPD, history of acute respiratory failure, EtOH abuse, status post tracheostomy and PEG tube in ___, recent DC in ___ for ___ in ___, now presenting with septic shock in setting of pyelonephritis and possible bladder perforation. ===================================== ICU COURSE: ===================================== # Shock - septic # Pyelonephritis: #ecoli bacteremia patient presented with hypotension to ___ requiring 5L IVF and pressor support in ED. CT abdomen/pelvis revealed right kidney with surrounding stranding concerning for right pyelonephritis as well as mild stranding around the left kidney also raises possibility of bilateral pyelonephritis. Of note, patient's previous urine cultures in ___ grew E. coli (pan sensitive), Raoultella planticola, Citrobacter, and Enterococcus (pan sensitive). ___ blood culture results with ecoli in ___ bottles. On norepinephrine while in ___ ED, stopped on arrival to ___. Pt will be treated with 3 weeks of antibiotics-IV ceftriaxone ___. Last day ___. Weekly CBC, lfts, chemistries while on IV ceftriaxone. # Concern for emphysematous cystitis vs. bladder perforation: Noted to have possibly extraluminal air on CT scan on admission. Urology consulted for question of bladder perforation. Per urology team, she has no obvious mechanism for bladder perforation (recent foley or procedures). Based on location of air noted on CT scan, any perforation, if present, would be retroperitoneal, and so the management would consist of decompression with urinary bladder catheter. Emphysematous cystitis is a potential cause of bladder perforation; management consists of antibiotics and bladder decompression. Urology recommended against cystogram, as this may distend the bladder and risk worsening septic spread. Will treat with bladder decompression and IV antibiotics. Final urology recs: Final recs: - improve blood sugar control as much as possible - total of 3 weeks of antibiotics. ___, last day ___ - foley for 1 more week, then voiding trial - follow up in ___ clinic in ___ weeks # Diabetes Mellitus, type 1- Very labile blood sugars due to her physiology and erratic po intake. Had element of DKA while in ICU, but was hypoglycemic on the floor and hyperglycemic. Had an episode of hypoglycemia to ___ with unresponsiveness. She is a brittle diabetic. She was evaluated by ___ consultation service closely. Her insulin scale was adjusted again today ___. Fingerstick QACHS, QPC2H, HS, 3AM Insulin SC Fixed Dose Orders Breakfast NPH 6 units with Humalog 2units, Lunch 2 units Humalog, Dinner NPH 4 units with 3 units of humalog Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose ___ mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-200 mg/dL 0 Units 0 Units 0 Units 0 Units 201-250 mg/dL 1 Units 1 Units 1 Units 0 Units 251-300 mg/dL 2 Units 2 Units 2 Units 1 Units 301-350 mg/dL 3 Units 3 Units 3 Units 2 Units > 350 mg/dL ___ M.D. ___ M.D. ___ M.D. ___. ___ recommended C-peptide+BG, anti-GAD, anti-islet labs but this can likely be ordered at time of follow up. *** Will need ___ f/u with Dr. ___ in 1 week. # Multifactorial acidosis - noted in ICU, resolved. patient initially presented to ___ with anion gap metabolic acidosis, marked hyperglycemia, and ketosis concerning for DKA, and anion gap has since closed with insulin drip. Of note, patient also has lactic acidosis likely due to septic shock. Likely secondary to lactic acidosis, ketosis, non-gap metabolic acidosis (GI losses, saline resuscitation), and concomitant respiratory acidosis (potentially due to respiratory muscle weakness, hypophosphatemia, and underlying COPD of undetermined severity). # Anemia: Hct 29 on admit; prior hct in ___ in mid ___ anemia likely multifactorial - due to myelosuppression ___ sepsis, phlebotomy; Vitamin B12, ferritin, reticulocyte performed - hemolysis labs negative and smear unremarkable. # ETOH abuse - per husband, she drinks up to one gallon of vodka a week - Received high dose thiamine x 3 days, followed by 100 mg PO daily - MVI with minerals, folate - Strongly discussed urge to quit alcohol use with this patient - it is causing cirrhosis, brittle diabetes, malnutrition and increased propensity for infection. ALso discussed my concerns very directly with husband, and asked that he not purchase alcohol for this patient. SW met with patient, but she seems entirely disinterested in entering a treatment program. # Severe malnutrition: Patient has poor nutrition at home due to her alcoholism. While hospitalized, she still had significant anorexia, eating small amounts and erratically (does not adhere to traditional meal times). She c/o food getting stuck in the throat; she met with speech and swallow and refused video swallow for better assessment. She was counseled repeatedly on need for improved, consistent po intake. # Hypokalemia/hypomagnesemia/hypophosphatemia: likely secondary to malnutrition and GI losses - Continued on home doses of potassium and magnesium initially. Dc'd standing order of potassium ___ due to hyperkalemia. Please monitoring electrolytes daily-every few days to ensure stable. =============== CHRONIC ISSUES: =============== # Cirrhosis; esophageal varices: Continued home spironolactone and propranolol after sepsis resolved. Propranolol should be held for SBP less than 100. # Thrombocytopenia/leukopenia: likely secondary to liver cirrhosis and bone marrow suppression from alcohol abuse. Stable # History of severe Recurrent C. diff requiring stool transplant: C.diff negative this admission. She should remain on prophylactic 125 mg PO vancomycin Q6H for now, and continue this for one week after cessation of antibiotics to end ___. # Diarrhea: ? antibiotic associated, using Imodium prn, consider creon as she likely has some element of exocrine deficiency. # Anxiety, depression: continue home paroxetine TRANSITIONAL CARE ___ F/U 1 WEEK 2.UROLOGY F/U 3 WEEKS 3.FOLEY DC'D IN 1 WEEK WITH VOIDING TRIAL 4.WEEKLY CBC, LFTS, CHEMISTRIES WHILE ON IV CEFTRIAXONE 5.DAILY-EVERY FEW DAY ELECTROLYTE MONITORING GIVEN HYPER/HYPO k, HYPOMAG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Gemfibrozil 600 mg PO BIDAC 3. Spironolactone 25 mg PO DAILY 4. Propranolol 10 mg PO BID 5. Oxybutynin 15 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath, wheezing 8. TraZODone 50 mg PO QHS 9. ___ 22 Units Breakfast ___ 22 Units Dinner 10. Magnesium Oxide 800 mg PO BID 11. Potassium Chloride 40 mEq PO BID 12. PARoxetine 20 mg PO DAILY Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H Please take this until ___ 2. FoLIC Acid 1 mg PO DAILY 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath, wheezing 4. LOPERamide 2 mg PO QID:PRN diarrhea 5. Mirtazapine 15 mg PO QHS 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Thiamine 100 mg PO DAILY 8. Tiotropium Bromide 1 CAP IH DAILY 9. Vancomycin Oral Liquid ___ mg PO Q6H Take this until ___ (one week after you have finished ceftriaxone) 10. Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 3 Units Dinner NPH 6 Units Breakfast NPH 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath, wheezing 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 13. Gemfibrozil 600 mg PO BIDAC 14. Magnesium Oxide 800 mg PO BID 15. Omeprazole 20 mg PO DAILY 16. PARoxetine 20 mg PO DAILY 17. Propranolol 10 mg PO BID 18. Spironolactone 25 mg PO DAILY 19. HELD- Potassium Chloride 40 mEq PO BID This medication was held. Do not restart Potassium Chloride until potassium rechecked and deemed necessary 20.Outpatient Lab Work weekly CBC, lfts, chemistries while on IV ceftriaxone Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Sepsis due to UTI/emphysematous cystitis, bacteremia 2. Alcoholic cirrhosis 3. Diabetes Mellitus 4. Dysphagia 5. Malnutrition 6. COPD 7. history of c.diff Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred here from ___ with sepsis (severe infection). This was due to a urinary tract infection that affected your bladder and may have caused a small perforation in your bladder. For this, you saw the urologist, and they recommended that you have a foley catheter placed for 3 weeks and that you receive antibiotics for 3 weeks. You were also seen by the nutritionist and the diabetes specialist given your difficult to control diabetes. You presently do NOT have C diff, but we will treat you for this so that you do not develop C diff infection while you are on antibiotics. It is very important that you stop drinking alcohol as we discussed. Followup Instructions: ___
[ "A4151", "R6521", "E43", "E1310", "D61811", "K521", "E874", "N12", "I8510", "F10288", "E871", "Z006", "N3080", "B9620", "B952", "B9689", "K7030", "R1310", "J449", "E1165", "Z794", "I10", "E785", "F17210", "F329", "F419", "K219", "R32", "E538", "E11649", "E876", "E8342", "E8339", "T3695XA", "Y92239", "R0902", "E8770", "I951" ]
Allergies: hydrocodone Chief Complaint: Fever, diarrhea, abdominal pain, dysuria Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with multiple medical problems including recurrent C. diff colitis, brittle diabetes mellitus, COPD, history of acute respiratory failure, EtOH abuse, status post tracheostomy and PEG tube in [MASKED], recent DC in [MASKED] for DKA in [MASKED], now transferred to [MASKED] with DKA. Pt reports 2 days of fevers (Tm 103), N/V, diarrhea, abd pain, dysuria. Endorses mild cough, fatigue, decreased PO intake. States has brittle DM, very diff to control FSGs, no recent change in insulin. Denies chest pain, shortness of breath, bleeding, GIB, hematemesis. She states she takes 2 shots brandy daily, has been ongoing for many yrs. At [MASKED], labs notable for WBC 2.2, platelets 85, Na 126, Cl 88, HCO3 20, Cr 1.25, Glu 464 with UA notable for 0.43 ketones. CXR revealed no evidence of acute cardiopulmonary process. Patient was started on an insulin drip and given 500 mg IV meropenem x1 prior to transfer. Patient was last hospitalized in [MASKED] for evaluation of hyperglycemia. She was found to be profoundly volume depleted with dehydration, and marked depletion of electrolytes including a potassium of 2.2 and magnesium of 1.7. She was evaluated to recurrent C. diff colitis and administered fidamoxicin and underwent a fecal transplant and colonoscopy. She was placed on [MASKED] protocol with Ativan due to alcohol abuse history, but had no signs of withdrawal at that time. Her blood sugars were very labile with bouts of marked hypo-and hyperglycemia asked couple of days, ranging from the [MASKED] up to 400, with some difficulty in control due to her varying PO status. She was additionally started KCl 40 mEq BID supplement and Mag-Ox 800 mg twice a day due to persistently low levels. In ED initial VS: 98, 80, 69/45, 16, 99% RA Exam: Hypotensive, RRR, s1/s2, no mgr, clear to ausculatation bilaterally, abdomen is soft, +distended, non-tender, no rebound/guarding, wwp, no lower extremity edema bilaterally EKG: Regular sinus rhythm at a rate of 89 beats per minute, Q waves and flattening of T wave in V1 and V2, STD in V3 through V5 and possibly in II. No prior ECG is available for comparison. On presentation, patient was hypotensive, she was administered 5L (NS -> D5NS with K), continued to still be hypotensive and minimally responsive after 2L, and was placed on a levophed drip. She became hypoglycemic on the insulin gtt, was given 25 gm 50% dextrose, then restarted on an insulin gtt. Lactate 5.5 -> 6.7, c/f mesenteric ischemia - CT abd/pelvis demonstrated 1. Foci of gas at the right anterior aspect of the bladder wall may be extraluminal and raises concern for emphysematous cystitis versus bladder perforation 2. Heterogeneity of the right kidney with surrounding stranding concerning for right pyelonephritis. Delayed bilateral nephrograms as well as mild stranding around the left kidney also raises possibility of bilateral pyelonephritis. 3. Cirrhosis with trace ascites. Labs: WBC 8.9 H/H 9.8/29.0 platelets 65 N:83 Band: 5 Na 131 Cl 93 BUN 22 glucose 49 AGap=21 K 2.7 Bicarb 20 Creatinine 1.1 Ca: 8.4 Mg: 1.4 P: 0.9 ALT: 9 AP: 49 Tbili: 0.8 AST: 25 [MASKED]: 14.0 PTT: 26.5 INR: 1.3 UA: WBC 126, bacteria none, no nitrite Trop-T: <0.01 Lactate:6.7 1045 ABG: pH 7.31 pCO2 42 pO2 37 HCO3 22 BaseXS -4 Consults: Urology: CT scan concerning for emphysematous cystitis vs. bladder perf. No mechanism for bladder perf and has severe UTI. Either way, no indication for intervention at this time. Will treat with bladder decompression and IV antibiotics. -upsize foley to [MASKED] -use saline to gently hand irrigate to clear debris in bladder (no CBI) -hold off on further imaging at this time -antibiotics for at least 3 weeks -further care per primary team VS prior to transfer: 92 92/52 19 99% RA On arrival to the MICU, patient reports nausea/vomiting. Denies chest pain, shortness of breath, abdominal pain, diarrhea. Tearful, states she would like a drink of water. Past Medical History: Past medical history: Hypertension, Hyperlipidemia, Type 2 diabetes mellitus maintained on an insulin, very brittle, recurrent episodes of DKA and hypoglycemia COPD, active smoker, degenerative joint disease, anxiety, depression, GERD, urinary incontinence, Etoh abuse, cirrhosis , esophageal varices, alcohol induced pancytopenia, folic acid deficiency, C. difficile colitis, recurrent, indicated for stool transplant, multiple ICU admissions mostly for respiratory failure, status post tracheostomy and gastrostomy [MASKED], malnutrition Past surgical history: Gastrostomy, tracheostomy, tubal ligation Social History: [MASKED] Family History: Father died age [MASKED] coronary artery disease, MI, mother died age [MASKED], COPD Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 100.9, 105, 118/74, 25, 100% RA GENERAL: Alert, oriented, appears uncomfortable, tearful HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, regular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Back: no CVA tenderness EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no significant rashes or lesions NEURO: moves all extremities with purpose, no focal deficits DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: ===================================== [MASKED] 09:14AM BLOOD WBC-8.9 RBC-3.05* Hgb-9.8* Hct-29.0* MCV-95 MCH-32.1* MCHC-33.8 RDW-13.5 RDWSD-46.4* Plt Ct-65* [MASKED] 09:14AM BLOOD Neuts-83* Bands-5 Lymphs-9* Monos-2* Eos-0 Baso-1 [MASKED] Myelos-0 NRBC-1* AbsNeut-7.83* AbsLymp-0.80* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.09* [MASKED] 09:14AM BLOOD [MASKED] PTT-26.5 [MASKED] [MASKED] 09:14AM BLOOD Glucose-49* UreaN-22* Creat-1.1 Na-131* K-2.7* Cl-93* HCO3-20* AnGap-21* [MASKED] 09:14AM BLOOD ALT-9 AST-25 AlkPhos-49 TotBili-0.8 [MASKED] 09:14AM BLOOD Calcium-8.4 Phos-0.9* Mg-1.4* Interim labs [MASKED] 06:40AM BLOOD WBC-6.1 RBC-2.54* Hgb-8.1* Hct-23.8* MCV-94 MCH-31.9 MCHC-34.0 RDW-14.3 RDWSD-47.8* Plt [MASKED] [MASKED]:40AM BLOOD Glucose-250* UreaN-6 Creat-0.7 Na-133 K-3.1* Cl-95* HCO3-26 AnGap-15 MICRO: ===================================== URINE CULTURE (Final [MASKED]: Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 R 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 Blood culture [MASKED] NGTD IMAGING: ===================================== CXR [MASKED] FINDINGS: Lungs are well inflated and notable for decreased conspicuity of right lower lobe opacity. No new opacity. No pleural effusion or pneumothorax. Heart size, mediastinal contour, and hila are unremarkable. A new left PICC tip projects over the right atrium. Right IJ CVL tip is in the low SVC. IMPRESSION: 1. Left PICC tip entering into right atrium. Consider withdrawing 1.5 cm for better positioning. 2. Decreased conspicuity of right lower lobe opacity suggestive of atelectasis/resolved pleural effusion. DISCHARGE LABS: ===================================== [MASKED] 06:03AM BLOOD WBC-8.8 RBC-2.72* Hgb-8.6* Hct-26.2* MCV-96 MCH-31.6 MCHC-32.8 RDW-15.1 RDWSD-52.7* Plt [MASKED] [MASKED] 06:03AM BLOOD Glucose-279* UreaN-5* Creat-0.6 Na-133 K-5.0 Cl-98 HCO3-24 AnGap-16 [MASKED] 06:03AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.4* [MASKED] 04:57AM BLOOD [MASKED] [MASKED] 03:13PM BLOOD Ret Aut-3.6* Abs Ret-0.10 [MASKED] 03:13PM BLOOD [MASKED] Ferritn-253* [MASKED] 04:57AM BLOOD Hapto-201* [MASKED] 06:03AM BLOOD Glucose-279* UreaN-5* Creat-0.6 Na-133 K-5.0 Cl-98 HCO3-24 AnGap-16 [MASKED] 07:50PM BLOOD K-5.0 [MASKED] 01:30PM BLOOD Glucose-134* UreaN-5* Creat-0.6 Na-132* K-5.7* Cl-96 HCO3-26 AnGap-16 [MASKED] 03:13PM BLOOD Glucose-252* UreaN-5* Creat-0.6 Na-136 K-3.6 Cl-98 HCO3-27 AnGap-15 [MASKED] 06:45AM BLOOD Glucose-66* UreaN-7 Creat-0.7 Na-140 K-3.3 Cl-101 HCO3-27 AnGap-15 [MASKED] 07:00PM BLOOD Glucose-143* UreaN-9 Creat-0.7 Na-134 K-2.9* Cl-100 HCO3-23 AnGap-[MASKED] with multiple medical problems including recurrent C. diff colitis, brittle diabetes mellitus, COPD, history of acute respiratory failure, EtOH abuse, status post tracheostomy and PEG tube in [MASKED], recent DC in [MASKED] for [MASKED] in [MASKED], now presenting with septic shock in setting of pyelonephritis and possible bladder perforation. ===================================== ICU COURSE: ===================================== # Shock - septic # Pyelonephritis: #ecoli bacteremia patient presented with hypotension to [MASKED] requiring 5L IVF and pressor support in ED. CT abdomen/pelvis revealed right kidney with surrounding stranding concerning for right pyelonephritis as well as mild stranding around the left kidney also raises possibility of bilateral pyelonephritis. Of note, patient's previous urine cultures in [MASKED] grew E. coli (pan sensitive), Raoultella planticola, Citrobacter, and Enterococcus (pan sensitive). [MASKED] blood culture results with ecoli in [MASKED] bottles. On norepinephrine while in [MASKED] ED, stopped on arrival to [MASKED]. Pt will be treated with 3 weeks of antibiotics-IV ceftriaxone [MASKED]. Last day [MASKED]. Weekly CBC, lfts, chemistries while on IV ceftriaxone. # Concern for emphysematous cystitis vs. bladder perforation: Noted to have possibly extraluminal air on CT scan on admission. Urology consulted for question of bladder perforation. Per urology team, she has no obvious mechanism for bladder perforation (recent foley or procedures). Based on location of air noted on CT scan, any perforation, if present, would be retroperitoneal, and so the management would consist of decompression with urinary bladder catheter. Emphysematous cystitis is a potential cause of bladder perforation; management consists of antibiotics and bladder decompression. Urology recommended against cystogram, as this may distend the bladder and risk worsening septic spread. Will treat with bladder decompression and IV antibiotics. Final urology recs: Final recs: - improve blood sugar control as much as possible - total of 3 weeks of antibiotics. [MASKED], last day [MASKED] - foley for 1 more week, then voiding trial - follow up in [MASKED] clinic in [MASKED] weeks # Diabetes Mellitus, type 1- Very labile blood sugars due to her physiology and erratic po intake. Had element of DKA while in ICU, but was hypoglycemic on the floor and hyperglycemic. Had an episode of hypoglycemia to [MASKED] with unresponsiveness. She is a brittle diabetic. She was evaluated by [MASKED] consultation service closely. Her insulin scale was adjusted again today [MASKED]. Fingerstick QACHS, QPC2H, HS, 3AM Insulin SC Fixed Dose Orders Breakfast NPH 6 units with Humalog 2units, Lunch 2 units Humalog, Dinner NPH 4 units with 3 units of humalog Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose [MASKED] mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-200 mg/dL 0 Units 0 Units 0 Units 0 Units 201-250 mg/dL 1 Units 1 Units 1 Units 0 Units 251-300 mg/dL 2 Units 2 Units 2 Units 1 Units 301-350 mg/dL 3 Units 3 Units 3 Units 2 Units > 350 mg/dL [MASKED] M.D. [MASKED] M.D. [MASKED] M.D. [MASKED]. [MASKED] recommended C-peptide+BG, anti-GAD, anti-islet labs but this can likely be ordered at time of follow up. *** Will need [MASKED] f/u with Dr. [MASKED] in 1 week. # Multifactorial acidosis - noted in ICU, resolved. patient initially presented to [MASKED] with anion gap metabolic acidosis, marked hyperglycemia, and ketosis concerning for DKA, and anion gap has since closed with insulin drip. Of note, patient also has lactic acidosis likely due to septic shock. Likely secondary to lactic acidosis, ketosis, non-gap metabolic acidosis (GI losses, saline resuscitation), and concomitant respiratory acidosis (potentially due to respiratory muscle weakness, hypophosphatemia, and underlying COPD of undetermined severity). # Anemia: Hct 29 on admit; prior hct in [MASKED] in mid [MASKED] anemia likely multifactorial - due to myelosuppression [MASKED] sepsis, phlebotomy; Vitamin B12, ferritin, reticulocyte performed - hemolysis labs negative and smear unremarkable. # ETOH abuse - per husband, she drinks up to one gallon of vodka a week - Received high dose thiamine x 3 days, followed by 100 mg PO daily - MVI with minerals, folate - Strongly discussed urge to quit alcohol use with this patient - it is causing cirrhosis, brittle diabetes, malnutrition and increased propensity for infection. ALso discussed my concerns very directly with husband, and asked that he not purchase alcohol for this patient. SW met with patient, but she seems entirely disinterested in entering a treatment program. # Severe malnutrition: Patient has poor nutrition at home due to her alcoholism. While hospitalized, she still had significant anorexia, eating small amounts and erratically (does not adhere to traditional meal times). She c/o food getting stuck in the throat; she met with speech and swallow and refused video swallow for better assessment. She was counseled repeatedly on need for improved, consistent po intake. # Hypokalemia/hypomagnesemia/hypophosphatemia: likely secondary to malnutrition and GI losses - Continued on home doses of potassium and magnesium initially. Dc'd standing order of potassium [MASKED] due to hyperkalemia. Please monitoring electrolytes daily-every few days to ensure stable. =============== CHRONIC ISSUES: =============== # Cirrhosis; esophageal varices: Continued home spironolactone and propranolol after sepsis resolved. Propranolol should be held for SBP less than 100. # Thrombocytopenia/leukopenia: likely secondary to liver cirrhosis and bone marrow suppression from alcohol abuse. Stable # History of severe Recurrent C. diff requiring stool transplant: C.diff negative this admission. She should remain on prophylactic 125 mg PO vancomycin Q6H for now, and continue this for one week after cessation of antibiotics to end [MASKED]. # Diarrhea: ? antibiotic associated, using Imodium prn, consider creon as she likely has some element of exocrine deficiency. # Anxiety, depression: continue home paroxetine TRANSITIONAL CARE [MASKED] F/U 1 WEEK 2.UROLOGY F/U 3 WEEKS 3.FOLEY DC'D IN 1 WEEK WITH VOIDING TRIAL 4.WEEKLY CBC, LFTS, CHEMISTRIES WHILE ON IV CEFTRIAXONE 5.DAILY-EVERY FEW DAY ELECTROLYTE MONITORING GIVEN HYPER/HYPO k, HYPOMAG Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO DAILY 2. Gemfibrozil 600 mg PO BIDAC 3. Spironolactone 25 mg PO DAILY 4. Propranolol 10 mg PO BID 5. Oxybutynin 15 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath, wheezing 8. TraZODone 50 mg PO QHS 9. [MASKED] 22 Units Breakfast [MASKED] 22 Units Dinner 10. Magnesium Oxide 800 mg PO BID 11. Potassium Chloride 40 mEq PO BID 12. PARoxetine 20 mg PO DAILY Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H Please take this until [MASKED] 2. FoLIC Acid 1 mg PO DAILY 3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath, wheezing 4. LOPERamide 2 mg PO QID:PRN diarrhea 5. Mirtazapine 15 mg PO QHS 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Thiamine 100 mg PO DAILY 8. Tiotropium Bromide 1 CAP IH DAILY 9. Vancomycin Oral Liquid [MASKED] mg PO Q6H Take this until [MASKED] (one week after you have finished ceftriaxone) 10. Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 3 Units Dinner NPH 6 Units Breakfast NPH 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath, wheezing 12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 13. Gemfibrozil 600 mg PO BIDAC 14. Magnesium Oxide 800 mg PO BID 15. Omeprazole 20 mg PO DAILY 16. PARoxetine 20 mg PO DAILY 17. Propranolol 10 mg PO BID 18. Spironolactone 25 mg PO DAILY 19. HELD- Potassium Chloride 40 mEq PO BID This medication was held. Do not restart Potassium Chloride until potassium rechecked and deemed necessary 20.Outpatient Lab Work weekly CBC, lfts, chemistries while on IV ceftriaxone Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: 1. Sepsis due to UTI/emphysematous cystitis, bacteremia 2. Alcoholic cirrhosis 3. Diabetes Mellitus 4. Dysphagia 5. Malnutrition 6. COPD 7. history of c.diff Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred here from [MASKED] with sepsis (severe infection). This was due to a urinary tract infection that affected your bladder and may have caused a small perforation in your bladder. For this, you saw the urologist, and they recommended that you have a foley catheter placed for 3 weeks and that you receive antibiotics for 3 weeks. You were also seen by the nutritionist and the diabetes specialist given your difficult to control diabetes. You presently do NOT have C diff, but we will treat you for this so that you do not develop C diff infection while you are on antibiotics. It is very important that you stop drinking alcohol as we discussed. Followup Instructions: [MASKED]
[]
[ "E871", "J449", "E1165", "Z794", "I10", "E785", "F17210", "F329", "F419", "K219" ]
[ "A4151: Sepsis due to Escherichia coli [E. coli]", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "E1310: Other specified diabetes mellitus with ketoacidosis without coma", "D61811: Other drug-induced pancytopenia", "K521: Toxic gastroenteritis and colitis", "E874: Mixed disorder of acid-base balance", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "I8510: Secondary esophageal varices without bleeding", "F10288: Alcohol dependence with other alcohol-induced disorder", "E871: Hypo-osmolality and hyponatremia", "Z006: Encounter for examination for normal comparison and control in clinical research program", "N3080: Other cystitis without hematuria", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "B952: Enterococcus as the cause of diseases classified elsewhere", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "K7030: Alcoholic cirrhosis of liver without ascites", "R1310: Dysphagia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R32: Unspecified urinary incontinence", "E538: Deficiency of other specified B group vitamins", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E876: Hypokalemia", "E8342: Hypomagnesemia", "E8339: Other disorders of phosphorus metabolism", "T3695XA: Adverse effect of unspecified systemic antibiotic, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R0902: Hypoxemia", "E8770: Fluid overload, unspecified", "I951: Orthostatic hypotension" ]
10,070,011
28,156,484
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: physohex Attending: ___. Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ Year-Old Female with hx of emphysema, lung cancer s/p resection in ___, COPD, HTN here w/ one week of cough, diarrhea and weakness. Since her lung resection she gets a bad cold annually which is treated with clarithryomycin with good effect. She does not go in for X rays. She calls her thoracic surgeon at ___ and he prescribes it for her over the telephone. Pt had chest congestion/cough/subjective fevers/ starting 5 days ago w/ watery diarrhea and night sweats. Of note her diarrhea began prior to her taking the abx. Pt was started on biaxin and has not had fevers/night sweats but was hypotensive and tachycardic and continues to have large volume diarrhea. Her last episode of diarrhea was yesterday. It was post prandial. She had profuse large volume diarrhea. She was able to eat a grilled cheese sandwich today without difficulty. She does not have chest pain. She has mild worsening of shortness of breath. She felt very fatigued and took her BP which was low to the ___ and HR = 105 three days ago. She stopped taking the biaxin. She continued to feel poorly and continued to have a diarrhea. She saw her PCP today who referred her to the ED. Upon arrival to the ED she was hypotensive with SBP = 90s. Pt found to have acute kidney injury. Baseline creatinine is 1.0. Her husband had a cold before her but did not have any GI sx. Her husband was around his grandchildren who were sick. When she breathes in her lung is sore and she feels like she needs an abx. She thinks her sx are similar to the flares of bronchitis for which Dr. ___ her clarithromycin. In the ED upon presentation: 0 |97.4 |98 |93/54 |18| 99% RA Hypotensive in the ED to 83/53 which improved with IVF. GIVEN LR X 4 L, alprazolam and advair. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Hx of lung cancer (stage I) s/p iVATS L lower lobe wedge resection on ___ COPD HTN Hyperlipidemia s/p Menopause Osteoporosis Eustachian tube dysfunction Benign positional vertigo Social History: ___ Family History: Her mother had HTN, PVD and a dissection of the aorta. Father died of lung cancer at age ___ Physical Exam: ADMISSION EXAM: VS: Temp: 98.0 PO BP: 101/64 HR: 88 RR: 18 O2 sat: 93% O2 delivery: RA GENERAL: Alert and in no apparent distress but she does look very tired 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. ? Mildly elevated JVP. RESP: Decreased breath sounds in the lower L lung field. No crackles or wheezes GI: Diminished bowel sounds throughout. Soft, non-distended, non-tender to palpation. No guarding or rebound. 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, slightly anxious . . DISCHARGE EXAM: Gen: NAD, well-appearing Cards: RR, no m/r/g Chest: CTAB with quiet/reduced breath sounds throughout; normal WOB at rest; no conversational dyspnea Abd: S, NT, ND, BS+ Neuro: AAOx3, conversant with clear speech, moving all 4s Psych: mildly anxious at times, cooperative, normal insight Pertinent Results: Admission labs: ================ ___ 01:38PM BLOOD WBC-9.5 RBC-3.05* Hgb-10.0* Hct-30.2* MCV-99* MCH-32.8* MCHC-33.1 RDW-12.3 RDWSD-44.8 Plt ___ ___ 01:38PM BLOOD Neuts-69.3 ___ Monos-6.8 Eos-2.5 Baso-0.6 Im ___ AbsNeut-6.56* AbsLymp-1.92 AbsMono-0.64 AbsEos-0.24 AbsBaso-0.06 ___ 01:38PM BLOOD Plt ___ ___ 01:38PM BLOOD Glucose-107* UreaN-38* Creat-3.7*# Na-137 K-4.1 Cl-96 HCO3-22 AnGap-19* ___ 01:38PM BLOOD ALT-36 AST-35 CK(CPK)-108 AlkPhos-145* TotBili-0.3 ___ 01:38PM BLOOD Lipase-60 ___ 01:38PM BLOOD CK-MB-3 cTropnT-<0.01 ___ 01:38PM BLOOD Albumin-4.2 Calcium-9.6 Phos-5.1* Mg-1.9 ___ 03:47PM BLOOD Lactate-1.1 ___ 04:34PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:34PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR* ___ 04:34PM URINE RBC-<1 WBC-6* Bacteri-FEW* Yeast-NONE Epi-2 ___ 04:34PM URINE CastHy-12* . . Discharge labs: =============== ___ 08:45AM BLOOD WBC-9.6 RBC-3.18* Hgb-10.3* Hct-31.2* MCV-98 MCH-32.4* MCHC-33.0 RDW-12.4 RDWSD-44.8 Plt ___ ___ 08:45AM BLOOD Glucose-109* UreaN-31* Creat-2.5*# Na-144 K-3.7 Cl-103 HCO3-22 AnGap-19* ___ 08:45AM BLOOD calTIBC-259* Ferritn-563* TRF-199* . . Micro: ======= ___ URINE URINE CULTURE-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING . . Imaging: ========== ___ CXR - "FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are hyperinflated but clear. Chain sutures are seen in the left lung base. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality." ___ Renal u/s - "FINDINGS: There is no hydronephrosis, large stones, or worrisome masses bilaterally. Note is made of a right lower pole renal cyst measuring 3.1 x 3.0 x 2.6 cm. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. -Right kidney: 10.1 cm -Left kidney: 10.3 cm The bladder is only minimally distended and can not be fully assessed on the current study. IMPRESSION: Normal exam." Brief Hospital Course: # Diarrhea: resolved prior to admission; we were unable to collect stool sample to send for infectious testing; she was tolerating regular diet with no GI symptoms on day of discharge # Hypotension: resolved with holding home metoprolol, lisinopril, HCTZ; home metoprolol resumed prior to discharge # ___: markedly improved w/ IVF (4L LR given in ED), resolution of diarrhea, and holding home metoprolol, lisinopril, HCTZ. Baseline Cr is 1, peak Cr was 3.7 on ___. Renal u/s was normal & non-obstructive. Cr improved to 2.5 on ___ and patient was feeling well and urinating normally. She was counseled to follow-up with Dr. ___ in ___ days for repeat chem10 to ensure renal function has returned to normal prior to resuming home lisinopril +/- HCTZ. [] needs repeat chem10 in ___ days to ensure renal function has returned to baseline [] resume lisinopril as soon as renal function normalizes (strong indication due to her hx of systolic HF w/ recovered EF) [] resume HCTZ only if needed for BP control # COPD exacerbation: mild; she reported she felt some chest congestion that was helped by clarithromycin at home and a dose of clarithromycin was given initially on admission at her request; her exam on the day of discharge was reassuring against a severe COPD flare and she said she felt her breathing was comfortable and that she would feel comfortable going home and doing her usual activities with her current breathing status, so she was not given steroids or sent home with a nebulizer treatment taper. We suspect she may have had a viral illness that triggered both a mild COPD flare as well as her diarrhea. . . . . Time in care: >60 minutes in discharge-related activities on the day of discharge including extensive patient & family counseling. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.25 mg PO QID:PRN anxiety 2. Atorvastatin 20 mg PO QPM 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath 6. Lisinopril 20 mg PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Medications: 1. GuaiFENesin 10 mL PO Q6H:PRN cough Duration: 3 Days 2. ALPRAZolam 0.25 mg PO QID:PRN anxiety 3. Atorvastatin 20 mg PO QPM 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until told to resume by Dr. ___ 8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do not restart Lisinopril until told to resume by Dr. ___ ___ Disposition: Home Discharge Diagnosis: # Diarrhea: resolved # Hypotension: resolved # ___: improving # COPD exacerbation: mild Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. ___, ___ were admitted to the hospital for acute kidney injury which we think was most likely due to severe dehydration/hypovolemia & low blood pressure in the setting of your profuse diarrhea. Your diarrhea has resolved and ___ are tolerating a regular diet. Please do not resume taking your home medications of lisinopril or hydrochlorothiazide until instructed to do so by Dr. ___. Please plan to see Dr. ___ in the next ___ days to have your labs checked to ensure that your kidney function has returned to your baseline, at which point one or both of those medications might be resumed. We wish ___ a full and speedy recovery. Sincerely, The ___ Medicine Tea Followup Instructions: ___
[ "N179", "J439", "J069", "E860", "E785", "I10", "D649", "Z888", "Z85118", "M810", "I959", "Z87891", "E861", "R197", "R000" ]
Allergies: physohex Chief Complaint: diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [MASKED] Year-Old Female with hx of emphysema, lung cancer s/p resection in [MASKED], COPD, HTN here w/ one week of cough, diarrhea and weakness. Since her lung resection she gets a bad cold annually which is treated with clarithryomycin with good effect. She does not go in for X rays. She calls her thoracic surgeon at [MASKED] and he prescribes it for her over the telephone. Pt had chest congestion/cough/subjective fevers/ starting 5 days ago w/ watery diarrhea and night sweats. Of note her diarrhea began prior to her taking the abx. Pt was started on biaxin and has not had fevers/night sweats but was hypotensive and tachycardic and continues to have large volume diarrhea. Her last episode of diarrhea was yesterday. It was post prandial. She had profuse large volume diarrhea. She was able to eat a grilled cheese sandwich today without difficulty. She does not have chest pain. She has mild worsening of shortness of breath. She felt very fatigued and took her BP which was low to the [MASKED] and HR = 105 three days ago. She stopped taking the biaxin. She continued to feel poorly and continued to have a diarrhea. She saw her PCP today who referred her to the ED. Upon arrival to the ED she was hypotensive with SBP = 90s. Pt found to have acute kidney injury. Baseline creatinine is 1.0. Her husband had a cold before her but did not have any GI sx. Her husband was around his grandchildren who were sick. When she breathes in her lung is sore and she feels like she needs an abx. She thinks her sx are similar to the flares of bronchitis for which Dr. [MASKED] her clarithromycin. In the ED upon presentation: 0 |97.4 |98 |93/54 |18| 99% RA Hypotensive in the ED to 83/53 which improved with IVF. GIVEN LR X 4 L, alprazolam and advair. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Hx of lung cancer (stage I) s/p iVATS L lower lobe wedge resection on [MASKED] COPD HTN Hyperlipidemia s/p Menopause Osteoporosis Eustachian tube dysfunction Benign positional vertigo Social History: [MASKED] Family History: Her mother had HTN, PVD and a dissection of the aorta. Father died of lung cancer at age [MASKED] Physical Exam: ADMISSION EXAM: VS: Temp: 98.0 PO BP: 101/64 HR: 88 RR: 18 O2 sat: 93% O2 delivery: RA GENERAL: Alert and in no apparent distress but she does look very tired 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. ? Mildly elevated JVP. RESP: Decreased breath sounds in the lower L lung field. No crackles or wheezes GI: Diminished bowel sounds throughout. Soft, non-distended, non-tender to palpation. No guarding or rebound. 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, slightly anxious . . DISCHARGE EXAM: Gen: NAD, well-appearing Cards: RR, no m/r/g Chest: CTAB with quiet/reduced breath sounds throughout; normal WOB at rest; no conversational dyspnea Abd: S, NT, ND, BS+ Neuro: AAOx3, conversant with clear speech, moving all 4s Psych: mildly anxious at times, cooperative, normal insight Pertinent Results: Admission labs: ================ [MASKED] 01:38PM BLOOD WBC-9.5 RBC-3.05* Hgb-10.0* Hct-30.2* MCV-99* MCH-32.8* MCHC-33.1 RDW-12.3 RDWSD-44.8 Plt [MASKED] [MASKED] 01:38PM BLOOD Neuts-69.3 [MASKED] Monos-6.8 Eos-2.5 Baso-0.6 Im [MASKED] AbsNeut-6.56* AbsLymp-1.92 AbsMono-0.64 AbsEos-0.24 AbsBaso-0.06 [MASKED] 01:38PM BLOOD Plt [MASKED] [MASKED] 01:38PM BLOOD Glucose-107* UreaN-38* Creat-3.7*# Na-137 K-4.1 Cl-96 HCO3-22 AnGap-19* [MASKED] 01:38PM BLOOD ALT-36 AST-35 CK(CPK)-108 AlkPhos-145* TotBili-0.3 [MASKED] 01:38PM BLOOD Lipase-60 [MASKED] 01:38PM BLOOD CK-MB-3 cTropnT-<0.01 [MASKED] 01:38PM BLOOD Albumin-4.2 Calcium-9.6 Phos-5.1* Mg-1.9 [MASKED] 03:47PM BLOOD Lactate-1.1 [MASKED] 04:34PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 04:34PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR* [MASKED] 04:34PM URINE RBC-<1 WBC-6* Bacteri-FEW* Yeast-NONE Epi-2 [MASKED] 04:34PM URINE CastHy-12* . . Discharge labs: =============== [MASKED] 08:45AM BLOOD WBC-9.6 RBC-3.18* Hgb-10.3* Hct-31.2* MCV-98 MCH-32.4* MCHC-33.0 RDW-12.4 RDWSD-44.8 Plt [MASKED] [MASKED] 08:45AM BLOOD Glucose-109* UreaN-31* Creat-2.5*# Na-144 K-3.7 Cl-103 HCO3-22 AnGap-19* [MASKED] 08:45AM BLOOD calTIBC-259* Ferritn-563* TRF-199* . . Micro: ======= [MASKED] URINE URINE CULTURE-PENDING [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING . . Imaging: ========== [MASKED] CXR - "FINDINGS: Heart size is normal. The mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Lungs are hyperinflated but clear. Chain sutures are seen in the left lung base. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality." [MASKED] Renal u/s - "FINDINGS: There is no hydronephrosis, large stones, or worrisome masses bilaterally. Note is made of a right lower pole renal cyst measuring 3.1 x 3.0 x 2.6 cm. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. -Right kidney: 10.1 cm -Left kidney: 10.3 cm The bladder is only minimally distended and can not be fully assessed on the current study. IMPRESSION: Normal exam." Brief Hospital Course: # Diarrhea: resolved prior to admission; we were unable to collect stool sample to send for infectious testing; she was tolerating regular diet with no GI symptoms on day of discharge # Hypotension: resolved with holding home metoprolol, lisinopril, HCTZ; home metoprolol resumed prior to discharge # [MASKED]: markedly improved w/ IVF (4L LR given in ED), resolution of diarrhea, and holding home metoprolol, lisinopril, HCTZ. Baseline Cr is 1, peak Cr was 3.7 on [MASKED]. Renal u/s was normal & non-obstructive. Cr improved to 2.5 on [MASKED] and patient was feeling well and urinating normally. She was counseled to follow-up with Dr. [MASKED] in [MASKED] days for repeat chem10 to ensure renal function has returned to normal prior to resuming home lisinopril +/- HCTZ. [] needs repeat chem10 in [MASKED] days to ensure renal function has returned to baseline [] resume lisinopril as soon as renal function normalizes (strong indication due to her hx of systolic HF w/ recovered EF) [] resume HCTZ only if needed for BP control # COPD exacerbation: mild; she reported she felt some chest congestion that was helped by clarithromycin at home and a dose of clarithromycin was given initially on admission at her request; her exam on the day of discharge was reassuring against a severe COPD flare and she said she felt her breathing was comfortable and that she would feel comfortable going home and doing her usual activities with her current breathing status, so she was not given steroids or sent home with a nebulizer treatment taper. We suspect she may have had a viral illness that triggered both a mild COPD flare as well as her diarrhea. . . . . Time in care: >60 minutes in discharge-related activities on the day of discharge including extensive patient & family counseling. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.25 mg PO QID:PRN anxiety 2. Atorvastatin 20 mg PO QPM 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath 6. Lisinopril 20 mg PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Medications: 1. GuaiFENesin 10 mL PO Q6H:PRN cough Duration: 3 Days 2. ALPRAZolam 0.25 mg PO QID:PRN anxiety 3. Atorvastatin 20 mg PO QPM 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN shortness of breath 6. Metoprolol Succinate XL 12.5 mg PO DAILY 7. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until told to resume by Dr. [MASKED] 8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do not restart Lisinopril until told to resume by Dr. [MASKED] [MASKED] Disposition: Home Discharge Diagnosis: # Diarrhea: resolved # Hypotension: resolved # [MASKED]: improving # COPD exacerbation: mild Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mrs. [MASKED], [MASKED] were admitted to the hospital for acute kidney injury which we think was most likely due to severe dehydration/hypovolemia & low blood pressure in the setting of your profuse diarrhea. Your diarrhea has resolved and [MASKED] are tolerating a regular diet. Please do not resume taking your home medications of lisinopril or hydrochlorothiazide until instructed to do so by Dr. [MASKED]. Please plan to see Dr. [MASKED] in the next [MASKED] days to have your labs checked to ensure that your kidney function has returned to your baseline, at which point one or both of those medications might be resumed. We wish [MASKED] a full and speedy recovery. Sincerely, The [MASKED] Medicine Tea Followup Instructions: [MASKED]
[]
[ "N179", "E785", "I10", "D649", "Z87891" ]
[ "N179: Acute kidney failure, unspecified", "J439: Emphysema, unspecified", "J069: Acute upper respiratory infection, unspecified", "E860: Dehydration", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "Z888: Allergy status to other drugs, medicaments and biological substances", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "M810: Age-related osteoporosis without current pathological fracture", "I959: Hypotension, unspecified", "Z87891: Personal history of nicotine dependence", "E861: Hypovolemia", "R197: Diarrhea, unspecified", "R000: Tachycardia, unspecified" ]
10,070,024
26,398,294
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 made a mistake." Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old female with a history of a mood disorder with psychotic features, discharged from ___ inpatient psychiatry yesterday ___, who was brought in by EMS after family called due to concerns for suicidal statements and disorganization. Psychiatry consulted for a safety evaluation. . Upon interview with patient, patient appeared pleasant and cooperative initially but quickly became guarded. She was asked about previous nights events, to which she replied "why do you want to know, it has nothing to do with you." After explaining that it appeared her being in the ED and last nights events were linked, she reported that she wanted to file a report on "a man following her" though she would not be more specific. . She stated that she is doing "well, I am very good. I have been taking my medications. I feel great. I don't want to hurt myself or anyone else. I want to get on with my life and go to college. I was going to even run 2 miles today." She was asked about how things were at home, which she became upset and stated "my family doesn't care about me. My brother was drunk. He is a liar. See, he hasn't even visited me to day. Its not a good environment for me. They stole my money and now I have been trying to live at shelters but can't without money." Patient was asked permission to speak to family, which she agreed to. . After getting collateral (see below), talked to patient again about concerns about her recent behavior. Patient began to become tearful and weep. She stated that she "just want to be normal and to live my life. I am a good person. I am not crazy. I don't believe in spirits or witchcraft. They tried to force that upon me, but that's not me. I believe in God. Do you have a church here? I want to pray because that is what I believe it. I just want to have my babies, and go to school, and to have a job. I am not in school because I am stupid. ___ I do need help." She did report drinking alcohol after confronting her due to +tox screen (level of 158), which she said she only drank 1 beer, but after further prompting said she did take "one shot." Though this is underreporting still given the level. . After further discussion with patient, patient was agreeable to inpatient psychiatric admission. She preferred not to be at ___. . COLLATERAL: Brother ___ (Home: ___ Patient's brother states that she has not been doing well since ___ of last week. They had been visiting her, but the last few days of admission she started to not look as well. She stated to the family she had been spitting out her meds. Upon discharge, she started acting strange and saying that she wanted to end her life. She then took her meds and flushed them down the toilet (Brother checked the bottle and it was empty). He states that she would start crying for no reason and ran up to her room. . Shortly after she came walking down the stairs and appeared "odd" eating chips and stating everything was okay. She then ran out of the house. He reports that she wanted alcohol but without money, she stood near liquor store and begged people to buy her alcohol. She also ran to the police station to file a report. The Brother called police station to inform them (she had already been there) but she did not file report. She then attempted to call the FBI. He states that patient was saying that "the doctors are trying to drug me. There is nothing wrong with me. I am not sick." He and patient's mother feel that she is not safe to return home at this time. . He also states she will downplay most of her symptoms and attempt to appear well. She also will become quite labile and aggressive at times. . Past Medical History: PAST PSYCHIATRIC HISTORY: Per Dr. ___ ___ psychiatric consultation note, updated as necessary: -Past diagnoses: per ___ discharge summary, mood disorder with psychotic features -Hospitalizations: ___, discharged ___ -Psychiatrist: patient was to be referred to psychiatry through her PCP -___ Risperdal, Zoloft -Self-injury/Suicide attempts: -Ran into a car while drunk ___ year ago; states that she blacked out and that she does not recall any details of whether she physically got hit by the car or how she got home; however, denies that EMS had to be called, and she did not have to go to a hospital -Tried to cut herself on the wrist with a knife 7 months ago, but "it wasn't sharp enough" -Harm to others: -___ years ago, was being kicked out of a bar by a "rich woman with bodyguards", became angry as she was being condescending and punched her in the face, which resulted in an arrest, 1 night at jail, and a charge of assault and battery leading to probation status -Trauma: reports being sexually abused by her step-father . PAST MEDICAL HISTORY: -Head trauma: -Multiple head injuries due to being dropped at age ___ -Microwave fell on her head at age ___ -Fell down the stairs and hit her head ___ years ago -Seizures: Denies -PMHx: R ovarian cyst removal ___ years ago . Social History: SUBSTANCE USE HISTORY: -EtOH: patient reports drinking "2 drinks" prior to ED presentation -Tobacco: Denies -Marijuana: patient denies currently, per chart review past use started at age ___, 3~7 joints/day -Illicits: Denies . FORENSIC HISTORY: Per Dr. ___ ___ psychiatric consultation note: -Arrests: -___ years ago, arrested for punching a woman in the face (per OMR review, patient was in ___ ED in ___ for hand fracture ___ to punching another individual) -Convictions and jail terms: -1 night in jail after punching incident -Current status (pending charges, probation, parole): -Assault and battery (per above episode of punching the woman), on probation: not allowed to leave the country, not allowed to go near the woman she punched, must attend AA . SOCIAL HISTORY: ___ Family History: FAMILY PSYCHIATRIC HISTORY: -Fam Dx: -Father: depression, bipolar, alcoholic -Mother: OCD -Brother: depression -___ Hospitalizations: Denies -Fam Hx Suicide: Unknown . Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.2 BP 113/77 HR 82 RR 16 ___ 97 Gen: NAD, normal posture, well-nourished, thin, appears younger than stated age HEENT: Sclera anicteric. Oropharynx benign. Mucous membranes moist. CV: warm and well-perfused Chest: normal work of breathing Abdomen: non-distended Ext: no edema. Skin: no rashes . Neuropsychiatric Examination: Neurological: *station and gait: normal stance, no truncal ataxia, steady gait *tone and strength: moves all four extremities spontaneously against gravity cranial nerves: no gross facial asymmetry, eyes track examiner appropriately abnormal movements: no adventitious movements or abnormal posturing noted frontal release: not assessed Cognition: Wakefulness/alertness: Awake, alert *Attention (digit span, MOYB): Attentive to interview *Orientation: Oriented to self, place, situation *Memory: Intact to recent and remote events *Fund of knowledge: Consistent with level of education *Speech: Rapid rate, but interruptible *Language: Fluent ___, no paraphasias noted Mental Status: *Appearance: Wearing own clothes, sitting at table, appears slightly younger than stated age Behavior: makes appropriate eye contact with interviewer *Mood and Affect: "depressed and anxious" *Thought process: linear, goal-directed *Thought Content: Denies SI, HI, AVH *Judgment and Insight: limited/limited DISCHARGE EXAM: Vital signs: T 98.1, BP 109/73, HR 69, RR 16, SpO2 97 Alertness/Wakefulness: alert, awake Ambulation status: ambulates independently Mental Status: *Appearance: well-appearing, NAD, appears somewhat younger than stated age Behavior: calm, cooperative, pleasant, appropriate eye contact *Mood and Affect: "good", euthymic, full range *Thought process: linear, goal-directed *Thought Content: Denies SI, HI, AVH *Judgment and Insight: fair/fair . Pertinent Results: LABS: ___ 09:18PM BLOOD Glucose-109* UreaN-16 Creat-0.7 Na-141 K-4.2 Cl-100 HCO3-26 AnGap-15 ___ 09:18PM BLOOD ALT-15 AST-14 AlkPhos-59 TotBili-0.3 ___ 09:18PM BLOOD Calcium-9.6 Phos-4.7* Mg-2.2 ___ 09:18PM BLOOD VitB12-___ ___ 09:18PM BLOOD TSH-2.7 ___ 09:18PM BLOOD HCG-<5 . Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. She was also placed on q5 minute checks status on admission and increased to q15 minute checks while being unit restricted. . Her parole officer was contacted to provide verification for patient's current admission such that she would not be able to attend her court appearance due ___. . 2. PSYCHIATRIC: #) Bipolar disorder with psychotic features; r/o substance induced mood disorder with psychotic features: . Ms. ___ presented again to the hospital on the same day as discharge from prior hospitalization with paranoia and depressed mood in the setting of alcohol intoxication. Her ED interview was notable for paranoia and pressured speech and her exam on admission to the psychiatry unit the following day was vastly different. She was noted to be friendly, engaged, attentive, with a good mood, euthymic affect, somewhat activated appearance, but linear, goal oriented thought process, and thought content devoid of paranoia, delusions, SI, or HI. She was able to give an organized history of acute stressors leading to re-hospitalization, including being contacted by another patient who was also recently discharged from the unit. This other patient was telling her to dump her medications and not to trust the pills or her providers and led her to flush all her antipsychotics down the toilet. She also went to the bar and became intoxicated, which worsened her paranoia and anxiety. Therefore, she was restarted on Risperidone and Sertraline, which is what she had been on during the previous hospitalization but had not been taking consistently (was cheeking meds). . Over the course of the hospitalization, she became increasingly more activated, with pressured speech with loose associations and emotionally labile. Overnight on ___, she had a behavioral trigger with paranoia, calling 911 for fear of her safety and needing constant supervision. This was thought to be worsening of underlying mania/ hypomania in the setting of Sertraline use. Therefore, Sertraline was stopped and Risperidone was increased. Risperidone was subsequently switched to Paliperidone for improved compliance with once daily administration, and patient tolerated the medication well. Standing Lorazepam was also added briefly and then weaned once her affect stabilized. With these changes, she had improvement in her mood and appeared less activated, less pressured and more linear. . Patient improved markedly after these medication changes. For several days leading prior to discharge, patient appeared calm with appropriate behavior, "good" mood, euthymic affect, absent lability, linear thought process without loosening of associations, no expressed suicidal ideation or thoughts of harming self or others; she denied the presence of hallucinations, nor did she appear internally preoccupied. She did not verbalize any delusional or paranoid thought content. Throughout her admission she remained consistently medication adherent, and she expressed willingness to continue her medications following discharge. Patient identified goals following discharge as attending her primary care appointment on ___ and report to her probation officer. Patient indicated that she would be willing to stay with her mother (who has been visiting her daily since admission). She will be discharged home with a plan to establish mental health care through her PCP. We encourage outpatient providers to consider long acting injectable formulation of Paliperidone in the future. . 3. SUBSTANCE USE DISORDERS: #) Alcohol use disorder: She was monitored on CIWA but did not score. She was encouraged to stop drinking alcohol. . #) Marijuana use disorder: She was encouraged to stop smoking marijuana, and patient indicated that she would abstain from further marijuana use. . 4. MEDICAL #) Vitamin D deficiency She was continued on vitamin D supplementation. . 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. . #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: - ___ (mother) ___ - ___ (aunt) ___ - ___ (brother) ___ - PCP: Dr. ___ ___ ___ Phone: ___ Fax: ___ - Parole officer: ___ Phone ___. Fax ___ . With patient's permission, spoke with patient's brother ___ ___ (___) after he called the night prior to discharge concerned about patient's safety; he reiterated previously stated concerns regarding patient's clinical status (please see note from ___ by Dr. ___. Brother qualified that he has not observed/visited patient during current admission, but was relaying observations made by family members. Patient cited behaviors and symptoms prior to admission (e.g. "She flushed her medications" "She wanted me to meet her at the liquor store" "She was acting crazy"). Brother expressed preference for patient to be admitted "for a month or so" in order to further stabilize; however, brother was unable to identify specifically how/when this would manifest. Of note, mother has not, nor other family members have not, communicated any concerns to treatment team since admission regarding patient's current symptoms. . INFORMED CONSENT: Paliperidone The team discussed the indications for, intended benefits of, and possible side effects and risks of starting Risperidone, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and the team answered the patient's questions. The patient appeared able to understand and consented to begin the medication. . RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon disorganization and psychosis. Her static factors noted at that time include history of abuse chronic mental illness, history of substance abuse, recent discharge from an inpatient psychiatric unit, and age. The modifiable risk factors were also addressed at that time, including psychosis, disorganized and unpredictable behavior, medication noncompliance, lack of engagement with outpatient treatment, agitation, recklessness, limited social supports, limited coping skills, active substance abuse/intoxication, impulsivity, polarized thinking. This was improved with antipsychotics and providing a safe and structured therapeutic environment. Finally, the patient is being discharged with many protective risk factors, including help-seeking nature, future-oriented viewpoint, sense of responsibility to family, life satisfaction, lack of suicidal ideation, and strong social supports. At time of discharge, patient demonstrated preserved capacity to engage in a meaningful conversation about safety planning in the event that thoughts of self-harm arise or psychiatric symptoms worsen (e.g. patient would present to the ED or call ___. Overall, based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. RisperiDONE 2 mg PO QHS 2. Sertraline 50 mg PO DAILY Discharge Medications: 1. PALIperidone ER 3 mg PO QHS 2. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half) tablet(s) by mouth daily Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Bipolar disorder with psychotic features rule out substance induced mood disorder with psychotic features 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. . We strongly recommend engaging in AA/NA/SMART recovery meetings for ongoing help with sobriety. Here is a website with links to meetings near your area: ___ . Followup Instructions: ___
[ "F3189", "E559", "F1290", "Z7289", "Z915", "Z818" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I made a mistake." Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old female with a history of a mood disorder with psychotic features, discharged from [MASKED] inpatient psychiatry yesterday [MASKED], who was brought in by EMS after family called due to concerns for suicidal statements and disorganization. Psychiatry consulted for a safety evaluation. . Upon interview with patient, patient appeared pleasant and cooperative initially but quickly became guarded. She was asked about previous nights events, to which she replied "why do you want to know, it has nothing to do with you." After explaining that it appeared her being in the ED and last nights events were linked, she reported that she wanted to file a report on "a man following her" though she would not be more specific. . She stated that she is doing "well, I am very good. I have been taking my medications. I feel great. I don't want to hurt myself or anyone else. I want to get on with my life and go to college. I was going to even run 2 miles today." She was asked about how things were at home, which she became upset and stated "my family doesn't care about me. My brother was drunk. He is a liar. See, he hasn't even visited me to day. Its not a good environment for me. They stole my money and now I have been trying to live at shelters but can't without money." Patient was asked permission to speak to family, which she agreed to. . After getting collateral (see below), talked to patient again about concerns about her recent behavior. Patient began to become tearful and weep. She stated that she "just want to be normal and to live my life. I am a good person. I am not crazy. I don't believe in spirits or witchcraft. They tried to force that upon me, but that's not me. I believe in God. Do you have a church here? I want to pray because that is what I believe it. I just want to have my babies, and go to school, and to have a job. I am not in school because I am stupid. [MASKED] I do need help." She did report drinking alcohol after confronting her due to +tox screen (level of 158), which she said she only drank 1 beer, but after further prompting said she did take "one shot." Though this is underreporting still given the level. . After further discussion with patient, patient was agreeable to inpatient psychiatric admission. She preferred not to be at [MASKED]. . COLLATERAL: Brother [MASKED] (Home: [MASKED] Patient's brother states that she has not been doing well since [MASKED] of last week. They had been visiting her, but the last few days of admission she started to not look as well. She stated to the family she had been spitting out her meds. Upon discharge, she started acting strange and saying that she wanted to end her life. She then took her meds and flushed them down the toilet (Brother checked the bottle and it was empty). He states that she would start crying for no reason and ran up to her room. . Shortly after she came walking down the stairs and appeared "odd" eating chips and stating everything was okay. She then ran out of the house. He reports that she wanted alcohol but without money, she stood near liquor store and begged people to buy her alcohol. She also ran to the police station to file a report. The Brother called police station to inform them (she had already been there) but she did not file report. She then attempted to call the FBI. He states that patient was saying that "the doctors are trying to drug me. There is nothing wrong with me. I am not sick." He and patient's mother feel that she is not safe to return home at this time. . He also states she will downplay most of her symptoms and attempt to appear well. She also will become quite labile and aggressive at times. . Past Medical History: PAST PSYCHIATRIC HISTORY: Per Dr. [MASKED] [MASKED] psychiatric consultation note, updated as necessary: -Past diagnoses: per [MASKED] discharge summary, mood disorder with psychotic features -Hospitalizations: [MASKED], discharged [MASKED] -Psychiatrist: patient was to be referred to psychiatry through her PCP -[MASKED] Risperdal, Zoloft -Self-injury/Suicide attempts: -Ran into a car while drunk [MASKED] year ago; states that she blacked out and that she does not recall any details of whether she physically got hit by the car or how she got home; however, denies that EMS had to be called, and she did not have to go to a hospital -Tried to cut herself on the wrist with a knife 7 months ago, but "it wasn't sharp enough" -Harm to others: -[MASKED] years ago, was being kicked out of a bar by a "rich woman with bodyguards", became angry as she was being condescending and punched her in the face, which resulted in an arrest, 1 night at jail, and a charge of assault and battery leading to probation status -Trauma: reports being sexually abused by her step-father . PAST MEDICAL HISTORY: -Head trauma: -Multiple head injuries due to being dropped at age [MASKED] -Microwave fell on her head at age [MASKED] -Fell down the stairs and hit her head [MASKED] years ago -Seizures: Denies -PMHx: R ovarian cyst removal [MASKED] years ago . Social History: SUBSTANCE USE HISTORY: -EtOH: patient reports drinking "2 drinks" prior to ED presentation -Tobacco: Denies -Marijuana: patient denies currently, per chart review past use started at age [MASKED], 3~7 joints/day -Illicits: Denies . FORENSIC HISTORY: Per Dr. [MASKED] [MASKED] psychiatric consultation note: -Arrests: -[MASKED] years ago, arrested for punching a woman in the face (per OMR review, patient was in [MASKED] ED in [MASKED] for hand fracture [MASKED] to punching another individual) -Convictions and jail terms: -1 night in jail after punching incident -Current status (pending charges, probation, parole): -Assault and battery (per above episode of punching the woman), on probation: not allowed to leave the country, not allowed to go near the woman she punched, must attend AA . SOCIAL HISTORY: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: -Fam Dx: -Father: depression, bipolar, alcoholic -Mother: OCD -Brother: depression -[MASKED] Hospitalizations: Denies -Fam Hx Suicide: Unknown . Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.2 BP 113/77 HR 82 RR 16 [MASKED] 97 Gen: NAD, normal posture, well-nourished, thin, appears younger than stated age HEENT: Sclera anicteric. Oropharynx benign. Mucous membranes moist. CV: warm and well-perfused Chest: normal work of breathing Abdomen: non-distended Ext: no edema. Skin: no rashes . Neuropsychiatric Examination: Neurological: *station and gait: normal stance, no truncal ataxia, steady gait *tone and strength: moves all four extremities spontaneously against gravity cranial nerves: no gross facial asymmetry, eyes track examiner appropriately abnormal movements: no adventitious movements or abnormal posturing noted frontal release: not assessed Cognition: Wakefulness/alertness: Awake, alert *Attention (digit span, MOYB): Attentive to interview *Orientation: Oriented to self, place, situation *Memory: Intact to recent and remote events *Fund of knowledge: Consistent with level of education *Speech: Rapid rate, but interruptible *Language: Fluent [MASKED], no paraphasias noted Mental Status: *Appearance: Wearing own clothes, sitting at table, appears slightly younger than stated age Behavior: makes appropriate eye contact with interviewer *Mood and Affect: "depressed and anxious" *Thought process: linear, goal-directed *Thought Content: Denies SI, HI, AVH *Judgment and Insight: limited/limited DISCHARGE EXAM: Vital signs: T 98.1, BP 109/73, HR 69, RR 16, SpO2 97 Alertness/Wakefulness: alert, awake Ambulation status: ambulates independently Mental Status: *Appearance: well-appearing, NAD, appears somewhat younger than stated age Behavior: calm, cooperative, pleasant, appropriate eye contact *Mood and Affect: "good", euthymic, full range *Thought process: linear, goal-directed *Thought Content: Denies SI, HI, AVH *Judgment and Insight: fair/fair . Pertinent Results: LABS: [MASKED] 09:18PM BLOOD Glucose-109* UreaN-16 Creat-0.7 Na-141 K-4.2 Cl-100 HCO3-26 AnGap-15 [MASKED] 09:18PM BLOOD ALT-15 AST-14 AlkPhos-59 TotBili-0.3 [MASKED] 09:18PM BLOOD Calcium-9.6 Phos-4.7* Mg-2.2 [MASKED] 09:18PM BLOOD VitB12-[MASKED] [MASKED] 09:18PM BLOOD TSH-2.7 [MASKED] 09:18PM BLOOD HCG-<5 . Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. She was also placed on q5 minute checks status on admission and increased to q15 minute checks while being unit restricted. . Her parole officer was contacted to provide verification for patient's current admission such that she would not be able to attend her court appearance due [MASKED]. . 2. PSYCHIATRIC: #) Bipolar disorder with psychotic features; r/o substance induced mood disorder with psychotic features: . Ms. [MASKED] presented again to the hospital on the same day as discharge from prior hospitalization with paranoia and depressed mood in the setting of alcohol intoxication. Her ED interview was notable for paranoia and pressured speech and her exam on admission to the psychiatry unit the following day was vastly different. She was noted to be friendly, engaged, attentive, with a good mood, euthymic affect, somewhat activated appearance, but linear, goal oriented thought process, and thought content devoid of paranoia, delusions, SI, or HI. She was able to give an organized history of acute stressors leading to re-hospitalization, including being contacted by another patient who was also recently discharged from the unit. This other patient was telling her to dump her medications and not to trust the pills or her providers and led her to flush all her antipsychotics down the toilet. She also went to the bar and became intoxicated, which worsened her paranoia and anxiety. Therefore, she was restarted on Risperidone and Sertraline, which is what she had been on during the previous hospitalization but had not been taking consistently (was cheeking meds). . Over the course of the hospitalization, she became increasingly more activated, with pressured speech with loose associations and emotionally labile. Overnight on [MASKED], she had a behavioral trigger with paranoia, calling 911 for fear of her safety and needing constant supervision. This was thought to be worsening of underlying mania/ hypomania in the setting of Sertraline use. Therefore, Sertraline was stopped and Risperidone was increased. Risperidone was subsequently switched to Paliperidone for improved compliance with once daily administration, and patient tolerated the medication well. Standing Lorazepam was also added briefly and then weaned once her affect stabilized. With these changes, she had improvement in her mood and appeared less activated, less pressured and more linear. . Patient improved markedly after these medication changes. For several days leading prior to discharge, patient appeared calm with appropriate behavior, "good" mood, euthymic affect, absent lability, linear thought process without loosening of associations, no expressed suicidal ideation or thoughts of harming self or others; she denied the presence of hallucinations, nor did she appear internally preoccupied. She did not verbalize any delusional or paranoid thought content. Throughout her admission she remained consistently medication adherent, and she expressed willingness to continue her medications following discharge. Patient identified goals following discharge as attending her primary care appointment on [MASKED] and report to her probation officer. Patient indicated that she would be willing to stay with her mother (who has been visiting her daily since admission). She will be discharged home with a plan to establish mental health care through her PCP. We encourage outpatient providers to consider long acting injectable formulation of Paliperidone in the future. . 3. SUBSTANCE USE DISORDERS: #) Alcohol use disorder: She was monitored on CIWA but did not score. She was encouraged to stop drinking alcohol. . #) Marijuana use disorder: She was encouraged to stop smoking marijuana, and patient indicated that she would abstain from further marijuana use. . 4. MEDICAL #) Vitamin D deficiency She was continued on vitamin D supplementation. . 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. . #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: - [MASKED] (mother) [MASKED] - [MASKED] (aunt) [MASKED] - [MASKED] (brother) [MASKED] - PCP: Dr. [MASKED] [MASKED] [MASKED] Phone: [MASKED] Fax: [MASKED] - Parole officer: [MASKED] Phone [MASKED]. Fax [MASKED] . With patient's permission, spoke with patient's brother [MASKED] [MASKED] ([MASKED]) after he called the night prior to discharge concerned about patient's safety; he reiterated previously stated concerns regarding patient's clinical status (please see note from [MASKED] by Dr. [MASKED]. Brother qualified that he has not observed/visited patient during current admission, but was relaying observations made by family members. Patient cited behaviors and symptoms prior to admission (e.g. "She flushed her medications" "She wanted me to meet her at the liquor store" "She was acting crazy"). Brother expressed preference for patient to be admitted "for a month or so" in order to further stabilize; however, brother was unable to identify specifically how/when this would manifest. Of note, mother has not, nor other family members have not, communicated any concerns to treatment team since admission regarding patient's current symptoms. . INFORMED CONSENT: Paliperidone The team discussed the indications for, intended benefits of, and possible side effects and risks of starting Risperidone, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and the team answered the patient's questions. The patient appeared able to understand and consented to begin the medication. . RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon disorganization and psychosis. Her static factors noted at that time include history of abuse chronic mental illness, history of substance abuse, recent discharge from an inpatient psychiatric unit, and age. The modifiable risk factors were also addressed at that time, including psychosis, disorganized and unpredictable behavior, medication noncompliance, lack of engagement with outpatient treatment, agitation, recklessness, limited social supports, limited coping skills, active substance abuse/intoxication, impulsivity, polarized thinking. This was improved with antipsychotics and providing a safe and structured therapeutic environment. Finally, the patient is being discharged with many protective risk factors, including help-seeking nature, future-oriented viewpoint, sense of responsibility to family, life satisfaction, lack of suicidal ideation, and strong social supports. At time of discharge, patient demonstrated preserved capacity to engage in a meaningful conversation about safety planning in the event that thoughts of self-harm arise or psychiatric symptoms worsen (e.g. patient would present to the ED or call [MASKED]. Overall, based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. RisperiDONE 2 mg PO QHS 2. Sertraline 50 mg PO DAILY Discharge Medications: 1. PALIperidone ER 3 mg PO QHS 2. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half) tablet(s) by mouth daily Disp #*20 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Bipolar disorder with psychotic features rule out substance induced mood disorder with psychotic features 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. . We strongly recommend engaging in AA/NA/SMART recovery meetings for ongoing help with sobriety. Here is a website with links to meetings near your area: [MASKED] . Followup Instructions: [MASKED]
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[ "F3189: Other bipolar disorder", "E559: Vitamin D deficiency, unspecified", "F1290: Cannabis use, unspecified, uncomplicated", "Z7289: Other problems related to lifestyle", "Z915: Personal history of self-harm", "Z818: Family history of other mental and behavioral disorders" ]
10,070,024
26,769,931
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 don't want to live anymore and I don't want to talk to my family." Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ yo F, no formerly diagnosed PPHx, self-reported depression since age ___, self-reported extensive trauma history of sexual abuse by multiple family members/relatives since age ___, 1 reported SA by walking into a car, no past psychiatric hospitalizations, who self-presented to the ___ ED with worsening depression and SI with plan to mix and ingest cleaning chemicals in the setting of being kicked out of her home 3 days ago. HISTORY OF PRESENT ILLNESS: Per Dr. ___ ___ ED Initial Psychiatry Consult note: "Patient states that since age ___, she has been sexually abused by multiple members of her family, including her stepfather, an uncle, and another distant relative. Since age ___, the primary abuser has been her stepfather, whom she claims would play with her doorknob at night to terrify her, would wait until she falls asleep to touch her, and once she became older, started to spike her drinks to make her lose consciousness to further sexually abuse her. Throughout the years, the patient has attempted to speak about this with her mother, but that her mother usually has minimized the patient's story, telling her that she is lying. Patient states that her mother's disbelief of the patient's reports became even more severe once the patient began to smoke cannabis, as her mother would blame her cannabis use as the source of her being paranoid and "crazy". 3 days ago, the patient again attempted to speak about the subject with her mother, who stated that "this is it" and got "fed up" and told the patient that she cannot stay with them anymore. Patient states that the mother also became extremely upset and called all of the family/extended family to "turn them against [the patient]", which the patient knows happened as she received a Facebook message from one of her aunts telling the patient that "you are a liar, you are crazy, you need to leave the family alone". The patient left the home around 21:00 and stayed at a male friend's place. 2 days ago, the patient stayed at a different male friend's place. She also visited her home to pick up clothes, when she ran into her stepfather who was packing things to leave and told the patient "I'll leave the home so you can have it all to yourself". This felt like proof to the patient that he is guilty as "if he didn't do anything wrong, why would he run away". Yesterday, the patient decided to stay at the ___ as she no longer felt safe staying over at men's places. While staying at the shelter, the patient felt distressed and depressed as she was tempted to use drugs other than cannabis. This morning, the patient went home to pick up clothes as she knew that no one would be home. Once she got home, she felt extremely depressed, hopeless, worthless, and was looking online for the most painless methods for suicide. She reports that for the past 1 week, she had watched videos on YouTube of "hanging, shooting, poisoning" and that out of these, she felt that SA by mixing household cleaners was the one that appeared to be the best. Then, she broke down crying and called her friend ___ (friend of an ex-boyfriend) who had gone through a similar situation as the patient (substance use, homelessness, sexual trauma) who on the phone was telling the patient to go to the hospital. The patient then took a shower and took the T to bring herself to the ___ ED. When asked how she has been feeling since being in the ED, states her mood is "good because I'm not at home" but then states she is "desperate", and feels depressed. She does not know where she can go, and that if she were to leave the hospital, she might end up alone at a park. States "I wouldn't mind if I died right now" but denies active SI with plan at this time. States "nobody's here for me, nobody cares"." In the ED, patient was in good behavioral control with no chemical or physical restraints required. Interview on the unit the day slightly limited by the patient's relative fatigue given at the time of interview around midnight. Patient endorses much of the HPI above, reaffirming that she does not want to live and that she does not want to talk to her family, especially her mother. Patient states that she believes that being away from her family will allow her to feel better. Denies any active suicidal ideation. REVIEW OF SYSTEMS: As per Dr. ___ evaluation: Depression: patient states she has had depressed mood since age ___ when she was bullied. Endorses anhedonia of ___ year (states she used to enjoy dancing, singing, art), increased appetite of 5 months (13 lbs. weight gain, with rapid weight loss 1 month ago due to 2 weeks of diarrhea), "terrible concentration" for ___ years, feeling hopeless/helpless/worthless/guilty as she feels "no ___ ever love me, I don't have money for the train, I feel like a failure, I don't see a future for myself". Psychosis: Since she was young, everyone wanted to be her friend, and she knew she was different/special. States she has always been very spiritual, has always prayed to the saints. ___ years ago, she first realized she had special abilities when she saw a man crying on the street and she knew that the man's son had died just by looking at him (states she told the man this and he confirmed this). Also states that she has been getting prophetic messages being communicated to her from the universe, and that she has been writing these messages down. Since ___ year ago, she has been able to see people's energies by focusing on them; she can visually see on top of their heads colors of either red, yellow, or green and that each of the colors mean something. 3 months ago, her friend hurt his foot; she massaged it and overnight, it healed. 2 months ago, she saw a man walking strangely on the street and she focused her energy on him, prayed for him, and suddenly he began to walk normally. Also shares that she met a ___ named ___ at a bar in ___, which changed her life, as he improved her memory and has been giving her hints such as "watch out for the iron" (and she would subsequently see her stepfather with an iron the next day). States that this man has become a mentor for her, but that as of today, she told him to stay away from her life as he responded to her call by saying "I'm busy". Denies sx of mania Denies sx of PTSD: [nightmares, flashbacks, hypervigilance, avoidance] Past Medical History: PAST PSYCHIATRIC HISTORY: [Extracted from Dr. ___ ___ ED Initial Psychiatry Consult note, reviewed with patient, and updated as appropriate.] No formal past psychiatric diagnoses, hospitalizations, psychiatrists/therapists/medication trials. PPHx significant for one suicide attempt ___ year ago when she ran into a car while drunk; patient states she blacked out and that she does not recall any of the details, denies that EMS had to be called, did not have to go to the hospital. Also tried to cut herself on the wrist with a knife 7 months ago, but "it wasn't sharp enough". -Harm to others: -___ years ago, was being kicked out of a bar by a "rich woman with bodyguards", became angry as she was being condescending and punched her in the face, which resulted in an arrest, 1 night at jail, and a charge of assault and battery leading to probation status -Trauma: -Per HPI PAST MEDICAL HISTORY: **PCP: ___ -___ trauma: -Multiple head injuries due to being dropped at age ___ -Microwave fell on her head at age ___ -Fell down the stairs and hit her head ___ years ago -Seizures: -Denies MEDICATIONS: [Including vitamins, herbs, supplements, OTC] None ALLERGIES: NKDA Social History: SUBSTANCE USE HISTORY: -EtOH: -Started at ___, stopped at age ___ briefly, then started again at ___ (4 drinks of hard liquor a day) and stopped ___ year ago -Tobacco: -Denies -Illicits: -Marijuana: started at age ___, 3~7 joints/day, last use 1 week ago FORENSIC HISTORY: -Arrests: -___ years ago, arrested for punching a woman in the face (per OMR review, patient was in ___ ED in ___ for hand fracture ___ to punching another individual) -Convictions and jail terms: -1 night in jail after punching incident -Current status (pending charges, probation, parole): -Assault and battery (per above episode of punching the woman), on probation: not allowed to leave the country, not allowed to go near the woman she punched, must attend ___ SOCIAL HISTORY: ___ Family History: FAMILY PSYCHIATRIC HISTORY: -Fam Dx: -Father: depression, bipolar, alcoholic -Mother: OCD -Brother: depression -___ Hospitalizations: -Denies -Fam Hx Suicide: -Unknown Physical Exam: Exam on admission VITAL SIGNS: T: 97.9 , HR: 59, BP: 121/80, RR , SpO2 100% on RA EXAM: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear, supple neck. No scleral icterus. -Cardiovascular: Regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops. Distal pulses ___ throughout. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -Abdominal: Non-distended, bowel sounds normoactive. No tenderness to palpation in all quadrants. No guarding, no rebound tenderness. -Extremities: Warm and well-perfused. No edema of the limbs. -Skin: No rashes or lesions noted. Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. ---III, IV, VI: EOMI without nystagmus ---V: Facial sensation intact to light touch in all distributions ---VII: No facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally ---VIII: Hearing intact to finger rub bilaterally ---IX, X: Palate elevates symmetrically ---XI: ___ strength in trapezii and SCM bilaterally ---XII: Tongue protrudes in midline -Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength ___ throughout. -Sensory: No deficits to fine touch throughout -DTRs: 2 and symmetrical throughout Coordination: Normal on finger to nose test, no intention tremor noted -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Cognition: -Wakefulness/alertness: Awake and alert -Attention: DOTWb with 0 errors -Orientation: ___, fourth floor" , ___ , oriented to self -Executive function (go-no go, Luria, trails, FAS): Not tested -Memory: ___ registration, ___ recall after 5 ___ grossly intact -Fund of knowledge: Consistent with education; intact to last 3 presidents -Calculations: Initially states 8, then corrects herself and states 7 = "$1.75" -Abstraction: Interprets "the grass is always greener on the other side" as "something can be better, but that is not always the case" -Visuospatial: Not assessed -Language: Non-native ___ speaker, no paraphasic errors, appropriate to conversation Mental Status: -Appearance: Thin woman appearing slightly younger than stated age with black glasses, well groomed, wearing hospital gown, in no apparent distress -Behavior: Sitting up in chair, appropriate eye contact, no psychomotor agitation or retardation -Attitude: Cooperative, engaged, friendly -Mood: "Tired" -Affect: Mood-congruent, dysphoric and intermittently tearful but laughs appropriately during conversation -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Content: ---Safety: SI as above, denies HI ---Delusions: Some suspicion that her family is working against her ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: Poor Exam on discharge Vitals: ___ 0804 Temp: 98.2 PO BP: 106/72 HR: 65 RR: 18 O2 sat: 99% Mental Status Exam: Appearance: Thin, younger than stated age, adequate hygiene, wearing scarf over hospital attire. Behavior: Calm, cooperative, fair eye contact, no PMA/PMR Speech: Accent, soft-spoken, normal speed, decreased prosody Mood: "much better" Affect: mood-congruent, euthymic, congruent with mood Thought Process: linear, coherent, goal-oriented. no loosening of associations Thought Content: Denies SI/HI/AH/VH, ideas that someone has dressed at her to get her in trouble Judgment and Insight: improving, fair/fair Neurological: Station and gait: WNL Tone and strength: Grossly intact Abnormal movements: None noted Cognition: Wakefulness/alertness: Awake and alert Attention: Intact to interview Orientation: Oriented to self and situation Memory: Intact to recent and past history Fund of knowledge: consistent with education Language: native ___ speaker, no paraphasic errors, appropriate to conversation. Pertinent Results: ___ 12:09PM BLOOD WBC-7.0 RBC-4.34 Hgb-13.0 Hct-38.4 MCV-89 MCH-30.0 MCHC-33.9 RDW-11.9 RDWSD-38.7 Plt ___ ___ 12:09PM BLOOD Neuts-65.2 ___ Monos-5.6 Eos-1.7 Baso-0.4 Im ___ AbsNeut-4.53 AbsLymp-1.86 AbsMono-0.39 AbsEos-0.12 AbsBaso-0.03 ___ 12:09PM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-141 K-4.0 Cl-102 HCO3-25 AnGap-14 ___ 06:19AM BLOOD ALT-9 AST-11 AlkPhos-45 TotBili-0.3 ___ 06:19AM BLOOD %HbA1c-4.7 eAG-88 ___ 06:19AM BLOOD Triglyc-59 HDL-59 CHOL/HD-2.4 LDLcalc-69 ___ 06:19AM BLOOD TSH-1.2 ___ 06:19AM BLOOD 25VitD-13* ___ 06:19AM BLOOD HCG-<5 ___ 12:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 07:00AM BLOOD WBC-7.0 RBC-3.91 Hgb-11.7 Hct-34.4 MCV-88 MCH-29.9 MCHC-34.0 RDW-11.9 RDWSD-38.1 Plt ___ ___ 07:00AM BLOOD Glucose-85 UreaN-13 Creat-0.6 Na-141 K-4.2 Cl-104 HCO3-28 AnGap-9* ___ 07:00AM BLOOD Calcium-9.5 Phos-4.5 Mg-2.2 ___ 11:38PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Urine culture: negative Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. They were also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. Their sharps were restricted over the first few days as patient had made statement about wanted to shave her head so that others would not be able to recognize her. As her psychiatric symptoms improved, her sharps status was advanced so that she could use a razor and attend project groups, which she tolerated well without incident. 2. PSYCHIATRIC: #) Unspecified mood disorder with psychotic features (bipolar vs MDD with psychotic features) Patient presented with suicidal ideation and intent to swallow household cleaners. She was started on Risperdal, which was increased to a final dose of 2 mg PO QHS, with good effect at reducing anxiety, paranoia, and insomnia. Additionally, Zoloft was started and increased to a final dose of 50 mg PO daily, with improvement in mood and anxiety. She tolerated both medications well and did not report side effects. She also attended groups and participated in individual, group, and milieu therapy. Family (mother and sister) were involved in treatment planning and visited frequently. - The following medications were started on this admission: Risperdal 2 mg PO QHS Zoloft 50 mg PO daily 3. SUBSTANCE USE DISORDERS: #)Cannabis use Patient reported marijuana use several times a week for last year. Encouraged cessation and counseling, particularly given patient's paranoia and anxiety. 4. MEDICAL # Constipation Patient reported constipation during hospitalization which was treated with milk of mag 30ml daily PRN with good effect. Patient had one episode of diarrhea after taking this medication which related bradycardia, dizziness, and vomiting. This medication was stopped and symptoms resolved. Patient had normal vitals and labs after this incident and it was not felt to be infectious or require further work up. # Low vitamin D Vitamin D 1000 UNIT PO/NG DAILY low Vitamin D 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient attended these groups that focused on teaching patients various coping skills. Patient remained friendly, compliant with milieu. She usually stayed to herself.. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: ___ (mother) ___- patient lived with her mother. Several days prior to hospitalization patient started staying in shelters due to worsening paranoia. On the discharge day, Ms. ___ was found in the day room: she had breakfast. She reported "feeling well". Denied any new complains. Reported that she feels "much better" with her new medications. She denied any side effects from the meds. She clearly denied S/H/Is. She asked to provide her with a letter to present for court. She asked good questions about outpatient treatment plan. She shared that her mood will pick her up from the hospital. INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting Risperdal, Vistaril, Zoloft, and Ativan medications, and risks and benefits of possible alternatives, including not taking the medications, with this patient. We discussed the patient's right to decide whether to take these medications as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medications. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and others based upon acute suicidal ideation with plan. Her static factors noted at that time include history of suicide attempts, history of abuse chronic mental illness, history of substance abuse, marital status. The modifiable risk factors were also addressed at that time. She was provided outpatient providers, counseled on marijuana cessation, given psychoeducation on depression as well as coping skills. Finally, the patient is being discharged with many protective risk factors, including gender, employment, help-seeking behavior, medication compliance. Overall, patient has improved in her ability to cope with stressors and reality test. Based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. Our Prognosis of this patient is fair. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. RisperiDONE 2 mg PO QHS agitation/anxiety/mood sx's 2. Sertraline 50 mg PO DAILY depression 3. Vitamin D 1000 UNIT PO DAILY low Vitamin D Discharge Disposition: Home Discharge Diagnosis: Depressive mood disorder with psychotic features 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: ___
[ "F323", "R45851", "F1290", "K5900", "Z915", "Z91410" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: "I don't want to live anymore and I don't want to talk to my family." Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] yo F, no formerly diagnosed PPHx, self-reported depression since age [MASKED], self-reported extensive trauma history of sexual abuse by multiple family members/relatives since age [MASKED], 1 reported SA by walking into a car, no past psychiatric hospitalizations, who self-presented to the [MASKED] ED with worsening depression and SI with plan to mix and ingest cleaning chemicals in the setting of being kicked out of her home 3 days ago. HISTORY OF PRESENT ILLNESS: Per Dr. [MASKED] [MASKED] ED Initial Psychiatry Consult note: "Patient states that since age [MASKED], she has been sexually abused by multiple members of her family, including her stepfather, an uncle, and another distant relative. Since age [MASKED], the primary abuser has been her stepfather, whom she claims would play with her doorknob at night to terrify her, would wait until she falls asleep to touch her, and once she became older, started to spike her drinks to make her lose consciousness to further sexually abuse her. Throughout the years, the patient has attempted to speak about this with her mother, but that her mother usually has minimized the patient's story, telling her that she is lying. Patient states that her mother's disbelief of the patient's reports became even more severe once the patient began to smoke cannabis, as her mother would blame her cannabis use as the source of her being paranoid and "crazy". 3 days ago, the patient again attempted to speak about the subject with her mother, who stated that "this is it" and got "fed up" and told the patient that she cannot stay with them anymore. Patient states that the mother also became extremely upset and called all of the family/extended family to "turn them against [the patient]", which the patient knows happened as she received a Facebook message from one of her aunts telling the patient that "you are a liar, you are crazy, you need to leave the family alone". The patient left the home around 21:00 and stayed at a male friend's place. 2 days ago, the patient stayed at a different male friend's place. She also visited her home to pick up clothes, when she ran into her stepfather who was packing things to leave and told the patient "I'll leave the home so you can have it all to yourself". This felt like proof to the patient that he is guilty as "if he didn't do anything wrong, why would he run away". Yesterday, the patient decided to stay at the [MASKED] as she no longer felt safe staying over at men's places. While staying at the shelter, the patient felt distressed and depressed as she was tempted to use drugs other than cannabis. This morning, the patient went home to pick up clothes as she knew that no one would be home. Once she got home, she felt extremely depressed, hopeless, worthless, and was looking online for the most painless methods for suicide. She reports that for the past 1 week, she had watched videos on YouTube of "hanging, shooting, poisoning" and that out of these, she felt that SA by mixing household cleaners was the one that appeared to be the best. Then, she broke down crying and called her friend [MASKED] (friend of an ex-boyfriend) who had gone through a similar situation as the patient (substance use, homelessness, sexual trauma) who on the phone was telling the patient to go to the hospital. The patient then took a shower and took the T to bring herself to the [MASKED] ED. When asked how she has been feeling since being in the ED, states her mood is "good because I'm not at home" but then states she is "desperate", and feels depressed. She does not know where she can go, and that if she were to leave the hospital, she might end up alone at a park. States "I wouldn't mind if I died right now" but denies active SI with plan at this time. States "nobody's here for me, nobody cares"." In the ED, patient was in good behavioral control with no chemical or physical restraints required. Interview on the unit the day slightly limited by the patient's relative fatigue given at the time of interview around midnight. Patient endorses much of the HPI above, reaffirming that she does not want to live and that she does not want to talk to her family, especially her mother. Patient states that she believes that being away from her family will allow her to feel better. Denies any active suicidal ideation. REVIEW OF SYSTEMS: As per Dr. [MASKED] evaluation: Depression: patient states she has had depressed mood since age [MASKED] when she was bullied. Endorses anhedonia of [MASKED] year (states she used to enjoy dancing, singing, art), increased appetite of 5 months (13 lbs. weight gain, with rapid weight loss 1 month ago due to 2 weeks of diarrhea), "terrible concentration" for [MASKED] years, feeling hopeless/helpless/worthless/guilty as she feels "no [MASKED] ever love me, I don't have money for the train, I feel like a failure, I don't see a future for myself". Psychosis: Since she was young, everyone wanted to be her friend, and she knew she was different/special. States she has always been very spiritual, has always prayed to the saints. [MASKED] years ago, she first realized she had special abilities when she saw a man crying on the street and she knew that the man's son had died just by looking at him (states she told the man this and he confirmed this). Also states that she has been getting prophetic messages being communicated to her from the universe, and that she has been writing these messages down. Since [MASKED] year ago, she has been able to see people's energies by focusing on them; she can visually see on top of their heads colors of either red, yellow, or green and that each of the colors mean something. 3 months ago, her friend hurt his foot; she massaged it and overnight, it healed. 2 months ago, she saw a man walking strangely on the street and she focused her energy on him, prayed for him, and suddenly he began to walk normally. Also shares that she met a [MASKED] named [MASKED] at a bar in [MASKED], which changed her life, as he improved her memory and has been giving her hints such as "watch out for the iron" (and she would subsequently see her stepfather with an iron the next day). States that this man has become a mentor for her, but that as of today, she told him to stay away from her life as he responded to her call by saying "I'm busy". Denies sx of mania Denies sx of PTSD: [nightmares, flashbacks, hypervigilance, avoidance] Past Medical History: PAST PSYCHIATRIC HISTORY: [Extracted from Dr. [MASKED] [MASKED] ED Initial Psychiatry Consult note, reviewed with patient, and updated as appropriate.] No formal past psychiatric diagnoses, hospitalizations, psychiatrists/therapists/medication trials. PPHx significant for one suicide attempt [MASKED] year ago when she ran into a car while drunk; patient states she blacked out and that she does not recall any of the details, denies that EMS had to be called, did not have to go to the hospital. Also tried to cut herself on the wrist with a knife 7 months ago, but "it wasn't sharp enough". -Harm to others: -[MASKED] years ago, was being kicked out of a bar by a "rich woman with bodyguards", became angry as she was being condescending and punched her in the face, which resulted in an arrest, 1 night at jail, and a charge of assault and battery leading to probation status -Trauma: -Per HPI PAST MEDICAL HISTORY: **PCP: [MASKED] -[MASKED] trauma: -Multiple head injuries due to being dropped at age [MASKED] -Microwave fell on her head at age [MASKED] -Fell down the stairs and hit her head [MASKED] years ago -Seizures: -Denies MEDICATIONS: [Including vitamins, herbs, supplements, OTC] None ALLERGIES: NKDA Social History: SUBSTANCE USE HISTORY: -EtOH: -Started at [MASKED], stopped at age [MASKED] briefly, then started again at [MASKED] (4 drinks of hard liquor a day) and stopped [MASKED] year ago -Tobacco: -Denies -Illicits: -Marijuana: started at age [MASKED], 3~7 joints/day, last use 1 week ago FORENSIC HISTORY: -Arrests: -[MASKED] years ago, arrested for punching a woman in the face (per OMR review, patient was in [MASKED] ED in [MASKED] for hand fracture [MASKED] to punching another individual) -Convictions and jail terms: -1 night in jail after punching incident -Current status (pending charges, probation, parole): -Assault and battery (per above episode of punching the woman), on probation: not allowed to leave the country, not allowed to go near the woman she punched, must attend [MASKED] SOCIAL HISTORY: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: -Fam Dx: -Father: depression, bipolar, alcoholic -Mother: OCD -Brother: depression -[MASKED] Hospitalizations: -Denies -Fam Hx Suicide: -Unknown Physical Exam: Exam on admission VITAL SIGNS: T: 97.9 , HR: 59, BP: 121/80, RR , SpO2 100% on RA EXAM: General: -HEENT: Normocephalic, atraumatic. Moist mucous membranes, oropharynx clear, supple neck. No scleral icterus. -Cardiovascular: Regular rate and rhythm, S1/S2 heard, no murmurs/rubs/gallops. Distal pulses [MASKED] throughout. -Pulmonary: No increased work of breathing. Lungs clear to auscultation bilaterally. No wheezes/rhonchi/rales. -Abdominal: Non-distended, bowel sounds normoactive. No tenderness to palpation in all quadrants. No guarding, no rebound tenderness. -Extremities: Warm and well-perfused. No edema of the limbs. -Skin: No rashes or lesions noted. Neurological: -Cranial Nerves: ---I: Olfaction not tested. ---II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. ---III, IV, VI: EOMI without nystagmus ---V: Facial sensation intact to light touch in all distributions ---VII: No facial droop, facial musculature symmetric and [MASKED] strength in upper and lower distributions, bilaterally ---VIII: Hearing intact to finger rub bilaterally ---IX, X: Palate elevates symmetrically ---XI: [MASKED] strength in trapezii and SCM bilaterally ---XII: Tongue protrudes in midline -Motor: Normal bulk and tone bilaterally. No abnormal movements, no tremor. Strength [MASKED] throughout. -Sensory: No deficits to fine touch throughout -DTRs: 2 and symmetrical throughout Coordination: Normal on finger to nose test, no intention tremor noted -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. Cognition: -Wakefulness/alertness: Awake and alert -Attention: DOTWb with 0 errors -Orientation: [MASKED], fourth floor" , [MASKED] , oriented to self -Executive function (go-no go, Luria, trails, FAS): Not tested -Memory: [MASKED] registration, [MASKED] recall after 5 [MASKED] grossly intact -Fund of knowledge: Consistent with education; intact to last 3 presidents -Calculations: Initially states 8, then corrects herself and states 7 = "$1.75" -Abstraction: Interprets "the grass is always greener on the other side" as "something can be better, but that is not always the case" -Visuospatial: Not assessed -Language: Non-native [MASKED] speaker, no paraphasic errors, appropriate to conversation Mental Status: -Appearance: Thin woman appearing slightly younger than stated age with black glasses, well groomed, wearing hospital gown, in no apparent distress -Behavior: Sitting up in chair, appropriate eye contact, no psychomotor agitation or retardation -Attitude: Cooperative, engaged, friendly -Mood: "Tired" -Affect: Mood-congruent, dysphoric and intermittently tearful but laughs appropriately during conversation -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Content: ---Safety: SI as above, denies HI ---Delusions: Some suspicion that her family is working against her ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: Poor Exam on discharge Vitals: [MASKED] 0804 Temp: 98.2 PO BP: 106/72 HR: 65 RR: 18 O2 sat: 99% Mental Status Exam: Appearance: Thin, younger than stated age, adequate hygiene, wearing scarf over hospital attire. Behavior: Calm, cooperative, fair eye contact, no PMA/PMR Speech: Accent, soft-spoken, normal speed, decreased prosody Mood: "much better" Affect: mood-congruent, euthymic, congruent with mood Thought Process: linear, coherent, goal-oriented. no loosening of associations Thought Content: Denies SI/HI/AH/VH, ideas that someone has dressed at her to get her in trouble Judgment and Insight: improving, fair/fair Neurological: Station and gait: WNL Tone and strength: Grossly intact Abnormal movements: None noted Cognition: Wakefulness/alertness: Awake and alert Attention: Intact to interview Orientation: Oriented to self and situation Memory: Intact to recent and past history Fund of knowledge: consistent with education Language: native [MASKED] speaker, no paraphasic errors, appropriate to conversation. Pertinent Results: [MASKED] 12:09PM BLOOD WBC-7.0 RBC-4.34 Hgb-13.0 Hct-38.4 MCV-89 MCH-30.0 MCHC-33.9 RDW-11.9 RDWSD-38.7 Plt [MASKED] [MASKED] 12:09PM BLOOD Neuts-65.2 [MASKED] Monos-5.6 Eos-1.7 Baso-0.4 Im [MASKED] AbsNeut-4.53 AbsLymp-1.86 AbsMono-0.39 AbsEos-0.12 AbsBaso-0.03 [MASKED] 12:09PM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-141 K-4.0 Cl-102 HCO3-25 AnGap-14 [MASKED] 06:19AM BLOOD ALT-9 AST-11 AlkPhos-45 TotBili-0.3 [MASKED] 06:19AM BLOOD %HbA1c-4.7 eAG-88 [MASKED] 06:19AM BLOOD Triglyc-59 HDL-59 CHOL/HD-2.4 LDLcalc-69 [MASKED] 06:19AM BLOOD TSH-1.2 [MASKED] 06:19AM BLOOD 25VitD-13* [MASKED] 06:19AM BLOOD HCG-<5 [MASKED] 12:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 07:00AM BLOOD WBC-7.0 RBC-3.91 Hgb-11.7 Hct-34.4 MCV-88 MCH-29.9 MCHC-34.0 RDW-11.9 RDWSD-38.1 Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-85 UreaN-13 Creat-0.6 Na-141 K-4.2 Cl-104 HCO3-28 AnGap-9* [MASKED] 07:00AM BLOOD Calcium-9.5 Phos-4.5 Mg-2.2 [MASKED] 11:38PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Urine culture: negative Brief Hospital Course: 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. They were also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. Their sharps were restricted over the first few days as patient had made statement about wanted to shave her head so that others would not be able to recognize her. As her psychiatric symptoms improved, her sharps status was advanced so that she could use a razor and attend project groups, which she tolerated well without incident. 2. PSYCHIATRIC: #) Unspecified mood disorder with psychotic features (bipolar vs MDD with psychotic features) Patient presented with suicidal ideation and intent to swallow household cleaners. She was started on Risperdal, which was increased to a final dose of 2 mg PO QHS, with good effect at reducing anxiety, paranoia, and insomnia. Additionally, Zoloft was started and increased to a final dose of 50 mg PO daily, with improvement in mood and anxiety. She tolerated both medications well and did not report side effects. She also attended groups and participated in individual, group, and milieu therapy. Family (mother and sister) were involved in treatment planning and visited frequently. - The following medications were started on this admission: Risperdal 2 mg PO QHS Zoloft 50 mg PO daily 3. SUBSTANCE USE DISORDERS: #)Cannabis use Patient reported marijuana use several times a week for last year. Encouraged cessation and counseling, particularly given patient's paranoia and anxiety. 4. MEDICAL # Constipation Patient reported constipation during hospitalization which was treated with milk of mag 30ml daily PRN with good effect. Patient had one episode of diarrhea after taking this medication which related bradycardia, dizziness, and vomiting. This medication was stopped and symptoms resolved. Patient had normal vitals and labs after this incident and it was not felt to be infectious or require further work up. # Low vitamin D Vitamin D 1000 UNIT PO/NG DAILY low Vitamin D 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient attended these groups that focused on teaching patients various coping skills. Patient remained friendly, compliant with milieu. She usually stayed to herself.. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT: [MASKED] (mother) [MASKED]- patient lived with her mother. Several days prior to hospitalization patient started staying in shelters due to worsening paranoia. On the discharge day, Ms. [MASKED] was found in the day room: she had breakfast. She reported "feeling well". Denied any new complains. Reported that she feels "much better" with her new medications. She denied any side effects from the meds. She clearly denied S/H/Is. She asked to provide her with a letter to present for court. She asked good questions about outpatient treatment plan. She shared that her mood will pick her up from the hospital. INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting Risperdal, Vistaril, Zoloft, and Ativan medications, and risks and benefits of possible alternatives, including not taking the medications, with this patient. We discussed the patient's right to decide whether to take these medications as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medications. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and others based upon acute suicidal ideation with plan. Her static factors noted at that time include history of suicide attempts, history of abuse chronic mental illness, history of substance abuse, marital status. The modifiable risk factors were also addressed at that time. She was provided outpatient providers, counseled on marijuana cessation, given psychoeducation on depression as well as coping skills. Finally, the patient is being discharged with many protective risk factors, including gender, employment, help-seeking behavior, medication compliance. Overall, patient has improved in her ability to cope with stressors and reality test. Based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. Our Prognosis of this patient is fair. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. RisperiDONE 2 mg PO QHS agitation/anxiety/mood sx's 2. Sertraline 50 mg PO DAILY depression 3. Vitamin D 1000 UNIT PO DAILY low Vitamin D Discharge Disposition: Home Discharge Diagnosis: Depressive mood disorder with psychotic features 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]
[]
[ "K5900" ]
[ "F323: Major depressive disorder, single episode, severe with psychotic features", "R45851: Suicidal ideations", "F1290: Cannabis use, unspecified, uncomplicated", "K5900: Constipation, unspecified", "Z915: Personal history of self-harm", "Z91410: Personal history of adult physical and sexual abuse" ]
10,070,201
29,368,106
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, shortness of breath Major Surgical or Invasive Procedure: ___: Coronary artery bypass grafting x 4, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the first marginal branch, second marginal branch and posterior descending artery. Removal of left ventricular intracardiac tumor. History of Present Illness: Mr. ___ is a very nice ___ year old male with history of chronic obstructive pulmonary disease, diabetes melltitus, hypertension, and obesity. He presented to ___ ___ with shortness of breath and chest pain. He ruled in for non-ST elevation myocardial infarction. A transthoracic echocardiogram demonstrated normal left ventricular function, dilated left atrium, and mild to moderate mitral regurgiation. A cardiac catheterization revealed three-vessel coronary artery disease. He was transferred to ___ for coronary artery bypass graft evaluation. Surgery was recommended to reduce his risk of future myocardial infarction and/or death. Past Medical History: Chronic Obstructive Pulmonary Disease Diabetes Mellitus type 2 Diabetic Neuropathy Hypertension Obesity Carpal Tunnel Release, bilateral Cataracts, bilateral Social History: ___ Family History: No known history of premature coronary artery disease Mother dies age ___ healthy father died age ___ healthy Physical Exam: HR: 81 BP: 162/92 RR: 18 O2 sat: 96% RA Height: 71 in Weight: 281 lbs ___: Obese appearing male arrived from OSH in NAD Skin: Dry [yeast in groin] intact [x] HEENT: PERRL [x] EOMI [] 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: none [] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: DP Right: + Left: + Radial Right: + Left: + Carotid Bruit: none appreciated Discharge Examination 24 HR Data (last updated ___ @ 909) Temp: 98 (Tm 98.0), BP: 117/67 (117-141/58-76), HR: 64 (63-75), RR: 16 (___), O2 sat: 96% (92-97), O2 delivery: Ra Fluid Balance (last updated ___ @ 906) Last 8 hours Total cumulative 10ml IN: Total 360ml, PO Amt 360ml OUT: Total 350ml, Urine Amt 350ml Last 24 hours Total cumulative 150ml IN: Total 1000ml, PO Amt 1000ml OUT: Total 850ml, Urine Amt 850ml ___: NAD Neurological: A/O x self and place no focal deficits unable to complete months backwards Cardiovascular: RRR Respiratory: diminished at bases No resp distress GI/Abdomen: Bowel sounds present Soft ND NT Extremities: Right Upper extremity Warm Edema trace Left Upper extremity Warm Edema trace Right Lower extremity Warm Edema trace Left Lower extremity Warm Edema trace Pulses: DP Right:p Left:p ___ Right:p Left:p Radial Right:p Left:p Ulnar Right: Left: Sternal: CDI no erythema or drainage Sternum stable Lower extremity: Left CDI Pertinent Results: Labs ___ 05:02AM BLOOD WBC-8.6 RBC-3.56* Hgb-11.0* Hct-33.3* MCV-94 MCH-30.9 MCHC-33.0 RDW-13.3 RDWSD-46.1 Plt ___ ___ 07:00PM BLOOD WBC-9.3 RBC-4.91 Hgb-15.1 Hct-45.1 MCV-92 MCH-30.8 MCHC-33.5 RDW-13.7 RDWSD-46.0 Plt ___ ___ 04:54AM BLOOD Glucose-123* UreaN-53* Creat-1.8* Na-135 K-3.7 Cl-93* HCO3-29 AnGap-13 ___ 01:28PM BLOOD Glucose-228* UreaN-41* Creat-2.3* Na-137 K-3.2* Cl-99 HCO3-23 AnGap-15 ___ 07:00PM BLOOD Glucose-209* UreaN-26* Creat-1.3* Na-138 K-3.7 Cl-98 HCO3-26 AnGap-14 ___ 07:00PM BLOOD ALT-39 AST-66* LD(LDH)-393* AlkPhos-71 Amylase-36 TotBili-0.8 ___ 07:00PM BLOOD Lipase-42 ___ 10:40AM BLOOD CK-MB-3 cTropnT-1.88* ___ 04:39AM BLOOD cTropnT-1.07* ___ 07:00PM BLOOD CK-MB-9 cTropnT-0.93* ___ 04:54AM BLOOD Mg-2.2 ___ 07:00PM BLOOD Albumin-4.1 Phos-2.7 Mg-1.5* ___ 07:00PM BLOOD %HbA1c-7.5* eAG-169* ___ 07:00PM BLOOD TSH-0.67 ___ CXR - Lungs are low volume with subsegmental atelectasis in the left lung base and right lung base. Right IJ line has been removed in the interim. Cardiomediastinal silhouette stable. No pneumothorax is seen. No new consolidations concerning for pneumonia. PFT ___ IMPRESSION MECHANICS: The ___ and FEV1 are moderately reduced. The FEV1/FVC ratio is normal. There was no significant change following inhaled bronchodilator. FLOW-VOLUME LOOP: Mildly reduced flows with an early termination of exhalation. LUNG VOLUMES: The TLC and FRC are mildly reduced. The RV is normal. The RV/TLC ratio is elevated. DLCO: The diffusion capacity uncorrected for hemoglobin is moderately reduced. Impression: Moderate gas exchange defect. Although results suggest a mild restrictive ventilatory defect the FVC may be underestimated due to an early termination of exhalation and the RV is likely overestimated and/or TLC underestimated due to a suboptimal SVC manuever. There are no prior studies available for comparison. LV mass pathology Mass, left ventricle, extraction: - Partially organized fibrinous nodule (0.7 cm) with focal dystrophic calcification and extensive associated histiocytic reaction (highlighted by a CD68 immunostain). - No malignancy identified; immunostains for cytokeratin cocktail and S100 are negative for any lesional cells. - Gram and GMS stains are negative for microorganisms. Note: See associated microbiologic culture results ___ ___ ___ for further characterization. Brief Hospital Course: Transferred from OSH ___ with significant coronary artery disease. He was evaluated by cardiology and felt to be better served by bypass surgery. He underwent preoperative workup including pulmonary function test. He remained hemodynamically stable and was taken to the operating room on ___. He underwent coronary artery bypass grafting x4 and removal of intracardiac tumor. Please see operative note for full details. He was taken to the intensive care unit post operative for management. Later that evening he was weaned from sedation, awoke and was extubated requiring face mask. On post operative day one he was started on Lasix drip for diuresis due to increasing oxygen requirement. He was started on betablockers and weaned of vasodilator drip. He however due to agitation and confusion was started on precede drip and then also treated with Haldol. Over the next few days he remained delirious with hypoxia and renal function worsened with noted acute kidney injury. Diuretics were adjusted and he was weaned down on oxygen to nasal cannula. His delirium was improving with improved sleep. His chest tubes and epicardial wires were removed per protocol. He was transitioned to the floor on post operative day six. He was weaned to room air and creatinine was improving but not fully to baseline. He worked with physical and occupational therapy with recommendation for acute rehab. He was clinically stable for discharge to acute rehab on post operative day nine. Continues with oral Lasix for diuresis, delirium resolving but still forgetful at times. Recommend recheck labs in few days to evaluate renal function and lytes. He was discharged to ___ rehab in ___. He was continued on insulin until creatinine stable to resume oral diabetic medications and was not placed on ___ for NSTEMI due to ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. CloNIDine 0.1 mg PO BID 4. Gabapentin 300 mg PO 5 TIMES DAILY 5. GlipiZIDE XL 20 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H please give ATC for 48 hours then change to as needed 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheezing 3. amLODIPine 10 mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Bisacodyl ___AILY:PRN constipation 7. Famotidine 20 mg PO DAILY Duration: 30 Days 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Furosemide 40 mg PO BID take twice a day for 5 days then daily for 5 days then if able restart HCTZ 10. Heparin 5000 UNIT SC BID stop when ambulating adequately 11. HydrALAZINE 75 mg PO Q6H 12. Glargine 40 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 13. Ipratropium Bromide MDI 2 PUFF IH QID 14. MetOLazone 2.5 mg PO DAILY Duration: 3 Days 15. Metoprolol Tartrate 25 mg PO TID 16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 17. Gabapentin 300 mg PO TID 18. CloNIDine 0.1 mg PO BID 19. HELD- GlipiZIDE XL 20 mg PO DAILY This medication was held. Do not restart GlipiZIDE XL until cr stable and ___ resolved 20. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until instructed as stopped due to ___ 21. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication was held. Do not restart MetFORMIN (Glucophage) until renal function stable 22.Outpatient Lab Work please check bmp ___ to monitor cr and lytes with diuresis results to cardiac surgery ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Coronary Artery Disease s/p coronary revascularization Left ventricular mass removed - micro negative Non-ST Elevation Myocardial Infarction Acute encephalopathy multifactorial Acute Kidney Injury Acute on chronic respiratory failure with hypoxia due to volume overload Secondary Diagnosis Chronic Obstructive Pulmonary Disease Diabetes Mellitus type 2 Diabetic Neuropathy Hypertension Obesity Discharge Condition: Alert and oriented x self and place - forgetful at times nonfocal Ambulating with assistance Incisional pain managed with acetaminophen Incisions: Sternal - healing well, no erythema or drainage Leg Left EVH - healing well, no erythema or drainage. Edema - trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart. ****call MD if weight goes up more than 3 lbs in 24 hours or 5 lbs over 5 days****. 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 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: ___
[ "I2510", "I214", "J9621", "N179", "J9811", "D62", "D4989", "J449", "E1140", "I10", "E669", "Z6836", "I340", "E8770" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: [MASKED]: Coronary artery bypass grafting x 4, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the first marginal branch, second marginal branch and posterior descending artery. Removal of left ventricular intracardiac tumor. History of Present Illness: Mr. [MASKED] is a very nice [MASKED] year old male with history of chronic obstructive pulmonary disease, diabetes melltitus, hypertension, and obesity. He presented to [MASKED] [MASKED] with shortness of breath and chest pain. He ruled in for non-ST elevation myocardial infarction. A transthoracic echocardiogram demonstrated normal left ventricular function, dilated left atrium, and mild to moderate mitral regurgiation. A cardiac catheterization revealed three-vessel coronary artery disease. He was transferred to [MASKED] for coronary artery bypass graft evaluation. Surgery was recommended to reduce his risk of future myocardial infarction and/or death. Past Medical History: Chronic Obstructive Pulmonary Disease Diabetes Mellitus type 2 Diabetic Neuropathy Hypertension Obesity Carpal Tunnel Release, bilateral Cataracts, bilateral Social History: [MASKED] Family History: No known history of premature coronary artery disease Mother dies age [MASKED] healthy father died age [MASKED] healthy Physical Exam: HR: 81 BP: 162/92 RR: 18 O2 sat: 96% RA Height: 71 in Weight: 281 lbs [MASKED]: Obese appearing male arrived from OSH in NAD Skin: Dry [yeast in groin] intact [x] HEENT: PERRL [x] EOMI [] 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: none [] Varicosities: None [x] Neuro: Grossly intact [x] Pulses: DP Right: + Left: + Radial Right: + Left: + Carotid Bruit: none appreciated Discharge Examination 24 HR Data (last updated [MASKED] @ 909) Temp: 98 (Tm 98.0), BP: 117/67 (117-141/58-76), HR: 64 (63-75), RR: 16 ([MASKED]), O2 sat: 96% (92-97), O2 delivery: Ra Fluid Balance (last updated [MASKED] @ 906) Last 8 hours Total cumulative 10ml IN: Total 360ml, PO Amt 360ml OUT: Total 350ml, Urine Amt 350ml Last 24 hours Total cumulative 150ml IN: Total 1000ml, PO Amt 1000ml OUT: Total 850ml, Urine Amt 850ml [MASKED]: NAD Neurological: A/O x self and place no focal deficits unable to complete months backwards Cardiovascular: RRR Respiratory: diminished at bases No resp distress GI/Abdomen: Bowel sounds present Soft ND NT Extremities: Right Upper extremity Warm Edema trace Left Upper extremity Warm Edema trace Right Lower extremity Warm Edema trace Left Lower extremity Warm Edema trace Pulses: DP Right:p Left:p [MASKED] Right:p Left:p Radial Right:p Left:p Ulnar Right: Left: Sternal: CDI no erythema or drainage Sternum stable Lower extremity: Left CDI Pertinent Results: Labs [MASKED] 05:02AM BLOOD WBC-8.6 RBC-3.56* Hgb-11.0* Hct-33.3* MCV-94 MCH-30.9 MCHC-33.0 RDW-13.3 RDWSD-46.1 Plt [MASKED] [MASKED] 07:00PM BLOOD WBC-9.3 RBC-4.91 Hgb-15.1 Hct-45.1 MCV-92 MCH-30.8 MCHC-33.5 RDW-13.7 RDWSD-46.0 Plt [MASKED] [MASKED] 04:54AM BLOOD Glucose-123* UreaN-53* Creat-1.8* Na-135 K-3.7 Cl-93* HCO3-29 AnGap-13 [MASKED] 01:28PM BLOOD Glucose-228* UreaN-41* Creat-2.3* Na-137 K-3.2* Cl-99 HCO3-23 AnGap-15 [MASKED] 07:00PM BLOOD Glucose-209* UreaN-26* Creat-1.3* Na-138 K-3.7 Cl-98 HCO3-26 AnGap-14 [MASKED] 07:00PM BLOOD ALT-39 AST-66* LD(LDH)-393* AlkPhos-71 Amylase-36 TotBili-0.8 [MASKED] 07:00PM BLOOD Lipase-42 [MASKED] 10:40AM BLOOD CK-MB-3 cTropnT-1.88* [MASKED] 04:39AM BLOOD cTropnT-1.07* [MASKED] 07:00PM BLOOD CK-MB-9 cTropnT-0.93* [MASKED] 04:54AM BLOOD Mg-2.2 [MASKED] 07:00PM BLOOD Albumin-4.1 Phos-2.7 Mg-1.5* [MASKED] 07:00PM BLOOD %HbA1c-7.5* eAG-169* [MASKED] 07:00PM BLOOD TSH-0.67 [MASKED] CXR - Lungs are low volume with subsegmental atelectasis in the left lung base and right lung base. Right IJ line has been removed in the interim. Cardiomediastinal silhouette stable. No pneumothorax is seen. No new consolidations concerning for pneumonia. PFT [MASKED] IMPRESSION MECHANICS: The [MASKED] and FEV1 are moderately reduced. The FEV1/FVC ratio is normal. There was no significant change following inhaled bronchodilator. FLOW-VOLUME LOOP: Mildly reduced flows with an early termination of exhalation. LUNG VOLUMES: The TLC and FRC are mildly reduced. The RV is normal. The RV/TLC ratio is elevated. DLCO: The diffusion capacity uncorrected for hemoglobin is moderately reduced. Impression: Moderate gas exchange defect. Although results suggest a mild restrictive ventilatory defect the FVC may be underestimated due to an early termination of exhalation and the RV is likely overestimated and/or TLC underestimated due to a suboptimal SVC manuever. There are no prior studies available for comparison. LV mass pathology Mass, left ventricle, extraction: - Partially organized fibrinous nodule (0.7 cm) with focal dystrophic calcification and extensive associated histiocytic reaction (highlighted by a CD68 immunostain). - No malignancy identified; immunostains for cytokeratin cocktail and S100 are negative for any lesional cells. - Gram and GMS stains are negative for microorganisms. Note: See associated microbiologic culture results [MASKED] [MASKED] [MASKED] for further characterization. Brief Hospital Course: Transferred from OSH [MASKED] with significant coronary artery disease. He was evaluated by cardiology and felt to be better served by bypass surgery. He underwent preoperative workup including pulmonary function test. He remained hemodynamically stable and was taken to the operating room on [MASKED]. He underwent coronary artery bypass grafting x4 and removal of intracardiac tumor. Please see operative note for full details. He was taken to the intensive care unit post operative for management. Later that evening he was weaned from sedation, awoke and was extubated requiring face mask. On post operative day one he was started on Lasix drip for diuresis due to increasing oxygen requirement. He was started on betablockers and weaned of vasodilator drip. He however due to agitation and confusion was started on precede drip and then also treated with Haldol. Over the next few days he remained delirious with hypoxia and renal function worsened with noted acute kidney injury. Diuretics were adjusted and he was weaned down on oxygen to nasal cannula. His delirium was improving with improved sleep. His chest tubes and epicardial wires were removed per protocol. He was transitioned to the floor on post operative day six. He was weaned to room air and creatinine was improving but not fully to baseline. He worked with physical and occupational therapy with recommendation for acute rehab. He was clinically stable for discharge to acute rehab on post operative day nine. Continues with oral Lasix for diuresis, delirium resolving but still forgetful at times. Recommend recheck labs in few days to evaluate renal function and lytes. He was discharged to [MASKED] rehab in [MASKED]. He was continued on insulin until creatinine stable to resume oral diabetic medications and was not placed on [MASKED] for NSTEMI due to [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. MetFORMIN (Glucophage) 1000 mg PO BID 3. CloNIDine 0.1 mg PO BID 4. Gabapentin 300 mg PO 5 TIMES DAILY 5. GlipiZIDE XL 20 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H please give ATC for 48 hours then change to as needed 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheezing 3. amLODIPine 10 mg PO DAILY 4. Aspirin EC 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Bisacodyl AILY:PRN constipation 7. Famotidine 20 mg PO DAILY Duration: 30 Days 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Furosemide 40 mg PO BID take twice a day for 5 days then daily for 5 days then if able restart HCTZ 10. Heparin 5000 UNIT SC BID stop when ambulating adequately 11. HydrALAZINE 75 mg PO Q6H 12. Glargine 40 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 13. Ipratropium Bromide MDI 2 PUFF IH QID 14. MetOLazone 2.5 mg PO DAILY Duration: 3 Days 15. Metoprolol Tartrate 25 mg PO TID 16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 17. Gabapentin 300 mg PO TID 18. CloNIDine 0.1 mg PO BID 19. HELD- GlipiZIDE XL 20 mg PO DAILY This medication was held. Do not restart GlipiZIDE XL until cr stable and [MASKED] resolved 20. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until instructed as stopped due to [MASKED] 21. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication was held. Do not restart MetFORMIN (Glucophage) until renal function stable 22.Outpatient Lab Work please check bmp [MASKED] to monitor cr and lytes with diuresis results to cardiac surgery [MASKED] Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Coronary Artery Disease s/p coronary revascularization Left ventricular mass removed - micro negative Non-ST Elevation Myocardial Infarction Acute encephalopathy multifactorial Acute Kidney Injury Acute on chronic respiratory failure with hypoxia due to volume overload Secondary Diagnosis Chronic Obstructive Pulmonary Disease Diabetes Mellitus type 2 Diabetic Neuropathy Hypertension Obesity Discharge Condition: Alert and oriented x self and place - forgetful at times nonfocal Ambulating with assistance Incisional pain managed with acetaminophen Incisions: Sternal - healing well, no erythema or drainage Leg Left EVH - healing well, no erythema or drainage. Edema - trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart. ****call MD if weight goes up more than 3 lbs in 24 hours or 5 lbs over 5 days****. 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 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]
[]
[ "I2510", "N179", "D62", "J449", "I10", "E669" ]
[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J9621: Acute and chronic respiratory failure with hypoxia", "N179: Acute kidney failure, unspecified", "J9811: Atelectasis", "D62: Acute posthemorrhagic anemia", "D4989: Neoplasm of unspecified behavior of other specified sites", "J449: Chronic obstructive pulmonary disease, unspecified", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "I10: Essential (primary) hypertension", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "I340: Nonrheumatic mitral (valve) insufficiency", "E8770: Fluid overload, unspecified" ]
10,070,311
23,721,596
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Augmentin Attending: ___. Chief Complaint: Cough and dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ male, history of three-vessel coronary artery disease, status post CABG, most recent cath ___, most recent stress echo ___, PPM, afib on Coumadin, p/w cough and SOB x 1 week. Patient reports his symptoms started while he was ___. There he was noncompliant with his home furosemide. He flew back from ___ about 2 days ago. He noticed LLE swelling, saw his PCP, and had LENIs which were negative. He progressively developed worsening SOB which prompted him to present to ED at ___. His cardiac history is notable for LIMA/LAD, SVG/RCA, SVG/D1, SVG/OM --> with an occluded saphenous vein graft to the OM1 segment. His most recent stress test showed poor exercise function and was nonspecific for myocardial ischemia. He had blood work performed at ___ which noted an elevated troponin 0.176 with an elevated CK. He underwent a chest x-ray that showed small bilateral effusions. He also had a CTA of the chest which showed no PE, but did show emphysematous changes with patchy RUL opacities c/w aspiration or PNA as well as small right pleural effusion. He did have a flu B PCR positive. He was transferred here for further management. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: 4V CABG ___ (LIMA->LAD, SVG->RCA, SVG->D1, SVG->OM/RI) -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: ___ EnRhythm dual-chamber pacemaker 3. OTHER PAST MEDICAL HISTORY: --Paroxysmal Atrial Fibrillation - first noted post-op ___ and complicated by complete heart block --Ulcerative Colitis ___ (s/p polypectomy w/ high grade dysplasia) --GERD --Diverticulosis --Inguinal hernia --Internal Hemorrhoids --Benign prostatic hypertrophy Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . The patient's father as well as two of his uncles had coronary artery disease. His maternal aunt had colon cancer. There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION EXAM =============== VS: Reviewed in metavision GEN: NAD, sitting comfortably in bed HEENT: MMM, PERRLA, EOMI NECK: Difficult to assess JVD CV: tachycardia, irregularly irregular, no m/r/g RESP: diffuse expiratory wheezing, bibasilar crackles GI: soft, NT/ND, +BS SKIN: No rashes, warm/well perfused EXT: LLE significant 3+ with some chronic underlying venous stasis changes, 1+ pitting edema in the right lower extremity NEURO: AAOx3 DISCHARGE EXAM =============== VITALS: ___ 0758 Temp: 98.4 PO BP: 127/67 L Sitting HR: 61 RR: 17 O2 sat: 92% O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: Sclerae anicteric. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Systolic ejection murmur. LUNGS: Clear to auscultation bilaterally. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Large erythematous rash on anterior left shin. 2+ Left ___, 1+ Right ___. SKIN: Warm. NEUROLOGIC: AOx3. Pertinent Results: ADMISSION LABS ================ ___ 01:15PM BLOOD WBC-8.6 RBC-4.99 Hgb-13.3* Hct-43.4 MCV-87 MCH-26.7 MCHC-30.6* RDW-16.5* RDWSD-52.2* Plt ___ ___ 10:31AM BLOOD ___ PTT-37.7* ___ ___ 01:15PM BLOOD Glucose-137* UreaN-18 Creat-1.1 Na-139 K-4.1 Cl-97 HCO3-22 AnGap-20* ___ 10:31AM BLOOD CK(CPK)-350* ___ 01:15PM BLOOD ALT-13 AST-37 AlkPhos-84 TotBili-0.7 ___ 10:31AM BLOOD cTropnT-0.12* ___ 01:15PM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9 ___ 05:54AM BLOOD TSH-1.6 ___ 10:36AM BLOOD ___ pO2-74* pCO2-46* pH-7.36 calTCO2-27 Base XS-0 DISCHARGE LABS =============== ___ 04:51AM BLOOD WBC-7.3 RBC-3.84* Hgb-10.3* Hct-33.5* MCV-87 MCH-26.8 MCHC-30.7* RDW-15.9* RDWSD-50.9* Plt ___ ___ 04:51AM BLOOD WBC-7.3 RBC-3.84* Hgb-10.3* Hct-33.5* MCV-87 MCH-26.8 MCHC-30.7* RDW-15.9* RDWSD-50.9* Plt ___ ___ 04:51AM BLOOD ___ ___ 04:51AM BLOOD Glucose-101* UreaN-22* Creat-1.1 Na-139 K-4.3 Cl-97 HCO3-27 AnGap-15 ___ 04:51AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.1 MICRO ====== ___ 10:56 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 10:31 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 4:07 pm URINE Source: Catheter. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. IMAGING ======= TTE ___ IMPRESSION: Suboptimal image quality. Normal left ventricular wall thickness and biventricular cavity sizes and regional/global systolic function. Mild mitral regurgitation.High normal estimated pulmonary artery systolic pressure. LLE DOPPLER ___. No evidence of deep venous thrombosis in the left lower extremity veins. 2. Nonspecific subcutaneous edema about the left calf. No focal fluid collection. Brief Hospital Course: ___ male history of 3VD s/p CABG, most recent cath ___, most recent stress echo ___, PPM, p/w cough and SOB found to be in hypoxic respiratory failure ___ influenza B PNA and volume overload from CHF. Initially admitted to the MICU for BiPAP, quickly weaned to NC with Tamiflu and IV Lasix. He was transferred to the floor and weaned to ___. He was diuresed with 40-80 IV Lasix to a weight of 87 kgs, with improvement in dyspnea and hypoxia. He completed a 5-day course of Tamiflu. He was discharged with close PCP ___. TRANSITIONAL ISSUES =================== [] Follow up CBC. Hgb decreased this admission 13.3 -> 10.3, no signs of blood loss. [] Consider switching warfarin to apixaban [] ___ weights, volume status, titrate Lasix prn (increased from 20 to 40 this admission). D/C weight: 87 kgs [] Next cardiology appointment scheduled for ___. Please evaluate need for more expedite appointment, as determined by adequacy of rate control, volume status [] Dermatology ___ arranged for LLE rash [] Continue counseling re: low salt diet ACUTE ISSUES: #Influenza infection #Acute on chronic HFpEF #Hypoxic respiratory failure: From flu and acute on chronic HFpEF. TTE repeated this admission with EF 72%. Treated with 5-day course of Tamiflu. Diuresed with 40-80 IV Lasix to a weight of 87 kgs. Discharged on increased dose of Lasix (40mg, from 20mg prior to admission). #AFib #Tachy-brady s/p PPM: Intermittent runs of AF with RVR while in MICU and prior to diuresis. At discharge, remained paced at 60 on home dilt 240 ER, sotalol 120 BID, metop tartrate 100 BID. #Type 2 NSTEMI: Trop peaked at 0.16. New EKG changes with TWI in lateral leads however given absence of chest pain, TTE with preserved EF and no new WMAs, discussed with cardiology who felt no need for repeat stress test or cath. #Rash: LLE rash x 3 months, in leg with vein harvest from prior CABG. Not painful or itchy, low concern for cellulitis or inflammatory dermatitis. More likely capillary leak/stasis dermatitis related to vein harvest. Derm ___ arranged at discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Mesalamine Enema 4 gm PR QHS 3. Sotalol 120 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Loratadine 10 mg PO DAILY 6. Warfarin 8 mg PO 4X/WEEK (___) 7. Warfarin 9 mg PO 3X/WEEK (___) 8. Diltiazem Extended-Release 240 mg PO DAILY 9. Valsartan 80 mg PO DAILY 10. Tamsulosin 0.4 mg PO QHS 11. FoLIC Acid 1 mg PO DAILY 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Atorvastatin 80 mg PO QPM 15. Metoprolol Tartrate 100 mg PO BID 16. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*60 Capsule Refills:*1 2. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 3. Warfarin 7 mg PO DAILY16 4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. balsalazide 2250 mg oral TID 8. Diltiazem Extended-Release 240 mg PO DAILY 9. Fluticasone Propionate NASAL 2 SPRY NU QHS 10. FoLIC Acid 1 mg PO DAILY 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Loratadine 10 mg PO DAILY 13. Mesalamine (Rectal) ___AILY 14. Mesalamine Enema 4 gm PR QHS 15. Metoprolol Tartrate 100 mg PO BID 16. Multivitamins 1 TAB PO DAILY 17. Sotalol 120 mg PO BID 18. Tamsulosin 0.4 mg PO QHS 19. Valsartan 80 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Influenza 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 IN THE HOSPITAL? - You were admitted to the hospital for shortness of breath from the flu WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You were treated for the flu - You were given diuretics to help remove the extra fluid WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "J111", "J9601", "I21A1", "I5033", "K5190", "J918", "I2510", "Z951", "Z9114", "Z950", "Z87891", "I482", "Z7901", "N400", "I110", "I495", "D696", "R21" ]
Allergies: Augmentin Chief Complaint: Cough and dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] male, history of three-vessel coronary artery disease, status post CABG, most recent cath [MASKED], most recent stress echo [MASKED], PPM, afib on Coumadin, p/w cough and SOB x 1 week. Patient reports his symptoms started while he was [MASKED]. There he was noncompliant with his home furosemide. He flew back from [MASKED] about 2 days ago. He noticed LLE swelling, saw his PCP, and had LENIs which were negative. He progressively developed worsening SOB which prompted him to present to ED at [MASKED]. His cardiac history is notable for LIMA/LAD, SVG/RCA, SVG/D1, SVG/OM --> with an occluded saphenous vein graft to the OM1 segment. His most recent stress test showed poor exercise function and was nonspecific for myocardial ischemia. He had blood work performed at [MASKED] which noted an elevated troponin 0.176 with an elevated CK. He underwent a chest x-ray that showed small bilateral effusions. He also had a CTA of the chest which showed no PE, but did show emphysematous changes with patchy RUL opacities c/w aspiration or PNA as well as small right pleural effusion. He did have a flu B PCR positive. He was transferred here for further management. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: 4V CABG [MASKED] (LIMA->LAD, SVG->RCA, SVG->D1, SVG->OM/RI) -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: [MASKED] EnRhythm dual-chamber pacemaker 3. OTHER PAST MEDICAL HISTORY: --Paroxysmal Atrial Fibrillation - first noted post-op [MASKED] and complicated by complete heart block --Ulcerative Colitis [MASKED] (s/p polypectomy w/ high grade dysplasia) --GERD --Diverticulosis --Inguinal hernia --Internal Hemorrhoids --Benign prostatic hypertrophy Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . The patient's father as well as two of his uncles had coronary artery disease. His maternal aunt had colon cancer. There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION EXAM =============== VS: Reviewed in metavision GEN: NAD, sitting comfortably in bed HEENT: MMM, PERRLA, EOMI NECK: Difficult to assess JVD CV: tachycardia, irregularly irregular, no m/r/g RESP: diffuse expiratory wheezing, bibasilar crackles GI: soft, NT/ND, +BS SKIN: No rashes, warm/well perfused EXT: LLE significant 3+ with some chronic underlying venous stasis changes, 1+ pitting edema in the right lower extremity NEURO: AAOx3 DISCHARGE EXAM =============== VITALS: [MASKED] 0758 Temp: 98.4 PO BP: 127/67 L Sitting HR: 61 RR: 17 O2 sat: 92% O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: Sclerae anicteric. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Systolic ejection murmur. LUNGS: Clear to auscultation bilaterally. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Large erythematous rash on anterior left shin. 2+ Left [MASKED], 1+ Right [MASKED]. SKIN: Warm. NEUROLOGIC: AOx3. Pertinent Results: ADMISSION LABS ================ [MASKED] 01:15PM BLOOD WBC-8.6 RBC-4.99 Hgb-13.3* Hct-43.4 MCV-87 MCH-26.7 MCHC-30.6* RDW-16.5* RDWSD-52.2* Plt [MASKED] [MASKED] 10:31AM BLOOD [MASKED] PTT-37.7* [MASKED] [MASKED] 01:15PM BLOOD Glucose-137* UreaN-18 Creat-1.1 Na-139 K-4.1 Cl-97 HCO3-22 AnGap-20* [MASKED] 10:31AM BLOOD CK(CPK)-350* [MASKED] 01:15PM BLOOD ALT-13 AST-37 AlkPhos-84 TotBili-0.7 [MASKED] 10:31AM BLOOD cTropnT-0.12* [MASKED] 01:15PM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9 [MASKED] 05:54AM BLOOD TSH-1.6 [MASKED] 10:36AM BLOOD [MASKED] pO2-74* pCO2-46* pH-7.36 calTCO2-27 Base XS-0 DISCHARGE LABS =============== [MASKED] 04:51AM BLOOD WBC-7.3 RBC-3.84* Hgb-10.3* Hct-33.5* MCV-87 MCH-26.8 MCHC-30.7* RDW-15.9* RDWSD-50.9* Plt [MASKED] [MASKED] 04:51AM BLOOD WBC-7.3 RBC-3.84* Hgb-10.3* Hct-33.5* MCV-87 MCH-26.8 MCHC-30.7* RDW-15.9* RDWSD-50.9* Plt [MASKED] [MASKED] 04:51AM BLOOD [MASKED] [MASKED] 04:51AM BLOOD Glucose-101* UreaN-22* Creat-1.1 Na-139 K-4.3 Cl-97 HCO3-27 AnGap-15 [MASKED] 04:51AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.1 MICRO ====== [MASKED] 10:56 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 10:31 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] 4:07 pm URINE Source: Catheter. **FINAL REPORT [MASKED] Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. IMAGING ======= TTE [MASKED] IMPRESSION: Suboptimal image quality. Normal left ventricular wall thickness and biventricular cavity sizes and regional/global systolic function. Mild mitral regurgitation.High normal estimated pulmonary artery systolic pressure. LLE DOPPLER [MASKED]. No evidence of deep venous thrombosis in the left lower extremity veins. 2. Nonspecific subcutaneous edema about the left calf. No focal fluid collection. Brief Hospital Course: [MASKED] male history of 3VD s/p CABG, most recent cath [MASKED], most recent stress echo [MASKED], PPM, p/w cough and SOB found to be in hypoxic respiratory failure [MASKED] influenza B PNA and volume overload from CHF. Initially admitted to the MICU for BiPAP, quickly weaned to NC with Tamiflu and IV Lasix. He was transferred to the floor and weaned to [MASKED]. He was diuresed with 40-80 IV Lasix to a weight of 87 kgs, with improvement in dyspnea and hypoxia. He completed a 5-day course of Tamiflu. He was discharged with close PCP [MASKED]. TRANSITIONAL ISSUES =================== [] Follow up CBC. Hgb decreased this admission 13.3 -> 10.3, no signs of blood loss. [] Consider switching warfarin to apixaban [] [MASKED] weights, volume status, titrate Lasix prn (increased from 20 to 40 this admission). D/C weight: 87 kgs [] Next cardiology appointment scheduled for [MASKED]. Please evaluate need for more expedite appointment, as determined by adequacy of rate control, volume status [] Dermatology [MASKED] arranged for LLE rash [] Continue counseling re: low salt diet ACUTE ISSUES: #Influenza infection #Acute on chronic HFpEF #Hypoxic respiratory failure: From flu and acute on chronic HFpEF. TTE repeated this admission with EF 72%. Treated with 5-day course of Tamiflu. Diuresed with 40-80 IV Lasix to a weight of 87 kgs. Discharged on increased dose of Lasix (40mg, from 20mg prior to admission). #AFib #Tachy-brady s/p PPM: Intermittent runs of AF with RVR while in MICU and prior to diuresis. At discharge, remained paced at 60 on home dilt 240 ER, sotalol 120 BID, metop tartrate 100 BID. #Type 2 NSTEMI: Trop peaked at 0.16. New EKG changes with TWI in lateral leads however given absence of chest pain, TTE with preserved EF and no new WMAs, discussed with cardiology who felt no need for repeat stress test or cath. #Rash: LLE rash x 3 months, in leg with vein harvest from prior CABG. Not painful or itchy, low concern for cellulitis or inflammatory dermatitis. More likely capillary leak/stasis dermatitis related to vein harvest. Derm [MASKED] arranged at discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Mesalamine Enema 4 gm PR QHS 3. Sotalol 120 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Loratadine 10 mg PO DAILY 6. Warfarin 8 mg PO 4X/WEEK ([MASKED]) 7. Warfarin 9 mg PO 3X/WEEK ([MASKED]) 8. Diltiazem Extended-Release 240 mg PO DAILY 9. Valsartan 80 mg PO DAILY 10. Tamsulosin 0.4 mg PO QHS 11. FoLIC Acid 1 mg PO DAILY 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Atorvastatin 80 mg PO QPM 15. Metoprolol Tartrate 100 mg PO BID 16. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Benzonatate 100 mg PO TID:PRN cough RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*60 Capsule Refills:*1 2. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 3. Warfarin 7 mg PO DAILY16 4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. balsalazide 2250 mg oral TID 8. Diltiazem Extended-Release 240 mg PO DAILY 9. Fluticasone Propionate NASAL 2 SPRY NU QHS 10. FoLIC Acid 1 mg PO DAILY 11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 12. Loratadine 10 mg PO DAILY 13. Mesalamine (Rectal) AILY 14. Mesalamine Enema 4 gm PR QHS 15. Metoprolol Tartrate 100 mg PO BID 16. Multivitamins 1 TAB PO DAILY 17. Sotalol 120 mg PO BID 18. Tamsulosin 0.4 mg PO QHS 19. Valsartan 80 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Influenza 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 IN THE HOSPITAL? - You were admitted to the hospital for shortness of breath from the flu WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? - You were treated for the flu - You were given diuretics to help remove the extra fluid WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? - Continue to take all your medicines as prescribed below. - Show up to your appointments as listed below. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "J9601", "I2510", "Z951", "Z87891", "Z7901", "N400", "I110", "D696" ]
[ "J111: Influenza due to unidentified influenza virus with other respiratory manifestations", "J9601: Acute respiratory failure with hypoxia", "I21A1: Myocardial infarction type 2", "I5033: Acute on chronic diastolic (congestive) heart failure", "K5190: Ulcerative colitis, unspecified, without complications", "J918: Pleural effusion in other conditions classified elsewhere", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z9114: Patient's other noncompliance with medication regimen", "Z950: Presence of cardiac pacemaker", "Z87891: Personal history of nicotine dependence", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I110: Hypertensive heart disease with heart failure", "I495: Sick sinus syndrome", "D696: Thrombocytopenia, unspecified", "R21: Rash and other nonspecific skin eruption" ]
10,070,352
25,529,964
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abnormal Labs - Leukocytosis and Transaminitis Major Surgical or Invasive Procedure: None History of Present Illness: Patient was admitted to ___ from ___ - ___ after presenting to ___ with jaundice, found to have ___ ~12 with presumed alcoholic hepatitis (AST 210, ALT 35). He was started on prednisolone and phenobarb but left AMA on ___. He then saw his PCP ___ ___ who instructed him to return to the hospital, and he was ultimately transferred to ___. On arrival on ___, ___ was 22. He was continued on prednisone and ___ downtrended to 18.3 at discharge. He then saw Dr. ___ in clinic on ___ at which point note is made of OSH labs showing: T bili 21.4, D bili 17.8, alk phos 151 AST 193, ALT 83 (unclear where this was). Labs were repeated that day and he was noted to have WBC 25 (increased from 15 at discharge), as well as rising transaminases and INR ___ was ~17). Recommendation was for him to return to the ED for steroid taper and possible liver biopsy, however he was going on a family trip and they decided against it. On return from their trip, he presented to the ED. Of note, Dr. ___ a ___ of 24 on labs from ___, although on review of their records, it appears ___ was 13 on ___ at ___. He reports feeling well since discharge from the hospital. He has been taking his prednisone every day and says it makes him feel a little "jittery," but otherwise has no complaints. He specifically denies fever/chills, n/v/d, abdominal pain, cough and dysuria. His family trip was to ___ for his grandmother's ___ birthday--says they went hiking but did check for ticks and he did not see any. He notes that his urine has been clearing up over the past week. Regarding his EtOH use, he is currently attending ___, has a sponsor, and states his last drink was ___. He denies any OTC medication use, other drug use. Past Medical History: Alcoholic hepatitis Subclinical hemochromatosis Depression Insomnia Social History: ___ Family History: Paternal side - ETOH abuse Physical Exam: ADMISSION PHYSICAL EXAMINATION: ============================ GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, icteric 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: mildly distended, nontender in all quadrants, no rebound/guarding, no fluid wave EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: Jaundiced, warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAMINATION: ============================ GENERAL: NAD, Resting comfortably in bed HEENT: AT/NC, EOMI, PERRL, mildly icteric 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: mildly distended, nontender in all quadrants, no rebound/guarding, no fluid wave EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: Mildly jaundiced, warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 05:52PM BLOOD WBC-21.7* RBC-3.62* Hgb-12.4* Hct-36.0* MCV-99* MCH-34.3* MCHC-34.4 RDW-19.7* RDWSD-72.9* Plt ___ ___ 05:52PM BLOOD Neuts-89.6* Lymphs-4.7* Monos-3.8* Eos-0.1* Baso-0.2 Im ___ AbsNeut-19.41* AbsLymp-1.01* AbsMono-0.82* AbsEos-0.02* AbsBaso-0.05 ___ 05:52PM BLOOD ___ PTT-35.6 ___ ___ 05:52PM BLOOD Glucose-190* UreaN-11 Creat-0.6 Na-139 K-4.4 Cl-105 HCO3-20* AnGap-14 ___ 05:52PM BLOOD ALT-114* AST-233* AlkPhos-141* TotBili-12.6* ___ 05:52PM BLOOD Albumin-3.4* INTERVAL LABS: ___ 05:29AM BLOOD WBC-21.2* RBC-3.34* Hgb-11.2* Hct-32.4* MCV-97 MCH-33.5* MCHC-34.6 RDW-19.5* RDWSD-69.4* Plt ___ ___ 05:29AM BLOOD ___ PTT-36.9* ___ ___ 05:29AM BLOOD ALT-96* AST-166* LD(LDH)-137 AlkPhos-123 TotBili-10.9* ___ 05:29AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.6 Mg-2.2 DISCHARGE LABS: ___ 05:09AM BLOOD WBC-20.8* RBC-3.40* Hgb-11.5* Hct-33.4* MCV-98 MCH-33.8* MCHC-34.4 RDW-19.1* RDWSD-68.1* Plt ___ ___ 05:09AM BLOOD ___ PTT-35.4 ___ ___ 05:09AM BLOOD Glucose-69* UreaN-11 Creat-0.7 Na-140 K-4.3 Cl-104 HCO3-24 AnGap-12 ___ 05:09AM BLOOD ALT-107* AST-170* LD(LDH)-140 AlkPhos-130 TotBili-10.6* ___ 05:09AM BLOOD Albumin-3.0* Calcium-8.8 Phos-3.8 Mg-2.1 IMAGING: ___ OR GALLBLADDER US 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Patent main portal vein, demonstrating slow hepatopetal flow. 3. Sludge filled gallbladder without evidence of cholecystitis. ___ (PA & LAT) No focal consolidation concerning for pneumonia. Brief Hospital Course: PATIENT SUMMARY ======================= ___ year old man with hx EtOH use disorder, hemochromatosis, recent diagnosis of alcoholic hepatitis, now on steroids, admitted for rising white count and persistent transaminitis. His liver function levels were improving with the steroid treatment he was admitted with and no infectious process was identified to explain leukocytosis. ACUTE ISSUES ADDRESSED ====================== #Alcoholic hepatitis #Transaminitis: The patient was noted to have labwork concerning for ongoing liver inflammation, with AST 233 ALT 114, from 102/53 at discharge on ___, and 216/98 on ___, also with worsening coagulopathy, with INR 2 from 1.6 prior. ___ was downtrending, however, 12.6 from 18.3 on ___, which was reassuring. It was possible that he has had another insult (i.e. ?infection, ?PVT, ?drug-induced liver injury) leading to ongoing liver injury, although it is more likely that he still has a degree of necro-inflammation from his alcoholic hepatitis, and that his transaminases and coagulopathy are simply lagging behind ___ (and will improve with time). Topamax and mirtazapine are both very rarely associated with hepatocellular injury, so we did not stop these medications. We continued the patient on his prior dose of prednisone 40mg daily, which he should continue to take for total of 28 days (last dose ___. Blood and urine cultures were negative at time of discharge, suggesting that there was no acute infectious process contributing to his abnormal lab values. A RUQ u/s demonstrated no evidence of portal vein thrombosis. Given improving LFTs and stable clinical status, the patient did not require a liver biopsy. He should continue to undergo a liver transplant evaluation as an outpatient. #Leukocytosis: Neutrophil predominant. This is possibly due to demargination from steroids, although could also be necrotizing inflammation from his EtOH hepatitis vs infection, which can be very difficult to assess in patients with hepatitis. No antibiotics started given lack of infectious symptoms and no growth on blood and urine cultures. Leukocytosis was persistent at time of discharge with WBC @ 20.8. #EtOH use disorder: Last drink ___. Has good support currently, patient was very motivated to remain abstinent from alcohol. CHRONIC ISSUES ADDRESSED: ======================== #Hemochromatosis Patient has no current f/u with hematology, but follows with Dr. ___ Hepatology, no current complications and has never required phlebotomy. We did no further work-up or interventions with regard to this diagnosis on this admission. The patient would likely benefit from hematology follow-up going forward. #Depression #Insomnia: We continued the patient's home Topamax and Remeron TRANSITIONAL ISSUES =================== [ ] Alcoholic hepatitis: [] Continue to take 40mg prednisone to finish a 28-day course, last day will be ___. [] Obtain CBC, LFTs within 1 week of discharge, forward to PCP and Dr. ___ [] Ensure adequate daily nutrition with Ensure 4x daily until Dr. ___ [ ] Hematochromatosis: the patient would likely benefit from hematology monitoring and follow-up going forward. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mirtazapine 30 mg PO QHS 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Thiamine 100 mg PO DAILY 5. Topiramate (Topamax) 50 mg PO DAILY 6. PredniSONE 40 mg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY Discharge Medications: 1. Magnesium Oxide 400 mg PO DAILY 2. Mirtazapine 30 mg PO QHS 3. Multivitamins W/minerals 1 TAB PO DAILY 4. Omeprazole 20 mg PO DAILY 5. PredniSONE 40 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. Topiramate (Topamax) 50 mg PO DAILY 8.Outpatient Lab Work Dx: Alcoholic Hepatitis (571.1) Draw LFTs (AST, ALT, ___, Albumin, LDH) within one week of hospital discharge on ___. Fax to: ___, MD ___ 9.Outpatient Lab Work Dx: Leukocytosis (288.60) Please obtain CBC within one week of hospital discharge on ___. Fax to: ___, MD ___ Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses ================= Alcoholic Hepatitis Leukocytosis SECONDARY ISSUES ================== EtOH use disorder 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 some abnormal lab tests noted by your outpatient provider. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We trended your blood counts and liver enzymes, which remained stable. - You did not need a liver biopsy during this hospitalization. - 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 in your care. We wish you the best! - Your ___ Care Team Followup Instructions: ___
[ "K7010", "D684", "F329", "G4700", "E83119", "D72829", "F1020" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abnormal Labs - Leukocytosis and Transaminitis Major Surgical or Invasive Procedure: None History of Present Illness: Patient was admitted to [MASKED] from [MASKED] - [MASKED] after presenting to [MASKED] with jaundice, found to have [MASKED] ~12 with presumed alcoholic hepatitis (AST 210, ALT 35). He was started on prednisolone and phenobarb but left AMA on [MASKED]. He then saw his PCP [MASKED] [MASKED] who instructed him to return to the hospital, and he was ultimately transferred to [MASKED]. On arrival on [MASKED], [MASKED] was 22. He was continued on prednisone and [MASKED] downtrended to 18.3 at discharge. He then saw Dr. [MASKED] in clinic on [MASKED] at which point note is made of OSH labs showing: T bili 21.4, D bili 17.8, alk phos 151 AST 193, ALT 83 (unclear where this was). Labs were repeated that day and he was noted to have WBC 25 (increased from 15 at discharge), as well as rising transaminases and INR [MASKED] was ~17). Recommendation was for him to return to the ED for steroid taper and possible liver biopsy, however he was going on a family trip and they decided against it. On return from their trip, he presented to the ED. Of note, Dr. [MASKED] a [MASKED] of 24 on labs from [MASKED], although on review of their records, it appears [MASKED] was 13 on [MASKED] at [MASKED]. He reports feeling well since discharge from the hospital. He has been taking his prednisone every day and says it makes him feel a little "jittery," but otherwise has no complaints. He specifically denies fever/chills, n/v/d, abdominal pain, cough and dysuria. His family trip was to [MASKED] for his grandmother's [MASKED] birthday--says they went hiking but did check for ticks and he did not see any. He notes that his urine has been clearing up over the past week. Regarding his EtOH use, he is currently attending [MASKED], has a sponsor, and states his last drink was [MASKED]. He denies any OTC medication use, other drug use. Past Medical History: Alcoholic hepatitis Subclinical hemochromatosis Depression Insomnia Social History: [MASKED] Family History: Paternal side - ETOH abuse Physical Exam: ADMISSION PHYSICAL EXAMINATION: ============================ GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, icteric 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: mildly distended, nontender in all quadrants, no rebound/guarding, no fluid wave EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: Jaundiced, warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAMINATION: ============================ GENERAL: NAD, Resting comfortably in bed HEENT: AT/NC, EOMI, PERRL, mildly icteric 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: mildly distended, nontender in all quadrants, no rebound/guarding, no fluid wave EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: Mildly jaundiced, warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: [MASKED] 05:52PM BLOOD WBC-21.7* RBC-3.62* Hgb-12.4* Hct-36.0* MCV-99* MCH-34.3* MCHC-34.4 RDW-19.7* RDWSD-72.9* Plt [MASKED] [MASKED] 05:52PM BLOOD Neuts-89.6* Lymphs-4.7* Monos-3.8* Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-19.41* AbsLymp-1.01* AbsMono-0.82* AbsEos-0.02* AbsBaso-0.05 [MASKED] 05:52PM BLOOD [MASKED] PTT-35.6 [MASKED] [MASKED] 05:52PM BLOOD Glucose-190* UreaN-11 Creat-0.6 Na-139 K-4.4 Cl-105 HCO3-20* AnGap-14 [MASKED] 05:52PM BLOOD ALT-114* AST-233* AlkPhos-141* TotBili-12.6* [MASKED] 05:52PM BLOOD Albumin-3.4* INTERVAL LABS: [MASKED] 05:29AM BLOOD WBC-21.2* RBC-3.34* Hgb-11.2* Hct-32.4* MCV-97 MCH-33.5* MCHC-34.6 RDW-19.5* RDWSD-69.4* Plt [MASKED] [MASKED] 05:29AM BLOOD [MASKED] PTT-36.9* [MASKED] [MASKED] 05:29AM BLOOD ALT-96* AST-166* LD(LDH)-137 AlkPhos-123 TotBili-10.9* [MASKED] 05:29AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.6 Mg-2.2 DISCHARGE LABS: [MASKED] 05:09AM BLOOD WBC-20.8* RBC-3.40* Hgb-11.5* Hct-33.4* MCV-98 MCH-33.8* MCHC-34.4 RDW-19.1* RDWSD-68.1* Plt [MASKED] [MASKED] 05:09AM BLOOD [MASKED] PTT-35.4 [MASKED] [MASKED] 05:09AM BLOOD Glucose-69* UreaN-11 Creat-0.7 Na-140 K-4.3 Cl-104 HCO3-24 AnGap-12 [MASKED] 05:09AM BLOOD ALT-107* AST-170* LD(LDH)-140 AlkPhos-130 TotBili-10.6* [MASKED] 05:09AM BLOOD Albumin-3.0* Calcium-8.8 Phos-3.8 Mg-2.1 IMAGING: [MASKED] OR GALLBLADDER US 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Patent main portal vein, demonstrating slow hepatopetal flow. 3. Sludge filled gallbladder without evidence of cholecystitis. [MASKED] (PA & LAT) No focal consolidation concerning for pneumonia. Brief Hospital Course: PATIENT SUMMARY ======================= [MASKED] year old man with hx EtOH use disorder, hemochromatosis, recent diagnosis of alcoholic hepatitis, now on steroids, admitted for rising white count and persistent transaminitis. His liver function levels were improving with the steroid treatment he was admitted with and no infectious process was identified to explain leukocytosis. ACUTE ISSUES ADDRESSED ====================== #Alcoholic hepatitis #Transaminitis: The patient was noted to have labwork concerning for ongoing liver inflammation, with AST 233 ALT 114, from 102/53 at discharge on [MASKED], and 216/98 on [MASKED], also with worsening coagulopathy, with INR 2 from 1.6 prior. [MASKED] was downtrending, however, 12.6 from 18.3 on [MASKED], which was reassuring. It was possible that he has had another insult (i.e. ?infection, ?PVT, ?drug-induced liver injury) leading to ongoing liver injury, although it is more likely that he still has a degree of necro-inflammation from his alcoholic hepatitis, and that his transaminases and coagulopathy are simply lagging behind [MASKED] (and will improve with time). Topamax and mirtazapine are both very rarely associated with hepatocellular injury, so we did not stop these medications. We continued the patient on his prior dose of prednisone 40mg daily, which he should continue to take for total of 28 days (last dose [MASKED]. Blood and urine cultures were negative at time of discharge, suggesting that there was no acute infectious process contributing to his abnormal lab values. A RUQ u/s demonstrated no evidence of portal vein thrombosis. Given improving LFTs and stable clinical status, the patient did not require a liver biopsy. He should continue to undergo a liver transplant evaluation as an outpatient. #Leukocytosis: Neutrophil predominant. This is possibly due to demargination from steroids, although could also be necrotizing inflammation from his EtOH hepatitis vs infection, which can be very difficult to assess in patients with hepatitis. No antibiotics started given lack of infectious symptoms and no growth on blood and urine cultures. Leukocytosis was persistent at time of discharge with WBC @ 20.8. #EtOH use disorder: Last drink [MASKED]. Has good support currently, patient was very motivated to remain abstinent from alcohol. CHRONIC ISSUES ADDRESSED: ======================== #Hemochromatosis Patient has no current f/u with hematology, but follows with Dr. [MASKED] Hepatology, no current complications and has never required phlebotomy. We did no further work-up or interventions with regard to this diagnosis on this admission. The patient would likely benefit from hematology follow-up going forward. #Depression #Insomnia: We continued the patient's home Topamax and Remeron TRANSITIONAL ISSUES =================== [ ] Alcoholic hepatitis: [] Continue to take 40mg prednisone to finish a 28-day course, last day will be [MASKED]. [] Obtain CBC, LFTs within 1 week of discharge, forward to PCP and Dr. [MASKED] [] Ensure adequate daily nutrition with Ensure 4x daily until Dr. [MASKED] [ ] Hematochromatosis: the patient would likely benefit from hematology monitoring and follow-up going forward. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mirtazapine 30 mg PO QHS 2. Multivitamins W/minerals 1 TAB PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Thiamine 100 mg PO DAILY 5. Topiramate (Topamax) 50 mg PO DAILY 6. PredniSONE 40 mg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY Discharge Medications: 1. Magnesium Oxide 400 mg PO DAILY 2. Mirtazapine 30 mg PO QHS 3. Multivitamins W/minerals 1 TAB PO DAILY 4. Omeprazole 20 mg PO DAILY 5. PredniSONE 40 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. Topiramate (Topamax) 50 mg PO DAILY 8.Outpatient Lab Work Dx: Alcoholic Hepatitis (571.1) Draw LFTs (AST, ALT, [MASKED], Albumin, LDH) within one week of hospital discharge on [MASKED]. Fax to: [MASKED], MD [MASKED] 9.Outpatient Lab Work Dx: Leukocytosis (288.60) Please obtain CBC within one week of hospital discharge on [MASKED]. Fax to: [MASKED], MD [MASKED] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses ================= Alcoholic Hepatitis Leukocytosis SECONDARY ISSUES ================== EtOH use disorder 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 some abnormal lab tests noted by your outpatient provider. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We trended your blood counts and liver enzymes, which remained stable. - You did not need a liver biopsy during this hospitalization. - 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 in your care. We wish you the best! - Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "F329", "G4700" ]
[ "K7010: Alcoholic hepatitis without ascites", "D684: Acquired coagulation factor deficiency", "F329: Major depressive disorder, single episode, unspecified", "G4700: Insomnia, unspecified", "E83119: Hemochromatosis, unspecified", "D72829: Elevated white blood cell count, unspecified", "F1020: Alcohol dependence, uncomplicated" ]
10,070,352
25,639,901
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Alcoholic Hepatitis Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old man with history of EtOH use disorder previously in remission who presented to the ___ with jaundice. He has a history of significant EtOH use in the past, but was recently at ___ ___ months ago) for detox. He had been sober until 5pm on ___, having relapsed in the setting of termination of a romantic relationship. He presented to ___ on ___ when his family and friends expressed concern that he was turning yellow. His labs on that day are notable for Total Bilirubin 11.98 H AST 210 H ALT 35 Alkaline Phosphatase 152 H INR 1.4 Serum EtOH on admission was 356 He was admitted and started on prednisolone ___s a phenobarbital taper. Unfortunately, he left on ___ against medical advice. He was provided with a prescription for prednisolone which he filled and was taking at home. He saw his PCP ___ ___ and was told to present to the ___ for jaundice and elevated bilirubin. He presented to ___, and was transferred to ___ ___ for subspecialty care. Past Medical History: Hemachromatosis Depression Insomnia Social History: ___ Family History: Paternal side with ETOH abuse Physical Exam: ADMISSION EXAM: VS: 97.6 BP 124/83 HR71 RR16 97% on RA GENERAL: NAD, diffusely jaundiced, distal wasting HEENT: AT/NC, EOMI, PERRL, icteric sclera, 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: distended with obvious hepatomegaly. Reducible umbilical hernia (since birth). No spider angiomas. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, speech is mildly slowed. No asterixis. Mild resting tremor. SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM 24 HR Data (last updated ___ @ 1146) Temp: 99.3 (Tm 100.5), BP: 118/73 (118-133/71-84), HR: 84 (73-86), RR: 18 (___), O2 sat: 96% (96-98), O2 delivery: Ra, Wt: 237.1 lb/107.55 kg GENERAL: Pleasant, lying in bed comfortably. Jaundice and scleral icterus. HEENT: Atraumatic, normocephalic. No lymphadenopathy. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, slightly distended with obvious hepatomegaly. Reducible umbilical hernia (since birth). No spider angiomas. EXT: No palmar erythema. Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses NEURO: No asterixis. No tremor. Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes Pertinent Results: Admission Labs ___ 12:07AM BLOOD WBC-14.1* RBC-3.63* Hgb-12.1* Hct-34.3* MCV-95 MCH-33.3* MCHC-35.3 RDW-19.9* RDWSD-69.3* Plt ___ ___ 12:07AM BLOOD Neuts-76.7* Lymphs-7.5* Monos-13.4* Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.79* AbsLymp-1.05* AbsMono-1.89* AbsEos-0.01* AbsBaso-0.03 ___ 12:07AM BLOOD Plt ___ ___ 04:24AM BLOOD ___ PTT-32.1 ___ ___ 12:07AM BLOOD Glucose-106* UreaN-9 Creat-0.6 Na-139 K-3.9 Cl-100 HCO3-20* AnGap-19* ___ 12:07AM BLOOD ALT-49* AST-101* AlkPhos-123 TotBili-22.0* DirBili-16.5* IndBili-5.5 ___ 12:07AM BLOOD Lipase-68* ___ 12:07AM BLOOD Albumin-3.5 Calcium-8.9 Phos-2.8 Mg-2.2 ___ 09:50AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG ___ 09:50AM BLOOD Smooth-NEGATIVE ___ 09:50AM BLOOD ___ ___ 12:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 09:50AM BLOOD HCV VL-NOT DETECT ___ 09:50AM BLOOD ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY-PND --------------- Discharge Labs ___ 05:30AM BLOOD WBC-14.9* RBC-3.64* Hgb-12.4* Hct-34.7* MCV-95 MCH-34.1* MCHC-35.7 RDW-20.6* RDWSD-72.3* Plt ___ ___ 05:30AM BLOOD Plt ___ ___ 05:30AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-138 K-3.9 Cl-102 HCO3-22 AnGap-14 ___ 05:30AM BLOOD ALT-53* AST-102* AlkPhos-119 TotBili-18.3* DirBili-15.9* IndBili-2.4 ___ 05:30AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.0 Mg-2.2 --------------- Micro ___ Urine Culture URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. --------------- Imaging None Brief Hospital Course: PATIENT SUMMARY Mr. ___ is a ___ year old man with history of EtOH use disorder, previously in remission, who presented with jaundice, currently be treated for alcoholic hepatitis. ACUTE ISSUES # ACUTE LIVER INJURY # PRESUMED ALCOHOLIC HEPATITIS On ___, Mr. ___ presented to ___ with jaundice and elevated liver enzymes. At ___, he had a RUQ-U/S showing hepatomegaly, and splenomegaly. He was subsequently transferred to ___ ___ for subspecialty care. Upon arrival to the ___ ___, he had no signs of hepatic encephalopathy and had labs showing tBili 22, AST and ALT elevation (101/49), INR 1.8 in the setting of recent EtOH use, concerning for alcoholic hepatitis. On ___, he was admitted, and continued on his 6-week steroid course. Per patient, he started steroids on ___. During his admission, Mr. ___ maintained elevated ALT/AST values, however his total bilirubin downtrended, and he showed signs of response to steroid treatment (Lille<0.45). He will require daily steroid medication until ___, then subsequent taper. Per patient, Mr. ___ has been previously counseled about his alcohol use by previous providers. He was counseled by medical team about the importance of abstaining from further alcohol use. He was evaluated by the ___ Liver Service, and is ineligible for a liver transplant a this time. HepC viral load, and HepB and autoantibody serologies were sent, and all returned negative. # COAGULOPATHY: Pt presented with INR 1.8, which was likely elevated in the setting of acute liver injury (as above). He was given two injections of vitamin K, and his INR improved to 1.6 on the day of discharge. #C - Chronic issues pertinent to admission (ex. HTN, held Lisinopril for ___ # EtOH USE DISORDER Per patient, last drink was on ___, prior to admission. Pt reports history of alcohol withdrawal in the past with tremors, palpitations, diaphoresis, but denies seizures. During his hospital admission, Mr. ___ denied withdrawal symptoms and had no signs of withdrawal on exam. He was monitored and treated per ___ protocol, and given thiamine and MV daily. He also met with our Social Work team on ___, and they created a plan to seek out IOP at ___ or ___. Mr. ___ will make contact with IOPs and SW will return to provide assistance with referrals. # HEMACHROMATOSIS Pt with reported history of sub-clinical hemochromatosis, which was discovered when he allowed blood test for research study at ___ (___). Records from partners were limited and did not confirm subclinical significance of lab findings. # DEPRESSION # INSOMNIA Continued home topiramate and mirtazapine which patient takes for sleep. Patient had no issues with sleep during admission. #T - Transitional Issues [] Presented with elevated liver enzymes and jaundice consistent with alcoholic hepatitis, treated with prednisone. [] Prednisone 40mg daily for 6 weeks then taper (___) [] On ___: Primary Care Visit with Lab Work (CBC, LFTs, Chem-7, Coagulation, Serum Tox Screen) [] On ___: Follow-up visit with Hepatologist Dr. ___ [] Ensure adequate daily nutrition with Ensure 4x daily until Dr. ___ [] Follow-up with Partners records to confirm sub-clinical significance of hemachromatosis. [] Follow-up with ___ Social Work for referral aid in connecting to IOP at ___ or ___. - New Meds: None - Stopped/Held Meds: None - Changed Meds: Prednisolone changed to Prednisone 40mg Daily for 6 weeks (started ___ end ___ - Follow-up appointments: Primary Care and Hepatology appointments. - Post-Discharge Follow-up Labs Needed: CBC, Chem-7, Coags, Tox Screen on ___. - Incidental Findings: None - Discharge weight: 237.1 lbs - Discharge creatinine: 0.7 - Discharge hgb: 12.4 # CODE: FULL Code # CONTACT: Health care proxy chosen: Yes Name of health care proxy: ___ Phone number: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mirtazapine 30 mg PO QHS 2. Topiramate (Topamax) 50 mg PO DAILY 3. prednisoLONE 15 mg/5 mL oral daily 4. Omeprazole 20 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Thiamine 100 mg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY Discharge Medications: 1. PredniSONE 40 mg PO DAILY 2. Magnesium Oxide 400 mg PO DAILY 3. Mirtazapine 30 mg PO QHS 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. Topiramate (Topamax) 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # ACUTE LIVER INJURY # ALCOHOLIC HEPATITIS # COAGULOPATHY # EtOH USE DISORDER # HEMACHROMATOSIS # DEPRESSION # INSOMNIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for jaundice (yellowing of the skin and eyes) and elevated liver enzymes concerning for alcoholic hepatitis. What was done for me while I was in the hospital? Once admitted to the hospital, you were continued on steroids to suppress the immune reaction in your liver. You were given medication and vitamins to reduce the symptoms of possible alcohol withdrawal. Your blood electrolytes were restored, and we gave you medication to help your blood clot. We performed blood tests to ensure that the steroid treatment was working. We performed blood tests to rule out autoimmune or infection causes of liver injury, and those returned negative. What should I do when I leave the hospital? The most important thing you can do once leaving the hospital is to not drink alcohol. Please continue taking your steroid medications as prescribed and continue to eat throughout the day to ensure adequate nutrition. We have scheduled an appointment for you to visit your Primary Care Physician on ___, where you will have more blood lab tests done. We have also scheduled an appointment for you to see Dr. ___ on ___ ___. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "K7010", "D684", "E83119", "F1010", "F329", "G4700" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Alcoholic Hepatitis Major Surgical or Invasive Procedure: None History of Present Illness: This is a [MASKED] year old man with history of EtOH use disorder previously in remission who presented to the [MASKED] with jaundice. He has a history of significant EtOH use in the past, but was recently at [MASKED] [MASKED] months ago) for detox. He had been sober until 5pm on [MASKED], having relapsed in the setting of termination of a romantic relationship. He presented to [MASKED] on [MASKED] when his family and friends expressed concern that he was turning yellow. His labs on that day are notable for Total Bilirubin 11.98 H AST 210 H ALT 35 Alkaline Phosphatase 152 H INR 1.4 Serum EtOH on admission was 356 He was admitted and started on prednisolone s a phenobarbital taper. Unfortunately, he left on [MASKED] against medical advice. He was provided with a prescription for prednisolone which he filled and was taking at home. He saw his PCP [MASKED] [MASKED] and was told to present to the [MASKED] for jaundice and elevated bilirubin. He presented to [MASKED], and was transferred to [MASKED] [MASKED] for subspecialty care. Past Medical History: Hemachromatosis Depression Insomnia Social History: [MASKED] Family History: Paternal side with ETOH abuse Physical Exam: ADMISSION EXAM: VS: 97.6 BP 124/83 HR71 RR16 97% on RA GENERAL: NAD, diffusely jaundiced, distal wasting HEENT: AT/NC, EOMI, PERRL, icteric sclera, 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: distended with obvious hepatomegaly. Reducible umbilical hernia (since birth). No spider angiomas. EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose, speech is mildly slowed. No asterixis. Mild resting tremor. SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM 24 HR Data (last updated [MASKED] @ 1146) Temp: 99.3 (Tm 100.5), BP: 118/73 (118-133/71-84), HR: 84 (73-86), RR: 18 ([MASKED]), O2 sat: 96% (96-98), O2 delivery: Ra, Wt: 237.1 lb/107.55 kg GENERAL: Pleasant, lying in bed comfortably. Jaundice and scleral icterus. HEENT: Atraumatic, normocephalic. No lymphadenopathy. CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi ABD: Normal bowel sounds, soft, nontender, slightly distended with obvious hepatomegaly. Reducible umbilical hernia (since birth). No spider angiomas. EXT: No palmar erythema. Warm, well perfused, no lower extremity edema PULSES: 2+ radial pulses, 2+ [MASKED] pulses, 2+ DP pulses NEURO: No asterixis. No tremor. Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes Pertinent Results: Admission Labs [MASKED] 12:07AM BLOOD WBC-14.1* RBC-3.63* Hgb-12.1* Hct-34.3* MCV-95 MCH-33.3* MCHC-35.3 RDW-19.9* RDWSD-69.3* Plt [MASKED] [MASKED] 12:07AM BLOOD Neuts-76.7* Lymphs-7.5* Monos-13.4* Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-10.79* AbsLymp-1.05* AbsMono-1.89* AbsEos-0.01* AbsBaso-0.03 [MASKED] 12:07AM BLOOD Plt [MASKED] [MASKED] 04:24AM BLOOD [MASKED] PTT-32.1 [MASKED] [MASKED] 12:07AM BLOOD Glucose-106* UreaN-9 Creat-0.6 Na-139 K-3.9 Cl-100 HCO3-20* AnGap-19* [MASKED] 12:07AM BLOOD ALT-49* AST-101* AlkPhos-123 TotBili-22.0* DirBili-16.5* IndBili-5.5 [MASKED] 12:07AM BLOOD Lipase-68* [MASKED] 12:07AM BLOOD Albumin-3.5 Calcium-8.9 Phos-2.8 Mg-2.2 [MASKED] 09:50AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG [MASKED] 09:50AM BLOOD Smooth-NEGATIVE [MASKED] 09:50AM BLOOD [MASKED] [MASKED] 12:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 09:50AM BLOOD HCV VL-NOT DETECT [MASKED] 09:50AM BLOOD ANTI-LIVER-KIDNEY-MICROSOME ANTIBODY-PND --------------- Discharge Labs [MASKED] 05:30AM BLOOD WBC-14.9* RBC-3.64* Hgb-12.4* Hct-34.7* MCV-95 MCH-34.1* MCHC-35.7 RDW-20.6* RDWSD-72.3* Plt [MASKED] [MASKED] 05:30AM BLOOD Plt [MASKED] [MASKED] 05:30AM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-138 K-3.9 Cl-102 HCO3-22 AnGap-14 [MASKED] 05:30AM BLOOD ALT-53* AST-102* AlkPhos-119 TotBili-18.3* DirBili-15.9* IndBili-2.4 [MASKED] 05:30AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.0 Mg-2.2 --------------- Micro [MASKED] Urine Culture URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. --------------- Imaging None Brief Hospital Course: PATIENT SUMMARY Mr. [MASKED] is a [MASKED] year old man with history of EtOH use disorder, previously in remission, who presented with jaundice, currently be treated for alcoholic hepatitis. ACUTE ISSUES # ACUTE LIVER INJURY # PRESUMED ALCOHOLIC HEPATITIS On [MASKED], Mr. [MASKED] presented to [MASKED] with jaundice and elevated liver enzymes. At [MASKED], he had a RUQ-U/S showing hepatomegaly, and splenomegaly. He was subsequently transferred to [MASKED] [MASKED] for subspecialty care. Upon arrival to the [MASKED] [MASKED], he had no signs of hepatic encephalopathy and had labs showing tBili 22, AST and ALT elevation (101/49), INR 1.8 in the setting of recent EtOH use, concerning for alcoholic hepatitis. On [MASKED], he was admitted, and continued on his 6-week steroid course. Per patient, he started steroids on [MASKED]. During his admission, Mr. [MASKED] maintained elevated ALT/AST values, however his total bilirubin downtrended, and he showed signs of response to steroid treatment (Lille<0.45). He will require daily steroid medication until [MASKED], then subsequent taper. Per patient, Mr. [MASKED] has been previously counseled about his alcohol use by previous providers. He was counseled by medical team about the importance of abstaining from further alcohol use. He was evaluated by the [MASKED] Liver Service, and is ineligible for a liver transplant a this time. HepC viral load, and HepB and autoantibody serologies were sent, and all returned negative. # COAGULOPATHY: Pt presented with INR 1.8, which was likely elevated in the setting of acute liver injury (as above). He was given two injections of vitamin K, and his INR improved to 1.6 on the day of discharge. #C - Chronic issues pertinent to admission (ex. HTN, held Lisinopril for [MASKED] # EtOH USE DISORDER Per patient, last drink was on [MASKED], prior to admission. Pt reports history of alcohol withdrawal in the past with tremors, palpitations, diaphoresis, but denies seizures. During his hospital admission, Mr. [MASKED] denied withdrawal symptoms and had no signs of withdrawal on exam. He was monitored and treated per [MASKED] protocol, and given thiamine and MV daily. He also met with our Social Work team on [MASKED], and they created a plan to seek out IOP at [MASKED] or [MASKED]. Mr. [MASKED] will make contact with IOPs and SW will return to provide assistance with referrals. # HEMACHROMATOSIS Pt with reported history of sub-clinical hemochromatosis, which was discovered when he allowed blood test for research study at [MASKED] ([MASKED]). Records from partners were limited and did not confirm subclinical significance of lab findings. # DEPRESSION # INSOMNIA Continued home topiramate and mirtazapine which patient takes for sleep. Patient had no issues with sleep during admission. #T - Transitional Issues [] Presented with elevated liver enzymes and jaundice consistent with alcoholic hepatitis, treated with prednisone. [] Prednisone 40mg daily for 6 weeks then taper ([MASKED]) [] On [MASKED]: Primary Care Visit with Lab Work (CBC, LFTs, Chem-7, Coagulation, Serum Tox Screen) [] On [MASKED]: Follow-up visit with Hepatologist Dr. [MASKED] [] Ensure adequate daily nutrition with Ensure 4x daily until Dr. [MASKED] [] Follow-up with Partners records to confirm sub-clinical significance of hemachromatosis. [] Follow-up with [MASKED] Social Work for referral aid in connecting to IOP at [MASKED] or [MASKED]. - New Meds: None - Stopped/Held Meds: None - Changed Meds: Prednisolone changed to Prednisone 40mg Daily for 6 weeks (started [MASKED] end [MASKED] - Follow-up appointments: Primary Care and Hepatology appointments. - Post-Discharge Follow-up Labs Needed: CBC, Chem-7, Coags, Tox Screen on [MASKED]. - Incidental Findings: None - Discharge weight: 237.1 lbs - Discharge creatinine: 0.7 - Discharge hgb: 12.4 # CODE: FULL Code # CONTACT: Health care proxy chosen: Yes Name of health care proxy: [MASKED] Phone number: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Mirtazapine 30 mg PO QHS 2. Topiramate (Topamax) 50 mg PO DAILY 3. prednisoLONE 15 mg/5 mL oral daily 4. Omeprazole 20 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Thiamine 100 mg PO DAILY 7. Magnesium Oxide 400 mg PO DAILY Discharge Medications: 1. PredniSONE 40 mg PO DAILY 2. Magnesium Oxide 400 mg PO DAILY 3. Mirtazapine 30 mg PO QHS 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. Topiramate (Topamax) 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # ACUTE LIVER INJURY # ALCOHOLIC HEPATITIS # COAGULOPATHY # EtOH USE DISORDER # HEMACHROMATOSIS # DEPRESSION # INSOMNIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a pleasure taking part in your care here at [MASKED]! Why was I admitted to the hospital? - You were admitted for jaundice (yellowing of the skin and eyes) and elevated liver enzymes concerning for alcoholic hepatitis. What was done for me while I was in the hospital? Once admitted to the hospital, you were continued on steroids to suppress the immune reaction in your liver. You were given medication and vitamins to reduce the symptoms of possible alcohol withdrawal. Your blood electrolytes were restored, and we gave you medication to help your blood clot. We performed blood tests to ensure that the steroid treatment was working. We performed blood tests to rule out autoimmune or infection causes of liver injury, and those returned negative. What should I do when I leave the hospital? The most important thing you can do once leaving the hospital is to not drink alcohol. Please continue taking your steroid medications as prescribed and continue to eat throughout the day to ensure adequate nutrition. We have scheduled an appointment for you to visit your Primary Care Physician on [MASKED], where you will have more blood lab tests done. We have also scheduled an appointment for you to see Dr. [MASKED] on [MASKED] [MASKED]. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "F329", "G4700" ]
[ "K7010: Alcoholic hepatitis without ascites", "D684: Acquired coagulation factor deficiency", "E83119: Hemochromatosis, unspecified", "F1010: Alcohol abuse, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "G4700: Insomnia, unspecified" ]
10,070,539
21,243,910
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: ERCP attach Pertinent Results: ___ 07:52AM BLOOD WBC-7.6 RBC-3.82* Hgb-12.0* Hct-35.8* MCV-94 MCH-31.4 MCHC-33.5 RDW-12.1 RDWSD-42.0 Plt ___ ___ 07:52AM BLOOD Glucose-81 UreaN-26* Creat-1.5* Na-141 K-4.3 Cl-104 HCO3-23 AnGap-14 ___ 08:15AM BLOOD ALT-21 AST-25 AlkPhos-72 Amylase-70 TotBili-0.5 DirBili-<0.2 IndBili-0.5 ___ 08:15AM BLOOD Lipase-39 Brief Hospital Course: This is a ___ M w/ hx of AF w/ Eliquis, HTN, GERD, gout, CKD3, acute cholecystitis s/p CCY, choledocholithiasis admitted following ECRP w/ sphincterotomy and extraction of stone/sludge. Pt was started on fluids overnight. He was able to tolerate clear liquids in the morning and was advanced to a regular diet. His apixaban was held and will continue to be held until ___ ___. The patient will f/u with Dr. ___ in 2 months. Transitional Issues: ( )resume apixaban ___ ( )f/u Dr ___ 2 months Discharge physical exam: GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, 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 PSYCH: pleasant, appropriate affect Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Apixaban 5 mg PO DAILY 5. Lisinopril 20 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Apixaban 5 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: ERCP Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, You were admitted for an ERCP procedure which was performed with sphincterotomy and removal of stones/sludge. You tolerated your diet after the procedure. You will need to follow up with your ERCP team in 2 months. Please hold your apixaban until ___. If you experience fever, pain, or any worsening symptoms, please contact ERCP fellow at ___ pager ___. Please follow up with ERCP team in 2 months. Followup Instructions: ___
[ "K9186", "K838", "I4891", "Z7902", "I129", "N183", "E669", "Z6833" ]
Allergies: No Known Allergies / Adverse Drug Reactions Major Surgical or Invasive Procedure: ERCP attach Pertinent Results: [MASKED] 07:52AM BLOOD WBC-7.6 RBC-3.82* Hgb-12.0* Hct-35.8* MCV-94 MCH-31.4 MCHC-33.5 RDW-12.1 RDWSD-42.0 Plt [MASKED] [MASKED] 07:52AM BLOOD Glucose-81 UreaN-26* Creat-1.5* Na-141 K-4.3 Cl-104 HCO3-23 AnGap-14 [MASKED] 08:15AM BLOOD ALT-21 AST-25 AlkPhos-72 Amylase-70 TotBili-0.5 DirBili-<0.2 IndBili-0.5 [MASKED] 08:15AM BLOOD Lipase-39 Brief Hospital Course: This is a [MASKED] M w/ hx of AF w/ Eliquis, HTN, GERD, gout, CKD3, acute cholecystitis s/p CCY, choledocholithiasis admitted following ECRP w/ sphincterotomy and extraction of stone/sludge. Pt was started on fluids overnight. He was able to tolerate clear liquids in the morning and was advanced to a regular diet. His apixaban was held and will continue to be held until [MASKED] [MASKED]. The patient will f/u with Dr. [MASKED] in 2 months. Transitional Issues: ( )resume apixaban [MASKED] ( )f/u Dr [MASKED] 2 months Discharge physical exam: GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, 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 PSYCH: pleasant, appropriate affect Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Apixaban 5 mg PO DAILY 5. Lisinopril 20 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Apixaban 5 mg PO DAILY 3. Chlorthalidone 25 mg PO DAILY 4. Lisinopril 20 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: ERCP 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 an ERCP procedure which was performed with sphincterotomy and removal of stones/sludge. You tolerated your diet after the procedure. You will need to follow up with your ERCP team in 2 months. Please hold your apixaban until [MASKED]. If you experience fever, pain, or any worsening symptoms, please contact ERCP fellow at [MASKED] pager [MASKED]. Please follow up with ERCP team in 2 months. Followup Instructions: [MASKED]
[]
[ "I4891", "Z7902", "I129", "E669" ]
[ "K9186: Retained cholelithiasis following cholecystectomy", "K838: Other specified diseases of biliary tract", "I4891: Unspecified atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "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)", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult" ]
10,070,594
20,956,461
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Fatigue Major Surgical or Invasive Procedure: ___ - Single lumen port placement History of Present Illness: Mr. ___ is a ___ male with history of metastatic neuroendocrine tumor of unknown origin on ___ who presents with fatigue. He was recently admitted for syncope as well as pancytopenia. He reports difficulty ambulating since ___. He has been feeling very tired for the past few days. The morning of admission he was too weak to get out of bed and needed his son to help. He also required a walker whereas before he needed no assistance. He reports an "awful" appetite. He has very poor PO intake, has been trying to take ___ Boosts per day as well as soft foods (pudding, applesauce, and ice cream). Restarted Lasix on ___ after reporting more edema and took two tablets yesterday. Notes worsening bilateral lower extremity parasthesia/numbness from his toes to the mid-thigh. Reports left leg more weak than the right. Notes continued chronic diarrhea although has improved with Imodium. He was also concerned for gout flare so took colchicine today. He denies any recent falls since last admission. On arrival to the ED, initial vitals were 98.3 98 104/53 16 98% RA. Exam was notable for clear lungs, soft abdomen, 2+ bilateral ___ edema to calf without erythema, knee effusions R>L, 4+/5 right hip flexion, ___ left hip flexion, numbness in bilateral dorsal toes and knees, and bilateral mild medial ankle tenderness. Labs were notable for WBC 23.0, H/H 9.0/27.2, Plt 308, INR 2.2, Na 140, K 4.0, BUN/Cr ___, and BNP 13875. CXR was negative for pneumonia. Patient was given Tylenol 1g PO and 1L NS. Prior to transfer vitals were 98.7 95 96/55 18 100% RA. On arrival to the floor, patient reports feeling tired. He denies pain. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: First developed abdominal bloating mid ___. He was then following up with one of our hepatologist, Dr. ___ he was found to have on ___, a 15.9-cm right lobe mass with multiple satellite lesions consistent with HCC and enlarged porta hepatis and retroperitoneal lymphadenopathy consistent with metastases. His case was discussed at ___ Conference and while the lymph nodes were concerning and rereviewed by Interventional Radiology, they were found to be not diagnostic for metastases. He underwent endoscopy with EUS on ___ which did not identify any primary lesions including in the pancreas. A biopsy of 1 of the lymph nodes returned as consistent with grade 2 neuroendocrine tumor with a Ki-67 percentage of about 20%. - ___ C1D1 Carboplatin/Etoposide PAST MEDICAL HISTORY: - ___-induced cirrhosis complicated by portal hypertension - Ascites and HCC - Atrial fibrillation - Hypertension - Obesity - BPH - Gout - Prediabetes Mellitus - Apparent CKD - Baseline Bell's palsy left side Social History: ___ Family History: His mother was diagnosed with intestinal cancer in her late ___ and died at age ___. Brother diagnosed in his ___ and living with bladder cancer. Sister living and has lymphoma. Sister living, diagnosed with breast cancer in her late ___. Physical Exam: ADMISSION EXAM: ================ VS: Temp 97.9, BP 113/71, HR 84, RR 18, O2 sat 100% RA. GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear, left-sided facial droop, temporal wasting. CARDIAC: Irregularly irregular, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-tender, non-distended, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, 2+ bilateral lower extremity edema to the knee. No ankle tenderness to palpation or pain with ROM. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. 4+/5 right hip flexion, ___ left hip flexion. Sensation to light touch intact. SKIN: No significant rashes. DISCHARGE EXAM: ============== VS: 97.6 PO 122 / 72 69 18 GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear, left-sided facial droop, temporal wasting. CARDIAC: Irregularly irregular LUNG: no respiratory distress, clear to auscultation bilaterally anterior an d posterior chest ABD: Soft, non-tender, non-distended EXT: Warm, well perfused, 1+ bilateral lower extremity edema to the knee, TEDS in place. No ankle tenderness to palpation or pain with ROM. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Sensation to light touch intact. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS: ================= ___ 07:21PM BLOOD WBC-23.0* RBC-3.04* Hgb-9.0* Hct-27.2* MCV-90 MCH-29.6 MCHC-33.1 RDW-18.6* RDWSD-57.3* Plt ___ ___ 07:21PM BLOOD Neuts-69 Bands-8* Lymphs-12* Monos-6 Eos-1 Baso-0 ___ Metas-2* Myelos-2* AbsNeut-17.71* AbsLymp-2.76 AbsMono-1.38* AbsEos-0.23 AbsBaso-0.00* ___ 07:21PM BLOOD ___ PTT-27.7 ___ ___ 07:21PM BLOOD Glucose-94 UreaN-19 Creat-1.1 Na-140 K-4.0 Cl-104 HCO3-22 AnGap-18 ___ 06:45AM BLOOD ALT-14 AST-13 LD(LDH)-325* AlkPhos-226* TotBili-0.7 ___ 07:21PM BLOOD ___ ___ 07:21PM BLOOD Albumin-2.3* Calcium-8.0* Phos-2.5* Mg-1.8 ___ 08:45AM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:45AM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 08:45AM URINE RBC-3* WBC->182* Bacteri-MANY Yeast-NONE Epi-<1 TransE-<1 ___ 08:45AM URINE CastHy-4* ___ 08:45AM URINE Mucous-FEW MICRO: ======== ___ 8:45 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING/STUDIES: ================= ___ CXR IMPRESSION: No acute cardiopulmonary process. ___ IMPRESSION: Successful placement of a single lumen chest power low-profile Port-a-cath via the left internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. ___ LUE U/S W/ DOPPLER IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. DISCHARGE LABS: =============== ___ 05:40AM BLOOD WBC-11.0* RBC-2.74* Hgb-7.8* Hct-24.5* MCV-89 MCH-28.5 MCHC-31.8* RDW-19.2* RDWSD-59.2* Plt ___ ___ 05:40AM BLOOD ___ PTT-28.7 ___ ___ 05:40AM BLOOD Glucose-104* UreaN-22* Creat-0.9 Na-139 K-4.1 Cl-104 HCO3-23 AnGap-16 ___ 05:40AM BLOOD ALT-12 AST-15 LD(LDH)-224 AlkPhos-184* TotBili-0.3 ___ 05:40AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.2 ___ 05:40AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.2 Brief Hospital Course: Mr. ___ is a ___ male with history of metastatic neuroendocrine tumor of unknown origin on ___ who presented with fatigue and failure to thrive, recovered with diuresis and ___ who received port placement and initiation of chemotherapy C2 with carboplatin/etoposide prior to transfer of care to ___ in ___. # UTI: # Fatigue/Failure to Thrive: The patient was admitted with failure to thrive and fatigue, unable to rise from bed on his own prior to admission. He was found to have positive U/A, for which he was treated empirically with ceftriaxone. Once speciation and sensitivity resulted, the patient's course was completed with ciprofloxacin, a total of 7d abx. He was able to work with ___ and with given symptomatic therapy for edema and improved nutrition after which he was able to self-mobilize sufficiently to be cleared for a home discharge. He received a port and his C2 carboplatin/etoposide, and is scheduled to establish care with ___ closer to his home in ___. # Metastatic Neuroendocrine Tumor: Metastatic to lymph nodes and liver. Treating with palliative intent with carboplatin and etoposide complicated by pancytopenia. The patient received a port while inpatient (apixaban was held then restarted) and his chemotherapy C2 carboplatin/etoposide was administered. He was discharged to be seen at ___ in ___ where he will be set up with Neupogen. # Right Upper Extremity PICC-Associated DVT: # Atrial Fibrillation: The patient was on apixaban for both PICC-associated DVT as well as AFib, and has malignancy not felt to require Lovenox. His apixaban was held for 48 hours prior place port, then resumed 24 hours post port placement per ___. No bleeding complications from port placement. Home metoprolol was continued. # Gout: Continued home allopurinol. # Lower Extremity Edema: Likely multifactorial including malnutrition/hypoalbuminemia and inactivity. The patient's home Lasix 40mg PO daily was continued and TEDS were used to good effect in symptom control. The patient was active with ___ during his stay and all therapies together reduced his overall edema. # Chronic Diarrhea: Likely from his neuro-endocrine tumor. Labs checked on admission and C. Diff negative. The patient had been using loperamide at home to good effect and this was continued during admission once infectious etiology ruled out. # Severe Protein-Calorie Malnutrition: Very poor intake and weight loss. Albumin 2.3 on admission. Nutrition was supplemented during admission with nutrition consultation. Discharged on multivitamin. # Anemia: Stable throughout admission without evidence of active bleeding. Likely due to inflammatory block from malignancy as well as possible marrow involvement. No indication for transfusion during stay. # NASH-Induced Cirrhosis: # Ascites: Patient felt to have synthetic dysfunction as a result of NASH cirrhosis or potential hepatic infiltration of NET. Malnutrition felt to be contributing to ascites and edema. Patient was given vitamin K 5mg PO x 2 and had improvement in coags including INR<1.5. Patient tolerated port placement without adverse bleeding outcome. # BPH: Continued home doxazosin and finasteride during admission. # Prediabetes Mellitus: Patient not placed on sliding scale, did not require any, and had serum glucose within normal range during admission. # CKD Stage II-IIIA: Cr at baseline throughout admission, medications renally dosed during admission. # Lower Extremity Neuropathy: Likely secondary to Carboplatin, unchanged during admission. # Bell's Palsy Left Side: Known prior to admission, monitored and unchanged during admission. TRANSITIONAL ISSUES: - new medications: multivitamin - changed medications: None - stopped medications: None - outpatient appt at ___ in ___ already set up for 1 pm on ___, where he will receive Neulasta - continue carboplatin/etoposide at ___ at ___ - discharged with existing home services - discharge blood counts: WBC 11 Hb 7.8 Plts 465 INR 1.3 - discharge creatinine: .9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Doxazosin 4 mg PO HS 3. Finasteride 5 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN constipation 5. Colchicine 0.6 mg PO DAILY:PRN gout 6. Metoprolol Succinate XL 200 mg PO DAILY 7. Apixaban 5 mg PO BID 8. Omeprazole 20 mg PO DAILY 9. Furosemide 40 mg PO DAILY:PRN edema 10. LOPERamide 2 mg PO QID:PRN diarrhea Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 2. Furosemide 40 mg PO DAILY 3. Allopurinol ___ mg PO DAILY 4. Apixaban 5 mg PO BID 5. Colchicine 0.6 mg PO DAILY:PRN gout 6. Doxazosin 4 mg PO HS 7. Finasteride 5 mg PO DAILY 8. LOPERamide 2 mg PO QID:PRN diarrhea 9. Metoprolol Succinate XL 200 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: UTI metastatic neuroendocrine tumor of unknown origin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You came to the hospital because of fatigue. While at the hospital it was determined that you had a urinary tract infection, which was treated. You also started chemotherapy for your cancer. We are discharging you home with follow up with your oncologist on ___. You had a port placed ___. We wish you all the best! -Your ___ Care Team Followup Instructions: ___
[ "N390", "E43", "C7B02", "C7B01", "R188", "K766", "B9689", "T82868A", "I82721", "R627", "Z6828", "R5383", "C801", "K7581", "I4891", "I129", "N183", "E669", "N400", "M109", "R7303", "G510", "Z87891", "Y92018", "Z7902", "E8809", "K529", "G620", "T451X5A", "Y92230", "D72829", "Z66" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [MASKED] - Single lumen port placement History of Present Illness: Mr. [MASKED] is a [MASKED] male with history of metastatic neuroendocrine tumor of unknown origin on [MASKED] who presents with fatigue. He was recently admitted for syncope as well as pancytopenia. He reports difficulty ambulating since [MASKED]. He has been feeling very tired for the past few days. The morning of admission he was too weak to get out of bed and needed his son to help. He also required a walker whereas before he needed no assistance. He reports an "awful" appetite. He has very poor PO intake, has been trying to take [MASKED] Boosts per day as well as soft foods (pudding, applesauce, and ice cream). Restarted Lasix on [MASKED] after reporting more edema and took two tablets yesterday. Notes worsening bilateral lower extremity parasthesia/numbness from his toes to the mid-thigh. Reports left leg more weak than the right. Notes continued chronic diarrhea although has improved with Imodium. He was also concerned for gout flare so took colchicine today. He denies any recent falls since last admission. On arrival to the ED, initial vitals were 98.3 98 104/53 16 98% RA. Exam was notable for clear lungs, soft abdomen, 2+ bilateral [MASKED] edema to calf without erythema, knee effusions R>L, 4+/5 right hip flexion, [MASKED] left hip flexion, numbness in bilateral dorsal toes and knees, and bilateral mild medial ankle tenderness. Labs were notable for WBC 23.0, H/H 9.0/27.2, Plt 308, INR 2.2, Na 140, K 4.0, BUN/Cr [MASKED], and BNP 13875. CXR was negative for pneumonia. Patient was given Tylenol 1g PO and 1L NS. Prior to transfer vitals were 98.7 95 96/55 18 100% RA. On arrival to the floor, patient reports feeling tired. He denies pain. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: First developed abdominal bloating mid [MASKED]. He was then following up with one of our hepatologist, Dr. [MASKED] he was found to have on [MASKED], a 15.9-cm right lobe mass with multiple satellite lesions consistent with HCC and enlarged porta hepatis and retroperitoneal lymphadenopathy consistent with metastases. His case was discussed at [MASKED] Conference and while the lymph nodes were concerning and rereviewed by Interventional Radiology, they were found to be not diagnostic for metastases. He underwent endoscopy with EUS on [MASKED] which did not identify any primary lesions including in the pancreas. A biopsy of 1 of the lymph nodes returned as consistent with grade 2 neuroendocrine tumor with a Ki-67 percentage of about 20%. - [MASKED] C1D1 Carboplatin/Etoposide PAST MEDICAL HISTORY: - [MASKED]-induced cirrhosis complicated by portal hypertension - Ascites and HCC - Atrial fibrillation - Hypertension - Obesity - BPH - Gout - Prediabetes Mellitus - Apparent CKD - Baseline Bell's palsy left side Social History: [MASKED] Family History: His mother was diagnosed with intestinal cancer in her late [MASKED] and died at age [MASKED]. Brother diagnosed in his [MASKED] and living with bladder cancer. Sister living and has lymphoma. Sister living, diagnosed with breast cancer in her late [MASKED]. Physical Exam: ADMISSION EXAM: ================ VS: Temp 97.9, BP 113/71, HR 84, RR 18, O2 sat 100% RA. GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear, left-sided facial droop, temporal wasting. CARDIAC: Irregularly irregular, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-tender, non-distended, normal bowel sounds, no hepatomegaly, no splenomegaly. EXT: Warm, well perfused, 2+ bilateral lower extremity edema to the knee. No ankle tenderness to palpation or pain with ROM. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. 4+/5 right hip flexion, [MASKED] left hip flexion. Sensation to light touch intact. SKIN: No significant rashes. DISCHARGE EXAM: ============== VS: 97.6 PO 122 / 72 69 18 GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear, left-sided facial droop, temporal wasting. CARDIAC: Irregularly irregular LUNG: no respiratory distress, clear to auscultation bilaterally anterior an d posterior chest ABD: Soft, non-tender, non-distended EXT: Warm, well perfused, 1+ bilateral lower extremity edema to the knee, TEDS in place. No ankle tenderness to palpation or pain with ROM. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Sensation to light touch intact. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS: ================= [MASKED] 07:21PM BLOOD WBC-23.0* RBC-3.04* Hgb-9.0* Hct-27.2* MCV-90 MCH-29.6 MCHC-33.1 RDW-18.6* RDWSD-57.3* Plt [MASKED] [MASKED] 07:21PM BLOOD Neuts-69 Bands-8* Lymphs-12* Monos-6 Eos-1 Baso-0 [MASKED] Metas-2* Myelos-2* AbsNeut-17.71* AbsLymp-2.76 AbsMono-1.38* AbsEos-0.23 AbsBaso-0.00* [MASKED] 07:21PM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 07:21PM BLOOD Glucose-94 UreaN-19 Creat-1.1 Na-140 K-4.0 Cl-104 HCO3-22 AnGap-18 [MASKED] 06:45AM BLOOD ALT-14 AST-13 LD(LDH)-325* AlkPhos-226* TotBili-0.7 [MASKED] 07:21PM BLOOD [MASKED] [MASKED] 07:21PM BLOOD Albumin-2.3* Calcium-8.0* Phos-2.5* Mg-1.8 [MASKED] 08:45AM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 08:45AM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [MASKED] 08:45AM URINE RBC-3* WBC->182* Bacteri-MANY Yeast-NONE Epi-<1 TransE-<1 [MASKED] 08:45AM URINE CastHy-4* [MASKED] 08:45AM URINE Mucous-FEW MICRO: ======== [MASKED] 8:45 am URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] CITROBACTER FREUNDII COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING/STUDIES: ================= [MASKED] CXR IMPRESSION: No acute cardiopulmonary process. [MASKED] IMPRESSION: Successful placement of a single lumen chest power low-profile Port-a-cath via the left internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. [MASKED] LUE U/S W/ DOPPLER IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. DISCHARGE LABS: =============== [MASKED] 05:40AM BLOOD WBC-11.0* RBC-2.74* Hgb-7.8* Hct-24.5* MCV-89 MCH-28.5 MCHC-31.8* RDW-19.2* RDWSD-59.2* Plt [MASKED] [MASKED] 05:40AM BLOOD [MASKED] PTT-28.7 [MASKED] [MASKED] 05:40AM BLOOD Glucose-104* UreaN-22* Creat-0.9 Na-139 K-4.1 Cl-104 HCO3-23 AnGap-16 [MASKED] 05:40AM BLOOD ALT-12 AST-15 LD(LDH)-224 AlkPhos-184* TotBili-0.3 [MASKED] 05:40AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.2 [MASKED] 05:40AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.2 Brief Hospital Course: Mr. [MASKED] is a [MASKED] male with history of metastatic neuroendocrine tumor of unknown origin on [MASKED] who presented with fatigue and failure to thrive, recovered with diuresis and [MASKED] who received port placement and initiation of chemotherapy C2 with carboplatin/etoposide prior to transfer of care to [MASKED] in [MASKED]. # UTI: # Fatigue/Failure to Thrive: The patient was admitted with failure to thrive and fatigue, unable to rise from bed on his own prior to admission. He was found to have positive U/A, for which he was treated empirically with ceftriaxone. Once speciation and sensitivity resulted, the patient's course was completed with ciprofloxacin, a total of 7d abx. He was able to work with [MASKED] and with given symptomatic therapy for edema and improved nutrition after which he was able to self-mobilize sufficiently to be cleared for a home discharge. He received a port and his C2 carboplatin/etoposide, and is scheduled to establish care with [MASKED] closer to his home in [MASKED]. # Metastatic Neuroendocrine Tumor: Metastatic to lymph nodes and liver. Treating with palliative intent with carboplatin and etoposide complicated by pancytopenia. The patient received a port while inpatient (apixaban was held then restarted) and his chemotherapy C2 carboplatin/etoposide was administered. He was discharged to be seen at [MASKED] in [MASKED] where he will be set up with Neupogen. # Right Upper Extremity PICC-Associated DVT: # Atrial Fibrillation: The patient was on apixaban for both PICC-associated DVT as well as AFib, and has malignancy not felt to require Lovenox. His apixaban was held for 48 hours prior place port, then resumed 24 hours post port placement per [MASKED]. No bleeding complications from port placement. Home metoprolol was continued. # Gout: Continued home allopurinol. # Lower Extremity Edema: Likely multifactorial including malnutrition/hypoalbuminemia and inactivity. The patient's home Lasix 40mg PO daily was continued and TEDS were used to good effect in symptom control. The patient was active with [MASKED] during his stay and all therapies together reduced his overall edema. # Chronic Diarrhea: Likely from his neuro-endocrine tumor. Labs checked on admission and C. Diff negative. The patient had been using loperamide at home to good effect and this was continued during admission once infectious etiology ruled out. # Severe Protein-Calorie Malnutrition: Very poor intake and weight loss. Albumin 2.3 on admission. Nutrition was supplemented during admission with nutrition consultation. Discharged on multivitamin. # Anemia: Stable throughout admission without evidence of active bleeding. Likely due to inflammatory block from malignancy as well as possible marrow involvement. No indication for transfusion during stay. # NASH-Induced Cirrhosis: # Ascites: Patient felt to have synthetic dysfunction as a result of NASH cirrhosis or potential hepatic infiltration of NET. Malnutrition felt to be contributing to ascites and edema. Patient was given vitamin K 5mg PO x 2 and had improvement in coags including INR<1.5. Patient tolerated port placement without adverse bleeding outcome. # BPH: Continued home doxazosin and finasteride during admission. # Prediabetes Mellitus: Patient not placed on sliding scale, did not require any, and had serum glucose within normal range during admission. # CKD Stage II-IIIA: Cr at baseline throughout admission, medications renally dosed during admission. # Lower Extremity Neuropathy: Likely secondary to Carboplatin, unchanged during admission. # Bell's Palsy Left Side: Known prior to admission, monitored and unchanged during admission. TRANSITIONAL ISSUES: - new medications: multivitamin - changed medications: None - stopped medications: None - outpatient appt at [MASKED] in [MASKED] already set up for 1 pm on [MASKED], where he will receive Neulasta - continue carboplatin/etoposide at [MASKED] at [MASKED] - discharged with existing home services - discharge blood counts: WBC 11 Hb 7.8 Plts 465 INR 1.3 - discharge creatinine: .9 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. Doxazosin 4 mg PO HS 3. Finasteride 5 mg PO DAILY 4. Senna 8.6 mg PO BID:PRN constipation 5. Colchicine 0.6 mg PO DAILY:PRN gout 6. Metoprolol Succinate XL 200 mg PO DAILY 7. Apixaban 5 mg PO BID 8. Omeprazole 20 mg PO DAILY 9. Furosemide 40 mg PO DAILY:PRN edema 10. LOPERamide 2 mg PO QID:PRN diarrhea Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 2. Furosemide 40 mg PO DAILY 3. Allopurinol [MASKED] mg PO DAILY 4. Apixaban 5 mg PO BID 5. Colchicine 0.6 mg PO DAILY:PRN gout 6. Doxazosin 4 mg PO HS 7. Finasteride 5 mg PO DAILY 8. LOPERamide 2 mg PO QID:PRN diarrhea 9. Metoprolol Succinate XL 200 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: UTI metastatic neuroendocrine tumor of unknown origin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You came to the hospital because of fatigue. While at the hospital it was determined that you had a urinary tract infection, which was treated. You also started chemotherapy for your cancer. We are discharging you home with follow up with your oncologist on [MASKED]. You had a port placed [MASKED]. We wish you all the best! -Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N390", "I4891", "I129", "E669", "N400", "M109", "Z87891", "Z7902", "Y92230", "Z66" ]
[ "N390: Urinary tract infection, site not specified", "E43: Unspecified severe protein-calorie malnutrition", "C7B02: Secondary carcinoid tumors of liver", "C7B01: Secondary carcinoid tumors of distant lymph nodes", "R188: Other ascites", "K766: Portal hypertension", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "I82721: Chronic embolism and thrombosis of deep veins of right upper extremity", "R627: Adult failure to thrive", "Z6828: Body mass index [BMI] 28.0-28.9, adult", "R5383: Other fatigue", "C801: Malignant (primary) neoplasm, unspecified", "K7581: Nonalcoholic steatohepatitis (NASH)", "I4891: Unspecified atrial fibrillation", "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)", "E669: Obesity, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M109: Gout, unspecified", "R7303: Prediabetes", "G510: Bell's palsy", "Z87891: Personal history of nicotine dependence", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "K529: Noninfective gastroenteritis and colitis, unspecified", "G620: Drug-induced polyneuropathy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "D72829: Elevated white blood cell count, unspecified", "Z66: Do not resuscitate" ]
10,070,594
24,108,690
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: pancytopenia Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of neuroendocrine tumor of unknown origin C1D11 of ___ and recent admission for syncope who presents from clinic with pancytopenia. The patient was recently admitted for syncope. He was also started on ___ ___ while inpatient. He also received neupogen ___. He presented to outpatient clinic today for routine labs and was noted to be newly pancytopenic and neutropenic. He also reported significant fatigue. He denied any fevers or infectious symptoms at home, however he does report decreased appetite and poor PO intake. On arrival to the floor, patient had no acute complaints other than ongoing fatigue that has worsened over the past several weeks. He denies HA, dizziness, blurry vision, chest pain, SOB/Cough, abdominal pain, constipation, dysuria or increased urinary frequency. He has his chronic baseline diarrhea which has not changed. Past Medical History: PAST ONCOLOGIC HISTORY: First developed abdominal bloating mid ___. He was then following up with one of our hepatologist, Dr. ___ he was found to have on ___, a 15.9-cm right lobe mass with multiple satellite lesions consistent with HCC and enlarged porta hepatis and retroperitoneal lymphadenopathy consistent with metastases. His case was discussed at ___ Conference and while the lymph nodes were concerning and rereviewed by Interventional Radiology, they were found to be not diagnostic for metastases. He underwent endoscopy with EUS on ___ which did not identify any primary lesions including in the pancreas. A biopsy of 1 of the lymph nodes returned as consistent with grade 2 neuroendocrine tumor with a Ki-67 percentage of about 20%. PAST MEDICAL HISTORY: 1. ___-induced cirrhosis complicated by portal hypertension. 2. Ascites and HCC. 3. Atrial fibrillation. 4. Hypertension. 5. Obesity. 6. BPH. 7. Gout. 8. Prediabetes mellitus. 9. Apparent CKD, which he is not aware of. 10. Baseline Bell's palsy left side. Social History: ___ Family History: His mother was diagnosed with intestinal cancer in her late ___ and died at age ___. Brother diagnosed in his ___ and living with bladder cancer. Sister living and has lymphoma. Sister living, diagnosed with breast cancer in her late ___. Physical Exam: ===ADMISSION PHYSICAL EXAM=== VS: 98.3; 104 / 60; 104; 16 99 RA GENERAL: Pleasant, lying in bed comfortably HEENT: NCAT. PERRL. EOMI. L sided facial droop - chronic. No oral lesions. CARDIAC: tachycardic, irregular. no MRG LUNG: CTAB ABD: Normal bowel sounds. RUQ mass palpated - fibrotic liver edge vs mass. Non-tender, non-distended. EXT: Warm, well perfused, 1+ pitting edema bilaterally NEURO: Alert, oriented, motor and sensory function grossly intact SKIN: No significant rashes other then resolving echymoses on bilateral upper arms ===DISCHARGE PHYSICAL EXAM=== Physical Exam: VS: 97.6PO 104 / 60 83 20 99% RA GENERAL: Pleasant, lying in bed comfortably HEENT: NCAT. L sided facial droop - chronic. No oral lesions. CARDIAC: irregularly irregular LUNG: CTAB ABD: Normal bowel sounds. RUQ mass palpated - fibrotic liver edge vs mass. Non-tender, non-distended. EXT: Warm, well perfused, 1+ pitting edema bilaterally NEURO: Alert, oriented, motor and sensory function grossly intact SKIN: No significant rashes other then resolving echymoses on bilateral upper arms Pertinent Results: ===ADMISSION LABS=== ___ 11:45AM BLOOD WBC-0.3*# RBC-2.99* Hgb-8.5* Hct-26.8* MCV-90 MCH-28.4 MCHC-31.7* RDW-17.8* RDWSD-58.4* Plt Ct-73*# ___ 07:00PM BLOOD Neuts-0 Bands-0 Lymphs-89* Monos-8 Eos-3 Baso-0 ___ Myelos-0 AbsNeut-0.00* AbsLymp-0.36* AbsMono-0.03* AbsEos-0.01* AbsBaso-0.00* ___ 07:00PM BLOOD ___ PTT-31.5 ___ ___ 11:45AM BLOOD UreaN-26* Creat-1.0 Na-147* K-4.6 Cl-112* HCO3-22 AnGap-18 ___ 11:45AM BLOOD ALT-32 AST-30 LD(LDH)-299* AlkPhos-300* TotBili-0.7 ___ 11:45AM BLOOD Albumin-2.9* Calcium-8.8 Phos-2.4* Mg-2.1 UricAcd-7.7* ___ 11:45AM BLOOD Hapto-203* ===DISCHARGE LABS=== ___ 07:16AM BLOOD WBC-3.7*# RBC-2.95* Hgb-8.2* Hct-25.7* MCV-87 MCH-27.8 MCHC-31.9* RDW-18.2* RDWSD-57.7* Plt Ct-24* ___ 07:16AM BLOOD Neuts-46 Bands-17* ___ Monos-6 Eos-2 Baso-0 ___ Metas-3* Myelos-0 NRBC-1* AbsNeut-2.33 AbsLymp-0.96* AbsMono-0.22 AbsEos-0.07 AbsBaso-0.00* ___ 07:16AM BLOOD ___ PTT-31.2 ___ ___ 07:16AM BLOOD Glucose-75 UreaN-20 Creat-1.0 Na-144 K-3.5 Cl-113* HCO3-21* AnGap-14 ___ 07:16AM BLOOD Calcium-7.8* Phos-1.9* Mg-1.9 UricAcd-7.2* ===MICRO=== None ===STUDIES=== None Brief Hospital Course: ___ with hx of neuroendocrine tumor of unknown origin C1D11 of ___ who presents from clinic with pancytopenia. Pancytopenia was attributed to his recent chemo administration. No localizing signs or symptoms of infection or fever, however given the patient's neutropenia on admission, patient was started on cipro prophylaxis and was maintained on neutropenic precautions. Due to fatigue and a hemoglobin of 7.2, patient was transfused with 1u prbc on ___, with symptomatic improvement. Hgb responded appropriately, and remained stable post-transfusion. WBC count improved during admission, as well, and patient was discharged with ANC of 2300 (was 0 on admission). Thromboycytopenia was 60 on admission, and initially declined during admission to nadir of 20, but was rising at the time of discharge (24). Patient was on apixaban for anticoagulation in the setting of a recent PICC-associated DVT as well as atrial fibrillation, which was transitioned to lovenox upon admission (though was discontinued when platelets fell below 50). Patient's labs should be closely monitored, and anticoagulation should be resumed when platelets rise. TRANSITIONAL ISSUES: ==================== - Please draw CBC with diff on ___ - Patient's anticoagulation was held at the time of discharge given thrombocytopenia. When platelets >50, consider resuming lovenox vs apixaban (depending on if DVT attributed to malignancy or PICC, as well as patient preference). - Cipro prophylaxis was discontinued at the time of discharge, as the patient is no longer neutropenic. - Allopurinol was changed to 200mg daily given renal function - Lasix held during admission, as he was clinically dry, and his weight has been declining. Was not resumed at the time of discharge. Consider resuming, as clinically indicated. CODE: DNR/DNI (confirmed in clinic with Dr. ___ COMMUNICATION: Patient, ___ (daughter) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Pegfilgrastim Onpro (On Body Injector) 6 mg SC ONCE 2. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE 3. Doxazosin 4 mg PO HS 4. Finasteride 5 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Allopurinol ___ mg PO DAILY 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation 9. Colchicine 0.6 mg PO DAILY:PRN Gout 10. Apixaban 5 mg PO BID Discharge Medications: 1. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 2. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 3. Colchicine 0.6 mg PO DAILY:PRN Gout 4. Doxazosin 4 mg PO HS 5. Finasteride 5 mg PO DAILY 6. Metoprolol Succinate XL 200 mg PO DAILY 7. Senna 8.6 mg PO BID:PRN constipation 8. HELD- Apixaban 5 mg PO BID This medication was held. Do not restart Apixaban until you have your repeat bloodwork drawn 9.Outpatient Lab Work ICD-9 284.1 CBC with differential Dr. ___ phone: ___ Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Primary Diagnosis: pancytopenia secondary diagnoses: symptomatic anemia thrombocytopenia neutropenia PICC associated DVT neuroendocrine tumor atrial fibrillation ___ cirrhosis BPH gout Pre-diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ because you were found to have low blood counts in your ___ clinic. We think the cause of your low blood counts was your recent chemotherapy administration. While you were here, you received a blood transfusion, which made you feel better. Your other blood counts improved, as well. It was a pleasure caring for you! Your ___ Care Team Followup Instructions: ___
[ "D61810", "C7A8", "E870", "C7B8", "K766", "I82729", "C220", "K529", "K7581", "I4891", "I129", "N189", "E669", "Z6826", "N400", "M109", "R7303", "G510", "Z87891", "Z66", "Z7902" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: pancytopenia Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with hx of neuroendocrine tumor of unknown origin C1D11 of [MASKED] and recent admission for syncope who presents from clinic with pancytopenia. The patient was recently admitted for syncope. He was also started on [MASKED] [MASKED] while inpatient. He also received neupogen [MASKED]. He presented to outpatient clinic today for routine labs and was noted to be newly pancytopenic and neutropenic. He also reported significant fatigue. He denied any fevers or infectious symptoms at home, however he does report decreased appetite and poor PO intake. On arrival to the floor, patient had no acute complaints other than ongoing fatigue that has worsened over the past several weeks. He denies HA, dizziness, blurry vision, chest pain, SOB/Cough, abdominal pain, constipation, dysuria or increased urinary frequency. He has his chronic baseline diarrhea which has not changed. Past Medical History: PAST ONCOLOGIC HISTORY: First developed abdominal bloating mid [MASKED]. He was then following up with one of our hepatologist, Dr. [MASKED] he was found to have on [MASKED], a 15.9-cm right lobe mass with multiple satellite lesions consistent with HCC and enlarged porta hepatis and retroperitoneal lymphadenopathy consistent with metastases. His case was discussed at [MASKED] Conference and while the lymph nodes were concerning and rereviewed by Interventional Radiology, they were found to be not diagnostic for metastases. He underwent endoscopy with EUS on [MASKED] which did not identify any primary lesions including in the pancreas. A biopsy of 1 of the lymph nodes returned as consistent with grade 2 neuroendocrine tumor with a Ki-67 percentage of about 20%. PAST MEDICAL HISTORY: 1. [MASKED]-induced cirrhosis complicated by portal hypertension. 2. Ascites and HCC. 3. Atrial fibrillation. 4. Hypertension. 5. Obesity. 6. BPH. 7. Gout. 8. Prediabetes mellitus. 9. Apparent CKD, which he is not aware of. 10. Baseline Bell's palsy left side. Social History: [MASKED] Family History: His mother was diagnosed with intestinal cancer in her late [MASKED] and died at age [MASKED]. Brother diagnosed in his [MASKED] and living with bladder cancer. Sister living and has lymphoma. Sister living, diagnosed with breast cancer in her late [MASKED]. Physical Exam: ===ADMISSION PHYSICAL EXAM=== VS: 98.3; 104 / 60; 104; 16 99 RA GENERAL: Pleasant, lying in bed comfortably HEENT: NCAT. PERRL. EOMI. L sided facial droop - chronic. No oral lesions. CARDIAC: tachycardic, irregular. no MRG LUNG: CTAB ABD: Normal bowel sounds. RUQ mass palpated - fibrotic liver edge vs mass. Non-tender, non-distended. EXT: Warm, well perfused, 1+ pitting edema bilaterally NEURO: Alert, oriented, motor and sensory function grossly intact SKIN: No significant rashes other then resolving echymoses on bilateral upper arms ===DISCHARGE PHYSICAL EXAM=== Physical Exam: VS: 97.6PO 104 / 60 83 20 99% RA GENERAL: Pleasant, lying in bed comfortably HEENT: NCAT. L sided facial droop - chronic. No oral lesions. CARDIAC: irregularly irregular LUNG: CTAB ABD: Normal bowel sounds. RUQ mass palpated - fibrotic liver edge vs mass. Non-tender, non-distended. EXT: Warm, well perfused, 1+ pitting edema bilaterally NEURO: Alert, oriented, motor and sensory function grossly intact SKIN: No significant rashes other then resolving echymoses on bilateral upper arms Pertinent Results: ===ADMISSION LABS=== [MASKED] 11:45AM BLOOD WBC-0.3*# RBC-2.99* Hgb-8.5* Hct-26.8* MCV-90 MCH-28.4 MCHC-31.7* RDW-17.8* RDWSD-58.4* Plt Ct-73*# [MASKED] 07:00PM BLOOD Neuts-0 Bands-0 Lymphs-89* Monos-8 Eos-3 Baso-0 [MASKED] Myelos-0 AbsNeut-0.00* AbsLymp-0.36* AbsMono-0.03* AbsEos-0.01* AbsBaso-0.00* [MASKED] 07:00PM BLOOD [MASKED] PTT-31.5 [MASKED] [MASKED] 11:45AM BLOOD UreaN-26* Creat-1.0 Na-147* K-4.6 Cl-112* HCO3-22 AnGap-18 [MASKED] 11:45AM BLOOD ALT-32 AST-30 LD(LDH)-299* AlkPhos-300* TotBili-0.7 [MASKED] 11:45AM BLOOD Albumin-2.9* Calcium-8.8 Phos-2.4* Mg-2.1 UricAcd-7.7* [MASKED] 11:45AM BLOOD Hapto-203* ===DISCHARGE LABS=== [MASKED] 07:16AM BLOOD WBC-3.7*# RBC-2.95* Hgb-8.2* Hct-25.7* MCV-87 MCH-27.8 MCHC-31.9* RDW-18.2* RDWSD-57.7* Plt Ct-24* [MASKED] 07:16AM BLOOD Neuts-46 Bands-17* [MASKED] Monos-6 Eos-2 Baso-0 [MASKED] Metas-3* Myelos-0 NRBC-1* AbsNeut-2.33 AbsLymp-0.96* AbsMono-0.22 AbsEos-0.07 AbsBaso-0.00* [MASKED] 07:16AM BLOOD [MASKED] PTT-31.2 [MASKED] [MASKED] 07:16AM BLOOD Glucose-75 UreaN-20 Creat-1.0 Na-144 K-3.5 Cl-113* HCO3-21* AnGap-14 [MASKED] 07:16AM BLOOD Calcium-7.8* Phos-1.9* Mg-1.9 UricAcd-7.2* ===MICRO=== None ===STUDIES=== None Brief Hospital Course: [MASKED] with hx of neuroendocrine tumor of unknown origin C1D11 of [MASKED] who presents from clinic with pancytopenia. Pancytopenia was attributed to his recent chemo administration. No localizing signs or symptoms of infection or fever, however given the patient's neutropenia on admission, patient was started on cipro prophylaxis and was maintained on neutropenic precautions. Due to fatigue and a hemoglobin of 7.2, patient was transfused with 1u prbc on [MASKED], with symptomatic improvement. Hgb responded appropriately, and remained stable post-transfusion. WBC count improved during admission, as well, and patient was discharged with ANC of 2300 (was 0 on admission). Thromboycytopenia was 60 on admission, and initially declined during admission to nadir of 20, but was rising at the time of discharge (24). Patient was on apixaban for anticoagulation in the setting of a recent PICC-associated DVT as well as atrial fibrillation, which was transitioned to lovenox upon admission (though was discontinued when platelets fell below 50). Patient's labs should be closely monitored, and anticoagulation should be resumed when platelets rise. TRANSITIONAL ISSUES: ==================== - Please draw CBC with diff on [MASKED] - Patient's anticoagulation was held at the time of discharge given thrombocytopenia. When platelets >50, consider resuming lovenox vs apixaban (depending on if DVT attributed to malignancy or PICC, as well as patient preference). - Cipro prophylaxis was discontinued at the time of discharge, as the patient is no longer neutropenic. - Allopurinol was changed to 200mg daily given renal function - Lasix held during admission, as he was clinically dry, and his weight has been declining. Was not resumed at the time of discharge. Consider resuming, as clinically indicated. CODE: DNR/DNI (confirmed in clinic with Dr. [MASKED] COMMUNICATION: Patient, [MASKED] (daughter) [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Pegfilgrastim Onpro (On Body Injector) 6 mg SC ONCE 2. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE 3. Doxazosin 4 mg PO HS 4. Finasteride 5 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Allopurinol [MASKED] mg PO DAILY 7. Metoprolol Succinate XL 200 mg PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation 9. Colchicine 0.6 mg PO DAILY:PRN Gout 10. Apixaban 5 mg PO BID Discharge Medications: 1. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 2. Allopurinol [MASKED] mg PO DAILY RX *allopurinol [MASKED] mg 2 tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0 3. Colchicine 0.6 mg PO DAILY:PRN Gout 4. Doxazosin 4 mg PO HS 5. Finasteride 5 mg PO DAILY 6. Metoprolol Succinate XL 200 mg PO DAILY 7. Senna 8.6 mg PO BID:PRN constipation 8. HELD- Apixaban 5 mg PO BID This medication was held. Do not restart Apixaban until you have your repeat bloodwork drawn 9.Outpatient Lab Work ICD-9 284.1 CBC with differential Dr. [MASKED] phone: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Primary Diagnosis: pancytopenia secondary diagnoses: symptomatic anemia thrombocytopenia neutropenia PICC associated DVT neuroendocrine tumor atrial fibrillation [MASKED] cirrhosis BPH gout Pre-diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] because you were found to have low blood counts in your [MASKED] clinic. We think the cause of your low blood counts was your recent chemotherapy administration. While you were here, you received a blood transfusion, which made you feel better. Your other blood counts improved, as well. It was a pleasure caring for you! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "I4891", "I129", "N189", "E669", "N400", "M109", "Z87891", "Z66", "Z7902" ]
[ "D61810: Antineoplastic chemotherapy induced pancytopenia", "C7A8: Other malignant neuroendocrine tumors", "E870: Hyperosmolality and hypernatremia", "C7B8: Other secondary neuroendocrine tumors", "K766: Portal hypertension", "I82729: Chronic embolism and thrombosis of deep veins of unspecified upper extremity", "C220: Liver cell carcinoma", "K529: Noninfective gastroenteritis and colitis, unspecified", "K7581: Nonalcoholic steatohepatitis (NASH)", "I4891: Unspecified atrial fibrillation", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "E669: Obesity, unspecified", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M109: Gout, unspecified", "R7303: Prediabetes", "G510: Bell's palsy", "Z87891: Personal history of nicotine dependence", "Z66: Do not resuscitate", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,070,594
29,430,934
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: Liver biopsy ___ History of Present Illness: ___ is a ___ man with metastatic neurodendocrine tumor, unknown primary, who is admitted from the ED with a sycnopal episode. Patient has had progressive functional decline over the last several months with associated poor po intake. He denies nausea or frank abdominal pain, but does note bloating and significant dysgeusia. He reports having eaten 'very little' over the previous month. Additionally, he has developed large volume diarrhea over the last three weeks, up to ___ stools per day (worse at night). He has also had increasing weakness over this time. His son brought him to his medical oncology clinic on day of admission, but he had a syncopal episode in the parking lot. Patient stood up out of the car, and felt light headed. He did not fall right away, but eventually his legs 'gave out'. His son caught him and lowered him to the ground. He had no LOC, no headstrike, and he remembers the event clearly. No preceeding CP, palpitations or SOB. Does have occaisional word finding difficulty, but no other new neurologic issues. He was seen in oncology where he was noted to have soft BP's (90/59), was unable to stand up, have word finding difficulties, and slight left facial droop. He was transported to the ED. In the ED, initial VS were: pain 0, T 97.2, HR 86, BP 108/74, RR 16, O2 100%RA. Labs notable for Na 140, K 3.8, HCO3 20, Cr 1.2, ALT 22, AST 54, ALP 348, LDH 467, TBIli 1.8, Alb 3.3, WBC 7.6, HCT 36.6, PLT 245, INR 1.9, Uric acid 16.7. CXR showed possible subtle right lateral mid lung consolidation. CT head showed new bilateral hygroma - neurosurgery recommended no intervention. Liver US showed known metastatic disease, but no biliary obstruction. Patient received 1LNS prior to admission. On arrival to the floor, patient reports feeling better than he has in several weeks. No recent fevers or chills. He does have significant dry mouth and food tastes 'awful'. No CP or SOB. No palpitations. No N/V. No frank abdominal pain, but does have bloating. No dysuria. No new leg pain or weakness. No significant flushing. No new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: First developed abdominal bloating mid ___. He was then following up with one of our hepatologist, Dr. ___ he was found to have on ___, a 15.9-cm right lobe mass with multiple satellite lesions consistent with HCC and enlarged porta hepatis and retroperitoneal lymphadenopathy consistent with metastases. His case was discussed at ___ Conference and while the lymph nodes were concerning and rereviewed by Interventional Radiology, they were found to be not diagnostic for metastases. He underwent endoscopy with EUS on ___ which did not identify any primary lesions including in the pancreas. A biopsy of 1 of the lymph nodes returned as consistent with grade 2 neuroendocrine tumor with a Ki-67 percentage of about 20%. PAST MEDICAL HISTORY: 1. NASH-induced cirrhosis complicated by portal hypertension. 2. Ascites and HCC. 3. Atrial fibrillation. 4. Hypertension. 5. Obesity. 6. BPH. 7. Gout. 8. Prediabetes mellitus. 9. Apparent CKD, which he is not aware of. 10. Baseline Bell's palsy left side. Social History: ___ Family History: His mother was diagnosed with intestinal cancer in her late ___ and died at age ___. Brother diagnosed in his ___ and living with bladder cancer. Sister living and has lymphoma. Sister living, diagnosed with breast cancer in her late ___. Physical Exam: DISCHARGE PHYSICAL EXAM: VS: T 97.5 115/67 79 18 98%RA WT 185 lbs from 173 on admit - was slightly dry on admit, but looks overloaded still at this point GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI, dry MM. ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Irregular rhythm, regular rate, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; mildly distended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. MUSKULOSKELATAL: Warm, well perfused extremities, 1+ ___ symmetric, slightly improved from yesterday RUE with PICC is swollen but neurologically intact, picc insertion site w/o erythema NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE EXAM VS: 97.5 PO 118 / 70 76 18 97 Ra WEIGHT: 83.92kg || 185.01lb GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI, dry MM. ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Irregular heart sounds, no murmurs, rubs, or gallops; 2+ radial pulses. JVP is 2cm above clavicle RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; mildly distended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. MUSKULOSKELATAL: Warm, well perfused extremities, 1+ ___ symmetric, slightly improved from yesterday RUE is swollen but neurologically intact NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses Pertinent Results: ADMISSION LABS: ___ 02:20PM BLOOD WBC-7.6 RBC-4.18* Hgb-12.0* Hct-36.6* MCV-88 MCH-28.7 MCHC-32.8 RDW-17.7* RDWSD-56.5* Plt ___ ___ 02:20PM BLOOD Neuts-82.9* Lymphs-9.5* Monos-6.9 Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.29* AbsLymp-0.72* AbsMono-0.52 AbsEos-0.01* AbsBaso-0.01 ___ 02:20PM BLOOD ___ PTT-30.3 ___ ___ 02:20PM BLOOD UreaN-29* Creat-1.2 Na-140 K-3.8 Cl-99 HCO3-20* AnGap-25* ___ 02:20PM BLOOD ALT-22 AST-54* LD(LDH)-467* AlkPhos-348* TotBili-1.8* ___ 02:20PM BLOOD Albumin-3.3* Calcium-8.9 Phos-2.1* Mg-2.2 UricAcd-16.7* DISCHARGE LABS: IMAGING: ___ Imaging CHEST (PA & LAT) Difficult to exclude a subtle lateral right mid lung consolidation. No focal consolidation seen elsewhere. Mild cardiomegaly. No pulmonary edema. ___ Imaging LIVER OR GALLBLADDER US 1. Enlarged heterogeneous liver parenchyma containing several heterogeneous masses including a 11 x 8 cm right liver lobe mass, better assessed on of ___ CT abdomen pelvis. Patent main portal vein with hepatopetal flow. 2. Cholelithiasis without evidence of acute cholecystitis. ___ Imaging CT HEAD W/O CONTRAST - Bilateral hygromas versus chronic subdural hematomas without significant midline shift. - No acute intracranial hemorrhage. Brief Hospital Course: ASSESSMENT AND PLAN: ___ is a ___ man with metastatic neurodendocrine tumor, unknown primary, who is admitted from the ED with a syncopal episode. # Syncope: Not clear he had a true syncopal episode, but most likely collapsed in parking lot getting out of the car in setting of orthostatic hypotension and hypovolemia as he was subsequently on evaluation found to by hypotensive with BP in ___. He has been having ongoing diarrhea for several weeks now, see below. Head CT showed concern for chronic subdural vs hygroma, unlikely that this would account for his symptoms. per NSGY this is not subdural and discussed w/ the NP from their service likely chronic hygroma and no need for further imaging and if anticoag needed that would be find from their standpoint. Pt was likely hypovolemic from ongoing diarrhea and very poor po intake. Doubt infectious process contributing, CXR without obvious infiltrate. See below for asymptomatic bacteruria. No leukocytosis or fever (developed elevated WBC after dex with chemotherapy). Doubt PE given was on anticoag at baseline. Cultures negative to date (see below for asx bacteruria) so DCd antibiotics early in course and pt continued to do quite well. # Afib/RVR - HR was up to ___ in setting of initially holding his metop/verapamil on admit due to syncope. He is asymptomatic. He has no prior CVA history. Uptitrated metop to 50mg q6 with excellent effect. Given hypotension/syncope on admit, will DC pt on metop 200mg XL (was on 100mg XL at home - but also with verapamil) and DC his verapamil as HR well controlled this admit on 50mg metop q6 and off verapamil, and possibly verapamil with more antihypertensive effect contributing to orthostasis. Was continued on apixaban given need for full anticoagulation due to RUE PICC associated DVT. # Elevated cardiac enzymes - mild, downtrended. per discussion w/ cardiology, most likely from demand in setting of hypovolemia. Pt has no history of prior MI. He has no chest pain and serial EKGs have had no dynamic changes (mild ST dep in lateral leads <1mm, stable, no e/o Q waves). Per discussion w/ cardiology, catheterization not indicated as wouldn't be candidate for dual platelet therapy most likely as anticipate thrombocytopenia in which case pt would be unable to come off of ASA/Plavix, posing significant challenges. TTE for baseline, but wouldn't likely be a surgical candidate even if significant valvular disease (showed mod MR, normal EF) Trended trops to peak (0.04). Cont metop on DC at higher dose. Could initiate statin but will consider any interactions there with chemotherapy. Per oncologist hold off on starting statin at this time given chemo and drug interactions. # Hyperbilirubinemia: # Hyperuricemia: Improved with chemo. Elevated bilirubin initially concerning for biliary obstruction, but RUQ showed no obvious obstruction. Given elevated uric acid, must also consider tumor lysis. Fortunately, his creatinine is at recent baseline and he has no gross electrolyte abnormalities. This may represent significant tumor burden turnover due to his large liver mass. He may have elevated uric acid at baseline given his historical problems with gout (none current). no e/o hemolysis on labs. ___ was hydrated initially as above. Initiated allopurinol. # Hygroma: Unclear significance. ___ be due to dehydration or possibly chronic subdural hematoma. No clear acute insult, and no history of falls outside of today's episode. Pt reports getting struck in the head as a child though unclear if related Per neurosurgery NTD at this point. Holding anticoagulation given concerns re anemia/anticpated thrombocytopenia, though from ___ standpoint ok to continue if needed from hygroma standpoint. # Diarrhea: Likely from his neuro-endocrine tumor. Stool cultures sent in ED and C.diff neg. Per pt improving over the course of the admission, using immodium prn. # Asymptomatic bacteruria - Ucx on admit grew citrobacter, but pt denied fever or leukocytosis, was not neutropenic, and continued to deny any urinary symptoms. He does at baseline have difficulty that when he urinates stool comes out along with it (pelvic muscle control issues?) but given this reflects asymptomatic bacteruria, held off on treating for now. # Protein calorie malnutrition. Nutrition consulted. Recommended supplements. # Neuroendocrine tumor: Metastatic to lymph nodes and presumably the liver. Unclear primary source. Based on cytology appears to be well differentiated high grade. Plan has been to start carboplatin/etoposide pending syncope workup and hyperbilirubinemia, which was given D1 on ___. PICC for access/chemo. Dr. ___ to arrange for outpatient port placement before next cycle. arranging for neulasta ___ appointment on ___ ___. Repeated liver biopsy ___ to rule out HCC and compare to neuroendocrine path from lymph node. Received D1-D3 of C1 Carboplatin/Etoposide while in-house. # Right arm swelling - picc in place, ultrasound showed PICC associated DVT. Patient was restarted on apixaban, PICC was pulled on ___. # Anemia - stable. likely inflammatory block and from malignancy, he may have marrow involvement. Drop initially likely hemodilutional as pt hemoconcentrated on admit. checked hemolysis labs (hapto 151, Tbili downtrending reassuring). # NASH-induced cirrhosis complicated by portal hypertension. # Ascites E/o volume overload after chemo and initial hydration. Got 20mg IV Lasix on ___ w some improvement on exam though weight stable. Resumed home 20mg Lasix daily subsequently. # Hypertension - borderline BPs in low 100s initially but normotensive upon discharge - Dose increased metoprolol, as above, and cont holding verapamil. Decreased doxazosin dose. # BPH: Dose reduced home doxazosin, continued finasteride # Gout: Initiated allopurinol, continue colchicine as needed # Prediabetes mellitus: On LSS/Fingersticks while in house # CKD: Stage IIIA. At most recent baseline # Bell's palsy left side: Known prior to admission TRANSITIONAL ISSUES: ==================== 1. Scheduled for Pegfilgrastim on ___ 2. Please monitor platelet count on ___ and C1D11 (___) as may require holding apixaban if platelet nadir <50 000 3. Discharged on increased dose of metoprolol XL (100 to 200mg) as verapamil being held in setting of orthostasis 4. Downtitrated doxazosin given orthostasis, no LUTS. Please monitor and titrate as needed. 5. Discharged on decreased dose of furosemide (40 to 20mg) given relatively poor PO intake. Discharge weight is 185lbs, dry weight assumed to be 181-182 lbs. Uptitrate to 40mg if weight after ___ is >185lbs. Discharge planning and coordination required >60 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Colchicine 0.6 mg PO DAILY:PRN Gout 3. Doxazosin 16 mg PO HS 4. Finasteride 5 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Verapamil SR 120 mg PO Q24H Discharge Medications: 1. Allopurinol ___ mg PO DAILY RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Metoprolol Succinate XL 200 mg PO DAILY RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE RX *pegfilgrastim [Neulasta] 6 mg/0.6 mL 6 mg subcu once Disp #*1 Syringe Refills:*0 4. Pegfilgrastim Onpro (On Body Injector) 6 mg SC ONCE Duration: 1 Dose RX *pegfilgrastim [Neulasta] 6 mg/0.6 mL deliverable (0.64 mL) 6 mg subcutaneous once Refills:*6 5. Senna 8.6 mg PO BID:PRN constipation 6. Doxazosin 4 mg PO HS RX *doxazosin 4 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Apixaban 5 mg PO BID 9. Colchicine 0.6 mg PO DAILY:PRN Gout 10. Finasteride 5 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Neuroendocrine carcinoma Atrial fibrillation Chronic kidney disease Cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted after fainting. We felt you were dehydrated. You also received chemotherapy and had a liver biopsy. We think some of your blood pressure medicines caused low blood pressure in setting of dehydration and contributed to the fainting. We changed these around. Please STOP your verapamil. We increased the dose of your metoprolol instead. Also, we decreased the dose of your doxazosin as this can cause low blood pressure. We are discharging you on apixaban mostly due to your blood clot in the right arm. If your platelets drop significantly with your chemotherapy your oncologist may ask you to stop the apixaban for a moment. Call your oncologist if any signs of bleeding. You need to get your neulasta injection on ___, see below. We are sending you home with home ___ services. Your ___ Team Followup Instructions: ___
[ "I952", "E43", "C7B8", "K766", "K7469", "I4891", "E860", "T82868A", "K7581", "E669", "N400", "M109", "R7303", "Z87891", "Z8052", "Z800", "Z803", "Z807", "E861", "D181", "E806", "R8271", "G510", "I129", "T461X5A", "Y92009", "Z6826", "K4090", "N183", "Y848", "Y92230" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Syncope Major Surgical or Invasive Procedure: Liver biopsy [MASKED] History of Present Illness: [MASKED] is a [MASKED] man with metastatic neurodendocrine tumor, unknown primary, who is admitted from the ED with a sycnopal episode. Patient has had progressive functional decline over the last several months with associated poor po intake. He denies nausea or frank abdominal pain, but does note bloating and significant dysgeusia. He reports having eaten 'very little' over the previous month. Additionally, he has developed large volume diarrhea over the last three weeks, up to [MASKED] stools per day (worse at night). He has also had increasing weakness over this time. His son brought him to his medical oncology clinic on day of admission, but he had a syncopal episode in the parking lot. Patient stood up out of the car, and felt light headed. He did not fall right away, but eventually his legs 'gave out'. His son caught him and lowered him to the ground. He had no LOC, no headstrike, and he remembers the event clearly. No preceeding CP, palpitations or SOB. Does have occaisional word finding difficulty, but no other new neurologic issues. He was seen in oncology where he was noted to have soft BP's (90/59), was unable to stand up, have word finding difficulties, and slight left facial droop. He was transported to the ED. In the ED, initial VS were: pain 0, T 97.2, HR 86, BP 108/74, RR 16, O2 100%RA. Labs notable for Na 140, K 3.8, HCO3 20, Cr 1.2, ALT 22, AST 54, ALP 348, LDH 467, TBIli 1.8, Alb 3.3, WBC 7.6, HCT 36.6, PLT 245, INR 1.9, Uric acid 16.7. CXR showed possible subtle right lateral mid lung consolidation. CT head showed new bilateral hygroma - neurosurgery recommended no intervention. Liver US showed known metastatic disease, but no biliary obstruction. Patient received 1LNS prior to admission. On arrival to the floor, patient reports feeling better than he has in several weeks. No recent fevers or chills. He does have significant dry mouth and food tastes 'awful'. No CP or SOB. No palpitations. No N/V. No frank abdominal pain, but does have bloating. No dysuria. No new leg pain or weakness. No significant flushing. No new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: First developed abdominal bloating mid [MASKED]. He was then following up with one of our hepatologist, Dr. [MASKED] he was found to have on [MASKED], a 15.9-cm right lobe mass with multiple satellite lesions consistent with HCC and enlarged porta hepatis and retroperitoneal lymphadenopathy consistent with metastases. His case was discussed at [MASKED] Conference and while the lymph nodes were concerning and rereviewed by Interventional Radiology, they were found to be not diagnostic for metastases. He underwent endoscopy with EUS on [MASKED] which did not identify any primary lesions including in the pancreas. A biopsy of 1 of the lymph nodes returned as consistent with grade 2 neuroendocrine tumor with a Ki-67 percentage of about 20%. PAST MEDICAL HISTORY: 1. NASH-induced cirrhosis complicated by portal hypertension. 2. Ascites and HCC. 3. Atrial fibrillation. 4. Hypertension. 5. Obesity. 6. BPH. 7. Gout. 8. Prediabetes mellitus. 9. Apparent CKD, which he is not aware of. 10. Baseline Bell's palsy left side. Social History: [MASKED] Family History: His mother was diagnosed with intestinal cancer in her late [MASKED] and died at age [MASKED]. Brother diagnosed in his [MASKED] and living with bladder cancer. Sister living and has lymphoma. Sister living, diagnosed with breast cancer in her late [MASKED]. Physical Exam: DISCHARGE PHYSICAL EXAM: VS: T 97.5 115/67 79 18 98%RA WT 185 lbs from 173 on admit - was slightly dry on admit, but looks overloaded still at this point GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI, dry MM. ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Irregular rhythm, regular rate, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; mildly distended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. MUSKULOSKELATAL: Warm, well perfused extremities, 1+ [MASKED] symmetric, slightly improved from yesterday RUE with PICC is swollen but neurologically intact, picc insertion site w/o erythema NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE EXAM VS: 97.5 PO 118 / 70 76 18 97 Ra WEIGHT: 83.92kg || 185.01lb GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI, dry MM. ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Irregular heart sounds, no murmurs, rubs, or gallops; 2+ radial pulses. JVP is 2cm above clavicle RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; mildly distended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly. MUSKULOSKELATAL: Warm, well perfused extremities, 1+ [MASKED] symmetric, slightly improved from yesterday RUE is swollen but neurologically intact NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses Pertinent Results: ADMISSION LABS: [MASKED] 02:20PM BLOOD WBC-7.6 RBC-4.18* Hgb-12.0* Hct-36.6* MCV-88 MCH-28.7 MCHC-32.8 RDW-17.7* RDWSD-56.5* Plt [MASKED] [MASKED] 02:20PM BLOOD Neuts-82.9* Lymphs-9.5* Monos-6.9 Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-6.29* AbsLymp-0.72* AbsMono-0.52 AbsEos-0.01* AbsBaso-0.01 [MASKED] 02:20PM BLOOD [MASKED] PTT-30.3 [MASKED] [MASKED] 02:20PM BLOOD UreaN-29* Creat-1.2 Na-140 K-3.8 Cl-99 HCO3-20* AnGap-25* [MASKED] 02:20PM BLOOD ALT-22 AST-54* LD(LDH)-467* AlkPhos-348* TotBili-1.8* [MASKED] 02:20PM BLOOD Albumin-3.3* Calcium-8.9 Phos-2.1* Mg-2.2 UricAcd-16.7* DISCHARGE LABS: IMAGING: [MASKED] Imaging CHEST (PA & LAT) Difficult to exclude a subtle lateral right mid lung consolidation. No focal consolidation seen elsewhere. Mild cardiomegaly. No pulmonary edema. [MASKED] Imaging LIVER OR GALLBLADDER US 1. Enlarged heterogeneous liver parenchyma containing several heterogeneous masses including a 11 x 8 cm right liver lobe mass, better assessed on of [MASKED] CT abdomen pelvis. Patent main portal vein with hepatopetal flow. 2. Cholelithiasis without evidence of acute cholecystitis. [MASKED] Imaging CT HEAD W/O CONTRAST - Bilateral hygromas versus chronic subdural hematomas without significant midline shift. - No acute intracranial hemorrhage. Brief Hospital Course: ASSESSMENT AND PLAN: [MASKED] is a [MASKED] man with metastatic neurodendocrine tumor, unknown primary, who is admitted from the ED with a syncopal episode. # Syncope: Not clear he had a true syncopal episode, but most likely collapsed in parking lot getting out of the car in setting of orthostatic hypotension and hypovolemia as he was subsequently on evaluation found to by hypotensive with BP in [MASKED]. He has been having ongoing diarrhea for several weeks now, see below. Head CT showed concern for chronic subdural vs hygroma, unlikely that this would account for his symptoms. per NSGY this is not subdural and discussed w/ the NP from their service likely chronic hygroma and no need for further imaging and if anticoag needed that would be find from their standpoint. Pt was likely hypovolemic from ongoing diarrhea and very poor po intake. Doubt infectious process contributing, CXR without obvious infiltrate. See below for asymptomatic bacteruria. No leukocytosis or fever (developed elevated WBC after dex with chemotherapy). Doubt PE given was on anticoag at baseline. Cultures negative to date (see below for asx bacteruria) so DCd antibiotics early in course and pt continued to do quite well. # Afib/RVR - HR was up to [MASKED] in setting of initially holding his metop/verapamil on admit due to syncope. He is asymptomatic. He has no prior CVA history. Uptitrated metop to 50mg q6 with excellent effect. Given hypotension/syncope on admit, will DC pt on metop 200mg XL (was on 100mg XL at home - but also with verapamil) and DC his verapamil as HR well controlled this admit on 50mg metop q6 and off verapamil, and possibly verapamil with more antihypertensive effect contributing to orthostasis. Was continued on apixaban given need for full anticoagulation due to RUE PICC associated DVT. # Elevated cardiac enzymes - mild, downtrended. per discussion w/ cardiology, most likely from demand in setting of hypovolemia. Pt has no history of prior MI. He has no chest pain and serial EKGs have had no dynamic changes (mild ST dep in lateral leads <1mm, stable, no e/o Q waves). Per discussion w/ cardiology, catheterization not indicated as wouldn't be candidate for dual platelet therapy most likely as anticipate thrombocytopenia in which case pt would be unable to come off of ASA/Plavix, posing significant challenges. TTE for baseline, but wouldn't likely be a surgical candidate even if significant valvular disease (showed mod MR, normal EF) Trended trops to peak (0.04). Cont metop on DC at higher dose. Could initiate statin but will consider any interactions there with chemotherapy. Per oncologist hold off on starting statin at this time given chemo and drug interactions. # Hyperbilirubinemia: # Hyperuricemia: Improved with chemo. Elevated bilirubin initially concerning for biliary obstruction, but RUQ showed no obvious obstruction. Given elevated uric acid, must also consider tumor lysis. Fortunately, his creatinine is at recent baseline and he has no gross electrolyte abnormalities. This may represent significant tumor burden turnover due to his large liver mass. He may have elevated uric acid at baseline given his historical problems with gout (none current). no e/o hemolysis on labs. [MASKED] was hydrated initially as above. Initiated allopurinol. # Hygroma: Unclear significance. [MASKED] be due to dehydration or possibly chronic subdural hematoma. No clear acute insult, and no history of falls outside of today's episode. Pt reports getting struck in the head as a child though unclear if related Per neurosurgery NTD at this point. Holding anticoagulation given concerns re anemia/anticpated thrombocytopenia, though from [MASKED] standpoint ok to continue if needed from hygroma standpoint. # Diarrhea: Likely from his neuro-endocrine tumor. Stool cultures sent in ED and C.diff neg. Per pt improving over the course of the admission, using immodium prn. # Asymptomatic bacteruria - Ucx on admit grew citrobacter, but pt denied fever or leukocytosis, was not neutropenic, and continued to deny any urinary symptoms. He does at baseline have difficulty that when he urinates stool comes out along with it (pelvic muscle control issues?) but given this reflects asymptomatic bacteruria, held off on treating for now. # Protein calorie malnutrition. Nutrition consulted. Recommended supplements. # Neuroendocrine tumor: Metastatic to lymph nodes and presumably the liver. Unclear primary source. Based on cytology appears to be well differentiated high grade. Plan has been to start carboplatin/etoposide pending syncope workup and hyperbilirubinemia, which was given D1 on [MASKED]. PICC for access/chemo. Dr. [MASKED] to arrange for outpatient port placement before next cycle. arranging for neulasta [MASKED] appointment on [MASKED] [MASKED]. Repeated liver biopsy [MASKED] to rule out HCC and compare to neuroendocrine path from lymph node. Received D1-D3 of C1 Carboplatin/Etoposide while in-house. # Right arm swelling - picc in place, ultrasound showed PICC associated DVT. Patient was restarted on apixaban, PICC was pulled on [MASKED]. # Anemia - stable. likely inflammatory block and from malignancy, he may have marrow involvement. Drop initially likely hemodilutional as pt hemoconcentrated on admit. checked hemolysis labs (hapto 151, Tbili downtrending reassuring). # NASH-induced cirrhosis complicated by portal hypertension. # Ascites E/o volume overload after chemo and initial hydration. Got 20mg IV Lasix on [MASKED] w some improvement on exam though weight stable. Resumed home 20mg Lasix daily subsequently. # Hypertension - borderline BPs in low 100s initially but normotensive upon discharge - Dose increased metoprolol, as above, and cont holding verapamil. Decreased doxazosin dose. # BPH: Dose reduced home doxazosin, continued finasteride # Gout: Initiated allopurinol, continue colchicine as needed # Prediabetes mellitus: On LSS/Fingersticks while in house # CKD: Stage IIIA. At most recent baseline # Bell's palsy left side: Known prior to admission TRANSITIONAL ISSUES: ==================== 1. Scheduled for Pegfilgrastim on [MASKED] 2. Please monitor platelet count on [MASKED] and C1D11 ([MASKED]) as may require holding apixaban if platelet nadir <50 000 3. Discharged on increased dose of metoprolol XL (100 to 200mg) as verapamil being held in setting of orthostasis 4. Downtitrated doxazosin given orthostasis, no LUTS. Please monitor and titrate as needed. 5. Discharged on decreased dose of furosemide (40 to 20mg) given relatively poor PO intake. Discharge weight is 185lbs, dry weight assumed to be 181-182 lbs. Uptitrate to 40mg if weight after [MASKED] is >185lbs. Discharge planning and coordination required >60 minutes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Colchicine 0.6 mg PO DAILY:PRN Gout 3. Doxazosin 16 mg PO HS 4. Finasteride 5 mg PO DAILY 5. Furosemide 40 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Verapamil SR 120 mg PO Q24H Discharge Medications: 1. Allopurinol [MASKED] mg PO DAILY RX *allopurinol [MASKED] mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Metoprolol Succinate XL 200 mg PO DAILY RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE RX *pegfilgrastim [Neulasta] 6 mg/0.6 mL 6 mg subcu once Disp #*1 Syringe Refills:*0 4. Pegfilgrastim Onpro (On Body Injector) 6 mg SC ONCE Duration: 1 Dose RX *pegfilgrastim [Neulasta] 6 mg/0.6 mL deliverable (0.64 mL) 6 mg subcutaneous once Refills:*6 5. Senna 8.6 mg PO BID:PRN constipation 6. Doxazosin 4 mg PO HS RX *doxazosin 4 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Apixaban 5 mg PO BID 9. Colchicine 0.6 mg PO DAILY:PRN Gout 10. Finasteride 5 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Neuroendocrine carcinoma Atrial fibrillation Chronic kidney disease Cirrhosis 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 after fainting. We felt you were dehydrated. You also received chemotherapy and had a liver biopsy. We think some of your blood pressure medicines caused low blood pressure in setting of dehydration and contributed to the fainting. We changed these around. Please STOP your verapamil. We increased the dose of your metoprolol instead. Also, we decreased the dose of your doxazosin as this can cause low blood pressure. We are discharging you on apixaban mostly due to your blood clot in the right arm. If your platelets drop significantly with your chemotherapy your oncologist may ask you to stop the apixaban for a moment. Call your oncologist if any signs of bleeding. You need to get your neulasta injection on [MASKED], see below. We are sending you home with home [MASKED] services. Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I4891", "E669", "N400", "M109", "Z87891", "I129", "Y92230" ]
[ "I952: Hypotension due to drugs", "E43: Unspecified severe protein-calorie malnutrition", "C7B8: Other secondary neuroendocrine tumors", "K766: Portal hypertension", "K7469: Other cirrhosis of liver", "I4891: Unspecified atrial fibrillation", "E860: Dehydration", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "K7581: Nonalcoholic steatohepatitis (NASH)", "E669: Obesity, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M109: Gout, unspecified", "R7303: Prediabetes", "Z87891: Personal history of nicotine dependence", "Z8052: Family history of malignant neoplasm of bladder", "Z800: Family history of malignant neoplasm of digestive organs", "Z803: Family history of malignant neoplasm of breast", "Z807: Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues", "E861: Hypovolemia", "D181: Lymphangioma, any site", "E806: Other disorders of bilirubin metabolism", "R8271: Bacteriuria", "G510: Bell's palsy", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "T461X5A: Adverse effect of calcium-channel blockers, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "K4090: Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent", "N183: Chronic kidney disease, stage 3 (moderate)", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,070,614
21,993,779
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Keflex / Ciprofloxacin / lisinopril Attending: ___. Chief Complaint: anemia Major Surgical or Invasive Procedure: ___: EGD, colonoscopy, diagnostic and therapeutic paracentesis History of Present Illness: ___ ___ with a history of DMII, CAD s/p MI and CABG, diastolic heart failure (TTE ___ with EF 55%), hepatitis B, ? pericardial nodules on ___ imaging, hypertension, and hyperlipidemia who presents with anemia. He reports having had worsening shortness of breath over the past month or two that has been refractory to increases in his diuretics. He was seen by his PCP and found to have a Hgb of 6.8 (MCV 68) from 10.9 (MCV 92) in ___. He was on iron previously although this was discontinued by the patient. Per his report, he has also had early satiety over the past two months, with associated bloating in the morning and evenings. He also felt food sometimes can feel stuck. He has not had any nausea or vomiting, or any unintentional weight loss (although weight varies by 3 lbs based on his Lasix use). He has not noticed any blood or black stools, although has not looked closely at his bowel movements. He has had a few nosebleeds recently in the morning but not large volume and predominantly clots. Of note, he has blood in his stool (red and black) ___ years ago when he was on Coumadin for afib. He was in ___ at the time and was feeling unwell. He was found to be tachycardic and anemic and his Coumadin was stopped. He does not feel that his current symptoms are similar to this, although he does describe feeling more fatigues and that his palms are more pale than normal. Past Medical History: - Diastolic Congestive Heart Failure (TTE ___ with EF 55%) - CAD s/p anteroseptal MI and 5-vessel CABG in ___ - Mitral Regurgitation - Aortic Regurgitation - Hypercholesterolemia - Hypertension - Atrial fibrillation and atrial flutter s/p flutter ablation in ___ - DMII - Hepatitis B - Tobacco Use, quit in ___ - Previous significant alcohol abuse, quit in ___ Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies; Mother died of MI age ___. No family history of diabetes, otherwise non-contributory. Physical Exam: ========================== ADMISSION EXAM: ========================== VITALS: 98.6 97.5 ___ 96/RA GENERAL: Pleasant, well-appearing, ___ speaking, in no apparent distress HEENT: Normocephalic, atraumatic, pale conjunctiva, no scleral icterus, PERRLA, EOMI, OP clear. CARDIAC: RRR, normal S1/S2, ___ holosystolic murmur heard at the apex. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, mildly distended, no organomegaly. EXTREMITIES: Warm and well-perfused. R > L trace lower extremity edema. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. ========================== DISCHARGE EXAM: ========================== Vitals: 98.6 98.6 114/63 66 18 100%RA Exam: GENERAL - Alert, interactive, ___ gentleman in NAD HEENT - sclerae pale but anicteric, MMM HEART - RRR, nl S1-S2, grade ___ holosystolic murmur heard loudest at apex LUNGS - CTAB, no wheezes, crackles, or rhonchi ABDOMEN - soft, nondistended, nontender, no palpable hepatosplenomegaly or masses, normoactive BS, small paracentesis site in LLQ clean/dry/intact EXTREMITIES - WWP, no cyanosis/clubbing, no lower extremity edema NEURO - CNs II-XII grossly intact, no focal deficits Pertinent Results: ========================== ADMISSION LABS: ========================== ___ 08:05PM BLOOD WBC-6.0 RBC-3.00*# Hgb-5.8*# Hct-20.8*# MCV-69*# MCH-19.3*# MCHC-27.9*# RDW-18.3* RDWSD-45.0 Plt ___ ___ 08:05PM BLOOD ___ PTT-33.0 ___ ___ 08:05PM BLOOD Ret Aut-2.1* Abs Ret-0.06 ___ 08:05PM BLOOD Glucose-162* UreaN-28* Creat-1.1 Na-134 K-4.4 Cl-104 HCO3-21* AnGap-13 ___ 08:05PM BLOOD ALT-8 AST-18 LD(___)-142 AlkPhos-118 TotBili-1.0 ___ 08:05PM BLOOD Albumin-4.1 Iron-136 ___ 08:05PM BLOOD calTIBC-580* ___ Ferritn-13* TRF-446* ========================== PERTINENT LABS: ========================== ___ 04:40AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* ___ 04:40AM BLOOD HCV Ab-Negative ___ 12:50PM BLOOD IgA-234 ___ 12:50PM BLOOD tTG-IgA-7 ___ 5:30 am IMMUNOLOGY **FINAL REPORT ___ HBV Viral Load (Final ___: HBV DNA not detected. Performed using the Cobas Ampliprep / Cobas Taqman HBV Test v2.0. Linear range of quantification: 20 IU/mL - 170 million IU/mL. Limit of detection: 20 IU/mL. Semi-solid and liquid stool throughout the colon that only partially cleared with washing and suctioning. Otherwise normal colonoscopy to cecum ========================== DISCHARGE LABS: ========================== ___ 06:10AM BLOOD WBC-5.8 RBC-3.69* Hgb-7.8* Hct-27.3* MCV-74* MCH-21.1* MCHC-28.6* RDW-23.0* RDWSD-53.3* Plt ___ ___ 06:10AM BLOOD ___ PTT-33.6 ___ ___ 06:10AM BLOOD Glucose-108* UreaN-18 Creat-1.0 Na-136 K-4.5 Cl-105 HCO3-21* AnGap-15 ___ 06:10AM BLOOD ALT-21 AST-27 LD(LDH)-160 AlkPhos-120 TotBili-1.2 ___ 06:10AM BLOOD Albumin-3.6 Calcium-8.5 Phos-3.4 Mg-1.8 ========================== URINE: ========================== ___ 10:31PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 10:31PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG ___ 10:31PM URINE RBC-3* WBC-3 Bacteri-FEW Yeast-NONE Epi-<1 ========================== ASCITES: ========================== ___ 05:10PM ASCITES WBC-158* RBC-690* Polys-5* Lymphs-36* Monos-1* Eos-1* Mesothe-2* Macroph-55* ___ 05:10PM ASCITES TotPro-4.2 Glucose-210 LD(LDH)-87 Amylase-24 TotBili-0.9 Albumin-2.4 ========================== IMAGING/STUDIES: ========================== CT CHEST ___: IMPRESSION: Status post CABG, pulmonary hypertension. Enlargement of the right heart. Moderate right and small left pleural effusion. Calcified mediastinal lymph nodes. No evidence of malignancy. CT ABDOMEN/PELVIS ___: IMPRESSION: 1. Heterogeneous enhancement, and interval increase in nodularity of the liver since ___, is concerning for advanced liver disease, such as cirrhosis. No definite focal hepatic lesions identified. Moderate ascites. 2. Moderate right and small left pleural effusions, better evaluated on the recent CT of the chest. 3. Extensive vascular calcifications, including moderate stenosis of the origin of the SMA. 4. 1.4 cm BPH nodule on the prostate gland. A urology consult is recommended for further evaluation. EGD ___: IMPRESSION: No varices seen Erythema and erosions in the antrum compatible with erosive gastritis Otherwise normal EGD to third part of the duodenum Colonoscopy ___: Findings: Protruding Lesions: A single sessile 5 mm polyp of benign appearance was found in the transverse. A single-piece polypectomy was performed using a cold snare. The polyp was completely removed but could be not be retrieved. Other Semi-solid and liquid stool throughout the colon that only partially cleared with washing and suctioning. Impression: Polyp in the transverse (polypectomy) Semi-solid and liquid stool throughout the colon that only partially cleared with washing and suctioning. Otherwise normal colonoscopy to cecum Brief Hospital Course: ====================== ACTIVE ISSUES: ====================== # Microcytic Anemia: His H/H was 5.8/20.8 on admission with MCV 69, down from Hgb 10.9 in ___. The patient was transfused 2 uPRBC on ___ with appropriate bump in H/H and improvement in his shortness of breath. Iron studies were consistent with iron deficiency anemia (low ferritin, high TIBC), hemoptysis labs (LDH, haptoglobin) were wnl. Blood smear showed microcytic, hypochromc anemia with frequent pencil forms and anisocytosis consistent with iron deficiency; no dysplastic findings are observed. No report of BRBPR or melena per patient, but he reportedly had positive FOBT in the past. Given symptoms of early satiety, abdominal distension, and this anemia, occult malignancy was on the differential. CT torso was done on ___ and showed no obvious malignancy, increase in nodularity of liver and moderate ascites concerning for advanced liver disease. EGD on ___ showed erosive gastritis, no ulcer, no varices. Colonoscopy on ___ showed prep inadequate, no bleeding or masses seen, polyp in transverse colon biopsied. Heme/onc was consulted and recommended ThePO iron supplements with plans for outpatient IV iron infusions. He will also have repeat colonoscopy as an outpatient and possible capsule study to better identify source of bleeding. # Erosive gastritis: The patient was found to have erosive gastritis on EGD. He was started on omeprazole 20mg BID on discharge with plans for GI follow up. # Cirrhosis: The patient presented with fatigue, early satiety, and abdominal distension with ascites present on physical exam and imaging. No unintentional weight loss. Cardiac MR in our system also with evidence of constrictive pericarditis. Torso CT and ___ negative for identifiable mass or malignancy which is reassuring; do show some calcified mediastinal and subcarinal lymph nodes. Patient underwent therapeutic paracentesis on ___ for 2L of fluid with relief of his abdominal distention symptoms. Paracentesis fluid chemistries/cell counts unremarkable, no s/s infection. Paracentesis fluid cytology was also sent which was pending at time of discharge. He will also be followed as an outpatient in Liver Clinic (appointment pending). ====================== CHRONIC ISSUES: ====================== # Coronary Artery Disease: Patient has a history of 5 vessel CABG ___: LIMA to LAD, SVG to diagonal, obtuse marginal, PLVB, PDA. In house, he was continued on his home rosuvastatin, aspirin 81mg. # Chronic Diastolic Congestive Heart Failure: Currently stable though very significant disease. TTE ___ with EF 55%. In house, he was continued on his home aspirin 81mg and Lasix 20mg PO daily. His metoprolol was fractionated into 6.25mg BID. His home losartan 12.5mg PO daily was initially held due to his IV contrast load, but was subsequently restarted. # DMII: The patient's home metformin was held in-house. He was maintained on a Humalog insulin sliding scale while an inpatient. # Hypertension: The patient's metoprolol was fractionated into 6.25mg BID. His home losartan 12.5mg PO daily was initially held due to his IV contrast load, but was subsequently restarted. # Hyperlipidemia: The patient was continued on his home rosuvastatin. # Hepatitis B: The patient has a known history of hepatitis B that was poorly documented/characterized in the currently available data. We sent repeat serologies which showed HBsAg negative, HBsAb positive, HBcAb positive, HCV Ab negative, indicating past HBV infection now inactive with protective titers. # Nosebleeds: Patient was having nosebleeds q1-2 days in hospital. He was written for Ocean nasal mist (saline) QID PRN dry nose/nosebleeds. ====================== TRANSITIONAL ISSUES: ====================== - Should have outpatient colonoscopy in 2 months. GI follow up scheduled - Will benefit from outpatient iron transfusions. He will be discharged on oral iron to be titrated as tolerated as well. - Will have follow up in Liver Clinic - Hepatitis serologies showed HBsAg negative, HBsAb positive, HBcAb positive, HCV Ab negative, indicating past HBV infection now inactive with protective titers. - Ascitic fluid culture and cytology pending at time of discharge - Vitamin B12 and folate levels pending at time of discharge - 1.4 cm BPH nodule was found incidentally on the prostate gland. A urology consult is recommended for further evaluation. - Full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 12.5 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Losartan Potassium 12.5 mg PO DAILY 5. Rosuvastatin Calcium 20 mg PO QPM 6. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Losartan Potassium 12.5 mg PO DAILY 4. Rosuvastatin Calcium 20 mg PO QPM 5. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - anemia, microcytic, iron deficiency - cirrhosis complicated by ascites - erosive gastritis Secondary diagnoses: - coronary artery disease - diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was our pleasure participating in your care here at ___. ___ were admitted on ___ with low blood counts. ___ underwent two procedures to look in your gut for signs of bleeding. The first procedure looked at your stomach and esophagus and showed some irritation. ___ were started on a medication called omeprazole to be taken twice a day. ___ also had pictures taken of your lower gut, called a colonoscopy. The doctors were unable to see the whole gut because of some stool. ___ should have a repeat colonoscopy procedure as an outpatient. ___ will have follow up with the Gastroenterology (stomach and gut) doctors. ___ were also found to have swelling around your abdomen. This was likely from liver disease that was caused by alcohol. ___ had this fluid drained and the final testing of this fluid is still pending. ___ will have follow up in Liver Clinic as an outpatient. ___ were evaluated by the Hematologists (blood doctors) for your low blood counts. They recommended outpatient Iron transfusions. If ___ develop worsening abdominal pain, red blood in your stool, black stool, please let your doctors ___. Again, it was our pleasure participating in your care. We wish ___ the best, Your ___ Medicine Team Followup Instructions: ___
[ "D62", "I5032", "K7460", "R188", "I080", "I4891", "D509", "K2960", "R5383", "E119", "I2510", "I10", "I252", "Z951", "E785", "Z9114", "R040", "N402", "D123", "Z87891", "Z8619" ]
Allergies: Keflex / Ciprofloxacin / lisinopril Chief Complaint: anemia Major Surgical or Invasive Procedure: [MASKED]: EGD, colonoscopy, diagnostic and therapeutic paracentesis History of Present Illness: [MASKED] [MASKED] with a history of DMII, CAD s/p MI and CABG, diastolic heart failure (TTE [MASKED] with EF 55%), hepatitis B, ? pericardial nodules on [MASKED] imaging, hypertension, and hyperlipidemia who presents with anemia. He reports having had worsening shortness of breath over the past month or two that has been refractory to increases in his diuretics. He was seen by his PCP and found to have a Hgb of 6.8 (MCV 68) from 10.9 (MCV 92) in [MASKED]. He was on iron previously although this was discontinued by the patient. Per his report, he has also had early satiety over the past two months, with associated bloating in the morning and evenings. He also felt food sometimes can feel stuck. He has not had any nausea or vomiting, or any unintentional weight loss (although weight varies by 3 lbs based on his Lasix use). He has not noticed any blood or black stools, although has not looked closely at his bowel movements. He has had a few nosebleeds recently in the morning but not large volume and predominantly clots. Of note, he has blood in his stool (red and black) [MASKED] years ago when he was on Coumadin for afib. He was in [MASKED] at the time and was feeling unwell. He was found to be tachycardic and anemic and his Coumadin was stopped. He does not feel that his current symptoms are similar to this, although he does describe feeling more fatigues and that his palms are more pale than normal. Past Medical History: - Diastolic Congestive Heart Failure (TTE [MASKED] with EF 55%) - CAD s/p anteroseptal MI and 5-vessel CABG in [MASKED] - Mitral Regurgitation - Aortic Regurgitation - Hypercholesterolemia - Hypertension - Atrial fibrillation and atrial flutter s/p flutter ablation in [MASKED] - DMII - Hepatitis B - Tobacco Use, quit in [MASKED] - Previous significant alcohol abuse, quit in [MASKED] Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies; Mother died of MI age [MASKED]. No family history of diabetes, otherwise non-contributory. Physical Exam: ========================== ADMISSION EXAM: ========================== VITALS: 98.6 97.5 [MASKED] 96/RA GENERAL: Pleasant, well-appearing, [MASKED] speaking, in no apparent distress HEENT: Normocephalic, atraumatic, pale conjunctiva, no scleral icterus, PERRLA, EOMI, OP clear. CARDIAC: RRR, normal S1/S2, [MASKED] holosystolic murmur heard at the apex. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, mildly distended, no organomegaly. EXTREMITIES: Warm and well-perfused. R > L trace lower extremity edema. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength [MASKED] throughout. ========================== DISCHARGE EXAM: ========================== Vitals: 98.6 98.6 114/63 66 18 100%RA Exam: GENERAL - Alert, interactive, [MASKED] gentleman in NAD HEENT - sclerae pale but anicteric, MMM HEART - RRR, nl S1-S2, grade [MASKED] holosystolic murmur heard loudest at apex LUNGS - CTAB, no wheezes, crackles, or rhonchi ABDOMEN - soft, nondistended, nontender, no palpable hepatosplenomegaly or masses, normoactive BS, small paracentesis site in LLQ clean/dry/intact EXTREMITIES - WWP, no cyanosis/clubbing, no lower extremity edema NEURO - CNs II-XII grossly intact, no focal deficits Pertinent Results: ========================== ADMISSION LABS: ========================== [MASKED] 08:05PM BLOOD WBC-6.0 RBC-3.00*# Hgb-5.8*# Hct-20.8*# MCV-69*# MCH-19.3*# MCHC-27.9*# RDW-18.3* RDWSD-45.0 Plt [MASKED] [MASKED] 08:05PM BLOOD [MASKED] PTT-33.0 [MASKED] [MASKED] 08:05PM BLOOD Ret Aut-2.1* Abs Ret-0.06 [MASKED] 08:05PM BLOOD Glucose-162* UreaN-28* Creat-1.1 Na-134 K-4.4 Cl-104 HCO3-21* AnGap-13 [MASKED] 08:05PM BLOOD ALT-8 AST-18 LD([MASKED])-142 AlkPhos-118 TotBili-1.0 [MASKED] 08:05PM BLOOD Albumin-4.1 Iron-136 [MASKED] 08:05PM BLOOD calTIBC-580* [MASKED] Ferritn-13* TRF-446* ========================== PERTINENT LABS: ========================== [MASKED] 04:40AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* [MASKED] 04:40AM BLOOD HCV Ab-Negative [MASKED] 12:50PM BLOOD IgA-234 [MASKED] 12:50PM BLOOD tTG-IgA-7 [MASKED] 5:30 am IMMUNOLOGY **FINAL REPORT [MASKED] HBV Viral Load (Final [MASKED]: HBV DNA not detected. Performed using the Cobas Ampliprep / Cobas Taqman HBV Test v2.0. Linear range of quantification: 20 IU/mL - 170 million IU/mL. Limit of detection: 20 IU/mL. Semi-solid and liquid stool throughout the colon that only partially cleared with washing and suctioning. Otherwise normal colonoscopy to cecum ========================== DISCHARGE LABS: ========================== [MASKED] 06:10AM BLOOD WBC-5.8 RBC-3.69* Hgb-7.8* Hct-27.3* MCV-74* MCH-21.1* MCHC-28.6* RDW-23.0* RDWSD-53.3* Plt [MASKED] [MASKED] 06:10AM BLOOD [MASKED] PTT-33.6 [MASKED] [MASKED] 06:10AM BLOOD Glucose-108* UreaN-18 Creat-1.0 Na-136 K-4.5 Cl-105 HCO3-21* AnGap-15 [MASKED] 06:10AM BLOOD ALT-21 AST-27 LD(LDH)-160 AlkPhos-120 TotBili-1.2 [MASKED] 06:10AM BLOOD Albumin-3.6 Calcium-8.5 Phos-3.4 Mg-1.8 ========================== URINE: ========================== [MASKED] 10:31PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 10:31PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG [MASKED] 10:31PM URINE RBC-3* WBC-3 Bacteri-FEW Yeast-NONE Epi-<1 ========================== ASCITES: ========================== [MASKED] 05:10PM ASCITES WBC-158* RBC-690* Polys-5* Lymphs-36* Monos-1* Eos-1* Mesothe-2* Macroph-55* [MASKED] 05:10PM ASCITES TotPro-4.2 Glucose-210 LD(LDH)-87 Amylase-24 TotBili-0.9 Albumin-2.4 ========================== IMAGING/STUDIES: ========================== CT CHEST [MASKED]: IMPRESSION: Status post CABG, pulmonary hypertension. Enlargement of the right heart. Moderate right and small left pleural effusion. Calcified mediastinal lymph nodes. No evidence of malignancy. CT ABDOMEN/PELVIS [MASKED]: IMPRESSION: 1. Heterogeneous enhancement, and interval increase in nodularity of the liver since [MASKED], is concerning for advanced liver disease, such as cirrhosis. No definite focal hepatic lesions identified. Moderate ascites. 2. Moderate right and small left pleural effusions, better evaluated on the recent CT of the chest. 3. Extensive vascular calcifications, including moderate stenosis of the origin of the SMA. 4. 1.4 cm BPH nodule on the prostate gland. A urology consult is recommended for further evaluation. EGD [MASKED]: IMPRESSION: No varices seen Erythema and erosions in the antrum compatible with erosive gastritis Otherwise normal EGD to third part of the duodenum Colonoscopy [MASKED]: Findings: Protruding Lesions: A single sessile 5 mm polyp of benign appearance was found in the transverse. A single-piece polypectomy was performed using a cold snare. The polyp was completely removed but could be not be retrieved. Other Semi-solid and liquid stool throughout the colon that only partially cleared with washing and suctioning. Impression: Polyp in the transverse (polypectomy) Semi-solid and liquid stool throughout the colon that only partially cleared with washing and suctioning. Otherwise normal colonoscopy to cecum Brief Hospital Course: ====================== ACTIVE ISSUES: ====================== # Microcytic Anemia: His H/H was 5.8/20.8 on admission with MCV 69, down from Hgb 10.9 in [MASKED]. The patient was transfused 2 uPRBC on [MASKED] with appropriate bump in H/H and improvement in his shortness of breath. Iron studies were consistent with iron deficiency anemia (low ferritin, high TIBC), hemoptysis labs (LDH, haptoglobin) were wnl. Blood smear showed microcytic, hypochromc anemia with frequent pencil forms and anisocytosis consistent with iron deficiency; no dysplastic findings are observed. No report of BRBPR or melena per patient, but he reportedly had positive FOBT in the past. Given symptoms of early satiety, abdominal distension, and this anemia, occult malignancy was on the differential. CT torso was done on [MASKED] and showed no obvious malignancy, increase in nodularity of liver and moderate ascites concerning for advanced liver disease. EGD on [MASKED] showed erosive gastritis, no ulcer, no varices. Colonoscopy on [MASKED] showed prep inadequate, no bleeding or masses seen, polyp in transverse colon biopsied. Heme/onc was consulted and recommended ThePO iron supplements with plans for outpatient IV iron infusions. He will also have repeat colonoscopy as an outpatient and possible capsule study to better identify source of bleeding. # Erosive gastritis: The patient was found to have erosive gastritis on EGD. He was started on omeprazole 20mg BID on discharge with plans for GI follow up. # Cirrhosis: The patient presented with fatigue, early satiety, and abdominal distension with ascites present on physical exam and imaging. No unintentional weight loss. Cardiac MR in our system also with evidence of constrictive pericarditis. Torso CT and [MASKED] negative for identifiable mass or malignancy which is reassuring; do show some calcified mediastinal and subcarinal lymph nodes. Patient underwent therapeutic paracentesis on [MASKED] for 2L of fluid with relief of his abdominal distention symptoms. Paracentesis fluid chemistries/cell counts unremarkable, no s/s infection. Paracentesis fluid cytology was also sent which was pending at time of discharge. He will also be followed as an outpatient in Liver Clinic (appointment pending). ====================== CHRONIC ISSUES: ====================== # Coronary Artery Disease: Patient has a history of 5 vessel CABG [MASKED]: LIMA to LAD, SVG to diagonal, obtuse marginal, PLVB, PDA. In house, he was continued on his home rosuvastatin, aspirin 81mg. # Chronic Diastolic Congestive Heart Failure: Currently stable though very significant disease. TTE [MASKED] with EF 55%. In house, he was continued on his home aspirin 81mg and Lasix 20mg PO daily. His metoprolol was fractionated into 6.25mg BID. His home losartan 12.5mg PO daily was initially held due to his IV contrast load, but was subsequently restarted. # DMII: The patient's home metformin was held in-house. He was maintained on a Humalog insulin sliding scale while an inpatient. # Hypertension: The patient's metoprolol was fractionated into 6.25mg BID. His home losartan 12.5mg PO daily was initially held due to his IV contrast load, but was subsequently restarted. # Hyperlipidemia: The patient was continued on his home rosuvastatin. # Hepatitis B: The patient has a known history of hepatitis B that was poorly documented/characterized in the currently available data. We sent repeat serologies which showed HBsAg negative, HBsAb positive, HBcAb positive, HCV Ab negative, indicating past HBV infection now inactive with protective titers. # Nosebleeds: Patient was having nosebleeds q1-2 days in hospital. He was written for Ocean nasal mist (saline) QID PRN dry nose/nosebleeds. ====================== TRANSITIONAL ISSUES: ====================== - Should have outpatient colonoscopy in 2 months. GI follow up scheduled - Will benefit from outpatient iron transfusions. He will be discharged on oral iron to be titrated as tolerated as well. - Will have follow up in Liver Clinic - Hepatitis serologies showed HBsAg negative, HBsAb positive, HBcAb positive, HCV Ab negative, indicating past HBV infection now inactive with protective titers. - Ascitic fluid culture and cytology pending at time of discharge - Vitamin B12 and folate levels pending at time of discharge - 1.4 cm BPH nodule was found incidentally on the prostate gland. A urology consult is recommended for further evaluation. - Full code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 12.5 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Losartan Potassium 12.5 mg PO DAILY 5. Rosuvastatin Calcium 20 mg PO QPM 6. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Losartan Potassium 12.5 mg PO DAILY 4. Rosuvastatin Calcium 20 mg PO QPM 5. Omeprazole 20 mg PO BID RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: - anemia, microcytic, iron deficiency - cirrhosis complicated by ascites - erosive gastritis Secondary diagnoses: - coronary artery disease - diastolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was our pleasure participating in your care here at [MASKED]. [MASKED] were admitted on [MASKED] with low blood counts. [MASKED] underwent two procedures to look in your gut for signs of bleeding. The first procedure looked at your stomach and esophagus and showed some irritation. [MASKED] were started on a medication called omeprazole to be taken twice a day. [MASKED] also had pictures taken of your lower gut, called a colonoscopy. The doctors were unable to see the whole gut because of some stool. [MASKED] should have a repeat colonoscopy procedure as an outpatient. [MASKED] will have follow up with the Gastroenterology (stomach and gut) doctors. [MASKED] were also found to have swelling around your abdomen. This was likely from liver disease that was caused by alcohol. [MASKED] had this fluid drained and the final testing of this fluid is still pending. [MASKED] will have follow up in Liver Clinic as an outpatient. [MASKED] were evaluated by the Hematologists (blood doctors) for your low blood counts. They recommended outpatient Iron transfusions. If [MASKED] develop worsening abdominal pain, red blood in your stool, black stool, please let your doctors [MASKED]. Again, it was our pleasure participating in your care. We wish [MASKED] the best, Your [MASKED] Medicine Team Followup Instructions: [MASKED]
[]
[ "D62", "I5032", "I4891", "D509", "E119", "I2510", "I10", "I252", "Z951", "E785", "Z87891" ]
[ "D62: Acute posthemorrhagic anemia", "I5032: Chronic diastolic (congestive) heart failure", "K7460: Unspecified cirrhosis of liver", "R188: Other ascites", "I080: Rheumatic disorders of both mitral and aortic valves", "I4891: Unspecified atrial fibrillation", "D509: Iron deficiency anemia, unspecified", "K2960: Other gastritis without bleeding", "R5383: Other fatigue", "E119: Type 2 diabetes mellitus without complications", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "I252: Old myocardial infarction", "Z951: Presence of aortocoronary bypass graft", "E785: Hyperlipidemia, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "R040: Epistaxis", "N402: Nodular prostate without lower urinary tract symptoms", "D123: Benign neoplasm of transverse colon", "Z87891: Personal history of nicotine dependence", "Z8619: Personal history of other infectious and parasitic diseases" ]
10,070,735
24,800,766
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Amoxicillin / tramadol / donepezil / Aricept / Keflex Attending: ___. Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ yo F with urinary frequency, GERD, osteoarthritis and constipation who presented to the ___ ED on ___ with altered mental status, fatigue, fever, abdominal pain, and concern for LLE cellultis. She cannot not recall where she is or the exact date. She also cannot explain where she was prior to her ED admission. The daughter does say that about a week prior, she saw her regular doctor and was found to have cellulitis of her left ___ digit and was given Keflex, but had an allergic reaction (hives) and only took ___ dosed prior to stopping it. In the ED, patient was noted to be ill appearing with redness in the lower extremities and pain c/f cellulitis. Past Medical History: PAST MEDICAL AND SURGICAL HISTORY: Dementia Hearing loss HTN Anxiety GERD Hyponatremia Left knee pain Insomnia Constipation Urinary incontinence Primary osteoarthritis of the left knee left knee sprain Hallux valgus (acquired), left foot Acquired pes planus of left foot Pseudophakia of both eyes Moderate stage chronic open angle claucoma Social History: ___ Family History: No history of cancers in the family, no early MI, strokes Physical Exam: ADMISSION EXAM: VS: 99 151/88 80 18 97% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: distended, slightly tender to palpation in lower, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: LLE erythematous and edematous, TTP PULSES: 1+ DP pulses bilaterally NEURO: Not oriented to time and place, moving all 4 extremities with purpose, unable to complete Mini-Cog exam Exam On Discharge: Note Date: ___ Time: 1415 Note Type: Progress note Note Title: Medicine Progress Note Signed by ___, MD on ___ at 7:16 pm Affiliation: ___ Cosigned by ___, MD on ___ at 9:54 pm =================================================== ___ PROGRESS NOTE Date of admission: ___ ==================================================== PCP: ___ CC: Altered mental status, fatigue and fever ID: Ms. ___ is a ___ yo F with history of urinary frequency, GERD, osteoarthritis and constipation who presented to the ___ ED on ___ with altered mental status, fatigue, fever, and left ___ erythema, admitted due to c/f for cellulitis, on vancomycin. Subjective: She says that she is very upset because she had multiple bowel movements overnight and is unsure why she was taking so many laxatives. She overall feels better today, and says that her abdomen is less painful. She has no chest pain, some shortness of breath but she says that this is baseline. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI PHYSICAL EXAM: VS: Temp: 97.6 HR 76 BP 170/81 RR 18 02 95% ___ GENERAL: AAOx 3, laying in bed in no pain or distress HEENT: AT/NC, EOMI, PERRL, anicteric sclera HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, some mild inspiratory wheezes, no rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: largely distended, non-tender to palpation in lower, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: LLE on medial aspect of shin markeldly improved, no longer erythematous, no tenderness to palpation PULSES: 1+ DP pulses bilaterally NEURO: oriented to place and month and year but not to date, moving all 4 extremities with purpose, patient failed days of the week backwards. Pertinent Results: Admission Labs ___ 10:07AM LACTATE-2.4* ___ 01:09AM LACTATE-2.9* K+-4.4 ___ 11:09PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 11:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 11:09PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-1 ___ 11:09PM URINE MUCOUS-RARE* ___ 09:19PM PO2-77* PCO2-36 PH-7.35 TOTAL CO2-21 BASE XS--4 ___ 09:19PM LACTATE-5.3* ___ 09:19PM O2 SAT-92 ___ 08:56PM GLUCOSE-140* UREA N-18 CREAT-1.0 SODIUM-137 POTASSIUM-5.7* CHLORIDE-95* TOTAL CO2-19* ANION GAP-23* ___ 08:56PM ALT(SGPT)-22 AST(SGOT)-36 ALK PHOS-85 TOT BILI-0.7 ___ 08:56PM LIPASE-22 ___ 08:56PM ALBUMIN-4.4 ___ 08:56PM WBC-27.3*# RBC-4.24 HGB-12.1 HCT-38.6 MCV-91 MCH-28.5 MCHC-31.3* RDW-13.5 RDWSD-44.9 ___ 08:56PM NEUTS-89.6* LYMPHS-2.0* MONOS-6.5 EOS-0.0* BASOS-0.3 IM ___ AbsNeut-24.42* AbsLymp-0.55* AbsMono-1.77* AbsEos-0.00* AbsBaso-0.08 ___ 08:56PM PLT COUNT-262 Imaging ====== CT ABD PELVIS ___ IMPRESSION: 1. No acute intra-abdominal or pelvic abnormality. 2. New haziness in the extraperitoneal fat surrounding the left external iliac vessels possibly represents inflammation. In the absence of recent trauma or intervention, findings may represent a lipomatous lesion. This is of uncertain significance at this age and if fat change in management would occur, nonemergent MRI pelvis could be obtained. CXR: ___ IMPRESSION: Low lung volumes with probable bibasilar atelectasis. Microbiology: URINE Cx: now growth final ___ 11:09 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 9:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 10:21 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): Discharge Labs: ___ 07:15AM BLOOD WBC-9.3 RBC-3.97 Hgb-11.4 Hct-38.3 MCV-97 MCH-28.7 MCHC-29.8* RDW-15.2 RDWSD-53.2* Plt ___ ___ 08:27AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-142 K-4.4 Cl-102 HCO3-22 AnGap-18 ___ 08:27AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.2 Brief Hospital Course: Ms. ___ is a ___ yo F with urinary frequency, GERD, osteoarthritis and constipation who presented to the ___ ED on ___ with altered mental status, fatigue, fever, and left lower extremity erythema, concerning for cellulitis. IN regard to toxic encephalopathy leading to altered mental status, we checked for sources of infection with UA/culture, blood cultures, CXR and abdominal CT; these diagnostics were negative. Altered mental status likely aggravated by constipation (which improved with a bowel regimen) and her left lower extremity cellulitis. She was treated with vancomycin for her cellulitis, transitioned to doxycycline for 7 day course (end date: ___. ============== ACUTE ISSUES: ============== # NON-PURULENT CELLULITIS: Patient with fever, tachypnea, leukocytosis, encephalopathy with left lower extremity erythema and exam concerning for cellulitis. Urine without concern for UTI, CXR without pneumonia, and abdominal imaging without source though exam concerning for cellulitis. Treated with vancomycin with improvement in her left lower extremity and leukocytosis which was transitioned to oral doxycycline with a plan for a 7 day course of treatment (end date: ___ # TOXIC METABOLIC ENCEPHALOPATHY: Likely aggravated by her left lower extremity cellulitis treated with antibiotics and stool impaction which improved with a bowel regimen. Per the family the patient was back to her baseline mental status on discharge. =============== CHRONIC ISSUES: =============== #Depression: Continued her home citalopram and trazodone #Hypertension: Atenolol held. Patient started on Amlodipine during this hospitalization #GERD: We continued home ranitidine #Nutritional Supplementation: We continued folic acid, B12 TRANSITIONAL ISSUES: ====================== [] We started Amlodipine 5mg in place of atenolol which may take ___ days to take full effect. Please uptitrate Amlodipine as needed [] Home atenolol held during this hospitalization and replaced with Amlodipine [] Patient treated for cellulitis with 7 day total course of antibiotics. Transitioned to Doxycycline on discharge with end date on ___ [] CT Finding will need outpatient follow up: New haziness in the extraperitoneal fat surrounding the left external iliac vessels possibly represents inflammation. In the absence of recent trauma or intervention, findings may represent a lipomatous lesion. This is of uncertain significance at this age but non-emergent MRI pelvis could be obtained. MEDICATIONS STOPPED: NONE MEDICATIONS HELD: Atenolol NEW MEDICATIONS: Doxycycline 100mg BID PO EOT ___ Amlodipine 5mg PO once daily #CODE: ___/OK to intubate #CONTACT: Name of health care proxy: ___ Relationship: Daughter Phone number: ___ Cell phone: ___ PROGRESS NOTE FROM DAY OF DISCHARGE I have seen and examined ___, reviewed the findings, data, and plan of care documented by Dr. ___ ___ and agree, except for any additional comments below. Patient much more interactive and alert today. Vital signs stable. LLE cellulitis continues to improve. Per ___ recommendations, discharging home with ___ today. Remainder of the plan per housestaff note. Greater than 30 minutes were spent on discharge planning, communication, and coordination of care. ___, MD MPH Section of ___ Medicine ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atenolol 25 mg PO BID 2. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID 3. Citalopram 20 mg PO DAILY 4. diclofenac sodium 1 % topical QID 5. Lactulose 15 mL PO DAILY 6. Ranitidine 150 mg PO BID 7. TraZODone 50 mg PO DAILY 8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO DAILY 11. Senna 8.6 mg PO BID:PRN constipation 12. Vitamin D ___ UNIT PO Q14 DAYS 13. Azopt (brinzolamide) 1 % ophthalmic (eye) TID 14. Cyanocobalamin 500 mcg PO DAILY 15. FoLIC Acid 1 mg PO DAILY 16. Sodium Chloride 1 gm PO BID Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 3 Doses RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*3 Capsule Refills:*0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 4. Aspirin 81 mg PO DAILY 5. Azopt (brinzolamide) 1 % ophthalmic (eye) TID 6. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID 7. Citalopram 20 mg PO DAILY 8. Cyanocobalamin 500 mcg PO DAILY 9. diclofenac sodium 1 % topical QID 10. Docusate Sodium 100 mg PO DAILY 11. FoLIC Acid 1 mg PO DAILY 12. Lactulose 15 mL PO DAILY 13. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___) 14. Ranitidine 150 mg PO BID 15. Senna 8.6 mg PO BID:PRN constipation 16. Sodium Chloride 1 gm PO BID 17. TraZODone 50 mg PO DAILY 18. Vitamin D ___ UNIT PO Q14 DAYS 19. HELD- Atenolol 25 mg PO BID This medication was held. Do not restart Atenolol until you see your regular doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses: #Non-purulent Cellulitis of left lower extremity #Altered mental status Secondary Diagnoses: #Hypertension #Gastroesphageal reflux disorder Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital for confusion and a new left lower leg infection called cellulitis. You were treated with antibiotics for your skin infection. What was done on this hospital stay. -You had tests to determine if you had a lung infection. Your chest x ray appeared normal. -You did not have signs of a UTI based on your urine studies. -You worked with physical therapy who recommend that you get physical therapy at least 3 times weekly at home -Your infection in your leg resolved with the antibiotics What you need to do once you leave the hospital. - It is important that you see your regular doctor - It is very important that you take all of your medications as prescribed It was a pleasure taking care of you on this hospital admission. We wish you the best. Sincerely, Your ___ Team Followup Instructions: ___
[ "L03116", "G92", "F0390", "I10", "K219", "Z66", "K5900", "F329", "H4010X2", "F419", "G4700", "R935" ]
Allergies: Amoxicillin / tramadol / donepezil / Aricept / Keflex Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms [MASKED] is a [MASKED] yo F with urinary frequency, GERD, osteoarthritis and constipation who presented to the [MASKED] ED on [MASKED] with altered mental status, fatigue, fever, abdominal pain, and concern for LLE cellultis. She cannot not recall where she is or the exact date. She also cannot explain where she was prior to her ED admission. The daughter does say that about a week prior, she saw her regular doctor and was found to have cellulitis of her left [MASKED] digit and was given Keflex, but had an allergic reaction (hives) and only took [MASKED] dosed prior to stopping it. In the ED, patient was noted to be ill appearing with redness in the lower extremities and pain c/f cellulitis. Past Medical History: PAST MEDICAL AND SURGICAL HISTORY: Dementia Hearing loss HTN Anxiety GERD Hyponatremia Left knee pain Insomnia Constipation Urinary incontinence Primary osteoarthritis of the left knee left knee sprain Hallux valgus (acquired), left foot Acquired pes planus of left foot Pseudophakia of both eyes Moderate stage chronic open angle claucoma Social History: [MASKED] Family History: No history of cancers in the family, no early MI, strokes Physical Exam: ADMISSION EXAM: VS: 99 151/88 80 18 97% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: distended, slightly tender to palpation in lower, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: LLE erythematous and edematous, TTP PULSES: 1+ DP pulses bilaterally NEURO: Not oriented to time and place, moving all 4 extremities with purpose, unable to complete Mini-Cog exam Exam On Discharge: Note Date: [MASKED] Time: 1415 Note Type: Progress note Note Title: Medicine Progress Note Signed by [MASKED], MD on [MASKED] at 7:16 pm Affiliation: [MASKED] Cosigned by [MASKED], MD on [MASKED] at 9:54 pm =================================================== [MASKED] PROGRESS NOTE Date of admission: [MASKED] ==================================================== PCP: [MASKED] CC: Altered mental status, fatigue and fever ID: Ms. [MASKED] is a [MASKED] yo F with history of urinary frequency, GERD, osteoarthritis and constipation who presented to the [MASKED] ED on [MASKED] with altered mental status, fatigue, fever, and left [MASKED] erythema, admitted due to c/f for cellulitis, on vancomycin. Subjective: She says that she is very upset because she had multiple bowel movements overnight and is unsure why she was taking so many laxatives. She overall feels better today, and says that her abdomen is less painful. She has no chest pain, some shortness of breath but she says that this is baseline. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI PHYSICAL EXAM: VS: Temp: 97.6 HR 76 BP 170/81 RR 18 02 95% [MASKED] GENERAL: AAOx 3, laying in bed in no pain or distress HEENT: AT/NC, EOMI, PERRL, anicteric sclera HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, some mild inspiratory wheezes, no rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: largely distended, non-tender to palpation in lower, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: LLE on medial aspect of shin markeldly improved, no longer erythematous, no tenderness to palpation PULSES: 1+ DP pulses bilaterally NEURO: oriented to place and month and year but not to date, moving all 4 extremities with purpose, patient failed days of the week backwards. Pertinent Results: Admission Labs [MASKED] 10:07AM LACTATE-2.4* [MASKED] 01:09AM LACTATE-2.9* K+-4.4 [MASKED] 11:09PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 11:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 11:09PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-1 [MASKED] 11:09PM URINE MUCOUS-RARE* [MASKED] 09:19PM PO2-77* PCO2-36 PH-7.35 TOTAL CO2-21 BASE XS--4 [MASKED] 09:19PM LACTATE-5.3* [MASKED] 09:19PM O2 SAT-92 [MASKED] 08:56PM GLUCOSE-140* UREA N-18 CREAT-1.0 SODIUM-137 POTASSIUM-5.7* CHLORIDE-95* TOTAL CO2-19* ANION GAP-23* [MASKED] 08:56PM ALT(SGPT)-22 AST(SGOT)-36 ALK PHOS-85 TOT BILI-0.7 [MASKED] 08:56PM LIPASE-22 [MASKED] 08:56PM ALBUMIN-4.4 [MASKED] 08:56PM WBC-27.3*# RBC-4.24 HGB-12.1 HCT-38.6 MCV-91 MCH-28.5 MCHC-31.3* RDW-13.5 RDWSD-44.9 [MASKED] 08:56PM NEUTS-89.6* LYMPHS-2.0* MONOS-6.5 EOS-0.0* BASOS-0.3 IM [MASKED] AbsNeut-24.42* AbsLymp-0.55* AbsMono-1.77* AbsEos-0.00* AbsBaso-0.08 [MASKED] 08:56PM PLT COUNT-262 Imaging ====== CT ABD PELVIS [MASKED] IMPRESSION: 1. No acute intra-abdominal or pelvic abnormality. 2. New haziness in the extraperitoneal fat surrounding the left external iliac vessels possibly represents inflammation. In the absence of recent trauma or intervention, findings may represent a lipomatous lesion. This is of uncertain significance at this age and if fat change in management would occur, nonemergent MRI pelvis could be obtained. CXR: [MASKED] IMPRESSION: Low lung volumes with probable bibasilar atelectasis. Microbiology: URINE Cx: now growth final [MASKED] 11:09 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 9:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 10:21 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): Discharge Labs: [MASKED] 07:15AM BLOOD WBC-9.3 RBC-3.97 Hgb-11.4 Hct-38.3 MCV-97 MCH-28.7 MCHC-29.8* RDW-15.2 RDWSD-53.2* Plt [MASKED] [MASKED] 08:27AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-142 K-4.4 Cl-102 HCO3-22 AnGap-18 [MASKED] 08:27AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.2 Brief Hospital Course: Ms. [MASKED] is a [MASKED] yo F with urinary frequency, GERD, osteoarthritis and constipation who presented to the [MASKED] ED on [MASKED] with altered mental status, fatigue, fever, and left lower extremity erythema, concerning for cellulitis. IN regard to toxic encephalopathy leading to altered mental status, we checked for sources of infection with UA/culture, blood cultures, CXR and abdominal CT; these diagnostics were negative. Altered mental status likely aggravated by constipation (which improved with a bowel regimen) and her left lower extremity cellulitis. She was treated with vancomycin for her cellulitis, transitioned to doxycycline for 7 day course (end date: [MASKED]. ============== ACUTE ISSUES: ============== # NON-PURULENT CELLULITIS: Patient with fever, tachypnea, leukocytosis, encephalopathy with left lower extremity erythema and exam concerning for cellulitis. Urine without concern for UTI, CXR without pneumonia, and abdominal imaging without source though exam concerning for cellulitis. Treated with vancomycin with improvement in her left lower extremity and leukocytosis which was transitioned to oral doxycycline with a plan for a 7 day course of treatment (end date: [MASKED] # TOXIC METABOLIC ENCEPHALOPATHY: Likely aggravated by her left lower extremity cellulitis treated with antibiotics and stool impaction which improved with a bowel regimen. Per the family the patient was back to her baseline mental status on discharge. =============== CHRONIC ISSUES: =============== #Depression: Continued her home citalopram and trazodone #Hypertension: Atenolol held. Patient started on Amlodipine during this hospitalization #GERD: We continued home ranitidine #Nutritional Supplementation: We continued folic acid, B12 TRANSITIONAL ISSUES: ====================== [] We started Amlodipine 5mg in place of atenolol which may take [MASKED] days to take full effect. Please uptitrate Amlodipine as needed [] Home atenolol held during this hospitalization and replaced with Amlodipine [] Patient treated for cellulitis with 7 day total course of antibiotics. Transitioned to Doxycycline on discharge with end date on [MASKED] [] CT Finding will need outpatient follow up: New haziness in the extraperitoneal fat surrounding the left external iliac vessels possibly represents inflammation. In the absence of recent trauma or intervention, findings may represent a lipomatous lesion. This is of uncertain significance at this age but non-emergent MRI pelvis could be obtained. MEDICATIONS STOPPED: NONE MEDICATIONS HELD: Atenolol NEW MEDICATIONS: Doxycycline 100mg BID PO EOT [MASKED] Amlodipine 5mg PO once daily #CODE: [MASKED]/OK to intubate #CONTACT: Name of health care proxy: [MASKED] Relationship: Daughter Phone number: [MASKED] Cell phone: [MASKED] PROGRESS NOTE FROM DAY OF DISCHARGE I have seen and examined [MASKED], reviewed the findings, data, and plan of care documented by Dr. [MASKED] [MASKED] and agree, except for any additional comments below. Patient much more interactive and alert today. Vital signs stable. LLE cellulitis continues to improve. Per [MASKED] recommendations, discharging home with [MASKED] today. Remainder of the plan per housestaff note. Greater than 30 minutes were spent on discharge planning, communication, and coordination of care. [MASKED], MD MPH Section of [MASKED] Medicine [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atenolol 25 mg PO BID 2. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID 3. Citalopram 20 mg PO DAILY 4. diclofenac sodium 1 % topical QID 5. Lactulose 15 mL PO DAILY 6. Ranitidine 150 mg PO BID 7. TraZODone 50 mg PO DAILY 8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO DAILY 11. Senna 8.6 mg PO BID:PRN constipation 12. Vitamin D [MASKED] UNIT PO Q14 DAYS 13. Azopt (brinzolamide) 1 % ophthalmic (eye) TID 14. Cyanocobalamin 500 mcg PO DAILY 15. FoLIC Acid 1 mg PO DAILY 16. Sodium Chloride 1 gm PO BID Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 3 Doses RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*3 Capsule Refills:*0 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 4. Aspirin 81 mg PO DAILY 5. Azopt (brinzolamide) 1 % ophthalmic (eye) TID 6. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID 7. Citalopram 20 mg PO DAILY 8. Cyanocobalamin 500 mcg PO DAILY 9. diclofenac sodium 1 % topical QID 10. Docusate Sodium 100 mg PO DAILY 11. FoLIC Acid 1 mg PO DAILY 12. Lactulose 15 mL PO DAILY 13. Levothyroxine Sodium 50 mcg PO 6X/WEEK ([MASKED]) 14. Ranitidine 150 mg PO BID 15. Senna 8.6 mg PO BID:PRN constipation 16. Sodium Chloride 1 gm PO BID 17. TraZODone 50 mg PO DAILY 18. Vitamin D [MASKED] UNIT PO Q14 DAYS 19. HELD- Atenolol 25 mg PO BID This medication was held. Do not restart Atenolol until you see your regular doctor Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: #Non-purulent Cellulitis of left lower extremity #Altered mental status Secondary Diagnoses: #Hypertension #Gastroesphageal reflux disorder Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital for confusion and a new left lower leg infection called cellulitis. You were treated with antibiotics for your skin infection. What was done on this hospital stay. -You had tests to determine if you had a lung infection. Your chest x ray appeared normal. -You did not have signs of a UTI based on your urine studies. -You worked with physical therapy who recommend that you get physical therapy at least 3 times weekly at home -Your infection in your leg resolved with the antibiotics What you need to do once you leave the hospital. - It is important that you see your regular doctor - It is very important that you take all of your medications as prescribed It was a pleasure taking care of you on this hospital admission. We wish you the best. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I10", "K219", "Z66", "K5900", "F329", "F419", "G4700" ]
[ "L03116: Cellulitis of left lower limb", "G92: Toxic encephalopathy", "F0390: Unspecified dementia without behavioral disturbance", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "Z66: Do not resuscitate", "K5900: Constipation, unspecified", "F329: Major depressive disorder, single episode, unspecified", "H4010X2: Unspecified open-angle glaucoma, moderate stage", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "R935: Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum" ]
10,070,850
23,483,897
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Halothane Attending: ___. Chief Complaint: right knee OA Major Surgical or Invasive Procedure: right knee replacement ___, ___ History of Present Illness: ___ year old male with right knee OA s/p R TKR. Past Medical History: BMI 38.46, dyslipidemia, atrial fibrillation, hypertension, shortness of breath, COPD, obstructive sleep apnea, arthritis, obesity 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 well-approximated * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 06:27AM BLOOD WBC-13.4* RBC-3.58* Hgb-10.5* Hct-32.8* MCV-92 MCH-29.3 MCHC-32.0 RDW-13.8 RDWSD-46.6* Plt ___ ___ 06:14AM BLOOD WBC-12.2* RBC-4.02* Hgb-11.9* Hct-37.3* MCV-93 MCH-29.6 MCHC-31.9* RDW-13.4 RDWSD-45.7 Plt ___ ___ 01:53PM BLOOD ___ PTT-29.3 ___ ___ 06:27AM BLOOD Creat-1.2 ___ 03:35PM BLOOD Creat-1.4* ___ 06:14AM BLOOD Glucose-148* UreaN-29* Creat-1.3* Na-142 K-4.3 Cl-104 HCO3-24 AnGap-14 ___ 06:14AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8 ___ 09:22AM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:22AM URINE Blood-MOD* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 09:22AM URINE RBC-22* WBC-4 Bacteri-FEW* Yeast-NONE Epi-0 ___ 09:22AM URINE Mucous-RARE* Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD #1, patient was administered 500ml IV fluid bolus for creatinine 1.3 (pre-op 1.2). Repeat Cr in the afternoon was 1.4. Lisinopril and Triamterine-HCTZ were discontinued at this time. POD #2, Cr was 1.2. #Leukocytosis: Urines were obtained on POD #2 due to slight increase in WBC from 12.2 to 13.4. Results showed few bacteria, moderate blood, RBC 22, otherwise negative. Patient remained afebrile. Final urine cultures were pending at the time of discharge and patient will be contacted if further treatment is needed. #Hypotension/Elevated Cr: Two of your blood pressure medications (Lisinopril and Triamterene-HCTZ) were held post-op due to low blood pressures and elevated creatinine. Cr 1.4 on POD #1, which downtrended to 1.2 at the time of discharge. Please follow up with your PCP within one week upon discharge for further management and discussion of when you should resume medication. PCP, ___, was notified via e-mail. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Eliquis BID 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. ___ brace locked in extension for 8 hours per day/night to help with flexion contracture. Mr. ___ is discharged to home with services in stable condition. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H 2. Lisinopril 5 mg PO DAILY 3. azelastine 137 mcg (0.1 %) nasal BID 4. Allopurinol ___ mg PO BID 5. Colchicine 0.6 mg PO DAILY 6. Meclizine 25 mg PO Q6H:PRN vertigo 7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB/Wheeze 8. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation DAILY 9. Atenolol 100 mg PO DAILY 10. Celecoxib 100 mg oral BID 11. amLODIPine 5 mg PO DAILY 12. Apixaban 5 mg PO BID 13. Simvastatin 10 mg PO QPM 14. Fluticasone Propionate 110mcg 2 PUFF IH BID 15. Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Gabapentin 100 mg PO TID 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 4. Pantoprazole 40 mg PO Q24H 5. Senna 8.6 mg PO BID 6. Acetaminophen 1000 mg PO Q8H 7. Allopurinol ___ mg PO BID 8. amLODIPine 5 mg PO DAILY 9. Apixaban 5 mg PO BID 10. Atenolol 100 mg PO DAILY 11. azelastine 137 mcg (0.1 %) nasal BID 12. Colchicine 0.6 mg PO DAILY 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB/Wheeze 15. Meclizine 25 mg PO Q6H:PRN vertigo 16. Simvastatin 10 mg PO QPM 17. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation DAILY 18. HELD- Celecoxib 100 mg oral BID This medication was held. Do not restart Celecoxib until you've been cleared by your surgeon 19. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until you've been cleared by your PCP 20. HELD- Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY This medication was held. Do not restart Triamterene-HCTZ (37.5/25) until you've been cleared by your PCP ___: Home With Service Facility: ___ Discharge Diagnosis: right knee OA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Eliquis twice daily for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, it is OK to continue at your previous dose after the four weeks is completed. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up appointment in two weeks. 10. ___ (once at home): Home ___, dressing changes as instructed, wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. ___ brace locked in extension for 8 hours per day/night to help with flexion contracture. Physical Therapy: WBAT RLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently ___ brace locked in extension for 8 hours per day/night to help with flexion contracture Treatments Frequency: daily dressing changes as needed for drainage wound checks daily ice staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: ___
[ "M1711", "E669", "I4891", "Z6841", "J449", "M24561", "E785", "I959", "H8109", "Z87891", "Z6838", "G4733", "I10", "Z7902" ]
Allergies: Halothane Chief Complaint: right knee OA Major Surgical or Invasive Procedure: right knee replacement [MASKED], [MASKED] History of Present Illness: [MASKED] year old male with right knee OA s/p R TKR. Past Medical History: BMI 38.46, dyslipidemia, atrial fibrillation, hypertension, shortness of breath, COPD, obstructive sleep apnea, arthritis, obesity 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 well-approximated * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 06:27AM BLOOD WBC-13.4* RBC-3.58* Hgb-10.5* Hct-32.8* MCV-92 MCH-29.3 MCHC-32.0 RDW-13.8 RDWSD-46.6* Plt [MASKED] [MASKED] 06:14AM BLOOD WBC-12.2* RBC-4.02* Hgb-11.9* Hct-37.3* MCV-93 MCH-29.6 MCHC-31.9* RDW-13.4 RDWSD-45.7 Plt [MASKED] [MASKED] 01:53PM BLOOD [MASKED] PTT-29.3 [MASKED] [MASKED] 06:27AM BLOOD Creat-1.2 [MASKED] 03:35PM BLOOD Creat-1.4* [MASKED] 06:14AM BLOOD Glucose-148* UreaN-29* Creat-1.3* Na-142 K-4.3 Cl-104 HCO3-24 AnGap-14 [MASKED] 06:14AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8 [MASKED] 09:22AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 09:22AM URINE Blood-MOD* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [MASKED] 09:22AM URINE RBC-22* WBC-4 Bacteri-FEW* Yeast-NONE Epi-0 [MASKED] 09:22AM URINE Mucous-RARE* Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD #1, patient was administered 500ml IV fluid bolus for creatinine 1.3 (pre-op 1.2). Repeat Cr in the afternoon was 1.4. Lisinopril and Triamterine-HCTZ were discontinued at this time. POD #2, Cr was 1.2. #Leukocytosis: Urines were obtained on POD #2 due to slight increase in WBC from 12.2 to 13.4. Results showed few bacteria, moderate blood, RBC 22, otherwise negative. Patient remained afebrile. Final urine cultures were pending at the time of discharge and patient will be contacted if further treatment is needed. #Hypotension/Elevated Cr: Two of your blood pressure medications (Lisinopril and Triamterene-HCTZ) were held post-op due to low blood pressures and elevated creatinine. Cr 1.4 on POD #1, which downtrended to 1.2 at the time of discharge. Please follow up with your PCP within one week upon discharge for further management and discussion of when you should resume medication. PCP, [MASKED], was notified via e-mail. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Eliquis BID 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. [MASKED] brace locked in extension for 8 hours per day/night to help with flexion contracture. Mr. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H 2. Lisinopril 5 mg PO DAILY 3. azelastine 137 mcg (0.1 %) nasal BID 4. Allopurinol [MASKED] mg PO BID 5. Colchicine 0.6 mg PO DAILY 6. Meclizine 25 mg PO Q6H:PRN vertigo 7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB/Wheeze 8. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation DAILY 9. Atenolol 100 mg PO DAILY 10. Celecoxib 100 mg oral BID 11. amLODIPine 5 mg PO DAILY 12. Apixaban 5 mg PO BID 13. Simvastatin 10 mg PO QPM 14. Fluticasone Propionate 110mcg 2 PUFF IH BID 15. Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Gabapentin 100 mg PO TID 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate 4. Pantoprazole 40 mg PO Q24H 5. Senna 8.6 mg PO BID 6. Acetaminophen 1000 mg PO Q8H 7. Allopurinol [MASKED] mg PO BID 8. amLODIPine 5 mg PO DAILY 9. Apixaban 5 mg PO BID 10. Atenolol 100 mg PO DAILY 11. azelastine 137 mcg (0.1 %) nasal BID 12. Colchicine 0.6 mg PO DAILY 13. Fluticasone Propionate 110mcg 2 PUFF IH BID 14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB/Wheeze 15. Meclizine 25 mg PO Q6H:PRN vertigo 16. Simvastatin 10 mg PO QPM 17. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation DAILY 18. HELD- Celecoxib 100 mg oral BID This medication was held. Do not restart Celecoxib until you've been cleared by your surgeon 19. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until you've been cleared by your PCP 20. HELD- Triamterene-HCTZ (37.5/25) 2 CAP PO DAILY This medication was held. Do not restart Triamterene-HCTZ (37.5/25) until you've been cleared by your PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: right knee OA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Eliquis twice daily for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking Aspirin prior to your surgery, it is OK to continue at your previous dose after the four weeks is completed. 9. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up appointment in two weeks. 10. [MASKED] (once at home): Home [MASKED], dressing changes as instructed, wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. [MASKED] brace locked in extension for 8 hours per day/night to help with flexion contracture. Physical Therapy: WBAT RLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently [MASKED] brace locked in extension for 8 hours per day/night to help with flexion contracture Treatments Frequency: daily dressing changes as needed for drainage wound checks daily ice staple removal and replace with steri-strips at follow up visit in clinic Followup Instructions: [MASKED]
[]
[ "E669", "I4891", "J449", "E785", "Z87891", "G4733", "I10", "Z7902" ]
[ "M1711: Unilateral primary osteoarthritis, right knee", "E669: Obesity, unspecified", "I4891: Unspecified atrial fibrillation", "Z6841: Body mass index [BMI]40.0-44.9, adult", "J449: Chronic obstructive pulmonary disease, unspecified", "M24561: Contracture, right knee", "E785: Hyperlipidemia, unspecified", "I959: Hypotension, unspecified", "H8109: Ménière's disease, unspecified ear", "Z87891: Personal history of nicotine dependence", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I10: Essential (primary) hypertension", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,070,932
24,727,163
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Attending: ___. Chief Complaint: fever, L flank pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with a history of chronic abdominal pain/nausea/constipation, ileus and SBO, recurrent C diff colitis s/p FMT transplant on ___, multiple line infections on TPN, endometriosis s/p total hysterectomy, bilateral PE (___) on lovenox, neurogenic bladder s/p sacral nerve stimulator (___), suspected mitochondrial disease, POTS, now presenting with 1 day of fevers and L flank pain. Of note, she was admitted in ___ with E. coli urinary tract infection and sepsis, and C. diff colitis. Yesterday during the day, she noted cloudy urine on straight cath, and reduced urine output. She began to have fevers. Last night she began feeling severe left flank pain, which occasionally radiates to left side when lying down. Endorses fevers, chills, rigors, Tmax at home 103. She felt so weak that she was unable to set up her TPN before bed. She typically drinks clear liquids, anything more makes her feel too full. Came in today because of persistent symptoms. Denies URI symptoms, chest pain, SOB. Has chronic abdominal pain and nausea not worse than baseline (is on anti-nausea home meds). Has not had many BMs or any diarrhea since FMT transplant on ___. Has chronic lymphedema of both legs, at baseline. In the ED, - Initial Vitals: Pain 10 T 100.8 HR 100 BP 101/66 RR 18 SpO2 99% RA - Exam: Gen: chronically ill-appearing middle-aged woman lying in bed in NAD HEENT: NC/AT, PERRL, oropharynx clear Lungs: CTAB Chest: RRR, no m/r/g, ___ site c/d/i without erythema or swelling Abd: +BS, soft, non-distended, diffusely mildly tender to palpation, no rebound or guarding Back: L CVA tenderness, no rashes or ecchymoses Extremities: warm and well perfused, 2+ pitting edema bilateral lower extremities - Labs: WBC 7.1 Hb 11.2 Plt 114 135 | 103 | ___ Gap 11 3.6 | 21 | 0.8\ ALT 10 AST 16 AP 53 Tbili 0.5 Alb 3.8 Lactate 0.8 Flu negative UA large leuks, pos nitrates, 46 WBC, sm blood, 6 rbc UA, BCx x2 pending - Imaging: CT A/P w/o contrast 1. No nephrolithiasis or hydronephrosis. 2. No acute abnormality within the imaged abdomen and pelvis within the limitations of this noncontrast enhanced study. - Consults: none - Interventions: 15 mg IV ketorolac 1g Tylenol 1L NS 1g IV cefepime 1L NS Levophed via ___ catheter 1g vanc On arrival to the FICU, pt endorses above history. Reports rigors are most bothersome to her, reminiscent of her last line infection. ROS: Positives as per HPI; otherwise negative. Past Medical History: - Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. - Neurogenic bladder s/p stimulator - Gallstones status post cholecystectomy - POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. - Neuropathy in lower extremities - Lymphedema - Chronic fatigue - PE unprovoked bilateral PE ___, has family history of clots. Hypercoagulable workup at ___ reportedly negative - ? mitochondrial disease Social History: ___ Family History: - Mother - PE and gallbladder disease - Father - healthy - Two sons with mitochondrial disease, pseudoobstruction, passed away at ages ___ and ___. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 101.9 HR 62 BP 132/82 RR 11 99% on RA GEN: ill appearing middle aged woman covered in blankets, rigoring weak voice, in pain NEURO: AAOx3, face symmetric, moves all 4 w purpose EYES: sclerae anicteric, PERRL, EOMI HENNT: oropharynx clear CV: nl rate, reg rhythm, ___ systolic murmur RESP: CTAB GI: hypoactive BS, non-distended, soft, diffusely mildly tender to palpation, no rebound or guarding BACK: +L CVA tenderness SKIN: R upper chest port c/d/i DISCHARGE PHYSICAL EXAM VS: Reviewed in EMR Gen: young woman, appears uncomfortable but NAD Eyes: anicteric, non-injected ENT: MMM, grossly nl OP Abd: soft, non-distend. midly TTP diffusely but improved from prior. NABS. No r/g/rigidity. Ext: WWP, trace b/l symmetric nonpitting edema NEURO: Alert, interactive, face symmetric, gaze conjugate with EOMI, speech fluent PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS ___ 12:14PM BLOOD WBC-7.1 RBC-3.64* Hgb-11.2 Hct-32.8* MCV-90 MCH-30.8 MCHC-34.1 RDW-12.5 RDWSD-41.1 Plt ___ ___ 12:14PM BLOOD Neuts-78.8* Lymphs-10.8* Monos-9.4 Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.56 AbsLymp-0.76* AbsMono-0.66 AbsEos-0.02* AbsBaso-0.02 ___ 03:22AM BLOOD ___ PTT-35.7 ___ ___:14PM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-135 K-3.6 Cl-103 HCO3-21* AnGap-11 ___ 03:22AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.5* ___ 12:14PM BLOOD Albumin-3.8 ___ 12:14PM BLOOD ALT-10 AST-16 AlkPhos-53 TotBili-0.5 ___ 12:14PM BLOOD Lipase-16 ___ 12:22PM BLOOD Lactate-0.8 ___ 03:27PM BLOOD freeCa-1.03* MICRO - CDI PCR+, but toxin negative - likely reflecting collection after tx initiation. - Blood Cultures: no growth - Urine culture: E. coli / Klebsiella KLEBSIELLA PNEUMONIAE | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 128 R <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=___BDOMEN PELVIS ___ 1. No nephrolithiasis or hydronephrosis. 2. No acute abnormality within the imaged abdomen and pelvis within the limitations of this noncontrast enhanced study. 3. Status post cholecystectomy. TTE ___ The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 66 %. Left ventricular cardiac index is high (>4.0 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure.No 2D echocardiographic evidence for endocarditis. Brief Hospital Course: ___ hx chronic abdominal issues (SBO, ileus), multiple CDI (s/p FMT ___, chronic TPN with multiple line infections, endometriosis s/p TAH, b/l PE (___) on lovenox, neurogenic bladder s/p sacral nerve stimulator (___), POTS, and suspected mitochondrial disorder originally admitted to ICU with septic shock with urinary source, with subsequent development of severe recurrent CDI and sepsis vs abx induced neutropenia. # Septic Shock # E coli / Klebsiella UTI: Patient was admitted with fever and left flank pain in the setting of several past episodes of urinary tract infections, mostly from pansensitive organisms, in the last 6 months PTA. In the ED she had an acute drop in blood pressure requiring norepinephrine, which were given through her ___ catheter through which she receives chronic TPN. In the ICU, she was continued on vancomycin and cefepime. Norepinephrine was weaned and with IVF administration her pressures improved; subsequently she was transferred to the floor. Blood cultures were negative. TTE ordered for cardiac murmur heard in ICU, but no evidence of vegetations. Urine culture now growing Klebsiella and E. Coli that are near pan-sensitive. Infectious disease was consulted and recommended de-escalation to CTX given micro sensitivities. She rec'd additional days of treatment on the floor and was later discharged home to receive CTX home infusions for an additional 2 days (per ID - shorter course for c/f beta-lactam induced neutropenia) # Recurrent severe CDI: s/p FMT 2 weeks PTA, but after initiation of antibiotics in the ICU she developmed abdominal pain, cramping and frequent diarrhea consistent with her typical CDI. She was empirically started on vancomycin 125mg QID and IV flagyl, and her stool sample was collected 1 day later. CDI test was PCR+ but toxin negative, which per ID consult was likely because sample collected after 2 days treatment. She was discharged to complete a vancomycin taper of 4x/d through ___ then 3x/day through ___, then twice a day until can be seen in ID follow up. ID ___ was moved closer to ___. Please note that discharge worksheet lists patient as taking QID 4x/day for two weeks, however, patient was contacted by phone on ___ and instructed to take vancomycin taper as per ID recommendations listed above. By day of discharge, her abdominal pain and BM frequency was improved # Leukopenia # Neutropenia: Patient developed worsening leukopenia throughout hospitalization. She had no fevers. This was felt to be related to either sepsis, her flagyl, or beta-lactam exposure. Per ID recommendations, flagyl was stopped and CTX to be continued only for 2 additional days after discharge. Patient remained neutropenic on day of discharge, but her clinical course was improving, she was afebrile, and she expressed a strong desire to leave the hospital. She was instructed to seek medical attention for any development of fever, and to have her blood drawn at PCP ___ on ___, the monitor course of neutropenia. Patient education provdided regarding this issues and warning signs discussed. She has good support at home to monitor her for symptoms. # Severe malnutrition: # Malabsorptive syndrome: Pt has Hickman for TPN. Per outpatient GI note, plan was to transition to ___ enteral feeding + po intake vs just po intake. Nutrition was consulted and TPN was continued. # History of unprovoked PE (___): continued home lovenox SC BID # Thrombocytopenia: Likely due to sepsis.. No bleeding sx # QT prolonging medicines: EKG here w QTc 420 # POTS/dysautonomia: consider outpatient f/u neurology # Peripheral neuropathy: continued home gabapentin # ? Mitochondrial disorder: f/u w/ genetics outpatient # Chronic constipation (currently has diarrhea): BM regimen held. Time spent coordinating discharge > 30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 10 mg PO QAM 2. BusPIRone 5 mg PO QPM 3. Clotrimazole Cream 1 Appl TP BID 4. Dronabinol 10 mg PO QAM 5. Enoxaparin Sodium 50 mg SC Q12H 6. FoLIC Acid 1 mg PO DAILY 7. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. ondansetron 4 mg oral Q8H 10. Promethazine 25 mg PR Q6H nausea 11. Pyridostigmine Bromide Syrup 60 mg PO TID 12. Thiamine 100 mg PO DAILY 13. Dronabinol 5 mg PO QPM Discharge Medications: 1. CefTRIAXone 1 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 g IV DAILY Disp #*2 Intravenous Bag Refills:*0 2. Vancomycin Oral Liquid ___ mg PO/NG QID RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day Disp #*84 Capsule Refills:*0 3. BusPIRone 10 mg PO QAM 4. BusPIRone 5 mg PO QPM 5. Clotrimazole Cream 1 Appl TP BID 6. Dronabinol 5 mg PO QPM 7. Dronabinol 10 mg PO QAM 8. Enoxaparin Sodium 50 mg SC Q12H 9. FoLIC Acid 1 mg PO DAILY 10. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. ondansetron 4 mg oral Q8H 13. Promethazine 25 mg PR Q6H nausea 14. Pyridostigmine Bromide Syrup 60 mg PO TID 15. Thiamine 100 mg PO DAILY 16.TPN Resume home TPN as written by usual outpatient providers ___: Home With Service Facility: ___ Discharge Diagnosis: Acute Recurrent Cdiff Colitis Pyelonephritis Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a fever and flank pain, you were found to have an infection in your urinary tract. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - In the hospital, it was determined that you likely had a urinary tract infection causing your symptoms. Due to low blood pressures you were originally in the ICU. Your infection was treated with IV antibiotics. However, you unfortunately developed a recurrence of C. diff and required treatment with IV and oral antibiotics. Dr ___ formulate an antibiotic plan for you while hospitalized. WHAT SHOULD I DO WHEN I GO HOME? - You will have to have your blood drawn by your PCP at your ___ appointment on ___ to make sure that your blood counts have recovered. - Seek immediate medical attention if you develop a fever > 100.4 as your blood counts (neutrophils) are low. - Please take all medications as prescribed and keep all scheduled doctor's appointments. Seek medical attention if you develop a worsening or recurrence of the same symptoms that originally brought you to the hospital, experience any of the warning signs listed below, or have any other symptoms that concern you. It was a pleasure taking care of you! Your ___ Care Team Followup Instructions: ___
[ "A4151", "R6521", "E43", "A0471", "Z681", "N390", "K909", "A4189", "Z90710", "Z90721", "Z8542", "N319", "R5382", "R011", "I959", "R110", "I890", "Z881", "Z885", "Z888", "G901", "G629", "Z86711", "D696", "K5909" ]
Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Chief Complaint: fever, L flank pain Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with a history of chronic abdominal pain/nausea/constipation, ileus and SBO, recurrent C diff colitis s/p FMT transplant on [MASKED], multiple line infections on TPN, endometriosis s/p total hysterectomy, bilateral PE ([MASKED]) on lovenox, neurogenic bladder s/p sacral nerve stimulator ([MASKED]), suspected mitochondrial disease, POTS, now presenting with 1 day of fevers and L flank pain. Of note, she was admitted in [MASKED] with E. coli urinary tract infection and sepsis, and C. diff colitis. Yesterday during the day, she noted cloudy urine on straight cath, and reduced urine output. She began to have fevers. Last night she began feeling severe left flank pain, which occasionally radiates to left side when lying down. Endorses fevers, chills, rigors, Tmax at home 103. She felt so weak that she was unable to set up her TPN before bed. She typically drinks clear liquids, anything more makes her feel too full. Came in today because of persistent symptoms. Denies URI symptoms, chest pain, SOB. Has chronic abdominal pain and nausea not worse than baseline (is on anti-nausea home meds). Has not had many BMs or any diarrhea since FMT transplant on [MASKED]. Has chronic lymphedema of both legs, at baseline. In the ED, - Initial Vitals: Pain 10 T 100.8 HR 100 BP 101/66 RR 18 SpO2 99% RA - Exam: Gen: chronically ill-appearing middle-aged woman lying in bed in NAD HEENT: NC/AT, PERRL, oropharynx clear Lungs: CTAB Chest: RRR, no m/r/g, [MASKED] site c/d/i without erythema or swelling Abd: +BS, soft, non-distended, diffusely mildly tender to palpation, no rebound or guarding Back: L CVA tenderness, no rashes or ecchymoses Extremities: warm and well perfused, 2+ pitting edema bilateral lower extremities - Labs: WBC 7.1 Hb 11.2 Plt 114 135 | 103 | [MASKED] Gap 11 3.6 | 21 | 0.8\ ALT 10 AST 16 AP 53 Tbili 0.5 Alb 3.8 Lactate 0.8 Flu negative UA large leuks, pos nitrates, 46 WBC, sm blood, 6 rbc UA, BCx x2 pending - Imaging: CT A/P w/o contrast 1. No nephrolithiasis or hydronephrosis. 2. No acute abnormality within the imaged abdomen and pelvis within the limitations of this noncontrast enhanced study. - Consults: none - Interventions: 15 mg IV ketorolac 1g Tylenol 1L NS 1g IV cefepime 1L NS Levophed via [MASKED] catheter 1g vanc On arrival to the FICU, pt endorses above history. Reports rigors are most bothersome to her, reminiscent of her last line infection. ROS: Positives as per HPI; otherwise negative. Past Medical History: - Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. - Neurogenic bladder s/p stimulator - Gallstones status post cholecystectomy - POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. - Neuropathy in lower extremities - Lymphedema - Chronic fatigue - PE unprovoked bilateral PE [MASKED], has family history of clots. Hypercoagulable workup at [MASKED] reportedly negative - ? mitochondrial disease Social History: [MASKED] Family History: - Mother - PE and gallbladder disease - Father - healthy - Two sons with mitochondrial disease, pseudoobstruction, passed away at ages [MASKED] and [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM VS: T 101.9 HR 62 BP 132/82 RR 11 99% on RA GEN: ill appearing middle aged woman covered in blankets, rigoring weak voice, in pain NEURO: AAOx3, face symmetric, moves all 4 w purpose EYES: sclerae anicteric, PERRL, EOMI HENNT: oropharynx clear CV: nl rate, reg rhythm, [MASKED] systolic murmur RESP: CTAB GI: hypoactive BS, non-distended, soft, diffusely mildly tender to palpation, no rebound or guarding BACK: +L CVA tenderness SKIN: R upper chest port c/d/i DISCHARGE PHYSICAL EXAM VS: Reviewed in EMR Gen: young woman, appears uncomfortable but NAD Eyes: anicteric, non-injected ENT: MMM, grossly nl OP Abd: soft, non-distend. midly TTP diffusely but improved from prior. NABS. No r/g/rigidity. Ext: WWP, trace b/l symmetric nonpitting edema NEURO: Alert, interactive, face symmetric, gaze conjugate with EOMI, speech fluent PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS [MASKED] 12:14PM BLOOD WBC-7.1 RBC-3.64* Hgb-11.2 Hct-32.8* MCV-90 MCH-30.8 MCHC-34.1 RDW-12.5 RDWSD-41.1 Plt [MASKED] [MASKED] 12:14PM BLOOD Neuts-78.8* Lymphs-10.8* Monos-9.4 Eos-0.3* Baso-0.3 Im [MASKED] AbsNeut-5.56 AbsLymp-0.76* AbsMono-0.66 AbsEos-0.02* AbsBaso-0.02 [MASKED] 03:22AM BLOOD [MASKED] PTT-35.7 [MASKED] [MASKED]:14PM BLOOD Glucose-114* UreaN-12 Creat-0.8 Na-135 K-3.6 Cl-103 HCO3-21* AnGap-11 [MASKED] 03:22AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.5* [MASKED] 12:14PM BLOOD Albumin-3.8 [MASKED] 12:14PM BLOOD ALT-10 AST-16 AlkPhos-53 TotBili-0.5 [MASKED] 12:14PM BLOOD Lipase-16 [MASKED] 12:22PM BLOOD Lactate-0.8 [MASKED] 03:27PM BLOOD freeCa-1.03* MICRO - CDI PCR+, but toxin negative - likely reflecting collection after tx initiation. - Blood Cultures: no growth - Urine culture: E. coli / Klebsiella KLEBSIELLA PNEUMONIAE | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 128 R <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <= BDOMEN PELVIS [MASKED] 1. No nephrolithiasis or hydronephrosis. 2. No acute abnormality within the imaged abdomen and pelvis within the limitations of this noncontrast enhanced study. 3. Status post cholecystectomy. TTE [MASKED] The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 66 %. Left ventricular cardiac index is high (>4.0 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender. The aortic arch diameter is normal. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure.No 2D echocardiographic evidence for endocarditis. Brief Hospital Course: [MASKED] hx chronic abdominal issues (SBO, ileus), multiple CDI (s/p FMT [MASKED], chronic TPN with multiple line infections, endometriosis s/p TAH, b/l PE ([MASKED]) on lovenox, neurogenic bladder s/p sacral nerve stimulator ([MASKED]), POTS, and suspected mitochondrial disorder originally admitted to ICU with septic shock with urinary source, with subsequent development of severe recurrent CDI and sepsis vs abx induced neutropenia. # Septic Shock # E coli / Klebsiella UTI: Patient was admitted with fever and left flank pain in the setting of several past episodes of urinary tract infections, mostly from pansensitive organisms, in the last 6 months PTA. In the ED she had an acute drop in blood pressure requiring norepinephrine, which were given through her [MASKED] catheter through which she receives chronic TPN. In the ICU, she was continued on vancomycin and cefepime. Norepinephrine was weaned and with IVF administration her pressures improved; subsequently she was transferred to the floor. Blood cultures were negative. TTE ordered for cardiac murmur heard in ICU, but no evidence of vegetations. Urine culture now growing Klebsiella and E. Coli that are near pan-sensitive. Infectious disease was consulted and recommended de-escalation to CTX given micro sensitivities. She rec'd additional days of treatment on the floor and was later discharged home to receive CTX home infusions for an additional 2 days (per ID - shorter course for c/f beta-lactam induced neutropenia) # Recurrent severe CDI: s/p FMT 2 weeks PTA, but after initiation of antibiotics in the ICU she developmed abdominal pain, cramping and frequent diarrhea consistent with her typical CDI. She was empirically started on vancomycin 125mg QID and IV flagyl, and her stool sample was collected 1 day later. CDI test was PCR+ but toxin negative, which per ID consult was likely because sample collected after 2 days treatment. She was discharged to complete a vancomycin taper of 4x/d through [MASKED] then 3x/day through [MASKED], then twice a day until can be seen in ID follow up. ID [MASKED] was moved closer to [MASKED]. Please note that discharge worksheet lists patient as taking QID 4x/day for two weeks, however, patient was contacted by phone on [MASKED] and instructed to take vancomycin taper as per ID recommendations listed above. By day of discharge, her abdominal pain and BM frequency was improved # Leukopenia # Neutropenia: Patient developed worsening leukopenia throughout hospitalization. She had no fevers. This was felt to be related to either sepsis, her flagyl, or beta-lactam exposure. Per ID recommendations, flagyl was stopped and CTX to be continued only for 2 additional days after discharge. Patient remained neutropenic on day of discharge, but her clinical course was improving, she was afebrile, and she expressed a strong desire to leave the hospital. She was instructed to seek medical attention for any development of fever, and to have her blood drawn at PCP [MASKED] on [MASKED], the monitor course of neutropenia. Patient education provdided regarding this issues and warning signs discussed. She has good support at home to monitor her for symptoms. # Severe malnutrition: # Malabsorptive syndrome: Pt has Hickman for TPN. Per outpatient GI note, plan was to transition to [MASKED] enteral feeding + po intake vs just po intake. Nutrition was consulted and TPN was continued. # History of unprovoked PE ([MASKED]): continued home lovenox SC BID # Thrombocytopenia: Likely due to sepsis.. No bleeding sx # QT prolonging medicines: EKG here w QTc 420 # POTS/dysautonomia: consider outpatient f/u neurology # Peripheral neuropathy: continued home gabapentin # ? Mitochondrial disorder: f/u w/ genetics outpatient # Chronic constipation (currently has diarrhea): BM regimen held. Time spent coordinating discharge > 30 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 10 mg PO QAM 2. BusPIRone 5 mg PO QPM 3. Clotrimazole Cream 1 Appl TP BID 4. Dronabinol 10 mg PO QAM 5. Enoxaparin Sodium 50 mg SC Q12H 6. FoLIC Acid 1 mg PO DAILY 7. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY 8. Multivitamins W/minerals 1 TAB PO DAILY 9. ondansetron 4 mg oral Q8H 10. Promethazine 25 mg PR Q6H nausea 11. Pyridostigmine Bromide Syrup 60 mg PO TID 12. Thiamine 100 mg PO DAILY 13. Dronabinol 5 mg PO QPM Discharge Medications: 1. CefTRIAXone 1 gm IV Q24H RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 g IV DAILY Disp #*2 Intravenous Bag Refills:*0 2. Vancomycin Oral Liquid [MASKED] mg PO/NG QID RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day Disp #*84 Capsule Refills:*0 3. BusPIRone 10 mg PO QAM 4. BusPIRone 5 mg PO QPM 5. Clotrimazole Cream 1 Appl TP BID 6. Dronabinol 5 mg PO QPM 7. Dronabinol 10 mg PO QAM 8. Enoxaparin Sodium 50 mg SC Q12H 9. FoLIC Acid 1 mg PO DAILY 10. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. ondansetron 4 mg oral Q8H 13. Promethazine 25 mg PR Q6H nausea 14. Pyridostigmine Bromide Syrup 60 mg PO TID 15. Thiamine 100 mg PO DAILY 16.TPN Resume home TPN as written by usual outpatient providers [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: Acute Recurrent Cdiff Colitis Pyelonephritis Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a fever and flank pain, you were found to have an infection in your urinary tract. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? - In the hospital, it was determined that you likely had a urinary tract infection causing your symptoms. Due to low blood pressures you were originally in the ICU. Your infection was treated with IV antibiotics. However, you unfortunately developed a recurrence of C. diff and required treatment with IV and oral antibiotics. Dr [MASKED] formulate an antibiotic plan for you while hospitalized. WHAT SHOULD I DO WHEN I GO HOME? - You will have to have your blood drawn by your PCP at your [MASKED] appointment on [MASKED] to make sure that your blood counts have recovered. - Seek immediate medical attention if you develop a fever > 100.4 as your blood counts (neutrophils) are low. - Please take all medications as prescribed and keep all scheduled doctor's appointments. Seek medical attention if you develop a worsening or recurrence of the same symptoms that originally brought you to the hospital, experience any of the warning signs listed below, or have any other symptoms that concern you. It was a pleasure taking care of you! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N390", "D696" ]
[ "A4151: Sepsis due to Escherichia coli [E. coli]", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "A0471: Enterocolitis due to Clostridium difficile, recurrent", "Z681: Body mass index [BMI] 19.9 or less, adult", "N390: Urinary tract infection, site not specified", "K909: Intestinal malabsorption, unspecified", "A4189: Other specified sepsis", "Z90710: Acquired absence of both cervix and uterus", "Z90721: Acquired absence of ovaries, unilateral", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "N319: Neuromuscular dysfunction of bladder, unspecified", "R5382: Chronic fatigue, unspecified", "R011: Cardiac murmur, unspecified", "I959: Hypotension, unspecified", "R110: Nausea", "I890: Lymphedema, not elsewhere classified", "Z881: Allergy status to other antibiotic agents", "Z885: Allergy status to narcotic agent", "Z888: Allergy status to other drugs, medicaments and biological substances", "G901: Familial dysautonomia [Riley-Day]", "G629: Polyneuropathy, unspecified", "Z86711: Personal history of pulmonary embolism", "D696: Thrombocytopenia, unspecified", "K5909: Other constipation" ]
10,070,932
25,110,555
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Attending: ___. Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: HPI(4): Ms. ___ is a ___ female with history of mitochondrial disorder, POTS, chronic abdominal pain, severe endometriosis, neurogenic bladder s/p stimulator, recurrent c diff infections, malnutrition on TPN since ___, a replacement of ___ done on ___ with removal of prior PICC presents due to fevers. Patient states she was feeling well until this morning when she had fevers up to 103. Also describes diffuse myalgias, abdominal pain, one episode of nausea, and diarrhea. She describes increased pain in her Hickman's site. She called the ID office who recommended she come to the emergency department for labs including blood cultures as well as empiric antibiotics. In the ED: VS: Tmax 102.2, P 80's, BP 89-100/50-60's, RR ___, 95-100% on RA PE: abd tenderness Labs: positive UA, leukocytosis to 19 Imaging: CXR w/ LLL infiltrate - atelectasis vs developing airspace dz Impression: ___ w/ multiple medical comorbidities (straight caths, recurrent c. diff), recent ___'s port placed p/w fever to 103. Blood cultures obtained. getting vanc/cefepime. admitting to medicine. BP's baseline Interventions: 1.5L NS, 1.5L of LR, 1g IV Tylenol, Vanc 1g, Cefepime 2g, dilaudid 0.5mg IV x2 ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. - Neurogenic bladder s/p stimulator - Gallstones status post cholecystectomy - POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. - Neuropathy in lower extremities - Lymphedema - Chronic fatigue - PE unprovoked bilateral PE ___, has family history of clots. Hypercoagulable workup at ___ reportedly negative - ? mitochondrial disease Social History: ___ Family History: - Mother - PE and gallbladder disease - Father - healthy - Two sons with mitochondrial disease, pseudoobstruction, passed away at ages ___ and ___. Physical Exam: Admission PE: EXAM(8) VITALS: Temp: 99.0, BP: 90/54, HR: 80, RR: 16, O2 sat: 98%, O2 delivery: Ra ___: Weight: 103.2 ___: BMI: 19.5 GENERAL: Alert, diaphoretic and ill-appearing EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema. 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, diffusely tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly symmetric SKIN: R chest Hickman with significant ttp but no surrounding erythema or fluctuance, dressing c/d/i NEURO: Alert, oriented, face symmetric, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Discharge PE:(Pending) Pertinent Results: Admission labs: ___ 11:48AM LACTATE-2.0 K+-3.8 ___ 11:30AM URINE HOURS-RANDOM ___ 11:30AM URINE UCG-NEGATIVE ___ 11:30AM URINE COLOR-Yellow APPEAR-Hazy* SP ___ ___ 11:30AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG* ___ 11:30AM URINE RBC-2 WBC-160* BACTERIA-MANY* YEAST-NONE EPI-<1 ___ 11:30AM URINE AMORPH-FEW ___ 11:30AM URINE MUCOUS-OCC* ___ 11:20AM GLUCOSE-96 UREA N-17 CREAT-0.8 SODIUM-137 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17 ___ 11:20AM estGFR-Using this ___ 11:20AM WBC-19.6* RBC-4.06 HGB-12.5 HCT-37.0 MCV-91 MCH-30.8 MCHC-33.8 RDW-13.2 RDWSD-43.8 ___ 11:20AM NEUTS-87.1* LYMPHS-5.5* MONOS-6.5 EOS-0.1* BASOS-0.3 IM ___ AbsNeut-17.12* AbsLymp-1.08* AbsMono-1.27* AbsEos-0.02* AbsBaso-0.05 ___ 11:20AM PLT COUNT-145* Micro: UA: lg lueks, nitrite +ve Ucx: 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 Microbiology/Serology FINAL REPORT ___ C. difficile PCR (Final ___: Reported to and read back by ___ (___) @ 1:03AM ON ___. POSITIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. Therefore, positive C. diff PCR tests trigger reflex C. difficile toxin testing, which is highly specific for CDI. C. difficile Toxin antigen assay (Final ___: POSITIVE. (Reference Range-Negative). PERFORMED BY EIA. This result indicates a high likelihood of C. difficile infection (CDI). ___ + 27 ngtd 2x ___ Bcx/Fungal cx: NGTD 2vCXR: 1. A right internal jugular dual-lumen central venous catheter, which terminates in the right atrium. 2. New patchy opacities in the left lower lobe, which may represent atelectasis or developing airspace disease. Discharge Labs: ___ 05:27AM BLOOD WBC-3.8* RBC-3.08* Hgb-9.0* Hct-28.4* MCV-92 MCH-29.2 MCHC-31.7* RDW-13.2 RDWSD-44.5 Plt ___ ___ 05:27AM BLOOD Glucose-84 UreaN-5* Creat-0.6 Na-144 K-4.2 Cl-110* HCO3-23 AnGap-___ year old female with PMH of possible mitochondrial disorder and POTS with malnutrition requiring TPN, hospitalized in late ___ for a CLABSI due to klebsiella pneumonia completed ceftriaxone on ___. She had replacement of ___ and removal of PICC line done on ___ with ___. She now presents with 1 day of high grade fevers, pain at ___ site, diarrhea and abdominal pain. Treating for sepsis with concern for line infection as well as likely C diff; clinically improving but with ongoing diarrhea and abdominal pain. #Sepsis due to E coli UTI and C diff infection She had replacement of ___ and removal of PICC line done on ___ with ___ and presented with 1 day of high grade fevers, pain at ___ site, diarrhea and abdominal pain. Impression was new ___ line infection vs c diff vs less likely UTI or PNA. Placed on broad spectrum abx; IV vanc + ceftazdime (per AST) + PO vanc (empiric c diff coverage). Blood cultures, including fungal NGTD. She was placed on a line holiday pending further culture results and in conjunction with ID recommendations and only tolerated small amounts of po. Her blood cultures were negative but urine culture was positive with significant pyuria. C diff was also positive, so ID staff felt that her symptoms were from these infections and not line sepsis so she was cleared to use her ___ for TPN, which she was going to resume at home. Patient felt well on discharge, no cough, no urinary symptoms. She completed four days of IV antibiotics in house for UTI, and was discharged on oral bactrim to complete a five day course, as recommended by ID. #C diff diarrhea: #Hx of recurrent C diff: ___ recurrence per pt. She completed a long taper recently. She was covered empirically with QID PO vancomycin. PCR +ve and toxin positive. Put on prolonged taper by ID staff and asked to f/u with GI to consider stool transplantation. # Severe malnutrition: # Malabsorptive syndrome: She was continued on home pyrodstigmine and home vitamins. TPN was placed on hold while pt was on line holiday.and resumed on discharge at home. Greater than ___ hour spent on care on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 10 mg PO QAM 2. Dronabinol 5 mg PO BID 3. Enoxaparin Sodium 50 mg SC Q12H 4. ondansetron 4 mg oral Q8H 5. Promethazine 25 mg PR Q6H nausea 6. Pyridostigmine Bromide Syrup 60 mg PO TID 7. Thiamine 100 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Clotrimazole Cream 1 Appl TP BID 10. Multivitamins W/minerals 1 TAB PO DAILY 11. BusPIRone 5 mg PO QPM 12. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 1 Day take it for one day starting on ___. Vancomycin Oral Liquid ___ mg PO QID then 125 mg/day for 1 wk,125 mg every 2 days for four weeks 3. BusPIRone 10 mg PO QAM 4. BusPIRone 5 mg PO QPM 5. Clotrimazole Cream 1 Appl TP BID 6. Dronabinol 5 mg PO BID 7. Enoxaparin Sodium 50 mg SC Q12H 8. FoLIC Acid 1 mg PO DAILY 9. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY 10. Multivitamins W/minerals 1 TAB PO DAILY 11. ondansetron 4 mg oral Q8H 12. Promethazine 25 mg PR Q6H nausea 13. Pyridostigmine Bromide Syrup 60 mg PO TID 14. Thiamine 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. UTI 2. C diff infection 3. POTS 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 concern for sepsis, and you were seen by the infectious disease doctors. They feel that your symptoms are from a UTI and from C diff. Please finish one additional day of antibiotics (Bactrim) for your UTI tomorrow and please complete the vancomcycin taper that was prescribed for your C diff. Given your recurrent C diff, please followup with Dr ___ ___ in GI as an outpatient to discuss a fecal transplant. Please resume your TPN tomorrow as we have not found any infection in your port. Your prescriptions for Bactrim and vancomycin have been sent to the ___ on ___ in ___. Followup Instructions: ___
[ "A0471", "E43", "N390", "K909", "Z681", "R000", "N319", "G629", "R5382", "Z86711", "F419" ]
Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: HPI(4): Ms. [MASKED] is a [MASKED] female with history of mitochondrial disorder, POTS, chronic abdominal pain, severe endometriosis, neurogenic bladder s/p stimulator, recurrent c diff infections, malnutrition on TPN since [MASKED], a replacement of [MASKED] done on [MASKED] with removal of prior PICC presents due to fevers. Patient states she was feeling well until this morning when she had fevers up to 103. Also describes diffuse myalgias, abdominal pain, one episode of nausea, and diarrhea. She describes increased pain in her Hickman's site. She called the ID office who recommended she come to the emergency department for labs including blood cultures as well as empiric antibiotics. In the ED: VS: Tmax 102.2, P 80's, BP 89-100/50-60's, RR [MASKED], 95-100% on RA PE: abd tenderness Labs: positive UA, leukocytosis to 19 Imaging: CXR w/ LLL infiltrate - atelectasis vs developing airspace dz Impression: [MASKED] w/ multiple medical comorbidities (straight caths, recurrent c. diff), recent [MASKED]'s port placed p/w fever to 103. Blood cultures obtained. getting vanc/cefepime. admitting to medicine. BP's baseline Interventions: 1.5L NS, 1.5L of LR, 1g IV Tylenol, Vanc 1g, Cefepime 2g, dilaudid 0.5mg IV x2 ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. - Neurogenic bladder s/p stimulator - Gallstones status post cholecystectomy - POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. - Neuropathy in lower extremities - Lymphedema - Chronic fatigue - PE unprovoked bilateral PE [MASKED], has family history of clots. Hypercoagulable workup at [MASKED] reportedly negative - ? mitochondrial disease Social History: [MASKED] Family History: - Mother - PE and gallbladder disease - Father - healthy - Two sons with mitochondrial disease, pseudoobstruction, passed away at ages [MASKED] and [MASKED]. Physical Exam: Admission PE: EXAM(8) VITALS: Temp: 99.0, BP: 90/54, HR: 80, RR: 16, O2 sat: 98%, O2 delivery: Ra [MASKED]: Weight: 103.2 [MASKED]: BMI: 19.5 GENERAL: Alert, diaphoretic and ill-appearing EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema. 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, diffusely tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly symmetric SKIN: R chest Hickman with significant ttp but no surrounding erythema or fluctuance, dressing c/d/i NEURO: Alert, oriented, face symmetric, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Discharge PE:(Pending) Pertinent Results: Admission labs: [MASKED] 11:48AM LACTATE-2.0 K+-3.8 [MASKED] 11:30AM URINE HOURS-RANDOM [MASKED] 11:30AM URINE UCG-NEGATIVE [MASKED] 11:30AM URINE COLOR-Yellow APPEAR-Hazy* SP [MASKED] [MASKED] 11:30AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG* [MASKED] 11:30AM URINE RBC-2 WBC-160* BACTERIA-MANY* YEAST-NONE EPI-<1 [MASKED] 11:30AM URINE AMORPH-FEW [MASKED] 11:30AM URINE MUCOUS-OCC* [MASKED] 11:20AM GLUCOSE-96 UREA N-17 CREAT-0.8 SODIUM-137 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17 [MASKED] 11:20AM estGFR-Using this [MASKED] 11:20AM WBC-19.6* RBC-4.06 HGB-12.5 HCT-37.0 MCV-91 MCH-30.8 MCHC-33.8 RDW-13.2 RDWSD-43.8 [MASKED] 11:20AM NEUTS-87.1* LYMPHS-5.5* MONOS-6.5 EOS-0.1* BASOS-0.3 IM [MASKED] AbsNeut-17.12* AbsLymp-1.08* AbsMono-1.27* AbsEos-0.02* AbsBaso-0.05 [MASKED] 11:20AM PLT COUNT-145* Micro: UA: lg lueks, nitrite +ve Ucx: 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 Microbiology/Serology FINAL REPORT [MASKED] C. difficile PCR (Final [MASKED]: Reported to and read back by [MASKED] ([MASKED]) @ 1:03AM ON [MASKED]. POSITIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. Therefore, positive C. diff PCR tests trigger reflex C. difficile toxin testing, which is highly specific for CDI. C. difficile Toxin antigen assay (Final [MASKED]: POSITIVE. (Reference Range-Negative). PERFORMED BY EIA. This result indicates a high likelihood of C. difficile infection (CDI). [MASKED] + 27 ngtd 2x [MASKED] Bcx/Fungal cx: NGTD 2vCXR: 1. A right internal jugular dual-lumen central venous catheter, which terminates in the right atrium. 2. New patchy opacities in the left lower lobe, which may represent atelectasis or developing airspace disease. Discharge Labs: [MASKED] 05:27AM BLOOD WBC-3.8* RBC-3.08* Hgb-9.0* Hct-28.4* MCV-92 MCH-29.2 MCHC-31.7* RDW-13.2 RDWSD-44.5 Plt [MASKED] [MASKED] 05:27AM BLOOD Glucose-84 UreaN-5* Creat-0.6 Na-144 K-4.2 Cl-110* HCO3-23 AnGap-[MASKED] year old female with PMH of possible mitochondrial disorder and POTS with malnutrition requiring TPN, hospitalized in late [MASKED] for a CLABSI due to klebsiella pneumonia completed ceftriaxone on [MASKED]. She had replacement of [MASKED] and removal of PICC line done on [MASKED] with [MASKED]. She now presents with 1 day of high grade fevers, pain at [MASKED] site, diarrhea and abdominal pain. Treating for sepsis with concern for line infection as well as likely C diff; clinically improving but with ongoing diarrhea and abdominal pain. #Sepsis due to E coli UTI and C diff infection She had replacement of [MASKED] and removal of PICC line done on [MASKED] with [MASKED] and presented with 1 day of high grade fevers, pain at [MASKED] site, diarrhea and abdominal pain. Impression was new [MASKED] line infection vs c diff vs less likely UTI or PNA. Placed on broad spectrum abx; IV vanc + ceftazdime (per AST) + PO vanc (empiric c diff coverage). Blood cultures, including fungal NGTD. She was placed on a line holiday pending further culture results and in conjunction with ID recommendations and only tolerated small amounts of po. Her blood cultures were negative but urine culture was positive with significant pyuria. C diff was also positive, so ID staff felt that her symptoms were from these infections and not line sepsis so she was cleared to use her [MASKED] for TPN, which she was going to resume at home. Patient felt well on discharge, no cough, no urinary symptoms. She completed four days of IV antibiotics in house for UTI, and was discharged on oral bactrim to complete a five day course, as recommended by ID. #C diff diarrhea: #Hx of recurrent C diff: [MASKED] recurrence per pt. She completed a long taper recently. She was covered empirically with QID PO vancomycin. PCR +ve and toxin positive. Put on prolonged taper by ID staff and asked to f/u with GI to consider stool transplantation. # Severe malnutrition: # Malabsorptive syndrome: She was continued on home pyrodstigmine and home vitamins. TPN was placed on hold while pt was on line holiday.and resumed on discharge at home. Greater than [MASKED] hour spent on care on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 10 mg PO QAM 2. Dronabinol 5 mg PO BID 3. Enoxaparin Sodium 50 mg SC Q12H 4. ondansetron 4 mg oral Q8H 5. Promethazine 25 mg PR Q6H nausea 6. Pyridostigmine Bromide Syrup 60 mg PO TID 7. Thiamine 100 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Clotrimazole Cream 1 Appl TP BID 10. Multivitamins W/minerals 1 TAB PO DAILY 11. BusPIRone 5 mg PO QPM 12. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 1 Day take it for one day starting on [MASKED]. Vancomycin Oral Liquid [MASKED] mg PO QID then 125 mg/day for 1 wk,125 mg every 2 days for four weeks 3. BusPIRone 10 mg PO QAM 4. BusPIRone 5 mg PO QPM 5. Clotrimazole Cream 1 Appl TP BID 6. Dronabinol 5 mg PO BID 7. Enoxaparin Sodium 50 mg SC Q12H 8. FoLIC Acid 1 mg PO DAILY 9. gabapentin 250 mg/5 mL oral TAKE 8ML BY MOUTH 3 TIMES A DAY 10. Multivitamins W/minerals 1 TAB PO DAILY 11. ondansetron 4 mg oral Q8H 12. Promethazine 25 mg PR Q6H nausea 13. Pyridostigmine Bromide Syrup 60 mg PO TID 14. Thiamine 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: 1. UTI 2. C diff infection 3. POTS 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 concern for sepsis, and you were seen by the infectious disease doctors. They feel that your symptoms are from a UTI and from C diff. Please finish one additional day of antibiotics (Bactrim) for your UTI tomorrow and please complete the vancomcycin taper that was prescribed for your C diff. Given your recurrent C diff, please followup with Dr [MASKED] [MASKED] in GI as an outpatient to discuss a fecal transplant. Please resume your TPN tomorrow as we have not found any infection in your port. Your prescriptions for Bactrim and vancomycin have been sent to the [MASKED] on [MASKED] in [MASKED]. Followup Instructions: [MASKED]
[]
[ "N390", "F419" ]
[ "A0471: Enterocolitis due to Clostridium difficile, recurrent", "E43: Unspecified severe protein-calorie malnutrition", "N390: Urinary tract infection, site not specified", "K909: Intestinal malabsorption, unspecified", "Z681: Body mass index [BMI] 19.9 or less, adult", "R000: Tachycardia, unspecified", "N319: Neuromuscular dysfunction of bladder, unspecified", "G629: Polyneuropathy, unspecified", "R5382: Chronic fatigue, unspecified", "Z86711: Personal history of pulmonary embolism", "F419: Anxiety disorder, unspecified" ]
10,070,932
25,124,281
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Attending: ___. Chief Complaint: Fever, SOB, Abdominal Pain Major Surgical or Invasive Procedure: ___ Central venous line placement in right IJ ___ EGD with biopsy ___ PICC placement ___ EGD-guided NJ tube placement History of Present Illness: Ms. ___ is a ___ year-old woman with PMH chronic abdominal pain, severe endometriosis, malnutrition on TPN since ___ via RUE ___ placed ___ @ ___ who presented to ___ ___ ___ with shortness of breath, abdominal pain, fevers, nausea, and loose stools, transferred to ___ for further management, triggered on arrival to ___ ED for hypotension was started on norepinephrine. She reports 3 days of fevers to 104 max at home that started suddenly, with a few episodes of vomiting. She was taking 500mg of acetaminophen TID which helped her fevers. She had some mild abdominal increase in abdominal pain associated with her fevers. Also feels her heart is skipping beats with some associated shortness of breath which prompted her to present to ___ ___ ___. She states her PICC has been working well other than one of the lumens being clogged recently. No erythema or drainage from the site. She otherwise denies any chest pain, cough, increase in loose stools, dysuria, rashes, or tick exposures. ___: -T 100.7, BP 90/57, HR 109, O2 99% RA -CT abdomen/pelvis w/ IV contrast: No evidence of acute intra-abdominal pathology. Left ovarian cyst and small r ovarian hemorrhagic cyst -Zosyn 3.375g once ED Course notable for: -Tmax 102.1, BP 77/43 on arrival, O2 98-100% -Received vanc/zosyn -Started on norepinephrine -> uptitrated to 0.15 mcg/kg/min Regarding her GI history: Has had extensive workup at ___ that has been unrevealing. Motility studies have demonstrated preserved gut motility and her providers there feel her symptoms are due to visceral hypersensitivity. She has had significant weight loss over the past year due to her symptoms and ultimately had enteral feeding initiated in ___ as she was unable to meet caloric needs. She had been receiving enteral feeds through NJ tube, but was hospitalized at ___ in ___ with septic shock and severe c. difficile. Her NJ tube was removed and she was started on TPN. Gabapentin was increased and she was also started on Marinol. She subsequently saw GI @ ___ ___ and had worsening abdominal pain and diarrhea, and a positive c. diff toxin assay from an outside lab and was started on a planned 6 week taper of PO vancomycin. Subsequently seen at ___ ___ with plan to transfer her care here. At that visit dronabinol was increased, she was started on buspirone for dyspepsia and nausea. Plan was for brain MRI and possible flex sig to rule out obstruction. On arrival to the MICU, she has no acute complaints, occasional rigors. Reports blood cultures from ___ drawn ___ prior to ED presentation were positive, but she is unsure if they were drawn from PICC or peripherally. ___ lab reports over the phone that cultures ___ growing staph epidermidis and enterobacter, sensitivities will be available ___. Past Medical History: -Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. -Neurogenic bladder s/p stimulator -Gallstones status post cholecystectomy -POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. -Neuropathy in lower extremities -Lymphedema -Chronic fatigue -PE unprovoked bilateral PE ___, has family history of clots. Hypercoagulable workup at ___ reportedly negative -? mitochondrial disease Social History: ___ Family History: Mother- PE and gallbladder disease Father- healthy Two sons with mitochondrial disease, pseudoobstruction, passed away at ages ___ and ___. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== GENERAL: Alert, oriented, appears ill but NAD HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, chronic lymphedema without pitting SKIN: RUE with PICC in place covered with dressing. No erythema, drainage from insertion site, non-tender to palpation. NEURO: A&O x 3, moves all extremities purposefully DISCHARGE PHYSICAL EXAM: ====================== T 98.5 BP 91/52 HR 72 RR 18 SaO2 98% Ra GENERAL: Adult woman lying in bed comfortably CARDIAC: RRR, no murmurs, rubs, or gallops LUNG: CTAB ABD: Soft, tender on deep palpation in lower quadrants bilaterally, tender on deep palpation in upper quadrants bilaterally, non-distended, +bowel sounds EXT: Warm, bilateral lower extremity edema, 2+ DP pulses NEURO: Alert, oriented, CN grossly intact, spontaneously moving all extremities Access: PICC line in LEFT ac Pertinent Results: ADMISSION LABS: ================= ___ 09:24PM WBC-6.1 RBC-3.35* HGB-10.3* HCT-30.8* MCV-92 MCH-30.7 MCHC-33.4 RDW-12.4 RDWSD-41.8 ___ 09:24PM GLUCOSE-107* UREA N-10 CREAT-0.7 SODIUM-137 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-22 ANION GAP-10 ___ 09:24PM CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-1.6 ___ 10:38AM ALBUMIN-2.7* ___ 04:30AM BLOOD Type-CENTRAL VE pO2-47* pCO2-39 pH-7.39 calTCO2-24 Base XS-0 DISCHARGE LABS: ================= ___ 04:48AM BLOOD WBC-3.5* RBC-3.39* Hgb-10.2* Hct-31.4* MCV-93 MCH-30.1 MCHC-32.5 RDW-12.9 RDWSD-43.3 Plt ___ ___ 04:48AM BLOOD Plt ___ ___ 04:48AM BLOOD Glucose-86 UreaN-19 Creat-0.6 Na-141 K-4.1 Cl-105 HCO3-27 AnGap-9* ___ 04:48AM BLOOD ALT-42* AST-29 LD(LDH)-157 AlkPhos-69 TotBili-0.4 ___ 04:48AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.7 Mg-1.8 MICROBIO: ___ 1:41 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY NOT S. SAPROPHYTICUS. 10,000-100,000 CFU/mL. ___ 11:45 am BLOOD CULTURE BACILLUS SPECIES; NOT ANTHRACIS. PREVIOUSLY REPORTED AS GRAM NEGATIVE ROD(S) ___ 10:45 am BLOOD CULTURE ENTEROBACTER CLOACAE COMPLEX ___ 12:46 am CATHETER TIP-IV Source: PICC. **FINAL REPORT ___ WOUND CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 COLONIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S ___ 4:09 am BLOOD CULTURE Source: Line-IJ. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:04 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source: Line-CVL. BLOOD/FUNGAL CULTURE (Pending): No growth to date. BLOOD/AFB CULTURE (Pending): No growth to date. ___ 3:43 am BLOOD CULTURE Source: Line-R IJ. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 3:43 am BLOOD CULTURE Source: Line-R IJ. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:13 am BLOOD CULTURE Source: Line-IJ. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:30 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 4:30 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:21 am BLOOD CULTURE Source: Line-RIJ. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. PATHOLOGY: DIFFICULT CROSSMATCH AND/OR EVALUATION OF IRREGULAR ANTIBODIES ___ DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. ___ has a confirmed diagnosis of an anti-K antibody. The ___ is a member of the Kell blood group system. Anti-K antibodies are clinically significant and capable of causing hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (HDFN). Ms. ___ should receive ___ negative products for all red cell transfusions. Approximately 90% of ABO compatible blood will be ___ negative. EGD Biopsies of esophagus, gastric antrum, and duodenum all within normal limits ___ IMAGING: CHEST X RAY ___ Patient rotated slightly to the left. Right-sided PICC appears to terminate somewhat deep in the right atrium; consider withdrawal by approximately 2-3 cm for more optimal positioning. No pneumothorax seen. CHEST X RAY ___ New right subclavian central venous catheter terminating minimally below the cavoatrial junction.; no pneumothorax found. ABDOMINAL X RAY ___ No radiographic evidence of bowel dilation. CHEST X RAY ___ Interval placement of left-sided PICC line that terminates in the cavoatrial junction. ABDOMINAL X RAY ___. The tip of an enteric tube lies past the ligament of Treitz and is in the jejunum. 2. Gaseous distention of the small and large bowel likely reflects an ileus. Brief Hospital Course: PATIENT SUMMARY: ================= ___ year-old woman with POTS, chronic abdominal pain, severe endometriosis, neurogenic bladder s/p stimulator, recurrent c diff infections, malnutrition on TPN since ___ via RUE ___ placed ___ at ___ who presented to ___ ___ ___ with shortness of breath, abdominal pain, fevers, nausea, and loose stools, transferred to ___ and admitted to MICU with septic shock and enterobacter bacteremia thought to be ___ PICC line. In the MICU she briefly required pressors and was started on broad spectrum antibiotics (vanc/zosyn ___ which were narrowed on ___ to ceftriaxone. Her central line was switched to a double lumen PICC for abx and she received an NJ tube via EGD for feeds. GI, nutrition, and pain services were all involved in managing her care. She ultimately failed her NJ tube feeding trial due to severe nausea and pain which precluded her from getting her tube feeds advanced, and she was discharged on TPN though the ___. ACUTE ISSUES: ============== # SEPTIC SHOCK She presented febrile and hypotensive requiring norepinephrine in the ICU. Blood cultures from ___ with enterobacter clocae (sensitive to TMP/SMX, Aztreonam, ceftazidime, ceftriaxone, gentamicin, meropenem, levofloxacin, tobramycin) and staph epidermidis (likely contaminant). Repeat blood culture from ___ growing enterobacter on ___. Negative blood cx since ___. Most likely source PICC which was removed. Her CXR showed no PNA and no respiratory symptoms, UA not concerning for infection. She is s/p vanc/zosyn (___) and was narrowed to IV cefepime ___ with plan for 2 week course from last negative blood cx (last date: ___. She is on vancomcyin for c diff prophylaxis, plan for 2 weeks after completion of IV cefepime. A new PICC line was placed to facilitate completion of IV antibiotics at home. Patient continued to do well on IV cefepime, remaining afebrile, hemodynamically stable, blood cx negative. # MALNUTRITION: In setting of chronic abdominal pain and nausea. Started enteral feeds ___, converted to TPN ___ in setting of severe c. diff, likely due to ongoing diarrhea. Goal TF rate difficult to achieve due to severe nausea when advancing rate. NJ tube replaced on ___, patient resumed on TF. Patient experienced severe nausea with TF despite very low rate (20 currently). Given high risk of clogging and minimal nutritional support at rate TF ___, decision made in consultation with GI, nutrition, and patient to discontinue TF and resume TPN on ___. Long-term plan for TPN vs surgical tube placement or other nutritional support options was deferred to outpatient setting. Patient receiving TPN through double-lumen PICC while in-hospital. Following completion of antibiotics course, can remove PICC and place Hickman for continued TPN. Patient medically stable and at goal TPN on ___. # C. DIFF INFECTION Initial episode ___, subsequently prescribed 6 weeks of vancomycin ___, currently taking 125mg daily at home. No recent change in stool. Vancomycin 125mg QID for c diff prophylaxis, plan to continue 2 weeks after completing antibiotic course for bacteremia. # CHRONIC ABDOMINAL PAIN, NAUSEA Extensive workup at ___ that was unrevealing, ?visceral hypersensitivity. Transferring to ___ GI ___. Mestinon increased from BID to TID on ___ without improvement in nausea. Abdominal pain and nausea worsened in setting of resuming tube feeds, variable depending on TF rate. Following discontinuation of TF on ___, patient reporting that abdominal pain and nausea significantly improved to baseline level. Plan for follow-up with ___ GI for further workup as outpatient and plan for long-term nutritional support as above. CHRONIC ISSUES: =============== # NEUROGENIC BLADDER S/P BLADDER STIMULATOR Monitored her urine output, creatinine stable at baseline 0.6. # ENDOMETRIOSIS S/P TAH/BSO continue to monitor and treat for abdominal pain as above # BRADYCARDIA, AV BLOCK On arrival to ICU had bradycardia to ___. ECG review with what appeared to be ___. Denies any prior arrhythmia history. She was monitored on tele without any additional episodes of this. # THROMBOCYTOPENIA Per review of ___ records, platelet count 70-80s throughout her admission in ___ platelet count ~100. Suspect secondary to sepsis on top of chronic thrombocytopenia possibly related to malnutrition as above. She remained on lovenox during this hospitalization. # POTS Previously on Mestinon with no improvement in symptoms. Retrialing Mestinon for nausea and abdominal pain with good effect. BPs stable throughout the hospitalization. TRANSITIONAL ISSUES: ===================== New Meds: IV cefepime, pyridostigmine Changed Meds: Gabapentin changed to 600mg PO TID, promethazine increased to 25mg q6H, vancomycin dose increased from daily to q6H Stopped/Held Meds: none [ ] Antibiotics - IV cefepime 2g q12H will be continued until end of ___. Oral vancomycin four times daily will be continued until ___, at which time patient can return to once daily [ ] Patient currently received IV cefepime and TPN through double lumen PICC. After completion of antibiotics, please coordinate removal of PICC and placement of Hickman port for TPN [ ] GI followup - discuss long-term plan for nutritional support [ ] Physical Therapy needs upon discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Promethazine 12.___ID:PRN nausea 3. Dronabinol 5 mg PO BID 4. BusPIRone 5 mg PO DAILY 5. gabapentin 8 ml oral TID 6. ondansetron 4 mg oral Q8H 7. vancomycin 125 mg oral DAILY 8. Enoxaparin Sodium 50 mg SC BID 9. Thiamine Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. CefePIME 2 g IV Q12H Duration: 3 Doses RX *cefepime 2 gram 2 g IV every twelve (12) hours Disp #*3 Vial Refills:*0 2. Pyridostigmine Bromide Syrup 60 mg PO TID RX *pyridostigmine bromide 60 mg 1 tablet by mouth three times a day Disp #*90 Tablet Refills:*0 3. Vancomycin Oral Liquid ___ mg PO QID Duration: 15 Days Please continue at this dose for two weeks after you complete IV antibiotics. RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day Disp #*80 Capsule Refills:*0 4. Gabapentin 600 mg PO TID RX *gabapentin 300 mg/6 mL (6 mL) 12 mL by mouth three times a day Disp #*1000 Milliliter Refills:*0 5. Promethazine 25 mg PR Q6H nausea RX *promethazine [Promethegan] 25 mg 1 suppository(s) rectally every six (6) hours Disp #*120 Suppository Refills:*0 6. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. BusPIRone 5 mg PO DAILY RX *buspirone 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Dronabinol 5 mg PO BID RX *dronabinol 5 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 9. Enoxaparin Sodium 50 mg SC BID RX *enoxaparin 100 mg/mL 0.5 (One half) mL subcutaneous every twelve (12) hours Disp #*60 Syringe Refills:*0 10. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. ondansetron 4 mg oral Q8H RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 12. HELD- vancomycin 125 mg oral DAILY This medication was held. Do not restart vancomycin until you have completed the more frequent dosing on ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: =================== septic shock malnutrition c. diff infection chronic abdominal pain, nausea SECONDARY DIAGNOSIS: ==================== thrombocytopenia neurogenic bladder POTS endometriosis bradycardia, AV block 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 part in your care here at ___! Why was I admitted to the hospital? - You were admitted for an infection in your bloodstream. What was done for me while I was in the hospital? - You received IV antibiotics. - A feeding tube was placed and you started tube feeds. Due to intractable nausea, your tube feeds had to be stopped and you were resumed on total parenteral nutrition. What should I do when I leave the hospital? - Please continue to take all of your medications. - Please attend all of your follow-up appointments. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "T80211A", "A4159", "R6521", "E43", "Z681", "A0472", "Y848", "Y92018", "R000", "I951", "R1032", "R1031", "N319", "N39498", "Z9049", "Z90710", "Z90722", "Z9079", "G629", "I890", "R5382", "Z86711", "Z87891", "R110", "I441", "D6959", "F4323" ]
Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Chief Complaint: Fever, SOB, Abdominal Pain Major Surgical or Invasive Procedure: [MASKED] Central venous line placement in right IJ [MASKED] EGD with biopsy [MASKED] PICC placement [MASKED] EGD-guided NJ tube placement History of Present Illness: Ms. [MASKED] is a [MASKED] year-old woman with PMH chronic abdominal pain, severe endometriosis, malnutrition on TPN since [MASKED] via RUE [MASKED] placed [MASKED] @ [MASKED] who presented to [MASKED] [MASKED] [MASKED] with shortness of breath, abdominal pain, fevers, nausea, and loose stools, transferred to [MASKED] for further management, triggered on arrival to [MASKED] ED for hypotension was started on norepinephrine. She reports 3 days of fevers to 104 max at home that started suddenly, with a few episodes of vomiting. She was taking 500mg of acetaminophen TID which helped her fevers. She had some mild abdominal increase in abdominal pain associated with her fevers. Also feels her heart is skipping beats with some associated shortness of breath which prompted her to present to [MASKED] [MASKED] [MASKED]. She states her PICC has been working well other than one of the lumens being clogged recently. No erythema or drainage from the site. She otherwise denies any chest pain, cough, increase in loose stools, dysuria, rashes, or tick exposures. [MASKED]: -T 100.7, BP 90/57, HR 109, O2 99% RA -CT abdomen/pelvis w/ IV contrast: No evidence of acute intra-abdominal pathology. Left ovarian cyst and small r ovarian hemorrhagic cyst -Zosyn 3.375g once ED Course notable for: -Tmax 102.1, BP 77/43 on arrival, O2 98-100% -Received vanc/zosyn -Started on norepinephrine -> uptitrated to 0.15 mcg/kg/min Regarding her GI history: Has had extensive workup at [MASKED] that has been unrevealing. Motility studies have demonstrated preserved gut motility and her providers there feel her symptoms are due to visceral hypersensitivity. She has had significant weight loss over the past year due to her symptoms and ultimately had enteral feeding initiated in [MASKED] as she was unable to meet caloric needs. She had been receiving enteral feeds through NJ tube, but was hospitalized at [MASKED] in [MASKED] with septic shock and severe c. difficile. Her NJ tube was removed and she was started on TPN. Gabapentin was increased and she was also started on Marinol. She subsequently saw GI @ [MASKED] [MASKED] and had worsening abdominal pain and diarrhea, and a positive c. diff toxin assay from an outside lab and was started on a planned 6 week taper of PO vancomycin. Subsequently seen at [MASKED] [MASKED] with plan to transfer her care here. At that visit dronabinol was increased, she was started on buspirone for dyspepsia and nausea. Plan was for brain MRI and possible flex sig to rule out obstruction. On arrival to the MICU, she has no acute complaints, occasional rigors. Reports blood cultures from [MASKED] drawn [MASKED] prior to ED presentation were positive, but she is unsure if they were drawn from PICC or peripherally. [MASKED] lab reports over the phone that cultures [MASKED] growing staph epidermidis and enterobacter, sensitivities will be available [MASKED]. Past Medical History: -Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. -Neurogenic bladder s/p stimulator -Gallstones status post cholecystectomy -POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. -Neuropathy in lower extremities -Lymphedema -Chronic fatigue -PE unprovoked bilateral PE [MASKED], has family history of clots. Hypercoagulable workup at [MASKED] reportedly negative -? mitochondrial disease Social History: [MASKED] Family History: Mother- PE and gallbladder disease Father- healthy Two sons with mitochondrial disease, pseudoobstruction, passed away at ages [MASKED] and [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== GENERAL: Alert, oriented, appears ill but NAD HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, chronic lymphedema without pitting SKIN: RUE with PICC in place covered with dressing. No erythema, drainage from insertion site, non-tender to palpation. NEURO: A&O x 3, moves all extremities purposefully DISCHARGE PHYSICAL EXAM: ====================== T 98.5 BP 91/52 HR 72 RR 18 SaO2 98% Ra GENERAL: Adult woman lying in bed comfortably CARDIAC: RRR, no murmurs, rubs, or gallops LUNG: CTAB ABD: Soft, tender on deep palpation in lower quadrants bilaterally, tender on deep palpation in upper quadrants bilaterally, non-distended, +bowel sounds EXT: Warm, bilateral lower extremity edema, 2+ DP pulses NEURO: Alert, oriented, CN grossly intact, spontaneously moving all extremities Access: PICC line in LEFT ac Pertinent Results: ADMISSION LABS: ================= [MASKED] 09:24PM WBC-6.1 RBC-3.35* HGB-10.3* HCT-30.8* MCV-92 MCH-30.7 MCHC-33.4 RDW-12.4 RDWSD-41.8 [MASKED] 09:24PM GLUCOSE-107* UREA N-10 CREAT-0.7 SODIUM-137 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-22 ANION GAP-10 [MASKED] 09:24PM CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-1.6 [MASKED] 10:38AM ALBUMIN-2.7* [MASKED] 04:30AM BLOOD Type-CENTRAL VE pO2-47* pCO2-39 pH-7.39 calTCO2-24 Base XS-0 DISCHARGE LABS: ================= [MASKED] 04:48AM BLOOD WBC-3.5* RBC-3.39* Hgb-10.2* Hct-31.4* MCV-93 MCH-30.1 MCHC-32.5 RDW-12.9 RDWSD-43.3 Plt [MASKED] [MASKED] 04:48AM BLOOD Plt [MASKED] [MASKED] 04:48AM BLOOD Glucose-86 UreaN-19 Creat-0.6 Na-141 K-4.1 Cl-105 HCO3-27 AnGap-9* [MASKED] 04:48AM BLOOD ALT-42* AST-29 LD(LDH)-157 AlkPhos-69 TotBili-0.4 [MASKED] 04:48AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.7 Mg-1.8 MICROBIO: [MASKED] 1:41 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY NOT S. SAPROPHYTICUS. 10,000-100,000 CFU/mL. [MASKED] 11:45 am BLOOD CULTURE BACILLUS SPECIES; NOT ANTHRACIS. PREVIOUSLY REPORTED AS GRAM NEGATIVE ROD(S) [MASKED] 10:45 am BLOOD CULTURE ENTEROBACTER CLOACAE COMPLEX [MASKED] 12:46 am CATHETER TIP-IV Source: PICC. **FINAL REPORT [MASKED] WOUND CULTURE (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 COLONIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=0.5 S [MASKED] 4:09 am BLOOD CULTURE Source: Line-IJ. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 10:04 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) Source: Line-CVL. BLOOD/FUNGAL CULTURE (Pending): No growth to date. BLOOD/AFB CULTURE (Pending): No growth to date. [MASKED] 3:43 am BLOOD CULTURE Source: Line-R IJ. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 3:43 am BLOOD CULTURE Source: Line-R IJ. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 5:13 am BLOOD CULTURE Source: Line-IJ. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 10:30 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 4:30 am BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 6:21 am BLOOD CULTURE Source: Line-RIJ. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. PATHOLOGY: DIFFICULT CROSSMATCH AND/OR EVALUATION OF IRREGULAR ANTIBODIES [MASKED] DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [MASKED] has a confirmed diagnosis of an anti-K antibody. The [MASKED] is a member of the Kell blood group system. Anti-K antibodies are clinically significant and capable of causing hemolytic transfusion reactions and hemolytic disease of the fetus and newborn (HDFN). Ms. [MASKED] should receive [MASKED] negative products for all red cell transfusions. Approximately 90% of ABO compatible blood will be [MASKED] negative. EGD Biopsies of esophagus, gastric antrum, and duodenum all within normal limits [MASKED] IMAGING: CHEST X RAY [MASKED] Patient rotated slightly to the left. Right-sided PICC appears to terminate somewhat deep in the right atrium; consider withdrawal by approximately 2-3 cm for more optimal positioning. No pneumothorax seen. CHEST X RAY [MASKED] New right subclavian central venous catheter terminating minimally below the cavoatrial junction.; no pneumothorax found. ABDOMINAL X RAY [MASKED] No radiographic evidence of bowel dilation. CHEST X RAY [MASKED] Interval placement of left-sided PICC line that terminates in the cavoatrial junction. ABDOMINAL X RAY [MASKED]. The tip of an enteric tube lies past the ligament of Treitz and is in the jejunum. 2. Gaseous distention of the small and large bowel likely reflects an ileus. Brief Hospital Course: PATIENT SUMMARY: ================= [MASKED] year-old woman with POTS, chronic abdominal pain, severe endometriosis, neurogenic bladder s/p stimulator, recurrent c diff infections, malnutrition on TPN since [MASKED] via RUE [MASKED] placed [MASKED] at [MASKED] who presented to [MASKED] [MASKED] [MASKED] with shortness of breath, abdominal pain, fevers, nausea, and loose stools, transferred to [MASKED] and admitted to MICU with septic shock and enterobacter bacteremia thought to be [MASKED] PICC line. In the MICU she briefly required pressors and was started on broad spectrum antibiotics (vanc/zosyn [MASKED] which were narrowed on [MASKED] to ceftriaxone. Her central line was switched to a double lumen PICC for abx and she received an NJ tube via EGD for feeds. GI, nutrition, and pain services were all involved in managing her care. She ultimately failed her NJ tube feeding trial due to severe nausea and pain which precluded her from getting her tube feeds advanced, and she was discharged on TPN though the [MASKED]. ACUTE ISSUES: ============== # SEPTIC SHOCK She presented febrile and hypotensive requiring norepinephrine in the ICU. Blood cultures from [MASKED] with enterobacter clocae (sensitive to TMP/SMX, Aztreonam, ceftazidime, ceftriaxone, gentamicin, meropenem, levofloxacin, tobramycin) and staph epidermidis (likely contaminant). Repeat blood culture from [MASKED] growing enterobacter on [MASKED]. Negative blood cx since [MASKED]. Most likely source PICC which was removed. Her CXR showed no PNA and no respiratory symptoms, UA not concerning for infection. She is s/p vanc/zosyn ([MASKED]) and was narrowed to IV cefepime [MASKED] with plan for 2 week course from last negative blood cx (last date: [MASKED]. She is on vancomcyin for c diff prophylaxis, plan for 2 weeks after completion of IV cefepime. A new PICC line was placed to facilitate completion of IV antibiotics at home. Patient continued to do well on IV cefepime, remaining afebrile, hemodynamically stable, blood cx negative. # MALNUTRITION: In setting of chronic abdominal pain and nausea. Started enteral feeds [MASKED], converted to TPN [MASKED] in setting of severe c. diff, likely due to ongoing diarrhea. Goal TF rate difficult to achieve due to severe nausea when advancing rate. NJ tube replaced on [MASKED], patient resumed on TF. Patient experienced severe nausea with TF despite very low rate (20 currently). Given high risk of clogging and minimal nutritional support at rate TF [MASKED], decision made in consultation with GI, nutrition, and patient to discontinue TF and resume TPN on [MASKED]. Long-term plan for TPN vs surgical tube placement or other nutritional support options was deferred to outpatient setting. Patient receiving TPN through double-lumen PICC while in-hospital. Following completion of antibiotics course, can remove PICC and place Hickman for continued TPN. Patient medically stable and at goal TPN on [MASKED]. # C. DIFF INFECTION Initial episode [MASKED], subsequently prescribed 6 weeks of vancomycin [MASKED], currently taking 125mg daily at home. No recent change in stool. Vancomycin 125mg QID for c diff prophylaxis, plan to continue 2 weeks after completing antibiotic course for bacteremia. # CHRONIC ABDOMINAL PAIN, NAUSEA Extensive workup at [MASKED] that was unrevealing, ?visceral hypersensitivity. Transferring to [MASKED] GI [MASKED]. Mestinon increased from BID to TID on [MASKED] without improvement in nausea. Abdominal pain and nausea worsened in setting of resuming tube feeds, variable depending on TF rate. Following discontinuation of TF on [MASKED], patient reporting that abdominal pain and nausea significantly improved to baseline level. Plan for follow-up with [MASKED] GI for further workup as outpatient and plan for long-term nutritional support as above. CHRONIC ISSUES: =============== # NEUROGENIC BLADDER S/P BLADDER STIMULATOR Monitored her urine output, creatinine stable at baseline 0.6. # ENDOMETRIOSIS S/P TAH/BSO continue to monitor and treat for abdominal pain as above # BRADYCARDIA, AV BLOCK On arrival to ICU had bradycardia to [MASKED]. ECG review with what appeared to be [MASKED]. Denies any prior arrhythmia history. She was monitored on tele without any additional episodes of this. # THROMBOCYTOPENIA Per review of [MASKED] records, platelet count 70-80s throughout her admission in [MASKED] platelet count ~100. Suspect secondary to sepsis on top of chronic thrombocytopenia possibly related to malnutrition as above. She remained on lovenox during this hospitalization. # POTS Previously on Mestinon with no improvement in symptoms. Retrialing Mestinon for nausea and abdominal pain with good effect. BPs stable throughout the hospitalization. TRANSITIONAL ISSUES: ===================== New Meds: IV cefepime, pyridostigmine Changed Meds: Gabapentin changed to 600mg PO TID, promethazine increased to 25mg q6H, vancomycin dose increased from daily to q6H Stopped/Held Meds: none [ ] Antibiotics - IV cefepime 2g q12H will be continued until end of [MASKED]. Oral vancomycin four times daily will be continued until [MASKED], at which time patient can return to once daily [ ] Patient currently received IV cefepime and TPN through double lumen PICC. After completion of antibiotics, please coordinate removal of PICC and placement of Hickman port for TPN [ ] GI followup - discuss long-term plan for nutritional support [ ] Physical Therapy needs upon discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Promethazine 12. ID:PRN nausea 3. Dronabinol 5 mg PO BID 4. BusPIRone 5 mg PO DAILY 5. gabapentin 8 ml oral TID 6. ondansetron 4 mg oral Q8H 7. vancomycin 125 mg oral DAILY 8. Enoxaparin Sodium 50 mg SC BID 9. Thiamine Dose is Unknown PO Frequency is Unknown Discharge Medications: 1. CefePIME 2 g IV Q12H Duration: 3 Doses RX *cefepime 2 gram 2 g IV every twelve (12) hours Disp #*3 Vial Refills:*0 2. Pyridostigmine Bromide Syrup 60 mg PO TID RX *pyridostigmine bromide 60 mg 1 tablet by mouth three times a day Disp #*90 Tablet Refills:*0 3. Vancomycin Oral Liquid [MASKED] mg PO QID Duration: 15 Days Please continue at this dose for two weeks after you complete IV antibiotics. RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day Disp #*80 Capsule Refills:*0 4. Gabapentin 600 mg PO TID RX *gabapentin 300 mg/6 mL (6 mL) 12 mL by mouth three times a day Disp #*1000 Milliliter Refills:*0 5. Promethazine 25 mg PR Q6H nausea RX *promethazine [Promethegan] 25 mg 1 suppository(s) rectally every six (6) hours Disp #*120 Suppository Refills:*0 6. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. BusPIRone 5 mg PO DAILY RX *buspirone 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Dronabinol 5 mg PO BID RX *dronabinol 5 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 9. Enoxaparin Sodium 50 mg SC BID RX *enoxaparin 100 mg/mL 0.5 (One half) mL subcutaneous every twelve (12) hours Disp #*60 Syringe Refills:*0 10. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. ondansetron 4 mg oral Q8H RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 12. HELD- vancomycin 125 mg oral DAILY This medication was held. Do not restart vancomycin until you have completed the more frequent dosing on [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: =================== septic shock malnutrition c. diff infection chronic abdominal pain, nausea SECONDARY DIAGNOSIS: ==================== thrombocytopenia neurogenic bladder POTS endometriosis bradycardia, AV block 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 part in your care here at [MASKED]! Why was I admitted to the hospital? - You were admitted for an infection in your bloodstream. What was done for me while I was in the hospital? - You received IV antibiotics. - A feeding tube was placed and you started tube feeds. Due to intractable nausea, your tube feeds had to be stopped and you were resumed on total parenteral nutrition. What should I do when I leave the hospital? - Please continue to take all of your medications. - Please attend all of your follow-up appointments. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "A4159: Other Gram-negative sepsis", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "R000: Tachycardia, unspecified", "I951: Orthostatic hypotension", "R1032: Left lower quadrant pain", "R1031: Right lower quadrant pain", "N319: Neuromuscular dysfunction of bladder, unspecified", "N39498: Other specified urinary incontinence", "Z9049: Acquired absence of other specified parts of digestive tract", "Z90710: Acquired absence of both cervix and uterus", "Z90722: Acquired absence of ovaries, bilateral", "Z9079: Acquired absence of other genital organ(s)", "G629: Polyneuropathy, unspecified", "I890: Lymphedema, not elsewhere classified", "R5382: Chronic fatigue, unspecified", "Z86711: Personal history of pulmonary embolism", "Z87891: Personal history of nicotine dependence", "R110: Nausea", "I441: Atrioventricular block, second degree", "D6959: Other secondary thrombocytopenia", "F4323: Adjustment disorder with mixed anxiety and depressed mood" ]
10,070,932
28,249,049
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: PICC removal PICC placement ___ History of Present Illness: Ms. ___ is a ___ female with a PMH of a possible mitochondrial disorder, POTS, chronic abdominal pain, severe endometriosis, neurogenic bladder s/p stimulator, recurrent c diff infections, malnutrition on TPN since ___, who presents to the ED with fever. On review of previous records, patient was hospitalized at ___ from ___ as a transfer from ___ ___. At that time, she was initially admitted to the MICU with septic shock and Enterobacter bacteremia thought to be secondary to a PICC line. She was initially on pressors, but improved with antibiotic therapy. Her PICC line was removed. She was ultimately narrowed to cefepime. A new PICC line was placed prior to discharge. Patient states that she was feeling well for the first week following discharge. She completed a course of cefepime on ___. However, she then began to experience chills during the first hour of her TPN infusions overnight. She began to have low-grade fevers which have slowly climbed. She only gets these fevers during the first hour of TPN infusions. They are also associated with headache and neck stiffness, as well as right ear pain. All of the symptoms are gone after the fever resolves. Patient was seen in ___ clinic for follow-up on the ___, after having completed antibiotics. She was doing well at that time. However she left a phone message on the ___ regarding her fevers. On the ___ it was recommended she present to the ED. Of note, patient performs intermittent bladder caths due to neurogenic bladder dysfuction. Denies any recent changes in her urine. She remains on p.o. vancomycin every 6 hours for treatment for C. difficile. She states that this was going to continue for 2 weeks following her antibiotic completion. Per review of records and discussion with patient, it appears that ultimate plan was for PICC line to be removed with placement of a port for TPN administration. Patient states that she uses TPN nightly, with ultimate plan to transition back to enteral feeding. She works closely with her GI doctor. In the ED, initial vitals: T 98.8, HR 74, BP 114/69, RR 16, 100% RA Labs were significant for - CBC: WBC 5.6, Hgb 10.4, Plt 132 - Lytes: 139 / 103 / 13 -------------- 83 3.7 \ 24 \ 0.6 - Lactate:1.0 Imaging was significant for: CXR with no acute cardiopulmonary abnormalities. Left upper extremity PICC tip projecting over the right atrium. Consider retraction by 3 cm. In the ED, pt received PO Tylenol and IV Zofran. Vitals prior to transfer: T 101.4, HR 100, BP 132/76, 18, 100% RA Currently, recounts history as above. States that she is currently feeling unwell, with some chills. ROS: Positive as noted above. Negative for: No weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria (though of note patient straight caths). No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: - Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. - Neurogenic bladder s/p stimulator - Gallstones status post cholecystectomy - POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. - Neuropathy in lower extremities - Lymphedema - Chronic fatigue - PE unprovoked bilateral PE ___, has family history of clots. Hypercoagulable workup at ___ reportedly negative - ? mitochondrial disease Social History: ___ Family History: - Mother - PE and gallbladder disease - Father - healthy - Two sons with mitochondrial disease, pseudoobstruction, passed away at ages ___ and ___. Physical Exam: ================================ EXAM ON ADMISSION ================================ VITALS: 103.0, HR 102, BP 93/49, RR 18, 96% RA GENERAL: Slightly shivering, ill-appearing EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart tachycardic and regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored BACK: nontender on palpation of spinal processes GI: Abdomen thin, soft, non-distended, mildy tender to palpation in center and left lower quadrant. 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 ================================ EXAM ON DISCHARGE ================================ Afebrile, aVSS Pain Scale: ___ GHEENT: eyes anicteric, normal hearing, nose unremarkable, dry MM without exudate CV: RRR no mrg, JVP 8cm, previous ___ site cdi Resp: crackles at bilateral bases GI: sntnd, NABS GU: no foley, neg CVAT MSK: no obvious synovitis Ext: wwp, neg edema in BLEs Skin: L dorsum foot with v small area of blanchable maculopapular erythema (unchanged from yesterday), not warm, not tender, no rash grossly visible, L pinky toe with onychomycosis Neuro: A&O grossly, MAEE, no facial droop, DOWB intact Psych: normal affect, pleasant Pertinent Results: ================================ LABS ON ADMISSION ================================ ___ 08:52PM BLOOD WBC-5.6 RBC-3.50* Hgb-10.4* Hct-31.4* MCV-90 MCH-29.7 MCHC-33.1 RDW-13.0 RDWSD-42.0 Plt ___ ___ 08:52PM BLOOD Neuts-51 Bands-5 ___ Monos-0 Eos-10* Baso-1 ___ Metas-2* Myelos-0 AbsNeut-3.14 AbsLymp-1.74 AbsMono-0.00* AbsEos-0.56* AbsBaso-0.06 ___ 08:52PM BLOOD Glucose-83 UreaN-13 Creat-0.6 Na-139 K-3.7 Cl-103 HCO3-24 AnGap-12 ___ 09:00PM BLOOD Lactate-1.0 ================================ MICROBIOLOGY ================================ BCx and Central Line Tip Cx: Blood Culture, Routine (Final ___: KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ================================ IMAGING ================================ ___ Chest Pa and Lat No acute cardiopulmonary abnormalities. Left upper extremity PICC tip projecting over the right atrium. Consider retraction by 3 cm. CXR post PICC placement ___ Left-sided PICC terminates in the distal SVC. No pneumothorax. Brief Hospital Course: ___ woman w possible mitochondrial d/o, POTS, chronic abd pain, severe endometriosis s/p TAH/BSO, neurogenic bladder s/p stimulator, recurrent c diff, malnutrition on TPN, recent TPN line infection p/w sepsis ___ GNR bacteremia from TPN line infection. ACUTE/ACTIVE PROBLEMS: # Sepsis: fever, hypotension, tachycardia, rigors. Secondary to # Central Line associated blood stream infection: TPN line Line infection found on admission, occurred prior to arrival, PICC discontinued on admission ___. Started on vancomycin (___) and cefepime on presentation (___). She was given a line holiday and PICC replaced ___. BCx and PICC tip cx grew pan-sensitive Klebsiella so antiibotics narrowed to IV Ceftriaxone 2gm daily which will continue for 14 days from line removal, last day ___. She will have outpatient follow up with ID within 3 weeks of discharge. # Thrombocytopenia: presented with thrombocytopenia, similar to previous infection episode, likely ___ sepsis. Low 4T score, no e/o DIC. Improved with sepsis treatment # Severe malnutrition: # Malabsorptive syndrome Continued home pyrodstigmine, thiamine, folate. Held TPN while line pulled. Started MVI. Will continue TPN per home regimen. Should consider placement of tunneled Hickman 2 weeks after completion of antibiotics. # Chronic stable anemia: monitored, stable throughout admission # Eosinophilia: mild on presentation. Unclear cause, has come down with treatment of infection but timing does not fit with medication effect. Resolved with treatment of above, though it is possible that this reduction was related to bacterial infection and so patient may have underlying eosinophilia. # Dorsal foot rash: noted to have a mild pruritic erythematous macular/papular lesion on dorsal foot, treated for tinea pedis. # h/o PE. Chronic, stable, continued home LMWH # Neurogenic bladder s/p stimulator # Chronic abd pain # Endometriosis s/p TAH/BSO Continued dronabinol, ondansetron per home regimen # Anxiety: continued home buspirone # neuropathy: continued home gabapentin ========= TRANSITIONAL ISSUES - recommend repeat CBC/diff to assess if eosinophilia persists - IV Ceftriaxone to continue until ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 5 mg PO DAILY 2. Dronabinol 5 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. ondansetron 4 mg oral Q8H 5. Promethazine 25 mg PR Q6H nausea 6. Thiamine 100 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. vancomycin 125 mg oral Q6H 9. Pyridostigmine Bromide Syrup 60 mg PO TID 10. Enoxaparin Sodium 50 mg SC Q12H Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H 2 weeks total from ___ RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV QDaily Disp #*11 Intravenous Bag Refills:*0 2. Clotrimazole Cream 1 Appl TP BID RX *clotrimazole 1 % Apply to skin twice a day Refills:*0 3. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 4. Vancomycin Oral Liquid ___ mg PO BID Please take for 1 week after completion of IV antibiotics RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp #*36 Capsule Refills:*0 5. BusPIRone 5 mg PO DAILY 6. Dronabinol 5 mg PO BID 7. Enoxaparin Sodium 50 mg SC Q12H 8. FoLIC Acid 1 mg PO DAILY 9. Gabapentin 600 mg PO TID 10. ondansetron 4 mg oral Q8H 11. Promethazine 25 mg PR Q6H nausea 12. Pyridostigmine Bromide Syrup 60 mg PO TID 13. Thiamine 100 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Sepsis Line infection Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure caring for you. You were admitted for fever and were found to have a line infection. You got better with antibiotics and removal of your line. Please complete your antibiotic course as prescribed which will end on ___. You should continue oral Vancomycin twice daily for 1 week after completion of IV antibiotics. We wish you the best in your recovery. Followup Instructions: ___
[ "T80211A", "A4150", "E43", "Z681", "E8840", "A0471", "K909", "Y838", "D696", "D721", "N319", "G8929", "R109", "G629", "F419", "Z792", "Z7901", "Z79899", "I498", "R5382", "K5900", "N809", "I890", "Z832", "B353", "Z86711" ]
Allergies: Demerol / ciprofloxacin / morphine / hydroxyzine Chief Complaint: fever Major Surgical or Invasive Procedure: PICC removal PICC placement [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] female with a PMH of a possible mitochondrial disorder, POTS, chronic abdominal pain, severe endometriosis, neurogenic bladder s/p stimulator, recurrent c diff infections, malnutrition on TPN since [MASKED], who presents to the ED with fever. On review of previous records, patient was hospitalized at [MASKED] from [MASKED] as a transfer from [MASKED] [MASKED]. At that time, she was initially admitted to the MICU with septic shock and Enterobacter bacteremia thought to be secondary to a PICC line. She was initially on pressors, but improved with antibiotic therapy. Her PICC line was removed. She was ultimately narrowed to cefepime. A new PICC line was placed prior to discharge. Patient states that she was feeling well for the first week following discharge. She completed a course of cefepime on [MASKED]. However, she then began to experience chills during the first hour of her TPN infusions overnight. She began to have low-grade fevers which have slowly climbed. She only gets these fevers during the first hour of TPN infusions. They are also associated with headache and neck stiffness, as well as right ear pain. All of the symptoms are gone after the fever resolves. Patient was seen in [MASKED] clinic for follow-up on the [MASKED], after having completed antibiotics. She was doing well at that time. However she left a phone message on the [MASKED] regarding her fevers. On the [MASKED] it was recommended she present to the ED. Of note, patient performs intermittent bladder caths due to neurogenic bladder dysfuction. Denies any recent changes in her urine. She remains on p.o. vancomycin every 6 hours for treatment for C. difficile. She states that this was going to continue for 2 weeks following her antibiotic completion. Per review of records and discussion with patient, it appears that ultimate plan was for PICC line to be removed with placement of a port for TPN administration. Patient states that she uses TPN nightly, with ultimate plan to transition back to enteral feeding. She works closely with her GI doctor. In the ED, initial vitals: T 98.8, HR 74, BP 114/69, RR 16, 100% RA Labs were significant for - CBC: WBC 5.6, Hgb 10.4, Plt 132 - Lytes: 139 / 103 / 13 -------------- 83 3.7 \ 24 \ 0.6 - Lactate:1.0 Imaging was significant for: CXR with no acute cardiopulmonary abnormalities. Left upper extremity PICC tip projecting over the right atrium. Consider retraction by 3 cm. In the ED, pt received PO Tylenol and IV Zofran. Vitals prior to transfer: T 101.4, HR 100, BP 132/76, 18, 100% RA Currently, recounts history as above. States that she is currently feeling unwell, with some chills. ROS: Positive as noted above. Negative for: No weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria (though of note patient straight caths). No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: - Stage IV endometriosis status post total hysterectomy and unilateral salpingo-oophorectomy along with multiple other abdominal surgeries for debulking of endometrial load. Per her, she has been refractory to all the hormonal therapies for endometriosis and is currently not on any therapy for the same. - Neurogenic bladder s/p stimulator - Gallstones status post cholecystectomy - POTS for which she has tried Mestinon with no improvement in symptoms. Of note, Mestinon also did not help her symptoms of constipation. - Neuropathy in lower extremities - Lymphedema - Chronic fatigue - PE unprovoked bilateral PE [MASKED], has family history of clots. Hypercoagulable workup at [MASKED] reportedly negative - ? mitochondrial disease Social History: [MASKED] Family History: - Mother - PE and gallbladder disease - Father - healthy - Two sons with mitochondrial disease, pseudoobstruction, passed away at ages [MASKED] and [MASKED]. Physical Exam: ================================ EXAM ON ADMISSION ================================ VITALS: 103.0, HR 102, BP 93/49, RR 18, 96% RA GENERAL: Slightly shivering, ill-appearing EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart tachycardic and regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored BACK: nontender on palpation of spinal processes GI: Abdomen thin, soft, non-distended, mildy tender to palpation in center and left lower quadrant. 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 ================================ EXAM ON DISCHARGE ================================ Afebrile, aVSS Pain Scale: [MASKED] GHEENT: eyes anicteric, normal hearing, nose unremarkable, dry MM without exudate CV: RRR no mrg, JVP 8cm, previous [MASKED] site cdi Resp: crackles at bilateral bases GI: sntnd, NABS GU: no foley, neg CVAT MSK: no obvious synovitis Ext: wwp, neg edema in BLEs Skin: L dorsum foot with v small area of blanchable maculopapular erythema (unchanged from yesterday), not warm, not tender, no rash grossly visible, L pinky toe with onychomycosis Neuro: A&O grossly, MAEE, no facial droop, DOWB intact Psych: normal affect, pleasant Pertinent Results: ================================ LABS ON ADMISSION ================================ [MASKED] 08:52PM BLOOD WBC-5.6 RBC-3.50* Hgb-10.4* Hct-31.4* MCV-90 MCH-29.7 MCHC-33.1 RDW-13.0 RDWSD-42.0 Plt [MASKED] [MASKED] 08:52PM BLOOD Neuts-51 Bands-5 [MASKED] Monos-0 Eos-10* Baso-1 [MASKED] Metas-2* Myelos-0 AbsNeut-3.14 AbsLymp-1.74 AbsMono-0.00* AbsEos-0.56* AbsBaso-0.06 [MASKED] 08:52PM BLOOD Glucose-83 UreaN-13 Creat-0.6 Na-139 K-3.7 Cl-103 HCO3-24 AnGap-12 [MASKED] 09:00PM BLOOD Lactate-1.0 ================================ MICROBIOLOGY ================================ BCx and Central Line Tip Cx: Blood Culture, Routine (Final [MASKED]: KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. [MASKED] KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ================================ IMAGING ================================ [MASKED] Chest Pa and Lat No acute cardiopulmonary abnormalities. Left upper extremity PICC tip projecting over the right atrium. Consider retraction by 3 cm. CXR post PICC placement [MASKED] Left-sided PICC terminates in the distal SVC. No pneumothorax. Brief Hospital Course: [MASKED] woman w possible mitochondrial d/o, POTS, chronic abd pain, severe endometriosis s/p TAH/BSO, neurogenic bladder s/p stimulator, recurrent c diff, malnutrition on TPN, recent TPN line infection p/w sepsis [MASKED] GNR bacteremia from TPN line infection. ACUTE/ACTIVE PROBLEMS: # Sepsis: fever, hypotension, tachycardia, rigors. Secondary to # Central Line associated blood stream infection: TPN line Line infection found on admission, occurred prior to arrival, PICC discontinued on admission [MASKED]. Started on vancomycin ([MASKED]) and cefepime on presentation ([MASKED]). She was given a line holiday and PICC replaced [MASKED]. BCx and PICC tip cx grew pan-sensitive Klebsiella so antiibotics narrowed to IV Ceftriaxone 2gm daily which will continue for 14 days from line removal, last day [MASKED]. She will have outpatient follow up with ID within 3 weeks of discharge. # Thrombocytopenia: presented with thrombocytopenia, similar to previous infection episode, likely [MASKED] sepsis. Low 4T score, no e/o DIC. Improved with sepsis treatment # Severe malnutrition: # Malabsorptive syndrome Continued home pyrodstigmine, thiamine, folate. Held TPN while line pulled. Started MVI. Will continue TPN per home regimen. Should consider placement of tunneled Hickman 2 weeks after completion of antibiotics. # Chronic stable anemia: monitored, stable throughout admission # Eosinophilia: mild on presentation. Unclear cause, has come down with treatment of infection but timing does not fit with medication effect. Resolved with treatment of above, though it is possible that this reduction was related to bacterial infection and so patient may have underlying eosinophilia. # Dorsal foot rash: noted to have a mild pruritic erythematous macular/papular lesion on dorsal foot, treated for tinea pedis. # h/o PE. Chronic, stable, continued home LMWH # Neurogenic bladder s/p stimulator # Chronic abd pain # Endometriosis s/p TAH/BSO Continued dronabinol, ondansetron per home regimen # Anxiety: continued home buspirone # neuropathy: continued home gabapentin ========= TRANSITIONAL ISSUES - recommend repeat CBC/diff to assess if eosinophilia persists - IV Ceftriaxone to continue until [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 5 mg PO DAILY 2. Dronabinol 5 mg PO BID 3. FoLIC Acid 1 mg PO DAILY 4. ondansetron 4 mg oral Q8H 5. Promethazine 25 mg PR Q6H nausea 6. Thiamine 100 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. vancomycin 125 mg oral Q6H 9. Pyridostigmine Bromide Syrup 60 mg PO TID 10. Enoxaparin Sodium 50 mg SC Q12H Discharge Medications: 1. CefTRIAXone 2 gm IV Q 24H 2 weeks total from [MASKED] RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV QDaily Disp #*11 Intravenous Bag Refills:*0 2. Clotrimazole Cream 1 Appl TP BID RX *clotrimazole 1 % Apply to skin twice a day Refills:*0 3. Multivitamins W/minerals 1 TAB PO DAILY RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 4. Vancomycin Oral Liquid [MASKED] mg PO BID Please take for 1 week after completion of IV antibiotics RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp #*36 Capsule Refills:*0 5. BusPIRone 5 mg PO DAILY 6. Dronabinol 5 mg PO BID 7. Enoxaparin Sodium 50 mg SC Q12H 8. FoLIC Acid 1 mg PO DAILY 9. Gabapentin 600 mg PO TID 10. ondansetron 4 mg oral Q8H 11. Promethazine 25 mg PR Q6H nausea 12. Pyridostigmine Bromide Syrup 60 mg PO TID 13. Thiamine 100 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Sepsis Line infection Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] was a pleasure caring for you. You were admitted for fever and were found to have a line infection. You got better with antibiotics and removal of your line. Please complete your antibiotic course as prescribed which will end on [MASKED]. You should continue oral Vancomycin twice daily for 1 week after completion of IV antibiotics. We wish you the best in your recovery. Followup Instructions: [MASKED]
[]
[ "D696", "G8929", "F419", "Z7901", "K5900" ]
[ "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "A4150: Gram-negative sepsis, unspecified", "E43: Unspecified severe protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "E8840: Mitochondrial metabolism disorder, unspecified", "A0471: Enterocolitis due to Clostridium difficile, recurrent", "K909: Intestinal malabsorption, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "D696: Thrombocytopenia, unspecified", "D721: Eosinophilia", "N319: Neuromuscular dysfunction of bladder, unspecified", "G8929: Other chronic pain", "R109: Unspecified abdominal pain", "G629: Polyneuropathy, unspecified", "F419: Anxiety disorder, unspecified", "Z792: Long term (current) use of antibiotics", "Z7901: Long term (current) use of anticoagulants", "Z79899: Other long term (current) drug therapy", "I498: Other specified cardiac arrhythmias", "R5382: Chronic fatigue, unspecified", "K5900: Constipation, unspecified", "N809: Endometriosis, unspecified", "I890: Lymphedema, not elsewhere classified", "Z832: Family history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism", "B353: Tinea pedis", "Z86711: Personal history of pulmonary embolism" ]
10,071,302
20,101,596
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Acute hypercarbic respiratory failure Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ female with history of COPD on home 2L NC, history of asbesteosis and known loculated left pleural effusion, presenting as a transfer from ___ for COPD exacerbation requiring BIPAP given lack of ICU beds, now on home oxygen requirement. The patient reported a worsening cough for the past week and developed difficulty breathing today. She was started on BiPAP by EMS and given 125 mg Solu-Medrol. She was maintained on BiPAP, may trialed her off BiPAP, she developed wheezing and shortness of breath, so they restarted her on BiPAP. Chest x-ray significant for left-sided pleural effusion. She received DuoNeb and azithromycin. Patient otherwise feels well, denying fevers, chills, headaches, visual changes, sore throat, chest pain, palpitations, nausea, vomiting, and abdominal pain, diarrhea dysuria. In the ED, patient was placed on 2 L O2 upon arrival. Vital signs notable for 97.8 77 110/60 24 98% on room air. Labs notable for normal CBC, normal BMP with creatinine of 1.0. VBG with pH 7.39, PCO2 51, PO2 124. She was reportedly breathing completely on room air. Upon arrival to the floor, the patient appears to be in acute respiratory distress. The history is limited due to significant difficulty breathing, ongoing accessory muscle use, inability to only speak a few words before she is short of breath. She reports she was recently on an antibiotic for an increased cough. She otherwise denies fevers, chills, chest pain, recent steroid use. She denies change in the chronic lower extremity edema. She reports she has had extreme reduced urinary output today. She has not eaten or drinking much. She otherwise denies urinary symptoms or dysuria. She reports she is very uncomfortable" just wants to be able to breathe." She triggered upon arrival for respiratory distress, tachypnea, diffuse expiratory wheezes, inability to speak in full sentences. I evaluated her promptly into the short history as above. She received a DuoNeb urgently followed by albuterol. I ordered IV methylprednisone 125 mg and 2 mg IV magnesium. Consult respiratory and ICU given her clinical exam, with concern for high risk of decompensation and likely need for BiPAP. Worsening symptoms may be because she last received IV Solu-Medrol at ___, appears to be prior to 1500, given short ___, ___ need further steroids. Following these interventions, the patient appeared more comfortable. She did still have some supraclavicular retractions, however was able to speak in full sentences and did appear more comfortable. ICU resident and agree she is at high risk for decompensation and if she fails to improve with medical treatment where she was a change in her ABG, she will be transferred to ICU. Approximately 1 hour after admission, patient is markedly improved patient still is mildly tachypneic with occasionaly mild supraclavicular retractions, however is now sleeping comfortably. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Asbestos exposure, pleural plaques, loculated left effusion COPD dependent on 2L O2 by NC at baseline Astham Major Depression Chronic Sinusitis GERD PSH Cholecystectomy Gastric bypass Hysterectomy Bladder surgery Social History: ___ Family History: Mother- ___ CA and CHD Father- ___ at an early age in ___ Physical Exam: Admission EXAM VITALS: 98.1 PO 124 / 72 L Lying 90 20 98 2L NC GENERAL: Alert, in obvious respiratory distress, able to speak in short sentences EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Wearing nebulizer machine CV: Heart regular, no murmur RESP: Lungs with diffuse expiratory wheezes in all lung fields, decreased air movement at the bases, + frequent supraclavicular retractions occurring with every breath GI: Abdomen soft, non-distended, non-tender 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 PSYCH: pleasant, appropriate affect Discharge Exam 24 HR Data (last updated ___ @ 826) Temp: 98.1 (Tm 98.9), BP: 107/56 (97-107/56-67), HR: 84 (77-103), RR: 18 (___), O2 sat: 100% (94-100), O2 delivery: 2L GEN: Alert, NAD, sitting in bed HEENT: NC/AT, neb mask in place CV: RRR, no m/r/g appreciated PULM: Very few wheezes, scattered bibasilar crackles, breathing appears comfortable on 2L NC ABD: Soft, NT/ND, BS present EXT: no ___ edema or calf tenderness SKIN: No apparent rashes on exposed skin NEURO: MAE PSYCH: Calm, appropriate Pertinent Results: Admission Labs ___ 08:30PM BLOOD WBC: 7.6 RBC: 4.31 Hgb: 12.9 Hct: 39.9 MCV: 93 MCH: 29.9 MCHC: 32.3 RDW: 13.5 RDWSD: 46.6* Plt Ct: 290 ___ 08:30PM BLOOD Neuts: 95.8* Lymphs: 2.9* Monos: 0.5* Eos: 0.1* Baso: 0.3 Im ___: 0.4 AbsNeut: 7.29* AbsLymp: 0.22* AbsMono: 0.04* AbsEos: 0.01* AbsBaso: 0.02 ___ 08:30PM BLOOD ___: 11.4 PTT: 29.8 ___: 1.1 ___ 08:30PM BLOOD Glucose: 129* UreaN: 12 Creat: 1.0 Na: 135 K: 4.8 Cl: 92* HCO3: 29 AnGap: 14 ___ 08:30PM BLOOD Type: ___ pO2: 124* pCO2: 51* pH: 7.39 calTCO2: 32* Base XS: 5 ___ 02:55AM BLOOD Type: ___ pO2: 147* pCO2: 55* pH: 7.35 calTCO2: 32* Base XS: 3 Intubat: NOT INTUBATED Comment: GREEN TOP TTE from ___ Technically difficult study due to lung disease, limited windows. Normal LV size with mildly increased wall thickness. Normal systolic function with calculated LVEF 65% by 2D measurement. Normal left atrium. The right atrium is normal seen. The right ventricle is not well seen. Normal trileaflet aortic valve structure and function. No aortic insufficiency or aortic stenosis. Aortic root and ascending aorta are normal in size. Mitral valve is mildly thickened with normal function. Trace mitral regurgitation. Normal tricuspid valve structure and function. Mild TR. Estimated PA systolic pressure 46 mmHg, assuming RA pressure of 15 mmHg. Dilated IVC with blunted respiratory variation. Mild pulmonary hypertension. Trace pulmonary insufficiency. Trivial (physiologic (pericardial effusion. CXR - IMPRESSION: Stable small left pleural effusion with atelectasis and pleural thickening. Interval improvement in right mid lung opacity. CTA CHEST - IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. New large, confluent ground-glass opacity in the right upper lobe, which is concerning for pneumonia or atypical infection. 3. Debris within the trachea and mucous plugging in the segmental and subsegmental airways of the right upper lobe and bilateral lower lobes, which most likely represents chronic bronchitis. 4. New peribronchial pulmonary nodules measuring up to 6 mm in the right lower lobe and a new 3 mm pulmonary nodule in the lingula. Please see recommendations for follow up of these nodules below. 5. Stable appearance of the small to moderate left pleural effusion with pleural thickening and enhancement. Unchanged adjacent compressive and rounded atelectasis in the lingula and left lower lobe. 6. Intracapsular rupture of the left subpectoral breast implant. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules measuring 6 to 8 mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended. Brief Hospital Course: ___ female with history of COPD on home 2L NC, history of asbestosis and known loculated left pleural effusion, presenting as a transfer from ___ for COPD exacerbation requiring BIPAP given lack of ICU beds, now on baseline home oxygen requirement found to have a right upper lobe healthcare associated pneumonia. # ACUTE ON CHRONIC HYPOXIC RESPIRATORY FAILURE # ACUTE COPD EXACERBATION # HEALTHCARE ASSOCIATED PNA Pt has improved with iv solumedrol, duonebs and vancomycin/cefepime IV for treatment of a healthcare associated pneumonia. CT scan negative for PE but did show right upper lobe pneumonia. Pulmonary was involved, and patient got back on her home O2 requirement. She reported that breathing has overall improved over course of hospitalization. Sputum cx finalized as MRSA and abx narrowed to vancomycin with plan for 10 day source. IV steroids were ultimately transitioned to PO prednisone with plan for 14 day taper. Per pulmonary, pt should continue TID NaCl 3% nebs and Acapella TID. Pt will need f/u chest CT as outpatient given pulmonary nodules seen on CT. # CONCERN FOR DYSPHAGIA: Subjective complaint of food getting stuck in her throat, suspect that this is more related to phlegm. Per RN, there has been no issue with eating and no coughing noted with PO intake. Would defer further evaluation to the outpatient setting if symptoms persist. # RUPTURED BREAST IMPLANT: Seen on CT scan. Plastics recommended outpatient f/u. # ASBESTOSIS # CHRONIC PLEURAL EFFUSION Per recent outpatient clinic note (Atrius), she had previously been evaluated by cardiothoracic surgery at ___, and felt to not need any surgical intervention. Will need outpatient f/u. # CHRONIC DIASTOLIC HF # PULMONARY EDEMA Patient did have some edema on exam, with improvement after IV Lasix. She has since been started on PO Lasix, with good UOP per pt report. # ETOH USE: Patient with prior history of heavy alcohol use, approximately ___ beers per day, with prior hospitalization significant for alcohol withdrawal. Patient reports she has not drank in approximately 4 months. Denies recent drinks. She has not exhibited signs of withdrawal on exam; however, she is also on standing benzo's which would make this unlikely. # IRON DEFICIENCY - Continue ferrous gluconate # DEPRESSION / ANXIETY # ADHD - Continue Fluoxetine 40 mg daily - Continue Amphetamine/Dextroamphetamine - Continue Clonazepam 1 mg TID # GERD - Continue Ranitidine 300 mg BID # HTN - Continue Metoprolol 25 mg BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ranitidine 300 mg PO BID 2. Metoprolol Tartrate 25 mg PO BID 3. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea 5. FLUoxetine 20 mg PO BID 6. Amphetamine-Dextroamphetamine 10 mg PO QAM 7. ClonazePAM 1 mg PO TID 8. Potassium Chloride 10 mEq PO DAILY 9. Furosemide 40 mg PO BID 10. Ferrous GLUCONATE 324 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Loratadine 10 mg PO DAILY 14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 15. Brovana (arformoterol) 15 mcg/2 mL inhalation BID 16. Fluticasone Propionate NASAL 2 SPRY NU DAILY 17. Fluticasone Propionate 110mcg 2 PUFF IH BID 18. TraZODone 150 mg PO QHS 19. Amphetamine-Dextroamphetamine 5 mg PO QPM Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Polyethylene Glycol 17 g PO DAILY 3. PredniSONE 20 mg PO DAILY Duration: 7 Days RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 5. Amphetamine-Dextroamphetamine 5 mg PO TID 6. Aspirin 81 mg PO DAILY 7. Brovana (arformoterol) 15 mcg/2 mL inhalation BID 8. ClonazePAM 1 mg PO TID 9. Ferrous GLUCONATE 324 mg PO DAILY 10. FLUoxetine 20 mg PO BID 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. Fluticasone Propionate NASAL 2 SPRY NU DAILY 13. FoLIC Acid 1 mg PO DAILY 14. Furosemide 40 mg PO BID 15. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY 16. Loratadine 10 mg PO DAILY 17. Metoprolol Tartrate 25 mg PO BID 18. Potassium Chloride 10 mEq PO DAILY 19. Ranitidine 300 mg PO BID 20. TraZODone 150 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute hypercarbic/hypoxic respiratory failure Acute Chronic Obstructive Pulmonary Disease Exacerbation Healthcare associated pneumonia Lung Nodules Breast Implant Rupture (intracapsular) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Hi Ms. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted here for treatment of an exacerbation of COPD as well as a pneumonia for which you were treated with antibiotics, steroids, and oxygen with improvement in your condition. You will continue to take steroids for another week. The chest CT scan obtained during your hospitalization showed lung nodules for which a repeat CT scan is advised in 3 months. Please follow up with your primary care physician to have this arranged. Please have your primary care doctor also verify a fungal (Aspergillus) test that was still pending. It is very important that you schedule with a pulmonary doctor near where you live so that you have a lung expert helping monitoring that part of your health. The CT scan also showed evidence of a breast implant rupture on the left. Please follow up with plastic surgery as an outpatient for additional evaluation. It was a pleasure caring for you. Sincerely, Your ___ Team Followup Instructions: ___
[ "J441", "J9621", "J9622", "J189", "T8549XA", "I5032", "J440", "I110", "I2720", "Z9981", "E860", "E611", "F1011", "F909", "F419", "J920", "F329", "K219", "R918", "K5900", "Y831", "Y92009" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Acute hypercarbic respiratory failure Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [MASKED] female with history of COPD on home 2L NC, history of asbesteosis and known loculated left pleural effusion, presenting as a transfer from [MASKED] for COPD exacerbation requiring BIPAP given lack of ICU beds, now on home oxygen requirement. The patient reported a worsening cough for the past week and developed difficulty breathing today. She was started on BiPAP by EMS and given 125 mg Solu-Medrol. She was maintained on BiPAP, may trialed her off BiPAP, she developed wheezing and shortness of breath, so they restarted her on BiPAP. Chest x-ray significant for left-sided pleural effusion. She received DuoNeb and azithromycin. Patient otherwise feels well, denying fevers, chills, headaches, visual changes, sore throat, chest pain, palpitations, nausea, vomiting, and abdominal pain, diarrhea dysuria. In the ED, patient was placed on 2 L O2 upon arrival. Vital signs notable for 97.8 77 110/60 24 98% on room air. Labs notable for normal CBC, normal BMP with creatinine of 1.0. VBG with pH 7.39, PCO2 51, PO2 124. She was reportedly breathing completely on room air. Upon arrival to the floor, the patient appears to be in acute respiratory distress. The history is limited due to significant difficulty breathing, ongoing accessory muscle use, inability to only speak a few words before she is short of breath. She reports she was recently on an antibiotic for an increased cough. She otherwise denies fevers, chills, chest pain, recent steroid use. She denies change in the chronic lower extremity edema. She reports she has had extreme reduced urinary output today. She has not eaten or drinking much. She otherwise denies urinary symptoms or dysuria. She reports she is very uncomfortable" just wants to be able to breathe." She triggered upon arrival for respiratory distress, tachypnea, diffuse expiratory wheezes, inability to speak in full sentences. I evaluated her promptly into the short history as above. She received a DuoNeb urgently followed by albuterol. I ordered IV methylprednisone 125 mg and 2 mg IV magnesium. Consult respiratory and ICU given her clinical exam, with concern for high risk of decompensation and likely need for BiPAP. Worsening symptoms may be because she last received IV Solu-Medrol at [MASKED], appears to be prior to 1500, given short [MASKED], [MASKED] need further steroids. Following these interventions, the patient appeared more comfortable. She did still have some supraclavicular retractions, however was able to speak in full sentences and did appear more comfortable. ICU resident and agree she is at high risk for decompensation and if she fails to improve with medical treatment where she was a change in her ABG, she will be transferred to ICU. Approximately 1 hour after admission, patient is markedly improved patient still is mildly tachypneic with occasionaly mild supraclavicular retractions, however is now sleeping comfortably. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Asbestos exposure, pleural plaques, loculated left effusion COPD dependent on 2L O2 by NC at baseline Astham Major Depression Chronic Sinusitis GERD PSH Cholecystectomy Gastric bypass Hysterectomy Bladder surgery Social History: [MASKED] Family History: Mother- [MASKED] CA and CHD Father- [MASKED] at an early age in [MASKED] Physical Exam: Admission EXAM VITALS: 98.1 PO 124 / 72 L Lying 90 20 98 2L NC GENERAL: Alert, in obvious respiratory distress, able to speak in short sentences EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate Wearing nebulizer machine CV: Heart regular, no murmur RESP: Lungs with diffuse expiratory wheezes in all lung fields, decreased air movement at the bases, + frequent supraclavicular retractions occurring with every breath GI: Abdomen soft, non-distended, non-tender 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 PSYCH: pleasant, appropriate affect Discharge Exam 24 HR Data (last updated [MASKED] @ 826) Temp: 98.1 (Tm 98.9), BP: 107/56 (97-107/56-67), HR: 84 (77-103), RR: 18 ([MASKED]), O2 sat: 100% (94-100), O2 delivery: 2L GEN: Alert, NAD, sitting in bed HEENT: NC/AT, neb mask in place CV: RRR, no m/r/g appreciated PULM: Very few wheezes, scattered bibasilar crackles, breathing appears comfortable on 2L NC ABD: Soft, NT/ND, BS present EXT: no [MASKED] edema or calf tenderness SKIN: No apparent rashes on exposed skin NEURO: MAE PSYCH: Calm, appropriate Pertinent Results: Admission Labs [MASKED] 08:30PM BLOOD WBC: 7.6 RBC: 4.31 Hgb: 12.9 Hct: 39.9 MCV: 93 MCH: 29.9 MCHC: 32.3 RDW: 13.5 RDWSD: 46.6* Plt Ct: 290 [MASKED] 08:30PM BLOOD Neuts: 95.8* Lymphs: 2.9* Monos: 0.5* Eos: 0.1* Baso: 0.3 Im [MASKED]: 0.4 AbsNeut: 7.29* AbsLymp: 0.22* AbsMono: 0.04* AbsEos: 0.01* AbsBaso: 0.02 [MASKED] 08:30PM BLOOD [MASKED]: 11.4 PTT: 29.8 [MASKED]: 1.1 [MASKED] 08:30PM BLOOD Glucose: 129* UreaN: 12 Creat: 1.0 Na: 135 K: 4.8 Cl: 92* HCO3: 29 AnGap: 14 [MASKED] 08:30PM BLOOD Type: [MASKED] pO2: 124* pCO2: 51* pH: 7.39 calTCO2: 32* Base XS: 5 [MASKED] 02:55AM BLOOD Type: [MASKED] pO2: 147* pCO2: 55* pH: 7.35 calTCO2: 32* Base XS: 3 Intubat: NOT INTUBATED Comment: GREEN TOP TTE from [MASKED] Technically difficult study due to lung disease, limited windows. Normal LV size with mildly increased wall thickness. Normal systolic function with calculated LVEF 65% by 2D measurement. Normal left atrium. The right atrium is normal seen. The right ventricle is not well seen. Normal trileaflet aortic valve structure and function. No aortic insufficiency or aortic stenosis. Aortic root and ascending aorta are normal in size. Mitral valve is mildly thickened with normal function. Trace mitral regurgitation. Normal tricuspid valve structure and function. Mild TR. Estimated PA systolic pressure 46 mmHg, assuming RA pressure of 15 mmHg. Dilated IVC with blunted respiratory variation. Mild pulmonary hypertension. Trace pulmonary insufficiency. Trivial (physiologic (pericardial effusion. CXR - IMPRESSION: Stable small left pleural effusion with atelectasis and pleural thickening. Interval improvement in right mid lung opacity. CTA CHEST - IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. New large, confluent ground-glass opacity in the right upper lobe, which is concerning for pneumonia or atypical infection. 3. Debris within the trachea and mucous plugging in the segmental and subsegmental airways of the right upper lobe and bilateral lower lobes, which most likely represents chronic bronchitis. 4. New peribronchial pulmonary nodules measuring up to 6 mm in the right lower lobe and a new 3 mm pulmonary nodule in the lingula. Please see recommendations for follow up of these nodules below. 5. Stable appearance of the small to moderate left pleural effusion with pleural thickening and enhancement. Unchanged adjacent compressive and rounded atelectasis in the lingula and left lower lobe. 6. Intracapsular rupture of the left subpectoral breast implant. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules measuring 6 to 8 mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended. Brief Hospital Course: [MASKED] female with history of COPD on home 2L NC, history of asbestosis and known loculated left pleural effusion, presenting as a transfer from [MASKED] for COPD exacerbation requiring BIPAP given lack of ICU beds, now on baseline home oxygen requirement found to have a right upper lobe healthcare associated pneumonia. # ACUTE ON CHRONIC HYPOXIC RESPIRATORY FAILURE # ACUTE COPD EXACERBATION # HEALTHCARE ASSOCIATED PNA Pt has improved with iv solumedrol, duonebs and vancomycin/cefepime IV for treatment of a healthcare associated pneumonia. CT scan negative for PE but did show right upper lobe pneumonia. Pulmonary was involved, and patient got back on her home O2 requirement. She reported that breathing has overall improved over course of hospitalization. Sputum cx finalized as MRSA and abx narrowed to vancomycin with plan for 10 day source. IV steroids were ultimately transitioned to PO prednisone with plan for 14 day taper. Per pulmonary, pt should continue TID NaCl 3% nebs and Acapella TID. Pt will need f/u chest CT as outpatient given pulmonary nodules seen on CT. # CONCERN FOR DYSPHAGIA: Subjective complaint of food getting stuck in her throat, suspect that this is more related to phlegm. Per RN, there has been no issue with eating and no coughing noted with PO intake. Would defer further evaluation to the outpatient setting if symptoms persist. # RUPTURED BREAST IMPLANT: Seen on CT scan. Plastics recommended outpatient f/u. # ASBESTOSIS # CHRONIC PLEURAL EFFUSION Per recent outpatient clinic note (Atrius), she had previously been evaluated by cardiothoracic surgery at [MASKED], and felt to not need any surgical intervention. Will need outpatient f/u. # CHRONIC DIASTOLIC HF # PULMONARY EDEMA Patient did have some edema on exam, with improvement after IV Lasix. She has since been started on PO Lasix, with good UOP per pt report. # ETOH USE: Patient with prior history of heavy alcohol use, approximately [MASKED] beers per day, with prior hospitalization significant for alcohol withdrawal. Patient reports she has not drank in approximately 4 months. Denies recent drinks. She has not exhibited signs of withdrawal on exam; however, she is also on standing benzo's which would make this unlikely. # IRON DEFICIENCY - Continue ferrous gluconate # DEPRESSION / ANXIETY # ADHD - Continue Fluoxetine 40 mg daily - Continue Amphetamine/Dextroamphetamine - Continue Clonazepam 1 mg TID # GERD - Continue Ranitidine 300 mg BID # HTN - Continue Metoprolol 25 mg BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ranitidine 300 mg PO BID 2. Metoprolol Tartrate 25 mg PO BID 3. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY 4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea 5. FLUoxetine 20 mg PO BID 6. Amphetamine-Dextroamphetamine 10 mg PO QAM 7. ClonazePAM 1 mg PO TID 8. Potassium Chloride 10 mEq PO DAILY 9. Furosemide 40 mg PO BID 10. Ferrous GLUCONATE 324 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Loratadine 10 mg PO DAILY 14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 15. Brovana (arformoterol) 15 mcg/2 mL inhalation BID 16. Fluticasone Propionate NASAL 2 SPRY NU DAILY 17. Fluticasone Propionate 110mcg 2 PUFF IH BID 18. TraZODone 150 mg PO QHS 19. Amphetamine-Dextroamphetamine 5 mg PO QPM Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Polyethylene Glycol 17 g PO DAILY 3. PredniSONE 20 mg PO DAILY Duration: 7 Days RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 5. Amphetamine-Dextroamphetamine 5 mg PO TID 6. Aspirin 81 mg PO DAILY 7. Brovana (arformoterol) 15 mcg/2 mL inhalation BID 8. ClonazePAM 1 mg PO TID 9. Ferrous GLUCONATE 324 mg PO DAILY 10. FLUoxetine 20 mg PO BID 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. Fluticasone Propionate NASAL 2 SPRY NU DAILY 13. FoLIC Acid 1 mg PO DAILY 14. Furosemide 40 mg PO BID 15. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY 16. Loratadine 10 mg PO DAILY 17. Metoprolol Tartrate 25 mg PO BID 18. Potassium Chloride 10 mEq PO DAILY 19. Ranitidine 300 mg PO BID 20. TraZODone 150 mg PO QHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Acute hypercarbic/hypoxic respiratory failure Acute Chronic Obstructive Pulmonary Disease Exacerbation Healthcare associated pneumonia Lung Nodules Breast Implant Rupture (intracapsular) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Hi Ms. [MASKED], It was a pleasure taking care of you during your hospitalization at [MASKED]. You were admitted here for treatment of an exacerbation of COPD as well as a pneumonia for which you were treated with antibiotics, steroids, and oxygen with improvement in your condition. You will continue to take steroids for another week. The chest CT scan obtained during your hospitalization showed lung nodules for which a repeat CT scan is advised in 3 months. Please follow up with your primary care physician to have this arranged. Please have your primary care doctor also verify a fungal (Aspergillus) test that was still pending. It is very important that you schedule with a pulmonary doctor near where you live so that you have a lung expert helping monitoring that part of your health. The CT scan also showed evidence of a breast implant rupture on the left. Please follow up with plastic surgery as an outpatient for additional evaluation. It was a pleasure caring for you. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I5032", "I110", "F419", "F329", "K219", "K5900" ]
[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J9621: Acute and chronic respiratory failure with hypoxia", "J9622: Acute and chronic respiratory failure with hypercapnia", "J189: Pneumonia, unspecified organism", "T8549XA: Other mechanical complication of breast prosthesis and implant, initial encounter", "I5032: Chronic diastolic (congestive) heart failure", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "I110: Hypertensive heart disease with heart failure", "I2720: Pulmonary hypertension, unspecified", "Z9981: Dependence on supplemental oxygen", "E860: Dehydration", "E611: Iron deficiency", "F1011: Alcohol abuse, in remission", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F419: Anxiety disorder, unspecified", "J920: Pleural plaque with presence of asbestos", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R918: Other nonspecific abnormal finding of lung field", "K5900: Constipation, unspecified", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
10,071,435
23,745,288
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___: Urgent coronary artery bypass grafting x3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the ramus intermedius branch and diagonal branch. History of Present Illness: ___ yo male with past medical history of hyperlipidemia, BPH, and active smoker presented to ___ with intermittent chest pain over the past five days. Complains of chest pain that typically comes on at rest and lasts ___ minutes and goes away. Yesterday he had an episode of similar discomfort, but it did not go away and was associated with sweating and shortness of breath. EMS was called and he was given 4 baby aspirin and SL nitro with resolution of chest pain. He was taken to ___ where he had +troponin. Cath today by Dr. ___ 90% LM ostial and distal, totally occluded Lcx & RCA, 80% ___ LAD. IABP placed, per report he remains stable, chest pain free, not on any pressors, and was not given any blood thinners. He is transferred to ___ for evaluation for coronary artery bypass grafts. Past Medical History: CAD Hyperlipidemia Benign Prostatic Hypertrophy Colon polyps Diverticulosis, Hemorrhoids Abdominal aortic aneurysm - followed by PCP ___ habituation ___ TURP Social History: ___ Family History: Mother deceased ___ ___ Uncle ___ Father deceased hx alcoholism Brother deceased hx alcoholism Physical Exam: ADMIT EXAM Pulse: 49 B/P ___ Resp: 12 O2 sat: 100% 2L NC Height: 71" Weight: 65.5 kg General: No acute distress Skin: Dry intact HEENT: PERRLA EOMI left eye with erythema no drainage no itching Neck: Supple Full ROM Chest: Lungs clear anteriorly as bedrest with IABP Heart: RRR no murmur or rub Abdomen: Soft non-distended non-tender bowel sounds + Extremities: Warm well-perfused Edema none Varicosities: None Neuro: Alert and oriented x3 no focal deficits noted for contracture in fingers mostly likely trigger fingers Pulses: Femoral Right: P IABP in place Left: P DP Right: D Left: D ___ Right: P Left: P Radial Right: TR band Left: P Carotid Bruit: Right: no bruit Left: no bruit DISCHARGE EXAM - 98.9 PO 122 / 64 R Lying 74 16 95 Ra . General: NAD Neurological: A/O x3 Moves all extremities Cardiovascular: RRR no murmur or rub Respiratory: CTA No resp distress GU/Renal: Urine clear [] GI/Abdomen: Bowel sounds + Soft ND NT Extremities: Right Upper extremity Warm Edema Left Upper extremity Warm Edema Right Lower extremity Warm Edema tr Left Lower extremity Warm Edema tr Pulses: DP Right: d Left:d ___ Right: p Left:p Radial Right: + Left:+ Sternal: CDI no erythema or drainage Sternum stable Lower extremity: Right- c/d/I Left - left SVH site at knee with large ___ that drained covered with adaptic Pertinent Results: Admission labs: ___ 01:40PM BLOOD WBC-6.5 RBC-3.92* Hgb-12.7* Hct-39.4* MCV-101* MCH-32.4* MCHC-32.2 RDW-13.9 RDWSD-51.0* Plt ___ ___ 01:40PM BLOOD ___ PTT-77.7* ___ ___ 01:40PM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-142 K-4.3 Cl-108 HCO3-26 AnGap-8* ___ 01:40PM BLOOD ALT-6 AST-16 LD(LDH)-221 CK(CPK)-54 AlkPhos-67 TotBili-0.4 ___ 01:40PM BLOOD TotProt-6.1* Albumin-3.9 Globuln-2.2 Calcium-8.9 Phos-3.4 Mg-2.0 ___ 01:40PM BLOOD %HbA1c-5.5 eAG-111 ..................... Radiology Report CHEST (PA & LAT) Study Date of ___ 9:53 AM Final Report: Compared to prior radiograph from ___, there is stable appearance of the cardiomediastinal silhouette. The left lung opacification has improved. Any residual pneumothorax is extremely small. There are small bilateral pleural effusions. There is linear opacity over the right hemidiaphragm consistent with atelectasis. IMPRESSION: 1. Any residual pneumothorax is extremely small. 2. Trace bilateral pleural effusions. 3. Right basilar atelectasis. .................. ___: PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm. Left Atrium (LA)/Pulmonary Veins: Normal LA size. 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): Mild symmetric hypertrophy. Mildly dilated cavity. Mild regional systolic dysfunction (see schematic). Mildly depressed ejection fraction. Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: Normal sinus diameter. Normal ascending diameter. Normal arch diameter. Mild descending aorta dilation. No aortic coarcation. No dissection. Focal calcifications in the sinus. Complex (>4mm) arch atheroma. Complex (>4mm) descending atheroma. IABP in descending aorta with tip 4-5 cm below left subclavian Aortic Valve: Mildly thickened (3) leaflets. Moderate leaflet calcification. Mild (>1.5cm2) stenosis. No regurgitation. Mitral Valve: Mildly thickened leaflets. No stenosis. Moderate annular calcification. Mild [1+] regurgitation. Central jet. Pulmonic Valve: Normal leaflets. Mild-moderate regurgitation. Tricuspid Valve: Normal leaflets. Mild [1+] regurgitation. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 10:18:00. AV paced rhythm. Left Ventricle: Similar to preoperative findings. Global ejection fraction is low normal. Right Ventricle: No change in systolic function. Aorta: Intact. No dissection. No change in IABP position. 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. Similar gradient to preoperative state. No change in valvular regurgitation from preoperative state. Tricuspid Valve: No change in tricuspid valve morphology vs. preoperative state. Pericardium: No effusion. .................................... ___ Final Report EXAMINATION: AORTA AND BRANCHES INDICATION: ___ year old man with ___ cabg// Evaluation of and aortic aneurysms TECHNIQUE: Grayscale and color Doppler ultrasound of the abdominal aorta was performed. COMPARISON: None. FINDINGS: The aorta measures 2.6 cm in the proximal portion, 2.7 cm in mid portion and 3.9 x 4.3 cm in the distal abdominal aorta. The aorta begins to dilate in the mid aorta, and is most dilated in the proximal infrarenal aorta with distal tapering such that the diameter of the aorta decreases to 2.5 cm just before the bifurcation. The aorta has heavy atherosclerosis throughout, with a larger area of thrombus/plaque peripherally in the infrarenal aorta. The right common iliac artery measures 2.5 cm and the left common iliac artery measures 1.2 cm. The right kidney measures 10.4 cm and the left kidney measures 10.5 cm. There is a 5.5 x 5.7 x 5.9 cm simple renal cyst in the left mid acute knee. Limited views of the kidneys are unremarkable without hydronephrosis. IMPRESSION: Infrarenal abdominal aortic aneurysm up to 4.3 cm. Right common iliac artery aneurysm up to 2.5 cm. NOTIFICATION: The findings were discussed with ___, NP, by ___ ___, M.D. on the telephone on ___ at 1:32 pm, 5 minutes after discovery of the findings. BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE. ___ ___, MD electronically signed on ___ 5:21 ___ Imaging Lab Report History MON ___ 5:21 ___ by INFORMATION,SYSTEMS Brief Hospital Course: Patient was transferred from ___ for surgical revascularization after ruling in for NSTEMI and cardiac catheterization that revealed Left Main and multi vessel disease for which and IABP was placed. He was admitted to the CVICU and remained pain free on IABP, Nitroglycerin and heparin infusion. He underwent routine preoperative evaluation and was cleared for surgery. The patient was brought to the Operating Room on ___ where the patient underwent coronary artery bypass grafting by Dr. ___ - see operative note for details. In summary he had: Urgent coronary artery bypass grafting x3, with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the ramus intermedius branch and diagonal branch. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He did well post-operatively and was extubated shortly after arrival to CVICU. POD 1 found the patient alert, oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. All chest tubes, lines and pacing wires were discontinued per cardiac surgery protocol without complication. Once on the stepdown floor the patient worked with nursing and was evaluated by the Physical Therapy service for assistance with strength and mobility. The remainder of his hospital stay was uneventful. 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, to a friend's house, with visiting nurses in good condition with appropriate follow up instructions. Of note, the patient does have a history of AAA. Imaging during this admission, ___, reveals, "Infrarenal abdominal aortic aneurysm up to 4.3 cm. Right common iliac artery aneurysm up to 2.5 cm." Results communicated to PCP. 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 Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*100 Tablet Refills:*0 2. Furosemide 20 mg PO BID 20 mg BID x 7 days then 20 mg daily x 10 days RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*24 Tablet Refills:*0 3. Lidocaine 5% Patch 1 PTCH TD QPM RX *lidocaine 5 % 1 patch qpm Disp #*10 Patch Refills:*0 4. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) patch by mouth twice a day Disp #*60 Tablet Refills:*1 5. Potassium Chloride 10 mEq PO Q12H 10 mEq BID x 7 days then 10 mEq daily x 10 days RX *potassium chloride 10 mEq 1 packet(s) by mouth twice a day Disp #*24 Tablet Refills:*0 6. Ranitidine 150 mg PO DAILY Duration: 30 Days RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Simvastatin 40 mg PO QPM RX *simvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet Refills:*1 8. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Coronary Artery Disease ___ cabg Secondary: Hyperlipidemia Benign Prostatic Hypertrophy Colon polyps Diverticulosis Hemorrhoids Abdominal aortic aneurysm ___ habituation 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 Bilat ___ incisions- right c/d/I, left with some serous drainage after blister reduced Edema trace bilat ___ 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 one month or while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
[ "I214", "D62", "I2510", "E785", "I714", "I723", "Z781", "F17210", "Z590", "Y832", "Y92239" ]
Allergies: No Allergies/ADRs on File Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED]: Urgent coronary artery bypass grafting x3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the ramus intermedius branch and diagonal branch. History of Present Illness: [MASKED] yo male with past medical history of hyperlipidemia, BPH, and active smoker presented to [MASKED] with intermittent chest pain over the past five days. Complains of chest pain that typically comes on at rest and lasts [MASKED] minutes and goes away. Yesterday he had an episode of similar discomfort, but it did not go away and was associated with sweating and shortness of breath. EMS was called and he was given 4 baby aspirin and SL nitro with resolution of chest pain. He was taken to [MASKED] where he had +troponin. Cath today by Dr. [MASKED] 90% LM ostial and distal, totally occluded Lcx & RCA, 80% [MASKED] LAD. IABP placed, per report he remains stable, chest pain free, not on any pressors, and was not given any blood thinners. He is transferred to [MASKED] for evaluation for coronary artery bypass grafts. Past Medical History: CAD Hyperlipidemia Benign Prostatic Hypertrophy Colon polyps Diverticulosis, Hemorrhoids Abdominal aortic aneurysm - followed by PCP [MASKED] habituation [MASKED] TURP Social History: [MASKED] Family History: Mother deceased [MASKED] [MASKED] Uncle [MASKED] Father deceased hx alcoholism Brother deceased hx alcoholism Physical Exam: ADMIT EXAM Pulse: 49 B/P [MASKED] Resp: 12 O2 sat: 100% 2L NC Height: 71" Weight: 65.5 kg General: No acute distress Skin: Dry intact HEENT: PERRLA EOMI left eye with erythema no drainage no itching Neck: Supple Full ROM Chest: Lungs clear anteriorly as bedrest with IABP Heart: RRR no murmur or rub Abdomen: Soft non-distended non-tender bowel sounds + Extremities: Warm well-perfused Edema none Varicosities: None Neuro: Alert and oriented x3 no focal deficits noted for contracture in fingers mostly likely trigger fingers Pulses: Femoral Right: P IABP in place Left: P DP Right: D Left: D [MASKED] Right: P Left: P Radial Right: TR band Left: P Carotid Bruit: Right: no bruit Left: no bruit DISCHARGE EXAM - 98.9 PO 122 / 64 R Lying 74 16 95 Ra . General: NAD Neurological: A/O x3 Moves all extremities Cardiovascular: RRR no murmur or rub Respiratory: CTA No resp distress GU/Renal: Urine clear [] GI/Abdomen: Bowel sounds + Soft ND NT Extremities: Right Upper extremity Warm Edema Left Upper extremity Warm Edema Right Lower extremity Warm Edema tr Left Lower extremity Warm Edema tr Pulses: DP Right: d Left:d [MASKED] Right: p Left:p Radial Right: + Left:+ Sternal: CDI no erythema or drainage Sternum stable Lower extremity: Right- c/d/I Left - left SVH site at knee with large [MASKED] that drained covered with adaptic Pertinent Results: Admission labs: [MASKED] 01:40PM BLOOD WBC-6.5 RBC-3.92* Hgb-12.7* Hct-39.4* MCV-101* MCH-32.4* MCHC-32.2 RDW-13.9 RDWSD-51.0* Plt [MASKED] [MASKED] 01:40PM BLOOD [MASKED] PTT-77.7* [MASKED] [MASKED] 01:40PM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-142 K-4.3 Cl-108 HCO3-26 AnGap-8* [MASKED] 01:40PM BLOOD ALT-6 AST-16 LD(LDH)-221 CK(CPK)-54 AlkPhos-67 TotBili-0.4 [MASKED] 01:40PM BLOOD TotProt-6.1* Albumin-3.9 Globuln-2.2 Calcium-8.9 Phos-3.4 Mg-2.0 [MASKED] 01:40PM BLOOD %HbA1c-5.5 eAG-111 ..................... Radiology Report CHEST (PA & LAT) Study Date of [MASKED] 9:53 AM Final Report: Compared to prior radiograph from [MASKED], there is stable appearance of the cardiomediastinal silhouette. The left lung opacification has improved. Any residual pneumothorax is extremely small. There are small bilateral pleural effusions. There is linear opacity over the right hemidiaphragm consistent with atelectasis. IMPRESSION: 1. Any residual pneumothorax is extremely small. 2. Trace bilateral pleural effusions. 3. Right basilar atelectasis. .................. [MASKED]: PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm. Left Atrium (LA)/Pulmonary Veins: Normal LA size. 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): Mild symmetric hypertrophy. Mildly dilated cavity. Mild regional systolic dysfunction (see schematic). Mildly depressed ejection fraction. Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: Normal sinus diameter. Normal ascending diameter. Normal arch diameter. Mild descending aorta dilation. No aortic coarcation. No dissection. Focal calcifications in the sinus. Complex (>4mm) arch atheroma. Complex (>4mm) descending atheroma. IABP in descending aorta with tip 4-5 cm below left subclavian Aortic Valve: Mildly thickened (3) leaflets. Moderate leaflet calcification. Mild (>1.5cm2) stenosis. No regurgitation. Mitral Valve: Mildly thickened leaflets. No stenosis. Moderate annular calcification. Mild [1+] regurgitation. Central jet. Pulmonic Valve: Normal leaflets. Mild-moderate regurgitation. Tricuspid Valve: Normal leaflets. Mild [1+] regurgitation. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 10:18:00. AV paced rhythm. Left Ventricle: Similar to preoperative findings. Global ejection fraction is low normal. Right Ventricle: No change in systolic function. Aorta: Intact. No dissection. No change in IABP position. 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. Similar gradient to preoperative state. No change in valvular regurgitation from preoperative state. Tricuspid Valve: No change in tricuspid valve morphology vs. preoperative state. Pericardium: No effusion. .................................... [MASKED] Final Report EXAMINATION: AORTA AND BRANCHES INDICATION: [MASKED] year old man with [MASKED] cabg// Evaluation of and aortic aneurysms TECHNIQUE: Grayscale and color Doppler ultrasound of the abdominal aorta was performed. COMPARISON: None. FINDINGS: The aorta measures 2.6 cm in the proximal portion, 2.7 cm in mid portion and 3.9 x 4.3 cm in the distal abdominal aorta. The aorta begins to dilate in the mid aorta, and is most dilated in the proximal infrarenal aorta with distal tapering such that the diameter of the aorta decreases to 2.5 cm just before the bifurcation. The aorta has heavy atherosclerosis throughout, with a larger area of thrombus/plaque peripherally in the infrarenal aorta. The right common iliac artery measures 2.5 cm and the left common iliac artery measures 1.2 cm. The right kidney measures 10.4 cm and the left kidney measures 10.5 cm. There is a 5.5 x 5.7 x 5.9 cm simple renal cyst in the left mid acute knee. Limited views of the kidneys are unremarkable without hydronephrosis. IMPRESSION: Infrarenal abdominal aortic aneurysm up to 4.3 cm. Right common iliac artery aneurysm up to 2.5 cm. NOTIFICATION: The findings were discussed with [MASKED], NP, by [MASKED] [MASKED], M.D. on the telephone on [MASKED] at 1:32 pm, 5 minutes after discovery of the findings. BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN ATTEST THAT [MASKED] HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE. [MASKED] [MASKED], MD electronically signed on [MASKED] 5:21 [MASKED] Imaging Lab Report History MON [MASKED] 5:21 [MASKED] by INFORMATION,SYSTEMS Brief Hospital Course: Patient was transferred from [MASKED] for surgical revascularization after ruling in for NSTEMI and cardiac catheterization that revealed Left Main and multi vessel disease for which and IABP was placed. He was admitted to the CVICU and remained pain free on IABP, Nitroglycerin and heparin infusion. He underwent routine preoperative evaluation and was cleared for surgery. The patient was brought to the Operating Room on [MASKED] where the patient underwent coronary artery bypass grafting by Dr. [MASKED] - see operative note for details. In summary he had: Urgent coronary artery bypass grafting x3, with left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the ramus intermedius branch and diagonal branch. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. He did well post-operatively and was extubated shortly after arrival to CVICU. POD 1 found the patient alert, oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. All chest tubes, lines and pacing wires were discontinued per cardiac surgery protocol without complication. Once on the stepdown floor the patient worked with nursing and was evaluated by the Physical Therapy service for assistance with strength and mobility. The remainder of his hospital stay was uneventful. 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, to a friend's house, with visiting nurses in good condition with appropriate follow up instructions. Of note, the patient does have a history of AAA. Imaging during this admission, [MASKED], reveals, "Infrarenal abdominal aortic aneurysm up to 4.3 cm. Right common iliac artery aneurysm up to 2.5 cm." Results communicated to PCP. 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 Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*100 Tablet Refills:*0 2. Furosemide 20 mg PO BID 20 mg BID x 7 days then 20 mg daily x 10 days RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*24 Tablet Refills:*0 3. Lidocaine 5% Patch 1 PTCH TD QPM RX *lidocaine 5 % 1 patch qpm Disp #*10 Patch Refills:*0 4. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) patch by mouth twice a day Disp #*60 Tablet Refills:*1 5. Potassium Chloride 10 mEq PO Q12H 10 mEq BID x 7 days then 10 mEq daily x 10 days RX *potassium chloride 10 mEq 1 packet(s) by mouth twice a day Disp #*24 Tablet Refills:*0 6. Ranitidine 150 mg PO DAILY Duration: 30 Days RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Simvastatin 40 mg PO QPM RX *simvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet Refills:*1 8. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: Coronary Artery Disease [MASKED] cabg Secondary: Hyperlipidemia Benign Prostatic Hypertrophy Colon polyps Diverticulosis Hemorrhoids Abdominal aortic aneurysm [MASKED] habituation 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 Bilat [MASKED] incisions- right c/d/I, left with some serous drainage after blister reduced Edema trace bilat [MASKED] 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 one month or 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", "I2510", "E785", "F17210" ]
[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "D62: Acute posthemorrhagic anemia", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I714: Abdominal aortic aneurysm, without rupture", "I723: Aneurysm of iliac artery", "Z781: Physical restraint status", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z590: Homelessness", "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", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]
10,071,611
27,474,298
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: hot pepper Attending: ___. Chief Complaint: acute situational anxiety to pregnancy, hemorrhagic shock Major Surgical or Invasive Procedure: dilation and evacuation complicated by intraoperative hemorrhage requiring exploratory laparotomy, total abdominal hysterectomy History of Present Illness: Ms. ___ is a ___, otherwise healthy, now s/p elective ___ week D&C c/b intraoperative bleeding requiring urgent ex lap and TAH. Pt was referred from Plant Parenthood to our ob/gyn department for elective abortion at ___ week. There was concern for placenta previa. Elective D&C was complicated by EBL ~ 2.0L, requiring ex lap TAH through midline incision. Intraoperative H&H was ___ initially. Repeat H&H ___ after 1U pRBC. She has received 4U of pRBC. Access includes PIV's x2 (16 and 18 gauge) and A-line. She's on phenylephrine gtt peripherally and maintaining her BP. Past Medical History: None Social History: ___ Family History: Unknown Physical Exam: ADMISSION Vitals: 85 105/67 12 100% GENERAL: sedated and intubated 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, midline incision with e/o bleeding on dressing EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rash NEURO: deferred . DISCHARGE Gen: NAD Resp: CTAB CV: RRR Abd: soft, midline incision clean/dry/intact with Steri strips Ext: no tenderness to palpation Pertinent Results: ADMISSION ___ 11:17AM BLOOD WBC-14.6* RBC-3.82* Hgb-11.5 Hct-34.4 MCV-90 MCH-30.1 MCHC-33.4 RDW-15.5 RDWSD-49.3* Plt Ct-93* ___ 11:17AM BLOOD ___ ___ 11:17AM BLOOD Glucose-155* UreaN-10 Creat-0.3* Na-136 K-3.8 Cl-113* HCO3-20* AnGap-7* ___ 11:28AM BLOOD D-Dimer-7391* ___ 11:17AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.2* ___ 09:28AM BLOOD Type-ART pO2-283* pCO2-36 pH-7.28* calTCO2-18* Base XS--8 . Pertinent: ___ 03:20PM BLOOD WBC-13.3* RBC-2.91* Hgb-8.8* Hct-25.7*# MCV-88 MCH-30.2 MCHC-34.2 RDW-16.1* RDWSD-50.5* Plt Ct-75* ___ 07:01PM BLOOD WBC-12.2* RBC-2.71* Hgb-8.1* Hct-23.4* MCV-86 MCH-29.9 MCHC-34.6 RDW-16.4* RDWSD-51.1* Plt Ct-71* ___ 01:43AM BLOOD WBC-9.3 RBC-2.41* Hgb-7.3* Hct-20.9* MCV-87 MCH-30.3 MCHC-34.9 RDW-16.5* RDWSD-51.9* Plt Ct-70* ___ 06:00AM BLOOD WBC-9.0 RBC-2.83* Hgb-8.5* Hct-25.1* MCV-89 MCH-30.0 MCHC-33.9 RDW-15.9* RDWSD-50.8* Plt Ct-70* ___ 03:18PM BLOOD WBC-9.6 RBC-2.72* Hgb-8.4* Hct-24.0* MCV-88 MCH-30.9 MCHC-35.0 RDW-16.0* RDWSD-51.6* Plt Ct-82* ___ 06:35AM BLOOD WBC-9.2 RBC-2.67* Hgb-8.1* Hct-23.9* MCV-90 MCH-30.3 MCHC-33.9 RDW-16.0* RDWSD-52.7* Plt Ct-86* ___ 07:01PM BLOOD ___ 01:43AM BLOOD ___ 01:43AM BLOOD Glucose-109* UreaN-7 Creat-0.4 Na-134 K-3.8 Cl-107 HCO3-20* AnGap-11 Brief Hospital Course: Ms. ___ is a ___, otherwise healthy, now status post dilation and curettage complicated by intraoperative bleeding requiring urgent TAH. *FICU Course ___ # Hemorrhagic shock: s/p elective ___ week D&C c/b intraop bleeding (ESBL ~ 2.0L), requiring ex-lap TAH. She has received 4U pRBC per mass transfusion protocol. In the FICU she was given 2 units FFP per mass transfusion protocol. Platelets held due to level of 71. Also given additional dose of Ancef. Levophed weaned in FICU. Also in FICU H/H trended to 7.3/20.9 from 8.1/23.4 so she was given another unit ___ total) with repeat H/H showing 8.5/25.1. She remained hemodynamically stable and thus was transferred to OBGYN service. # Concern for DIC: D/t recent obstetrical complications. Fibrinogen level obtained which was 115. Dx likely based on low fibrinogen (115), INR 1.2, plt 93. Supported by acute significant bleeding and shock. # Respiratory failure: Pt intubated for procedure. Currently on CMV mode. Current barrier to extubation is hemodynamic stability. Pt was paralyzed in OR. Ventilation quickly weaned upon arrival to FICU and she was extubated. # Hyponatremia: Low 130's. Baseline unknown. Volume status currently hypovolemic to euvolemic. SIADH has been associated with pregnancy but may be due to poor po intake. Serum osm 272, consistent with hypotonic hyponatremia. Urine lytes obtained show Urine Na 219. Picture most consistent with volume loss. # Leukocytosis: most likely reactive. # Electrolyte abnormalities: Notable for low Mg and phos. Repleted. *End of FICU Course* Patient was transferred to the OBGYN service on post operative day 1. She remained hemodynamically stable with stable hematocrit and hemoglobin, electrolytes within normal range. She was tolerating a regular diet, pain was controlled on oral ibuprofen and Tylenol with IV dilaudid for breakthrough pain. Her urine output was adequate and foley catheter was removed on post operative day 2. . By post-operative day 3, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain do not take more than 4000mg per day RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills:*2 3. Ibuprofen 600 mg PO Q6H:PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*1 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN severe pain do not drive or drink alcohol while taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute anxiety to pregnancy, placenta previa, intraoperative hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
[ "Z332", "J9690", "T8119XA", "E222", "O4402", "N9961", "O99342", "F419", "O99282", "N736", "Z3A18", "Y838" ]
Allergies: hot pepper Chief Complaint: acute situational anxiety to pregnancy, hemorrhagic shock Major Surgical or Invasive Procedure: dilation and evacuation complicated by intraoperative hemorrhage requiring exploratory laparotomy, total abdominal hysterectomy History of Present Illness: Ms. [MASKED] is a [MASKED], otherwise healthy, now s/p elective [MASKED] week D&C c/b intraoperative bleeding requiring urgent ex lap and TAH. Pt was referred from Plant Parenthood to our ob/gyn department for elective abortion at [MASKED] week. There was concern for placenta previa. Elective D&C was complicated by EBL ~ 2.0L, requiring ex lap TAH through midline incision. Intraoperative H&H was [MASKED] initially. Repeat H&H [MASKED] after 1U pRBC. She has received 4U of pRBC. Access includes PIV's x2 (16 and 18 gauge) and A-line. She's on phenylephrine gtt peripherally and maintaining her BP. Past Medical History: None Social History: [MASKED] Family History: Unknown Physical Exam: ADMISSION Vitals: 85 105/67 12 100% GENERAL: sedated and intubated 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, midline incision with e/o bleeding on dressing EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rash NEURO: deferred . DISCHARGE Gen: NAD Resp: CTAB CV: RRR Abd: soft, midline incision clean/dry/intact with Steri strips Ext: no tenderness to palpation Pertinent Results: ADMISSION [MASKED] 11:17AM BLOOD WBC-14.6* RBC-3.82* Hgb-11.5 Hct-34.4 MCV-90 MCH-30.1 MCHC-33.4 RDW-15.5 RDWSD-49.3* Plt Ct-93* [MASKED] 11:17AM BLOOD [MASKED] [MASKED] 11:17AM BLOOD Glucose-155* UreaN-10 Creat-0.3* Na-136 K-3.8 Cl-113* HCO3-20* AnGap-7* [MASKED] 11:28AM BLOOD D-Dimer-7391* [MASKED] 11:17AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.2* [MASKED] 09:28AM BLOOD Type-ART pO2-283* pCO2-36 pH-7.28* calTCO2-18* Base XS--8 . Pertinent: [MASKED] 03:20PM BLOOD WBC-13.3* RBC-2.91* Hgb-8.8* Hct-25.7*# MCV-88 MCH-30.2 MCHC-34.2 RDW-16.1* RDWSD-50.5* Plt Ct-75* [MASKED] 07:01PM BLOOD WBC-12.2* RBC-2.71* Hgb-8.1* Hct-23.4* MCV-86 MCH-29.9 MCHC-34.6 RDW-16.4* RDWSD-51.1* Plt Ct-71* [MASKED] 01:43AM BLOOD WBC-9.3 RBC-2.41* Hgb-7.3* Hct-20.9* MCV-87 MCH-30.3 MCHC-34.9 RDW-16.5* RDWSD-51.9* Plt Ct-70* [MASKED] 06:00AM BLOOD WBC-9.0 RBC-2.83* Hgb-8.5* Hct-25.1* MCV-89 MCH-30.0 MCHC-33.9 RDW-15.9* RDWSD-50.8* Plt Ct-70* [MASKED] 03:18PM BLOOD WBC-9.6 RBC-2.72* Hgb-8.4* Hct-24.0* MCV-88 MCH-30.9 MCHC-35.0 RDW-16.0* RDWSD-51.6* Plt Ct-82* [MASKED] 06:35AM BLOOD WBC-9.2 RBC-2.67* Hgb-8.1* Hct-23.9* MCV-90 MCH-30.3 MCHC-33.9 RDW-16.0* RDWSD-52.7* Plt Ct-86* [MASKED] 07:01PM BLOOD [MASKED] 01:43AM BLOOD [MASKED] 01:43AM BLOOD Glucose-109* UreaN-7 Creat-0.4 Na-134 K-3.8 Cl-107 HCO3-20* AnGap-11 Brief Hospital Course: Ms. [MASKED] is a [MASKED], otherwise healthy, now status post dilation and curettage complicated by intraoperative bleeding requiring urgent TAH. *FICU Course [MASKED] # Hemorrhagic shock: s/p elective [MASKED] week D&C c/b intraop bleeding (ESBL ~ 2.0L), requiring ex-lap TAH. She has received 4U pRBC per mass transfusion protocol. In the FICU she was given 2 units FFP per mass transfusion protocol. Platelets held due to level of 71. Also given additional dose of Ancef. Levophed weaned in FICU. Also in FICU H/H trended to 7.3/20.9 from 8.1/23.4 so she was given another unit [MASKED] total) with repeat H/H showing 8.5/25.1. She remained hemodynamically stable and thus was transferred to OBGYN service. # Concern for DIC: D/t recent obstetrical complications. Fibrinogen level obtained which was 115. Dx likely based on low fibrinogen (115), INR 1.2, plt 93. Supported by acute significant bleeding and shock. # Respiratory failure: Pt intubated for procedure. Currently on CMV mode. Current barrier to extubation is hemodynamic stability. Pt was paralyzed in OR. Ventilation quickly weaned upon arrival to FICU and she was extubated. # Hyponatremia: Low 130's. Baseline unknown. Volume status currently hypovolemic to euvolemic. SIADH has been associated with pregnancy but may be due to poor po intake. Serum osm 272, consistent with hypotonic hyponatremia. Urine lytes obtained show Urine Na 219. Picture most consistent with volume loss. # Leukocytosis: most likely reactive. # Electrolyte abnormalities: Notable for low Mg and phos. Repleted. *End of FICU Course* Patient was transferred to the OBGYN service on post operative day 1. She remained hemodynamically stable with stable hematocrit and hemoglobin, electrolytes within normal range. She was tolerating a regular diet, pain was controlled on oral ibuprofen and Tylenol with IV dilaudid for breakthrough pain. Her urine output was adequate and foley catheter was removed on post operative day 2. . By post-operative day 3, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN pain do not take more than 4000mg per day RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*50 Capsule Refills:*2 3. Ibuprofen 600 mg PO Q6H:PRN pain take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*1 4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN severe pain do not drive or drink alcohol while taking this medication RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Acute anxiety to pregnancy, placenta previa, intraoperative hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]
[]
[ "F419" ]
[ "Z332: Encounter for elective termination of pregnancy", "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "T8119XA: Other postprocedural shock, initial encounter", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "O4402: Complete placenta previa NOS or without hemorrhage, second trimester", "N9961: Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure", "O99342: Other mental disorders complicating pregnancy, second trimester", "F419: Anxiety disorder, unspecified", "O99282: Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester", "N736: Female pelvic peritoneal adhesions (postinfective)", "Z3A18: 18 weeks gestation of pregnancy", "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" ]
10,071,690
23,009,762
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Lisinopril / Univasc Attending: ___. Chief Complaint: Left tibiotalar arthritis Major Surgical or Invasive Procedure: left tibiotalar fusion ___ ___ History of Present Illness: She is a pleasant ___ yr old female with left ankle pain and swelling. Notably, she was involved in a traumatic gunshot injury in the late ___. She developed a foot drop following this incident. She has undergone several surgeries to her knee. She reports use of AFO in the past. Due to discomfort, she has discontinued use. She denies frequent falls or tripping over the extremity. She mainly complains of pain across the anterior ankle joint itself. She is takes ibuprofen and anti-inflammatories for pain relief. Past Medical History: COLONIC POLYPS ___ Adenoma ___- ___ yr f/u rec'ed ASTHMA GASTROESOPHAGEAL REFLUX Classic sx in ___. Treating with lifestyle modification and prilosec for 2 month trial. Will plan EGD if sx persist despite therapy. NEPHROLITHIASIS ___ Calcium Oxalate per stone analysis HYPERCHOLESTEROLEMIA well controlled on lipitor HYPERTENSION ___ HCTZ begun. Still with poor control on HCTZ 25qd (LVH by EKG) so lisinopril added ___. Pt with cough on lisinopril, so changed to norvasc ___. LEFT KNEE PROSTHESIS ___ Secondary to gunshot wound. OBESITY BMI=30. Advised to see nutritionist and increase exercise level. F/u in 2 months. Lost 7 lbs over 2 months. Pt requesting wt reduction med, but will try lifestyle mod for now. ANEMIA ___ Pt on iron replacement. Hx sickle cell trait. Hx menorrhagia. S/P TAH-LSO for fibroid uterus and L adenexal cyst ___ Anemia resolved post-surgery. Hct normal ___. *S/P HYSTERECTOMY ___ No longer needs Paps RIGHT KNEE PAIN pt with right knee pain first noted in the fall of 200 chest xray reveals dejenerative joint disease pt started on celebrex with little relief, referred to ortho for further evaluation HEADACHES h/o both migraine and tension HA per report of pt, infrequent and treated symptomatically with tylenol BACK PAIN Social History: ___ Family History: Non-contributory Physical Exam: Left Lower Extremity: Dressing c/d/i SILT over distal toes Toes wwp Wiggles toes Pertinent Results: ___ 11:00AM BLOOD Hgb-10.9* Hct-33.5* Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on ___ for left tibiotalar fusion, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weight bearing in the left lower extremity, and will be discharged on Aspirin 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: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. amLODIPine 10 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD 1X/WEEK (___) 5. Hydrochlorothiazide 25 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. Montelukast 10 mg PO DAILY 8. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Aspirin 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 5. Senna 17.2 mg PO HS 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 7. amLODIPine 10 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD 1X/WEEK (___) 10. Hydrochlorothiazide 25 mg PO DAILY 11. Losartan Potassium 100 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left tibiotalar 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: Thank you for allowing me to assist in your care. It is a privilege to be able to take care of you. Should you have any questions about your post-operative care feel free to call my office at ___ during business hours and either myself or ___, NP will address any questions or concerns you may have. If this is an urgent matter at night or on weekends please call ___ and ask the page operator to page the covering ___ call orthopaedic physician. Prescription refills or changes cannot be addressed after normal business hours or on weekends. PAIN CONTROL: -You may or may not have had a nerve block depending on the type of surgery. This will likely wear off later in the evening and it is normal to have increased pain when the nerve block wears off. Please take your prescribed pain medications as directed with food prior to the nerve block wearing off. -Stay ahead of the pain! -Narcotic pain medications can cause constipation. Please take a stool softener while taking these and drink plenty of water. -Please plan ahead! If you are running out of your medication prior to your followup appointment please call during business hours with a ___ day notice. Prescription refills or changes cannot be addressed after normal business hours or on weekends. ACTIVITY: -You will likely have swelling after surgery. Please keep the foot elevated on ___ pillows at all times possible. You can apply a dry icebag on top of your dressing for 20 minutes at a time as often as you like. -Unless instructed otherwise you should not put any weight down on your operated extremity until you come back for your first postoperative visit. CARE FOR YOUR DRESSING: -You should not remove your dressing. I will do so when I see you for your first post-operative visit. -It is not unusual to have a little bloody staining through your dressing. However please call the office for any concerns. -Keep your dressing clean and dry. You will have to cover it when you bath or shower. If it gets wet please call the office immediately. PREVENTION OF BLOOD CLOTS: -You have been instructed to take medication in order to help prevent blood clots after surgery. Please take an aspirin 325 mg every day unless you have been specifically prescribed a different medication by me. If there is some reason why you cannot take aspirin please notify my office. DRIVING: -My recommendation is that you should not drive if you: (1)are still taking narcotic pain medications (2)have any type of immobilization on your right side (3)are unable to fully bear weight without pain on your right side (the above also apply to the left side if you have a manual transmission (“stick shift”) WHEN TO CALL: -Please call the office if you have any questions or concerns regarding your post-operative care. We need to know if things are not going well. -Please make sure you call the office or page the ___ call orthopaedic physician immediately if you are having any of the following problems: 1.Fever greater than 101.0 2.Increasing pain not controlled on pain medications 3.Increasing bloody staining on the dressing 4.Chest pain, difficulty breathing, nausea or vomiting 5.Cold toes, toes that are not normal color (pink) 6.Any other concerning symptoms Physical Therapy: ___ LLE splint on until followup Treatments Frequency: ___ Followup Instructions: ___
[ "M19172", "M21372", "J45909", "I10", "D649", "E669", "E785", "D573", "T1490XS", "W3400XS", "Z6830" ]
Allergies: Lisinopril / Univasc Chief Complaint: Left tibiotalar arthritis Major Surgical or Invasive Procedure: left tibiotalar fusion [MASKED] [MASKED] History of Present Illness: She is a pleasant [MASKED] yr old female with left ankle pain and swelling. Notably, she was involved in a traumatic gunshot injury in the late [MASKED]. She developed a foot drop following this incident. She has undergone several surgeries to her knee. She reports use of AFO in the past. Due to discomfort, she has discontinued use. She denies frequent falls or tripping over the extremity. She mainly complains of pain across the anterior ankle joint itself. She is takes ibuprofen and anti-inflammatories for pain relief. Past Medical History: COLONIC POLYPS [MASKED] Adenoma [MASKED]- [MASKED] yr f/u rec'ed ASTHMA GASTROESOPHAGEAL REFLUX Classic sx in [MASKED]. Treating with lifestyle modification and prilosec for 2 month trial. Will plan EGD if sx persist despite therapy. NEPHROLITHIASIS [MASKED] Calcium Oxalate per stone analysis HYPERCHOLESTEROLEMIA well controlled on lipitor HYPERTENSION [MASKED] HCTZ begun. Still with poor control on HCTZ 25qd (LVH by EKG) so lisinopril added [MASKED]. Pt with cough on lisinopril, so changed to norvasc [MASKED]. LEFT KNEE PROSTHESIS [MASKED] Secondary to gunshot wound. OBESITY BMI=30. Advised to see nutritionist and increase exercise level. F/u in 2 months. Lost 7 lbs over 2 months. Pt requesting wt reduction med, but will try lifestyle mod for now. ANEMIA [MASKED] Pt on iron replacement. Hx sickle cell trait. Hx menorrhagia. S/P TAH-LSO for fibroid uterus and L adenexal cyst [MASKED] Anemia resolved post-surgery. Hct normal [MASKED]. *S/P HYSTERECTOMY [MASKED] No longer needs Paps RIGHT KNEE PAIN pt with right knee pain first noted in the fall of 200 chest xray reveals dejenerative joint disease pt started on celebrex with little relief, referred to ortho for further evaluation HEADACHES h/o both migraine and tension HA per report of pt, infrequent and treated symptomatically with tylenol BACK PAIN Social History: [MASKED] Family History: Non-contributory Physical Exam: Left Lower Extremity: Dressing c/d/i SILT over distal toes Toes wwp Wiggles toes Pertinent Results: [MASKED] 11:00AM BLOOD Hgb-10.9* Hct-33.5* Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on [MASKED] for left tibiotalar fusion, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home with services was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weight bearing in the left lower extremity, and will be discharged on Aspirin 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: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. amLODIPine 10 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD 1X/WEEK ([MASKED]) 5. Hydrochlorothiazide 25 mg PO DAILY 6. Losartan Potassium 100 mg PO DAILY 7. Montelukast 10 mg PO DAILY 8. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Aspirin 325 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 5. Senna 17.2 mg PO HS 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 7. amLODIPine 10 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD 1X/WEEK ([MASKED]) 10. Hydrochlorothiazide 25 mg PO DAILY 11. Losartan Potassium 100 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Left tibiotalar 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: Thank you for allowing me to assist in your care. It is a privilege to be able to take care of you. Should you have any questions about your post-operative care feel free to call my office at [MASKED] during business hours and either myself or [MASKED], NP will address any questions or concerns you may have. If this is an urgent matter at night or on weekends please call [MASKED] and ask the page operator to page the covering [MASKED] call orthopaedic physician. Prescription refills or changes cannot be addressed after normal business hours or on weekends. PAIN CONTROL: -You may or may not have had a nerve block depending on the type of surgery. This will likely wear off later in the evening and it is normal to have increased pain when the nerve block wears off. Please take your prescribed pain medications as directed with food prior to the nerve block wearing off. -Stay ahead of the pain! -Narcotic pain medications can cause constipation. Please take a stool softener while taking these and drink plenty of water. -Please plan ahead! If you are running out of your medication prior to your followup appointment please call during business hours with a [MASKED] day notice. Prescription refills or changes cannot be addressed after normal business hours or on weekends. ACTIVITY: -You will likely have swelling after surgery. Please keep the foot elevated on [MASKED] pillows at all times possible. You can apply a dry icebag on top of your dressing for 20 minutes at a time as often as you like. -Unless instructed otherwise you should not put any weight down on your operated extremity until you come back for your first postoperative visit. CARE FOR YOUR DRESSING: -You should not remove your dressing. I will do so when I see you for your first post-operative visit. -It is not unusual to have a little bloody staining through your dressing. However please call the office for any concerns. -Keep your dressing clean and dry. You will have to cover it when you bath or shower. If it gets wet please call the office immediately. PREVENTION OF BLOOD CLOTS: -You have been instructed to take medication in order to help prevent blood clots after surgery. Please take an aspirin 325 mg every day unless you have been specifically prescribed a different medication by me. If there is some reason why you cannot take aspirin please notify my office. DRIVING: -My recommendation is that you should not drive if you: (1)are still taking narcotic pain medications (2)have any type of immobilization on your right side (3)are unable to fully bear weight without pain on your right side (the above also apply to the left side if you have a manual transmission (“stick shift”) WHEN TO CALL: -Please call the office if you have any questions or concerns regarding your post-operative care. We need to know if things are not going well. -Please make sure you call the office or page the [MASKED] call orthopaedic physician immediately if you are having any of the following problems: 1.Fever greater than 101.0 2.Increasing pain not controlled on pain medications 3.Increasing bloody staining on the dressing 4.Chest pain, difficulty breathing, nausea or vomiting 5.Cold toes, toes that are not normal color (pink) 6.Any other concerning symptoms Physical Therapy: [MASKED] LLE splint on until followup Treatments Frequency: [MASKED] Followup Instructions: [MASKED]
[]
[ "J45909", "I10", "D649", "E669", "E785" ]
[ "M19172: Post-traumatic osteoarthritis, left ankle and foot", "M21372: Foot drop, left foot", "J45909: Unspecified asthma, uncomplicated", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "E669: Obesity, unspecified", "E785: Hyperlipidemia, unspecified", "D573: Sickle-cell trait", "T1490XS: Injury, unspecified, sequela", "W3400XS: Accidental discharge from unspecified firearms or gun, sequela", "Z6830: Body mass index [BMI]30.0-30.9, adult" ]
10,071,795
20,675,745
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Latex / Percocet / Neosporin / Levaquin / Bacitracin / oxycodone / levofloxacin / Dilaudid Attending: ___. Chief Complaint: lower abdominal pain/bloating Major Surgical or Invasive Procedure: none Physical Exam: Gen NAD, comfortable CV regular rate Pulm nl respiratory effort Abd soft, nondistended, minimally TTP in RLQ. no R/G Extrem no edema, no TTP Pertinent Results: ___ 07:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 07:31PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:40PM PLT COUNT-266 ___ 09:40PM NEUTS-56.5 ___ MONOS-8.5 EOS-2.0 BASOS-0.8 IM ___ AbsNeut-3.65 AbsLymp-2.06 AbsMono-0.55 AbsEos-0.13 AbsBaso-0.05 ___ 09:40PM WBC-6.5 RBC-3.79* HGB-10.9* HCT-33.4* MCV-88 MCH-28.8 MCHC-32.6 RDW-14.6 RDWSD-46.9* ___ PUS IMPRESSION: 1. Persistent, thick-walled complex right adnexal collection however, decreased in size and complexity with less demonstrated vascularity when compared to prior examination which was performed prior to drainage of the right ___. This could represent pus or blood. The appearance of the right adnexa by ultrasound should be correlated with the current clinical scenario and patient's symptoms in order to determine if residual infection persists. 2. Numerous intramural uterine fibroids. 3. Normal left ovary. Brief Hospital Course: Ms. ___ was admitted to gynecology service after presenting with lower abdominal pain and bloating, in the setting of a recent admission for ___ and drainage of same, and after the completion of a course of augmentin. She underwent a PUS and found persistent, thick walled complex right adnexal collection, decreased in size and complexity with less demonstrated vascularity when compared to prior examination. However, given recurrent lower abdominal pain and bloating, patient was admitted for IV antibiotics. She was began on IV gent/clinda for 24 hours. She had a CBC/diff wnl limits. She had adequate pain control. On HD2, she remained afebrile, her pain was well controlled and she was transitioned to oral augmentin (patient unable to tolerate flagyl/doxy due to GI upset). She was thus discharged home in stable condition. Medications on Admission: Medications - Prescription ALBUTEROL - Dosage uncertain - (Prescribed by Other Provider) CETIRIZINE [ZYRTEC] - Dosage uncertain - (Prescribed by Other Provider) METHYLPHENIDATE HCL [CONCERTA] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin XR] 1,000 mg-62.5 mg 2 tablets by mouth every 12 hours Disp #*56 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: recurrent tubo-ovarian abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after presenting with abdominal pain, bloating, and US consistent with a right adnexal collection concerning for persistent tubo-ovarian abscess. The team now believes you have recovered well and are ready to be discharged home. Please complete the full course of antibiotics as prescribed. Please call Dr. ___ office with any questions or concerns. General instructions: * Take your medications as prescribed. * Please complete the full course of antibiotics as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
[ "N7093", "N390", "B373", "D251", "J45909" ]
Allergies: Latex / Percocet / Neosporin / Levaquin / Bacitracin / oxycodone / levofloxacin / Dilaudid Chief Complaint: lower abdominal pain/bloating Major Surgical or Invasive Procedure: none Physical Exam: Gen NAD, comfortable CV regular rate Pulm nl respiratory effort Abd soft, nondistended, minimally TTP in RLQ. no R/G Extrem no edema, no TTP Pertinent Results: [MASKED] 07:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 07:31PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 09:40PM PLT COUNT-266 [MASKED] 09:40PM NEUTS-56.5 [MASKED] MONOS-8.5 EOS-2.0 BASOS-0.8 IM [MASKED] AbsNeut-3.65 AbsLymp-2.06 AbsMono-0.55 AbsEos-0.13 AbsBaso-0.05 [MASKED] 09:40PM WBC-6.5 RBC-3.79* HGB-10.9* HCT-33.4* MCV-88 MCH-28.8 MCHC-32.6 RDW-14.6 RDWSD-46.9* [MASKED] PUS IMPRESSION: 1. Persistent, thick-walled complex right adnexal collection however, decreased in size and complexity with less demonstrated vascularity when compared to prior examination which was performed prior to drainage of the right [MASKED]. This could represent pus or blood. The appearance of the right adnexa by ultrasound should be correlated with the current clinical scenario and patient's symptoms in order to determine if residual infection persists. 2. Numerous intramural uterine fibroids. 3. Normal left ovary. Brief Hospital Course: Ms. [MASKED] was admitted to gynecology service after presenting with lower abdominal pain and bloating, in the setting of a recent admission for [MASKED] and drainage of same, and after the completion of a course of augmentin. She underwent a PUS and found persistent, thick walled complex right adnexal collection, decreased in size and complexity with less demonstrated vascularity when compared to prior examination. However, given recurrent lower abdominal pain and bloating, patient was admitted for IV antibiotics. She was began on IV gent/clinda for 24 hours. She had a CBC/diff wnl limits. She had adequate pain control. On HD2, she remained afebrile, her pain was well controlled and she was transitioned to oral augmentin (patient unable to tolerate flagyl/doxy due to GI upset). She was thus discharged home in stable condition. Medications on Admission: Medications - Prescription ALBUTEROL - Dosage uncertain - (Prescribed by Other Provider) CETIRIZINE [ZYRTEC] - Dosage uncertain - (Prescribed by Other Provider) METHYLPHENIDATE HCL [CONCERTA] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Do not take more than 4000mg in 24 hours. RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H RX *amoxicillin-pot clavulanate [Augmentin XR] 1,000 mg-62.5 mg 2 tablets by mouth every 12 hours Disp #*56 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*50 Tablet Refills:*1 Discharge Disposition: Home Discharge Diagnosis: recurrent tubo-ovarian abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology service after presenting with abdominal pain, bloating, and US consistent with a right adnexal collection concerning for persistent tubo-ovarian abscess. The team now believes you have recovered well and are ready to be discharged home. Please complete the full course of antibiotics as prescribed. Please call Dr. [MASKED] office with any questions or concerns. General instructions: * Take your medications as prescribed. * Please complete the full course of antibiotics as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]
[]
[ "N390", "J45909" ]
[ "N7093: Salpingitis and oophoritis, unspecified", "N390: Urinary tract infection, site not specified", "B373: Candidiasis of vulva and vagina", "D251: Intramural leiomyoma of uterus", "J45909: Unspecified asthma, uncomplicated" ]
10,071,795
24,331,732
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Latex / Percocet / Neosporin / Levaquin / Bacitracin / oxycodone / levofloxacin / Dilaudid Attending: ___. Chief Complaint: abdominal pain, fever Major Surgical or Invasive Procedure: ___ aspiration of tubo-ovarian abscess History of Present Illness: ___ ___ presenting with 10 day history of abdominal pain as well as fever at home to 101 a week ago. She states she first noted left-sided cramping about 10 days ago, and then developed a sharper right-sided pain a week ago. She feels pain has been constant. She was evaluated by her PCP and diagnosed with a UTI based on U/A, and was treated with course of Bactrim. She also reports increased vaginal discharge recently. She had a PUS done with her OBGYN which was suspicious for a right-sided ___, and was instructed to present to ___ for IV antibiotic treatment. However, she preferred to be treated her and was transferred to our ED. Here, she reports feeling intermittent nausea but has not vomited today or in past week. She denies urinary symptoms. Having regular BMs. No current fevers or chills. No CP, SOB. Continues to feel she is having increased vaginal discharge. She has had recent unprotected sex with a new male partner. Past Medical History: OB History: - ___&C at age ___ GYN History: Menarche age ___. LMP ___, regular menses every 21 days with 8 days of very heavy flow, significant pelvic pain.Denies a history of abnormal Pap smears. Uses condoms for birth control, no hormonal methods. Reports history of self-aborting fibroid at age ___ and history of ovarian cysts. Has genital herpes diagnosed at age ___, infrequent outbreaks, not on suppression. H/o trichomonas, no other STIs. Medical Problems: - Asthma, denies intubations or hospitalizations - Liver injury s/p laparoscopic cholecystectomy Surgical History: 1. ___, tonsillectomy. 2. ___, left knee arthroscopy. 3. ___ TAB with D&C 4. In ___, laparoscopic cholecystectomy at ___. 5. In ___, repeat surgery, laparoscopy converted to open surgery for repair of liver injury associated with laparoscopic cholecystectomy by Dr. ___ at ___. 6. ___, Operative HSC and myomectomy Social History: ___ Family History: Non-contributory Physical Exam: On day of discharge: T 98.8 PO 101 / 64 70 16 98 `BP `HR `RR`O2 UOP: multiple voids, not measured PE: General: NAD, A&Ox3 Lungs: No respiratory distress, normal work of breathing Abd: soft, nontender, minimally distended, improved from last exam. no rebound or guarding. +BS Extremities: no calf tenderness Pertinent Results: ___ 07:10AM HIV Ab-NEG ___ 07:10AM WBC-8.5 RBC-3.61* HGB-10.5* HCT-31.7* MCV-88 MCH-29.1 MCHC-33.1 RDW-14.4 RDWSD-46.0 ___ 07:10AM NEUTS-65.4 ___ MONOS-7.4 EOS-2.6 BASOS-0.5 IM ___ AbsNeut-5.56 AbsLymp-2.01 AbsMono-0.63 AbsEos-0.22 AbsBaso-0.04 ___ 07:10AM PLT COUNT-305 ___ 07:10AM ___ PTT-32.0 ___ ___ 07:10AM ___ ___ 04:59AM OTHER BODY FLUID CT-NEG NG-NEG ___ 12:20AM URINE HOURS-RANDOM ___ 12:20AM URINE UCG-NEG ___ 12:20AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR* ___ 12:20AM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-2 ___ 10:46PM LACTATE-1.0 ___ 10:30PM GLUCOSE-83 UREA N-9 CREAT-1.0 SODIUM-138 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15 ___ 10:30PM estGFR-Using this ___ 10:30PM ALT(SGPT)-18 AST(SGOT)-23 ALK PHOS-99 TOT BILI-0.2 ___ 10:30PM LIPASE-25 ___ 10:30PM ALBUMIN-3.6 ___ 10:30PM WBC-9.7 RBC-3.61* HGB-10.6* HCT-32.0* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.2 RDWSD-46.0 ___ 10:30PM NEUTS-67.6 ___ MONOS-6.2 EOS-1.9 BASOS-0.4 IM ___ AbsNeut-6.52* AbsLymp-2.28 AbsMono-0.60 AbsEos-0.18 AbsBaso-0.04 ___ 10:30PM PLT COUNT-300 Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after presenting to the ED with fever and abdominal pain, found to have right-sided ___. On admission, she was started on IV gentamicin and clindamycin. Her post-operative course was uncomplicated. On hospital day 1 she had ultrasound guided pelvic aspiration of the pelvic collection with drainage of 17 mL of complex fluid. Her diet was advanced without difficulty and her pain was controlled with PO dilaudid/Tylenol/ibuprofen. On hospital day2, she was transitioned to PO doxycycline and flagyl. By hospital day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, afebrile and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: 1. Zyrtec p.r.n. 2. Albuterol inhaler p.r.n., asthma attacks. 3. Concerta Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Do not exceed 4gm per day. RX *acetaminophen 500 mg ___ capsule(s) by mouth every six (6) hours Disp #*30 Capsule Refills:*1 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 12 Days RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*24 Capsule Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*1 4. Metoclopramide 10 mg PO Q8H:PRN nausea RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 5. MetroNIDAZOLE 500 mg PO BID do not drink alcohol while on this medication RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #*24 Tablet Refills:*0 6. Cetirizine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: tubo-ovarian abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the gynecology service for your abdominal pain and fever and was found to have a tubo-ovarian abscess. You were started on antibiotics and had ___ drainage of the abscess with improvement in your symptoms. Please complete the 2 week course of antibiotics to ensure that the infection completely resolves. Please call the office at ___ with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks until your follow-up appointment * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
[ "N7093", "J45909", "T7840XA", "X58XXXA", "Y92239" ]
Allergies: Latex / Percocet / Neosporin / Levaquin / Bacitracin / oxycodone / levofloxacin / Dilaudid Chief Complaint: abdominal pain, fever Major Surgical or Invasive Procedure: [MASKED] aspiration of tubo-ovarian abscess History of Present Illness: [MASKED] [MASKED] presenting with 10 day history of abdominal pain as well as fever at home to 101 a week ago. She states she first noted left-sided cramping about 10 days ago, and then developed a sharper right-sided pain a week ago. She feels pain has been constant. She was evaluated by her PCP and diagnosed with a UTI based on U/A, and was treated with course of Bactrim. She also reports increased vaginal discharge recently. She had a PUS done with her OBGYN which was suspicious for a right-sided [MASKED], and was instructed to present to [MASKED] for IV antibiotic treatment. However, she preferred to be treated her and was transferred to our ED. Here, she reports feeling intermittent nausea but has not vomited today or in past week. She denies urinary symptoms. Having regular BMs. No current fevers or chills. No CP, SOB. Continues to feel she is having increased vaginal discharge. She has had recent unprotected sex with a new male partner. Past Medical History: OB History: - [MASKED]&C at age [MASKED] GYN History: Menarche age [MASKED]. LMP [MASKED], regular menses every 21 days with 8 days of very heavy flow, significant pelvic pain.Denies a history of abnormal Pap smears. Uses condoms for birth control, no hormonal methods. Reports history of self-aborting fibroid at age [MASKED] and history of ovarian cysts. Has genital herpes diagnosed at age [MASKED], infrequent outbreaks, not on suppression. H/o trichomonas, no other STIs. Medical Problems: - Asthma, denies intubations or hospitalizations - Liver injury s/p laparoscopic cholecystectomy Surgical History: 1. [MASKED], tonsillectomy. 2. [MASKED], left knee arthroscopy. 3. [MASKED] TAB with D&C 4. In [MASKED], laparoscopic cholecystectomy at [MASKED]. 5. In [MASKED], repeat surgery, laparoscopy converted to open surgery for repair of liver injury associated with laparoscopic cholecystectomy by Dr. [MASKED] at [MASKED]. 6. [MASKED], Operative HSC and myomectomy Social History: [MASKED] Family History: Non-contributory Physical Exam: On day of discharge: T 98.8 PO 101 / 64 70 16 98 `BP `HR `RR`O2 UOP: multiple voids, not measured PE: General: NAD, A&Ox3 Lungs: No respiratory distress, normal work of breathing Abd: soft, nontender, minimally distended, improved from last exam. no rebound or guarding. +BS Extremities: no calf tenderness Pertinent Results: [MASKED] 07:10AM HIV Ab-NEG [MASKED] 07:10AM WBC-8.5 RBC-3.61* HGB-10.5* HCT-31.7* MCV-88 MCH-29.1 MCHC-33.1 RDW-14.4 RDWSD-46.0 [MASKED] 07:10AM NEUTS-65.4 [MASKED] MONOS-7.4 EOS-2.6 BASOS-0.5 IM [MASKED] AbsNeut-5.56 AbsLymp-2.01 AbsMono-0.63 AbsEos-0.22 AbsBaso-0.04 [MASKED] 07:10AM PLT COUNT-305 [MASKED] 07:10AM [MASKED] PTT-32.0 [MASKED] [MASKED] 07:10AM [MASKED] [MASKED] 04:59AM OTHER BODY FLUID CT-NEG NG-NEG [MASKED] 12:20AM URINE HOURS-RANDOM [MASKED] 12:20AM URINE UCG-NEG [MASKED] 12:20AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR* [MASKED] 12:20AM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE EPI-2 [MASKED] 10:46PM LACTATE-1.0 [MASKED] 10:30PM GLUCOSE-83 UREA N-9 CREAT-1.0 SODIUM-138 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15 [MASKED] 10:30PM estGFR-Using this [MASKED] 10:30PM ALT(SGPT)-18 AST(SGOT)-23 ALK PHOS-99 TOT BILI-0.2 [MASKED] 10:30PM LIPASE-25 [MASKED] 10:30PM ALBUMIN-3.6 [MASKED] 10:30PM WBC-9.7 RBC-3.61* HGB-10.6* HCT-32.0* MCV-89 MCH-29.4 MCHC-33.1 RDW-14.2 RDWSD-46.0 [MASKED] 10:30PM NEUTS-67.6 [MASKED] MONOS-6.2 EOS-1.9 BASOS-0.4 IM [MASKED] AbsNeut-6.52* AbsLymp-2.28 AbsMono-0.60 AbsEos-0.18 AbsBaso-0.04 [MASKED] 10:30PM PLT COUNT-300 Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after presenting to the ED with fever and abdominal pain, found to have right-sided [MASKED]. On admission, she was started on IV gentamicin and clindamycin. Her post-operative course was uncomplicated. On hospital day 1 she had ultrasound guided pelvic aspiration of the pelvic collection with drainage of 17 mL of complex fluid. Her diet was advanced without difficulty and her pain was controlled with PO dilaudid/Tylenol/ibuprofen. On hospital day2, she was transitioned to PO doxycycline and flagyl. By hospital day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, afebrile and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: 1. Zyrtec p.r.n. 2. Albuterol inhaler p.r.n., asthma attacks. 3. Concerta Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Do not exceed 4gm per day. RX *acetaminophen 500 mg [MASKED] capsule(s) by mouth every six (6) hours Disp #*30 Capsule Refills:*1 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 12 Days RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*24 Capsule Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*1 4. Metoclopramide 10 mg PO Q8H:PRN nausea RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 5. MetroNIDAZOLE 500 mg PO BID do not drink alcohol while on this medication RX *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp #*24 Tablet Refills:*0 6. Cetirizine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: tubo-ovarian abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the gynecology service for your abdominal pain and fever and was found to have a tubo-ovarian abscess. You were started on antibiotics and had [MASKED] drainage of the abscess with improvement in your symptoms. Please complete the 2 week course of antibiotics to ensure that the infection completely resolves. Please call the office at [MASKED] with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 2 weeks until your follow-up appointment * You may eat a regular diet. * You may walk up and down stairs. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink [MASKED] liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener [MASKED] times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]
[]
[ "J45909" ]
[ "N7093: Salpingitis and oophoritis, unspecified", "J45909: Unspecified asthma, uncomplicated", "T7840XA: Allergy, unspecified, initial encounter", "X58XXXA: Exposure to other specified factors, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]
10,071,795
26,270,837
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Latex / Percocet / Neosporin / Levaquin / Bacitracin / levofloxacin / Dilaudid / paper tape / shellfish derived / tree nuts / environmental Attending: ___ Chief Complaint: Uterine fibroids and right ovarian mass Major Surgical or Invasive Procedure: Abdominal myomectomy History of Present Illness: Ms. ___ is a ___ gravida 1 para 0010 with a last menstrual period of ___ who has a known fibroid uterus, history of tubo-ovarian abscess and right adnexal mass who would like the removal of her multiple fibroids and right adnexal mass. Status post endometrial biopsy on ___ which showed proliferative endometrium and was negative for chronic endometritis or endometrial hyperplasia. Prior to today's visit, I saw this patient on ___ after she had undergone drainage of a right sided tubo-ovarian abscess. She was discharged home from the ___ GYN service on ___. At our ___ visit, it was decided that it would be important for her body to fully recover from that medical challenges before having a major operative procedure. On ___, she had a repeat ultrasound at the ___ which showed an anteverted uterus that measured 11.3 by a 6.9 x 7.9 cm. The endometrial stripe was normal for the patient's age measuring 9 mm. There was a 3.1 cm posterior mid body, 2.8 cm left fundal, 3.7 cm mid fundal and 4.1 cm right fundal fibroids. The right and left ovaries were normal in size measuring 2.9 x 2.3 x 3 cm and 4.1 x 1.9 x 2.6 cm. A homogenous hypoechoic 2.9 x 2.3 x 3 cm unchanged endometrium was present on the right ovary. There was no free fluid. These findings were all reviewed with the patient and her questions were answered to her satisfaction. On ___ she had an MRI which showed an anteverted uterus that measured 10.9 x 6.3 x 9.6 cm, larger compared to prior to CT from ___. At least 7 intramural fibroids were identified in the uterus, many of them centrally nonenhancing and larger compared to the CT from ___ the largest fibroid measures 3.9 x 3.9 x 4.0 cm and located at the left anterior fundus. There was a 2.1 x 1.9 cm structure with fluid level identified in the right ovary consistent with hemorrhagic material. The left ovary was visualized and appeared normal. Of note, she has a history of a vaginal myomectomy. OB/GYN history: Menarche age ___, menses every 21 days with 8 days of very heavy flow. During her heaviest bleeding. She change the pad or tampon every 1.5 hours. She endorses dysmenorrhea, intermenstrual bleeding, postcoital bleeding and dyspareunia. She states that she had an abnormal Pap in the past requiring no treatment. Last Pap was ___ and normal. She is heterosexual and not sexually active at this time. Reports history of an aborting fibroid at age ___ and history of ovarian cysts. Has genital herpes diagnosed at age ___, infrequent outbreaks, not on suppression. H/o trichomonas, no other STIs. TAB via D&C at age ___ Medical history: RIGHT TUBO-OVARIAN ABSCESS UTERINE FIBROIDS Surgical History: US-GUIDED ASPIRATION OF A RIGHT TUBO-OVARIAN ABSCESS. ___ 17 CC OF ___ TISSUE: ENDOMETRIAL BIOPSY ___ ___ ___ FINAL Endometrium, biopsy: Fragments of early secretory endometrium. Surgical History: 1. ___, tonsillectomy. 2. ___, left knee arthroscopy. 3. ___, ? TAB vs ectopic pregnancy surgery (pt uncertain of side or location or if she underwent medical treatment). 4. ___, laparoscopic cholecystectomy at ___ ___. 5. ___, repeat surgery, laparoscopy converted to open surgery for repair of liver injury associated with laparoscopic cholecystectomy by Dr. ___ at ___. 6. Vaginal Myomecomy @ 21 Family History: Comments: Family History: Denies a family history of any GYN or female cancers such as breast, ovarian, uterine, cervical, vaginal, or colon cancer. She reports mother with skin cancer, diabetes, hypertension, heart disease, and hypercholesterolemia. She also reports two brothers with hypertension and grandparents with heart disease. Social History: Marital status: Single Children: No Work: ___ Sexual orientation: Male Domestic violence: Denies Contraception: None Contraception would like pregnancy/has had evaluation and comments: was told was "not ovulating" but has regular menses Tobacco use: Never smoker --------------- --------------- --------------- --------------- Active Medication list as of ___: Medications - Prescription ALBUTEROL - Dosage uncertain - (Prescribed by Other Provider) CETIRIZINE [ZYRTEC] - Dosage uncertain - (Prescribed by Other Provider) MEDROXYPROGESTERONE - medroxyprogesterone 10 mg tablet. One tablet(s) by mouth Daily METHYLPHENIDATE HCL [CONCERTA] - Dosage uncertain - (Prescribed by Other Provider) VITAMIN D - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC BIOTIN - Dosage uncertain - (OTC) BUDESONIDE-FORMOTEROL [SYMBICORT] - Dosage uncertain - (OTC) VITAMIN B - Vitamin B . - (OTC) --------------- --------------- --------------- --------------- Allergies: Bacitracin Dilaudid Latex Levaquin levofloxacin Neosporin (Neomycin Sulfate/Bacitracin/Polymyxin B) oxycodone Percocet (Oxycodone Hcl/Acetaminophen) Physical Exam: General: NAD, comfortable CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, dressing removed, incision w/ steri strips clean/dry/intact, superficial ecchymosis along superior aspect of incision Extremities: no edema, no TTP, pneumoboots in place bilaterally Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing EXAM UNDER ANESTHESIA and MULTIPLE MYOMECTOMIES. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with morphine and tordal. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, she was ambulating, and she was transitioned to PO oxycodone/ibuprofen/acetaminophen. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*9 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe do not drink alcohol or drive while taking oxycodone RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 6. Sertraline 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Uterine fibroids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Followup Instructions: ___
[ "D259", "N736", "F329", "F419" ]
Allergies: Latex / Percocet / Neosporin / Levaquin / Bacitracin / levofloxacin / Dilaudid / paper tape / shellfish derived / tree nuts / environmental Chief Complaint: Uterine fibroids and right ovarian mass Major Surgical or Invasive Procedure: Abdominal myomectomy History of Present Illness: Ms. [MASKED] is a [MASKED] gravida 1 para 0010 with a last menstrual period of [MASKED] who has a known fibroid uterus, history of tubo-ovarian abscess and right adnexal mass who would like the removal of her multiple fibroids and right adnexal mass. Status post endometrial biopsy on [MASKED] which showed proliferative endometrium and was negative for chronic endometritis or endometrial hyperplasia. Prior to today's visit, I saw this patient on [MASKED] after she had undergone drainage of a right sided tubo-ovarian abscess. She was discharged home from the [MASKED] GYN service on [MASKED]. At our [MASKED] visit, it was decided that it would be important for her body to fully recover from that medical challenges before having a major operative procedure. On [MASKED], she had a repeat ultrasound at the [MASKED] which showed an anteverted uterus that measured 11.3 by a 6.9 x 7.9 cm. The endometrial stripe was normal for the patient's age measuring 9 mm. There was a 3.1 cm posterior mid body, 2.8 cm left fundal, 3.7 cm mid fundal and 4.1 cm right fundal fibroids. The right and left ovaries were normal in size measuring 2.9 x 2.3 x 3 cm and 4.1 x 1.9 x 2.6 cm. A homogenous hypoechoic 2.9 x 2.3 x 3 cm unchanged endometrium was present on the right ovary. There was no free fluid. These findings were all reviewed with the patient and her questions were answered to her satisfaction. On [MASKED] she had an MRI which showed an anteverted uterus that measured 10.9 x 6.3 x 9.6 cm, larger compared to prior to CT from [MASKED]. At least 7 intramural fibroids were identified in the uterus, many of them centrally nonenhancing and larger compared to the CT from [MASKED] the largest fibroid measures 3.9 x 3.9 x 4.0 cm and located at the left anterior fundus. There was a 2.1 x 1.9 cm structure with fluid level identified in the right ovary consistent with hemorrhagic material. The left ovary was visualized and appeared normal. Of note, she has a history of a vaginal myomectomy. OB/GYN history: Menarche age [MASKED], menses every 21 days with 8 days of very heavy flow. During her heaviest bleeding. She change the pad or tampon every 1.5 hours. She endorses dysmenorrhea, intermenstrual bleeding, postcoital bleeding and dyspareunia. She states that she had an abnormal Pap in the past requiring no treatment. Last Pap was [MASKED] and normal. She is heterosexual and not sexually active at this time. Reports history of an aborting fibroid at age [MASKED] and history of ovarian cysts. Has genital herpes diagnosed at age [MASKED], infrequent outbreaks, not on suppression. H/o trichomonas, no other STIs. TAB via D&C at age [MASKED] Medical history: RIGHT TUBO-OVARIAN ABSCESS UTERINE FIBROIDS Surgical History: US-GUIDED ASPIRATION OF A RIGHT TUBO-OVARIAN ABSCESS. [MASKED] 17 CC OF [MASKED] TISSUE: ENDOMETRIAL BIOPSY [MASKED] [MASKED] [MASKED] FINAL Endometrium, biopsy: Fragments of early secretory endometrium. Surgical History: 1. [MASKED], tonsillectomy. 2. [MASKED], left knee arthroscopy. 3. [MASKED], ? TAB vs ectopic pregnancy surgery (pt uncertain of side or location or if she underwent medical treatment). 4. [MASKED], laparoscopic cholecystectomy at [MASKED] [MASKED]. 5. [MASKED], repeat surgery, laparoscopy converted to open surgery for repair of liver injury associated with laparoscopic cholecystectomy by Dr. [MASKED] at [MASKED]. 6. Vaginal Myomecomy @ 21 Family History: Comments: Family History: Denies a family history of any GYN or female cancers such as breast, ovarian, uterine, cervical, vaginal, or colon cancer. She reports mother with skin cancer, diabetes, hypertension, heart disease, and hypercholesterolemia. She also reports two brothers with hypertension and grandparents with heart disease. Social History: Marital status: Single Children: No Work: [MASKED] Sexual orientation: Male Domestic violence: Denies Contraception: None Contraception would like pregnancy/has had evaluation and comments: was told was "not ovulating" but has regular menses Tobacco use: Never smoker --------------- --------------- --------------- --------------- Active Medication list as of [MASKED]: Medications - Prescription ALBUTEROL - Dosage uncertain - (Prescribed by Other Provider) CETIRIZINE [ZYRTEC] - Dosage uncertain - (Prescribed by Other Provider) MEDROXYPROGESTERONE - medroxyprogesterone 10 mg tablet. One tablet(s) by mouth Daily METHYLPHENIDATE HCL [CONCERTA] - Dosage uncertain - (Prescribed by Other Provider) VITAMIN D - Dosage uncertain - (Prescribed by Other Provider) Medications - OTC BIOTIN - Dosage uncertain - (OTC) BUDESONIDE-FORMOTEROL [SYMBICORT] - Dosage uncertain - (OTC) VITAMIN B - Vitamin B . - (OTC) --------------- --------------- --------------- --------------- Allergies: Bacitracin Dilaudid Latex Levaquin levofloxacin Neosporin (Neomycin Sulfate/Bacitracin/Polymyxin B) oxycodone Percocet (Oxycodone Hcl/Acetaminophen) Physical Exam: General: NAD, comfortable CV: RRR, normal s1 and s2, no m/r/g Lungs: normal work of breathing, CTAB Abdomen: soft, non-distended, appropriately tender to palpation without rebound or guarding, dressing removed, incision w/ steri strips clean/dry/intact, superficial ecchymosis along superior aspect of incision Extremities: no edema, no TTP, pneumoboots in place bilaterally Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing EXAM UNDER ANESTHESIA and MULTIPLE MYOMECTOMIES. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with morphine and tordal. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. Her diet was advanced without difficulty, she was ambulating, and she was transitioned to PO oxycodone/ibuprofen/acetaminophen. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity do not exceed 4000mg in 24 hours RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*90 Tablet Refills:*1 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp #*50 Tablet Refills:*1 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*9 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe do not drink alcohol or drive while taking oxycodone RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*0 6. Sertraline 50 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Uterine fibroids Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * Since you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Followup Instructions: [MASKED]
[]
[ "F329", "F419" ]
[ "D259: Leiomyoma of uterus, unspecified", "N736: Female pelvic peritoneal adhesions (postinfective)", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]
10,071,847
22,771,062
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall Major Surgical or Invasive Procedure: ___ Placement of DUAL CHAMBER ___ PACEMAKER History of Present Illness: ___ s/p mechanical fall, transferred from ___ w/ R ___ rib fractures. Patient reports that she was sweeping her side walk, and turned around too fast, and fell to the ground. She does not think she hit her head, and no LOC. She was helped up people who were nearby, and went home. However, she noticed continued right sided chest pain. She denies shortness of breath, dyspnea, and did not report any lightheadedness or dizziness prior to her fall. She denies abdominal pain, nausea, or vomiting. She has not had a history of frequent falls. Past Medical History: HTN Social History: ___ Family History: Noncontributory Physical Exam: Admission Physical Exam: ========================= Vitals: 98.1 60 178/65 18 98% RA Gen: A&Ox3, comfortable lying in bed, NAD HEENT: EOMI, mmm, no facial abrasions, no scalp lacerations, no facial tenderness, oropharynx and nares clear, PERRL, trachea midline Pulm: R lower lateral chest wall tenderness, no crepitus Abd: soft, nontender, nondistended, no rebound or guarding Ext: WWP, no edema, no abrasions, 2+ DP bilaterally Discharge Physical Exam: ======================= - VITALS: 98.2 90/55-166/67 ___ 93-97%RA - I/Os: 24H: 700/975 - WEIGHT: 53.8 - TELEMETRY: Sinus. Paced. General: thin, elderly woman, lying in bed, NAD HEENT: no scleral icterus, mmm Neck: ___ J collar in place CV: regular, no m/r/g Lungs: decreased breath sounds at bilateral bases, no crackles or wheezes Abdomen: soft, NT/ND, +bs GU: no foley Ext: warm, no edema. right chest wall TTP Neuro: PERRL, EOMI, CN II-XII grossly intact, moving all 4 extremities Skin: no rashes or jaundice. L chest wall PPM dressing in place, clean, dry and intact Pertinent Results: ADMISSION LABS: ================ ___ 09:40PM BLOOD WBC-8.2 RBC-4.37 Hgb-12.8 Hct-40.5 MCV-93 MCH-29.3 MCHC-31.6* RDW-12.6 RDWSD-43.0 Plt ___ ___ 09:40PM BLOOD Neuts-72.5* Lymphs-17.0* Monos-9.5 Eos-0.2* Baso-0.4 Im ___ AbsNeut-5.96 AbsLymp-1.40 AbsMono-0.78 AbsEos-0.02* AbsBaso-0.03 ___ 09:40PM BLOOD ___ PTT-27.6 ___ ___ 09:40PM BLOOD Glucose-121* UreaN-23* Creat-0.9 Na-135 K-4.4 Cl-97 HCO3-27 AnGap-15 ___ 08:50PM URINE Color-Straw Appear-Clear Sp ___ ___ 08:50PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 08:50PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 DISCHARGE LABS ============== ___ 07:00AM BLOOD WBC-7.3 RBC-4.46 Hgb-13.3 Hct-41.5 MCV-93 MCH-29.8 MCHC-32.0 RDW-13.2 RDWSD-44.1 Plt ___ ___ 07:00AM BLOOD Glucose-115* UreaN-29* Creat-1.2* Na-133 K-4.4 Cl-96 HCO3-28 AnGap-13 ___ 07:00AM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.0 Mg-2.1 MICRO: ======= URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ========= ___ Imaging MR CERVICAL SPINE W/O C 1. Fracture through the anterior arch of C1 is better characterized on cervical spine CT. There is associated prevertebral edema extending from C1 through C4, which is likely related to the fracture, although the anterior longitudinal ligamentous injury without a discrete tear cannot be excluded. 2. Prevertebral edema at C7-T1 may suggest anterior longitudinal ligamentous injury, although there is no discrete tear. 3. Multilevel degenerative changes are most severe at C5-6 where there is moderate canal and bilateral neural foraminal narrowing. 4. There is no cord signal abnormality. ___-SPINE W/O CONTRAST 1. Acute minimally displaced fracture through the anterior arch of C1. 2. No traumatic malalignment. 3. Minimally displaced right first and fourth rib fractures. ___ Imaging CT HEAD W/O CONTRAST No acute intracranial process on motion limited study. ___ CXR New left-sided pacemaker with lead tips over right atrium right ventricle. Suspect small pneumothorax seen anteriorly. Small to moderate right and small left pleural thickening and/or fluid. Otherwise, no acute pulmonary process identified. Compression deformity of lower thoracic vertebral body, question T12. There is spurring suggestive of a chronic injury, though, if the patient has new superimposed symptoms in this location, the possibility of a superimposed acute fracture component would be difficult to exclude. Brief Hospital Course: ___ F w/ HTN presented after a mechanical fall, found to have right rib fractures in ribs ___ & C1 fracture. #Mechanical Fall: Spine surgery was consulted for C1 fracture, and recommended no surgery, but ___ J collar at all times. She was admitted initially to the surgical service for pain management, and pain was controlled with Tylenol, oxycodone, and lidocaine patch. No surgery indicated for the ribs. #Syncope, Paroxysmal AV Block: She was improving from a pain standpoint following her trauma but had a syncopal episode on ___, with telemetry showing paroxysmal AV block. EP was consulted, and dual chamber PPM was placed on ___ without complications. Pacer was interrogated by EP and was working normally on the day of discharge. The patient had hypotension to SBP ___ on the day of discharge. She was asymptomatic. There was no fever or hypoxia. She had negative orthostatics. EP fellow performed bedside TTE without signs of pericardial effusion and recommended discharge to rehab. #Hypertension: Her SBPs were in the 160s-190s range with a HR in mid50s-60s range. She was continued on her home carvedilol with little effect on her HTN. On HD 2 she was 190s and given 10mg IV hydral x1 with subsequent SBPs 100s-120s range. BP stabilized with intermittent low BP to SBP ___ before discharge and she was kept on her home antihypertensive regimen. See above for hypotension on day of discharge. ___: The patient was found to have mild ___ with creatinine from 0.9 to 1.2 on the day of discharge after her syncopal episode and PPM placement. She was tolerate PO intake and this was encouraged before discharge. TRANSITIONAL ISSUES ==================== NEW MEDICATIONS: - Acetaminophen 650 mg PO TID - Docusate Sodium 100 mg PO BID - Lidocaine 5% Patch 1 PTCH TD QAM right rib pain - OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe - Senna 8.6 mg PO BID:PRN constipation - Antibiotics: Needs 3 days of antibiotics (___) after pacer placement. She completed vancomycin to cover ___ and ___. She should be given Keflex on discharge for one day (Cephalexin 500 mg PO Q8H Duration: 3 Doses on ___. [] Follow up blood pressure. Encourage PO intake. Hold antihypertensive medications if systolic blood pressure is below 100. Monitor for signs of infection. She was asymptomatic at the time of discharge. [] Please check electrolytes on ___ to assess for improvement in creatinine [] Monitor blood pressure and adjust antihypertensive medications as needed [] Pleasure ensure follow up: - EP follow-up: Patient has new DUAL CHAMBER ___ PACEMAKER and will need to follow up in device clinic in 1 week - Spine follow-up: Will need to wear ___ J collar at all times, and follow up with Spine in 4 weeks for repeat imaging - Outpatient ___ arranged # CODE: Full (confirmed with patient) # CONTACT: Daughter (___) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. B Complete (vitamin B complex) 1 tab oral DAILY 2. Denosumab (Prolia) 60 mg SC Q6MONTHS 3. Simvastatin 40 mg PO QPM 4. Carvedilol 12.5 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Cephalexin 500 mg PO Q8H Duration: 3 Doses 3. Docusate Sodium 100 mg PO BID 4. Lidocaine 5% Patch 1 PTCH TD QAM right rib pain 5. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Every 4 hours Disp #*21 Tablet Refills:*0 6. Senna 8.6 mg PO BID:PRN constipation 7. B Complete (vitamin B complex) 1 tab oral DAILY 8. Carvedilol 12.5 mg PO BID 9. Denosumab (Prolia) 60 mg SC Q6MONTHS 10. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES - Syncope secondary to paroxysmal atrioventricular block - rib fractures - cervical fracture SECONDARY DIAGNOSES - hypertension - hyperlipidemia 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 a fall. While you were here, you were found to have a broken bone in your neck and some broken ribs. You will need to wear the neck collar for the next 4 weeks, then follow up with the spine doctors to ___ if it can be taken off. You were also given medicines for your rib pain. You passed out when you were working with physical therapy, and we found that you had an abnormal heart rhythm. You had a pacemaker placed to fix this problem. When you go home, please take all of your medicines as prescribed. Wear your neck collar at all times. Call your doctor if you have any more episodes of passing out, fevers, or worsening pain. You will need to follow up with the heart rhythm doctors in one week. They will call you to help set this up. You will need to follow up with Dr. ___ in 4 weeks in the spine clinic. We wish you all the best in the future. Sincerely, your ___ Care Team Followup Instructions: ___
[ "I442", "I462", "S12000A", "N179", "S2241XA", "M8088XA", "I10", "W1839XA", "Y92480", "R55", "E785", "E559" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: s/p fall Major Surgical or Invasive Procedure: [MASKED] Placement of DUAL CHAMBER [MASKED] PACEMAKER History of Present Illness: [MASKED] s/p mechanical fall, transferred from [MASKED] w/ R [MASKED] rib fractures. Patient reports that she was sweeping her side walk, and turned around too fast, and fell to the ground. She does not think she hit her head, and no LOC. She was helped up people who were nearby, and went home. However, she noticed continued right sided chest pain. She denies shortness of breath, dyspnea, and did not report any lightheadedness or dizziness prior to her fall. She denies abdominal pain, nausea, or vomiting. She has not had a history of frequent falls. Past Medical History: HTN Social History: [MASKED] Family History: Noncontributory Physical Exam: Admission Physical Exam: ========================= Vitals: 98.1 60 178/65 18 98% RA Gen: A&Ox3, comfortable lying in bed, NAD HEENT: EOMI, mmm, no facial abrasions, no scalp lacerations, no facial tenderness, oropharynx and nares clear, PERRL, trachea midline Pulm: R lower lateral chest wall tenderness, no crepitus Abd: soft, nontender, nondistended, no rebound or guarding Ext: WWP, no edema, no abrasions, 2+ DP bilaterally Discharge Physical Exam: ======================= - VITALS: 98.2 90/55-166/67 [MASKED] 93-97%RA - I/Os: 24H: 700/975 - WEIGHT: 53.8 - TELEMETRY: Sinus. Paced. General: thin, elderly woman, lying in bed, NAD HEENT: no scleral icterus, mmm Neck: [MASKED] J collar in place CV: regular, no m/r/g Lungs: decreased breath sounds at bilateral bases, no crackles or wheezes Abdomen: soft, NT/ND, +bs GU: no foley Ext: warm, no edema. right chest wall TTP Neuro: PERRL, EOMI, CN II-XII grossly intact, moving all 4 extremities Skin: no rashes or jaundice. L chest wall PPM dressing in place, clean, dry and intact Pertinent Results: ADMISSION LABS: ================ [MASKED] 09:40PM BLOOD WBC-8.2 RBC-4.37 Hgb-12.8 Hct-40.5 MCV-93 MCH-29.3 MCHC-31.6* RDW-12.6 RDWSD-43.0 Plt [MASKED] [MASKED] 09:40PM BLOOD Neuts-72.5* Lymphs-17.0* Monos-9.5 Eos-0.2* Baso-0.4 Im [MASKED] AbsNeut-5.96 AbsLymp-1.40 AbsMono-0.78 AbsEos-0.02* AbsBaso-0.03 [MASKED] 09:40PM BLOOD [MASKED] PTT-27.6 [MASKED] [MASKED] 09:40PM BLOOD Glucose-121* UreaN-23* Creat-0.9 Na-135 K-4.4 Cl-97 HCO3-27 AnGap-15 [MASKED] 08:50PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 08:50PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [MASKED] 08:50PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 DISCHARGE LABS ============== [MASKED] 07:00AM BLOOD WBC-7.3 RBC-4.46 Hgb-13.3 Hct-41.5 MCV-93 MCH-29.8 MCHC-32.0 RDW-13.2 RDWSD-44.1 Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-115* UreaN-29* Creat-1.2* Na-133 K-4.4 Cl-96 HCO3-28 AnGap-13 [MASKED] 07:00AM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.0 Mg-2.1 MICRO: ======= URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ========= [MASKED] Imaging MR CERVICAL SPINE W/O C 1. Fracture through the anterior arch of C1 is better characterized on cervical spine CT. There is associated prevertebral edema extending from C1 through C4, which is likely related to the fracture, although the anterior longitudinal ligamentous injury without a discrete tear cannot be excluded. 2. Prevertebral edema at C7-T1 may suggest anterior longitudinal ligamentous injury, although there is no discrete tear. 3. Multilevel degenerative changes are most severe at C5-6 where there is moderate canal and bilateral neural foraminal narrowing. 4. There is no cord signal abnormality. [MASKED]-SPINE W/O CONTRAST 1. Acute minimally displaced fracture through the anterior arch of C1. 2. No traumatic malalignment. 3. Minimally displaced right first and fourth rib fractures. [MASKED] Imaging CT HEAD W/O CONTRAST No acute intracranial process on motion limited study. [MASKED] CXR New left-sided pacemaker with lead tips over right atrium right ventricle. Suspect small pneumothorax seen anteriorly. Small to moderate right and small left pleural thickening and/or fluid. Otherwise, no acute pulmonary process identified. Compression deformity of lower thoracic vertebral body, question T12. There is spurring suggestive of a chronic injury, though, if the patient has new superimposed symptoms in this location, the possibility of a superimposed acute fracture component would be difficult to exclude. Brief Hospital Course: [MASKED] F w/ HTN presented after a mechanical fall, found to have right rib fractures in ribs [MASKED] & C1 fracture. #Mechanical Fall: Spine surgery was consulted for C1 fracture, and recommended no surgery, but [MASKED] J collar at all times. She was admitted initially to the surgical service for pain management, and pain was controlled with Tylenol, oxycodone, and lidocaine patch. No surgery indicated for the ribs. #Syncope, Paroxysmal AV Block: She was improving from a pain standpoint following her trauma but had a syncopal episode on [MASKED], with telemetry showing paroxysmal AV block. EP was consulted, and dual chamber PPM was placed on [MASKED] without complications. Pacer was interrogated by EP and was working normally on the day of discharge. The patient had hypotension to SBP [MASKED] on the day of discharge. She was asymptomatic. There was no fever or hypoxia. She had negative orthostatics. EP fellow performed bedside TTE without signs of pericardial effusion and recommended discharge to rehab. #Hypertension: Her SBPs were in the 160s-190s range with a HR in mid50s-60s range. She was continued on her home carvedilol with little effect on her HTN. On HD 2 she was 190s and given 10mg IV hydral x1 with subsequent SBPs 100s-120s range. BP stabilized with intermittent low BP to SBP [MASKED] before discharge and she was kept on her home antihypertensive regimen. See above for hypotension on day of discharge. [MASKED]: The patient was found to have mild [MASKED] with creatinine from 0.9 to 1.2 on the day of discharge after her syncopal episode and PPM placement. She was tolerate PO intake and this was encouraged before discharge. TRANSITIONAL ISSUES ==================== NEW MEDICATIONS: - Acetaminophen 650 mg PO TID - Docusate Sodium 100 mg PO BID - Lidocaine 5% Patch 1 PTCH TD QAM right rib pain - OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe - Senna 8.6 mg PO BID:PRN constipation - Antibiotics: Needs 3 days of antibiotics ([MASKED]) after pacer placement. She completed vancomycin to cover [MASKED] and [MASKED]. She should be given Keflex on discharge for one day (Cephalexin 500 mg PO Q8H Duration: 3 Doses on [MASKED]. [] Follow up blood pressure. Encourage PO intake. Hold antihypertensive medications if systolic blood pressure is below 100. Monitor for signs of infection. She was asymptomatic at the time of discharge. [] Please check electrolytes on [MASKED] to assess for improvement in creatinine [] Monitor blood pressure and adjust antihypertensive medications as needed [] Pleasure ensure follow up: - EP follow-up: Patient has new DUAL CHAMBER [MASKED] PACEMAKER and will need to follow up in device clinic in 1 week - Spine follow-up: Will need to wear [MASKED] J collar at all times, and follow up with Spine in 4 weeks for repeat imaging - Outpatient [MASKED] arranged # CODE: Full (confirmed with patient) # CONTACT: Daughter ([MASKED]) [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. B Complete (vitamin B complex) 1 tab oral DAILY 2. Denosumab (Prolia) 60 mg SC Q6MONTHS 3. Simvastatin 40 mg PO QPM 4. Carvedilol 12.5 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Cephalexin 500 mg PO Q8H Duration: 3 Doses 3. Docusate Sodium 100 mg PO BID 4. Lidocaine 5% Patch 1 PTCH TD QAM right rib pain 5. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - Severe RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Every 4 hours Disp #*21 Tablet Refills:*0 6. Senna 8.6 mg PO BID:PRN constipation 7. B Complete (vitamin B complex) 1 tab oral DAILY 8. Carvedilol 12.5 mg PO BID 9. Denosumab (Prolia) 60 mg SC Q6MONTHS 10. Simvastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES - Syncope secondary to paroxysmal atrioventricular block - rib fractures - cervical fracture SECONDARY DIAGNOSES - hypertension - hyperlipidemia 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 a fall. While you were here, you were found to have a broken bone in your neck and some broken ribs. You will need to wear the neck collar for the next 4 weeks, then follow up with the spine doctors to [MASKED] if it can be taken off. You were also given medicines for your rib pain. You passed out when you were working with physical therapy, and we found that you had an abnormal heart rhythm. You had a pacemaker placed to fix this problem. When you go home, please take all of your medicines as prescribed. Wear your neck collar at all times. Call your doctor if you have any more episodes of passing out, fevers, or worsening pain. You will need to follow up with the heart rhythm doctors in one week. They will call you to help set this up. You will need to follow up with Dr. [MASKED] in 4 weeks in the spine clinic. We wish you all the best in the future. Sincerely, your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "I10", "E785" ]
[ "I442: Atrioventricular block, complete", "I462: Cardiac arrest due to underlying cardiac condition", "S12000A: Unspecified displaced fracture of first cervical vertebra, initial encounter for closed fracture", "N179: Acute kidney failure, unspecified", "S2241XA: Multiple fractures of ribs, right side, initial encounter for closed fracture", "M8088XA: Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture", "I10: Essential (primary) hypertension", "W1839XA: Other fall on same level, initial encounter", "Y92480: Sidewalk as the place of occurrence of the external cause", "R55: Syncope and collapse", "E785: Hyperlipidemia, unspecified", "E559: Vitamin D deficiency, unspecified" ]
10,071,869
20,895,291
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hypoxemia Major Surgical or Invasive Procedure: none History of Present Illness: ___ who has chart history of dementia, recent diagnosis of Enterococcus bacteremia and Osteomyelitis on Ampicillin until ___, Afib on Coumadin who is transferred from ___ due to respiratory distress. Per review of Rehab notes and phone discussion with wife, he presented to ___ on ___ (14d ago) after d/c from ___. At ___ he was admitted there for about 2 weeks and per Rehab notes found to have Enterococcal bacteremia and Osteomyelitis (unclear where). Per Rehab notes he is supposed to be on Ampicillin 2g Q4 until ___. On day of arrival at ___ patient acutely hypoxemic with inc O2 requirement, CXR at Rehab showed ?Opacity of R Lung. In the ED, initial vitals: Afebrile, normotensive, HR 70-100, 80% on 6L, 98% on NRB - Exam notable for: intermittentl oriented elderly man with tachypnea who had SaO2 mid ___ on 6L - Labs were notable for: ABG: pH ___ INR 5.0, Hgb 7.3 / Hct 23, LFTs wnl, Alb 2.3, Lactate 1.9, BUN 23, Cr 0.6, Na 148, UA normal, - Imaging: CXR shows Significant opacification of the right lung and left lower lobe - Patient was given: Vanc/Cefepime/Flagyl Given ___ need for high flow O2, he was sent to the ICU. On arrival to the MICU patient is on a NRB at 100% and switched to high flow. He was comfortable, not in distress or pain. He was thirsty and had diarrhea. Per wife at baseline patient was independent until admission to ___ at the beginning of ___. Wife was not aware of dementia diagnosis or any infection diagnoses. She was aware of his Afib hx. I confirmed that he is DNR/DNI. Past Medical History: - CHF (unclear type or EF) - Afib on warfarin - Enterococcus Bacteremia and ?Osteomyelitis on Ampicillin - Rheumatoid Arthritis on Prednisone - Myelodysplastic syndrome - H/O GI Bleed d/t NSAIDs - H/O Prostate CA - H/O Left TKR ___ Social History: ___ Family History: -- "heart problems" per wife in ___ family Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: afebrile, normotensive, 95% on high flow GENERAL: Thin, Chronically ill appearing man, not in distress. Hard of hearing HEENT: Mild yellow discoloration of his sclera, dry mucosa, edentulous without dentures NECK: thin, no LAD LUNGS: Coarse crackles anteriorly CV: Irregularly irregular, < 100 ABD: Thin, soft, non tender EXT: Sacral pitting edema, no pitting edema of legs SKIN: multiple bruises diffusely NEURO: Knows his name/dob, knows wife's name, knows kids' names, knows where he lives, does not know the year (thinks ___, thinks it is ___, hard of hearing ACCESS: PICC on left looks clean DISCHARGE EXAM Expired Pertinent Results: ADMISSION LABS ___ 08:00PM ___ PTT-38.0* ___ ___ 08:00PM PLT SMR-NORMAL PLT COUNT-159 ___ 08:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+ ___ 08:00PM NEUTS-93* BANDS-2 LYMPHS-3* MONOS-1* EOS-1 BASOS-0 ___ MYELOS-0 NUC RBCS-1* AbsNeut-8.55* AbsLymp-0.27* AbsMono-0.09* AbsEos-0.09 AbsBaso-0.00* ___ 08:00PM WBC-9.0 RBC-2.14* HGB-7.3* HCT-23.0* MCV-108* MCH-34.1* MCHC-31.7* RDW-24.6* RDWSD-92.1* ___ 08:00PM VIT B12-895 ___ FERRITIN-3117* ___ 08:00PM ALBUMIN-2.3* ___ 08:00PM proBNP-5657* ___ 08:00PM cTropnT-0.06* ___ 08:00PM LIPASE-24 ___ 08:00PM ALT(SGPT)-22 AST(SGOT)-25 ALK PHOS-113* TOT BILI-0.3 ___ 08:00PM estGFR-Using this ___ 08:00PM estGFR-Using this ___ 08:00PM GLUCOSE-227* UREA N-23* CREAT-0.6 SODIUM-148* POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-25 ANION GAP-15 ___ 08:23PM LACTATE-1.9 ___ 08:38PM URINE MUCOUS-RARE ___ 08:38PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 08:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.5 LEUK-NEG ___ 08:38PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:07PM TYPE-ART PO2-154* PCO2-31* PH-7.53* TOTAL CO2-27 BASE XS-4 BLOOD GAS TREND; ___ 09:07PM BLOOD Type-ART pO2-154* pCO2-31* pH-7.53* calTCO2-27 Base XS-4 ___ 12:56AM BLOOD ___ Temp-37.2 pO2-33* pCO2-39 pH-7.46* calTCO2-29 Base XS-3 Intubat-NOT INTUBA ___ 02:55AM BLOOD ___ pO2-31* pCO2-39 pH-7.47* calTCO2-29 Base XS-3 ___ 05:03PM BLOOD ___ pH-7.52* ___ 04:23AM BLOOD Type-MIX pO2-38* pCO2-50* pH-7.48* calTCO2-38* Base XS-11 ___ 10:27AM BLOOD ___ pO2-34* pCO2-43 pH-7.52* calTCO2-36* Base XS-10 ___ 06:00PM BLOOD ___ pO2-46* pCO2-45 pH-7.52* calTCO2-38* Base XS-11 ___ 03:21AM BLOOD Type-MIX pO2-33* pCO2-50* pH-7.48* calTCO2-38* Base XS-11 ___ 02:34AM BLOOD Type-MIX pO2-36* pCO2-44 pH-7.50* calTCO2-36* Base XS-9 ___ 02:05AM BLOOD Type-MIX pO2-67* pCO2-72* pH-7.30* calTCO2-37* Base XS-5 ___ 05:14AM BLOOD Type-MIX pO2-35* pCO2-54* pH-7.41 calTCO2-35* Base XS-7 ___ LABS ___ 08:00PM BLOOD VitB12-895 ___ Ferritn-3117* ___ 06:43AM BLOOD Cortsol-36.1* ___ 06:43AM BLOOD Vanco-18.4 ___ 03:31AM BLOOD Digoxin-1.1 IMAGING STUDIES: ECHO ___ Suboptimal image quality. The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF = 65%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area = 1.9 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen (may be underestimated). The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen (may be underestimated). There is borderline pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. ___ CT CHEST Although there are moderate bilateral pleural effusions, severe coronary calcification and sufficient aortic valvular calcification to produce aortic stenosis, the extremely asymmetric and non dependent distribution of the severe interstitial and alveolar abnormality, favoring the right lung and scattered elsewhere in the periphery of the left lung means that cardiogenic pulmonary edema is not a sufficient explanation for the severe lung findings although it may be contributory. Differential diagnosis of the pulmonary abnormality includes severe viral infection, viral infection leading to diffuse alveolar damage, and acute interstitial pneumonia. The large region of sparing in the left lower lobe argues against pneumocystis pneumonia, but certainly does not exclude that diagnosis. Severe generalized atherosclerotic calcification involves the head and neck vessels, particular the carotid arteries in addition to the coronaries. ___ CT CHEST: 1. Slight interval improvement in persistent extensive pulmonary parenchymal abnormalities, worst in the right upper lobe. Differential diagnosis includes, as before, severe viral infection and acute interstitial pneumonia. Chronic aspiration is possible as well. 2. Posterior defect in the trachea is not currently seen and likely represented artifact on prior CT. Confirmation of tracheoesophageal fistula would require barium swallow study under fluoroscopy. MICRO: ___ 6:26 pm Rapid Respiratory Viral Screen & Culture Site: NASOPHARYNX Source: Nasopharyngeal swab. **FINAL REPORT ___ Respiratory Viral Culture (Final ___: TEST CANCELLED, PATIENT CREDITED. Refer to respiratory viral antigen screen and respiratory virus identification test results for further information. Respiratory Viral Antigen Screen (Final ___: Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. Respiratory Virus Identification (Final ___: Reported to and read back by ___ (4I) ___ AT 1139. POSITIVE FOR PARAINFLUENZA TYPE 3. Viral antigen identified by immunofluorescence. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. ___ 4:27 am SPUTUM GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): ___ 12:23 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ URINE CULTURE - NEG ___ BLOOD CULTURE - NEG DISCHARGE LABS: ___ 01:56AM BLOOD WBC-12.3* RBC-2.28* Hgb-7.3* Hct-22.0* MCV-97 MCH-32.0 MCHC-33.2 RDW-20.3* RDWSD-70.2* Plt ___ ___ 01:56AM BLOOD Plt ___ ___ 01:56AM BLOOD ___ PTT-35.2 ___ ___ 01:56AM BLOOD Glucose-101* UreaN-16 Creat-1.0 Na-126* K-4.1 Cl-86* HCO3-30 AnGap-14 ___ 01:56AM BLOOD ALT-29 AST-31 LD(LDH)-577* AlkPhos-127 TotBili-0.___ y/o male with a PMH of rheumatoid arthritis currently receiving rituximab (q6 months), plaquenil, and prednisone (history of multiple previous DMARDs), recent diagnosis of Enterococcal bacteremia and osteomyelitis at an OSH, MDS, afib, and CHF currently admitted to ___ with dyspnea and hypoxia found to have substantial bilateral interstitial and alveolar disease on CT imaging. The patient has remained profoundly hypoxemic despite broad abx coverage and diuresis, and he was found to have an elevated B-glucan and LDH, as well as NP swab positive for parainfluenza. #Goals of care: ___ wife was called on ___ by Dr. ___ ___ to discuss worsening respiratory status despite maximum intervention within the current goals of care with worsening metabolic state and agitation. Discussed that he has had ongoing treatment for pneumonia (PCP and viral pneumonia) and diuresis without improvement in his oxygenation and noted to have worsening O2 needs. Relayed that our hope has been to get him through his acute illness but that he is currently showing signs of deterioration in terms of his pulmonary function, mental status and electrolytes concerning for worsening disease process. Dr. ___ discussed with ___ family that we could continue to move forward with current care but the concern is that he is worsening and at risk of death. Also noted that he is more uncomfortable with rising oxygen needs. ___ wife spoke to her son and called back to confirm they would like to transition to comfort focused care. On ___, Dr. ___ met with the ___ wife and two sons at the ___ bedside to confirm their understanding of the severity of his illness and his wished for ongoing care. Patient unable to participate in discussion due to delirium. ___ wife and sons noted that they understood that he was worsening and "dying" and that they wanted to transition to comfort for the patient, per his prior wishes. We discussed the steps for this transition including medications to make his breathing more comfortable, help with agitation and delirium. The family was offered hospice services to help with coping but declined. All questions were answered. After this, his oxygen was removed and IV morphine drip was initiated for comfort. # Acute Hypoxemic Respiratory Failure # Viral/HCAP/Multilobar/Interstitial Pneumonia Presented with persistent hypoxemia. CXR and CT scan suggested multifocal pneumonia most consistent with an atypical viral or bacterial etiology. CT showing diffuse asymmetric parenchymal changes c/w viral vs. interstitial pneumonia vs. alveolar hemorrhage with underlying volume overload possibly contributing as well. Because he was DNR/DNI, bronch was not able to pursued b/c would have compromised his already tenuous respiratory status. Initially started on vanc/zosyn for HCAP, steroids and Bactrim for possible PCP ___ (given recent steroid use), and resp viral panel came back positive for H flu. He did not improve on this regimen and still had substantial oxygen requirement. Duiresis was attempted without improvement in oxygenation. During his course developed worsening acidosis, hyponatremia, and altered mental status. He was unable to tolerate POs due to altered mental status, and it was confirmed with family that NGT/PEG were not in goals of care. In this setting he was transitioned to comfort care. On ___, MD called to bedside by RN at 00:10 for declining O2 saturations and bradycardia. Patient appeared comfortable taking shallow, intermittent respirations on morphine drip. Respiratory rate decreased and then ceased. Intermittent ectopy noted on telemetry then ceased and pulses were lost. Auscultated for breath sounds and cardiac sounds x1 minute with no activity. Pupillary response absent. No withdrawal to painful stimuli. Time of death 00:15. Cause of death: parainfluenza pneumonia. Family (son, ___ notified at 00:20 and expressed gratitude to ICU team. Autopsy was declined. Support offered to ___ family. Admitting office, overnight ICU attending (Dr. ___, NEOB (declined) and PCP (Dr. ___- answering service) notified. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO QHS 4. Ondansetron 4 mg IV Q8H:PRN nausea 5. Digoxin 0.125 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Nystatin Oral Suspension 5 mL PO QID 9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 10. PredniSONE 10 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Ampicillin 2 g IV Q4H 13. Metoprolol Tartrate 75 mg PO BID 14. Lactulose 15 mL PO Q8H:PRN constip 15. Diltiazem 60 mg PO Q6H 16. Famotidine 20 mg PO DAILY 17. Warfarin 3 mg PO DAILY16 18. Multivitamins 1 TAB PO DAILY Discharge Medications: none (deceased) Discharge Disposition: Expired Discharge Diagnosis: Acute hypoxemic respiratory failure secondary to parainfluenza 3 pneumonia Acute on chronic diastolic heart failure Deep vein thrombosis Atrial fibrillation Rheumatoid arthritis Osteomyelitis Discharge Condition: Deceased Discharge Instructions: Deceased ___ MD ___ Completed by: ___
[ "J122", "J9601", "I5033", "E870", "J90", "D469", "I82411", "E872", "E871", "M868X8", "I4891", "M069", "F0390", "Z7952", "Z8546", "Z96652", "D539", "B952", "Z87891", "Z7901", "Z515", "Z66", "J8410" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: hypoxemia Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] who has chart history of dementia, recent diagnosis of Enterococcus bacteremia and Osteomyelitis on Ampicillin until [MASKED], Afib on Coumadin who is transferred from [MASKED] due to respiratory distress. Per review of Rehab notes and phone discussion with wife, he presented to [MASKED] on [MASKED] (14d ago) after d/c from [MASKED]. At [MASKED] he was admitted there for about 2 weeks and per Rehab notes found to have Enterococcal bacteremia and Osteomyelitis (unclear where). Per Rehab notes he is supposed to be on Ampicillin 2g Q4 until [MASKED]. On day of arrival at [MASKED] patient acutely hypoxemic with inc O2 requirement, CXR at Rehab showed ?Opacity of R Lung. In the ED, initial vitals: Afebrile, normotensive, HR 70-100, 80% on 6L, 98% on NRB - Exam notable for: intermittentl oriented elderly man with tachypnea who had SaO2 mid [MASKED] on 6L - Labs were notable for: ABG: pH [MASKED] INR 5.0, Hgb 7.3 / Hct 23, LFTs wnl, Alb 2.3, Lactate 1.9, BUN 23, Cr 0.6, Na 148, UA normal, - Imaging: CXR shows Significant opacification of the right lung and left lower lobe - Patient was given: Vanc/Cefepime/Flagyl Given [MASKED] need for high flow O2, he was sent to the ICU. On arrival to the MICU patient is on a NRB at 100% and switched to high flow. He was comfortable, not in distress or pain. He was thirsty and had diarrhea. Per wife at baseline patient was independent until admission to [MASKED] at the beginning of [MASKED]. Wife was not aware of dementia diagnosis or any infection diagnoses. She was aware of his Afib hx. I confirmed that he is DNR/DNI. Past Medical History: - CHF (unclear type or EF) - Afib on warfarin - Enterococcus Bacteremia and ?Osteomyelitis on Ampicillin - Rheumatoid Arthritis on Prednisone - Myelodysplastic syndrome - H/O GI Bleed d/t NSAIDs - H/O Prostate CA - H/O Left TKR [MASKED] Social History: [MASKED] Family History: -- "heart problems" per wife in [MASKED] family Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: afebrile, normotensive, 95% on high flow GENERAL: Thin, Chronically ill appearing man, not in distress. Hard of hearing HEENT: Mild yellow discoloration of his sclera, dry mucosa, edentulous without dentures NECK: thin, no LAD LUNGS: Coarse crackles anteriorly CV: Irregularly irregular, < 100 ABD: Thin, soft, non tender EXT: Sacral pitting edema, no pitting edema of legs SKIN: multiple bruises diffusely NEURO: Knows his name/dob, knows wife's name, knows kids' names, knows where he lives, does not know the year (thinks [MASKED], thinks it is [MASKED], hard of hearing ACCESS: PICC on left looks clean DISCHARGE EXAM Expired Pertinent Results: ADMISSION LABS [MASKED] 08:00PM [MASKED] PTT-38.0* [MASKED] [MASKED] 08:00PM PLT SMR-NORMAL PLT COUNT-159 [MASKED] 08:00PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+ [MASKED] 08:00PM NEUTS-93* BANDS-2 LYMPHS-3* MONOS-1* EOS-1 BASOS-0 [MASKED] MYELOS-0 NUC RBCS-1* AbsNeut-8.55* AbsLymp-0.27* AbsMono-0.09* AbsEos-0.09 AbsBaso-0.00* [MASKED] 08:00PM WBC-9.0 RBC-2.14* HGB-7.3* HCT-23.0* MCV-108* MCH-34.1* MCHC-31.7* RDW-24.6* RDWSD-92.1* [MASKED] 08:00PM VIT B12-895 [MASKED] FERRITIN-3117* [MASKED] 08:00PM ALBUMIN-2.3* [MASKED] 08:00PM proBNP-5657* [MASKED] 08:00PM cTropnT-0.06* [MASKED] 08:00PM LIPASE-24 [MASKED] 08:00PM ALT(SGPT)-22 AST(SGOT)-25 ALK PHOS-113* TOT BILI-0.3 [MASKED] 08:00PM estGFR-Using this [MASKED] 08:00PM estGFR-Using this [MASKED] 08:00PM GLUCOSE-227* UREA N-23* CREAT-0.6 SODIUM-148* POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-25 ANION GAP-15 [MASKED] 08:23PM LACTATE-1.9 [MASKED] 08:38PM URINE MUCOUS-RARE [MASKED] 08:38PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 08:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.5 LEUK-NEG [MASKED] 08:38PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 09:07PM TYPE-ART PO2-154* PCO2-31* PH-7.53* TOTAL CO2-27 BASE XS-4 BLOOD GAS TREND; [MASKED] 09:07PM BLOOD Type-ART pO2-154* pCO2-31* pH-7.53* calTCO2-27 Base XS-4 [MASKED] 12:56AM BLOOD [MASKED] Temp-37.2 pO2-33* pCO2-39 pH-7.46* calTCO2-29 Base XS-3 Intubat-NOT INTUBA [MASKED] 02:55AM BLOOD [MASKED] pO2-31* pCO2-39 pH-7.47* calTCO2-29 Base XS-3 [MASKED] 05:03PM BLOOD [MASKED] pH-7.52* [MASKED] 04:23AM BLOOD Type-MIX pO2-38* pCO2-50* pH-7.48* calTCO2-38* Base XS-11 [MASKED] 10:27AM BLOOD [MASKED] pO2-34* pCO2-43 pH-7.52* calTCO2-36* Base XS-10 [MASKED] 06:00PM BLOOD [MASKED] pO2-46* pCO2-45 pH-7.52* calTCO2-38* Base XS-11 [MASKED] 03:21AM BLOOD Type-MIX pO2-33* pCO2-50* pH-7.48* calTCO2-38* Base XS-11 [MASKED] 02:34AM BLOOD Type-MIX pO2-36* pCO2-44 pH-7.50* calTCO2-36* Base XS-9 [MASKED] 02:05AM BLOOD Type-MIX pO2-67* pCO2-72* pH-7.30* calTCO2-37* Base XS-5 [MASKED] 05:14AM BLOOD Type-MIX pO2-35* pCO2-54* pH-7.41 calTCO2-35* Base XS-7 [MASKED] LABS [MASKED] 08:00PM BLOOD VitB12-895 [MASKED] Ferritn-3117* [MASKED] 06:43AM BLOOD Cortsol-36.1* [MASKED] 06:43AM BLOOD Vanco-18.4 [MASKED] 03:31AM BLOOD Digoxin-1.1 IMAGING STUDIES: ECHO [MASKED] Suboptimal image quality. The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF = 65%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area = 1.9 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen (may be underestimated). The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen (may be underestimated). There is borderline pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. [MASKED] CT CHEST Although there are moderate bilateral pleural effusions, severe coronary calcification and sufficient aortic valvular calcification to produce aortic stenosis, the extremely asymmetric and non dependent distribution of the severe interstitial and alveolar abnormality, favoring the right lung and scattered elsewhere in the periphery of the left lung means that cardiogenic pulmonary edema is not a sufficient explanation for the severe lung findings although it may be contributory. Differential diagnosis of the pulmonary abnormality includes severe viral infection, viral infection leading to diffuse alveolar damage, and acute interstitial pneumonia. The large region of sparing in the left lower lobe argues against pneumocystis pneumonia, but certainly does not exclude that diagnosis. Severe generalized atherosclerotic calcification involves the head and neck vessels, particular the carotid arteries in addition to the coronaries. [MASKED] CT CHEST: 1. Slight interval improvement in persistent extensive pulmonary parenchymal abnormalities, worst in the right upper lobe. Differential diagnosis includes, as before, severe viral infection and acute interstitial pneumonia. Chronic aspiration is possible as well. 2. Posterior defect in the trachea is not currently seen and likely represented artifact on prior CT. Confirmation of tracheoesophageal fistula would require barium swallow study under fluoroscopy. MICRO: [MASKED] 6:26 pm Rapid Respiratory Viral Screen & Culture Site: NASOPHARYNX Source: Nasopharyngeal swab. **FINAL REPORT [MASKED] Respiratory Viral Culture (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. Refer to respiratory viral antigen screen and respiratory virus identification test results for further information. Respiratory Viral Antigen Screen (Final [MASKED]: Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. Respiratory Virus Identification (Final [MASKED]: Reported to and read back by [MASKED] (4I) [MASKED] AT 1139. POSITIVE FOR PARAINFLUENZA TYPE 3. Viral antigen identified by immunofluorescence. **FINAL REPORT [MASKED] Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [MASKED] 4:27 am SPUTUM GRAM STAIN (Final [MASKED]: >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): [MASKED] 12:23 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. [MASKED] URINE CULTURE - NEG [MASKED] BLOOD CULTURE - NEG DISCHARGE LABS: [MASKED] 01:56AM BLOOD WBC-12.3* RBC-2.28* Hgb-7.3* Hct-22.0* MCV-97 MCH-32.0 MCHC-33.2 RDW-20.3* RDWSD-70.2* Plt [MASKED] [MASKED] 01:56AM BLOOD Plt [MASKED] [MASKED] 01:56AM BLOOD [MASKED] PTT-35.2 [MASKED] [MASKED] 01:56AM BLOOD Glucose-101* UreaN-16 Creat-1.0 Na-126* K-4.1 Cl-86* HCO3-30 AnGap-14 [MASKED] 01:56AM BLOOD ALT-29 AST-31 LD(LDH)-577* AlkPhos-127 TotBili-0.[MASKED] y/o male with a PMH of rheumatoid arthritis currently receiving rituximab (q6 months), plaquenil, and prednisone (history of multiple previous DMARDs), recent diagnosis of Enterococcal bacteremia and osteomyelitis at an OSH, MDS, afib, and CHF currently admitted to [MASKED] with dyspnea and hypoxia found to have substantial bilateral interstitial and alveolar disease on CT imaging. The patient has remained profoundly hypoxemic despite broad abx coverage and diuresis, and he was found to have an elevated B-glucan and LDH, as well as NP swab positive for parainfluenza. #Goals of care: [MASKED] wife was called on [MASKED] by Dr. [MASKED] [MASKED] to discuss worsening respiratory status despite maximum intervention within the current goals of care with worsening metabolic state and agitation. Discussed that he has had ongoing treatment for pneumonia (PCP and viral pneumonia) and diuresis without improvement in his oxygenation and noted to have worsening O2 needs. Relayed that our hope has been to get him through his acute illness but that he is currently showing signs of deterioration in terms of his pulmonary function, mental status and electrolytes concerning for worsening disease process. Dr. [MASKED] discussed with [MASKED] family that we could continue to move forward with current care but the concern is that he is worsening and at risk of death. Also noted that he is more uncomfortable with rising oxygen needs. [MASKED] wife spoke to her son and called back to confirm they would like to transition to comfort focused care. On [MASKED], Dr. [MASKED] met with the [MASKED] wife and two sons at the [MASKED] bedside to confirm their understanding of the severity of his illness and his wished for ongoing care. Patient unable to participate in discussion due to delirium. [MASKED] wife and sons noted that they understood that he was worsening and "dying" and that they wanted to transition to comfort for the patient, per his prior wishes. We discussed the steps for this transition including medications to make his breathing more comfortable, help with agitation and delirium. The family was offered hospice services to help with coping but declined. All questions were answered. After this, his oxygen was removed and IV morphine drip was initiated for comfort. # Acute Hypoxemic Respiratory Failure # Viral/HCAP/Multilobar/Interstitial Pneumonia Presented with persistent hypoxemia. CXR and CT scan suggested multifocal pneumonia most consistent with an atypical viral or bacterial etiology. CT showing diffuse asymmetric parenchymal changes c/w viral vs. interstitial pneumonia vs. alveolar hemorrhage with underlying volume overload possibly contributing as well. Because he was DNR/DNI, bronch was not able to pursued b/c would have compromised his already tenuous respiratory status. Initially started on vanc/zosyn for HCAP, steroids and Bactrim for possible PCP [MASKED] (given recent steroid use), and resp viral panel came back positive for H flu. He did not improve on this regimen and still had substantial oxygen requirement. Duiresis was attempted without improvement in oxygenation. During his course developed worsening acidosis, hyponatremia, and altered mental status. He was unable to tolerate POs due to altered mental status, and it was confirmed with family that NGT/PEG were not in goals of care. In this setting he was transitioned to comfort care. On [MASKED], MD called to bedside by RN at 00:10 for declining O2 saturations and bradycardia. Patient appeared comfortable taking shallow, intermittent respirations on morphine drip. Respiratory rate decreased and then ceased. Intermittent ectopy noted on telemetry then ceased and pulses were lost. Auscultated for breath sounds and cardiac sounds x1 minute with no activity. Pupillary response absent. No withdrawal to painful stimuli. Time of death 00:15. Cause of death: parainfluenza pneumonia. Family (son, [MASKED] notified at 00:20 and expressed gratitude to ICU team. Autopsy was declined. Support offered to [MASKED] family. Admitting office, overnight ICU attending (Dr. [MASKED], NEOB (declined) and PCP (Dr. [MASKED]- answering service) notified. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO QHS 4. Ondansetron 4 mg IV Q8H:PRN nausea 5. Digoxin 0.125 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H 8. Nystatin Oral Suspension 5 mL PO QID 9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID 10. PredniSONE 10 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Ampicillin 2 g IV Q4H 13. Metoprolol Tartrate 75 mg PO BID 14. Lactulose 15 mL PO Q8H:PRN constip 15. Diltiazem 60 mg PO Q6H 16. Famotidine 20 mg PO DAILY 17. Warfarin 3 mg PO DAILY16 18. Multivitamins 1 TAB PO DAILY Discharge Medications: none (deceased) Discharge Disposition: Expired Discharge Diagnosis: Acute hypoxemic respiratory failure secondary to parainfluenza 3 pneumonia Acute on chronic diastolic heart failure Deep vein thrombosis Atrial fibrillation Rheumatoid arthritis Osteomyelitis Discharge Condition: Deceased Discharge Instructions: Deceased [MASKED] MD [MASKED] Completed by: [MASKED]
[]
[ "J9601", "E872", "E871", "I4891", "Z87891", "Z7901", "Z515", "Z66" ]
[ "J122: Parainfluenza virus pneumonia", "J9601: Acute respiratory failure with hypoxia", "I5033: Acute on chronic diastolic (congestive) heart failure", "E870: Hyperosmolality and hypernatremia", "J90: Pleural effusion, not elsewhere classified", "D469: Myelodysplastic syndrome, unspecified", "I82411: Acute embolism and thrombosis of right femoral vein", "E872: Acidosis", "E871: Hypo-osmolality and hyponatremia", "M868X8: Other osteomyelitis, other site", "I4891: Unspecified atrial fibrillation", "M069: Rheumatoid arthritis, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "Z7952: Long term (current) use of systemic steroids", "Z8546: Personal history of malignant neoplasm of prostate", "Z96652: Presence of left artificial knee joint", "D539: Nutritional anemia, unspecified", "B952: Enterococcus as the cause of diseases classified elsewhere", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "Z515: Encounter for palliative care", "Z66: Do not resuscitate", "J8410: Pulmonary fibrosis, unspecified" ]
10,072,214
29,071,979
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: left arm/leg numbness and weakness on awakening Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ left-handed female with a PMHx of DM, HTN, and prior stroke (right-sided numbness and weakness ___ years ago) who presents with left arm/leg numbness and weakness on awakening today. She was in her USOH until she awoke this morning (___) at 6 AM. At that time, she noticed that her left arm and leg were numb. She denies any symptoms yesterday. There were no paresthesias. She did not notice any facial numbness. She tried to get up, and she fell to the floor. She was unable to get up. She scooted on her rear to the bathroom, and she pulled herself up via the vanity to get to the toilet. She notes that she had more movement initially than she does now. She denies any headache, facial droop, or slurred speech. The patient, and her daughter who is at the bedside, denies any changes in her speech including paraphasic errors, inappropriate speech, or difficulty with comprehension. She presented to be ___, where a non-contrast head CT was negative. A CTA head and neck was done which demonstrated left ICA stenosis at the origin with calcified and non-calcified plaques resulting in high-grade >75% stenosis. She was then transferred to ___. Of note, the patient says she had a stroke ___ years ago. At that time she awoke with malaise and "did not want to breathe." She was told that she had depression. Subsequently, she developed right arm numbness. She also had trouble walking, and became weak on her right side. She saw Dr. ___ at ___ and she was told she had a stroke. She is currently on aspirin 81 mg daily, and she denies missing any doses. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus, and hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Diabetes Stroke Hypertension Obesity Hyperlipidemia Social History: ___ Family History: No family history of strokes or other neurological disorders Physical Exam: Vitals: T: ___ P: 70 RR: 20 BP: 150/75 SaO2: 98% on room air General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple No nuchal rigidity. Pulmonary: Lungs CTA bilaterally Cardiac: RRR on monitor Abdomen: Non-distended Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: Please see top of note for NIHSS. -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 dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. No cortical sensory loss. -Cranial Nerves: II, III, IV, VI: Mild anisocoria, left 4-->3 mm, right 3-->2 mm. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Left facial droop 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. No pronation on right, unable to test on left. No adventitious movements, such as tremor, noted. [___] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 2 3** 3** 0 0 0 2 3 2 0 0 0 R 5 5 5 5 5 5 5 5 5 5 5 5 Left thumb abduction ___ **Does not sustain *All: Represents maximum effort obtained from patient -Sensory: No deficits to light touch, cold sensation, proprioception throughout. No extinction to DSS. -DTRs: reflexes more brisk on left than right, +crossed abductors and suprapatellar on left, no pectoralis jerks, left toe equivocal, right withdrawal -Coordination: No intention tremor in RUE. No dysmetria on FNF or HKS bilaterally on right. Could not test on left. -Gait: Unable to test. DISCHARGE PHYSICAL EXAM: Neurologic Exam: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was mildly dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. No cortical sensory loss. -Cranial Nerves: II, III, IV, VI: pupils equally reactive to light, 2.5mm->1.5mm. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Mild left facial droop, left eye closure slightly weaker than right IX, X: Palate elevates symmetrically. XII: Tongue protrudes slightly to the left -Motor: Normal bulk and tone. No pronation on right, unable to test on left. No adventitious movements, such as tremor, noted. [Delt][Bic][Tri][ECR][FExt][FFlex][IO][IP][Quad][Ham] L 3 3 0 2 1 2 0 3 3 2 R 5 5 5 5 5 5 5 5 5 5 *of note, pt seen to move L hemibody more spontaneously and briskly when not tested on confrontational exam -Sensory: No deficits to light touch, cold sensation, proprioception throughout. No extinction to DSS. No agraphesthesia or stereoagnosis. -DTRs: Bi Tri ___ Pat Ach PecJerk CrossAbd L 3 3 3 2 2 - + R 2+ 2+ 2+ 2 1 - - Plantar response was equivocal on left and withdrawal on right -Coordination: No intention tremor in RUE. No dysmetria on FNF or HKS bilaterally on right. Could not test on left. -Gait: Unable to test. Pertinent Results: ___ 04:08PM BLOOD WBC-10.6* RBC-4.63 Hgb-14.0 Hct-41.5 MCV-90 MCH-30.2 MCHC-33.7 RDW-13.1 RDWSD-42.7 Plt ___ ___ 10:05AM BLOOD WBC-7.3 RBC-4.37 Hgb-13.2 Hct-39.8 MCV-91 MCH-30.2 MCHC-33.2 RDW-13.2 RDWSD-43.2 Plt ___ ___ 04:08PM BLOOD Neuts-72.6* ___ Monos-6.0 Eos-0.4* Baso-0.3 Im ___ AbsNeut-7.72* AbsLymp-2.15 AbsMono-0.64 AbsEos-0.04 AbsBaso-0.03 ___ 10:05AM BLOOD Neuts-60.1 ___ Monos-7.2 Eos-1.5 Baso-0.6 Im ___ AbsNeut-4.38 AbsLymp-2.18 AbsMono-0.52 AbsEos-0.11 AbsBaso-0.04 ___ 10:05AM BLOOD ___ PTT-28.2 ___ ___ 10:05AM BLOOD Glucose-308* UreaN-13 Creat-0.7 Na-140 K-4.1 Cl-102 HCO3-25 AnGap-17 ___ 10:05AM BLOOD ALT-22 AST-21 LD(LDH)-122 CK(CPK)-49 AlkPhos-94 TotBili-0.3 ___ 10:05AM BLOOD TotProt-6.5 Albumin-3.6 Globuln-2.9 Cholest-243* ___ 10:05AM BLOOD %HbA1c-11.4* eAG-280* ___ 10:05AM BLOOD Triglyc-177* HDL-49 CHOL/HD-5.0 LDLcalc-159* ___ 10:05AM BLOOD TSH-1.4 ___ 06:50AM BLOOD WBC-8.2 RBC-4.68 Hgb-13.8 Hct-42.1 MCV-90 MCH-29.5 MCHC-32.8 RDW-13.2 RDWSD-42.9 Plt ___ ___ 06:50AM BLOOD Glucose-175* UreaN-15 Creat-0.7 Na-135 K-4.3 Cl-100 HCO3-24 AnGap-15 ___ 06:50AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8 ___ Head w/o There is a focus of slow diffusion in the right thalamus extending into the right cerebral peduncle. There is no associated hemorrhage. This region is faintly hyperintense on the FLAIR images suggesting a subacute infarction. Images of the remainder of the brain appear normal. No other areas of infarction are detected. There is no evidence of hemorrhage, edema or masses. The ventricles and sulci are normal in caliber and configuration. ___ No cardiac source of embolism identified. No evidence of right-to-left shunting at the atrial level, assessed by injection of agitated saline contrast at rest and following cough and Valsalva maneuver. Mild symmetric left ventricular hypertrophy with preserved regional/global systolic function. Brief Hospital Course: Patient initially presented to ___ with L sided weakness and was seen to have a negative CT/CTA. She was transferred to ___ ED and admitted to the neurology stroke service, where she received screening labs, telemetry monitoring, MRI/MRA, and ___ consultation. U/A revealed likely urinary tract infection, which was promptly treated with IV ceftriaxone for 3 days. Screening labs were significant for elevated HbA1c, elevted total cholesterol, elevated LDL, and elevated triglycerides. MRI/MRA revealed subacute right cerebral peduncle infarction consistent with history and exam findings. Echocardiogram w/ bubble study was negative. For future stroke prophylaxis, pt was started on dual antiplatelet and statin therapies. Pt was discharged to rehabilitation center, with follow up scheduled with Dr. ___ in outpatient stroke clinic for ___. Transition Issues: -Pt will need to continue taking Aspirin and Plavix for 90 days, and then switch to monotherapy with Plavix -Pt will need to continue taking Atorvastatin and Fluoxetine -Pt will need to follow up with Neurology in the near future 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? () Yes - () No 4. LDL documented? (X) Yes (LDL = 159) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if LDL if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL] 6. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (X) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No 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: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Glargine 28 Units Breakfast Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. FLUoxetine 20 mg PO DAILY 4. Glargine 28 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Aspirin 81 mg PO DAILY 6. Lisinopril 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subacute ischemic stroke of the right thalamus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of left arm/leg numbness and weakness on awakening resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Diabetes Hypertension Hyperlipidemia Previous stroke We are changing your medications as follows: Clopidogrel 75mg DAILY Atorastatin 40mg DAILY Insulin Humalog 6 units with each meal in addition to preexisting Glargine 28 units in morning Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
[ "I638", "G8194", "I10", "N390", "R471", "R29810", "E119", "I6522", "E785", "E669", "Z6836", "Z794", "Z8673" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left arm/leg numbness and weakness on awakening Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] left-handed female with a PMHx of DM, HTN, and prior stroke (right-sided numbness and weakness [MASKED] years ago) who presents with left arm/leg numbness and weakness on awakening today. She was in her USOH until she awoke this morning ([MASKED]) at 6 AM. At that time, she noticed that her left arm and leg were numb. She denies any symptoms yesterday. There were no paresthesias. She did not notice any facial numbness. She tried to get up, and she fell to the floor. She was unable to get up. She scooted on her rear to the bathroom, and she pulled herself up via the vanity to get to the toilet. She notes that she had more movement initially than she does now. She denies any headache, facial droop, or slurred speech. The patient, and her daughter who is at the bedside, denies any changes in her speech including paraphasic errors, inappropriate speech, or difficulty with comprehension. She presented to be [MASKED], where a non-contrast head CT was negative. A CTA head and neck was done which demonstrated left ICA stenosis at the origin with calcified and non-calcified plaques resulting in high-grade >75% stenosis. She was then transferred to [MASKED]. Of note, the patient says she had a stroke [MASKED] years ago. At that time she awoke with malaise and "did not want to breathe." She was told that she had depression. Subsequently, she developed right arm numbness. She also had trouble walking, and became weak on her right side. She saw Dr. [MASKED] at [MASKED] and she was told she had a stroke. She is currently on aspirin 81 mg daily, and she denies missing any doses. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus, and hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Diabetes Stroke Hypertension Obesity Hyperlipidemia Social History: [MASKED] Family History: No family history of strokes or other neurological disorders Physical Exam: Vitals: T: [MASKED] P: 70 RR: 20 BP: 150/75 SaO2: 98% on room air General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple No nuchal rigidity. Pulmonary: Lungs CTA bilaterally Cardiac: RRR on monitor Abdomen: Non-distended Extremities: No C/C/E bilaterally Skin: no rashes or lesions noted. Neurologic: Please see top of note for NIHSS. -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 dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall [MASKED] at 5 minutes. There was no evidence of apraxia or neglect. No cortical sensory loss. -Cranial Nerves: II, III, IV, VI: Mild anisocoria, left 4-->3 mm, right 3-->2 mm. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Left facial droop 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. No pronation on right, unable to test on left. No adventitious movements, such as tremor, noted. [[MASKED]] [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] L 2 3** 3** 0 0 0 2 3 2 0 0 0 R 5 5 5 5 5 5 5 5 5 5 5 5 Left thumb abduction [MASKED] **Does not sustain *All: Represents maximum effort obtained from patient -Sensory: No deficits to light touch, cold sensation, proprioception throughout. No extinction to DSS. -DTRs: reflexes more brisk on left than right, +crossed abductors and suprapatellar on left, no pectoralis jerks, left toe equivocal, right withdrawal -Coordination: No intention tremor in RUE. No dysmetria on FNF or HKS bilaterally on right. Could not test on left. -Gait: Unable to test. DISCHARGE PHYSICAL EXAM: Neurologic Exam: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Speech was mildly dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. No cortical sensory loss. -Cranial Nerves: II, III, IV, VI: pupils equally reactive to light, 2.5mm->1.5mm. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Mild left facial droop, left eye closure slightly weaker than right IX, X: Palate elevates symmetrically. XII: Tongue protrudes slightly to the left -Motor: Normal bulk and tone. No pronation on right, unable to test on left. No adventitious movements, such as tremor, noted. [Delt][Bic][Tri][ECR][FExt][FFlex][IO][IP][Quad][Ham] L 3 3 0 2 1 2 0 3 3 2 R 5 5 5 5 5 5 5 5 5 5 *of note, pt seen to move L hemibody more spontaneously and briskly when not tested on confrontational exam -Sensory: No deficits to light touch, cold sensation, proprioception throughout. No extinction to DSS. No agraphesthesia or stereoagnosis. -DTRs: Bi Tri [MASKED] Pat Ach PecJerk CrossAbd L 3 3 3 2 2 - + R 2+ 2+ 2+ 2 1 - - Plantar response was equivocal on left and withdrawal on right -Coordination: No intention tremor in RUE. No dysmetria on FNF or HKS bilaterally on right. Could not test on left. -Gait: Unable to test. Pertinent Results: [MASKED] 04:08PM BLOOD WBC-10.6* RBC-4.63 Hgb-14.0 Hct-41.5 MCV-90 MCH-30.2 MCHC-33.7 RDW-13.1 RDWSD-42.7 Plt [MASKED] [MASKED] 10:05AM BLOOD WBC-7.3 RBC-4.37 Hgb-13.2 Hct-39.8 MCV-91 MCH-30.2 MCHC-33.2 RDW-13.2 RDWSD-43.2 Plt [MASKED] [MASKED] 04:08PM BLOOD Neuts-72.6* [MASKED] Monos-6.0 Eos-0.4* Baso-0.3 Im [MASKED] AbsNeut-7.72* AbsLymp-2.15 AbsMono-0.64 AbsEos-0.04 AbsBaso-0.03 [MASKED] 10:05AM BLOOD Neuts-60.1 [MASKED] Monos-7.2 Eos-1.5 Baso-0.6 Im [MASKED] AbsNeut-4.38 AbsLymp-2.18 AbsMono-0.52 AbsEos-0.11 AbsBaso-0.04 [MASKED] 10:05AM BLOOD [MASKED] PTT-28.2 [MASKED] [MASKED] 10:05AM BLOOD Glucose-308* UreaN-13 Creat-0.7 Na-140 K-4.1 Cl-102 HCO3-25 AnGap-17 [MASKED] 10:05AM BLOOD ALT-22 AST-21 LD(LDH)-122 CK(CPK)-49 AlkPhos-94 TotBili-0.3 [MASKED] 10:05AM BLOOD TotProt-6.5 Albumin-3.6 Globuln-2.9 Cholest-243* [MASKED] 10:05AM BLOOD %HbA1c-11.4* eAG-280* [MASKED] 10:05AM BLOOD Triglyc-177* HDL-49 CHOL/HD-5.0 LDLcalc-159* [MASKED] 10:05AM BLOOD TSH-1.4 [MASKED] 06:50AM BLOOD WBC-8.2 RBC-4.68 Hgb-13.8 Hct-42.1 MCV-90 MCH-29.5 MCHC-32.8 RDW-13.2 RDWSD-42.9 Plt [MASKED] [MASKED] 06:50AM BLOOD Glucose-175* UreaN-15 Creat-0.7 Na-135 K-4.3 Cl-100 HCO3-24 AnGap-15 [MASKED] 06:50AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8 [MASKED] Head w/o There is a focus of slow diffusion in the right thalamus extending into the right cerebral peduncle. There is no associated hemorrhage. This region is faintly hyperintense on the FLAIR images suggesting a subacute infarction. Images of the remainder of the brain appear normal. No other areas of infarction are detected. There is no evidence of hemorrhage, edema or masses. The ventricles and sulci are normal in caliber and configuration. [MASKED] No cardiac source of embolism identified. No evidence of right-to-left shunting at the atrial level, assessed by injection of agitated saline contrast at rest and following cough and Valsalva maneuver. Mild symmetric left ventricular hypertrophy with preserved regional/global systolic function. Brief Hospital Course: Patient initially presented to [MASKED] with L sided weakness and was seen to have a negative CT/CTA. She was transferred to [MASKED] ED and admitted to the neurology stroke service, where she received screening labs, telemetry monitoring, MRI/MRA, and [MASKED] consultation. U/A revealed likely urinary tract infection, which was promptly treated with IV ceftriaxone for 3 days. Screening labs were significant for elevated HbA1c, elevted total cholesterol, elevated LDL, and elevated triglycerides. MRI/MRA revealed subacute right cerebral peduncle infarction consistent with history and exam findings. Echocardiogram w/ bubble study was negative. For future stroke prophylaxis, pt was started on dual antiplatelet and statin therapies. Pt was discharged to rehabilitation center, with follow up scheduled with Dr. [MASKED] in outpatient stroke clinic for [MASKED]. Transition Issues: -Pt will need to continue taking Aspirin and Plavix for 90 days, and then switch to monotherapy with Plavix -Pt will need to continue taking Atorvastatin and Fluoxetine -Pt will need to follow up with Neurology in the near future 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? () Yes - () No 4. LDL documented? (X) Yes (LDL = 159) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if LDL if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL] 6. Smoking cessation counseling given? () Yes - (X) No [reason (X) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (X) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No 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: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Glargine 28 Units Breakfast Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. FLUoxetine 20 mg PO DAILY 4. Glargine 28 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Aspirin 81 mg PO DAILY 6. Lisinopril 20 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Subacute ischemic stroke of the right thalamus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], You were hospitalized due to symptoms of left arm/leg numbness and weakness on awakening resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Diabetes Hypertension Hyperlipidemia Previous stroke We are changing your medications as follows: Clopidogrel 75mg DAILY Atorastatin 40mg DAILY Insulin Humalog 6 units with each meal in addition to preexisting Glargine 28 units in morning Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your [MASKED] Neurology Team Followup Instructions: [MASKED]
[]
[ "I10", "N390", "E119", "E785", "E669", "Z794", "Z8673" ]
[ "I638: Other cerebral infarction", "G8194: Hemiplegia, unspecified affecting left nondominant side", "I10: Essential (primary) hypertension", "N390: Urinary tract infection, site not specified", "R471: Dysarthria and anarthria", "R29810: Facial weakness", "E119: Type 2 diabetes mellitus without complications", "I6522: Occlusion and stenosis of left carotid artery", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "Z794: Long term (current) use of insulin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]
10,072,264
28,943,956
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: ___ Large Volume Paracentesis History of Present Illness: Ms. ___ is a ___ woman with a history of Child B, MELD 20 cirrhosis of unclear etiology (cholestatic injury, dx'd ___ c/b portal hypertension and refractory ascites requiring weekly paracenteses, insulin-dependent type 2 diabetes, ESRD on HD (___), hypertension, and diastolic heart failure who presents after a fall yesterday ___ lower extremity weakness. No head strike or LOC. She missed HD today as she was too weak to ambulate or travel to appointment. She is scheduled for a therapeutic paracentesis tomorrow. Per daughter, she has had chronic intermittent episodes of emesis and diarrhea over the past several months. Reports decreased appetite and PO intake. Denies fevers but reports chronic chills without rigors. She also reports chronic lower abdominal pain and lower back pain in the setting of ascites. No urinary/bowel retention or incontinence. In the ED, initial vitals were: T 96.9, HR 87, BP 160/96, RR 16, SaO2 100% RA. Labs were HEMOLYZED but notable for: WBC 3.0, H/H 9.9/30.7, plts 146, Na 125, K 5.3, Cl 89, HCO3, AG 15, BUN 58, Cr 6.1, glucose 526, ALT 28, AST 81, AP 211, LDH 697, troponin 0.17. Flu negative. Repeat whole blood K 5, lactate 1.6. Imaging notable for: Negative NCHCT, RUQ ultrasound with Dopplers showed patent vasculature. Diagnostic paracentesis with WBC 28 (0% PMNs, 91% macrophages). Patient was given: 10 units lispro, metoprolol 100 mg, hydralazine 25 mg, and atorvastatin 20 mg On the floor, patient endorses the above history. She states that she has felt weak all over for the past several weeks. ROS: per HPI, denies fever, night sweats, headache, cough, shortness of breath, chest pain, dysuria, hematuria. Past Medical History: 1. Diabetes, on insulin. 2. Hypertension. 3. History of diastolic heart failure. 4. End-stage renal disease on HD. 5. Cirrhosis. 6. History of osteomyelitis. PAST SURGICAL HISTORY: 1. Left arm fistula 2. C-section 3. Right middle toe amputation Social History: ___ Family History: Her uncle passed away of complications of liver disease. He did drink alcohol. There is no other family history of autoimmune disease. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.4, HR 90, BP 158/89, RR 20, SaO2 94% RA, weight 59.4 kg General: Thin Hispanic woman, appears older than stated age, comfortable-appearing HEENT: NC/AT, PERRL, EOMI, oropharynx clear Neck: Supple, no JVD CV: RRR, no m/r/g, normal S1 and S2 Lungs: Breathing comfortably, lungs CTAB Abdomen: Distended with positive fluid wave, umbilical hernia, nontender, no rebound/guarding Ext: Warm and well-perfused, 2+ peripheral pulses, no edema, LUE fistula Neuro: AAOx3, strength normal Skin: Multiple scattered erythematous and hyperpigmented papules with excoriations, some scarring DISCHARGE PHYSICAL EXAM: ======================== VS: Tm 99.3 Tc 97.8 HR 88-101, BP 107-125/52-54, RR ___, 100 RA + orthostatics (130/72->120/64->100/64, w/ ambulation 96/60), asx FSG 222 (eating)--125-270s General: Thin Hispanic woman, pleasant comfortable-appearing HEENT: PERRL, EOMI, oropharynx clear CV: RRR, no m/r/g, normal S1 and S2 Lungs: Breathing comfortably, lungs CTAB Abdomen: appears distended again, with positive fluid wave, soft on palpation, nontender, no rebound/guarding, Ext: Warm and well-perfused, 2+ peripheral pulses, 1+ edema, LUE fistula Neuro: AAOx3, no asterixis. ___ strength bilaterally UE and ___ Skin: Multiple scattered erythematous and hyperpigmented papules with excoriations, appear improved Pertinent Results: ADMISSION LABS: =============== ___ 05:40PM BLOOD WBC-3.0* RBC-3.17* Hgb-9.9* Hct-30.7* MCV-97 MCH-31.2 MCHC-32.2 RDW-14.2 RDWSD-50.5* Plt ___ ___ 05:40PM BLOOD Glucose-601* UreaN-57* Creat-6.0* Na-123* K-6.8* Cl-88* HCO3-20* AnGap-22* ___ 05:40PM BLOOD ALT-28 AST-81* LD(LDH)-697* AlkPhos-211* TotBili-0.5 DirBili-0.1 IndBili-0.4 ___ 05:40PM BLOOD Albumin-2.9* Calcium-8.4 Phos-5.9*# Mg-2.4 PERTINENT LABS: =============== Ascites Analysis: 28 ___, ___ RBC, 0 Polys, 9 Lymphs, ___ Monos HbA1c: 12.6 25 VitD: <3.20 Flu PCR negative DISCHARGE LABS: ================ ___ 09:52AM BLOOD WBC-3.7* RBC-3.03* Hgb-9.4* Hct-29.8* MCV-98 MCH-31.0 MCHC-31.5* RDW-13.9 RDWSD-49.5* Plt ___ ___ 09:52AM BLOOD Glucose-186* UreaN-35* Creat-4.0* Na-132* K-4.5 Cl-91* HCO3-30 AnGap-16 ___ 05:37AM BLOOD ALT-17 AST-34 AlkPhos-194* TotBili-0.3 ___ 09:52AM BLOOD Calcium-8.9 Phos-5.5* Mg-2.2 MICRO: ======= ___ Blood culture: pending ___ Peritoneal Fluid: 1+ PMNs, no microorganisms, no growth (final), no growth anaerobic culture IMAGING: ======== CT Head (___): IMPRESSION: No evidence for acute intracranial process. CXR (___): IMPRESSION: No evidence for acute intracranial process. RUQ U/S with Dopplers (___): 1. Patent hepatic vasculature. 2. Persistent sequelae of portal hypertension, including large volume ascites, splenomegaly, and gallbladder wall edema. 3. Coarsened hepatic echotexture compatible with cirrhosis without focal lesion. Brief Hospital Course: Ms. ___ is a ___ woman with PMH Child B, MELD 21 (___) cyptogenic cirrhosis(dx ___ c/b refractory ascites), insulin dependent type 2 diabetes, HTN, chronic dCHF, and ESRD on HD (___), presenting for evaluation of weakness, vomiting, and increased sleepiness/confusion. #Weakness.Fall: patient presented for worsening weakness for about 2 weeks, with no acute precipitant, who now presents after sustaining a fall and missing her dialysis session. She has had a prior admission with malnutrition, at that time requiring tube feeds and overall having lost ___ lbs since her dialgnosis of cirrhosis. Pt was thin on admission with large ascites with no evidence of encephalopathy. There was no indication of a syncopal event, but patient's blood pressures were noted to be lower than average, and very tightly controlled on her current blood pressure regimen. Patient was orthostatic albeit asymptomatic when working with physical therapy. Her fall appeared to be largely mechanical given large ascites, with symptoms much improved after having a 8L paracentesis. Her weakness is also likely from poor nutrition, hyperglycemia (as adressed below), and low vitamin D (undetectable level). Infectious workup was negative. Given relative confusion reported by family (no asterixis on exam), patient was trialed on lactulose during the hospitalization, but with no new changes, this was discontinued. Patient's blood pressure regimen was also changed as below. She was started on Vitamin D 5000 u, 2/week. She also reported diarrhea with nepro supplementation, so psyllium was added to help with her stool consistency. She felt well on discharge, and was scheduled for 2/week paracentesis, to be done ___ at ___ ___. # Insulin dependent diabetes type 2 with nephropathy, retinopathy, and neuropathy: At home takes Lantus 14 qam and 18 qpm with humalog during meals. Her blood sugars were elevated to 500s-600s in the ED. Labs were not consistent with DKA (no AG acidosis). Per patient, she has been taking her insulin and blood sugars at home are in 100s. However, her home regimen was continued inpatient with relatively good sugars. Prior A1c was noted to be 8.8, on repeat testing, elevated to 12.6. Patient was educated on insulin compliance, continued on a diabetic diet. She was given insulin pen injections to ease with compliance as well as reinstating ___ care to help with medication management. # Diarrhea: Patient had frequent diarrhea, light brown in color, likely exacerbated in house with lactulose administration and also side effect of nepro. Previously, she had underwent a colonoscopy that showed no evidence of masses or visible erythema. # Cryptogenic Cirrhosis: Patient diagnosed with cirrhosis in ___, Childs class B8. MELD 20 (mostly ___ ESRD). Her liver biopsy reported to show mild lymphoplasmacytic infiltrates with focal periportal inflammation and interface hepatitis and mild lobular injury. There was evidence of early cirrhosis, focal bile duct injury with bile duct proliferation. She has no history of HE, not on lactulose or rifaximin. Grade I-II varices on last EGD, not on nadolol due to renal failure. RUQ ultrasound with Dopplers showed patent vasculature. She received paracentesis as above. She was scheduled with transplant followup. # ESRD on HD ___: Initially missed on day, was resumed on home schedule. # Hypertension: Pt had SBP up 200 on prior admission, however on current admission, SBP ranged from 100-140, with positive orthostais. Home lisinopril and hydralazine were discontinued. Patient to follow up with PCP for further medication titration. Home metoprolol was continued. CHRONIC ISSUES ---------------- # GIB/VARICES: No history of GIB in the past. Had endo/colonoscopy which was negative for varices. EGD on ___ showed grade I-II varices. She was not started on nadolol given renal failure. # Hyperlipidemia: continued atorvastatin 10mg daily TRANSITIONAL ISSUES: ==================== -Patient's daughter (___) to call ___ for 2/week paracentesis (___), prescription provided -Patient would benefit from increased supervision and diabetes education regarding insulin administration. Her insulin dosing seems adequate and sugars were well controlled in the hospital with her home regimen. -Patient noted to be vitamin D Deficient, may be contributing to her weakness, started on Vitamin D 50,000 Units oral 2 times a week (___). Please follow up vitamin D level as clinically appropriate. -Patient noted to be orthostatic (although asymptomatic) with BPs in 100s, on Hydralazine and Lisinopril. These were discontinued to assess her baseline pressure. Her discharge blood pressure regimen is: -Please continue Nepro supplementation for nutrition (3 shakes a day), added Metamucil given reported diarrhea to help bulk her stools -Full Code -Contact: ___ (daughter) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 10 mg PO DAILY 2. Metoprolol Tartrate 100 mg PO BID 3. Ursodiol 500 mg PO DAILY 4. HydrALAzine 25 mg PO TID 5. Atorvastatin 10 mg PO QPM 6. Glargine 14 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Renal Caps (B complex with C#20-folic acid) 1 mg oral DAILY Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Metoprolol Tartrate 100 mg PO BID 3. Ursodiol 500 mg PO DAILY 4. Renal Caps (B complex with C#20-folic acid) 1 mg oral DAILY 5. Outpatient Lab Work Please do paracentesis twice a week ___ and ___ ICD 9: R18 6. Sarna Lotion 1 Appl TP TID RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply as needed for itching Refills:*0 7. Vitamin D ___ UNIT PO 2X/WEEK (MO,TH) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth Two times a week Disp #*20 Capsule Refills:*0 8. Glargine 14 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 14 Units before BKFT; 18 Units before BED; Disp #*10 Syringe Refills:*3 RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 12 Units QID per sliding scale Disp #*5 Syringe Refills:*3 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: -Hepatic Ascites -Hyperglycemia/Diabetes type II -Decompensated Cryptogenic Cirrhosis, Childs Class B -Nutritional Deficiency/Vitamin D Deficiency -Hypertension -End Stage Renal Disease on Hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ on ___ for feeling worsening weakness and nausea. We think this was likely from a lot of fluid in your stomach and having high sugars from your diabetes. We took out a large amount of fluid and put you on your home insulin scale. Your sugars were better controlled in the hospital on the same doses as your home. We would recommend getting new insulin supplies and making sure you are taking your medicine correctly, as high sugars can also make you very tired. Please continue taking your Nepro shakes three times a day to make sure you get enough energy. You can use metamucil to help you with your diarrhea. It is VERY Important that you go to ___ for your paracentesis (taking fluid out from your stomach) on ___ and ___. We wish you the best Your ___ care team Followup Instructions: ___
[ "K7469", "N186", "E1310", "R188", "K521", "I120", "I5032", "E871", "E559", "T39315A", "E785", "K429", "W19XXXA", "D649", "E876", "Z992", "Z794" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weakness Major Surgical or Invasive Procedure: [MASKED] Large Volume Paracentesis History of Present Illness: Ms. [MASKED] is a [MASKED] woman with a history of Child B, MELD 20 cirrhosis of unclear etiology (cholestatic injury, dx'd [MASKED] c/b portal hypertension and refractory ascites requiring weekly paracenteses, insulin-dependent type 2 diabetes, ESRD on HD ([MASKED]), hypertension, and diastolic heart failure who presents after a fall yesterday [MASKED] lower extremity weakness. No head strike or LOC. She missed HD today as she was too weak to ambulate or travel to appointment. She is scheduled for a therapeutic paracentesis tomorrow. Per daughter, she has had chronic intermittent episodes of emesis and diarrhea over the past several months. Reports decreased appetite and PO intake. Denies fevers but reports chronic chills without rigors. She also reports chronic lower abdominal pain and lower back pain in the setting of ascites. No urinary/bowel retention or incontinence. In the ED, initial vitals were: T 96.9, HR 87, BP 160/96, RR 16, SaO2 100% RA. Labs were HEMOLYZED but notable for: WBC 3.0, H/H 9.9/30.7, plts 146, Na 125, K 5.3, Cl 89, HCO3, AG 15, BUN 58, Cr 6.1, glucose 526, ALT 28, AST 81, AP 211, LDH 697, troponin 0.17. Flu negative. Repeat whole blood K 5, lactate 1.6. Imaging notable for: Negative NCHCT, RUQ ultrasound with Dopplers showed patent vasculature. Diagnostic paracentesis with WBC 28 (0% PMNs, 91% macrophages). Patient was given: 10 units lispro, metoprolol 100 mg, hydralazine 25 mg, and atorvastatin 20 mg On the floor, patient endorses the above history. She states that she has felt weak all over for the past several weeks. ROS: per HPI, denies fever, night sweats, headache, cough, shortness of breath, chest pain, dysuria, hematuria. Past Medical History: 1. Diabetes, on insulin. 2. Hypertension. 3. History of diastolic heart failure. 4. End-stage renal disease on HD. 5. Cirrhosis. 6. History of osteomyelitis. PAST SURGICAL HISTORY: 1. Left arm fistula 2. C-section 3. Right middle toe amputation Social History: [MASKED] Family History: Her uncle passed away of complications of liver disease. He did drink alcohol. There is no other family history of autoimmune disease. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: T 98.4, HR 90, BP 158/89, RR 20, SaO2 94% RA, weight 59.4 kg General: Thin Hispanic woman, appears older than stated age, comfortable-appearing HEENT: NC/AT, PERRL, EOMI, oropharynx clear Neck: Supple, no JVD CV: RRR, no m/r/g, normal S1 and S2 Lungs: Breathing comfortably, lungs CTAB Abdomen: Distended with positive fluid wave, umbilical hernia, nontender, no rebound/guarding Ext: Warm and well-perfused, 2+ peripheral pulses, no edema, LUE fistula Neuro: AAOx3, strength normal Skin: Multiple scattered erythematous and hyperpigmented papules with excoriations, some scarring DISCHARGE PHYSICAL EXAM: ======================== VS: Tm 99.3 Tc 97.8 HR 88-101, BP 107-125/52-54, RR [MASKED], 100 RA + orthostatics (130/72->120/64->100/64, w/ ambulation 96/60), asx FSG 222 (eating)--125-270s General: Thin Hispanic woman, pleasant comfortable-appearing HEENT: PERRL, EOMI, oropharynx clear CV: RRR, no m/r/g, normal S1 and S2 Lungs: Breathing comfortably, lungs CTAB Abdomen: appears distended again, with positive fluid wave, soft on palpation, nontender, no rebound/guarding, Ext: Warm and well-perfused, 2+ peripheral pulses, 1+ edema, LUE fistula Neuro: AAOx3, no asterixis. [MASKED] strength bilaterally UE and [MASKED] Skin: Multiple scattered erythematous and hyperpigmented papules with excoriations, appear improved Pertinent Results: ADMISSION LABS: =============== [MASKED] 05:40PM BLOOD WBC-3.0* RBC-3.17* Hgb-9.9* Hct-30.7* MCV-97 MCH-31.2 MCHC-32.2 RDW-14.2 RDWSD-50.5* Plt [MASKED] [MASKED] 05:40PM BLOOD Glucose-601* UreaN-57* Creat-6.0* Na-123* K-6.8* Cl-88* HCO3-20* AnGap-22* [MASKED] 05:40PM BLOOD ALT-28 AST-81* LD(LDH)-697* AlkPhos-211* TotBili-0.5 DirBili-0.1 IndBili-0.4 [MASKED] 05:40PM BLOOD Albumin-2.9* Calcium-8.4 Phos-5.9*# Mg-2.4 PERTINENT LABS: =============== Ascites Analysis: 28 [MASKED], [MASKED] RBC, 0 Polys, 9 Lymphs, [MASKED] Monos HbA1c: 12.6 25 VitD: <3.20 Flu PCR negative DISCHARGE LABS: ================ [MASKED] 09:52AM BLOOD WBC-3.7* RBC-3.03* Hgb-9.4* Hct-29.8* MCV-98 MCH-31.0 MCHC-31.5* RDW-13.9 RDWSD-49.5* Plt [MASKED] [MASKED] 09:52AM BLOOD Glucose-186* UreaN-35* Creat-4.0* Na-132* K-4.5 Cl-91* HCO3-30 AnGap-16 [MASKED] 05:37AM BLOOD ALT-17 AST-34 AlkPhos-194* TotBili-0.3 [MASKED] 09:52AM BLOOD Calcium-8.9 Phos-5.5* Mg-2.2 MICRO: ======= [MASKED] Blood culture: pending [MASKED] Peritoneal Fluid: 1+ PMNs, no microorganisms, no growth (final), no growth anaerobic culture IMAGING: ======== CT Head ([MASKED]): IMPRESSION: No evidence for acute intracranial process. CXR ([MASKED]): IMPRESSION: No evidence for acute intracranial process. RUQ U/S with Dopplers ([MASKED]): 1. Patent hepatic vasculature. 2. Persistent sequelae of portal hypertension, including large volume ascites, splenomegaly, and gallbladder wall edema. 3. Coarsened hepatic echotexture compatible with cirrhosis without focal lesion. Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with PMH Child B, MELD 21 ([MASKED]) cyptogenic cirrhosis(dx [MASKED] c/b refractory ascites), insulin dependent type 2 diabetes, HTN, chronic dCHF, and ESRD on HD ([MASKED]), presenting for evaluation of weakness, vomiting, and increased sleepiness/confusion. #Weakness.Fall: patient presented for worsening weakness for about 2 weeks, with no acute precipitant, who now presents after sustaining a fall and missing her dialysis session. She has had a prior admission with malnutrition, at that time requiring tube feeds and overall having lost [MASKED] lbs since her dialgnosis of cirrhosis. Pt was thin on admission with large ascites with no evidence of encephalopathy. There was no indication of a syncopal event, but patient's blood pressures were noted to be lower than average, and very tightly controlled on her current blood pressure regimen. Patient was orthostatic albeit asymptomatic when working with physical therapy. Her fall appeared to be largely mechanical given large ascites, with symptoms much improved after having a 8L paracentesis. Her weakness is also likely from poor nutrition, hyperglycemia (as adressed below), and low vitamin D (undetectable level). Infectious workup was negative. Given relative confusion reported by family (no asterixis on exam), patient was trialed on lactulose during the hospitalization, but with no new changes, this was discontinued. Patient's blood pressure regimen was also changed as below. She was started on Vitamin D 5000 u, 2/week. She also reported diarrhea with nepro supplementation, so psyllium was added to help with her stool consistency. She felt well on discharge, and was scheduled for 2/week paracentesis, to be done [MASKED] at [MASKED] [MASKED]. # Insulin dependent diabetes type 2 with nephropathy, retinopathy, and neuropathy: At home takes Lantus 14 qam and 18 qpm with humalog during meals. Her blood sugars were elevated to 500s-600s in the ED. Labs were not consistent with DKA (no AG acidosis). Per patient, she has been taking her insulin and blood sugars at home are in 100s. However, her home regimen was continued inpatient with relatively good sugars. Prior A1c was noted to be 8.8, on repeat testing, elevated to 12.6. Patient was educated on insulin compliance, continued on a diabetic diet. She was given insulin pen injections to ease with compliance as well as reinstating [MASKED] care to help with medication management. # Diarrhea: Patient had frequent diarrhea, light brown in color, likely exacerbated in house with lactulose administration and also side effect of nepro. Previously, she had underwent a colonoscopy that showed no evidence of masses or visible erythema. # Cryptogenic Cirrhosis: Patient diagnosed with cirrhosis in [MASKED], Childs class B8. MELD 20 (mostly [MASKED] ESRD). Her liver biopsy reported to show mild lymphoplasmacytic infiltrates with focal periportal inflammation and interface hepatitis and mild lobular injury. There was evidence of early cirrhosis, focal bile duct injury with bile duct proliferation. She has no history of HE, not on lactulose or rifaximin. Grade I-II varices on last EGD, not on nadolol due to renal failure. RUQ ultrasound with Dopplers showed patent vasculature. She received paracentesis as above. She was scheduled with transplant followup. # ESRD on HD [MASKED]: Initially missed on day, was resumed on home schedule. # Hypertension: Pt had SBP up 200 on prior admission, however on current admission, SBP ranged from 100-140, with positive orthostais. Home lisinopril and hydralazine were discontinued. Patient to follow up with PCP for further medication titration. Home metoprolol was continued. CHRONIC ISSUES ---------------- # GIB/VARICES: No history of GIB in the past. Had endo/colonoscopy which was negative for varices. EGD on [MASKED] showed grade I-II varices. She was not started on nadolol given renal failure. # Hyperlipidemia: continued atorvastatin 10mg daily TRANSITIONAL ISSUES: ==================== -Patient's daughter ([MASKED]) to call [MASKED] for 2/week paracentesis ([MASKED]), prescription provided -Patient would benefit from increased supervision and diabetes education regarding insulin administration. Her insulin dosing seems adequate and sugars were well controlled in the hospital with her home regimen. -Patient noted to be vitamin D Deficient, may be contributing to her weakness, started on Vitamin D 50,000 Units oral 2 times a week ([MASKED]). Please follow up vitamin D level as clinically appropriate. -Patient noted to be orthostatic (although asymptomatic) with BPs in 100s, on Hydralazine and Lisinopril. These were discontinued to assess her baseline pressure. Her discharge blood pressure regimen is: -Please continue Nepro supplementation for nutrition (3 shakes a day), added Metamucil given reported diarrhea to help bulk her stools -Full Code -Contact: [MASKED] (daughter) [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lisinopril 10 mg PO DAILY 2. Metoprolol Tartrate 100 mg PO BID 3. Ursodiol 500 mg PO DAILY 4. HydrALAzine 25 mg PO TID 5. Atorvastatin 10 mg PO QPM 6. Glargine 14 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Renal Caps (B complex with C#20-folic acid) 1 mg oral DAILY Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Metoprolol Tartrate 100 mg PO BID 3. Ursodiol 500 mg PO DAILY 4. Renal Caps (B complex with C#20-folic acid) 1 mg oral DAILY 5. Outpatient Lab Work Please do paracentesis twice a week [MASKED] and [MASKED] ICD 9: R18 6. Sarna Lotion 1 Appl TP TID RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply as needed for itching Refills:*0 7. Vitamin D [MASKED] UNIT PO 2X/WEEK (MO,TH) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth Two times a week Disp #*20 Capsule Refills:*0 8. Glargine 14 Units Breakfast Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 14 Units before BKFT; 18 Units before BED; Disp #*10 Syringe Refills:*3 RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 12 Units QID per sliding scale Disp #*5 Syringe Refills:*3 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: -Hepatic Ascites -Hyperglycemia/Diabetes type II -Decompensated Cryptogenic Cirrhosis, Childs Class B -Nutritional Deficiency/Vitamin D Deficiency -Hypertension -End Stage Renal Disease on Hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] on [MASKED] for feeling worsening weakness and nausea. We think this was likely from a lot of fluid in your stomach and having high sugars from your diabetes. We took out a large amount of fluid and put you on your home insulin scale. Your sugars were better controlled in the hospital on the same doses as your home. We would recommend getting new insulin supplies and making sure you are taking your medicine correctly, as high sugars can also make you very tired. Please continue taking your Nepro shakes three times a day to make sure you get enough energy. You can use metamucil to help you with your diarrhea. It is VERY Important that you go to [MASKED] for your paracentesis (taking fluid out from your stomach) on [MASKED] and [MASKED]. We wish you the best Your [MASKED] care team Followup Instructions: [MASKED]
[]
[ "I5032", "E871", "E785", "D649", "Z794" ]
[ "K7469: Other cirrhosis of liver", "N186: End stage renal disease", "E1310: Other specified diabetes mellitus with ketoacidosis without coma", "R188: Other ascites", "K521: Toxic gastroenteritis and colitis", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I5032: Chronic diastolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "E559: Vitamin D deficiency, unspecified", "T39315A: Adverse effect of propionic acid derivatives, initial encounter", "E785: Hyperlipidemia, unspecified", "K429: Umbilical hernia without obstruction or gangrene", "W19XXXA: Unspecified fall, initial encounter", "D649: Anemia, unspecified", "E876: Hypokalemia", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin" ]
10,072,799
24,733,519
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache, left arm and leg pain and numbness. Major Surgical or Invasive Procedure: Epidural blood patch. History of Present Illness: Ms. ___ is a ___ left-handed woman with a remote history of migraine, also gastritis, chronic constipation, and acne, who presents with 5 days of fluctuating headache and lightheadedness, 4 days of intermittent blurry vision, and 1 day of right arm pain and paresthesias. Last ___ around 12PM, she experienced sudden-onset posterior head heaviness/dull pressure, ___ intensity, accompanied by lightheadedness and lethargy. She says she felt lethargic as though she had taken oxycodone. There was no associated nausea, vomiting, weakness, numbness, or visual symptoms. It improved by 2pm to ___ intensity, and the lightheadedness and lethargy also improved. It recurred ___, back to the original ___ intensity, and lasted until 10pm. She fell asleep without any significant symptoms. The headache pain improved with laying down (she notes the head heaviness "felt like my head wanted to go backwards"), was not exacerbated by bending over, coughing, or any particular activities she could recall. She did not take any medications including acetaminophen, NSAIDs, or otherwise to treat the headache (she prefers not taking medication, and is NSAID intolerant due to gastritis). The next day, her course was similar with the headache recurring around noontime, and waxing and waning over the course of the day. However, she had a new symptom of brief episodes of blurry vision lasting ___ seconds at a time, variously in the top, bottom, or both halves of her visual field in both eyes (together or individually). There was no diplopia, though she noted the blurriness primarily when reading. It occurred ___ times throughout the day. Of note, she goes kickboxing for 1 hour in the morning every day, and went on ___ and ___ but not thereafter. There is no contact or sparring and she denies trauma. On ___, the same headache with mid-day onset and fluctuating symptoms recurred (including blurry vision), but now included a sharper bifrontal and apical head pain ___ that accompanied the posterior head heaviness/dull pressure. She presented to ___ on ___, where basic labs and UA were done. She was given Reglan which made her feel lethargic and lightheaded. No head imaging was done and she was discharged to outpatient neurology ___. Yesterday, ___, she "felt okay" during the day and saw her PCP who wanted her to have a CT scan. There were some problems with insurance authorization, so it didn't occur immediately. Today, her symptoms returned as they had been on ___, with fluctuating dull posterior headache, sharper bifrontal/apical headache, lightheadedness, fatigue, and intermittent blurry vision. In addition, she had new "pins and needles" paresthesias (but no numbness) and dull pain in her right neck (~trapezius area), upper and lower arm. She denies any recent neck trauma, chiropractic manipulation, salon basin hair washes, fender-benders, or other trauma she could recall. She presented to ___ ED where it was also noted that she had mild right arm weakness, and slowed rapid alternating movements on the right. She has been taking retinoic acid (Retin-A) for the last 3 months for her acne. Past Medical History: - Gastritis (many years, sensitive to peppers and NSAIDs despite PPI) - Chronic constipation ___ years) - Acne Social History: ___ Family History: Mother with ischemic stroke at ___, which led to discovery of breast cancer. Physical Exam: ADMISSION EXAM -Vitals: T:97.4 BP:107/67 HR:73 RR:14 SaO2:100% -General: Awake, cooperative, NAD. -HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. ** Tenderness to pressure at right aspect of occiput ** -Neck: Supple. No nuchal rigidity. No tenderness or spasm of right trapezius. -Cardiac: RRR. Well perfused. -Pulmonary: Breathing comfortably on room air. -Abdomen: Soft, NT/ND. -Extremities: No cyanosis, clubbing, or edema bilaterally. -Skin: No rashes or other lesions noted. Henna tattoo on left arm. NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive to exam, detailed history and questions. Language is fluent with intact comprehension. Normal prosody. There are no paraphasic errors. Able to read cell phone without difficulty. Speech is not dysarthric. Able to follow both midline and appendicular commands. Had good knowledge of current events. There is no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation and no extinction. ** Pupils dilated with phenylephrine at 6pm ___ **. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. Optic margins crisp. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally, however right arm trembles irregularly when held to test drift. No give way weakness, excellent effort. 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 4+ ___ 5 4+ 4+ 4+ 5 5 5 5 * Subtle trembling weakness in above areas of 4+. Excellent effort. -Sensory: No deficits to light touch, cold sensation, or pinprick - including on right arm/neck. Proprioception intact at great toes and index fingers bilaterally. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L Tr 1 0 2* 0 R Tr 1 0 2* 0 * Required facilitation with 2 modalities. Plantar response was flexor bilaterally. -Coordination: Slowed and subtly irregular cadence with repetitive finger tapping on the right (patient is left-handed, but felt it was awkward and worse than baseline). No dysmetria on FNF bilaterally, however, able to continue FNF with eyes closed on left, but past-pointed to the right when using right arm (eyes closed). Rapid toe tapping symmetric. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. ========================================================= DISCHARGE EXAM -Vitals: T: 97.9 BP: 110/66 HR:64 RR:18 SaO2:100% -General: Awake, cooperative, NAD. -HEENT: NC/AT. No scleral icterus noted. MMM. -Neck: Supple. No nuchal rigidity. -Cardiac: Warm, well perfused. -Pulmonary: Breathing comfortably on room air. -Extremities: No cyanosis or edema bilaterally. -Skin: No rashes or other lesions noted. NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive to exam, detailed history and questions. Language is fluent with intact comprehension. Follows midline and appendicular commands. There is no evidence of apraxia or neglect. -Cranial Nerves: PERRL. EOMI without nystagmus. Facial sensation intact to light touch. No facial droop, facial musculature symmetric. Hearing grossly intact to speech. Palate elevates symmetrically. ___ strength in trapezii and SCM bilaterally. Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally, no tremor or other adventitious movement. 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. No extinction to DSS. -DTRs: ___. -Coordination: Deferred. Pertinent Results: ___ 05:15AM BLOOD WBC-4.5 RBC-4.25 Hgb-10.8* Hct-34.7 MCV-82 MCH-25.4* MCHC-31.1* RDW-12.7 RDWSD-37.4 Plt ___ ___ 10:15AM BLOOD ___ PTT-35.7 ___ ___ 05:15AM BLOOD Glucose-85 UreaN-5* Creat-0.9 Na-144 K-4.6 Cl-107 HCO3-24 AnGap-13 ___ 05:15AM BLOOD Calcium-8.8 ___ 10:10 am CSF;SPINAL FLUID Source: LP CSF TUBE 3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH MR HEAD W AND W/O CONTRAST T___ MR HEAD. 1. There is no evidence of acute intracranial process or hemorrhage. No diffusion abnormalities are detected to indicate acute or subacute ischemic changes. 2. Mild mucosal thickening is identified in the ethmoidal air cells, more significant on the right. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE 1. No evidence of cord signal abnormality. 2. Mild multilevel degenerative changes as above, most notable at C5-C6 with mild to moderate spinal canal narrowing. There is no neural foraminal narrowing. CTA HEAD AND CTA NECK Q16 CT NECK 1. No large infarct, intracranial hemorrhage, or mass effect. 2. Normal CTA of the head. 3. 6 mm in length segment of slight luminal dilation of the left internal carotid artery may reflect a normal variant or due to mild atherosclerotic disease. The internal carotid arteries and vertebral arteries otherwise appear normal. Brief Hospital Course: 1. Cervicogenic headaches: CTA and MRI of the brain were unremarkable, arguing against infarct, neoplasm, or mass effect as cause of patient's headache and left arm and leg paresthesias. MRI of the C-spine notable for mild-to-moderate canal narrowing at C5-C6, which may have contributed to headache and sensory symptoms. Lumbar puncture accordingly did not show signs of inflammation or infection. Patient's symptoms responded to management with Fioricet, and recommendations were made to use a soft cervical collar at bedtime; gabapentin was also initiated to relieve paresthesias, with plan for titration by patient's outpatient neurologist. Fioricet was prescribed for as-needed use in the interim. 2. Post-dural puncture headache versus spontaneous intracranial hypotension: Following patient's lumbar puncture, she reported new retro-orbital headaches that were relieved while supine and exacerbated while sitting, suggestive of post-dural puncture headache. These episodes were also associated with nausea. Beacuse there also had been a postural component to her headaches before admission (improved with lying down), it was uncertain if she had spontaneous intracranial hypotension that coincidentally worsened after the LP, or if this was a post-LP HA (or possibly both). Patient underwent placement of an epidural blood patch by anesthesia for relief of her symptoms. If further ___ with the pain center is required, an appointment may be scheduled with the ___ by calling ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tretinoin 0.05% Cream 1 Appl TP QHS 2. Omeprazole 20 mg PO DAILY 3. Bisacodyl ___ mg PO QHS 4. Psyllium Powder 1 PKT PO QHS Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1 (One) capsule(s) by mouth every four (4) hours Disp #*30 Capsule Refills:*0 2. Gabapentin 100 mg PO QHS RX *gabapentin 100 mg 1 (One) capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*3 3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea Duration: 7 Days RX *ondansetron 4 mg 1 (One) tablet(s) by mouth every eight (8) hours Disp #*14 Tablet Refills:*0 4. Bisacodyl ___ mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. Psyllium Powder 1 PKT PO QHS 7. Tretinoin 0.05% Cream 1 Appl TP QHS Discharge Disposition: Home Discharge Diagnosis: 1. Cervicogenic headaches 2. Spontaneous intracranial hypotension, and/or post-dural puncture headache 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 evaluation of headaches and right arm pain and tingling. An MRI of your brain did not show any concerning findings, and a lumbar puncture did not show signs of inflammation of the nervous system. An MRI of your neck showed mild narrowing of the area around your spinal cord, which may be responsible for your arm and leg symptoms. Your headache may also have been due to this narrowing. To help with your headache, you may use a soft cervical collar at nighttime. You were also prescribed a medication (gabapentin) to take at night to help with your arm and leg pain and tingling. You also received a prescription for Fioricet, a medication that you can take occasionally to stop severe headaches. Aside from your spine narrowing, you also experienced a different headache and nausea that was likely related to your lumbar puncture. A blood patch was placed by anesthesiology to help relieve the fluid leakage that led to this headache. You received a prescription for a nausea medication (ondansetron) to take if needed. Please follow up with Dr. ___ at your ___ appointment listed below. It was a pleasure taking care of you at ___. Sincerely, Neurology at ___ Followup Instructions: ___
[ "G4489", "M4802", "H538", "R200", "K5900", "L709", "K2950", "G971", "Y844", "Y92230" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Headache, left arm and leg pain and numbness. Major Surgical or Invasive Procedure: Epidural blood patch. History of Present Illness: Ms. [MASKED] is a [MASKED] left-handed woman with a remote history of migraine, also gastritis, chronic constipation, and acne, who presents with 5 days of fluctuating headache and lightheadedness, 4 days of intermittent blurry vision, and 1 day of right arm pain and paresthesias. Last [MASKED] around 12PM, she experienced sudden-onset posterior head heaviness/dull pressure, [MASKED] intensity, accompanied by lightheadedness and lethargy. She says she felt lethargic as though she had taken oxycodone. There was no associated nausea, vomiting, weakness, numbness, or visual symptoms. It improved by 2pm to [MASKED] intensity, and the lightheadedness and lethargy also improved. It recurred [MASKED], back to the original [MASKED] intensity, and lasted until 10pm. She fell asleep without any significant symptoms. The headache pain improved with laying down (she notes the head heaviness "felt like my head wanted to go backwards"), was not exacerbated by bending over, coughing, or any particular activities she could recall. She did not take any medications including acetaminophen, NSAIDs, or otherwise to treat the headache (she prefers not taking medication, and is NSAID intolerant due to gastritis). The next day, her course was similar with the headache recurring around noontime, and waxing and waning over the course of the day. However, she had a new symptom of brief episodes of blurry vision lasting [MASKED] seconds at a time, variously in the top, bottom, or both halves of her visual field in both eyes (together or individually). There was no diplopia, though she noted the blurriness primarily when reading. It occurred [MASKED] times throughout the day. Of note, she goes kickboxing for 1 hour in the morning every day, and went on [MASKED] and [MASKED] but not thereafter. There is no contact or sparring and she denies trauma. On [MASKED], the same headache with mid-day onset and fluctuating symptoms recurred (including blurry vision), but now included a sharper bifrontal and apical head pain [MASKED] that accompanied the posterior head heaviness/dull pressure. She presented to [MASKED] on [MASKED], where basic labs and UA were done. She was given Reglan which made her feel lethargic and lightheaded. No head imaging was done and she was discharged to outpatient neurology [MASKED]. Yesterday, [MASKED], she "felt okay" during the day and saw her PCP who wanted her to have a CT scan. There were some problems with insurance authorization, so it didn't occur immediately. Today, her symptoms returned as they had been on [MASKED], with fluctuating dull posterior headache, sharper bifrontal/apical headache, lightheadedness, fatigue, and intermittent blurry vision. In addition, she had new "pins and needles" paresthesias (but no numbness) and dull pain in her right neck (~trapezius area), upper and lower arm. She denies any recent neck trauma, chiropractic manipulation, salon basin hair washes, fender-benders, or other trauma she could recall. She presented to [MASKED] ED where it was also noted that she had mild right arm weakness, and slowed rapid alternating movements on the right. She has been taking retinoic acid (Retin-A) for the last 3 months for her acne. Past Medical History: - Gastritis (many years, sensitive to peppers and NSAIDs despite PPI) - Chronic constipation [MASKED] years) - Acne Social History: [MASKED] Family History: Mother with ischemic stroke at [MASKED], which led to discovery of breast cancer. Physical Exam: ADMISSION EXAM -Vitals: T:97.4 BP:107/67 HR:73 RR:14 SaO2:100% -General: Awake, cooperative, NAD. -HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. ** Tenderness to pressure at right aspect of occiput ** -Neck: Supple. No nuchal rigidity. No tenderness or spasm of right trapezius. -Cardiac: RRR. Well perfused. -Pulmonary: Breathing comfortably on room air. -Abdomen: Soft, NT/ND. -Extremities: No cyanosis, clubbing, or edema bilaterally. -Skin: No rashes or other lesions noted. Henna tattoo on left arm. NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive to exam, detailed history and questions. Language is fluent with intact comprehension. Normal prosody. There are no paraphasic errors. Able to read cell phone without difficulty. Speech is not dysarthric. Able to follow both midline and appendicular commands. Had good knowledge of current events. There is no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation and no extinction. ** Pupils dilated with phenylephrine at 6pm [MASKED] **. Fundoscopic exam revealed no papilledema, exudates, or hemorrhages. Optic margins crisp. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally, however right arm trembles irregularly when held to test drift. No give way weakness, excellent effort. 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 5 4+ [MASKED] 5 4+ 4+ 4+ 5 5 5 5 * Subtle trembling weakness in above areas of 4+. Excellent effort. -Sensory: No deficits to light touch, cold sensation, or pinprick - including on right arm/neck. Proprioception intact at great toes and index fingers bilaterally. No extinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L Tr 1 0 2* 0 R Tr 1 0 2* 0 * Required facilitation with 2 modalities. Plantar response was flexor bilaterally. -Coordination: Slowed and subtly irregular cadence with repetitive finger tapping on the right (patient is left-handed, but felt it was awkward and worse than baseline). No dysmetria on FNF bilaterally, however, able to continue FNF with eyes closed on left, but past-pointed to the right when using right arm (eyes closed). Rapid toe tapping symmetric. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. ========================================================= DISCHARGE EXAM -Vitals: T: 97.9 BP: 110/66 HR:64 RR:18 SaO2:100% -General: Awake, cooperative, NAD. -HEENT: NC/AT. No scleral icterus noted. MMM. -Neck: Supple. No nuchal rigidity. -Cardiac: Warm, well perfused. -Pulmonary: Breathing comfortably on room air. -Extremities: No cyanosis or edema bilaterally. -Skin: No rashes or other lesions noted. NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive to exam, detailed history and questions. Language is fluent with intact comprehension. Follows midline and appendicular commands. There is no evidence of apraxia or neglect. -Cranial Nerves: PERRL. EOMI without nystagmus. Facial sensation intact to light touch. No facial droop, facial musculature symmetric. Hearing grossly intact to speech. Palate elevates symmetrically. [MASKED] strength in trapezii and SCM bilaterally. Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally, no tremor or other adventitious movement. 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. No extinction to DSS. -DTRs: [MASKED]. -Coordination: Deferred. Pertinent Results: [MASKED] 05:15AM BLOOD WBC-4.5 RBC-4.25 Hgb-10.8* Hct-34.7 MCV-82 MCH-25.4* MCHC-31.1* RDW-12.7 RDWSD-37.4 Plt [MASKED] [MASKED] 10:15AM BLOOD [MASKED] PTT-35.7 [MASKED] [MASKED] 05:15AM BLOOD Glucose-85 UreaN-5* Creat-0.9 Na-144 K-4.6 Cl-107 HCO3-24 AnGap-13 [MASKED] 05:15AM BLOOD Calcium-8.8 [MASKED] 10:10 am CSF;SPINAL FLUID Source: LP CSF TUBE 3. GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH MR HEAD W AND W/O CONTRAST T MR HEAD. 1. There is no evidence of acute intracranial process or hemorrhage. No diffusion abnormalities are detected to indicate acute or subacute ischemic changes. 2. Mild mucosal thickening is identified in the ethmoidal air cells, more significant on the right. MR CERVICAL SPINE W/O CONTRAST [MASKED] MR [MASKED] SPINE 1. No evidence of cord signal abnormality. 2. Mild multilevel degenerative changes as above, most notable at C5-C6 with mild to moderate spinal canal narrowing. There is no neural foraminal narrowing. CTA HEAD AND CTA NECK Q16 CT NECK 1. No large infarct, intracranial hemorrhage, or mass effect. 2. Normal CTA of the head. 3. 6 mm in length segment of slight luminal dilation of the left internal carotid artery may reflect a normal variant or due to mild atherosclerotic disease. The internal carotid arteries and vertebral arteries otherwise appear normal. Brief Hospital Course: 1. Cervicogenic headaches: CTA and MRI of the brain were unremarkable, arguing against infarct, neoplasm, or mass effect as cause of patient's headache and left arm and leg paresthesias. MRI of the C-spine notable for mild-to-moderate canal narrowing at C5-C6, which may have contributed to headache and sensory symptoms. Lumbar puncture accordingly did not show signs of inflammation or infection. Patient's symptoms responded to management with Fioricet, and recommendations were made to use a soft cervical collar at bedtime; gabapentin was also initiated to relieve paresthesias, with plan for titration by patient's outpatient neurologist. Fioricet was prescribed for as-needed use in the interim. 2. Post-dural puncture headache versus spontaneous intracranial hypotension: Following patient's lumbar puncture, she reported new retro-orbital headaches that were relieved while supine and exacerbated while sitting, suggestive of post-dural puncture headache. These episodes were also associated with nausea. Beacuse there also had been a postural component to her headaches before admission (improved with lying down), it was uncertain if she had spontaneous intracranial hypotension that coincidentally worsened after the LP, or if this was a post-LP HA (or possibly both). Patient underwent placement of an epidural blood patch by anesthesia for relief of her symptoms. If further [MASKED] with the pain center is required, an appointment may be scheduled with the [MASKED] by calling [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tretinoin 0.05% Cream 1 Appl TP QHS 2. Omeprazole 20 mg PO DAILY 3. Bisacodyl [MASKED] mg PO QHS 4. Psyllium Powder 1 PKT PO QHS Discharge Medications: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1 (One) capsule(s) by mouth every four (4) hours Disp #*30 Capsule Refills:*0 2. Gabapentin 100 mg PO QHS RX *gabapentin 100 mg 1 (One) capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*3 3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea Duration: 7 Days RX *ondansetron 4 mg 1 (One) tablet(s) by mouth every eight (8) hours Disp #*14 Tablet Refills:*0 4. Bisacodyl [MASKED] mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. Psyllium Powder 1 PKT PO QHS 7. Tretinoin 0.05% Cream 1 Appl TP QHS Discharge Disposition: Home Discharge Diagnosis: 1. Cervicogenic headaches 2. Spontaneous intracranial hypotension, and/or post-dural puncture headache 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 evaluation of headaches and right arm pain and tingling. An MRI of your brain did not show any concerning findings, and a lumbar puncture did not show signs of inflammation of the nervous system. An MRI of your neck showed mild narrowing of the area around your spinal cord, which may be responsible for your arm and leg symptoms. Your headache may also have been due to this narrowing. To help with your headache, you may use a soft cervical collar at nighttime. You were also prescribed a medication (gabapentin) to take at night to help with your arm and leg pain and tingling. You also received a prescription for Fioricet, a medication that you can take occasionally to stop severe headaches. Aside from your spine narrowing, you also experienced a different headache and nausea that was likely related to your lumbar puncture. A blood patch was placed by anesthesiology to help relieve the fluid leakage that led to this headache. You received a prescription for a nausea medication (ondansetron) to take if needed. Please follow up with Dr. [MASKED] at your [MASKED] appointment listed below. It was a pleasure taking care of you at [MASKED]. Sincerely, Neurology at [MASKED] Followup Instructions: [MASKED]
[]
[ "K5900", "Y92230" ]
[ "G4489: Other headache syndrome", "M4802: Spinal stenosis, cervical region", "H538: Other visual disturbances", "R200: Anesthesia of skin", "K5900: Constipation, unspecified", "L709: Acne, unspecified", "K2950: Unspecified chronic gastritis without bleeding", "G971: Other reaction to spinal and lumbar puncture", "Y844: Aspiration of fluid 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" ]
10,072,799
28,944,995
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right arm movement, facial twitching, stuttering speech. Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a ___ year-old left-handed woman with history of migraine, gastritis, chronic constipation and recent admission to the neurology service for headache and right arm parasthesias and pain attributed to cervicogenic headache, following an extensive workup, who presents today with 2 day history of a constellation of symptoms, including worsening headache, right facial spasms, right arm tremors, and increased emotional lability. History provided by patient, husband and sister at the bedside, as well as review of records. Ms. ___ was recently hospitalized ___ on the Neurology service with a 5 day history of fluctuating headache, lightheadedness, intermittent blurry vision and right arm pain and parasthesias. She had an extensive workup. This included CTA and MRI of the brain w/ and w/o contrast which were unremarkable, with no evidence of infarct, neoplasm, or mass effect. MRI C-spine notable for mild-to-moderate canal narrowing at C5-C6, which may have contributed to headache and sensory symptoms. Lumbar puncture on ___ was unremarkable (WBC 1, RBC 0, total protein 20, glucose 57, MS profile with no oligoclonal bands, CSF gram stain and culture negative). Following the LP there was concern for post-dural puncture headache versus spontaneous intracranial hypotension, as she reported new retro-orbital headaches that were relieved while supine and exacerbated while sitting, suggestive of post-dural puncture headache. These episodes were also associated with nausea. Given that there also had been a postural component to her headaches before admission (improved with lying down), it was uncertain if she had spontaneous intracranial hypotension that coincidentally worsened after the LP, or if this was a post-LP HA (or possibly both). Patient underwent placement of an epidural blood patch by anesthesia for relief of her symptoms. By the time of discharge, her symptoms responded to management with Fioricet, and recommendations were made to use a soft cervical collar at bedtime; gabapentin was also initiated to relieve paresthesias, with plan for titration by patient's outpatient neurologist. Fioricet was prescribed for as-needed use in the interim, which patient has been taking since discharge as prescribed. Since discharge on ___, patient has had a constellation of neurologic symptoms. On ___, in the evening following discharge, she reported an ongoing headache, consistent with her semiology described during admission. It was severe, but improved after taking her gabapentin and fiorcet, and she was able to sleep through the night. On that evening, however, she did find out the unfortunate news that a family friend had passed away (her aunt's daughter), whom Ms. ___ was very close to. This family friend had been ill for some time, so the death was not unexpected. However, it was especially distressing to her because her aunt did not contact anyone about the death, and she felt like it was being concealed. When the patient woke up on ___, her headache head improved. Her husband notes that her walk was somewhat unsteady at that time but the patient denied it, and was still able to walk household distances without falling or needing to hold onto objects. In the late afternoon, she began to have several new issues: 1) episodes of right arm tremor and higher amplitude movements. Her husband recorded this on video, which I reviewed. It consisted of non-rhythmic movements of the right arm, irregular in frequency, with maintained alertness. At times it appeared more like a right arm tremor and at other times it was more like nonrhythmic shaking. Patient reports that during this event, she was fully alert and aware of her arm doing it. She could suppress the movements somewhat if she concentrated, and her sister could suppress them with touching. Duration lasted anywhere from a few minutes to 10 minutes or more. She had several episodes of this over the course of the evening. 2) episodes of right face "spasm." Also recorded on video, this consisted of twitching of the right lower face, intermixed with puckering of the lip. This appears somewhat like right hemifacial spasm versus tardative dyskinesias (though it only affects the right side of the face). As with episode #1 above, could last anywhere from a few minutes to 10 minutes or more. 3) episodes of "word finding" difficulty. Patient had periods when she seemed to have difficulty expressing herself, lasting for only a few seconds at a time (never more than this). For example, when her husband asked her if she wanted to go outside to get some fresh air, she said "Lets go oo--" and unable to finish saying "out." They cannot think of any other examples of this. She had no difficulties understanding speech and still could express a few words. Sometimes when she seemed to think of a word, her eyes would "roll back" for a second or two. She otherwise was at her baseline. She contacted her Dr. ___ who recommended that she return to the Emergency Department for further evaluation, but patient declined. As these events occurred overnight, the patient woke up today (___) with no further episodes of semiologies 1 and 2. She woke up and her headache had resumed. She went to lie down and took a nap until 1:30PM. When she woke up at 1:30PM, she reported feeling "a heavy depression." She said she felt sad, though not at any one particular thing, which her husband says is typical for her. She did not mention anything about the recent passing of the family friend. She called her husband on the phone (who works as a ___ and was at work) and appeared "emotionally labile." Husband notes that she would alternate between having a "baby voice" and seeming juvenile, to crying and shouting. She was making sense while talking, and discussed her headaches. He was concerned and soon went back home, where he found her sitting on the swing, talking to EMS. Currently, patient reports she feels back to her baseline apart from ___ headache, and is anxious to be discharged from ED to go back home. Her husband notes that she still is off from her baseline, intermittently with emotional lability and "not quite with it." Past Medical History: Cervicogenic headaches s/p recent epidural patch for ?spinal headache Gastritis Chronic constipation Social History: ___ Family History: Mother with ischemic stroke at age ___. Physical Exam: ADMISSION EXAM Vitals: T 98.6F, HR 90, BP 136/90, RR 22, O2 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 non labored on room air Cardiac: warm and well perfused; regular on telemetry 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. Intermittently becomes tearful (typically when discussing topics that are distressing for her such as the loss of her family friend, and having to return to the hospital), acts somewhat juvenille, resolves after reassurance. 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. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. Reports mood is "kind of sad." Denies SI, HI. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. 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. Mild R arm postural tremor. 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 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. Discharge examination unchanged from above. Pertinent Results: ___ 07:20AM BLOOD WBC-3.3* RBC-3.94 Hgb-9.9* Hct-32.1* MCV-82 MCH-25.1* MCHC-30.8* RDW-12.7 RDWSD-37.5 Plt ___ ___ 07:20AM BLOOD ___ PTT-30.6 ___ ___ 07:20AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-143 K-4.5 Cl-109* HCO3-21* AnGap-13 ___ 07:20AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8 ___ 05:56PM URINE Color-PINK* Appear-Clear Sp ___ ___ 05:56PM URINE Blood-MOD* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 05:56PM URINE RBC->182* WBC-2 Bacteri-NONE Yeast-NONE Epi-3 TransE-<1 ___ 05:56PM URINE UCG-NEGATIVE ___ 05:56PM URINE bnzodzp-NEG barbitr-POS* opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 11:07AM CEREBROSPINAL FLUID (CSF) PARANEOPLASTIC AUTOANTIBODY EVALUATION, CSF-PND ___ 11:07AM CEREBROSPINAL FLUID (CSF) NMDA RECEPTOR AB, CSF-PND CT HEAD W/O CONTRAST No acute intracranial abnormalities. However, please note that acute ischemic changes are better detected on MRI. Brief Hospital Course: 1. Unspecified mood disorder: Patient and her husband noted a constellation of symptoms, including suppressible, non-rhythmic movements of the right upper extremity, intermittent voluntary right-sided facial grimacing, and intermittent speech, all captured on video. These findings were not clearly stereotyped, not associated with a change in mental status, and not associated with a post-ictal state, with no clear metabolic, infectious, or ischemic processes noted on testing and imaging, together reducing suspicion for seizures. Given onset of symptoms two days prior to presentation, the absence of ischemia on non-contrast head CT also argued against new infarct as contributor to patient's symptoms, particularly in light of negative brain MRI with and without contrast less than a week prior to presentation. Given patient's recent headaches and behavioral change, an autoimmune encephalitis panel (in addition to a paraneoplastic panel) were requested from CSF obtained during the most recent admission. Given the absence of a convincing neurologic etiology for patient's symptoms, patient was evaluated by the Psychiatry service, who suspected an unspecified mood disorder or possible panic disorder; consideration was also given to underlying conversion disorder or histrionic personality disorder. Recommendations included discontinuation of gabapentin, initiation of clonazepam as bridging therapy to outpatient psychiatric care, and referral for an outpatient psychiatric provider. A referral number was provided to the patient for an outpatient psychiatry NP with intake planned for within one week of discharge. In addition to the above changes, as-needed sumatriptan was prescribed for migraine headaches, with as-needed lorazepam for severe panic episodes not responding to reassurance and redirection (which patient's husband and family have been comfortably able to provide at home). As noted above, these medications will need to be reviewed by patient's outpatient psychiatry provider on ___. Neurology ___ was maintained as scheduled, with recommendation for PCP ___ in one week. Medications on Admission: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache 2. Gabapentin 100 mg PO QHS 3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea 4. Bisacodyl ___ mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. Psyllium Powder 1 PKT PO QHS 7. Tretinoin 0.05% Cream 1 Appl TP QHS Discharge Medications: 1. ClonazePAM 0.5 mg PO BID Duration: 7 Days Do not drive or operate heavy machinery on this medication. RX *clonazepam 0.5 mg 1 (One) tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. LORazepam 0.5 mg PO Q8H:PRN Severe panic attacks Duration: 7 Days Do not drive or operate heavy machinery while on this medication. RX *lorazepam 0.5 mg 1 (One) by mouth every eight (8) hours Disp #*14 Tablet Refills:*0 3. Sumatriptan Succinate 25 mg PO Q6H:PRN Migraine headache Duration: 7 Days ___ take a second dose if no relief after 2 hours. No more than 8 doses per day. RX *sumatriptan succinate 25 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 4. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache 5. Bisacodyl ___ mg PO QHS 6. Omeprazole 20 mg PO DAILY 7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea 8. Psyllium Powder 1 PKT PO QHS 9. Tretinoin 0.05% Cream 1 Appl TP QHS Discharge Disposition: Home Discharge Diagnosis: Mood disorder, not otherwise specified. 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 evaluation of right arm movements, right facial twitching, and stuttering speech for two days. A CT scan of your head did not show signs of a new stroke, and your neurologic examination remained stable without new concerning findings. You were seen by the Psychiatry service, who felt that your symptoms were due to a mood disorder and possibly panic attacks. They recommended stopping one of your medications (gabapentin) and starting a new medication (clonazepam) to manage your anxiety; they also felt strongly that you would benefit from seeing a psychiatry provider outside of the hospital. You also received new prescriptions for medications for your headache (sumatriptan) and as-needed medication (lorazepam) for severe panic attacks until you are seen in ___. Please follow up with your primary care provider within one week of discharge. Please also follow up with Dr. ___ at your appointment listed below; she can follow up on tests sent from your spinal fluid obtained during your last hospital stay. Please also call Anadyne Psychotherapy at ___ to schedule an intake assessment within one week of discharge to follow up on your mood symptoms. It was a pleasure taking care of you at ___. Sincerely, Neurology at ___ Followup Instructions: ___
[ "F39", "F419", "F410", "G43809", "R112", "K5909" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Right arm movement, facial twitching, stuttering speech. Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a [MASKED] year-old left-handed woman with history of migraine, gastritis, chronic constipation and recent admission to the neurology service for headache and right arm parasthesias and pain attributed to cervicogenic headache, following an extensive workup, who presents today with 2 day history of a constellation of symptoms, including worsening headache, right facial spasms, right arm tremors, and increased emotional lability. History provided by patient, husband and sister at the bedside, as well as review of records. Ms. [MASKED] was recently hospitalized [MASKED] on the Neurology service with a 5 day history of fluctuating headache, lightheadedness, intermittent blurry vision and right arm pain and parasthesias. She had an extensive workup. This included CTA and MRI of the brain w/ and w/o contrast which were unremarkable, with no evidence of infarct, neoplasm, or mass effect. MRI C-spine notable for mild-to-moderate canal narrowing at C5-C6, which may have contributed to headache and sensory symptoms. Lumbar puncture on [MASKED] was unremarkable (WBC 1, RBC 0, total protein 20, glucose 57, MS profile with no oligoclonal bands, CSF gram stain and culture negative). Following the LP there was concern for post-dural puncture headache versus spontaneous intracranial hypotension, as she reported new retro-orbital headaches that were relieved while supine and exacerbated while sitting, suggestive of post-dural puncture headache. These episodes were also associated with nausea. Given that there also had been a postural component to her headaches before admission (improved with lying down), it was uncertain if she had spontaneous intracranial hypotension that coincidentally worsened after the LP, or if this was a post-LP HA (or possibly both). Patient underwent placement of an epidural blood patch by anesthesia for relief of her symptoms. By the time of discharge, her symptoms responded to management with Fioricet, and recommendations were made to use a soft cervical collar at bedtime; gabapentin was also initiated to relieve paresthesias, with plan for titration by patient's outpatient neurologist. Fioricet was prescribed for as-needed use in the interim, which patient has been taking since discharge as prescribed. Since discharge on [MASKED], patient has had a constellation of neurologic symptoms. On [MASKED], in the evening following discharge, she reported an ongoing headache, consistent with her semiology described during admission. It was severe, but improved after taking her gabapentin and fiorcet, and she was able to sleep through the night. On that evening, however, she did find out the unfortunate news that a family friend had passed away (her aunt's daughter), whom Ms. [MASKED] was very close to. This family friend had been ill for some time, so the death was not unexpected. However, it was especially distressing to her because her aunt did not contact anyone about the death, and she felt like it was being concealed. When the patient woke up on [MASKED], her headache head improved. Her husband notes that her walk was somewhat unsteady at that time but the patient denied it, and was still able to walk household distances without falling or needing to hold onto objects. In the late afternoon, she began to have several new issues: 1) episodes of right arm tremor and higher amplitude movements. Her husband recorded this on video, which I reviewed. It consisted of non-rhythmic movements of the right arm, irregular in frequency, with maintained alertness. At times it appeared more like a right arm tremor and at other times it was more like nonrhythmic shaking. Patient reports that during this event, she was fully alert and aware of her arm doing it. She could suppress the movements somewhat if she concentrated, and her sister could suppress them with touching. Duration lasted anywhere from a few minutes to 10 minutes or more. She had several episodes of this over the course of the evening. 2) episodes of right face "spasm." Also recorded on video, this consisted of twitching of the right lower face, intermixed with puckering of the lip. This appears somewhat like right hemifacial spasm versus tardative dyskinesias (though it only affects the right side of the face). As with episode #1 above, could last anywhere from a few minutes to 10 minutes or more. 3) episodes of "word finding" difficulty. Patient had periods when she seemed to have difficulty expressing herself, lasting for only a few seconds at a time (never more than this). For example, when her husband asked her if she wanted to go outside to get some fresh air, she said "Lets go oo--" and unable to finish saying "out." They cannot think of any other examples of this. She had no difficulties understanding speech and still could express a few words. Sometimes when she seemed to think of a word, her eyes would "roll back" for a second or two. She otherwise was at her baseline. She contacted her Dr. [MASKED] who recommended that she return to the Emergency Department for further evaluation, but patient declined. As these events occurred overnight, the patient woke up today ([MASKED]) with no further episodes of semiologies 1 and 2. She woke up and her headache had resumed. She went to lie down and took a nap until 1:30PM. When she woke up at 1:30PM, she reported feeling "a heavy depression." She said she felt sad, though not at any one particular thing, which her husband says is typical for her. She did not mention anything about the recent passing of the family friend. She called her husband on the phone (who works as a [MASKED] and was at work) and appeared "emotionally labile." Husband notes that she would alternate between having a "baby voice" and seeming juvenile, to crying and shouting. She was making sense while talking, and discussed her headaches. He was concerned and soon went back home, where he found her sitting on the swing, talking to EMS. Currently, patient reports she feels back to her baseline apart from [MASKED] headache, and is anxious to be discharged from ED to go back home. Her husband notes that she still is off from her baseline, intermittently with emotional lability and "not quite with it." Past Medical History: Cervicogenic headaches s/p recent epidural patch for ?spinal headache Gastritis Chronic constipation Social History: [MASKED] Family History: Mother with ischemic stroke at age [MASKED]. Physical Exam: ADMISSION EXAM Vitals: T 98.6F, HR 90, BP 136/90, RR 22, O2 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 non labored on room air Cardiac: warm and well perfused; regular on telemetry 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. Intermittently becomes tearful (typically when discussing topics that are distressing for her such as the loss of her family friend, and having to return to the hospital), acts somewhat juvenille, resolves after reassurance. 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. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall [MASKED] at 5 minutes. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. Reports mood is "kind of sad." Denies SI, HI. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. 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. Mild R arm postural tremor. 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 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. Discharge examination unchanged from above. Pertinent Results: [MASKED] 07:20AM BLOOD WBC-3.3* RBC-3.94 Hgb-9.9* Hct-32.1* MCV-82 MCH-25.1* MCHC-30.8* RDW-12.7 RDWSD-37.5 Plt [MASKED] [MASKED] 07:20AM BLOOD [MASKED] PTT-30.6 [MASKED] [MASKED] 07:20AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-143 K-4.5 Cl-109* HCO3-21* AnGap-13 [MASKED] 07:20AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8 [MASKED] 05:56PM URINE Color-PINK* Appear-Clear Sp [MASKED] [MASKED] 05:56PM URINE Blood-MOD* Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 05:56PM URINE RBC->182* WBC-2 Bacteri-NONE Yeast-NONE Epi-3 TransE-<1 [MASKED] 05:56PM URINE UCG-NEGATIVE [MASKED] 05:56PM URINE bnzodzp-NEG barbitr-POS* opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG [MASKED] 11:07AM CEREBROSPINAL FLUID (CSF) PARANEOPLASTIC AUTOANTIBODY EVALUATION, CSF-PND [MASKED] 11:07AM CEREBROSPINAL FLUID (CSF) NMDA RECEPTOR AB, CSF-PND CT HEAD W/O CONTRAST No acute intracranial abnormalities. However, please note that acute ischemic changes are better detected on MRI. Brief Hospital Course: 1. Unspecified mood disorder: Patient and her husband noted a constellation of symptoms, including suppressible, non-rhythmic movements of the right upper extremity, intermittent voluntary right-sided facial grimacing, and intermittent speech, all captured on video. These findings were not clearly stereotyped, not associated with a change in mental status, and not associated with a post-ictal state, with no clear metabolic, infectious, or ischemic processes noted on testing and imaging, together reducing suspicion for seizures. Given onset of symptoms two days prior to presentation, the absence of ischemia on non-contrast head CT also argued against new infarct as contributor to patient's symptoms, particularly in light of negative brain MRI with and without contrast less than a week prior to presentation. Given patient's recent headaches and behavioral change, an autoimmune encephalitis panel (in addition to a paraneoplastic panel) were requested from CSF obtained during the most recent admission. Given the absence of a convincing neurologic etiology for patient's symptoms, patient was evaluated by the Psychiatry service, who suspected an unspecified mood disorder or possible panic disorder; consideration was also given to underlying conversion disorder or histrionic personality disorder. Recommendations included discontinuation of gabapentin, initiation of clonazepam as bridging therapy to outpatient psychiatric care, and referral for an outpatient psychiatric provider. A referral number was provided to the patient for an outpatient psychiatry NP with intake planned for within one week of discharge. In addition to the above changes, as-needed sumatriptan was prescribed for migraine headaches, with as-needed lorazepam for severe panic episodes not responding to reassurance and redirection (which patient's husband and family have been comfortably able to provide at home). As noted above, these medications will need to be reviewed by patient's outpatient psychiatry provider on [MASKED]. Neurology [MASKED] was maintained as scheduled, with recommendation for PCP [MASKED] in one week. Medications on Admission: 1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache 2. Gabapentin 100 mg PO QHS 3. Ondansetron ODT 4 mg PO Q8H:PRN Nausea 4. Bisacodyl [MASKED] mg PO QHS 5. Omeprazole 20 mg PO DAILY 6. Psyllium Powder 1 PKT PO QHS 7. Tretinoin 0.05% Cream 1 Appl TP QHS Discharge Medications: 1. ClonazePAM 0.5 mg PO BID Duration: 7 Days Do not drive or operate heavy machinery on this medication. RX *clonazepam 0.5 mg 1 (One) tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. LORazepam 0.5 mg PO Q8H:PRN Severe panic attacks Duration: 7 Days Do not drive or operate heavy machinery while on this medication. RX *lorazepam 0.5 mg 1 (One) by mouth every eight (8) hours Disp #*14 Tablet Refills:*0 3. Sumatriptan Succinate 25 mg PO Q6H:PRN Migraine headache Duration: 7 Days [MASKED] take a second dose if no relief after 2 hours. No more than 8 doses per day. RX *sumatriptan succinate 25 mg 1 (One) tablet(s) by mouth every six (6) hours Disp #*28 Tablet Refills:*0 4. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache 5. Bisacodyl [MASKED] mg PO QHS 6. Omeprazole 20 mg PO DAILY 7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea 8. Psyllium Powder 1 PKT PO QHS 9. Tretinoin 0.05% Cream 1 Appl TP QHS Discharge Disposition: Home Discharge Diagnosis: Mood disorder, not otherwise specified. 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 evaluation of right arm movements, right facial twitching, and stuttering speech for two days. A CT scan of your head did not show signs of a new stroke, and your neurologic examination remained stable without new concerning findings. You were seen by the Psychiatry service, who felt that your symptoms were due to a mood disorder and possibly panic attacks. They recommended stopping one of your medications (gabapentin) and starting a new medication (clonazepam) to manage your anxiety; they also felt strongly that you would benefit from seeing a psychiatry provider outside of the hospital. You also received new prescriptions for medications for your headache (sumatriptan) and as-needed medication (lorazepam) for severe panic attacks until you are seen in [MASKED]. Please follow up with your primary care provider within one week of discharge. Please also follow up with Dr. [MASKED] at your appointment listed below; she can follow up on tests sent from your spinal fluid obtained during your last hospital stay. Please also call Anadyne Psychotherapy at [MASKED] to schedule an intake assessment within one week of discharge to follow up on your mood symptoms. It was a pleasure taking care of you at [MASKED]. Sincerely, Neurology at [MASKED] Followup Instructions: [MASKED]
[]
[ "F419" ]
[ "F39: Unspecified mood [affective] disorder", "F419: Anxiety disorder, unspecified", "F410: Panic disorder [episodic paroxysmal anxiety]", "G43809: Other migraine, not intractable, without status migrainosus", "R112: Nausea with vomiting, unspecified", "K5909: Other constipation" ]
10,073,239
28,901,382
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: CAD, volume overload Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: Mr. ___ is a ___ man with CAD (3v disease, previously declined CABG), ischemic cardiomyopathy, HFrEF (LVEF 35%), Atrial fibrillation (on Coumadin), CKD III, HTN, DMII, BPH s/p recent TURP, who initially presented to ___ with an acute systolic heart failure exacerbation and is not transferred to ___ for management of his severe CAD and MR. ___ patient recently underwent TURB for BPH in ___. After his procedure he noted progressive dyspnea on exertion and bilateral lower extremity swelling. His diuretic was changed from Lasix 80mg daily to Torsemide 40mg daily without improvement. He also began to experience chest tightness during exertion which would improve with rest. There was no associated nausea or diaphoresis. He has not experienced any palpitations or chest pain. He was adherent to his medications and had no dietary changes or illnesses. He did not experience PND but does have orthopnea at baseline. Given the above he presented to ___ on ___. While at ___, the patient was diuresed with a Lasix gtt up to 7.5mg with improvement in his weight from 92.3 kg to 88.9 kg (though there was skepticism on accuracy of weights). His creatinine on admission was 2.2 which improved with diuresis to 1.8. An echo demonstrated an EF of 38% with hypokinesis of the inferior wall, distal antral septium, and apex with diastolic dysfunction and severe biatrial enlargement with 4+ MR. ___ metoprolol was initially held in the setting of hypotension, however it was re-started prior to transfer. He underwent LHC on ___ that showed 3v disease with total occlusion of RCA. The plan was made to transfer the patient to ___ for possible LAD PCI and EP consult for consideration of LV pacing lead versus structural team consult for possible mitral clip. Of note, his hospital course was also complicated by bilateral feet pain (for which he received oxycodone prn) and a superficial LLE skin wound for which he was started on Keflex ___ QID for 5 days ___ to ___. On arrival to ___ the patient appears generally well and is in no distress. He endorses the above. Currently, he has no chest discomfort or tightness. He denies palpitations, pre-syncope, dyspnea, cough, fevers, or chills. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD (occluded RCA, disease in LAD and CX) - LVEF 35% - Atrial fibrillation / atrial flutter (on Coumadin) - s/p PPM 3. OTHER PAST MEDICAL HISTORY - CKD Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VS: ___ Temp: 97.9 PO BP: 104/64 L Sitting HR: 64 RR: 16 O2 sat: 92% O2 delivery: RA GENERAL: Well developed, well nourished man in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. soft mobile non-tender superficial mass over the superior SCM. JVP elevated to the mandible. CARDIAC: PMI located in ___ intercostal space, midclavicular line. Normal S1, S2. Systolic murmur heard best at apex. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. There is dullness to percussion and decreased breath sounds at the left base. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: ======================== Pertinent Results: ADMISSION LABS: =============== ___ 09:15PM GLUCOSE-199* UREA N-45* CREAT-1.8* SODIUM-132* POTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-26 ANION GAP-15 ___ 09:15PM estGFR-Using this ___ 09:15PM CALCIUM-8.8 PHOSPHATE-4.1 MAGNESIUM-1.7 ___ 09:15PM WBC-8.2 RBC-3.82* HGB-11.2* HCT-36.6* MCV-96 MCH-29.3 MCHC-30.6* RDW-15.2 RDWSD-53.5* ___ 09:15PM PLT COUNT-210 ___ 09:15PM ___ DISCHARGE LABS: =============== STUDIES: ======== ___ CXR: Moderate cardiomegaly with retrocardiac opacification suggesting left pleural effusion and/or atelectasis. ___ L UE USN: No evidence of deep vein thrombosis in the left upper extremity. ___ ECG: Ventricular-paced rhythm, 61 bpm, RBBB, inverted T-waves in I and aVL Brief Hospital Course: Mr. ___ was an ___ year old man with CAD (3v disease, previously declined CABG), ischemic cardiomyopathy, HFrEF (LVEF 29%), atrial fibrillation (on Coumadin w/ PPM), CKD III, HTN, DMII, BPH s/p recent TURP, admitted for acute systolic heart failure exacerbation in the setting of severe MR, TR, and AS, as well as triple vessel disease. He had a prolonged hospitalization focused on management of his heart failure, which was complicated by his valvular disease. He was briefly in the CCU on ___ out of concern for cardiogenic shock; received inotropic support with diuresis and improved. On the floor his RHC numbers were still concerning, and he became more lethargic prompting transfer back to the CCU on ___ after having an Impella placed for mechanical support. He was progressively more delirious and his numbers suggested cardiogenic shock. A multidisciplinary meeting with Cardiac Surgery and Structural Cardiology considered him high risk for any procedures. Furthermore, his family indicated that the patient had previously shared that he wouldn't want to undergo prolonged rehab and not be able to return to his previous life at home. The decision was made to transition to comfort measures only. The patient passed away on ___ at 15:20 surrounded by his family. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Torsemide 40 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS 5. Finasteride 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. GlipiZIDE 5 mg PO DAILY 8. Magnesium Oxide 400 mg PO BID 9. Moexipril 7.5 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Simvastatin 40 mg PO QPM 12. Warfarin 2 mg PO DAILY16 13. Cephalexin 500 mg PO Q8H 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic shock Discharge Condition: Expired Discharge Instructions: None Followup Instructions: ___
[ "I130", "I5023", "K7200", "F05", "E871", "N390", "N179", "I97638", "D684", "R570", "I2582", "I340", "E1122", "I2510", "I255", "N183", "I361", "I480", "I350", "E785", "Z515", "Z794", "Z7901", "Z87891", "E1142", "L989", "I952", "T501X5A", "Y92230", "N401", "R338", "E860", "I2720", "R319", "Y848", "Y92239", "Z950" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: CAD, volume overload Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: Mr. [MASKED] is a [MASKED] man with CAD (3v disease, previously declined CABG), ischemic cardiomyopathy, HFrEF (LVEF 35%), Atrial fibrillation (on Coumadin), CKD III, HTN, DMII, BPH s/p recent TURP, who initially presented to [MASKED] with an acute systolic heart failure exacerbation and is not transferred to [MASKED] for management of his severe CAD and MR. [MASKED] patient recently underwent TURB for BPH in [MASKED]. After his procedure he noted progressive dyspnea on exertion and bilateral lower extremity swelling. His diuretic was changed from Lasix 80mg daily to Torsemide 40mg daily without improvement. He also began to experience chest tightness during exertion which would improve with rest. There was no associated nausea or diaphoresis. He has not experienced any palpitations or chest pain. He was adherent to his medications and had no dietary changes or illnesses. He did not experience PND but does have orthopnea at baseline. Given the above he presented to [MASKED] on [MASKED]. While at [MASKED], the patient was diuresed with a Lasix gtt up to 7.5mg with improvement in his weight from 92.3 kg to 88.9 kg (though there was skepticism on accuracy of weights). His creatinine on admission was 2.2 which improved with diuresis to 1.8. An echo demonstrated an EF of 38% with hypokinesis of the inferior wall, distal antral septium, and apex with diastolic dysfunction and severe biatrial enlargement with 4+ MR. [MASKED] metoprolol was initially held in the setting of hypotension, however it was re-started prior to transfer. He underwent LHC on [MASKED] that showed 3v disease with total occlusion of RCA. The plan was made to transfer the patient to [MASKED] for possible LAD PCI and EP consult for consideration of LV pacing lead versus structural team consult for possible mitral clip. Of note, his hospital course was also complicated by bilateral feet pain (for which he received oxycodone prn) and a superficial LLE skin wound for which he was started on Keflex [MASKED] QID for 5 days [MASKED] to [MASKED]. On arrival to [MASKED] the patient appears generally well and is in no distress. He endorses the above. Currently, he has no chest discomfort or tightness. He denies palpitations, pre-syncope, dyspnea, cough, fevers, or chills. Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - CAD (occluded RCA, disease in LAD and CX) - LVEF 35% - Atrial fibrillation / atrial flutter (on Coumadin) - s/p PPM 3. OTHER PAST MEDICAL HISTORY - CKD Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VS: [MASKED] Temp: 97.9 PO BP: 104/64 L Sitting HR: 64 RR: 16 O2 sat: 92% O2 delivery: RA GENERAL: Well developed, well nourished man in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. soft mobile non-tender superficial mass over the superior SCM. JVP elevated to the mandible. CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. Normal S1, S2. Systolic murmur heard best at apex. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. There is dullness to percussion and decreased breath sounds at the left base. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: ======================== Pertinent Results: ADMISSION LABS: =============== [MASKED] 09:15PM GLUCOSE-199* UREA N-45* CREAT-1.8* SODIUM-132* POTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-26 ANION GAP-15 [MASKED] 09:15PM estGFR-Using this [MASKED] 09:15PM CALCIUM-8.8 PHOSPHATE-4.1 MAGNESIUM-1.7 [MASKED] 09:15PM WBC-8.2 RBC-3.82* HGB-11.2* HCT-36.6* MCV-96 MCH-29.3 MCHC-30.6* RDW-15.2 RDWSD-53.5* [MASKED] 09:15PM PLT COUNT-210 [MASKED] 09:15PM [MASKED] DISCHARGE LABS: =============== STUDIES: ======== [MASKED] CXR: Moderate cardiomegaly with retrocardiac opacification suggesting left pleural effusion and/or atelectasis. [MASKED] L UE USN: No evidence of deep vein thrombosis in the left upper extremity. [MASKED] ECG: Ventricular-paced rhythm, 61 bpm, RBBB, inverted T-waves in I and aVL Brief Hospital Course: Mr. [MASKED] was an [MASKED] year old man with CAD (3v disease, previously declined CABG), ischemic cardiomyopathy, HFrEF (LVEF 29%), atrial fibrillation (on Coumadin w/ PPM), CKD III, HTN, DMII, BPH s/p recent TURP, admitted for acute systolic heart failure exacerbation in the setting of severe MR, TR, and AS, as well as triple vessel disease. He had a prolonged hospitalization focused on management of his heart failure, which was complicated by his valvular disease. He was briefly in the CCU on [MASKED] out of concern for cardiogenic shock; received inotropic support with diuresis and improved. On the floor his RHC numbers were still concerning, and he became more lethargic prompting transfer back to the CCU on [MASKED] after having an Impella placed for mechanical support. He was progressively more delirious and his numbers suggested cardiogenic shock. A multidisciplinary meeting with Cardiac Surgery and Structural Cardiology considered him high risk for any procedures. Furthermore, his family indicated that the patient had previously shared that he wouldn't want to undergo prolonged rehab and not be able to return to his previous life at home. The decision was made to transition to comfort measures only. The patient passed away on [MASKED] at 15:20 surrounded by his family. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Torsemide 40 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS 5. Finasteride 5 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. GlipiZIDE 5 mg PO DAILY 8. Magnesium Oxide 400 mg PO BID 9. Moexipril 7.5 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Simvastatin 40 mg PO QPM 12. Warfarin 2 mg PO DAILY16 13. Cephalexin 500 mg PO Q8H 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic shock Discharge Condition: Expired Discharge Instructions: None Followup Instructions: [MASKED]
[]
[ "I130", "E871", "N390", "N179", "E1122", "I2510", "I480", "E785", "Z515", "Z794", "Z7901", "Z87891", "Y92230" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "K7200: Acute and subacute hepatic failure without coma", "F05: Delirium due to known physiological condition", "E871: Hypo-osmolality and hyponatremia", "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "I97638: Postprocedural hematoma of a circulatory system organ or structure following other circulatory system procedure", "D684: Acquired coagulation factor deficiency", "R570: Cardiogenic shock", "I2582: Chronic total occlusion of coronary artery", "I340: Nonrheumatic mitral (valve) insufficiency", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I255: Ischemic cardiomyopathy", "N183: Chronic kidney disease, stage 3 (moderate)", "I361: Nonrheumatic tricuspid (valve) insufficiency", "I480: Paroxysmal atrial fibrillation", "I350: Nonrheumatic aortic (valve) stenosis", "E785: Hyperlipidemia, unspecified", "Z515: Encounter for palliative care", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "L989: Disorder of the skin and subcutaneous tissue, unspecified", "I952: Hypotension due to drugs", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "E860: Dehydration", "I2720: Pulmonary hypertension, unspecified", "R319: Hematuria, unspecified", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z950: Presence of cardiac pacemaker" ]
10,073,247
25,584,602
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Neosporin AF / adhesive tape Attending: ___. Chief Complaint: Nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH metastatic breast CA currently on immunotherapy, bell's palsy with left-sided facial droop, vasovagal episodes with significant bradycardia and cyanosis, p/w nausea, vomiting, diarrhea and thrush. Patient developed several episodes of emesis last night and was having difficulty tolerating PO. Also endorsing sore throat and thrush, for which she has been prescribed magic mouthwash with minimal resolution. Denies fevers/chills, CP, dyspnea, abdominal pain, BRBPR, melena, dysuria, and rashes. ED spoke w her oncologist in ___ (Dr. ___ ___), said to hold her new immunotherapy drug Ibrance as thought to be causing the above symptoms. She started the drug about 2.5 weeks ago. In the ED, initial vitals:98.4 80 122/46 18 98% RA - Exam notable for: General: pale-appearing elderly female in NAD HEENT: NC, AT. PERRLA. EOMI. Nares patent. EOMI. Neck: cervical lymphadenopathy Chest: coarse lung sound to LLL CV: RRR, nrml s1/s2, no m/g/r. Abdomen: soft, non-tender, no HSM Ext: trace pitting edema to BLLE Neuro: AOx3, left facial droop, otherwise cn2-12 intact. - Labs notable for: - CBC 2.2/7.___ w 510 ANC - CHEM BUN 24 Cr 1.8 - Coags INR 1.2 - LFTs AP 114 - UA perfectly normal - Imaging notable for: normal CXR - Pt given: ___ 22:39 PO/NG Atorvastatin 10 mg ___ ___ 22:39 PO/NG Carvedilol 6.25 mg ___ ___ 22:39 TD Fentanyl Patch 12 mcg/h ___ 22:39 PO/NG Mirtazapine 15 mg ___ ___ 22:51 PO/NG LORazepam .5 mg ___ - Vitals prior to transfer: 98.4 81 126/57 18 97% RA Upon arrival to the floor, the patient reports the above story. Past Medical History: Metastatic breast cancer ___ s/p lumpectomy and ___ (involvement of bone, liver) ___ Decreased EF and MR after ___ that has since largely resolved neuropathy secondary to ___ htn anxiety glaucoma CKD Social History: ___ Family History: No history of heart disease or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: T 98.5 PO BP: 112/56 HR: 86 RR: 18 O2 sat: 94% RA GENERAL: appears younger than age, NAD HEENT: sclera anicteric, MMM, OP w thrush CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room air ABDOMEN: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley EXTREMITIES: warm, well perfused, no cyanosis or edema NEURO: AOx3, known L facial droop (bell's), moving all extremities w purpose and against gravity DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated ___ @ 1129) Temp: 97.3 (Tm 99.4), BP: 111/61 (103-124/61-70), HR: 74 (74-88), RR: 18 (___), O2 sat: 95% (94-96), O2 delivery: Ra GENERAL: appears younger than age, NAD. HEENT: sclera anicteric, MMM, thrush appears to be resolving on OP exam, does have what appears to be some angular chelitis. CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room air ABDOMEN: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding EXTREMITIES: warm, well perfused, no cyanosis or edema NEURO: AOx3, known L facial droop (bell's), moving all extremities w purpose and against gravity Pertinent Results: ADMISSION LABS: ============== ___ 05:35PM BLOOD WBC-2.2* RBC-2.77* Hgb-7.7* Hct-24.5* MCV-88 MCH-27.8 MCHC-31.4* RDW-19.8* RDWSD-56.0* Plt Ct-36* ___ 05:35PM BLOOD Neuts-23* Bands-0 Lymphs-71* Monos-5 Eos-0 Baso-1 ___ Myelos-0 AbsNeut-0.51* AbsLymp-1.56 AbsMono-0.11* AbsEos-0.00* AbsBaso-0.02 ___ 10:00PM BLOOD ___ PTT-28.2 ___ ___ 05:35PM BLOOD Glucose-124* UreaN-24* Creat-1.8* Na-140 K-5.0 Cl-95* HCO3-28 AnGap-17 ___ 10:00PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.4 ___ 05:35PM BLOOD ALT-16 AST-38 AlkPhos-114* TotBili-0.3 ___ 05:35PM BLOOD Lipase-47 ___ 09:48PM BLOOD Lactate-1.4 PERTINENT LABS/MICRO/IMAGING: ============================ ___ 01:21PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:21PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD* ___ 01:21PM URINE RBC-1 WBC-7* Bacteri-FEW* Yeast-NONE Epi-0 ___ 9:27 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 9:34 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 9:54 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 9:30 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. Time Taken Not Noted Log-In Date/Time: ___ 1:58 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 1:21 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S Imaging: ---------- CXR ___: No acute intrathoracic process. DISCHARGE LABS: =============== ___ 08:38AM BLOOD WBC-3.0* RBC-3.19* Hgb-9.0* Hct-29.5* MCV-93 MCH-28.2 MCHC-30.5* RDW-18.9* RDWSD-55.8* Plt Ct-21* ___ 08:38AM BLOOD Neuts-20* Bands-0 Lymphs-75* Monos-3* Eos-0 Baso-0 Atyps-2* ___ Myelos-0 NRBC-1* AbsNeut-0.60* AbsLymp-2.31 AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* ___ 08:38AM BLOOD Glucose-105* UreaN-26* Creat-1.6* Na-139 K-4.5 Cl-100 HCO3-25 AnGap-14 ___ 08:38AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.3 Brief Hospital Course: PATIENT SUMMARY: ================ ___ with PMH of metastatic breast CA currently on immunotherapy (Ibrance), left-sided Bell's Palsy, Bezold-Jarisch, who presents with nausea, vomiting, diarrhea and odynophagia with thrush, found to be pancytopenic and dehydrated at urgent care, sent to ___ for further workup and management. Symptoms improved and counts recovering after stopping Ibrance. ACUTE ISSUES: ============= # Pancytopenia: Likely secondary to her immunotherapy (Ibrance) which she just started about 2.5 weeks prior to admission. Her Ibrance was stopped and her counts seem to be recovering. Can also consider bone marrow suppression from viral illness, though has been afebrile and symptoms have resolved with stopping of Ibrance. She received 1 unit of pRBCs on ___ given Hgb 7.7 and symptomatic with fatigue, ED had spoken with heme/onc fellow at ___ in ___ where she receives her cancer care and recommended/agreed with transfusion. She responded appropriately to transfusion. # GI Upset: Patient presented with nausea, vomiting, diarrhea. Per her oncologist, likely side effect of new immunotherapy (Ibrance). Symptoms largely resolved since she stopped the Ibrance. Initially received IVF (total of 1250cc), now able to tolerate PO back to baseline. # Odynophagia: Patient with ___ odynophagia on admission, likely worsened by vomiting over the past day. Noted to have extensive oral thrush by HCP Hope, was on Magic Mouthwash w/ Nystatin at home. Continued Magic Mouthwash and Nystatin rinses here and odynophagia improved and patient able to take PO back to baseline. If continues to have odynophagia that impairs PO intake, would consider further workup like EGD in the future to look for esophagitis ___ vs. CMV vs. HSV). # Angular chelitis: Patient noted to have some angular chelitis on ___, deferred starting on clotrimazole cream given patient allergy to neosporin, which is similar in makeup. Instead gave lip cream/moisturizer. Recommend barrier protection with vaseline and close monitoring. # Elevated temperature: Patient had intermittently elevated temperature to a max of 100.3 without hemodynamic instability or localizing symptoms. She was not neutropenic at that time. Infectious work-up was only remarkable for a mixed bacterial flora, consistent with skin contamination. Of note, one of the bacteria was pseudomonas (>100,000 CFU/mL). Remainder of infectious work up was negative. Given absence of neutropenia and localizing symptoms, and resolution of elevated temperature without intervention, decision was made not to treat for UTI. Patient was afebrile for 24h prior to discharge and feeling at her baseline. CHRONIC ISSUES: =============== # Metastatic breast cancer: Followed by Dr. ___ at ___ in ___, ___. Started on Ibrance about 2.5 weeks prior to admission after discovery of further mets in liver (in addition to already known mets in bones and other sites). ED touched base with heme/onc fellow at ___ re: stopping Ibrance. Patient originally had follow-up appointment on ___, however will need to reschedule. # ___: Patient with history of severe vasovagal episodes where she becomes unresponsive with bradycardia and cyanosis. Has been seen by neurology for this. Awakens with pinching of cheek or sternal rubs. # Bell's palsy: Left-sided. Stable since childhood. # GOC: Spoke briefly with the patient at beside. She had papers from PA a few years back documenting DNR/DNI however patient states that if the clinicians believe that it was something reversible that caused her heart to stop or her to need intubation, then she wants to be resuscitated/intubated. Will require ongoing assessment of clinical status and continuing ___ discussions. TRANSITIONAL ISSUES: =================== [] Pancytopenia: Continue to monitor CBC/diff off Ibrance. [] Odynophagia: Continue to monitor, if patient with increasing difficulty tolerating PO then would do further workup with EGD to look for ___ esophagitis. [] Encourage and ensure adequate PO intake. [] Angular chelitis: monitor, ensure no signs concerning for HSV. [] In case of elevated temperature, check for neutropenia. Consider treatment for UTI (urine growing Pseudomonas (>100,000 CFU/mL) sensitive to cefepime, ceftazidime, ciprofloxacin, gentamicin, meropenem, Zosyn, tobramycin). [] Ensure patient has follow-up with ___, as missed her appt ___. [] ___: Continue ___ discussions, and consider filling out new MOLST (or PA equivalent). # Contact/HCP: ___, best friend, ___, ___ # Code status: Full code (see #___ above) . . . . Time in care: greater than 30 minutes in discharge-related activities today. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 6.25 mg PO BID 2. Fentanyl Patch 12 mcg/h TD Q72H 3. Sertraline 25 mg PO DAILY 4. Letrozole 2.5 mg PO DAILY 5. Movantik (naloxegol) 25 mg oral DAILY 6. Mirtazapine 15 mg PO QHS 7. Atorvastatin 10 mg PO QPM 8. Aspirin 81 mg PO DAILY 9. LORazepam 0.5 mg PO BID 10. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Maalox/Lidocaine 15 mL ORAL Q4H:PRN pain with swallowing RX *alum-mag hydroxide-simeth [Almacone] 200 mg-200 mg-20 mg/5 mL 15 ml by mouth every four hours as needed Disp #*355 Milliliter Milliliter Refills:*1 2. Nystatin Oral Suspension 5 mL PO TID:PRN thrush RX *nystatin 100,000 unit/mL 5 ml by mouth every eight hours as needed Disp #*480 Milliliter Milliliter Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Carvedilol 6.25 mg PO BID 6. Fentanyl Patch 12 mcg/h TD Q72H 7. Letrozole 2.5 mg PO DAILY 8. LORazepam 0.5 mg PO BID 9. Mirtazapine 15 mg PO QHS 10. Movantik (naloxegol) 25 mg oral DAILY 11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN BREAKTHROUGH PAIN 12. Sertraline 25 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: -Pancytopenia -Vomiting/Diarrhea -Odynophagia SECONDARY: -Metastatic breast cancer -___ Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. WHY WAS I ADMITTED TO THE HOSPITAL? You were admitted to the hospital because your blood counts were low and you were vomiting and having diarrhea. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -You received IV fluids because you were dehydrated from the vomiting and diarrhea. -You received a blood transfusion because your hemoglobin was low and you were feeling more tired than usual, and you responded appropriately to the transfusion. -Your blood counts continue to improve since stopping the Ibrance. -Your vomiting and diarrhea resolved since stopping the Ibrance and getting IV fluids, and your sore throat improved with the Magic Mouthwash and Nystatin rinses. As a result, you were able to eat and drink more. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? -Continue to take all medications as prescribed. -Please attend all ___ clinic appointments. -Please follow-up with your oncologist at ___ in ___ to discuss further treatment options. We wish you all the best, Your ___ Care Team Followup Instructions: ___
[ "D61810", "B370", "C7951", "C787", "N179", "R112", "R197", "R1310", "Z66", "G510", "E860", "Z853", "G622" ]
Allergies: Penicillins / Neosporin AF / adhesive tape Chief Complaint: Nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH metastatic breast CA currently on immunotherapy, bell's palsy with left-sided facial droop, vasovagal episodes with significant bradycardia and cyanosis, p/w nausea, vomiting, diarrhea and thrush. Patient developed several episodes of emesis last night and was having difficulty tolerating PO. Also endorsing sore throat and thrush, for which she has been prescribed magic mouthwash with minimal resolution. Denies fevers/chills, CP, dyspnea, abdominal pain, BRBPR, melena, dysuria, and rashes. ED spoke w her oncologist in [MASKED] (Dr. [MASKED] [MASKED]), said to hold her new immunotherapy drug Ibrance as thought to be causing the above symptoms. She started the drug about 2.5 weeks ago. In the ED, initial vitals:98.4 80 122/46 18 98% RA - Exam notable for: General: pale-appearing elderly female in NAD HEENT: NC, AT. PERRLA. EOMI. Nares patent. EOMI. Neck: cervical lymphadenopathy Chest: coarse lung sound to LLL CV: RRR, nrml s1/s2, no m/g/r. Abdomen: soft, non-tender, no HSM Ext: trace pitting edema to BLLE Neuro: AOx3, left facial droop, otherwise cn2-12 intact. - Labs notable for: - CBC 2.2/7.[MASKED] w 510 ANC - CHEM BUN 24 Cr 1.8 - Coags INR 1.2 - LFTs AP 114 - UA perfectly normal - Imaging notable for: normal CXR - Pt given: [MASKED] 22:39 PO/NG Atorvastatin 10 mg [MASKED] [MASKED] 22:39 PO/NG Carvedilol 6.25 mg [MASKED] [MASKED] 22:39 TD Fentanyl Patch 12 mcg/h [MASKED] 22:39 PO/NG Mirtazapine 15 mg [MASKED] [MASKED] 22:51 PO/NG LORazepam .5 mg [MASKED] - Vitals prior to transfer: 98.4 81 126/57 18 97% RA Upon arrival to the floor, the patient reports the above story. Past Medical History: Metastatic breast cancer [MASKED] s/p lumpectomy and [MASKED] (involvement of bone, liver) [MASKED] Decreased EF and MR after [MASKED] that has since largely resolved neuropathy secondary to [MASKED] htn anxiety glaucoma CKD Social History: [MASKED] Family History: No history of heart disease or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: T 98.5 PO BP: 112/56 HR: 86 RR: 18 O2 sat: 94% RA GENERAL: appears younger than age, NAD HEENT: sclera anicteric, MMM, OP w thrush CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room air ABDOMEN: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding GU: No foley EXTREMITIES: warm, well perfused, no cyanosis or edema NEURO: AOx3, known L facial droop (bell's), moving all extremities w purpose and against gravity DISCHARGE PHYSICAL EXAM: ======================== 24 HR Data (last updated [MASKED] @ 1129) Temp: 97.3 (Tm 99.4), BP: 111/61 (103-124/61-70), HR: 74 (74-88), RR: 18 ([MASKED]), O2 sat: 95% (94-96), O2 delivery: Ra GENERAL: appears younger than age, NAD. HEENT: sclera anicteric, MMM, thrush appears to be resolving on OP exam, does have what appears to be some angular chelitis. CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room air ABDOMEN: soft, non-tender, non-distended, bowel sounds present, no rebound or guarding EXTREMITIES: warm, well perfused, no cyanosis or edema NEURO: AOx3, known L facial droop (bell's), moving all extremities w purpose and against gravity Pertinent Results: ADMISSION LABS: ============== [MASKED] 05:35PM BLOOD WBC-2.2* RBC-2.77* Hgb-7.7* Hct-24.5* MCV-88 MCH-27.8 MCHC-31.4* RDW-19.8* RDWSD-56.0* Plt Ct-36* [MASKED] 05:35PM BLOOD Neuts-23* Bands-0 Lymphs-71* Monos-5 Eos-0 Baso-1 [MASKED] Myelos-0 AbsNeut-0.51* AbsLymp-1.56 AbsMono-0.11* AbsEos-0.00* AbsBaso-0.02 [MASKED] 10:00PM BLOOD [MASKED] PTT-28.2 [MASKED] [MASKED] 05:35PM BLOOD Glucose-124* UreaN-24* Creat-1.8* Na-140 K-5.0 Cl-95* HCO3-28 AnGap-17 [MASKED] 10:00PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.4 [MASKED] 05:35PM BLOOD ALT-16 AST-38 AlkPhos-114* TotBili-0.3 [MASKED] 05:35PM BLOOD Lipase-47 [MASKED] 09:48PM BLOOD Lactate-1.4 PERTINENT LABS/MICRO/IMAGING: ============================ [MASKED] 01:21PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 01:21PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD* [MASKED] 01:21PM URINE RBC-1 WBC-7* Bacteri-FEW* Yeast-NONE Epi-0 [MASKED] 9:27 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] 9:34 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] 9:54 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 9:30 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. Time Taken Not Noted Log-In Date/Time: [MASKED] 1:58 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] 1:21 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S Imaging: ---------- CXR [MASKED]: No acute intrathoracic process. DISCHARGE LABS: =============== [MASKED] 08:38AM BLOOD WBC-3.0* RBC-3.19* Hgb-9.0* Hct-29.5* MCV-93 MCH-28.2 MCHC-30.5* RDW-18.9* RDWSD-55.8* Plt Ct-21* [MASKED] 08:38AM BLOOD Neuts-20* Bands-0 Lymphs-75* Monos-3* Eos-0 Baso-0 Atyps-2* [MASKED] Myelos-0 NRBC-1* AbsNeut-0.60* AbsLymp-2.31 AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00* [MASKED] 08:38AM BLOOD Glucose-105* UreaN-26* Creat-1.6* Na-139 K-4.5 Cl-100 HCO3-25 AnGap-14 [MASKED] 08:38AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.3 Brief Hospital Course: PATIENT SUMMARY: ================ [MASKED] with PMH of metastatic breast CA currently on immunotherapy (Ibrance), left-sided Bell's Palsy, Bezold-Jarisch, who presents with nausea, vomiting, diarrhea and odynophagia with thrush, found to be pancytopenic and dehydrated at urgent care, sent to [MASKED] for further workup and management. Symptoms improved and counts recovering after stopping Ibrance. ACUTE ISSUES: ============= # Pancytopenia: Likely secondary to her immunotherapy (Ibrance) which she just started about 2.5 weeks prior to admission. Her Ibrance was stopped and her counts seem to be recovering. Can also consider bone marrow suppression from viral illness, though has been afebrile and symptoms have resolved with stopping of Ibrance. She received 1 unit of pRBCs on [MASKED] given Hgb 7.7 and symptomatic with fatigue, ED had spoken with heme/onc fellow at [MASKED] in [MASKED] where she receives her cancer care and recommended/agreed with transfusion. She responded appropriately to transfusion. # GI Upset: Patient presented with nausea, vomiting, diarrhea. Per her oncologist, likely side effect of new immunotherapy (Ibrance). Symptoms largely resolved since she stopped the Ibrance. Initially received IVF (total of 1250cc), now able to tolerate PO back to baseline. # Odynophagia: Patient with [MASKED] odynophagia on admission, likely worsened by vomiting over the past day. Noted to have extensive oral thrush by HCP Hope, was on Magic Mouthwash w/ Nystatin at home. Continued Magic Mouthwash and Nystatin rinses here and odynophagia improved and patient able to take PO back to baseline. If continues to have odynophagia that impairs PO intake, would consider further workup like EGD in the future to look for esophagitis [MASKED] vs. CMV vs. HSV). # Angular chelitis: Patient noted to have some angular chelitis on [MASKED], deferred starting on clotrimazole cream given patient allergy to neosporin, which is similar in makeup. Instead gave lip cream/moisturizer. Recommend barrier protection with vaseline and close monitoring. # Elevated temperature: Patient had intermittently elevated temperature to a max of 100.3 without hemodynamic instability or localizing symptoms. She was not neutropenic at that time. Infectious work-up was only remarkable for a mixed bacterial flora, consistent with skin contamination. Of note, one of the bacteria was pseudomonas (>100,000 CFU/mL). Remainder of infectious work up was negative. Given absence of neutropenia and localizing symptoms, and resolution of elevated temperature without intervention, decision was made not to treat for UTI. Patient was afebrile for 24h prior to discharge and feeling at her baseline. CHRONIC ISSUES: =============== # Metastatic breast cancer: Followed by Dr. [MASKED] at [MASKED] in [MASKED], [MASKED]. Started on Ibrance about 2.5 weeks prior to admission after discovery of further mets in liver (in addition to already known mets in bones and other sites). ED touched base with heme/onc fellow at [MASKED] re: stopping Ibrance. Patient originally had follow-up appointment on [MASKED], however will need to reschedule. # [MASKED]: Patient with history of severe vasovagal episodes where she becomes unresponsive with bradycardia and cyanosis. Has been seen by neurology for this. Awakens with pinching of cheek or sternal rubs. # Bell's palsy: Left-sided. Stable since childhood. # GOC: Spoke briefly with the patient at beside. She had papers from PA a few years back documenting DNR/DNI however patient states that if the clinicians believe that it was something reversible that caused her heart to stop or her to need intubation, then she wants to be resuscitated/intubated. Will require ongoing assessment of clinical status and continuing [MASKED] discussions. TRANSITIONAL ISSUES: =================== [] Pancytopenia: Continue to monitor CBC/diff off Ibrance. [] Odynophagia: Continue to monitor, if patient with increasing difficulty tolerating PO then would do further workup with EGD to look for [MASKED] esophagitis. [] Encourage and ensure adequate PO intake. [] Angular chelitis: monitor, ensure no signs concerning for HSV. [] In case of elevated temperature, check for neutropenia. Consider treatment for UTI (urine growing Pseudomonas (>100,000 CFU/mL) sensitive to cefepime, ceftazidime, ciprofloxacin, gentamicin, meropenem, Zosyn, tobramycin). [] Ensure patient has follow-up with [MASKED], as missed her appt [MASKED]. [] [MASKED]: Continue [MASKED] discussions, and consider filling out new MOLST (or PA equivalent). # Contact/HCP: [MASKED], best friend, [MASKED], [MASKED] # Code status: Full code (see #[MASKED] above) . . . . Time in care: greater than 30 minutes in discharge-related activities today. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carvedilol 6.25 mg PO BID 2. Fentanyl Patch 12 mcg/h TD Q72H 3. Sertraline 25 mg PO DAILY 4. Letrozole 2.5 mg PO DAILY 5. Movantik (naloxegol) 25 mg oral DAILY 6. Mirtazapine 15 mg PO QHS 7. Atorvastatin 10 mg PO QPM 8. Aspirin 81 mg PO DAILY 9. LORazepam 0.5 mg PO BID 10. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN BREAKTHROUGH PAIN Discharge Medications: 1. Maalox/Lidocaine 15 mL ORAL Q4H:PRN pain with swallowing RX *alum-mag hydroxide-simeth [Almacone] 200 mg-200 mg-20 mg/5 mL 15 ml by mouth every four hours as needed Disp #*355 Milliliter Milliliter Refills:*1 2. Nystatin Oral Suspension 5 mL PO TID:PRN thrush RX *nystatin 100,000 unit/mL 5 ml by mouth every eight hours as needed Disp #*480 Milliliter Milliliter Refills:*0 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Carvedilol 6.25 mg PO BID 6. Fentanyl Patch 12 mcg/h TD Q72H 7. Letrozole 2.5 mg PO DAILY 8. LORazepam 0.5 mg PO BID 9. Mirtazapine 15 mg PO QHS 10. Movantik (naloxegol) 25 mg oral DAILY 11. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN BREAKTHROUGH PAIN 12. Sertraline 25 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY: -Pancytopenia -Vomiting/Diarrhea -Odynophagia SECONDARY: -Metastatic breast cancer -[MASKED] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? You were admitted to the hospital because your blood counts were low and you were vomiting and having diarrhea. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -You received IV fluids because you were dehydrated from the vomiting and diarrhea. -You received a blood transfusion because your hemoglobin was low and you were feeling more tired than usual, and you responded appropriately to the transfusion. -Your blood counts continue to improve since stopping the Ibrance. -Your vomiting and diarrhea resolved since stopping the Ibrance and getting IV fluids, and your sore throat improved with the Magic Mouthwash and Nystatin rinses. As a result, you were able to eat and drink more. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? -Continue to take all medications as prescribed. -Please attend all [MASKED] clinic appointments. -Please follow-up with your oncologist at [MASKED] in [MASKED] to discuss further treatment options. We wish you all the best, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N179", "Z66" ]
[ "D61810: Antineoplastic chemotherapy induced pancytopenia", "B370: Candidal stomatitis", "C7951: Secondary malignant neoplasm of bone", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "N179: Acute kidney failure, unspecified", "R112: Nausea with vomiting, unspecified", "R197: Diarrhea, unspecified", "R1310: Dysphagia, unspecified", "Z66: Do not resuscitate", "G510: Bell's palsy", "E860: Dehydration", "Z853: Personal history of malignant neoplasm of breast", "G622: Polyneuropathy due to other toxic agents" ]
10,073,248
20,220,513
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: anasarca, proteinuria, hematuria Major Surgical or Invasive Procedure: None performed. History of Present Illness: HISTORY OF THE PRESENTING ILLNESS: Mr ___ is a ___ year old man with a history of prostate cancer s/p radical prostatectomy in ___ who presented to the ___ ED with leg swelling. Over the past several months, he has noticed gradual worsening bilateral lower extremity edema. Additionally, he started taking more ibuprofen, up to 8/day as he works ___. He was not entirely sure if the swelling started before or after he started taking more NSAIDs. Eventually, he was evaluated by his primary care doctor and referred to the ___ clinic at ___ and has an appointment scheduled in ___. He has been trying compressive stockings. Today his wife noticed that his arms were swollen so brought him to the ER. He also reported that he felt like his eyes were becoming puffy. He denies any fevers, chills, chest pain, dyspnea, abdominal pain, nausea, emesis, constipation, diarrhea, change in urination or dysuria. He has noticed an increase in blood pressure recently. His wife notes that he also had a "kidney scan" 2 months ago that was told was normal. Patient gets all of his care at a clinic in ___, so outside records are unavailable for comparison at time of admission. In the ED, initial vitals were: Temp: 97.8 HR: 79 BP: 193/105 Resp: 16 O2 Sat: 99% RA Exam notable for: Bilateral lower extremity pitting edema to upper thigh, bilateral hand edema; skin is absent of lesions, lacerations, rashes Labs notable for: -H/H 11.7/ 34.7 -UA: - Leuk, + Prot. and Glu, 7 RBC and 7 WBC -BUN/CR: ___ Gluc 124, and Alb 1.7, ALT, AST, AP WNL Imaging was notable for: -Prelim read of Renal U/S: Normal renal ultrasound Patient was given: -Labetalol 100mg PO Upon arrival to the floor, patient reports that he has no new symptoms since arriving to the ED. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative PAST MEDICAL HISTORY: -s/p radical prostatectomy -GERD -HLD MEDICATIONS: The Preadmission Medication list is accurate and complete 1. Atorvastatin 40 mg PO QPM 2. Cialis (tadalafil) 20 mg oral DAILY:PRN as needed 3. Omeprazole Dose is Unknown PO DAILY ALLERGIES: -NKDA Past Medical History: PAST MEDICAL HISTORY: -s/p radical prostatectomy -GERD -HLD Social History: ___ Family History: FAMILY HISTORY: No family history of kidney disease Physical Exam: EXAM ON ADMISSION =================== VITAL SIGNS: ___ Temp: 98.3 PO BP: 160/102 HR: 70 RR: 18 O2 sat: 99% O2 delivery: Ra GENERAL: Calm, sitting comfortably. Anasarca HEENT: Mild periorbital edema CARDIAC: RRR, no rub/murmurs/gallop LUNGS: CTAB, no wheezes/crackles/rhonchi ABDOMEN: Nondistended though edema noted. Soft, nontender EXTREMITIES: 2+ edema past hips NEUROLOGIC: CN2-12 intact EXAM ON DISCHARGE =================== VITAL SIGNS: Temp: 97.6 PO BP: 159/94 HR: 68 RR: 16 O2 sat: 98% O2 delivery: RA GENERAL: NAD. HEENT: No evidence of periorbital edema. CARDIAC: RRR. Normal S1 S2. No murmurs, rubs or gallops. LUNGS: CTAB. No wheezes/crackles/rhonchi. No increased work of breathing. ABDOMEN: Soft. Mild edema noted in lower quadrants. Mildly tender to palpation in RLQ. EXTREMITIES: Bilateral 2+ pitting edema to hips. Bilateral upper extremity edema. Unchanged from prior. NEUROLOGIC: CNII-XII intact. No focal neuro deficits. Pertinent Results: LABS ON ADMISSION ================= ___ 02:07PM BLOOD WBC-7.3 RBC-3.80* Hgb-11.4* Hct-34.7* MCV-91 MCH-30.0 MCHC-32.9 RDW-12.9 RDWSD-42.4 Plt ___ ___ 02:07PM BLOOD Glucose-124* UreaN-27* Creat-2.0* Na-143 K-4.2 Cl-112* HCO3-21* AnGap-10 ___ 02:07PM BLOOD Albumin-1.7* Cholest-254* ___ 02:07PM BLOOD Free T4-0.7* ___ 02:07PM BLOOD TSH-5.8* ___ 02:07PM BLOOD Triglyc-218* HDL-50 CHOL/HD-5.1 LDLcalc-160* ___ 01:15PM BLOOD %HbA1c-5.7 eAG-117 ___ 07:05AM BLOOD HCV Ab-NEG ___ 01:15PM BLOOD HIV Ab-NEG ___ 01:15PM BLOOD Trep Ab-NEG LABS ON DISCHARGE ================== ___ 06:45AM BLOOD WBC-6.8 RBC-3.71* Hgb-11.1* Hct-34.7* MCV-94 MCH-29.9 MCHC-32.0 RDW-12.9 RDWSD-44.1 Plt ___ ___ 06:45AM BLOOD Glucose-89 UreaN-24* Creat-2.2* Na-145 K-4.6 Cl-110* HCO3-22 AnGap-13 MICROBIOLOGY =============== ___ 2:23 pm URINE ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. IMAGING ============= RENAL U/S IMPRESSION: Normal renal ultrasound. RUE U/S IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. ___ 06:45AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.0 ___ 06:45AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.0 MRV W/O CONTRAST IMPRESSION: No evidence of cerebral venous thrombosis. Brief Hospital Course: Mr. ___ is a ___ year old with recent increase in NSAID use who presented with anasarca, found to have proteinuria, microscopic hematuria, and acute kidney injury concerning for nephrotic syndrome. Extensive work up for cause of possible nephrotic syndrome was negative (as detailed below) and the most likely etiology was thought to be secondary to NSAID use. Renal biopsy was deferred to the outpatient setting as the patient recently had taken aspirin. He was diuresed with IV Lasix and blood pressure was managed with diltiazem. TRANSITIONAL ISSUES ===================== [ ] Started furosemide 40mg PO BID for at least one month until he is able to follow up with a kidney doctor ___ pending). [ ] Discharged with a prescription of Zofran for relief of nausea/vomiting [ ] Started diltiazem 180 mg ER once per day for management of hypertension in the setting of nephrotic syndrome [ ] Please get repeat lab testing to monitor kidney function in the setting of diuresis by ___ or ___; script provided [ ] Recommend avoiding omeprazole as it can potentiate Acute Interstitial Nephritis, worsening kidney function. In place, he has been discharged on ranitidine twice per day. He can also take tums more frequently for symptoms of indigestion. [ ] Highly recommend avoiding any NSAID use to avoid further nephrotoxicity [ ] The patient will be scheduled for a renal biopsy at ___. He will be contacted by our nephrology department regarding the biopsy. [ ] The patient reported frequent headaches associated with emesis. We obtained an MRI to rule out cerebral venous thrombosis which was negative. We recommend that the patient follow up with a neurologist to further evaluate the cause of his headaches. [ ] The patient was found to have negative serology results for Hepatitis B which indicate that the patient is not currently immunized against the virus. We recommend that the patient follow up with a PCP to receive the appropriate vaccination. [ ] The patient was found to have an elevated TSH (5.8) and decreased T4 (0.7). The patient denied any symptoms consistent with hypothyroidism. We recommend that the patient follow up with a PCP to determine if the patient is a candidate for further evaluation and treatment after his renal issues are resolved. [ ] The patient had elevated blood pressure (SBPs 150-160s) and cholesterol (254), triglycerides (218) and LDL (160). We recommend that the patient follow up with a PCP to determine if he needs to adjust his current medication regimen once his renal issues are resolved. [ ] Consider GI referral for persistent N/V that seems to be related to GERD. Patient's omeprazole was stopped this hospitalization given risk of AIN, but was replaced with ranitidine. ACUTE/ACTIVE ISSUES ===================== # Anasarca # Nephrotic Syndrome # ___ Mr. ___ presented with hypertension, proteinuria, hypoalbuminemia, hypercholesterolemia, spot urine protein/Cr 11.2 and anasarca consistent with nephrotic syndrome. Creatinine on admission at 2.0, with baseline 1.6 on ___. Most likely NSAID-induced given patient reports recent increase to approximately 8 pills/day several times each week. Alternate etiologies of nephrotic syndrome, including infectious, malignancy, and inflammatory were explored and were largely negative. A1C 5.7%. SPEP/UPEP negative for ___, normal Kappa/Lambda ratio. Normal C3/C4. IgG decreased at 200. IgM, IgA normal. HIV negative. Hepatitis serology negative. Syphilis negative. He was diuresed with IV furosemide with a mild improvement in pitting edema and a slight decrease in weight. In addition, he was started on protein supplementation for his diet. Creatinine stable at 2.1 on discharge. # Headache Patient reported a several month history of headaches located above forehead which occur ___ and resolve with aspirin or ibuprofen and thus were the precipitating factor for the patient's excessive NSAID use. These were well controlled with PO Tylenol. However given the his hypercoagulable risk, an MRV was also performed to assess for cerebral vein thrombosis, which was negative. Consider outpatient neurology referral. # Hypertension Patient presented with BP 193/105. Hypertension diagnosed incidentally at dentist several months ago. Patient not actively monitoring BP or taking medication. Nephrotic syndrome likely contributor. Renal artery thrombosis unlikely given normal renal US in ED and patient does not endorse flank pain. Patient received labetalol 100mg PO in ED and was controlled with diltiazem 30mg q6h while on the medicine floor. # Hypercholesterolemia Patient presented with total cholesterol 254, LDL 160. Likely elevated secondary to nephrotic syndrome. Continued home atorvastatin 80mg PO DAILY. # GERD Home omeprazole held secondary to concern for AIN, although less likely. Started Ranitidine 75mg PO twice a day with tums as needed. CHRONIC ISSUES: =============== # Hypothyroidism: TSH elevated 5.8. Free T4 0.7. Currently asymptomatic. ===== # CODE: Full (presumed) # CONTACT: ___ (wife) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Cialis (tadalafil) 20 mg oral DAILY:PRN as needed 3. Omeprazole Dose is Unknown PO DAILY Discharge Medications: 1. Diltiazem Extended-Release 180 mg PO DAILY RX *diltiazem HCl 180 mg 1 capsule(s) by mouth once daily Disp #*30 Capsule Refills:*0 2. Furosemide 40 mg PO BID RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line RX *ondansetron 4 mg 1 tablet(s) by mouth up to three times a day Disp #*12 Tablet Refills:*0 4. Ranitidine 75 mg PO BID RX *ranitidine HCl 75 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Atorvastatin 40 mg PO QPM 6. HELD- Cialis (tadalafil) 20 mg oral DAILY:PRN as needed This medication was held. Do not restart Cialis until you speak with your primary care doctor due to risk of hypertension. 7.Outpatient Lab Work LABS: CHEM 7 and CBC ICD 9: 581.9 SEND TO: ___: ___ & ___ NEPHROLOGY ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES =================== Nephrotic Syndrome Hypertension SECONDARY DIAGNOSES ==================== GERD Hypercholesteremia Hyperthyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___! WHY WAS I IN THE HOSPITAL? You came to the hospital because you were having full body swelling and you were urinating protein and microscopic blood. WHAT HAPPENED TO ME IN THE HOSPITAL? After doing further urine and blood studies, we found that you may have a condition called nephrotic syndrome. This causes your kidneys to leak out protein and blood and can cause you to become fluid overloaded. You were given medicine to help get some of the fluid off of you. In addition, you underwent a scan of your head which showed that there were no blood clots in your brain. WHAT SHOULD I DO WHEN I GO HOME? When you go home, you should continue to take your new blood pressure medication and also to take the water pill. This will help to get some of the fluid off of your body. You will need to follow up with the kidney doctors to get a biopsy of your kidney. DO NOT TAKE ANY OF THE FOLLOWING MEDICATIONS: ASPIRIN, EXCEDRIN, MOTRIN, OR IBUPROFEN. If you are in pain, take only Tylenol. We wish you all the best! Sincerely, Your ___ team Followup Instructions: ___
[ "N049", "N179", "T39391A", "Y929", "G4440", "E7800", "K219", "E039", "E785", "Z8546", "I160" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: anasarca, proteinuria, hematuria Major Surgical or Invasive Procedure: None performed. History of Present Illness: HISTORY OF THE PRESENTING ILLNESS: Mr [MASKED] is a [MASKED] year old man with a history of prostate cancer s/p radical prostatectomy in [MASKED] who presented to the [MASKED] ED with leg swelling. Over the past several months, he has noticed gradual worsening bilateral lower extremity edema. Additionally, he started taking more ibuprofen, up to 8/day as he works [MASKED]. He was not entirely sure if the swelling started before or after he started taking more NSAIDs. Eventually, he was evaluated by his primary care doctor and referred to the [MASKED] clinic at [MASKED] and has an appointment scheduled in [MASKED]. He has been trying compressive stockings. Today his wife noticed that his arms were swollen so brought him to the ER. He also reported that he felt like his eyes were becoming puffy. He denies any fevers, chills, chest pain, dyspnea, abdominal pain, nausea, emesis, constipation, diarrhea, change in urination or dysuria. He has noticed an increase in blood pressure recently. His wife notes that he also had a "kidney scan" 2 months ago that was told was normal. Patient gets all of his care at a clinic in [MASKED], so outside records are unavailable for comparison at time of admission. In the ED, initial vitals were: Temp: 97.8 HR: 79 BP: 193/105 Resp: 16 O2 Sat: 99% RA Exam notable for: Bilateral lower extremity pitting edema to upper thigh, bilateral hand edema; skin is absent of lesions, lacerations, rashes Labs notable for: -H/H 11.7/ 34.7 -UA: - Leuk, + Prot. and Glu, 7 RBC and 7 WBC -BUN/CR: [MASKED] Gluc 124, and Alb 1.7, ALT, AST, AP WNL Imaging was notable for: -Prelim read of Renal U/S: Normal renal ultrasound Patient was given: -Labetalol 100mg PO Upon arrival to the floor, patient reports that he has no new symptoms since arriving to the ED. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative PAST MEDICAL HISTORY: -s/p radical prostatectomy -GERD -HLD MEDICATIONS: The Preadmission Medication list is accurate and complete 1. Atorvastatin 40 mg PO QPM 2. Cialis (tadalafil) 20 mg oral DAILY:PRN as needed 3. Omeprazole Dose is Unknown PO DAILY ALLERGIES: -NKDA Past Medical History: PAST MEDICAL HISTORY: -s/p radical prostatectomy -GERD -HLD Social History: [MASKED] Family History: FAMILY HISTORY: No family history of kidney disease Physical Exam: EXAM ON ADMISSION =================== VITAL SIGNS: [MASKED] Temp: 98.3 PO BP: 160/102 HR: 70 RR: 18 O2 sat: 99% O2 delivery: Ra GENERAL: Calm, sitting comfortably. Anasarca HEENT: Mild periorbital edema CARDIAC: RRR, no rub/murmurs/gallop LUNGS: CTAB, no wheezes/crackles/rhonchi ABDOMEN: Nondistended though edema noted. Soft, nontender EXTREMITIES: 2+ edema past hips NEUROLOGIC: CN2-12 intact EXAM ON DISCHARGE =================== VITAL SIGNS: Temp: 97.6 PO BP: 159/94 HR: 68 RR: 16 O2 sat: 98% O2 delivery: RA GENERAL: NAD. HEENT: No evidence of periorbital edema. CARDIAC: RRR. Normal S1 S2. No murmurs, rubs or gallops. LUNGS: CTAB. No wheezes/crackles/rhonchi. No increased work of breathing. ABDOMEN: Soft. Mild edema noted in lower quadrants. Mildly tender to palpation in RLQ. EXTREMITIES: Bilateral 2+ pitting edema to hips. Bilateral upper extremity edema. Unchanged from prior. NEUROLOGIC: CNII-XII intact. No focal neuro deficits. Pertinent Results: LABS ON ADMISSION ================= [MASKED] 02:07PM BLOOD WBC-7.3 RBC-3.80* Hgb-11.4* Hct-34.7* MCV-91 MCH-30.0 MCHC-32.9 RDW-12.9 RDWSD-42.4 Plt [MASKED] [MASKED] 02:07PM BLOOD Glucose-124* UreaN-27* Creat-2.0* Na-143 K-4.2 Cl-112* HCO3-21* AnGap-10 [MASKED] 02:07PM BLOOD Albumin-1.7* Cholest-254* [MASKED] 02:07PM BLOOD Free T4-0.7* [MASKED] 02:07PM BLOOD TSH-5.8* [MASKED] 02:07PM BLOOD Triglyc-218* HDL-50 CHOL/HD-5.1 LDLcalc-160* [MASKED] 01:15PM BLOOD %HbA1c-5.7 eAG-117 [MASKED] 07:05AM BLOOD HCV Ab-NEG [MASKED] 01:15PM BLOOD HIV Ab-NEG [MASKED] 01:15PM BLOOD Trep Ab-NEG LABS ON DISCHARGE ================== [MASKED] 06:45AM BLOOD WBC-6.8 RBC-3.71* Hgb-11.1* Hct-34.7* MCV-94 MCH-29.9 MCHC-32.0 RDW-12.9 RDWSD-44.1 Plt [MASKED] [MASKED] 06:45AM BLOOD Glucose-89 UreaN-24* Creat-2.2* Na-145 K-4.6 Cl-110* HCO3-22 AnGap-13 MICROBIOLOGY =============== [MASKED] 2:23 pm URINE [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. IMAGING ============= RENAL U/S IMPRESSION: Normal renal ultrasound. RUE U/S IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. [MASKED] 06:45AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.0 [MASKED] 06:45AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.0 MRV W/O CONTRAST IMPRESSION: No evidence of cerebral venous thrombosis. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old with recent increase in NSAID use who presented with anasarca, found to have proteinuria, microscopic hematuria, and acute kidney injury concerning for nephrotic syndrome. Extensive work up for cause of possible nephrotic syndrome was negative (as detailed below) and the most likely etiology was thought to be secondary to NSAID use. Renal biopsy was deferred to the outpatient setting as the patient recently had taken aspirin. He was diuresed with IV Lasix and blood pressure was managed with diltiazem. TRANSITIONAL ISSUES ===================== [ ] Started furosemide 40mg PO BID for at least one month until he is able to follow up with a kidney doctor [MASKED] pending). [ ] Discharged with a prescription of Zofran for relief of nausea/vomiting [ ] Started diltiazem 180 mg ER once per day for management of hypertension in the setting of nephrotic syndrome [ ] Please get repeat lab testing to monitor kidney function in the setting of diuresis by [MASKED] or [MASKED]; script provided [ ] Recommend avoiding omeprazole as it can potentiate Acute Interstitial Nephritis, worsening kidney function. In place, he has been discharged on ranitidine twice per day. He can also take tums more frequently for symptoms of indigestion. [ ] Highly recommend avoiding any NSAID use to avoid further nephrotoxicity [ ] The patient will be scheduled for a renal biopsy at [MASKED]. He will be contacted by our nephrology department regarding the biopsy. [ ] The patient reported frequent headaches associated with emesis. We obtained an MRI to rule out cerebral venous thrombosis which was negative. We recommend that the patient follow up with a neurologist to further evaluate the cause of his headaches. [ ] The patient was found to have negative serology results for Hepatitis B which indicate that the patient is not currently immunized against the virus. We recommend that the patient follow up with a PCP to receive the appropriate vaccination. [ ] The patient was found to have an elevated TSH (5.8) and decreased T4 (0.7). The patient denied any symptoms consistent with hypothyroidism. We recommend that the patient follow up with a PCP to determine if the patient is a candidate for further evaluation and treatment after his renal issues are resolved. [ ] The patient had elevated blood pressure (SBPs 150-160s) and cholesterol (254), triglycerides (218) and LDL (160). We recommend that the patient follow up with a PCP to determine if he needs to adjust his current medication regimen once his renal issues are resolved. [ ] Consider GI referral for persistent N/V that seems to be related to GERD. Patient's omeprazole was stopped this hospitalization given risk of AIN, but was replaced with ranitidine. ACUTE/ACTIVE ISSUES ===================== # Anasarca # Nephrotic Syndrome # [MASKED] Mr. [MASKED] presented with hypertension, proteinuria, hypoalbuminemia, hypercholesterolemia, spot urine protein/Cr 11.2 and anasarca consistent with nephrotic syndrome. Creatinine on admission at 2.0, with baseline 1.6 on [MASKED]. Most likely NSAID-induced given patient reports recent increase to approximately 8 pills/day several times each week. Alternate etiologies of nephrotic syndrome, including infectious, malignancy, and inflammatory were explored and were largely negative. A1C 5.7%. SPEP/UPEP negative for [MASKED], normal Kappa/Lambda ratio. Normal C3/C4. IgG decreased at 200. IgM, IgA normal. HIV negative. Hepatitis serology negative. Syphilis negative. He was diuresed with IV furosemide with a mild improvement in pitting edema and a slight decrease in weight. In addition, he was started on protein supplementation for his diet. Creatinine stable at 2.1 on discharge. # Headache Patient reported a several month history of headaches located above forehead which occur [MASKED] and resolve with aspirin or ibuprofen and thus were the precipitating factor for the patient's excessive NSAID use. These were well controlled with PO Tylenol. However given the his hypercoagulable risk, an MRV was also performed to assess for cerebral vein thrombosis, which was negative. Consider outpatient neurology referral. # Hypertension Patient presented with BP 193/105. Hypertension diagnosed incidentally at dentist several months ago. Patient not actively monitoring BP or taking medication. Nephrotic syndrome likely contributor. Renal artery thrombosis unlikely given normal renal US in ED and patient does not endorse flank pain. Patient received labetalol 100mg PO in ED and was controlled with diltiazem 30mg q6h while on the medicine floor. # Hypercholesterolemia Patient presented with total cholesterol 254, LDL 160. Likely elevated secondary to nephrotic syndrome. Continued home atorvastatin 80mg PO DAILY. # GERD Home omeprazole held secondary to concern for AIN, although less likely. Started Ranitidine 75mg PO twice a day with tums as needed. CHRONIC ISSUES: =============== # Hypothyroidism: TSH elevated 5.8. Free T4 0.7. Currently asymptomatic. ===== # CODE: Full (presumed) # CONTACT: [MASKED] (wife) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Cialis (tadalafil) 20 mg oral DAILY:PRN as needed 3. Omeprazole Dose is Unknown PO DAILY Discharge Medications: 1. Diltiazem Extended-Release 180 mg PO DAILY RX *diltiazem HCl 180 mg 1 capsule(s) by mouth once daily Disp #*30 Capsule Refills:*0 2. Furosemide 40 mg PO BID RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line RX *ondansetron 4 mg 1 tablet(s) by mouth up to three times a day Disp #*12 Tablet Refills:*0 4. Ranitidine 75 mg PO BID RX *ranitidine HCl 75 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Atorvastatin 40 mg PO QPM 6. HELD- Cialis (tadalafil) 20 mg oral DAILY:PRN as needed This medication was held. Do not restart Cialis until you speak with your primary care doctor due to risk of hypertension. 7.Outpatient Lab Work LABS: CHEM 7 and CBC ICD 9: 581.9 SEND TO: [MASKED]: [MASKED] & [MASKED] NEPHROLOGY [MASKED] Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES =================== Nephrotic Syndrome Hypertension SECONDARY DIAGNOSES ==================== GERD Hypercholesteremia Hyperthyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED]! WHY WAS I IN THE HOSPITAL? You came to the hospital because you were having full body swelling and you were urinating protein and microscopic blood. WHAT HAPPENED TO ME IN THE HOSPITAL? After doing further urine and blood studies, we found that you may have a condition called nephrotic syndrome. This causes your kidneys to leak out protein and blood and can cause you to become fluid overloaded. You were given medicine to help get some of the fluid off of you. In addition, you underwent a scan of your head which showed that there were no blood clots in your brain. WHAT SHOULD I DO WHEN I GO HOME? When you go home, you should continue to take your new blood pressure medication and also to take the water pill. This will help to get some of the fluid off of your body. You will need to follow up with the kidney doctors to get a biopsy of your kidney. DO NOT TAKE ANY OF THE FOLLOWING MEDICATIONS: ASPIRIN, EXCEDRIN, MOTRIN, OR IBUPROFEN. If you are in pain, take only Tylenol. We wish you all the best! Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "N179", "Y929", "K219", "E039", "E785" ]
[ "N049: Nephrotic syndrome with unspecified morphologic changes", "N179: Acute kidney failure, unspecified", "T39391A: Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], accidental (unintentional), initial encounter", "Y929: Unspecified place or not applicable", "G4440: Drug-induced headache, not elsewhere classified, not intractable", "E7800: Pure hypercholesterolemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "I160: Hypertensive urgency" ]
10,074,474
26,500,750
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: codeine / Sulfa (Sulfonamide Antibiotics) / naproxen Attending: ___. Chief Complaint: fatigue, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with PMH significant for indolent non-Hodgkin B cell lymphoma that transformed into DLBCL for which he is on R-CHOP as recently as 3 days ago, chronic left plantar ulcer, chronic hepatitis C, cirrhosis, anemia, polysubstance abuse, tobacco dependence, and latent TB presented from nursing home with AMS and fatigue. Per notes from nursing home, the patient had an acute change in mental status today and slept all day at his nursing home. He was satting 84-88% on RA, for which he was put on 2L and went up to 96%. In ED, patient was found to be hypotensive to as low as ___ and was started on levophed through his right chest port. He was also given cefepime 2g IV and vancomycin 1g IV, as well as 3L NS for sepsis. A CXR showed a right hilar opacity concerning for pneumonia. He was also given 2u pRBCs for a Hgb of 5.7. Notable labs from the ED include WBC 0.3 with absolute neutrophil count 0.10, hemoglobin 5.7, platelets 27, INR 1.5, AST 145 ALT 31. A non-contrast head CT was negative for acute intracranial process. Patient endorses pain in his left foot which he attributes to a chronic wound. Of note, a cast was placed last month by podiatry over the foot and is still in place. Cultures of the wound form ___ grew MRSA. Patient denies nausea, vomiting, chest pain, shortness of breath, cough, abdominal pain, diarrhea. Past Medical History: DLBCL on R-CHOP (last treatment ___ Ulcer of left foot with MRSA on culture from ___ Chronic hepatitis C Cirrhosis Anemia Polysubstance abuse Tobacco dependence disorder Social History: ___ Family History: N/A Physical Exam: ADMISSION PHYSICAL EXAM VITALS: T 98.7 HR 90 BP 115/76 RR 16 SpO2 97% on 3L GENERAL: Laying in bed. Appears restless. Somnolent but arousable. Drifting off to sleep intermittently. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Crackles in the right mid and lower lung fields. No wheezes or rhonci. 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, no edema. LLE in hard cast below the knee. SKIN: No lesions or rashes noted. Exam of LLE limited by cast. NEURO: CNII-XII grossly intact. Moving all 4 extremities. No focal deficits. Oriented to place, knew it was ___. DISCHARGE PHYSICAL EXAM: VITALS: 98.4 99/46 84 98% RA GENERAL: Sitting up in bed eating a cheeseburger, well appearing. Cachectic. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Decreased breath sounds bilaterally, no appreciable rales or 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, no edema. left foot in gauze dressing. NEURO: CNII-XII grossly intact. Moving all 4 extremities. No focal deficits. AOx3. Pertinent Results: Admission labs =============== ___ 05:40PM BLOOD WBC-0.3* RBC-2.03* Hgb-5.7* Hct-17.8* MCV-88 MCH-28.1 MCHC-32.0 RDW-15.2 RDWSD-48.7* Plt Ct-27* ___ 05:40PM BLOOD Neuts-19* Bands-13* ___ Monos-41* Eos-0 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-0.10* AbsLymp-0.08* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* ___ 05:40PM BLOOD ___ PTT-30.4 ___ ___ 06:40PM BLOOD ___ ___ 05:40PM BLOOD Glucose-136* UreaN-9 Creat-0.6 Na-135 K-3.6 Cl-100 HCO3-23 AnGap-12 ___ 05:40PM BLOOD ALT-31 AST-145* LD(LDH)-320* AlkPhos-113 TotBili-1.6* ___ 05:40PM BLOOD Lipase-8 ___ 05:40PM BLOOD Albumin-3.3* Calcium-8.1* Phos-1.6* Mg-1.8 UricAcd-1.6* ___ 05:40PM BLOOD Hapto-215* ___ 11:10PM BLOOD ___ pO2-41* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 ___ 06:27PM BLOOD Lactate-2.5* ___ 11:10PM BLOOD freeCa-1.02* ___ 08:10PM URINE Color-Yellow Appear-Clear Sp ___ ___ 08:10PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 08:10PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 Pertinent labs =============== ___ 10:48PM BLOOD WBC-1.0*# RBC-2.87*# Hgb-8.2*# Hct-24.9*# MCV-87 MCH-28.6 MCHC-32.9 RDW-14.6 RDWSD-46.0 Plt Ct-52*# ___ 05:45AM BLOOD WBC-0.4*# RBC-2.49* Hgb-7.2* Hct-21.4* MCV-86 MCH-28.9 MCHC-33.6 RDW-14.7 RDWSD-45.6 Plt Ct-36* ___ 10:48PM BLOOD Neuts-50 Bands-4 Lymphs-12* Monos-29* Eos-0 Baso-0 Atyps-4* Metas-1* Myelos-0 AbsNeut-0.54* AbsLymp-0.16* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00* ___ 05:45AM BLOOD Neuts-46 Bands-5 Lymphs-18* Monos-31* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.20* AbsLymp-0.07* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* ___ 05:45AM BLOOD Neuts-46 Bands-5 Lymphs-18* Monos-31* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.20* AbsLymp-0.07* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* ___ 10:48PM BLOOD ___ PTT-34.9 ___ ___ 05:45AM BLOOD ___ PTT-34.3 ___ ___ 10:48PM BLOOD Glucose-156* UreaN-9 Creat-0.5 Na-141 K-3.0* Cl-106 HCO3-19* AnGap-16 ___ 05:45AM BLOOD Glucose-123* UreaN-8 Creat-0.4* Na-137 K-3.1* Cl-105 HCO3-21* AnGap-11 ___ 02:30PM BLOOD Glucose-172* UreaN-8 Creat-0.4* Na-139 K-3.1* Cl-105 HCO3-22 AnGap-12 ___ 10:48PM BLOOD ALT-28 AST-117* LD(___)-321* AlkPhos-99 TotBili-2.8* ___ 05:45AM BLOOD DirBili-1.1* ___ 10:48PM BLOOD Albumin-2.9* Calcium-7.1* Phos-2.0* Mg-1.7 UricAcd-1.3* Discharge labs =============== ___ 06:01AM BLOOD Glucose-107* UreaN-8 Creat-0.5 Na-139 K-4.4 Cl-98 HCO3-23 AnGap-18* ___ 02:08AM BLOOD ALT-27 AST-69* AlkPhos-85 TotBili-0.9 ___ 06:01AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.7 Studies =============== CXR ___: Right suprahilar opacity. Given patient's port, question of underlying malignancy in this location. Alternatively, infection would be possible. Correlation with prior imaging sh would be of use. Followup will be necessary. CT head w/o contrast (___): IMPRESSION: 1. Moderately limited study due to patient motion. 2. No large intracranial hemorrhage, mass effect or acute large territorial infarction. FOOT AP,LAT & OBL LEFT (___): IMPRESSION: There is soft tissue swelling about the first MTP joint. There is soft tissue calcification lateral to the first metatarsal head. There is slight bony irregularity along the first metatarsal head medially and at the first proximal phalangeal base. This is equivocal for osteomyelitis.Comparison two old films if available would be helpful. Alternatively, MRI could also be performed. Calcaneal spur is seen. There are mild degenerative changes of the talonavicular joint and spurring of the talar head. CT CHEST W/O CONTRAST ___: Large, partially necrotic mass like lesion, anterior segment right upper lobe has features which suggest treated primary tumorand needs to be compared with pretreatment imaging to assess the real change. If this is not the primary lymphoma, or the lymphoma involuted substantially, then the lung lesion is a necrotizing pneumonia. Right hilar and right lower paratracheal lymph nodes are enlarged. Several other mediastinal lymph nodes are top-normal size. =============== Microbiology =============== Blood culture (___) (x3): no growth to date Urine culture (___): no growth MRSA screen (___): positive swab Respiratory viral panel (___): negative urine legionella antigen (___): negative Brief Hospital Course: Mr. ___ is a ___ year old man diffuse large B cell lymphoma (C2 of R-CHOP), chronic left plantar ulcer, HCV cirrhosis (unclear decompensation history), history of polysubstance abuse, and history of latent TB who presented from his nursing home with neutropenic fever in septic shock. #Neutropenic fever: #Septic shock: Patient presented with septic shock, requiring levophed after IV fluid resuscitation. He was started on vancomycin, cefepime and azithromycin as concern that source was pneumonia. A CT chest was done that showed a mass consistent with his known DLBCL, but there is concern that this may have led to development of pneumonia. Although his ANC improved to 960 prior to discharge and he remained afebrile, antibiotics were continued to complete an ___ecause there was concern that this was a true pneumonia. Vancomycin was included in the final antibiotic regimen as he had a positive MRSA screen. Last day of vancomycin and cefepime is ___, and last day for azithromycin is ___. #Diffuse large B cell lymphoma: The patient is currently under the care of Dr. ___ at ___. He is now on cycle 2 of R-CHOP, with cycle 2 day 1 on ___. Per Dr. ___ had a good response to the first round of chemotherapy. It is unclear if he received filgastrim or neuopogen at rehab; he did not receive any while inpatient. Home allopurinol was continued. #Pancytopenia: Likely secondary to chemotherapy, but there is likely a component of bone marrow suppression from cirrhosis and HCV (although do not know the extent of his disease). Patient received 2 units of pRBCs in ED with appropriate response. #Chronic left foot plantar ulcer: The patient came in with a hard cast on the left lower extremity. This cast was removed so that the ulcer could be exonerated as a source of infection. Podiatry evaluated his foot and deemed it to be chronic ulceration with no signs of infection at this time. Thus, surgical intervention not warranted. He will follow up with his outpatient podiatrist at ___. #Coagulopathy: INR 1.5 during hospitalization despite no anticoagulation. Likely secondary to chronic liver disease and malnutrition, with potential worsening for antibiotics. #Malnutrition: albumin 2.9 in setting of known malignancy. Nutrition was consulted who recommended regular diet without neutropenic restriction. They sent chocolate Ensure frappe TID, and encouraged intake Agree with MVI, x5 days thiamine/folate as well. #Hx of latent TB: Per outside notes, patient has been treated with INH and rifampin in the past. No signs of acute TB at this time. #HCV/HBV cirrhosis: Unknown decompensation history. Patient had no ascites or signs of hepatic encephalopathy. His variceal status is unknown to us as he does not receive care here, but had no signs of GI bleeding. Patient was continued on tenofovir for HBV. #HTN: Patient's home amlodipine was held in setting of hypotension at admission. His blood pressures were in the low 100s throughout the rest of his hospitalization, and therefore amlodipine was not continued at discharge. #Chronic pain: Patient continued on home regimen of oxycontin 20mg BID and oxycodone 10mg q4hrs for breakthrough pain. #Anxiety: Continued home alprazolam 1mg TID at home once initial encephalopathy resolved. TRANSITIONAL ISSUES: #Follow up final blood cultures #Antibiotic plan at discharge: vancomycin and cefepime last day = ___, last day azithromycin ___ #Repeat CBC with differential on ___, review with MD at rehab #Vancomycin trough to be drawn before morning dose on ___, please confirm with pharmacy safe to give dose after this #Followed by Dr. ___ at ___ for oncologic care #Cycle 2 Day 1 of R-CHOP = ___ #Patient should follow up with outpatient podiatrist in 3 weeks #Patient is weight bearing on left heel, should wear surgical boot #Amlodipine discontinued for SBPs in 100s #Recommend evaluation by nutrition at rehab for optimization of malnutrition and supplementation in the setting of cirrhosis and malignancy #If patient does not have a hepatologist, recommend referral for management of HCV cirrhosis #Code status: DNR/DNI #Contact: ___, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 5. protein 40 mL oral QID 6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 7. Ondansetron 4 mg PO Q8H:PRN Nausea, vomiting 8. ALPRAZolam 1 mg PO TID 9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH PAIN 10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever 11. Bisacodyl 10 mg PR QHS:PRN Constipation 12. Fleet Enema (Mineral Oil) ___AILY:PRN Constipation 13. Milk of Magnesia 30 mL PO DAILY:PRN Constipation Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 1 Day Last day ___ 2. CefePIME 2 g IV Q8H Last day ___. 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Nicotine Patch 14 mg TD DAILY 6. Thiamine 100 mg PO DAILY 7. Vancomycin 1250 mg IV Q 12H Last day ___. 8. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever 9. Allopurinol ___ mg PO DAILY 10. ALPRAZolam 1 mg PO TID 11. Bisacodyl 10 mg PR QHS:PRN Constipation 12. Docusate Sodium 100 mg PO DAILY 13. Fleet Enema (Mineral Oil) ___AILY:PRN Constipation 14. Milk of Magnesia 30 mL PO DAILY:PRN Constipation 15. Ondansetron 4 mg PO Q8H:PRN Nausea, vomiting 16. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH PAIN 17. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 18. protein 40 mL oral QID 19. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Septic shock Neutropenic fever SECONDARY DIAGNOSES Diffuse large B cell lymphoma HCV cirrhosis Chronic pain Chronic left plantar ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at the ___. You were admitted to the hospital because you had a fever and low white blood cell counts, and we were concerned you had an infection. You required admission to the intensive care unit. Your infection is most likely in your lungs, this is also called pneumonia. You were given IV antibiotics, and will continue to get these for 4 more days once you go back to rehab. You should continue to follow up with your oncologist, Dr. ___ your podiatry (foot doctor) team. If you have fevers, chills, problems breathing, or anything symptoms that concerns you, please seek medical attention. We wish you the best of luck in your health. Warmly, Your ___ Care Team Followup Instructions: ___
[ "A419", "R6521", "J9601", "E872", "D684", "J189", "E46", "D6959", "C8330", "L97429", "F17210", "K7460", "B182", "D701", "T451X5A", "R5081", "Y929", "D6481", "I10", "F419", "Z590", "Z66", "Z6821" ]
Allergies: codeine / Sulfa (Sulfonamide Antibiotics) / naproxen Chief Complaint: fatigue, altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old male with PMH significant for indolent non-Hodgkin B cell lymphoma that transformed into DLBCL for which he is on R-CHOP as recently as 3 days ago, chronic left plantar ulcer, chronic hepatitis C, cirrhosis, anemia, polysubstance abuse, tobacco dependence, and latent TB presented from nursing home with AMS and fatigue. Per notes from nursing home, the patient had an acute change in mental status today and slept all day at his nursing home. He was satting 84-88% on RA, for which he was put on 2L and went up to 96%. In ED, patient was found to be hypotensive to as low as [MASKED] and was started on levophed through his right chest port. He was also given cefepime 2g IV and vancomycin 1g IV, as well as 3L NS for sepsis. A CXR showed a right hilar opacity concerning for pneumonia. He was also given 2u pRBCs for a Hgb of 5.7. Notable labs from the ED include WBC 0.3 with absolute neutrophil count 0.10, hemoglobin 5.7, platelets 27, INR 1.5, AST 145 ALT 31. A non-contrast head CT was negative for acute intracranial process. Patient endorses pain in his left foot which he attributes to a chronic wound. Of note, a cast was placed last month by podiatry over the foot and is still in place. Cultures of the wound form [MASKED] grew MRSA. Patient denies nausea, vomiting, chest pain, shortness of breath, cough, abdominal pain, diarrhea. Past Medical History: DLBCL on R-CHOP (last treatment [MASKED] Ulcer of left foot with MRSA on culture from [MASKED] Chronic hepatitis C Cirrhosis Anemia Polysubstance abuse Tobacco dependence disorder Social History: [MASKED] Family History: N/A Physical Exam: ADMISSION PHYSICAL EXAM VITALS: T 98.7 HR 90 BP 115/76 RR 16 SpO2 97% on 3L GENERAL: Laying in bed. Appears restless. Somnolent but arousable. Drifting off to sleep intermittently. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Crackles in the right mid and lower lung fields. No wheezes or rhonci. 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, no edema. LLE in hard cast below the knee. SKIN: No lesions or rashes noted. Exam of LLE limited by cast. NEURO: CNII-XII grossly intact. Moving all 4 extremities. No focal deficits. Oriented to place, knew it was [MASKED]. DISCHARGE PHYSICAL EXAM: VITALS: 98.4 99/46 84 98% RA GENERAL: Sitting up in bed eating a cheeseburger, well appearing. Cachectic. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: Supple, JVP not elevated, no LAD LUNGS: Decreased breath sounds bilaterally, no appreciable rales or 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, no edema. left foot in gauze dressing. NEURO: CNII-XII grossly intact. Moving all 4 extremities. No focal deficits. AOx3. Pertinent Results: Admission labs =============== [MASKED] 05:40PM BLOOD WBC-0.3* RBC-2.03* Hgb-5.7* Hct-17.8* MCV-88 MCH-28.1 MCHC-32.0 RDW-15.2 RDWSD-48.7* Plt Ct-27* [MASKED] 05:40PM BLOOD Neuts-19* Bands-13* [MASKED] Monos-41* Eos-0 Baso-0 Atyps-1* [MASKED] Myelos-0 AbsNeut-0.10* AbsLymp-0.08* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* [MASKED] 05:40PM BLOOD [MASKED] PTT-30.4 [MASKED] [MASKED] 06:40PM BLOOD [MASKED] [MASKED] 05:40PM BLOOD Glucose-136* UreaN-9 Creat-0.6 Na-135 K-3.6 Cl-100 HCO3-23 AnGap-12 [MASKED] 05:40PM BLOOD ALT-31 AST-145* LD(LDH)-320* AlkPhos-113 TotBili-1.6* [MASKED] 05:40PM BLOOD Lipase-8 [MASKED] 05:40PM BLOOD Albumin-3.3* Calcium-8.1* Phos-1.6* Mg-1.8 UricAcd-1.6* [MASKED] 05:40PM BLOOD Hapto-215* [MASKED] 11:10PM BLOOD [MASKED] pO2-41* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 [MASKED] 06:27PM BLOOD Lactate-2.5* [MASKED] 11:10PM BLOOD freeCa-1.02* [MASKED] 08:10PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 08:10PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 08:10PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 Pertinent labs =============== [MASKED] 10:48PM BLOOD WBC-1.0*# RBC-2.87*# Hgb-8.2*# Hct-24.9*# MCV-87 MCH-28.6 MCHC-32.9 RDW-14.6 RDWSD-46.0 Plt Ct-52*# [MASKED] 05:45AM BLOOD WBC-0.4*# RBC-2.49* Hgb-7.2* Hct-21.4* MCV-86 MCH-28.9 MCHC-33.6 RDW-14.7 RDWSD-45.6 Plt Ct-36* [MASKED] 10:48PM BLOOD Neuts-50 Bands-4 Lymphs-12* Monos-29* Eos-0 Baso-0 Atyps-4* Metas-1* Myelos-0 AbsNeut-0.54* AbsLymp-0.16* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00* [MASKED] 05:45AM BLOOD Neuts-46 Bands-5 Lymphs-18* Monos-31* Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-0.20* AbsLymp-0.07* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* [MASKED] 05:45AM BLOOD Neuts-46 Bands-5 Lymphs-18* Monos-31* Eos-0 Baso-0 [MASKED] Myelos-0 AbsNeut-0.20* AbsLymp-0.07* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* [MASKED] 10:48PM BLOOD [MASKED] PTT-34.9 [MASKED] [MASKED] 05:45AM BLOOD [MASKED] PTT-34.3 [MASKED] [MASKED] 10:48PM BLOOD Glucose-156* UreaN-9 Creat-0.5 Na-141 K-3.0* Cl-106 HCO3-19* AnGap-16 [MASKED] 05:45AM BLOOD Glucose-123* UreaN-8 Creat-0.4* Na-137 K-3.1* Cl-105 HCO3-21* AnGap-11 [MASKED] 02:30PM BLOOD Glucose-172* UreaN-8 Creat-0.4* Na-139 K-3.1* Cl-105 HCO3-22 AnGap-12 [MASKED] 10:48PM BLOOD ALT-28 AST-117* LD([MASKED])-321* AlkPhos-99 TotBili-2.8* [MASKED] 05:45AM BLOOD DirBili-1.1* [MASKED] 10:48PM BLOOD Albumin-2.9* Calcium-7.1* Phos-2.0* Mg-1.7 UricAcd-1.3* Discharge labs =============== [MASKED] 06:01AM BLOOD Glucose-107* UreaN-8 Creat-0.5 Na-139 K-4.4 Cl-98 HCO3-23 AnGap-18* [MASKED] 02:08AM BLOOD ALT-27 AST-69* AlkPhos-85 TotBili-0.9 [MASKED] 06:01AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.7 Studies =============== CXR [MASKED]: Right suprahilar opacity. Given patient's port, question of underlying malignancy in this location. Alternatively, infection would be possible. Correlation with prior imaging sh would be of use. Followup will be necessary. CT head w/o contrast ([MASKED]): IMPRESSION: 1. Moderately limited study due to patient motion. 2. No large intracranial hemorrhage, mass effect or acute large territorial infarction. FOOT AP,LAT & OBL LEFT ([MASKED]): IMPRESSION: There is soft tissue swelling about the first MTP joint. There is soft tissue calcification lateral to the first metatarsal head. There is slight bony irregularity along the first metatarsal head medially and at the first proximal phalangeal base. This is equivocal for osteomyelitis.Comparison two old films if available would be helpful. Alternatively, MRI could also be performed. Calcaneal spur is seen. There are mild degenerative changes of the talonavicular joint and spurring of the talar head. CT CHEST W/O CONTRAST [MASKED]: Large, partially necrotic mass like lesion, anterior segment right upper lobe has features which suggest treated primary tumorand needs to be compared with pretreatment imaging to assess the real change. If this is not the primary lymphoma, or the lymphoma involuted substantially, then the lung lesion is a necrotizing pneumonia. Right hilar and right lower paratracheal lymph nodes are enlarged. Several other mediastinal lymph nodes are top-normal size. =============== Microbiology =============== Blood culture ([MASKED]) (x3): no growth to date Urine culture ([MASKED]): no growth MRSA screen ([MASKED]): positive swab Respiratory viral panel ([MASKED]): negative urine legionella antigen ([MASKED]): negative Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man diffuse large B cell lymphoma (C2 of R-CHOP), chronic left plantar ulcer, HCV cirrhosis (unclear decompensation history), history of polysubstance abuse, and history of latent TB who presented from his nursing home with neutropenic fever in septic shock. #Neutropenic fever: #Septic shock: Patient presented with septic shock, requiring levophed after IV fluid resuscitation. He was started on vancomycin, cefepime and azithromycin as concern that source was pneumonia. A CT chest was done that showed a mass consistent with his known DLBCL, but there is concern that this may have led to development of pneumonia. Although his ANC improved to 960 prior to discharge and he remained afebrile, antibiotics were continued to complete an ecause there was concern that this was a true pneumonia. Vancomycin was included in the final antibiotic regimen as he had a positive MRSA screen. Last day of vancomycin and cefepime is [MASKED], and last day for azithromycin is [MASKED]. #Diffuse large B cell lymphoma: The patient is currently under the care of Dr. [MASKED] at [MASKED]. He is now on cycle 2 of R-CHOP, with cycle 2 day 1 on [MASKED]. Per Dr. [MASKED] had a good response to the first round of chemotherapy. It is unclear if he received filgastrim or neuopogen at rehab; he did not receive any while inpatient. Home allopurinol was continued. #Pancytopenia: Likely secondary to chemotherapy, but there is likely a component of bone marrow suppression from cirrhosis and HCV (although do not know the extent of his disease). Patient received 2 units of pRBCs in ED with appropriate response. #Chronic left foot plantar ulcer: The patient came in with a hard cast on the left lower extremity. This cast was removed so that the ulcer could be exonerated as a source of infection. Podiatry evaluated his foot and deemed it to be chronic ulceration with no signs of infection at this time. Thus, surgical intervention not warranted. He will follow up with his outpatient podiatrist at [MASKED]. #Coagulopathy: INR 1.5 during hospitalization despite no anticoagulation. Likely secondary to chronic liver disease and malnutrition, with potential worsening for antibiotics. #Malnutrition: albumin 2.9 in setting of known malignancy. Nutrition was consulted who recommended regular diet without neutropenic restriction. They sent chocolate Ensure frappe TID, and encouraged intake Agree with MVI, x5 days thiamine/folate as well. #Hx of latent TB: Per outside notes, patient has been treated with INH and rifampin in the past. No signs of acute TB at this time. #HCV/HBV cirrhosis: Unknown decompensation history. Patient had no ascites or signs of hepatic encephalopathy. His variceal status is unknown to us as he does not receive care here, but had no signs of GI bleeding. Patient was continued on tenofovir for HBV. #HTN: Patient's home amlodipine was held in setting of hypotension at admission. His blood pressures were in the low 100s throughout the rest of his hospitalization, and therefore amlodipine was not continued at discharge. #Chronic pain: Patient continued on home regimen of oxycontin 20mg BID and oxycodone 10mg q4hrs for breakthrough pain. #Anxiety: Continued home alprazolam 1mg TID at home once initial encephalopathy resolved. TRANSITIONAL ISSUES: #Follow up final blood cultures #Antibiotic plan at discharge: vancomycin and cefepime last day = [MASKED], last day azithromycin [MASKED] #Repeat CBC with differential on [MASKED], review with MD at rehab #Vancomycin trough to be drawn before morning dose on [MASKED], please confirm with pharmacy safe to give dose after this #Followed by Dr. [MASKED] at [MASKED] for oncologic care #Cycle 2 Day 1 of R-CHOP = [MASKED] #Patient should follow up with outpatient podiatrist in 3 weeks #Patient is weight bearing on left heel, should wear surgical boot #Amlodipine discontinued for SBPs in 100s #Recommend evaluation by nutrition at rehab for optimization of malnutrition and supplementation in the setting of cirrhosis and malignancy #If patient does not have a hepatologist, recommend referral for management of HCV cirrhosis #Code status: DNR/DNI #Contact: [MASKED], [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol [MASKED] mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 5. protein 40 mL oral QID 6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 7. Ondansetron 4 mg PO Q8H:PRN Nausea, vomiting 8. ALPRAZolam 1 mg PO TID 9. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH PAIN 10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever 11. Bisacodyl 10 mg PR QHS:PRN Constipation 12. Fleet Enema (Mineral Oil) AILY:PRN Constipation 13. Milk of Magnesia 30 mL PO DAILY:PRN Constipation Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 1 Day Last day [MASKED] 2. CefePIME 2 g IV Q8H Last day [MASKED]. 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Nicotine Patch 14 mg TD DAILY 6. Thiamine 100 mg PO DAILY 7. Vancomycin 1250 mg IV Q 12H Last day [MASKED]. 8. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever 9. Allopurinol [MASKED] mg PO DAILY 10. ALPRAZolam 1 mg PO TID 11. Bisacodyl 10 mg PR QHS:PRN Constipation 12. Docusate Sodium 100 mg PO DAILY 13. Fleet Enema (Mineral Oil) AILY:PRN Constipation 14. Milk of Magnesia 30 mL PO DAILY:PRN Constipation 15. Ondansetron 4 mg PO Q8H:PRN Nausea, vomiting 16. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN BREAKTHROUGH PAIN 17. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H 18. protein 40 mL oral QID 19. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES Septic shock Neutropenic fever SECONDARY DIAGNOSES Diffuse large B cell lymphoma HCV cirrhosis Chronic pain Chronic left plantar ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you during your hospitalization at the [MASKED]. You were admitted to the hospital because you had a fever and low white blood cell counts, and we were concerned you had an infection. You required admission to the intensive care unit. Your infection is most likely in your lungs, this is also called pneumonia. You were given IV antibiotics, and will continue to get these for 4 more days once you go back to rehab. You should continue to follow up with your oncologist, Dr. [MASKED] your podiatry (foot doctor) team. If you have fevers, chills, problems breathing, or anything symptoms that concerns you, please seek medical attention. We wish you the best of luck in your health. Warmly, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "J9601", "E872", "F17210", "Y929", "I10", "F419", "Z66" ]
[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "J9601: Acute respiratory failure with hypoxia", "E872: Acidosis", "D684: Acquired coagulation factor deficiency", "J189: Pneumonia, unspecified organism", "E46: Unspecified protein-calorie malnutrition", "D6959: Other secondary thrombocytopenia", "C8330: Diffuse large B-cell lymphoma, unspecified site", "L97429: Non-pressure chronic ulcer of left heel and midfoot with unspecified severity", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K7460: Unspecified cirrhosis of liver", "B182: Chronic viral hepatitis C", "D701: Agranulocytosis secondary to cancer chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "R5081: Fever presenting with conditions classified elsewhere", "Y929: Unspecified place or not applicable", "D6481: Anemia due to antineoplastic chemotherapy", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "Z590: Homelessness", "Z66: Do not resuscitate", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]
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Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___ ___ Complaint: admission for cycle #4 of EPOCH Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old male with recent diagnosis of primary mediastinal lymphoma who is admitted for planned fourth cycle of DA-EPOCH-R. He originally presented for 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH and is now presenting for cycle 4 of regimen. ROS: Overall, he reports feeling well. Denies recent nausea, vomiting, diarrhea, fever, chills or rigors. No sick contacts. No urinary complaints, rashes, lesions. Has been keeping active and working out. Denies neuropathy, chest pain, dyspnea cough, tremors or lower extremity weakness. All other ROS negative. Past Medical History: PAST ONCOLOGIC HISTORY: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 ___ -Da-EPOCH C2 at level 2 ___ -Dose #1 Rituxan ___ -Da-EPOCH C3 at level 3 ___ -Dose#2 Rituxan ___ -DA-EPOCH C4 at level 4 ___ -Dose#3 Rituxan ___ PAST MEDICAL HISTORY: -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in ___ -GERD -Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.1 HR 76 BP 138/70 RR 18 SAT 96% O2 on RA GEN: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; non-distended; soft, non-tender without rebound or guarding; no hepatomegaly/splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes RECTAL: External exam normal LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses ACCESS: POC on R chest DISCHARGE PHYSICAL EXAM: VS: TC 97.9 ___ 18 98-99%RA WT: 83.55 KG ADMIT WT: 81 KG GEN: Pleasant, sitting in bed comfortably EYES: Anicteric sclerea, no conjunctival injection ENT: Oropharynx clear without lesion, MMM CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: non-distended; soft, non-tender in all quadrants without rebound or guarding MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema NEURO: Alert, oriented, normal gait SKIN: No significant rashes ACCESS: POC on R chest deaccessed prior to discharge Pertinent Results: ADMISSION LABS: ___ 08:20AM PLT SMR-NORMAL PLT COUNT-322# ___ 08:20AM HYPOCHROM-1+* ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* MICROCYT-OCCASIONAL POLYCHROM-1+* OVALOCYT-1+* SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL ELLIPTOCY-1+* ___ 08:20AM NEUTS-69 BANDS-2 LYMPHS-5* MONOS-18* EOS-1 BASOS-0 ATYPS-1* METAS-3* MYELOS-1* AbsNeut-3.34 AbsLymp-0.28* AbsMono-0.85* AbsEos-0.05 AbsBaso-0.00* ___ 08:20AM WBC-4.7# RBC-3.96* HGB-11.5* HCT-34.0* MCV-86 MCH-29.0 MCHC-33.8 RDW-20.3* RDWSD-60.9* ___ 08:20AM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-3.4 MAGNESIUM-1.9 URIC ACID-6.7 ___ 08:20AM ALT(SGPT)-30 AST(SGOT)-26 LD(LDH)-262* ALK PHOS-86 TOT BILI-0.2 ___ 08:20AM estGFR-Using this ___ 08:20AM UREA N-14 CREAT-1.2 SODIUM-138 POTASSIUM-4.3 ___ 08:20AM GLUCOSE-120* ___ 12:00AM PLT SMR-NORMAL PLT COUNT-308 ___ 12:00AM HYPOCHROM-1+* ANISOCYT-1+* POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-1+* POLYCHROM-1+* SPHEROCYT-2+* OVALOCYT-1+* SCHISTOCY-OCCASIONAL TEARDROP-1+* ___ 12:00AM NEUTS-93* BANDS-1 LYMPHS-3* MONOS-0 EOS-0 BASOS-0 ___ METAS-1* MYELOS-2* AbsNeut-6.49* AbsLymp-0.21* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM WBC-6.9 RBC-3.61* HGB-10.6* HCT-31.1* MCV-86 MCH-29.4 MCHC-34.1 RDW-20.2* RDWSD-61.0* ___ 12:00AM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-2.1* MAGNESIUM-2.0 URIC ACID-5.6 ___ 12:00AM ALT(SGPT)-34 AST(SGOT)-29 LD(LDH)-280* ALK PHOS-78 TOT BILI-0.2 ___ 12:00AM GLUCOSE-161* UREA N-12 CREAT-1.1 SODIUM-143 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18* DISCHARGE LABS: ___ 12:00AM BLOOD WBC-3.2* RBC-3.59* Hgb-10.5* Hct-31.0* MCV-86 MCH-29.2 MCHC-33.9 RDW-20.1* RDWSD-61.5* Plt ___ ___ 12:00AM BLOOD Neuts-90.9* Lymphs-6.0* Monos-2.2* Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.87 AbsLymp-0.19* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Plt ___ ___ 12:00AM BLOOD Glucose-142* UreaN-18 Creat-0.9 Na-141 K-3.8 Cl-100 HCO3-24 AnGap-17* ___ 12:00AM BLOOD ALT-24 AST-16 LD(LDH)-172 AlkPhos-61 TotBili-0.6 ___ 12:00AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.8 Mg-2.___SSESSMENT AND PLAN: ___ year old male with recent diagnosis of primary mediastinal lymphoma who is admitted for planned fourth cycle of DA-EPOCH-R. #Primary mediastinal lymphoma: now S/P C4 DA-EPOCH-R at dose level 4 without acute complications. Cardiac MR after previous discharge showed no invasion into heart or large vessels. Repeat PET ___ showed a dramatic decrease in size of his lymphadenopathy. There is some mild residual PET avidity surrounding the residual radiographic abnormality. He also has some right facial muscle uptake is likely related to movement during procedure. He has had very significant response to his first 2 cycles of chemotherapy. He will have a follow up PET on ___ -Continue acyclovir and bactrim prophylaxis -Not on allopurinol, TLS WNL -Neupogen following treatment on ___ -Outpatient Appointment on ___ #Weight increase: mild, up 5lbs without fluid overload symptoms so held diuresis but decreased IVF rate with improvement, expect resolution outpatient #Chronic pancreatitis #Pancreatic divisum #Pancreatic pseudocyst: Not currently symptomatic. Monitor for symptoms -Continue home creon, colesevelam, and nortriptyline #GERD: Not on meds at home. Ranitidine in-house #Mucositis: No active exacerbations, continue MMW as needed #Constipation: Colace/Senna/Miralax BID per home regimen ACCESS: POC placed ___ CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: ___ DISPO: Discharged ___. RTC ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Docusate Sodium 100 mg PO BID 4. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 5. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 6. Nortriptyline 10 mg PO QHS 7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 9. Polyethylene Glycol 17 g PO DAILY constipation 10. Senna 8.6 mg PO BID 11. Creon ___ CAP PO QID:PRN snacks 12. Creon 12 2 CAP PO TID W/MEALS 13. Filgrastim 480 mcg SC Q24H 14. Levofloxacin 500 mg PO Q24H 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Ondansetron 8 mg PO Q8H:PRN nausea 17. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon ___ CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. Filgrastim-sndz 480 mcg SC Q24H You will start this injection on ___ 7. Levofloxacin 500 mg PO Q24H ___. ___ WILL LET YOU KNOW WHEN TO RESTART THIS MEDICATION 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Senna 8.6 mg PO BID 17. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary mediastinal lymphoma 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 receive your fourth cycle of chemotherapy for your lymphoma. You tolerated this very well and will be discharged home today. You gained fluid weight due to the chemotherapy, which improved with decreasing your IV fluids. You will inject neupogen daily starting ___. You will continue this daily injection until you are told to stop. You will continue to take medications to prevent infection: acyclovir and bactrim. Your nausea medications are as follows: 1 zofran 2 ativan Please continue to take colace and senna for the next two weeks as ordered. If your stools become frequent, you may decrease the senna to once daily. If you become constipated despite the colace/senna, please purchase miralax over the counter and use this daily. If you remain constipated despite these medications, please call us. Please drink enough fluids so that your urine is close to clear (this is usually between 48-64 oz of fluid per day). You will follow up in the outpatient clinic as stated below. Please do not hesitate to call in the meantime with any questions or concerns. Followup Instructions: ___
[ "Z5111", "C8529", "K863", "K861", "Q453", "K219", "K1230", "K5900" ]
Allergies: Penicillins [MASKED] Complaint: admission for cycle #4 of EPOCH Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] year old male with recent diagnosis of primary mediastinal lymphoma who is admitted for planned fourth cycle of DA-EPOCH-R. He originally presented for 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH and is now presenting for cycle 4 of regimen. ROS: Overall, he reports feeling well. Denies recent nausea, vomiting, diarrhea, fever, chills or rigors. No sick contacts. No urinary complaints, rashes, lesions. Has been keeping active and working out. Denies neuropathy, chest pain, dyspnea cough, tremors or lower extremity weakness. All other ROS negative. Past Medical History: PAST ONCOLOGIC HISTORY: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 [MASKED] -Da-EPOCH C2 at level 2 [MASKED] -Dose #1 Rituxan [MASKED] -Da-EPOCH C3 at level 3 [MASKED] -Dose#2 Rituxan [MASKED] -DA-EPOCH C4 at level 4 [MASKED] -Dose#3 Rituxan [MASKED] PAST MEDICAL HISTORY: -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] -GERD -Nephrolithiasis Social History: [MASKED] Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.1 HR 76 BP 138/70 RR 18 SAT 96% O2 on RA GEN: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; non-distended; soft, non-tender without rebound or guarding; no hepatomegaly/splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes RECTAL: External exam normal LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses ACCESS: POC on R chest DISCHARGE PHYSICAL EXAM: VS: TC 97.9 [MASKED] 18 98-99%RA WT: 83.55 KG ADMIT WT: 81 KG GEN: Pleasant, sitting in bed comfortably EYES: Anicteric sclerea, no conjunctival injection ENT: Oropharynx clear without lesion, MMM CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: non-distended; soft, non-tender in all quadrants without rebound or guarding MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema NEURO: Alert, oriented, normal gait SKIN: No significant rashes ACCESS: POC on R chest deaccessed prior to discharge Pertinent Results: ADMISSION LABS: [MASKED] 08:20AM PLT SMR-NORMAL PLT COUNT-322# [MASKED] 08:20AM HYPOCHROM-1+* ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* MICROCYT-OCCASIONAL POLYCHROM-1+* OVALOCYT-1+* SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL ELLIPTOCY-1+* [MASKED] 08:20AM NEUTS-69 BANDS-2 LYMPHS-5* MONOS-18* EOS-1 BASOS-0 ATYPS-1* METAS-3* MYELOS-1* AbsNeut-3.34 AbsLymp-0.28* AbsMono-0.85* AbsEos-0.05 AbsBaso-0.00* [MASKED] 08:20AM WBC-4.7# RBC-3.96* HGB-11.5* HCT-34.0* MCV-86 MCH-29.0 MCHC-33.8 RDW-20.3* RDWSD-60.9* [MASKED] 08:20AM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-3.4 MAGNESIUM-1.9 URIC ACID-6.7 [MASKED] 08:20AM ALT(SGPT)-30 AST(SGOT)-26 LD(LDH)-262* ALK PHOS-86 TOT BILI-0.2 [MASKED] 08:20AM estGFR-Using this [MASKED] 08:20AM UREA N-14 CREAT-1.2 SODIUM-138 POTASSIUM-4.3 [MASKED] 08:20AM GLUCOSE-120* [MASKED] 12:00AM PLT SMR-NORMAL PLT COUNT-308 [MASKED] 12:00AM HYPOCHROM-1+* ANISOCYT-1+* POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-1+* POLYCHROM-1+* SPHEROCYT-2+* OVALOCYT-1+* SCHISTOCY-OCCASIONAL TEARDROP-1+* [MASKED] 12:00AM NEUTS-93* BANDS-1 LYMPHS-3* MONOS-0 EOS-0 BASOS-0 [MASKED] METAS-1* MYELOS-2* AbsNeut-6.49* AbsLymp-0.21* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM WBC-6.9 RBC-3.61* HGB-10.6* HCT-31.1* MCV-86 MCH-29.4 MCHC-34.1 RDW-20.2* RDWSD-61.0* [MASKED] 12:00AM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-2.1* MAGNESIUM-2.0 URIC ACID-5.6 [MASKED] 12:00AM ALT(SGPT)-34 AST(SGOT)-29 LD(LDH)-280* ALK PHOS-78 TOT BILI-0.2 [MASKED] 12:00AM GLUCOSE-161* UREA N-12 CREAT-1.1 SODIUM-143 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18* DISCHARGE LABS: [MASKED] 12:00AM BLOOD WBC-3.2* RBC-3.59* Hgb-10.5* Hct-31.0* MCV-86 MCH-29.2 MCHC-33.9 RDW-20.1* RDWSD-61.5* Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-90.9* Lymphs-6.0* Monos-2.2* Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-2.87 AbsLymp-0.19* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Plt [MASKED] [MASKED] 12:00AM BLOOD Glucose-142* UreaN-18 Creat-0.9 Na-141 K-3.8 Cl-100 HCO3-24 AnGap-17* [MASKED] 12:00AM BLOOD ALT-24 AST-16 LD(LDH)-172 AlkPhos-61 TotBili-0.6 [MASKED] 12:00AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.8 Mg-2. SSESSMENT AND PLAN: [MASKED] year old male with recent diagnosis of primary mediastinal lymphoma who is admitted for planned fourth cycle of DA-EPOCH-R. #Primary mediastinal lymphoma: now S/P C4 DA-EPOCH-R at dose level 4 without acute complications. Cardiac MR after previous discharge showed no invasion into heart or large vessels. Repeat PET [MASKED] showed a dramatic decrease in size of his lymphadenopathy. There is some mild residual PET avidity surrounding the residual radiographic abnormality. He also has some right facial muscle uptake is likely related to movement during procedure. He has had very significant response to his first 2 cycles of chemotherapy. He will have a follow up PET on [MASKED] -Continue acyclovir and bactrim prophylaxis -Not on allopurinol, TLS WNL -Neupogen following treatment on [MASKED] -Outpatient Appointment on [MASKED] #Weight increase: mild, up 5lbs without fluid overload symptoms so held diuresis but decreased IVF rate with improvement, expect resolution outpatient #Chronic pancreatitis #Pancreatic divisum #Pancreatic pseudocyst: Not currently symptomatic. Monitor for symptoms -Continue home creon, colesevelam, and nortriptyline #GERD: Not on meds at home. Ranitidine in-house #Mucositis: No active exacerbations, continue MMW as needed #Constipation: Colace/Senna/Miralax BID per home regimen ACCESS: POC placed [MASKED] CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: [MASKED] DISPO: Discharged [MASKED]. RTC [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Docusate Sodium 100 mg PO BID 4. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 5. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 6. Nortriptyline 10 mg PO QHS 7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 9. Polyethylene Glycol 17 g PO DAILY constipation 10. Senna 8.6 mg PO BID 11. Creon [MASKED] CAP PO QID:PRN snacks 12. Creon 12 2 CAP PO TID W/MEALS 13. Filgrastim 480 mcg SC Q24H 14. Levofloxacin 500 mg PO Q24H 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Ondansetron 8 mg PO Q8H:PRN nausea 17. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon [MASKED] CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. Filgrastim-sndz 480 mcg SC Q24H You will start this injection on [MASKED] 7. Levofloxacin 500 mg PO Q24H [MASKED]. [MASKED] WILL LET YOU KNOW WHEN TO RESTART THIS MEDICATION 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Senna 8.6 mg PO BID 17. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary mediastinal lymphoma 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 receive your fourth cycle of chemotherapy for your lymphoma. You tolerated this very well and will be discharged home today. You gained fluid weight due to the chemotherapy, which improved with decreasing your IV fluids. You will inject neupogen daily starting [MASKED]. You will continue this daily injection until you are told to stop. You will continue to take medications to prevent infection: acyclovir and bactrim. Your nausea medications are as follows: 1 zofran 2 ativan Please continue to take colace and senna for the next two weeks as ordered. If your stools become frequent, you may decrease the senna to once daily. If you become constipated despite the colace/senna, please purchase miralax over the counter and use this daily. If you remain constipated despite these medications, please call us. Please drink enough fluids so that your urine is close to clear (this is usually between 48-64 oz of fluid per day). You will follow up in the outpatient clinic as stated below. Please do not hesitate to call in the meantime with any questions or concerns. Followup Instructions: [MASKED]
[]
[ "K219", "K5900" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8529: Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites", "K863: Pseudocyst of pancreas", "K861: Other chronic pancreatitis", "Q453: Other congenital malformations of pancreas and pancreatic duct", "K219: Gastro-esophageal reflux disease without esophagitis", "K1230: Oral mucositis (ulcerative), unspecified", "K5900: Constipation, unspecified" ]
10,074,556
21,972,840
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Abdominal pain, nausea, chills Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a ___ hx DLBCL s/p 5 cycles EPOCH (C5D12) presented to clinic for routine follow-up and reported there that he is feeling unwell. Since midnight he had intermittent nausea, abdominal pain described as "gas pain" located in lower abdomen, intermittent chills and "hot and cold feeling." He does note that his stools were looser than usual on the weekend, he backed off on bowel regimen (has not taken since ___ AM), now feels more constipated, stool much harder. He was treated in the office with vanc/cefe/flagyl and brought to ___ for monitoring and work up. On arrival to the floor patient reports symptoms have improved significantly. Nausea has decreased significantly, abdominal pain likewise is somewhat improved. Denies HA, vision changes, CP, SOB, cough, new sputum, BRBPR, melena, dysuria. Past Medical History: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 ___ -Da-EPOCH C2 at level 2 ___ -Dose #1 Rituxan ___ -Da-EPOCH C3 at level 3 ___ -Dose#2 Rituxan ___ -DA-EPOCH C4 at level 4 ___ -Dose#3 Rituxan ___ -DA-EPOCH C5 at level 4 ___ -Dose #4 Rituxan ___ PAST MEDICAL HISTORY: -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in ___ -GERD -Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: ================== Vitals: 98.0, 129/76, 99, 18, 100% RA GEN: Pleasant and NAD HEENT: EOMI, PERRLA, OP clear without lesions, CARDIOVASCULAR: RRR, nl s1/s2, no m/r/g, 2+ pulses RESPIRATORY: CTA b/l, no w/r/c GI: S/ND, mild/minimal tenderness of lower abdomen, BS normoactive, no masses palpated MUSKULOSKELATAL: WWP, non-edematous, normal bulk & tone NEURO: AOx3, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes or lesions LYMPHATIC: No cervical, supraclavicular, submandibular LAD. SKIN: No significant ecchymosis, rashes ACCESS: POC on R chest without swelling, erythema or pain DISCHARGE PHYSICAL EXAM: ================== Vitals: 98.8 PO BP 124 / 70 HR 89 RR 18 O2 100 RA GEN: Pleasant and NAD, sitting up in bed HEENT: EOMI, PERRLA, OP clear without lesions CARDIOVASCULAR: RRR, nl s1/s2, no m/r/g RESPIRATORY: CTA b/l, no w/r/c GI: S/ND, mild/minimal tenderness of lower abdomen, BS normoactive MUSKULOSKELATAL: WWP, non-edematous, normal bulk & tone NEURO: AAOx3 SKIN: No significant rashes or lesions SKIN: No significant ecchymosis, rashes ACCESS: POC on R chest without swelling, erythema or pain Pertinent Results: ADMISSION LABS: =============== ___ 08:30AM BLOOD WBC-0.5*# RBC-3.65* Hgb-11.1* Hct-32.0* MCV-88 MCH-30.4 MCHC-34.7 RDW-15.6* RDWSD-50.1* Plt Ct-52*# ___ 08:30AM BLOOD Neuts-57 Bands-0 ___ Monos-4* Eos-0 Baso-4* ___ Myelos-0 AbsNeut-0.29* AbsLymp-0.18* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.02 ___ 08:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+* Schisto-1+* Tear Dr-1+* ___ 08:30AM BLOOD Plt Smr-VERY LOW* Plt Ct-52*# ___ 08:30AM BLOOD UreaN-18 Creat-1.0 Na-138 K-4.8 ___ 08:30AM BLOOD ALT-29 AST-16 LD(LDH)-128 AlkPhos-96 Amylase-50 TotBili-0.7 ___ 08:30AM BLOOD Calcium-9.8 Phos-4.1 Mg-2.1 DISCHARGE LABS: =========== ___ 04:43AM BLOOD WBC-1.8*# RBC-2.49* Hgb-7.7* Hct-22.0* MCV-88 MCH-30.9 MCHC-35.0 RDW-15.0 RDWSD-48.5* Plt Ct-26* ___ 04:43AM BLOOD Neuts-49 Bands-4 Lymphs-17* Monos-28* Eos-1 Baso-1 ___ Myelos-0 AbsNeut-0.95* AbsLymp-0.31* AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02 ___ 04:43AM BLOOD Plt Smr-VERY LOW* Plt Ct-26* ___ 04:43AM BLOOD Glucose-97 UreaN-14 Creat-1.1 Na-141 K-4.3 Cl-103 HCO3-24 AnGap-14 ___ 04:43AM BLOOD ALT-18 AST-13 LD(LDH)-114 AlkPhos-67 TotBili-0.3 ___ 04:43AM BLOOD Albumin-3.8 Calcium-9.1 Phos-2.7 Mg-2.0 MICROBIOLOGY: ========== ___ Urine culture negative ___ Blood culture pending IMAGING: ======= ___ CT abd/pelvis 1. No evidence of an acute intra-abdominal or intrapelvic process corresponding to patient's symptoms. 2. Previously described mediastinal and pericardial masses appear decreased in size compared to prior exam performed ___. CXR ___ Vague ill-defined opacity within the medial aspect of the right lower lobe, could be secondary to an infectious process. Mild prominence of the mediastinum, consistent with patient's known lymphoma, better evaluated on the PET-CT from ___. ECHO ___ The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 60%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: BRIEF HOSPITAL COURSE: =============================== ___ man with h/o pancreas divisum c/b pancreatitis w/necrosis s/p necrosectomy & DLBCL s/p 5 cycles EPOCH who presented with 1 day of malaise, abdominal pain, nausea, and chills. He was started on Vanc/Cefepime/Flagyl, and was pan-cultured. He underwent CXR, which showed a possible pneumonia. He had CT A/P, which was negative for an acute process. He never spiked a fever. He was continued on home Neupogen, and his counts increased to >900. Vanc/Flagyl were stopped on ___, and Cefepime was changed to Cefpodoxime on ___. Cultures were negative. His symptoms resolved upon arrival to the oncology floor, and he felt well at time of discharge. Given the findings on CXR, we will treat for a 7-day course of pneumonia. Of note, we also completed a TTE that had been scheduled as an outpatient, and this had a normal EF with less ectopy compared to prior. TRANSITIONAL ISSUES: =============================== - Patient was continued on Neupogen at discharge. Please continue to monitor his neutrophil counts. ANC>900 at discharge - Patient was discharged on Cefpodoxime 200mg BID for pneumonia. He should complete a 7-day course. His ppx levoquin was held. Bactrim and acyclovir continued. He was counseled on warning signs - Patient has scheduled follow-up with Dr. ___ on ___ # EMERGENCY CONTACT: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon ___ CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 7. Nortriptyline 10 mg PO QHS 8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 9. Polyethylene Glycol 17 g PO DAILY constipation 10. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting 11. Senna 8.6 mg PO BID 12. Sulfameth/Trimethoprim SS 1 TAB PO QHS 13. Filgrastim-sndz 480 mcg SC Q24H 14. Levofloxacin 500 mg PO Q24H 15. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Ondansetron 8 mg PO Q8H:PRN nausea 18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 7 Days RX *cefpodoxime 200 mg 1 tablet(s) by mouth q12 hours Disp #*14 Tablet Refills:*0 2. Acyclovir 400 mg PO Q8H 3. colesevelam 625 mg oral BID 4. Creon ___ CAP PO QID:PRN snacks 5. Creon 12 2 CAP PO TID W/MEALS 6. Docusate Sodium 100 mg PO BID 7. Filgrastim-sndz 480 mcg SC Q24H 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting 17. Senna 8.6 mg PO BID 18. Sulfameth/Trimethoprim SS 1 TAB PO QHS 19. HELD- Levofloxacin 500 mg PO Q24H This medication was held. Do not restart Levofloxacin until you are done with your Cefpodoxime Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: DLBCL Pneumonia Secondary Diagnosis: 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 pleasure taking care of you. Why was I admitted to the hospital? - You were brought in out of concern that you had an infection. What happened when I was in the hospital? - You were started on antibiotics and multiple tests to search for an infection were negative. - You were taken off of antibiotics and did not develop any more signs of infection. What should I do when I go home? - Keep taking your medicines and follow up with Dr. ___ ___ appointments are listed below) - If you have any fevers, you need to come to the Emergency Department - If you have chills, cough, nausea, vomiting, or any other new symptoms, please call Dr. ___ Followup Instructions: ___
[ "D701", "J189", "C8522", "K861", "K219", "G4700", "K5900", "K1230", "R6883" ]
Allergies: Penicillins Chief Complaint: Abdominal pain, nausea, chills Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [MASKED] hx DLBCL s/p 5 cycles EPOCH (C5D12) presented to clinic for routine follow-up and reported there that he is feeling unwell. Since midnight he had intermittent nausea, abdominal pain described as "gas pain" located in lower abdomen, intermittent chills and "hot and cold feeling." He does note that his stools were looser than usual on the weekend, he backed off on bowel regimen (has not taken since [MASKED] AM), now feels more constipated, stool much harder. He was treated in the office with vanc/cefe/flagyl and brought to [MASKED] for monitoring and work up. On arrival to the floor patient reports symptoms have improved significantly. Nausea has decreased significantly, abdominal pain likewise is somewhat improved. Denies HA, vision changes, CP, SOB, cough, new sputum, BRBPR, melena, dysuria. Past Medical History: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 [MASKED] -Da-EPOCH C2 at level 2 [MASKED] -Dose #1 Rituxan [MASKED] -Da-EPOCH C3 at level 3 [MASKED] -Dose#2 Rituxan [MASKED] -DA-EPOCH C4 at level 4 [MASKED] -Dose#3 Rituxan [MASKED] -DA-EPOCH C5 at level 4 [MASKED] -Dose #4 Rituxan [MASKED] PAST MEDICAL HISTORY: -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] -GERD -Nephrolithiasis Social History: [MASKED] Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: ================== Vitals: 98.0, 129/76, 99, 18, 100% RA GEN: Pleasant and NAD HEENT: EOMI, PERRLA, OP clear without lesions, CARDIOVASCULAR: RRR, nl s1/s2, no m/r/g, 2+ pulses RESPIRATORY: CTA b/l, no w/r/c GI: S/ND, mild/minimal tenderness of lower abdomen, BS normoactive, no masses palpated MUSKULOSKELATAL: WWP, non-edematous, normal bulk & tone NEURO: AOx3, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes or lesions LYMPHATIC: No cervical, supraclavicular, submandibular LAD. SKIN: No significant ecchymosis, rashes ACCESS: POC on R chest without swelling, erythema or pain DISCHARGE PHYSICAL EXAM: ================== Vitals: 98.8 PO BP 124 / 70 HR 89 RR 18 O2 100 RA GEN: Pleasant and NAD, sitting up in bed HEENT: EOMI, PERRLA, OP clear without lesions CARDIOVASCULAR: RRR, nl s1/s2, no m/r/g RESPIRATORY: CTA b/l, no w/r/c GI: S/ND, mild/minimal tenderness of lower abdomen, BS normoactive MUSKULOSKELATAL: WWP, non-edematous, normal bulk & tone NEURO: AAOx3 SKIN: No significant rashes or lesions SKIN: No significant ecchymosis, rashes ACCESS: POC on R chest without swelling, erythema or pain Pertinent Results: ADMISSION LABS: =============== [MASKED] 08:30AM BLOOD WBC-0.5*# RBC-3.65* Hgb-11.1* Hct-32.0* MCV-88 MCH-30.4 MCHC-34.7 RDW-15.6* RDWSD-50.1* Plt Ct-52*# [MASKED] 08:30AM BLOOD Neuts-57 Bands-0 [MASKED] Monos-4* Eos-0 Baso-4* [MASKED] Myelos-0 AbsNeut-0.29* AbsLymp-0.18* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.02 [MASKED] 08:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+* Schisto-1+* Tear Dr-1+* [MASKED] 08:30AM BLOOD Plt Smr-VERY LOW* Plt Ct-52*# [MASKED] 08:30AM BLOOD UreaN-18 Creat-1.0 Na-138 K-4.8 [MASKED] 08:30AM BLOOD ALT-29 AST-16 LD(LDH)-128 AlkPhos-96 Amylase-50 TotBili-0.7 [MASKED] 08:30AM BLOOD Calcium-9.8 Phos-4.1 Mg-2.1 DISCHARGE LABS: =========== [MASKED] 04:43AM BLOOD WBC-1.8*# RBC-2.49* Hgb-7.7* Hct-22.0* MCV-88 MCH-30.9 MCHC-35.0 RDW-15.0 RDWSD-48.5* Plt Ct-26* [MASKED] 04:43AM BLOOD Neuts-49 Bands-4 Lymphs-17* Monos-28* Eos-1 Baso-1 [MASKED] Myelos-0 AbsNeut-0.95* AbsLymp-0.31* AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02 [MASKED] 04:43AM BLOOD Plt Smr-VERY LOW* Plt Ct-26* [MASKED] 04:43AM BLOOD Glucose-97 UreaN-14 Creat-1.1 Na-141 K-4.3 Cl-103 HCO3-24 AnGap-14 [MASKED] 04:43AM BLOOD ALT-18 AST-13 LD(LDH)-114 AlkPhos-67 TotBili-0.3 [MASKED] 04:43AM BLOOD Albumin-3.8 Calcium-9.1 Phos-2.7 Mg-2.0 MICROBIOLOGY: ========== [MASKED] Urine culture negative [MASKED] Blood culture pending IMAGING: ======= [MASKED] CT abd/pelvis 1. No evidence of an acute intra-abdominal or intrapelvic process corresponding to patient's symptoms. 2. Previously described mediastinal and pericardial masses appear decreased in size compared to prior exam performed [MASKED]. CXR [MASKED] Vague ill-defined opacity within the medial aspect of the right lower lobe, could be secondary to an infectious process. Mild prominence of the mediastinum, consistent with patient's known lymphoma, better evaluated on the PET-CT from [MASKED]. ECHO [MASKED] The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 60%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: BRIEF HOSPITAL COURSE: =============================== [MASKED] man with h/o pancreas divisum c/b pancreatitis w/necrosis s/p necrosectomy & DLBCL s/p 5 cycles EPOCH who presented with 1 day of malaise, abdominal pain, nausea, and chills. He was started on Vanc/Cefepime/Flagyl, and was pan-cultured. He underwent CXR, which showed a possible pneumonia. He had CT A/P, which was negative for an acute process. He never spiked a fever. He was continued on home Neupogen, and his counts increased to >900. Vanc/Flagyl were stopped on [MASKED], and Cefepime was changed to Cefpodoxime on [MASKED]. Cultures were negative. His symptoms resolved upon arrival to the oncology floor, and he felt well at time of discharge. Given the findings on CXR, we will treat for a 7-day course of pneumonia. Of note, we also completed a TTE that had been scheduled as an outpatient, and this had a normal EF with less ectopy compared to prior. TRANSITIONAL ISSUES: =============================== - Patient was continued on Neupogen at discharge. Please continue to monitor his neutrophil counts. ANC>900 at discharge - Patient was discharged on Cefpodoxime 200mg BID for pneumonia. He should complete a 7-day course. His ppx levoquin was held. Bactrim and acyclovir continued. He was counseled on warning signs - Patient has scheduled follow-up with Dr. [MASKED] on [MASKED] # EMERGENCY CONTACT: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon [MASKED] CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 7. Nortriptyline 10 mg PO QHS 8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 9. Polyethylene Glycol 17 g PO DAILY constipation 10. Prochlorperazine [MASKED] mg PO Q6H:PRN nausea/vomiting 11. Senna 8.6 mg PO BID 12. Sulfameth/Trimethoprim SS 1 TAB PO QHS 13. Filgrastim-sndz 480 mcg SC Q24H 14. Levofloxacin 500 mg PO Q24H 15. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Ondansetron 8 mg PO Q8H:PRN nausea 18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 7 Days RX *cefpodoxime 200 mg 1 tablet(s) by mouth q12 hours Disp #*14 Tablet Refills:*0 2. Acyclovir 400 mg PO Q8H 3. colesevelam 625 mg oral BID 4. Creon [MASKED] CAP PO QID:PRN snacks 5. Creon 12 2 CAP PO TID W/MEALS 6. Docusate Sodium 100 mg PO BID 7. Filgrastim-sndz 480 mcg SC Q24H 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Prochlorperazine [MASKED] mg PO Q6H:PRN nausea/vomiting 17. Senna 8.6 mg PO BID 18. Sulfameth/Trimethoprim SS 1 TAB PO QHS 19. HELD- Levofloxacin 500 mg PO Q24H This medication was held. Do not restart Levofloxacin until you are done with your Cefpodoxime Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: DLBCL Pneumonia Secondary Diagnosis: 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 pleasure taking care of you. Why was I admitted to the hospital? - You were brought in out of concern that you had an infection. What happened when I was in the hospital? - You were started on antibiotics and multiple tests to search for an infection were negative. - You were taken off of antibiotics and did not develop any more signs of infection. What should I do when I go home? - Keep taking your medicines and follow up with Dr. [MASKED] [MASKED] appointments are listed below) - If you have any fevers, you need to come to the Emergency Department - If you have chills, cough, nausea, vomiting, or any other new symptoms, please call Dr. [MASKED] Followup Instructions: [MASKED]
[]
[ "K219", "G4700", "K5900" ]
[ "D701: Agranulocytosis secondary to cancer chemotherapy", "J189: Pneumonia, unspecified organism", "C8522: Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes", "K861: Other chronic pancreatitis", "K219: Gastro-esophageal reflux disease without esophagitis", "G4700: Insomnia, unspecified", "K5900: Constipation, unspecified", "K1230: Oral mucositis (ulcerative), unspecified", "R6883: Chills (without fever)" ]
10,074,556
22,210,939
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: lymphoma Major Surgical or Invasive Procedure: ___: Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. History of Present Illness: ============================================================= ONCOLOGY HOSPITALIST ADMISSION NOTE ___ ============================================================= PRIMARY ONCOLOGIST: ___ PRIMARY DIAGNOSIS: Primary mediastinal lymphoma TREATMENT REGIMEN: DA-EPOCH-R CC: ___ HISTORY OF PRESENTING ILLNESS: ___ is a ___ man with recent diagnosis of primary mediastinal lymphoma who is admitted for planned second cycle of DA-EPOCH. Patient recently admitted ___, at which time he was noted to have large mediastinal mass and underwent biopsy. Pathology demonstrated a DLBCL. He was transferred to the ___ team and underwent C1 DA-EPOCH without issue. He was discharged on ___ in good condition. After discharge, he noted some back pain associated with his neupogen, but resolved quickly with a single dose of ibuprofen. Also reports some generalized fatigue and symptoms of constipation and symptomatic hemorrhoids (burning pain with defecaton and occaisional flecks of blood on toilet paper). Last ___ was this morning. Otherwise he feels well. No FC. No sore throat. Minor mucositis immediately after discharge which resolved quickly. No current odynophagia or dysphagia. No CP, SOB or cough. No N/V/D. No abdominal pain. No new rashes, joint pain, or swelling. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in ___ - GERD - Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: VS: 97.5 PO 144 / 100 84 18 98 RA GENERAL: Pleasant, ambulating floor comfortably EYES: Anicteric sclerae ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regularly irregular ryhthm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: Slight pink hue underneath both eyes along the cheekbones not involving conjunctiva nor the nasal bridge now has resolved today Pertinent Results: ___ 12:00AM BLOOD WBC-4.1 RBC-4.54* Hgb-12.3* Hct-36.3* MCV-80* MCH-27.1 MCHC-33.9 RDW-14.7 RDWSD-40.0 Plt ___ ___ 12:00AM BLOOD Neuts-92.6* Lymphs-5.2* Monos-1.7* Eos-0.0* Baso-0.0 Im ___ AbsNeut-3.76 AbsLymp-0.21* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Glucose-124* UreaN-18 Creat-0.9 Na-137 K-3.8 Cl-97 HCO3-27 AnGap-17 ___ 12:00AM BLOOD ALT-29 AST-19 LD(LDH)-160 AlkPhos-83 TotBili-0.7 ___ 12:00AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.0 Mg-2.3 ___ 08:00AM BLOOD Albumin-4.4 Calcium-9.6 Phos-2.9 Mg-2.2 UricAcd-7.5* Brief Hospital Course: ___ is a ___ man with recent diagnosis of primary mediastinal lymphoma who is admitted for planned second cycle of DA-EPOCH. # Primary mediastinal lymphoma: SP C1 DA-EPOCH ___. Tolerated well. Cardiac MR after discharge shows no invasion into heart or large vessels. Ritux was deferred first cycle due to tumor burden. He tolerated C2 EPOCH well at dose level 2 without any significant comlpications. We were aggressive with the bowel regimen on admission and he had regular daily bowel movements. He had a TTE on D5 which revealed no cardiac involvement and was unremarkable so he received Rituxan on D6 and tolerated it well. - Con't home acyclovir ppx - We started atovaquone as ? reaction to Bactrim ppx (had transient redness on upper cheekbones that resolved after stopping bactrim) - Aggressive bowel regimen - uptitrated miralax to bid w/ adequate relief - Not on allopurinol, urate mildly elevated - Started neupogen - f/u on ___ w/ BMT and then on ___ for counts - Will need PET-CT on the day of admission for C3 # Arrhythmia: EKG shows bigeminal PVC's. He reports he has had this for awhile, and is asymptomatic w/ resting HR 120s. Regardless, does have tumor near heart, although per cMRI not invading into the heart or great vessels. Started low dose beta blocker and tolerated it well w/o significant fatigue. - cont metoprolol 25 mg xl daily # Chronic pancreatitis # Pancreatic divisum # Pancreatic pseudocyst: Not currently symptomatic. - Con't home creon, colesevelam, and nortriptyline # GERD: Not on meds at home, cont Ranitidine prn ACCESS: POC CODE: Full (presumed) COMMUNICATION: Patient DISPO: Home w/o services BILLING: >30 min spent coordinating care for discharge ____________________ ___, D.O. Heme/___ Hospitalist ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon (lipase-protease-amylase) 3 caps PO TID W/MEALS 2. Nortriptyline 10 mg PO QHS 3. WelChol (colesevelam) 625 mg PO BID 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea 5. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 17.2 mg PO BID constipation 8. Docusate Sodium 100 mg PO TID:PRN constipation 9. Filgrastim 480 mcg IV Q24H 10. Acyclovir 400 mg PO Q8H 11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY RX *atovaquone 750 mg/5 mL 1500 mg by mouth daily Refills:*3 2. Loratadine 10 mg PO DAILY:PRN neupogen related bone pain RX *loratadine 10 mg 1 tablet(s) by mouth daily prn Disp #*30 Tablet Refills:*0 3. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 4. Acyclovir 400 mg PO Q8H 5. Creon (lipase-protease-amylase) 3 caps PO TID W/MEALS 6. Docusate Sodium 100 mg PO TID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth tid prn Disp #*90 Capsule Refills:*0 7. Filgrastim 480 mcg IV Q24H 8. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting RX *lorazepam 0.5 mg 0.5-1 mg by mouth every six (6) hours Disp #*30 Tablet Refills:*0 9. Nortriptyline 10 mg PO QHS 10. Ondansetron ODT 4 mg PO Q8H:PRN nausea 11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram/dose 17 gm by mouth daily prn Refills:*0 13. Senna 17.2 mg PO BID constipation 14. WelChol (colesevelam) 625 mg PO BID Discharge Disposition: Home Discharge Diagnosis: DLBCL Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for Cycle 2 EPOCH and you tolerated the chemotherapy well. You completed chemotherapy on ___ so you can start taking your neupogen the evening of ___. You had a port placed and tolerated that procedure well. You will need to follow up in clinic on ___. We started you on two new medications and advised you not take bactrim due to a facial rash. It was a pleasure taking care of you at ___! Your ___ Team Followup Instructions: ___
[ "Z5111", "C8332", "K863", "Q453", "K861", "I493", "K5900", "K649", "K219", "L271", "T370X5A", "Y92230" ]
Allergies: Penicillins Chief Complaint: lymphoma Major Surgical or Invasive Procedure: [MASKED]: Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. History of Present Illness: ============================================================= ONCOLOGY HOSPITALIST ADMISSION NOTE [MASKED] ============================================================= PRIMARY ONCOLOGIST: [MASKED] PRIMARY DIAGNOSIS: Primary mediastinal lymphoma TREATMENT REGIMEN: DA-EPOCH-R CC: [MASKED] HISTORY OF PRESENTING ILLNESS: [MASKED] is a [MASKED] man with recent diagnosis of primary mediastinal lymphoma who is admitted for planned second cycle of DA-EPOCH. Patient recently admitted [MASKED], at which time he was noted to have large mediastinal mass and underwent biopsy. Pathology demonstrated a DLBCL. He was transferred to the [MASKED] team and underwent C1 DA-EPOCH without issue. He was discharged on [MASKED] in good condition. After discharge, he noted some back pain associated with his neupogen, but resolved quickly with a single dose of ibuprofen. Also reports some generalized fatigue and symptoms of constipation and symptomatic hemorrhoids (burning pain with defecaton and occaisional flecks of blood on toilet paper). Last [MASKED] was this morning. Otherwise he feels well. No FC. No sore throat. Minor mucositis immediately after discharge which resolved quickly. No current odynophagia or dysphagia. No CP, SOB or cough. No N/V/D. No abdominal pain. No new rashes, joint pain, or swelling. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] - GERD - Nephrolithiasis Social History: [MASKED] Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: VS: 97.5 PO 144 / 100 84 18 98 RA GENERAL: Pleasant, ambulating floor comfortably EYES: Anicteric sclerae ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regularly irregular ryhthm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: Slight pink hue underneath both eyes along the cheekbones not involving conjunctiva nor the nasal bridge now has resolved today Pertinent Results: [MASKED] 12:00AM BLOOD WBC-4.1 RBC-4.54* Hgb-12.3* Hct-36.3* MCV-80* MCH-27.1 MCHC-33.9 RDW-14.7 RDWSD-40.0 Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-92.6* Lymphs-5.2* Monos-1.7* Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-3.76 AbsLymp-0.21* AbsMono-0.07* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Glucose-124* UreaN-18 Creat-0.9 Na-137 K-3.8 Cl-97 HCO3-27 AnGap-17 [MASKED] 12:00AM BLOOD ALT-29 AST-19 LD(LDH)-160 AlkPhos-83 TotBili-0.7 [MASKED] 12:00AM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.0 Mg-2.3 [MASKED] 08:00AM BLOOD Albumin-4.4 Calcium-9.6 Phos-2.9 Mg-2.2 UricAcd-7.5* Brief Hospital Course: [MASKED] is a [MASKED] man with recent diagnosis of primary mediastinal lymphoma who is admitted for planned second cycle of DA-EPOCH. # Primary mediastinal lymphoma: SP C1 DA-EPOCH [MASKED]. Tolerated well. Cardiac MR after discharge shows no invasion into heart or large vessels. Ritux was deferred first cycle due to tumor burden. He tolerated C2 EPOCH well at dose level 2 without any significant comlpications. We were aggressive with the bowel regimen on admission and he had regular daily bowel movements. He had a TTE on D5 which revealed no cardiac involvement and was unremarkable so he received Rituxan on D6 and tolerated it well. - Con't home acyclovir ppx - We started atovaquone as ? reaction to Bactrim ppx (had transient redness on upper cheekbones that resolved after stopping bactrim) - Aggressive bowel regimen - uptitrated miralax to bid w/ adequate relief - Not on allopurinol, urate mildly elevated - Started neupogen - f/u on [MASKED] w/ BMT and then on [MASKED] for counts - Will need PET-CT on the day of admission for C3 # Arrhythmia: EKG shows bigeminal PVC's. He reports he has had this for awhile, and is asymptomatic w/ resting HR 120s. Regardless, does have tumor near heart, although per cMRI not invading into the heart or great vessels. Started low dose beta blocker and tolerated it well w/o significant fatigue. - cont metoprolol 25 mg xl daily # Chronic pancreatitis # Pancreatic divisum # Pancreatic pseudocyst: Not currently symptomatic. - Con't home creon, colesevelam, and nortriptyline # GERD: Not on meds at home, cont Ranitidine prn ACCESS: POC CODE: Full (presumed) COMMUNICATION: Patient DISPO: Home w/o services BILLING: >30 min spent coordinating care for discharge [MASKED] [MASKED], D.O. Heme/[MASKED] Hospitalist [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon (lipase-protease-amylase) 3 caps PO TID W/MEALS 2. Nortriptyline 10 mg PO QHS 3. WelChol (colesevelam) 625 mg PO BID 4. Ondansetron ODT 4 mg PO Q8H:PRN nausea 5. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. Senna 17.2 mg PO BID constipation 8. Docusate Sodium 100 mg PO TID:PRN constipation 9. Filgrastim 480 mcg IV Q24H 10. Acyclovir 400 mg PO Q8H 11. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Atovaquone Suspension 1500 mg PO DAILY RX *atovaquone 750 mg/5 mL 1500 mg by mouth daily Refills:*3 2. Loratadine 10 mg PO DAILY:PRN neupogen related bone pain RX *loratadine 10 mg 1 tablet(s) by mouth daily prn Disp #*30 Tablet Refills:*0 3. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 4. Acyclovir 400 mg PO Q8H 5. Creon (lipase-protease-amylase) 3 caps PO TID W/MEALS 6. Docusate Sodium 100 mg PO TID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth tid prn Disp #*90 Capsule Refills:*0 7. Filgrastim 480 mcg IV Q24H 8. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting RX *lorazepam 0.5 mg 0.5-1 mg by mouth every six (6) hours Disp #*30 Tablet Refills:*0 9. Nortriptyline 10 mg PO QHS 10. Ondansetron ODT 4 mg PO Q8H:PRN nausea 11. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 17 gram/dose 17 gm by mouth daily prn Refills:*0 13. Senna 17.2 mg PO BID constipation 14. WelChol (colesevelam) 625 mg PO BID Discharge Disposition: Home Discharge Diagnosis: DLBCL Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted for Cycle 2 EPOCH and you tolerated the chemotherapy well. You completed chemotherapy on [MASKED] so you can start taking your neupogen the evening of [MASKED]. You had a port placed and tolerated that procedure well. You will need to follow up in clinic on [MASKED]. We started you on two new medications and advised you not take bactrim due to a facial rash. It was a pleasure taking care of you at [MASKED]! Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "K5900", "K219", "Y92230" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8332: Diffuse large B-cell lymphoma, intrathoracic lymph nodes", "K863: Pseudocyst of pancreas", "Q453: Other congenital malformations of pancreas and pancreatic duct", "K861: Other chronic pancreatitis", "I493: Ventricular premature depolarization", "K5900: Constipation, unspecified", "K649: Unspecified hemorrhoids", "K219: Gastro-esophageal reflux disease without esophagitis", "L271: Localized skin eruption due to drugs and medicaments taken internally", "T370X5A: Adverse effect of sulfonamides, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,074,556
22,281,978
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: admission for C1 ICE Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a pleasant ___ originally diagnosed w/ primary mediastinal lymphoma s/p 6C of da-EPOCH with restaging consistent with persistent mediastinal mass. Patient underwent bx consistent with mostly dead DLBCL cells, however small population of Hodgkin lymphoma was seen. Patient likely has composite lymphoma with chemo response in regards to DLBCL but not in regards to HL. Patient now presents for C1 ICE. Past Medical History: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 ___ -Da-EPOCH C2 at level 2 ___ -Dose #1 Rituxan ___ -Da-EPOCH C3 at level 3 ___ -Dose#2 Rituxan ___ -DA-EPOCH C4 at level 4 ___ -Dose#3 Rituxan ___ -DA-EPOCH C5 at level 4 ___ -Dose #4 Rituxan ___ -DA-EPOCH C6 at level 4 ___ -C1 ICE ___ PAST MEDICAL HISTORY (per OMR): -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in ___ -GERD -Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 97.6 PO 139/90 HR 98 18 98 RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities, skin overlying R port intact NEURO: Grossly normal DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 97.6 PO 152/76 HR 83 18 98 RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities, skin overlying R port intact NEURO: Grossly normal, A/0 x3 Pertinent Results: ADMISSION LABS: ___ 09:00AM BLOOD WBC-3.2* RBC-4.81 Hgb-14.5 Hct-42.8 MCV-89 MCH-30.1 MCHC-33.9 RDW-11.9 RDWSD-38.5 Plt ___ ___ 09:00AM BLOOD Neuts-66.9 Lymphs-13.6* Monos-15.8* Eos-3.1 Baso-0.3 Im ___ AbsNeut-2.16 AbsLymp-0.44* AbsMono-0.51 AbsEos-0.10 AbsBaso-0.01 ___ 09:00AM BLOOD Glucose-124* ___ 09:00AM BLOOD UreaN-11 Creat-1.0 Na-140 K-4.2 ___ 09:00AM BLOOD ALT-17 AST-25 LD(___)-165 AlkPhos-80 TotBili-0.3 ___ 09:00AM BLOOD Albumin-4.7 Calcium-9.8 Phos-3.4 Mg-2.1 UricAcd-5.4 DISCHARGE LABS: ___ 12:00AM BLOOD WBC-8.4# RBC-4.21* Hgb-12.8* Hct-37.6* MCV-89 MCH-30.4 MCHC-34.0 RDW-11.9 RDWSD-38.2 Plt ___ ___ 12:00AM BLOOD Neuts-93.6* Lymphs-3.6* Monos-2.1* Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.88*# AbsLymp-0.30* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.01 ___ 12:00AM BLOOD Plt ___ ___ 12:00AM BLOOD Glucose-111* UreaN-19 Creat-1.1 Na-141 K-4.0 Cl-103 HCO3-23 AnGap-15 ___ 12:00AM BLOOD ALT-14 AST-18 LD(___)-151 AlkPhos-63 TotBili-0.4 ___ 12:00AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.1 Mg-1.9 UricAcd-3.1* Brief Hospital Course: ASSESSMENT AND PLAN: ___ w/ primary mediastinal lymphoma s/p 6C of da-EPOCH with persistent disease on imaging with LN bx consistent with Hodgkin lymphoma, now presenting for C1 ICE. #Primary Mediastinal Lymphoma #Hodgkin lymphoma: most recent PET shown continued mass with LN bx showing no evidence of DLBCL but noted for Hodgkin involvement. Plan for 2C of ICE followed by autologous stem cell transplant if disease response. He did not receive Rituxan as CD20 negative. He continues on acyclovir and bactrim prophylaxis. He received allopurinol in-house but this was discontinued at discharge as he has no evidence of TLS. Neupogen support to start following treatment on ___ in the evening or ___. Outpatient appointment scheduled with primary team next week ___. #Chronic pancreatitis #Pancreatic divisum #Pancreatic pseudocyst: Not currently symptomatic. Continue creon, colesevelam, and nortriptyline #Anxiety: exacerbated now with new Hodgkin lymphoma diagnosis, Ativan prn. Continue SW support. ACCESS: POC placed ___ CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: ___ DISPO: Discharged ___. RTC ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. colesevelam 625 mg oral BID 2. Creon ___ CAP PO QID PRN meals and snacks 3. LORazepam 0.5-1 mg PO Q4H:PRN nausea anxiety insomnia 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Nortriptyline 10 mg PO QHS 6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Filgrastim 480 mcg SC Q24H start this either ___ night or ___ morning 3. Ondansetron ODT 4 mg PO Q8H:PRN nausea 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 5. colesevelam 625 mg oral BID 6. Creon ___ CAP PO QID PRN meals and snacks 7. LORazepam 0.5-1 mg PO Q4H:PRN nausea anxiety insomnia 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Nortriptyline 10 mg PO QHS 10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: #Primary Mediastinal Lymphoma/Hodgkin's Lymphoma SECONDARY DIAGNOSIS: #Chronic pancreatitis #GERD #Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to receive your cycle #1 of ICE chemotherapy. You tolerated this well and will be discharged home today. You will begin neupogen injections either ___ night or ___ morning and continue daily until Dr. ___ you to discontinue. You will follow up in the clinic as stated below. It was a pleasure taking care of you. Followup Instructions: ___
[ "Z5111", "C8528", "K861", "F419", "K219", "G4701" ]
Allergies: Penicillins Chief Complaint: admission for C1 ICE Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] originally diagnosed w/ primary mediastinal lymphoma s/p 6C of da-EPOCH with restaging consistent with persistent mediastinal mass. Patient underwent bx consistent with mostly dead DLBCL cells, however small population of Hodgkin lymphoma was seen. Patient likely has composite lymphoma with chemo response in regards to DLBCL but not in regards to HL. Patient now presents for C1 ICE. Past Medical History: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 [MASKED] -Da-EPOCH C2 at level 2 [MASKED] -Dose #1 Rituxan [MASKED] -Da-EPOCH C3 at level 3 [MASKED] -Dose#2 Rituxan [MASKED] -DA-EPOCH C4 at level 4 [MASKED] -Dose#3 Rituxan [MASKED] -DA-EPOCH C5 at level 4 [MASKED] -Dose #4 Rituxan [MASKED] -DA-EPOCH C6 at level 4 [MASKED] -C1 ICE [MASKED] PAST MEDICAL HISTORY (per OMR): -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] -GERD -Nephrolithiasis Social History: [MASKED] Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 97.6 PO 139/90 HR 98 18 98 RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no [MASKED], no tremors SKIN: No rashes on the extremities, skin overlying R port intact NEURO: Grossly normal DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 97.6 PO 152/76 HR 83 18 98 RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no [MASKED], no tremors SKIN: No rashes on the extremities, skin overlying R port intact NEURO: Grossly normal, A/0 x3 Pertinent Results: ADMISSION LABS: [MASKED] 09:00AM BLOOD WBC-3.2* RBC-4.81 Hgb-14.5 Hct-42.8 MCV-89 MCH-30.1 MCHC-33.9 RDW-11.9 RDWSD-38.5 Plt [MASKED] [MASKED] 09:00AM BLOOD Neuts-66.9 Lymphs-13.6* Monos-15.8* Eos-3.1 Baso-0.3 Im [MASKED] AbsNeut-2.16 AbsLymp-0.44* AbsMono-0.51 AbsEos-0.10 AbsBaso-0.01 [MASKED] 09:00AM BLOOD Glucose-124* [MASKED] 09:00AM BLOOD UreaN-11 Creat-1.0 Na-140 K-4.2 [MASKED] 09:00AM BLOOD ALT-17 AST-25 LD([MASKED])-165 AlkPhos-80 TotBili-0.3 [MASKED] 09:00AM BLOOD Albumin-4.7 Calcium-9.8 Phos-3.4 Mg-2.1 UricAcd-5.4 DISCHARGE LABS: [MASKED] 12:00AM BLOOD WBC-8.4# RBC-4.21* Hgb-12.8* Hct-37.6* MCV-89 MCH-30.4 MCHC-34.0 RDW-11.9 RDWSD-38.2 Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-93.6* Lymphs-3.6* Monos-2.1* Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-7.88*# AbsLymp-0.30* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.01 [MASKED] 12:00AM BLOOD Plt [MASKED] [MASKED] 12:00AM BLOOD Glucose-111* UreaN-19 Creat-1.1 Na-141 K-4.0 Cl-103 HCO3-23 AnGap-15 [MASKED] 12:00AM BLOOD ALT-14 AST-18 LD([MASKED])-151 AlkPhos-63 TotBili-0.4 [MASKED] 12:00AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.1 Mg-1.9 UricAcd-3.1* Brief Hospital Course: ASSESSMENT AND PLAN: [MASKED] w/ primary mediastinal lymphoma s/p 6C of da-EPOCH with persistent disease on imaging with LN bx consistent with Hodgkin lymphoma, now presenting for C1 ICE. #Primary Mediastinal Lymphoma #Hodgkin lymphoma: most recent PET shown continued mass with LN bx showing no evidence of DLBCL but noted for Hodgkin involvement. Plan for 2C of ICE followed by autologous stem cell transplant if disease response. He did not receive Rituxan as CD20 negative. He continues on acyclovir and bactrim prophylaxis. He received allopurinol in-house but this was discontinued at discharge as he has no evidence of TLS. Neupogen support to start following treatment on [MASKED] in the evening or [MASKED]. Outpatient appointment scheduled with primary team next week [MASKED]. #Chronic pancreatitis #Pancreatic divisum #Pancreatic pseudocyst: Not currently symptomatic. Continue creon, colesevelam, and nortriptyline #Anxiety: exacerbated now with new Hodgkin lymphoma diagnosis, Ativan prn. Continue SW support. ACCESS: POC placed [MASKED] CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: [MASKED] DISPO: Discharged [MASKED]. RTC [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. colesevelam 625 mg oral BID 2. Creon [MASKED] CAP PO QID PRN meals and snacks 3. LORazepam 0.5-1 mg PO Q4H:PRN nausea anxiety insomnia 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Nortriptyline 10 mg PO QHS 6. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Filgrastim 480 mcg SC Q24H start this either [MASKED] night or [MASKED] morning 3. Ondansetron ODT 4 mg PO Q8H:PRN nausea 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 5. colesevelam 625 mg oral BID 6. Creon [MASKED] CAP PO QID PRN meals and snacks 7. LORazepam 0.5-1 mg PO Q4H:PRN nausea anxiety insomnia 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Nortriptyline 10 mg PO QHS 10. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: #Primary Mediastinal Lymphoma/Hodgkin's Lymphoma SECONDARY DIAGNOSIS: #Chronic pancreatitis #GERD #Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to receive your cycle #1 of ICE chemotherapy. You tolerated this well and will be discharged home today. You will begin neupogen injections either [MASKED] night or [MASKED] morning and continue daily until Dr. [MASKED] you to discontinue. You will follow up in the clinic as stated below. It was a pleasure taking care of you. Followup Instructions: [MASKED]
[]
[ "F419", "K219" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8528: Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites", "K861: Other chronic pancreatitis", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4701: Insomnia due to medical condition" ]
10,074,556
23,686,717
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Scheduled chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a pleasant ___ w/ primary mediastinal lymphoma who is admitted for C6 DA-EPOCH-R. He originally presented for 6 months of symptoms including weight loss night sweats, and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH and is now presenting for cycle 6 of regimen. Feels well since his most recent admission for abd pain and completed abx course for PNA. REVIEW OF SYSTEMS: 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 ___ -Da-EPOCH C2 at level 2 ___ -Dose #1 Rituxan ___ -Da-EPOCH C3 at level 3 ___ -Dose#2 Rituxan ___ -DA-EPOCH C4 at level 4 ___ -Dose#3 Rituxan ___ -DA-EPOCH C5 at level 4 ___ -Dose #4 Rituxan ___ -DA-EPOCH C6 at level 4 ___ PAST MEDICAL HISTORY (per OMR): -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in ___ -GERD -Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ON ADMISSION ============ VITAL SIGNS: 98.3 PO 134 / 83 R Sitting 85 18 98 RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities, skin overlying R port intact NEURO: Grossly normal ON DISCHARGE ============ VS: 97.5 PO 125 / 76 93 20 99% RA General: Well-appearing young man, sitting in bed comfortably. HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RRR, no MRG PULM: No respiratory difficulty. Clear to auscultation bilaterally. ABD: Bowel sounds present, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___ SKIN: Mildly flushed skin in face and upper thorax. No rashes NEURO: Alert and oriented, grossly preserved strength and skin sensation. Pertinent Results: ON ADMISSION ============= ___ 09:50AM BLOOD WBC-5.4# RBC-3.32* Hgb-10.4* Hct-30.9* MCV-93 MCH-31.3 MCHC-33.7 RDW-17.7* RDWSD-58.9* Plt ___ ___ 09:50AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6 Eos-1 Baso-0 ___ Metas-3* Myelos-0 AbsNeut-4.59 AbsLymp-0.27* AbsMono-0.32 AbsEos-0.05 AbsBaso-0.00* ___ 09:50AM BLOOD UreaN-10 Creat-1.0 Na-137 K-4.6 ___ 09:50AM BLOOD ALT-18 AST-16 LD(___)-245 AlkPhos-96 TotBili-0.2 ___ 09:50AM BLOOD Albumin-4.5 Calcium-9.2 Phos-3.6 Mg-2.1 UricAcd-5.6 ON DISCHARGE ============= ___ 06:00AM BLOOD WBC-1.9* RBC-2.88* Hgb-8.8* Hct-26.3* MCV-91 MCH-30.6 MCHC-33.5 RDW-16.1* RDWSD-53.5* Plt ___ ___ 06:00AM BLOOD Neuts-82.9* Lymphs-7.7* Monos-7.7 Eos-0.0* Baso-0.0 NRBC-1.1* Im ___ AbsNeut-1.50* AbsLymp-0.14* AbsMono-0.14* AbsEos-0.00* AbsBaso-0.00* ___ 06:00AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-143 K-4.0 Cl-103 HCO3-27 AnGap-13 ___ 06:00AM BLOOD ALT-11 AST-10 LD(LDH)-142 AlkPhos-57 TotBili-0.7 Brief Hospital Course: Mr. ___ is a ___ year-old gentleman with a primary mediastinal lymphoma admitted for C6 DA-EPOCH-R which he tolerated. # Primary Mediastinal Lymphoma: Most recent PET scan on ___ revealed mixed response. Dose level of DA-R-EPOCH at level 4 with plan to repeat PET after this cycle. Tolerated this cycle well with only minor nausea and dysgeusia which he had during his previous cycles. # Chronic pancreatitis: Remained asymptomatic. Continued on home creon, colesevelam, and nortriptyline # GERD: Remained asymptomatic. # Insomnia: Related to exogenous factors (hospital lights, noise). Was continued on lorazepam. Received zolpidem ___ prn TRANSITIIONAL ISSUES #Discharged with plan to start filgrastim at home (has syringes) on ___ #Leukopenic upon discharge, will restart levofloxacin for neutropenic prophylaxis (wrote for 10 day course) #Required zolpidem prn for insomnia in house, requesting continued medication, discharged with 1 week supply More than 30 minutes were spent planning and coordinating this patient's discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon ___ CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. Filgrastim-sndz 480 mcg SC Q24H 7. LORazepam 1 mg PO QHS 8. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 9. Nortriptyline 10 mg PO QHS 10. Nystatin Oral Suspension 5 mL PO QID thrush 11. Ondansetron 8 mg PO Q8H:PRN nausea 12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 13. Polyethylene Glycol 17 g PO DAILY constipation 14. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting 15. Senna 8.6 mg PO BID 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Medications: 1. Levofloxacin 500 mg PO Q24H As directed per ___. Start tomorrow ___. 2. Zolpidem Tartrate ___ mg PO QHS:PRN insomnia RX *zolpidem 5 mg ___ tablet(s) by mouth at bedtime Disp #*14 Tablet Refills:*0 3. Acyclovir 400 mg PO Q8H 4. colesevelam 625 mg oral BID 5. Creon 12 2 CAP PO TID W/MEALS 6. Creon ___ CAP PO QID:PRN snacks 7. Docusate Sodium 100 mg PO BID 8. Filgrastim-sndz 480 mcg SC Q24H 9. LORazepam 1 mg PO QHS 10. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Nortriptyline 10 mg PO QHS 13. Nystatin Oral Suspension 5 mL PO QID thrush 14. Ondansetron 8 mg PO Q8H:PRN nausea 15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 16. Polyethylene Glycol 17 g PO DAILY constipation 17. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting 18. Senna 8.6 mg PO BID 19. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: #Encounter for antineoplastic chemotherapy #Primary Mediastinal Lymphoma SECONDARY DIAGNOSIS: #Chronic pancreatitis #GERD #Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted for your sixth cycle of chemotherapy which you tolerated very well. It was a pleasure to take care of you. Your ___ Team Followup Instructions: ___
[ "Z5111", "C8332", "Q453", "K861", "K219", "G4700" ]
Allergies: Penicillins Chief Complaint: Scheduled chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] w/ primary mediastinal lymphoma who is admitted for C6 DA-EPOCH-R. He originally presented for 6 months of symptoms including weight loss night sweats, and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH and is now presenting for cycle 6 of regimen. Feels well since his most recent admission for abd pain and completed abx course for PNA. REVIEW OF SYSTEMS: 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 [MASKED] -Da-EPOCH C2 at level 2 [MASKED] -Dose #1 Rituxan [MASKED] -Da-EPOCH C3 at level 3 [MASKED] -Dose#2 Rituxan [MASKED] -DA-EPOCH C4 at level 4 [MASKED] -Dose#3 Rituxan [MASKED] -DA-EPOCH C5 at level 4 [MASKED] -Dose #4 Rituxan [MASKED] -DA-EPOCH C6 at level 4 [MASKED] PAST MEDICAL HISTORY (per OMR): -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] -GERD -Nephrolithiasis Social History: [MASKED] Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ON ADMISSION ============ VITAL SIGNS: 98.3 PO 134 / 83 R Sitting 85 18 98 RA General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no [MASKED], no tremors SKIN: No rashes on the extremities, skin overlying R port intact NEURO: Grossly normal ON DISCHARGE ============ VS: 97.5 PO 125 / 76 93 20 99% RA General: Well-appearing young man, sitting in bed comfortably. HEENT: MMM, no OP lesions, no cervical/supraclavicular adenopathy CV: RRR, no MRG PULM: No respiratory difficulty. Clear to auscultation bilaterally. ABD: Bowel sounds present, soft, NTND, no palpable masses or HSM LIMBS: WWP, no [MASKED] SKIN: Mildly flushed skin in face and upper thorax. No rashes NEURO: Alert and oriented, grossly preserved strength and skin sensation. Pertinent Results: ON ADMISSION ============= [MASKED] 09:50AM BLOOD WBC-5.4# RBC-3.32* Hgb-10.4* Hct-30.9* MCV-93 MCH-31.3 MCHC-33.7 RDW-17.7* RDWSD-58.9* Plt [MASKED] [MASKED] 09:50AM BLOOD Neuts-84* Bands-1 Lymphs-5* Monos-6 Eos-1 Baso-0 [MASKED] Metas-3* Myelos-0 AbsNeut-4.59 AbsLymp-0.27* AbsMono-0.32 AbsEos-0.05 AbsBaso-0.00* [MASKED] 09:50AM BLOOD UreaN-10 Creat-1.0 Na-137 K-4.6 [MASKED] 09:50AM BLOOD ALT-18 AST-16 LD([MASKED])-245 AlkPhos-96 TotBili-0.2 [MASKED] 09:50AM BLOOD Albumin-4.5 Calcium-9.2 Phos-3.6 Mg-2.1 UricAcd-5.6 ON DISCHARGE ============= [MASKED] 06:00AM BLOOD WBC-1.9* RBC-2.88* Hgb-8.8* Hct-26.3* MCV-91 MCH-30.6 MCHC-33.5 RDW-16.1* RDWSD-53.5* Plt [MASKED] [MASKED] 06:00AM BLOOD Neuts-82.9* Lymphs-7.7* Monos-7.7 Eos-0.0* Baso-0.0 NRBC-1.1* Im [MASKED] AbsNeut-1.50* AbsLymp-0.14* AbsMono-0.14* AbsEos-0.00* AbsBaso-0.00* [MASKED] 06:00AM BLOOD Glucose-95 UreaN-16 Creat-0.8 Na-143 K-4.0 Cl-103 HCO3-27 AnGap-13 [MASKED] 06:00AM BLOOD ALT-11 AST-10 LD(LDH)-142 AlkPhos-57 TotBili-0.7 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old gentleman with a primary mediastinal lymphoma admitted for C6 DA-EPOCH-R which he tolerated. # Primary Mediastinal Lymphoma: Most recent PET scan on [MASKED] revealed mixed response. Dose level of DA-R-EPOCH at level 4 with plan to repeat PET after this cycle. Tolerated this cycle well with only minor nausea and dysgeusia which he had during his previous cycles. # Chronic pancreatitis: Remained asymptomatic. Continued on home creon, colesevelam, and nortriptyline # GERD: Remained asymptomatic. # Insomnia: Related to exogenous factors (hospital lights, noise). Was continued on lorazepam. Received zolpidem [MASKED] prn TRANSITIIONAL ISSUES #Discharged with plan to start filgrastim at home (has syringes) on [MASKED] #Leukopenic upon discharge, will restart levofloxacin for neutropenic prophylaxis (wrote for 10 day course) #Required zolpidem prn for insomnia in house, requesting continued medication, discharged with 1 week supply More than 30 minutes were spent planning and coordinating this patient's discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon [MASKED] CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. Filgrastim-sndz 480 mcg SC Q24H 7. LORazepam 1 mg PO QHS 8. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 9. Nortriptyline 10 mg PO QHS 10. Nystatin Oral Suspension 5 mL PO QID thrush 11. Ondansetron 8 mg PO Q8H:PRN nausea 12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 13. Polyethylene Glycol 17 g PO DAILY constipation 14. Prochlorperazine [MASKED] mg PO Q6H:PRN nausea/vomiting 15. Senna 8.6 mg PO BID 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Medications: 1. Levofloxacin 500 mg PO Q24H As directed per [MASKED]. Start tomorrow [MASKED]. 2. Zolpidem Tartrate [MASKED] mg PO QHS:PRN insomnia RX *zolpidem 5 mg [MASKED] tablet(s) by mouth at bedtime Disp #*14 Tablet Refills:*0 3. Acyclovir 400 mg PO Q8H 4. colesevelam 625 mg oral BID 5. Creon 12 2 CAP PO TID W/MEALS 6. Creon [MASKED] CAP PO QID:PRN snacks 7. Docusate Sodium 100 mg PO BID 8. Filgrastim-sndz 480 mcg SC Q24H 9. LORazepam 1 mg PO QHS 10. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Nortriptyline 10 mg PO QHS 13. Nystatin Oral Suspension 5 mL PO QID thrush 14. Ondansetron 8 mg PO Q8H:PRN nausea 15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 16. Polyethylene Glycol 17 g PO DAILY constipation 17. Prochlorperazine [MASKED] mg PO Q6H:PRN nausea/vomiting 18. Senna 8.6 mg PO BID 19. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: #Encounter for antineoplastic chemotherapy #Primary Mediastinal Lymphoma SECONDARY DIAGNOSIS: #Chronic pancreatitis #GERD #Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were admitted for your sixth cycle of chemotherapy which you tolerated very well. It was a pleasure to take care of you. Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "K219", "G4700" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8332: Diffuse large B-cell lymphoma, intrathoracic lymph nodes", "Q453: Other congenital malformations of pancreas and pancreatic duct", "K861: Other chronic pancreatitis", "K219: Gastro-esophageal reflux disease without esophagitis", "G4700: Insomnia, unspecified" ]
10,074,556
23,864,934
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Chills Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with primary mediastinal lymphoma s/p 6 cycles of dose adjusted R-EPOCH in ___ with residual disease (CHL) now s/p ICE who is admitted from the ED with chills, low grade temperatures and nasal congestion. Patient reports about 3 days of nasal congestion and rhinitis with clear discharge. He was seen in ___ clinic on ___, and was otherwise feeling well. However, after getting home at 3pm, he noted chills. He checked his temperature and it was 99.7. Chills continued and his temperature fluctuated from mid- 99's up to 100.2. He has a mild ___ headache. No visual changes. No ST. No CP, SOB, or cough. He remains quite active. No N/V. Mild constipation, last BM this am. No dysuria. No new rashes. No new joint pains or leg swelling. He reports some close contacts with cold symptoms. In the ED, initial VS were pain 0, T 98.6, HR 125, BP 135/99, RR 17, O2 100%RA. Initial labs were notable for WBC 7.2 (ANC 4390), HCT 40.8, PLT 112, NA 139, K 3.8, HCO3 28, Cr 1.0, UA negative, rapid flu swab negative. CXR showed no acute process. No interventions were performed. VS prior to transfer were pain 4, T 97.9, HR 76, BP 132/84, RR 18, O2 99%RA. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. - EPOCH C1 ___ - DA-R-EPOCH dose level 2 (Rituxan on last day of chemo) ___ - DA-R-EPOCH dose level 3 ___ - DA-R-EPOCH dose level 4 ___ - DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg - DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg - ___ PET-CT shows residual FDG-avid disease - ___: Right video assisted thoroscopy mediastinal lymph node biopsy which ultimately came back positive for classical hodgkin's lymphoma with no residual evidence for viable DLBCL. - ___: C1D1 ICE Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in ___ - GERD - Nephrolithiasis - Arrhythmia Social History: ___ Family History: Mother and father with hypertension. No known family history of leukemia or lymphoma. Physical Exam: ADMISSION PHYSICAL EXAM: ================================= VS: T 99.1 HR 113 BP 142/83 RR 18 SAT 93% O2 on RA GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regularly irregular rate, tachycardic, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: ================================== VS: T 99.1 HR 113 BP 142/83 RR 18 SAT 93% O2 on RA GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, EOMI ENT: Oropharynx clear without lesion CARDIOVASCULAR: Tachycardic, regular rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses Pertinent Results: ADMISSION LABS: ======================= ___ 10:30AM BLOOD WBC-7.3# RBC-4.42* Hgb-13.1* Hct-38.5* MCV-87 MCH-29.6 MCHC-34.0 RDW-12.3 RDWSD-38.7 Plt ___ ___ 10:30AM BLOOD Neuts-64 Bands-2 Lymphs-13* Monos-9 Eos-0 Baso-0 ___ Metas-10* Myelos-2* AbsNeut-4.82 AbsLymp-0.95* AbsMono-0.66 AbsEos-0.00* AbsBaso-0.00* ___ 10:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL ___ 10:30AM BLOOD Plt Smr-LOW* Plt ___ ___ 10:30AM BLOOD UreaN-10 Creat-0.9 Na-140 K-4.3 ___ 10:30AM BLOOD Glucose-98 ___ 10:30AM BLOOD ALT-44* AST-36 LD(LDH)-241 AlkPhos-129 TotBili-0.2 ___ 10:30AM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.4 Mg-2.2 UricAcd-5.2 DISCHARGE LABS: ======================= ___ 04:34AM BLOOD WBC-7.7 RBC-4.08* Hgb-12.1* Hct-35.7* MCV-88 MCH-29.7 MCHC-33.9 RDW-12.3 RDWSD-39.0 Plt Ct-88* ___ 04:34AM BLOOD Neuts-80* Bands-0 Lymphs-5* Monos-14* Eos-0 Baso-0 ___ Myelos-1* AbsNeut-6.16* AbsLymp-0.39* AbsMono-1.08* AbsEos-0.00* AbsBaso-0.00* ___ 04:34AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+* Macrocy-NORMAL Microcy-1+* Polychr-1+* Spheroc-1+* Ovalocy-1+* Tear Dr-OCCASIONAL ___ 04:34AM BLOOD Glucose-149* UreaN-7 Creat-1.0 Na-137 K-4.1 Cl-97 HCO3-27 AnGap-13 ___ 04:34AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1 MICROBIOLOGY: ======================= BLOOD/URINE CX NEGATIVE, RESPIRATORY PANEL NEGATIVE, FLU PCR NEGATIVE IMAGING: ======================= ___ CXR: FINDINGS: Lungs are fully expanded and clear. No pleural abnormalities. Heart size is normal. Cardiomediastinal and hilar silhouettes are unremarkable - extensive mediastinal lymphadenopathy previously seen on CT is not appreciated. A dual lumen right IJ central venous Port-A-Cath tip projects over the right atrium. IMPRESSION: No evidence of an acute cardiopulmonary abnormality. Brief Hospital Course: Mr. ___ is a ___ with Hodgkin's lymphoma and primary mediastinal lymphoma who presented with 1 day of low grade fever (max 100.2F) and chills consistent with an upper respiratory infection, likely viral in nature. # Low-grade temperatures # Chills # Nasal congestion/rhinitis: No documented fever but chills, low grade temps, and nasal congestion/rhinitis c/f acute URTI. No other clear infectious symptoms. Young children at home with cold-like symptoms. Flu swab negative, additional respiratory viral panel pending. He likely has as viral process. He had no fevers while inpatient and was able to be discharged with follow-up. # Primary mediastinal lymphoma # Classical Hodgkin's lymphoma: SP 6 cycles EPOCH for mediastinal DLBCL. Now with residual classical Hodgkin's lymphoma. SP C1 ICE with plan for second cycle followed by auto-SCT consolidation. He has recovered his counts from prior ICE cycle and is no longer on neupogen or levoflox ppx. He was continued on home Bactrim and acyclovir ppx. # Tachycardia: Patient has history of bigeminal PVC's and sinus tachycardia. EKG in ED showed sinus tach with PVC's. He is asymptomatic. Appears similar to outpatient rates. Pt states that this is his baseline. Home metoprolol was continued. # History of pancreatitis: Continued home creon. # Biopsychocial - Cont home nortyptiline - Cont home ativan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. colesevelam 625 mg oral BID 2. Creon ___ CAP PO QID PRN meals and snacks 3. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 4. Nortriptyline 10 mg PO QHS 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 6. Acyclovir 400 mg PO Q8H 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Ondansetron ODT 4 mg PO Q8H:PRN nausea 10. Filgrastim 480 mcg SC ASDIR 11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Medications: 1. Filgrastim 480 mcg SC ASDIR 2. Acyclovir 400 mg PO Q8H 3. colesevelam 625 mg oral BID 4. Creon ___ CAP PO QID PRN meals and snacks 5. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Nortriptyline 10 mg PO QHS 8. Ondansetron ODT 4 mg PO Q8H:PRN nausea 9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary: Viral Sinusitis Primary mediastina lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted after having low grade fevers, chills and nasal congestion. We checked you for the flu which was negative. We also did a chest x-ray which did not show any pneumonia. You did not have any fevers while you were here. You likely have a virus which is causing nasal congestion. Please keep your follow-up appointments and take your medications as listed below. It was a pleasure taking care of you, -Your ___ Team Followup Instructions: ___
[ "J0190", "B9789", "C8332", "C8190", "R000", "K8689" ]
Allergies: Penicillins Chief Complaint: Chills Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old male with primary mediastinal lymphoma s/p 6 cycles of dose adjusted R-EPOCH in [MASKED] with residual disease (CHL) now s/p ICE who is admitted from the ED with chills, low grade temperatures and nasal congestion. Patient reports about 3 days of nasal congestion and rhinitis with clear discharge. He was seen in [MASKED] clinic on [MASKED], and was otherwise feeling well. However, after getting home at 3pm, he noted chills. He checked his temperature and it was 99.7. Chills continued and his temperature fluctuated from mid- 99's up to 100.2. He has a mild [MASKED] headache. No visual changes. No ST. No CP, SOB, or cough. He remains quite active. No N/V. Mild constipation, last BM this am. No dysuria. No new rashes. No new joint pains or leg swelling. He reports some close contacts with cold symptoms. In the ED, initial VS were pain 0, T 98.6, HR 125, BP 135/99, RR 17, O2 100%RA. Initial labs were notable for WBC 7.2 (ANC 4390), HCT 40.8, PLT 112, NA 139, K 3.8, HCO3 28, Cr 1.0, UA negative, rapid flu swab negative. CXR showed no acute process. No interventions were performed. VS prior to transfer were pain 4, T 97.9, HR 76, BP 132/84, RR 18, O2 99%RA. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. - EPOCH C1 [MASKED] - DA-R-EPOCH dose level 2 (Rituxan on last day of chemo) [MASKED] - DA-R-EPOCH dose level 3 [MASKED] - DA-R-EPOCH dose level 4 [MASKED] - DA-R-EPOCH dose level 4 [MASKED]- Vincristine cap at 2mg - DA-R-EPOCH dose level 4 [MASKED]- Vincristine cap at 2mg - [MASKED] PET-CT shows residual FDG-avid disease - [MASKED]: Right video assisted thoroscopy mediastinal lymph node biopsy which ultimately came back positive for classical hodgkin's lymphoma with no residual evidence for viable DLBCL. - [MASKED]: C1D1 ICE Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] - GERD - Nephrolithiasis - Arrhythmia Social History: [MASKED] Family History: Mother and father with hypertension. No known family history of leukemia or lymphoma. Physical Exam: ADMISSION PHYSICAL EXAM: ================================= VS: T 99.1 HR 113 BP 142/83 RR 18 SAT 93% O2 on RA GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regularly irregular rate, tachycardic, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: ================================== VS: T 99.1 HR 113 BP 142/83 RR 18 SAT 93% O2 on RA GENERAL: Pleasant, well appearing man, lying in bed comfortably EYES: Anicteric sclerea, EOMI ENT: Oropharynx clear without lesion CARDIOVASCULAR: Tachycardic, regular rhythm, no murmurs, rubs, or gallops; 2+ radial pulses, 2+ DP pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN III-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses Pertinent Results: ADMISSION LABS: ======================= [MASKED] 10:30AM BLOOD WBC-7.3# RBC-4.42* Hgb-13.1* Hct-38.5* MCV-87 MCH-29.6 MCHC-34.0 RDW-12.3 RDWSD-38.7 Plt [MASKED] [MASKED] 10:30AM BLOOD Neuts-64 Bands-2 Lymphs-13* Monos-9 Eos-0 Baso-0 [MASKED] Metas-10* Myelos-2* AbsNeut-4.82 AbsLymp-0.95* AbsMono-0.66 AbsEos-0.00* AbsBaso-0.00* [MASKED] 10:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [MASKED] 10:30AM BLOOD Plt Smr-LOW* Plt [MASKED] [MASKED] 10:30AM BLOOD UreaN-10 Creat-0.9 Na-140 K-4.3 [MASKED] 10:30AM BLOOD Glucose-98 [MASKED] 10:30AM BLOOD ALT-44* AST-36 LD(LDH)-241 AlkPhos-129 TotBili-0.2 [MASKED] 10:30AM BLOOD Albumin-4.4 Calcium-9.6 Phos-3.4 Mg-2.2 UricAcd-5.2 DISCHARGE LABS: ======================= [MASKED] 04:34AM BLOOD WBC-7.7 RBC-4.08* Hgb-12.1* Hct-35.7* MCV-88 MCH-29.7 MCHC-33.9 RDW-12.3 RDWSD-39.0 Plt Ct-88* [MASKED] 04:34AM BLOOD Neuts-80* Bands-0 Lymphs-5* Monos-14* Eos-0 Baso-0 [MASKED] Myelos-1* AbsNeut-6.16* AbsLymp-0.39* AbsMono-1.08* AbsEos-0.00* AbsBaso-0.00* [MASKED] 04:34AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+* Macrocy-NORMAL Microcy-1+* Polychr-1+* Spheroc-1+* Ovalocy-1+* Tear Dr-OCCASIONAL [MASKED] 04:34AM BLOOD Glucose-149* UreaN-7 Creat-1.0 Na-137 K-4.1 Cl-97 HCO3-27 AnGap-13 [MASKED] 04:34AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1 MICROBIOLOGY: ======================= BLOOD/URINE CX NEGATIVE, RESPIRATORY PANEL NEGATIVE, FLU PCR NEGATIVE IMAGING: ======================= [MASKED] CXR: FINDINGS: Lungs are fully expanded and clear. No pleural abnormalities. Heart size is normal. Cardiomediastinal and hilar silhouettes are unremarkable - extensive mediastinal lymphadenopathy previously seen on CT is not appreciated. A dual lumen right IJ central venous Port-A-Cath tip projects over the right atrium. IMPRESSION: No evidence of an acute cardiopulmonary abnormality. Brief Hospital Course: Mr. [MASKED] is a [MASKED] with Hodgkin's lymphoma and primary mediastinal lymphoma who presented with 1 day of low grade fever (max 100.2F) and chills consistent with an upper respiratory infection, likely viral in nature. # Low-grade temperatures # Chills # Nasal congestion/rhinitis: No documented fever but chills, low grade temps, and nasal congestion/rhinitis c/f acute URTI. No other clear infectious symptoms. Young children at home with cold-like symptoms. Flu swab negative, additional respiratory viral panel pending. He likely has as viral process. He had no fevers while inpatient and was able to be discharged with follow-up. # Primary mediastinal lymphoma # Classical Hodgkin's lymphoma: SP 6 cycles EPOCH for mediastinal DLBCL. Now with residual classical Hodgkin's lymphoma. SP C1 ICE with plan for second cycle followed by auto-SCT consolidation. He has recovered his counts from prior ICE cycle and is no longer on neupogen or levoflox ppx. He was continued on home Bactrim and acyclovir ppx. # Tachycardia: Patient has history of bigeminal PVC's and sinus tachycardia. EKG in ED showed sinus tach with PVC's. He is asymptomatic. Appears similar to outpatient rates. Pt states that this is his baseline. Home metoprolol was continued. # History of pancreatitis: Continued home creon. # Biopsychocial - Cont home nortyptiline - Cont home ativan Medications on Admission: The Preadmission Medication list is accurate and complete. 1. colesevelam 625 mg oral BID 2. Creon [MASKED] CAP PO QID PRN meals and snacks 3. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 4. Nortriptyline 10 mg PO QHS 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 6. Acyclovir 400 mg PO Q8H 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Ondansetron ODT 4 mg PO Q8H:PRN nausea 10. Filgrastim 480 mcg SC ASDIR 11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Medications: 1. Filgrastim 480 mcg SC ASDIR 2. Acyclovir 400 mg PO Q8H 3. colesevelam 625 mg oral BID 4. Creon [MASKED] CAP PO QID PRN meals and snacks 5. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Nortriptyline 10 mg PO QHS 8. Ondansetron ODT 4 mg PO Q8H:PRN nausea 9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary: Viral Sinusitis Primary mediastina lymphoma 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 after having low grade fevers, chills and nasal congestion. We checked you for the flu which was negative. We also did a chest x-ray which did not show any pneumonia. You did not have any fevers while you were here. You likely have a virus which is causing nasal congestion. Please keep your follow-up appointments and take your medications as listed below. It was a pleasure taking care of you, -Your [MASKED] Team Followup Instructions: [MASKED]
[]
[]
[ "J0190: Acute sinusitis, unspecified", "B9789: Other viral agents as the cause of diseases classified elsewhere", "C8332: Diffuse large B-cell lymphoma, intrathoracic lymph nodes", "C8190: Hodgkin lymphoma, unspecified, unspecified site", "R000: Tachycardia, unspecified", "K8689: Other specified diseases of pancreas" ]
10,074,556
24,049,696
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Mediastinal Mass Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old male, with past history of acute pancreatitis c/b necrosis requiring necrosectomy in ___, GERD, who is presenting today for expedited workup of a chest mass. Patient was recently seen by the GI department for ___ on ___ because of progressive weight and skin lesions, given history of necrotic pancreatitis. This was notable for a partially visualized heterogeneously enhancing necrotic soft tissue masses within the anterior mediastinum, with the largest masses measuring up to 8.1 cm in the right cardiophrenic space, causing mass effect on the right atrium with possible invasion of the underlying heart. There is also invasion of the chest wall anteriorly with abnormal enhancement within the lower aspect of the sternum suggestive of bony invasion, concerning for an aggressive neoplastic disease. Because of this on MRCP, patient then underwent a CT chest on ___ (delay due to insurance issues), which was remarkable for large necrotic, multi lobulated anterior mediastinal mass/masses with suspected pericardial invasion, with associated chest wall, hilar, axillary and supraclavicular lymphadenopathy. Patient therefore presents to the ED for expedited oncology workup. Patient reports that he started to feel unwell about ___ months prior. He was started to about 15 lb weight loss (unintentionally, ___ lb weight loss per month), with significant night sweats and also pruritis. Notably because of pruritis, patient was evaluated by dermatology and started on some course of prednisone which resulted improvement in the pruritis. He denies any chest pains, palpitations. He does report the dyspnea on exertion with specifically weight lifting. He denies any abdominal pains, nausea/vomiting, diarrhea. Notably, patient was also seen by cardiology on ___ for evaluation of sinus tachycardia. Also noted on that note that patient had been having ongoing weight loss and pruritis. At that time, patient had been recommended endocrinology evaluation and a TTE was ordered. In the ED, initial vitals: 0 98.4 119 149/96 18 100% RA - Labs were significant for: WBC 5.5 (PMN 74%), Hgb 13.2, Hct 40.9, Platelet 319. MCV 83. Sodium 139, K 5.2, Chloride 98, Bicarb 27, BUN 12, Cr 1.2. Glucose 95. - ALT 26, AST 54, AP 98, LDH 636, T-bili 0.5. Uric Acid: 6.5 - Urinalysis: Cloudy, 1.016, pH 7, Trace Protein, RBC 1. - Imaging: None new. - In the ED, s/he received: No medications - Vitals prior to transfer: 0 112 142/72 15 100% RA Upon arrival to the floor, ##### REVIEW OF SYSTEMS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in ___ - GERD - Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: >> Admission Physical Exam: Vital Signs: 99.5 153/86 118 18 97%RA Pulsus - 6 mmHg General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rganomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . >> Discharge Physical Exam: Pertinent Results: >> Admission Labs: ___ 01:30PM BLOOD WBC-5.5 RBC-4.95 Hgb-13.2*# Hct-40.9 MCV-83 MCH-26.7 MCHC-32.3 RDW-12.7 RDWSD-37.9 Plt ___ ___ 01:30PM BLOOD Neuts-74.4* Lymphs-9.0* Monos-15.2* Eos-0.6* Baso-0.4 Im ___ AbsNeut-4.06 AbsLymp-0.49* AbsMono-0.83* AbsEos-0.03* AbsBaso-0.02 ___ 07:15AM BLOOD ___ PTT-29.5 ___ ___ 01:30PM BLOOD Glucose-95 UreaN-12 Creat-1.2 Na-139 K-5.2* Cl-98 HCO3-27 AnGap-19 ___ 01:30PM BLOOD ALT-26 AST-54* LD(LDH)-636* AlkPhos-98 TotBili-0.5 ___ 01:30PM BLOOD b2micro-3.6* ___ 01:30PM BLOOD HCV Ab-Negative ___ 09:28PM BLOOD HIV Ab-Negative . >> Discharge Labs: . >> Pertinent Reports: ___ Cardiovascular ECHO; The left atrium is normal in size. 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. The estimated cardiac index is normal (>=2.5L/min/m2). Diastolic function could not be assessed. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Normal global biventricular systolic function. Technically suboptimal to exclude focal wall motion abnormality. Small to moderate circumferential pericardial effusion without echocardiographic signs of tamponade. . ___HEST W/CONTRAST: Large necrotic, multilobulated anterior mediastinal mass/masses with suspected pericardial invasion. Associated chest wall, hilar, axillary and supraclavicular lymphadenopathy. The nodule in the left upper lobe is concerning for pulmonary involvement of this neoplastic process. At the top of my differential diagnosis consider lymphoma, other diagnostic considerations include thymic carcinoma and less likely an immature germ cell tumor or sarcomatous lesion. After review of the MR images, there is apparent loss of the fascial plane between the right pericardial mass and the right atrium which is concerning for myocardial infiltration. Correlation with histology advised. Left axillary lymph nodes would be amenable to biopsy. In the differential diagnosis for the pulmonary nodule consider a primary lung malignancy (would be unlikely though) and infection. Brief Hospital Course: Mr. ___ is a ___ year old male, with past history of pancreatic necrosis s/p necresectomy in ___, now with imaging concerning for large mediastinal mass found to have DLBCL. # Mediastinal Mass, DLBCL: Patient is having now invasion of a large mediastinal mass/masses with necrosis, with suspected pericardial and chest wall invasion. There is significant lymphadenopathy as well that is associated with this. Given location and size, as well as B-symptoms, this would be concerning most likely for a lymphoma process type process at top of differential for malignancy. Most notable at this time is potentially compression of the SVC as well invasion into the pericardium, however at this time clinically stable without pulsus. Pt had axillary lymph node biopsies given that an MRCP for routine pancreatitis incidentally found a mediastinal mass concerning for lymphoma. Pt later transferred from medicine to ___ given concerns of active lymphoma. Biopsies showed DLBCL. Decision was made to pursue EPOCH treatment, rituxan was deferred for cycle 1 given tumor burden. Pt tolerated EPOCH without complications, some bowel concerns with alternating constipation and diarrhea but resolved at discharge. Pt also taught neupogen injections which he will continue outpatient. No concerns with tumor lysis syndrome given labs and ECHO, hepatitis non-concerning. Patient will follow up with oncology within the next week. Pt will receive a phone call to make this appointment. #Sinus tachycardia: Patient found to be tachycardic HR 120s for past 6 months, unclear etiology initially and saw cardiologist outpatient who started beta-blocker which was later discontinued by another cardiologist. Pt's ECHO was unrevealing although CT showed involvement of the SVC and RA. Tachycardia improved at discharge with HR in 80-100s. # History of Acute Pancreatitis now s/p necresectomy: patient has been tolerating well, with increased weight loss now likely ___ to underlying process. Continued creon, colesevelam, nortriptyline. Hyocyamine held in setting of diarrhea. # GERD Continued pantoprazole. TRANSITIONAL ====================== -Pt is to continue neupogen and pick this up outpatient. He has been informed regarding this and how to self-inject. -Pt will follow up with oncology now that his cycle 1 of EPOCH is complete. He will receive a phone call regarding the appointment time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 2 CAP PO TID W/MEALS 2. colesevelam 625 mg oral BID 3. Nortriptyline 10 mg PO QHS 4. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO TID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth up to three times a day as needed Disp #*30 Capsule Refills:*0 2. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting RX *lorazepam [Ativan] 0.5 mg ___ tabs by mouth every 12 hours as needed Disp #*30 Tablet Refills:*0 3. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hrs as needed for nausea Disp #*30 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s) by mouth as needed daily Refills:*0 5. Senna 17.2 mg PO BID constipation RX *sennosides [senna] 8.8 mg/5 mL 1 syrup by mouth ___ tablespoon Refills:*0 6. WelChol (colesevelam) 625 mg PO BID 7. Creon (lipase-protease-amylase) 3 caps PO TID W/MEALS 8. colesevelam 625 mg oral BID 9. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID 10. Nortriptyline 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== DLBCL SECONDARY DIAGNOSIS ==================== pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted for your lymphoma which was classified as diffuse large B-cell lymphoma. You were treated with chemotherapy called EPOCH and you tolerated the chemotherapy well without severe symptoms. You will continue neupogen injections at home, and this has been explained to you. If you have worsening symptoms of nausea, fever, chills, shortness of breath, please return for further evaluation. It was a pleasure taking care of you at ___! Your ___ Team Followup Instructions: ___
[ "C8332", "I96", "K861", "K219", "Z800" ]
Allergies: Penicillins Chief Complaint: Mediastinal Mass Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] year old male, with past history of acute pancreatitis c/b necrosis requiring necrosectomy in [MASKED], GERD, who is presenting today for expedited workup of a chest mass. Patient was recently seen by the GI department for [MASKED] on [MASKED] because of progressive weight and skin lesions, given history of necrotic pancreatitis. This was notable for a partially visualized heterogeneously enhancing necrotic soft tissue masses within the anterior mediastinum, with the largest masses measuring up to 8.1 cm in the right cardiophrenic space, causing mass effect on the right atrium with possible invasion of the underlying heart. There is also invasion of the chest wall anteriorly with abnormal enhancement within the lower aspect of the sternum suggestive of bony invasion, concerning for an aggressive neoplastic disease. Because of this on MRCP, patient then underwent a CT chest on [MASKED] (delay due to insurance issues), which was remarkable for large necrotic, multi lobulated anterior mediastinal mass/masses with suspected pericardial invasion, with associated chest wall, hilar, axillary and supraclavicular lymphadenopathy. Patient therefore presents to the ED for expedited oncology workup. Patient reports that he started to feel unwell about [MASKED] months prior. He was started to about 15 lb weight loss (unintentionally, [MASKED] lb weight loss per month), with significant night sweats and also pruritis. Notably because of pruritis, patient was evaluated by dermatology and started on some course of prednisone which resulted improvement in the pruritis. He denies any chest pains, palpitations. He does report the dyspnea on exertion with specifically weight lifting. He denies any abdominal pains, nausea/vomiting, diarrhea. Notably, patient was also seen by cardiology on [MASKED] for evaluation of sinus tachycardia. Also noted on that note that patient had been having ongoing weight loss and pruritis. At that time, patient had been recommended endocrinology evaluation and a TTE was ordered. In the ED, initial vitals: 0 98.4 119 149/96 18 100% RA - Labs were significant for: WBC 5.5 (PMN 74%), Hgb 13.2, Hct 40.9, Platelet 319. MCV 83. Sodium 139, K 5.2, Chloride 98, Bicarb 27, BUN 12, Cr 1.2. Glucose 95. - ALT 26, AST 54, AP 98, LDH 636, T-bili 0.5. Uric Acid: 6.5 - Urinalysis: Cloudy, 1.016, pH 7, Trace Protein, RBC 1. - Imaging: None new. - In the ED, s/he received: No medications - Vitals prior to transfer: 0 112 142/72 15 100% RA Upon arrival to the floor, ##### REVIEW OF SYSTEMS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] - GERD - Nephrolithiasis Social History: [MASKED] Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: >> Admission Physical Exam: Vital Signs: 99.5 153/86 118 18 97%RA Pulsus - 6 mmHg General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rganomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . >> Discharge Physical Exam: Pertinent Results: >> Admission Labs: [MASKED] 01:30PM BLOOD WBC-5.5 RBC-4.95 Hgb-13.2*# Hct-40.9 MCV-83 MCH-26.7 MCHC-32.3 RDW-12.7 RDWSD-37.9 Plt [MASKED] [MASKED] 01:30PM BLOOD Neuts-74.4* Lymphs-9.0* Monos-15.2* Eos-0.6* Baso-0.4 Im [MASKED] AbsNeut-4.06 AbsLymp-0.49* AbsMono-0.83* AbsEos-0.03* AbsBaso-0.02 [MASKED] 07:15AM BLOOD [MASKED] PTT-29.5 [MASKED] [MASKED] 01:30PM BLOOD Glucose-95 UreaN-12 Creat-1.2 Na-139 K-5.2* Cl-98 HCO3-27 AnGap-19 [MASKED] 01:30PM BLOOD ALT-26 AST-54* LD(LDH)-636* AlkPhos-98 TotBili-0.5 [MASKED] 01:30PM BLOOD b2micro-3.6* [MASKED] 01:30PM BLOOD HCV Ab-Negative [MASKED] 09:28PM BLOOD HIV Ab-Negative . >> Discharge Labs: . >> Pertinent Reports: [MASKED] Cardiovascular ECHO; The left atrium is normal in size. 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. The estimated cardiac index is normal (>=2.5L/min/m2). Diastolic function could not be assessed. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Normal global biventricular systolic function. Technically suboptimal to exclude focal wall motion abnormality. Small to moderate circumferential pericardial effusion without echocardiographic signs of tamponade. . HEST W/CONTRAST: Large necrotic, multilobulated anterior mediastinal mass/masses with suspected pericardial invasion. Associated chest wall, hilar, axillary and supraclavicular lymphadenopathy. The nodule in the left upper lobe is concerning for pulmonary involvement of this neoplastic process. At the top of my differential diagnosis consider lymphoma, other diagnostic considerations include thymic carcinoma and less likely an immature germ cell tumor or sarcomatous lesion. After review of the MR images, there is apparent loss of the fascial plane between the right pericardial mass and the right atrium which is concerning for myocardial infiltration. Correlation with histology advised. Left axillary lymph nodes would be amenable to biopsy. In the differential diagnosis for the pulmonary nodule consider a primary lung malignancy (would be unlikely though) and infection. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male, with past history of pancreatic necrosis s/p necresectomy in [MASKED], now with imaging concerning for large mediastinal mass found to have DLBCL. # Mediastinal Mass, DLBCL: Patient is having now invasion of a large mediastinal mass/masses with necrosis, with suspected pericardial and chest wall invasion. There is significant lymphadenopathy as well that is associated with this. Given location and size, as well as B-symptoms, this would be concerning most likely for a lymphoma process type process at top of differential for malignancy. Most notable at this time is potentially compression of the SVC as well invasion into the pericardium, however at this time clinically stable without pulsus. Pt had axillary lymph node biopsies given that an MRCP for routine pancreatitis incidentally found a mediastinal mass concerning for lymphoma. Pt later transferred from medicine to [MASKED] given concerns of active lymphoma. Biopsies showed DLBCL. Decision was made to pursue EPOCH treatment, rituxan was deferred for cycle 1 given tumor burden. Pt tolerated EPOCH without complications, some bowel concerns with alternating constipation and diarrhea but resolved at discharge. Pt also taught neupogen injections which he will continue outpatient. No concerns with tumor lysis syndrome given labs and ECHO, hepatitis non-concerning. Patient will follow up with oncology within the next week. Pt will receive a phone call to make this appointment. #Sinus tachycardia: Patient found to be tachycardic HR 120s for past 6 months, unclear etiology initially and saw cardiologist outpatient who started beta-blocker which was later discontinued by another cardiologist. Pt's ECHO was unrevealing although CT showed involvement of the SVC and RA. Tachycardia improved at discharge with HR in 80-100s. # History of Acute Pancreatitis now s/p necresectomy: patient has been tolerating well, with increased weight loss now likely [MASKED] to underlying process. Continued creon, colesevelam, nortriptyline. Hyocyamine held in setting of diarrhea. # GERD Continued pantoprazole. TRANSITIONAL ====================== -Pt is to continue neupogen and pick this up outpatient. He has been informed regarding this and how to self-inject. -Pt will follow up with oncology now that his cycle 1 of EPOCH is complete. He will receive a phone call regarding the appointment time. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon 12 2 CAP PO TID W/MEALS 2. colesevelam 625 mg oral BID 3. Nortriptyline 10 mg PO QHS 4. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO TID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth up to three times a day as needed Disp #*30 Capsule Refills:*0 2. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting RX *lorazepam [Ativan] 0.5 mg [MASKED] tabs by mouth every 12 hours as needed Disp #*30 Tablet Refills:*0 3. Ondansetron ODT 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hrs as needed for nausea Disp #*30 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s) by mouth as needed daily Refills:*0 5. Senna 17.2 mg PO BID constipation RX *sennosides [senna] 8.8 mg/5 mL 1 syrup by mouth [MASKED] tablespoon Refills:*0 6. WelChol (colesevelam) 625 mg PO BID 7. Creon (lipase-protease-amylase) 3 caps PO TID W/MEALS 8. colesevelam 625 mg oral BID 9. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID 10. Nortriptyline 10 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== DLBCL SECONDARY DIAGNOSIS ==================== pancreatitis 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 your lymphoma which was classified as diffuse large B-cell lymphoma. You were treated with chemotherapy called EPOCH and you tolerated the chemotherapy well without severe symptoms. You will continue neupogen injections at home, and this has been explained to you. If you have worsening symptoms of nausea, fever, chills, shortness of breath, please return for further evaluation. It was a pleasure taking care of you at [MASKED]! Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "K219" ]
[ "C8332: Diffuse large B-cell lymphoma, intrathoracic lymph nodes", "I96: Gangrene, not elsewhere classified", "K861: Other chronic pancreatitis", "K219: Gastro-esophageal reflux disease without esophagitis", "Z800: Family history of malignant neoplasm of digestive organs" ]
10,074,556
25,566,058
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Bactrim Attending: ___. Chief Complaint: C3 da-EPOCH Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ man with recent diagnosis of primary mediastinal lymphoma who is admitted for planned third cycle of DA-EPOCH. He originally presented for 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient he is currently s/p 2C c/b mucositis otherwise no acute issues. He now presents for C3. Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in ___ - GERD - Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.1 HR 76 BP 138/70 RR 18 SAT 96% O2 on RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes RECTAL: External exam normal LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: VITALS - weight 81.87 kg, T 98.1, BP 142/70, HR 89, R 18, SpO2 97%/RA GENERAL - well-appearing, in no distress HEENT - sclerae anicteric, PERRL, no mucositis NECK - supple CARDIAC - regular, normal S1/S2, no murmur RESPIRATORY - clear to auscultation bilaterally ABDOMEN - soft, non-tender, non-distended, well-healed midline scar EXTREMITIES - no peripheral edema, warm SKIN - no rash Pertinent Results: ___ 12:00AM BLOOD WBC-3.4* RBC-4.13* Hgb-11.4* Hct-34.0* MCV-82 MCH-27.6 MCHC-33.5 RDW-18.4* RDWSD-53.2* Plt ___ ___ 09:50AM BLOOD WBC-4.2# RBC-4.58* Hgb-12.6* Hct-37.9* MCV-83 MCH-27.5 MCHC-33.2 RDW-18.8* RDWSD-53.1* Plt ___ ___ 12:00AM BLOOD Neuts-89.4* Lymphs-5.6* Monos-3.5* Eos-0.0* Baso-0.0 Im ___ AbsNeut-3.06 AbsLymp-0.19* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* ___ 09:50AM BLOOD Neuts-77* Bands-1 Lymphs-13* Monos-6 Eos-1 Baso-0 ___ Metas-2* Myelos-0 NRBC-1* AbsNeut-3.28 AbsLymp-0.55* AbsMono-0.25 AbsEos-0.04 AbsBaso-0.00* ___ 12:00AM BLOOD Glucose-120* UreaN-18 Creat-0.8 Na-142 K-3.9 Cl-102 HCO3-26 AnGap-18 ___ 09:50AM BLOOD UreaN-15 Creat-1.0 Na-135 K-3.8 ___ 12:00AM BLOOD ALT-71* AST-40 LD(___)-199 AlkPhos-73 TotBili-1.2 ___ 09:50AM BLOOD ALT-23 AST-17 LD(___)-228 AlkPhos-109 TotBili-0.4 ___ 12:00AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.3 Mg-2.2 UricAcd-3.8 ___ 09:50AM BLOOD Albumin-4.3 Calcium-9.4 Phos-3.3 Mg-1.9 UricAcd-6.3 Brief Hospital Course: Mr. ___ is a ___ year old man with recent diagnosis of primary mediastinal lymphoma who is admitted for planned third cycle of DA-EPOCH. ACTIVE ISSUES # Primary mediastinal lymphoma: completed 2 cycles of DA-EPOCH, which he tolerated well despite mucositis. Cardiac MR after discharge shows no invasion into heart or large vessels; scan from ___ also without cardiac invasion and disease response. Uric acid down from 6.3 to 3.7. - Continue C3 R-EPOCH - Continue acyclovir & atovaquone prophylaxis - No need for allopurinol at this time - Will require GCSF on discharge will start ___ - f/u ___ or sooner if issues asrise # Constipation: - Colace/Senna daily to BID - Increase Miralax to BID CHRONIC/INACTIVE ISSUES: # Chronic pancreatitis, # Pancreatic divisum, # Pancreatic pseudocyst: Not currently symptomatic. - Continue home Creon, colesevelam, and nortriptyline # GERD: asymptomatic. - Ranitidine prn # Mucositis: inactive. - Continue nystatin & Magic Mouthwash CORE MEASURES: # ACCESS: PICC # FEN: regular diet, sliding scale # PROPHYLAXIS: enoxaparin, acyclovir, atovaquone # PAIN CONTROL: PRN oxycodone # BOWEL REGIMEN: Senna/Colace, MiraLax # CONTACT: ___, wife, HCP, ___ # DISPOSITION: home once chemo completes # CODE STATUS: presumed Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Atovaquone Suspension 1500 mg PO DAILY 3. colesevelam 625 mg oral BID 4. Filgrastim 480 mcg SC Q24H 5. Levofloxacin 500 mg PO Q24H 6. Creon 12 2 CAP PO TID W/MEALS 7. Creon ___ CAP PO QID:PRN snacks 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Docusate Sodium 100 mg PO BID 16. Senna 8.6 mg PO BID 17. Polyethylene Glycol 17 g PO DAILY constipation Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Atovaquone Suspension 1500 mg PO DAILY 3. colesevelam 625 mg oral BID 4. Creon ___ CAP PO QID:PRN snacks 5. Creon 12 2 CAP PO TID W/MEALS 6. Docusate Sodium 100 mg PO BID 7. Filgrastim 480 mcg SC Q24H 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Senna 8.6 mg PO BID 17. HELD- Levofloxacin 500 mg PO Q24H This medication was held. Do not restart Levofloxacin until outpatient team tells you to do so Discharge Disposition: Home Discharge Diagnosis: lymphoma 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 receive your third cycle of chemotherapy for your lymphoma. You tolerated this very well. You gained fluid weight due to the chemotherapy, which improved with decreasing your IV fluids. You will inject neupogen daily starting ___, continue until you are told to stop. You will continue to take medications to prevent infection: acyclovir. Dr. ___ start you on another medication called Dapsone outpatient to prevent a certain type of pneumonia while your immune system is low, he will discuss this with you at your next appointment visit. Your nausea medications are as follows: 1 zofran 2 ativan Please continue to take colace and senna for the next two weeks as ordered. If your stools become frequent, you may decrease the senna to once daily. If you become constipated despite the colace/senna, please purchase miralax over the counter and use this daily. If you remain constipated despite these medications, please call us. Please drink enough fluids so that your urine is close to clear (this is usually between 48-64 oz of fluid per day). You will follow up in the outpatient clinic as stated below. Please do not hesitate to call in the meantime with any questions or concerns. Followup Instructions: ___
[ "Z5111", "C8332", "K863", "K861", "K219", "K1231", "T451X5A", "K5900", "Y929" ]
Allergies: Penicillins / Bactrim Chief Complaint: C3 da-EPOCH Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] man with recent diagnosis of primary mediastinal lymphoma who is admitted for planned third cycle of DA-EPOCH. He originally presented for 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient he is currently s/p 2C c/b mucositis otherwise no acute issues. He now presents for C3. Past Medical History: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] - GERD - Nephrolithiasis Social History: [MASKED] Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 98.1 HR 76 BP 138/70 RR 18 SAT 96% O2 on RA GENERAL: Pleasant, lying in bed comfortably EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes RECTAL: External exam normal LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE PHYSICAL EXAM: VITALS - weight 81.87 kg, T 98.1, BP 142/70, HR 89, R 18, SpO2 97%/RA GENERAL - well-appearing, in no distress HEENT - sclerae anicteric, PERRL, no mucositis NECK - supple CARDIAC - regular, normal S1/S2, no murmur RESPIRATORY - clear to auscultation bilaterally ABDOMEN - soft, non-tender, non-distended, well-healed midline scar EXTREMITIES - no peripheral edema, warm SKIN - no rash Pertinent Results: [MASKED] 12:00AM BLOOD WBC-3.4* RBC-4.13* Hgb-11.4* Hct-34.0* MCV-82 MCH-27.6 MCHC-33.5 RDW-18.4* RDWSD-53.2* Plt [MASKED] [MASKED] 09:50AM BLOOD WBC-4.2# RBC-4.58* Hgb-12.6* Hct-37.9* MCV-83 MCH-27.5 MCHC-33.2 RDW-18.8* RDWSD-53.1* Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-89.4* Lymphs-5.6* Monos-3.5* Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-3.06 AbsLymp-0.19* AbsMono-0.12* AbsEos-0.00* AbsBaso-0.00* [MASKED] 09:50AM BLOOD Neuts-77* Bands-1 Lymphs-13* Monos-6 Eos-1 Baso-0 [MASKED] Metas-2* Myelos-0 NRBC-1* AbsNeut-3.28 AbsLymp-0.55* AbsMono-0.25 AbsEos-0.04 AbsBaso-0.00* [MASKED] 12:00AM BLOOD Glucose-120* UreaN-18 Creat-0.8 Na-142 K-3.9 Cl-102 HCO3-26 AnGap-18 [MASKED] 09:50AM BLOOD UreaN-15 Creat-1.0 Na-135 K-3.8 [MASKED] 12:00AM BLOOD ALT-71* AST-40 LD([MASKED])-199 AlkPhos-73 TotBili-1.2 [MASKED] 09:50AM BLOOD ALT-23 AST-17 LD([MASKED])-228 AlkPhos-109 TotBili-0.4 [MASKED] 12:00AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.3 Mg-2.2 UricAcd-3.8 [MASKED] 09:50AM BLOOD Albumin-4.3 Calcium-9.4 Phos-3.3 Mg-1.9 UricAcd-6.3 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with recent diagnosis of primary mediastinal lymphoma who is admitted for planned third cycle of DA-EPOCH. ACTIVE ISSUES # Primary mediastinal lymphoma: completed 2 cycles of DA-EPOCH, which he tolerated well despite mucositis. Cardiac MR after discharge shows no invasion into heart or large vessels; scan from [MASKED] also without cardiac invasion and disease response. Uric acid down from 6.3 to 3.7. - Continue C3 R-EPOCH - Continue acyclovir & atovaquone prophylaxis - No need for allopurinol at this time - Will require GCSF on discharge will start [MASKED] - f/u [MASKED] or sooner if issues asrise # Constipation: - Colace/Senna daily to BID - Increase Miralax to BID CHRONIC/INACTIVE ISSUES: # Chronic pancreatitis, # Pancreatic divisum, # Pancreatic pseudocyst: Not currently symptomatic. - Continue home Creon, colesevelam, and nortriptyline # GERD: asymptomatic. - Ranitidine prn # Mucositis: inactive. - Continue nystatin & Magic Mouthwash CORE MEASURES: # ACCESS: PICC # FEN: regular diet, sliding scale # PROPHYLAXIS: enoxaparin, acyclovir, atovaquone # PAIN CONTROL: PRN oxycodone # BOWEL REGIMEN: Senna/Colace, MiraLax # CONTACT: [MASKED], wife, HCP, [MASKED] # DISPOSITION: home once chemo completes # CODE STATUS: presumed Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Atovaquone Suspension 1500 mg PO DAILY 3. colesevelam 625 mg oral BID 4. Filgrastim 480 mcg SC Q24H 5. Levofloxacin 500 mg PO Q24H 6. Creon 12 2 CAP PO TID W/MEALS 7. Creon [MASKED] CAP PO QID:PRN snacks 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Docusate Sodium 100 mg PO BID 16. Senna 8.6 mg PO BID 17. Polyethylene Glycol 17 g PO DAILY constipation Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Atovaquone Suspension 1500 mg PO DAILY 3. colesevelam 625 mg oral BID 4. Creon [MASKED] CAP PO QID:PRN snacks 5. Creon 12 2 CAP PO TID W/MEALS 6. Docusate Sodium 100 mg PO BID 7. Filgrastim 480 mcg SC Q24H 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Senna 8.6 mg PO BID 17. HELD- Levofloxacin 500 mg PO Q24H This medication was held. Do not restart Levofloxacin until outpatient team tells you to do so Discharge Disposition: Home Discharge Diagnosis: lymphoma 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 receive your third cycle of chemotherapy for your lymphoma. You tolerated this very well. You gained fluid weight due to the chemotherapy, which improved with decreasing your IV fluids. You will inject neupogen daily starting [MASKED], continue until you are told to stop. You will continue to take medications to prevent infection: acyclovir. Dr. [MASKED] start you on another medication called Dapsone outpatient to prevent a certain type of pneumonia while your immune system is low, he will discuss this with you at your next appointment visit. Your nausea medications are as follows: 1 zofran 2 ativan Please continue to take colace and senna for the next two weeks as ordered. If your stools become frequent, you may decrease the senna to once daily. If you become constipated despite the colace/senna, please purchase miralax over the counter and use this daily. If you remain constipated despite these medications, please call us. Please drink enough fluids so that your urine is close to clear (this is usually between 48-64 oz of fluid per day). You will follow up in the outpatient clinic as stated below. Please do not hesitate to call in the meantime with any questions or concerns. Followup Instructions: [MASKED]
[]
[ "K219", "K5900", "Y929" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8332: Diffuse large B-cell lymphoma, intrathoracic lymph nodes", "K863: Pseudocyst of pancreas", "K861: Other chronic pancreatitis", "K219: Gastro-esophageal reflux disease without esophagitis", "K1231: Oral mucositis (ulcerative) due to antineoplastic therapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "K5900: Constipation, unspecified", "Y929: Unspecified place or not applicable" ]
10,074,556
27,273,088
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: autologous stem cell transplant Major Surgical or Invasive Procedure: tunneled line removal prior to discharge History of Present Illness: ___ with composite primary mediastinal and classical hodgkin's lymphoma s/p chemotherapy as per oncologic history who is admitted for planned autologous transplant with BEAM conditioning as consolidation therapy. His oncologic history is well documented below and from prior notes. Briefly, per OMR "He is s/p 6 cycles of dose adjusted EPOCH in ___ (Rituxan was added with ___ cycle). We went up to dose level 4 with the ___, and ___ cycles. Patient with admission this week for chills, vague abdominal/gas pains and nausea in setting of neutropenia. CT abd/pelvis with no acute process. Also, r/o for acute pancreatitis given hx. ? Vague ill-defined opacity within the medial aspect of the right lower lobe on chest xray. Transitioned to po antibiotics and sent home to complete course of cefpodoxime. Treatment was also completed by mucositis. Repeat PET-CT upon completion of upfront chemotherapy with residual uptake. He underwent a right video assisted thoroscopy mediastinal lymph node biopsy which ultimately came back positive for classical hodgkin's lymphoma with no residual evidence for viable DLBCL. Ultimately decision made to proceed with 2 cycles of ICE chemotherapy followed by an Autologous stem cell transplant for consolidation." Past Medical History: PAST ONCOLOGIC HISTORY: As per Dr ___ clinic note: "Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. - EPOCH C1 ___ - DA-R-EPOCH dose level 2 (Rituxan on last day of chemo) ___ - DA-R-EPOCH dose level 3 ___ - DA-R-EPOCH dose level 4 ___ - DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg - DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg ICE- ___ PAST MEDICAL HISTORY: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in ___ - GERD - Nephrolithiasis - Arrhythmia Social History: ___ Family History: Mother and father with hypertension. No known family history of leukemia or lymphoma. Physical Exam: DISCHARGE PHYSICAL EXAM: Vitals: Temp: 97.7 (Tm 97.9), BP: 126/58 (126-135/58-91), HR: 77 (77-91), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA, Wt: 186.6 lb/84.64 kg Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: no appreciable JVP LYMPH: No cervical or supraclav LAD CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: WWP. No ___ edema. SKIN: No rashes/lesions, petechiae/purpura ecchymoses. NEURO: A&Ox3. LINES: R chest CVC, L chest central line both c/d/I DISCHARGE PHYSICAL EXAM: T 97.9 BP 120/90 HR 113 RR 18 O2 99% Gen: Pleasant, calm and NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: no appreciable JVP LYMPH: No cervical or supraclavicular LAD CV: mild tachycardia, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT/ND. EXT: WWP. No ___ edema. SKIN: No rashes/lesions, petechiae/purpura ecchymosis. NEURO: A&Ox3. Grossly non-focal LINES: R chest CVC C/D/I Pertinent Results: ADMISSION LABS: ___ 09:05AM BLOOD WBC-2.5*# RBC-3.98* Hgb-11.9* Hct-35.0* MCV-88 MCH-29.9 MCHC-34.0 RDW-16.5* RDWSD-50.8* Plt ___ ___ 09:05AM BLOOD Neuts-62.4 Lymphs-18.8* Monos-17.6* Eos-0.4* Baso-0.4 Im ___ AbsNeut-1.53*# AbsLymp-0.46* AbsMono-0.43 AbsEos-0.01* AbsBaso-0.01 ___ 09:05AM BLOOD Glucose-141* UreaN-12 Creat-0.9 Na-140 K-3.9 Cl-102 HCO3-25 AnGap-13 ___ 09:05AM BLOOD ALT-14 AST-16 LD(LDH)-154 AlkPhos-92 TotBili-0.3 DirBili-<0.2 IndBili-0.3 ___ 09:05AM BLOOD TotProt-6.6 Albumin-4.4 Globuln-2.2 Calcium-9.2 Phos-3.0 Mg-2.1 UricAcd-4.5 DISCHARGE LABS: ___ 12:00AM BLOOD WBC-13.8* RBC-2.89* Hgb-8.6* Hct-25.8* MCV-89 MCH-29.8 MCHC-33.3 RDW-16.1* RDWSD-47.3* Plt Ct-35* ___ 12:00AM BLOOD Neuts-71 Bands-1 Lymphs-6* Monos-14* Eos-0 Baso-0 ___ Metas-1* Myelos-2* Promyel-1* Blasts-4* AbsNeut-9.94* AbsLymp-0.83* AbsMono-1.93* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Glucose-126* UreaN-5* Creat-0.9 Na-144 K-4.0 Cl-102 HCO3-26 AnGap-16 ___ 12:00AM BLOOD ALT-25 AST-28 LD(LDH)-335* AlkPhos-144* TotBili-0.3 ___ 12:00AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.4 Mg-1.___ with composite primary mediastinal and classical Hodgkin's lymphoma s/p chemotherapy now admitted for planned autologous transplant with BEAM conditioning as consolidation therapy. ACUTE ISSUES: ============= #Composite Lymphoma: admitted for AutoSCT w/ BEAM -Conditioning per protocol -D0 re-infusion, 3 BAGS INFUSED ___ TOTAL CD34/kg= 6.81e6 -Filgrastim on D+4, started ___ -hold home TMP/SMX until Day +21 or plt count recovery -Supportive care per protocol - d/c to apartments ___ and f/u to be arranged ___ or sooner if issues arise #Pancytopenia: recovering. likely due to high dose chemotherapy -Transfuse if plts < 10 and/or hgb < 7 -Received platelets ___ -off neupogen #Tachycardia: Improving. Regular rhythm, suspect volume depletion from decreased PO intake and diarrhea (though now improved). Does have history of sinus tachy with PVCs, on meto with parameters -IVF bolus PRN -f/u with Dr. ___ CHRONIC/STABLE ISSUES: ====================== #Febrile Neutrapenia: Resolved. First spike on ___ with a T max of 103. He has been afebrile since then. Initially, c/o generalized unwell feeling, nausea, mild mucositis and diarrhea but overall these symptoms have now resolved. He was initiated empirically on vancomycin and cefepime given severe neutropenia but this has been discontinued in the setting of counts recovery. No identified source of infection. -u/a bland and urine culture neg -F/U b culture -vanco/cefe (day 1: ___ -Tylenol, supportive care, monitor fever curve #Pancreas Divisum #History of acute pancreatitis and necrosectomy Continue home colesevelam and Creon #Nausea: Improving, -will go home with ondansetron compazine and ativan as needed #Diarrhea (resolved) #Pain with defecation: resolved, suspect secondary to melphalan and likely secondary to mucositis -Imodium PRN, supportive care prn #Insomnia/Anxiety: Continue home nortryptiline and trazadone #Chronic pain: Continue prn oxycodone #FEN: IVF PRN/Replete PRN/Transplant low-bacteria diet #ACCESS: L central line #PROPHYLAXIS: -Pain: oxycodone prn -Bowel: prn -GI: prn -DVT: holding lovenox given TCP #CODE: Full #CONTACT: Name of health care proxy: ___ Relationship: Spouse Phone number: ___ #DISPO: to apartments Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon ___ CAP PO TID W/MEALS meals and snacks 4. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Nortriptyline 10 mg PO QHS 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Medications: 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Prochlorperazine ___ mg PO Q6H:PRN nausea 3. Ranitidine 150 mg PO DAILY:PRN HEARTBURN 4. TraZODone 25 mg PO QHS:PRN insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth @hs prn Disp #*30 Tablet Refills:*0 5. Acyclovir 400 mg PO Q8H 6. colesevelam 625 mg oral BID 7. Creon ___ CAP PO TID W/MEALS meals and snacks 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Nortriptyline 10 mg PO QHS 11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY DO NOT START UNTIL THE OUTPATIENT TEAM TELLS YOU TO DO SO Discharge Disposition: Home Discharge Diagnosis: composite lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___ You were admitted for an autologous stem cell transplant. You had a fever and mouth pain while your blood counts were low. We did a work up including blood testing, urine testing, and chest x rays which did not find a source of infection. You were placed on antibiotics for your fever spikes and your fevers resolved. You also developed nausea, diarrhea and loss of appetite while you were admitted. These are common side effects after transplant and your symptoms continue to improve. Your nausea medications are as follows: 1 zofran 2 ativan 3 compazine You will continue to take acyclovir to prevent infection. You will start to take Bactrim to prevent a certain type of pneumonia once your counts have fully recovered. Your outpatient provider ___ tell you when to start this. Please take your temperature twice a day, and call us if it goes above 100.4. Please be sure to drink at least 2L (64oz) of fluid daily. Call if you are unable to do so, or if you have worsening nausea or watery stools. It has been a pleasure taking care of you. Followup Instructions: ___
[ "C8172", "C8334", "D701", "K521", "K8689", "Y92230", "E869", "T451X5A", "R000", "I493", "R5081", "R110", "K1231", "G4700", "F419", "G8929", "Z006" ]
Allergies: Penicillins Chief Complaint: autologous stem cell transplant Major Surgical or Invasive Procedure: tunneled line removal prior to discharge History of Present Illness: [MASKED] with composite primary mediastinal and classical hodgkin's lymphoma s/p chemotherapy as per oncologic history who is admitted for planned autologous transplant with BEAM conditioning as consolidation therapy. His oncologic history is well documented below and from prior notes. Briefly, per OMR "He is s/p 6 cycles of dose adjusted EPOCH in [MASKED] (Rituxan was added with [MASKED] cycle). We went up to dose level 4 with the [MASKED], and [MASKED] cycles. Patient with admission this week for chills, vague abdominal/gas pains and nausea in setting of neutropenia. CT abd/pelvis with no acute process. Also, r/o for acute pancreatitis given hx. ? Vague ill-defined opacity within the medial aspect of the right lower lobe on chest xray. Transitioned to po antibiotics and sent home to complete course of cefpodoxime. Treatment was also completed by mucositis. Repeat PET-CT upon completion of upfront chemotherapy with residual uptake. He underwent a right video assisted thoroscopy mediastinal lymph node biopsy which ultimately came back positive for classical hodgkin's lymphoma with no residual evidence for viable DLBCL. Ultimately decision made to proceed with 2 cycles of ICE chemotherapy followed by an Autologous stem cell transplant for consolidation." Past Medical History: PAST ONCOLOGIC HISTORY: As per Dr [MASKED] clinic note: "Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. - EPOCH C1 [MASKED] - DA-R-EPOCH dose level 2 (Rituxan on last day of chemo) [MASKED] - DA-R-EPOCH dose level 3 [MASKED] - DA-R-EPOCH dose level 4 [MASKED] - DA-R-EPOCH dose level 4 [MASKED]- Vincristine cap at 2mg - DA-R-EPOCH dose level 4 [MASKED]- Vincristine cap at 2mg ICE- [MASKED] PAST MEDICAL HISTORY: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] - GERD - Nephrolithiasis - Arrhythmia Social History: [MASKED] Family History: Mother and father with hypertension. No known family history of leukemia or lymphoma. Physical Exam: DISCHARGE PHYSICAL EXAM: Vitals: Temp: 97.7 (Tm 97.9), BP: 126/58 (126-135/58-91), HR: 77 (77-91), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA, Wt: 186.6 lb/84.64 kg Gen: Pleasant, calm HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: no appreciable JVP LYMPH: No cervical or supraclav LAD CV: Normocardic, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT, ND. EXT: WWP. No [MASKED] edema. SKIN: No rashes/lesions, petechiae/purpura ecchymoses. NEURO: A&Ox3. LINES: R chest CVC, L chest central line both c/d/I DISCHARGE PHYSICAL EXAM: T 97.9 BP 120/90 HR 113 RR 18 O2 99% Gen: Pleasant, calm and NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: no appreciable JVP LYMPH: No cervical or supraclavicular LAD CV: mild tachycardia, regular. Normal S1,S2. No MRG. LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. ABD: NABS. Soft, NT/ND. EXT: WWP. No [MASKED] edema. SKIN: No rashes/lesions, petechiae/purpura ecchymosis. NEURO: A&Ox3. Grossly non-focal LINES: R chest CVC C/D/I Pertinent Results: ADMISSION LABS: [MASKED] 09:05AM BLOOD WBC-2.5*# RBC-3.98* Hgb-11.9* Hct-35.0* MCV-88 MCH-29.9 MCHC-34.0 RDW-16.5* RDWSD-50.8* Plt [MASKED] [MASKED] 09:05AM BLOOD Neuts-62.4 Lymphs-18.8* Monos-17.6* Eos-0.4* Baso-0.4 Im [MASKED] AbsNeut-1.53*# AbsLymp-0.46* AbsMono-0.43 AbsEos-0.01* AbsBaso-0.01 [MASKED] 09:05AM BLOOD Glucose-141* UreaN-12 Creat-0.9 Na-140 K-3.9 Cl-102 HCO3-25 AnGap-13 [MASKED] 09:05AM BLOOD ALT-14 AST-16 LD(LDH)-154 AlkPhos-92 TotBili-0.3 DirBili-<0.2 IndBili-0.3 [MASKED] 09:05AM BLOOD TotProt-6.6 Albumin-4.4 Globuln-2.2 Calcium-9.2 Phos-3.0 Mg-2.1 UricAcd-4.5 DISCHARGE LABS: [MASKED] 12:00AM BLOOD WBC-13.8* RBC-2.89* Hgb-8.6* Hct-25.8* MCV-89 MCH-29.8 MCHC-33.3 RDW-16.1* RDWSD-47.3* Plt Ct-35* [MASKED] 12:00AM BLOOD Neuts-71 Bands-1 Lymphs-6* Monos-14* Eos-0 Baso-0 [MASKED] Metas-1* Myelos-2* Promyel-1* Blasts-4* AbsNeut-9.94* AbsLymp-0.83* AbsMono-1.93* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Glucose-126* UreaN-5* Creat-0.9 Na-144 K-4.0 Cl-102 HCO3-26 AnGap-16 [MASKED] 12:00AM BLOOD ALT-25 AST-28 LD(LDH)-335* AlkPhos-144* TotBili-0.3 [MASKED] 12:00AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.4 Mg-1.[MASKED] with composite primary mediastinal and classical Hodgkin's lymphoma s/p chemotherapy now admitted for planned autologous transplant with BEAM conditioning as consolidation therapy. ACUTE ISSUES: ============= #Composite Lymphoma: admitted for AutoSCT w/ BEAM -Conditioning per protocol -D0 re-infusion, 3 BAGS INFUSED [MASKED] TOTAL CD34/kg= 6.81e6 -Filgrastim on D+4, started [MASKED] -hold home TMP/SMX until Day +21 or plt count recovery -Supportive care per protocol - d/c to apartments [MASKED] and f/u to be arranged [MASKED] or sooner if issues arise #Pancytopenia: recovering. likely due to high dose chemotherapy -Transfuse if plts < 10 and/or hgb < 7 -Received platelets [MASKED] -off neupogen #Tachycardia: Improving. Regular rhythm, suspect volume depletion from decreased PO intake and diarrhea (though now improved). Does have history of sinus tachy with PVCs, on meto with parameters -IVF bolus PRN -f/u with Dr. [MASKED] CHRONIC/STABLE ISSUES: ====================== #Febrile Neutrapenia: Resolved. First spike on [MASKED] with a T max of 103. He has been afebrile since then. Initially, c/o generalized unwell feeling, nausea, mild mucositis and diarrhea but overall these symptoms have now resolved. He was initiated empirically on vancomycin and cefepime given severe neutropenia but this has been discontinued in the setting of counts recovery. No identified source of infection. -u/a bland and urine culture neg -F/U b culture -vanco/cefe (day 1: [MASKED] -Tylenol, supportive care, monitor fever curve #Pancreas Divisum #History of acute pancreatitis and necrosectomy Continue home colesevelam and Creon #Nausea: Improving, -will go home with ondansetron compazine and ativan as needed #Diarrhea (resolved) #Pain with defecation: resolved, suspect secondary to melphalan and likely secondary to mucositis -Imodium PRN, supportive care prn #Insomnia/Anxiety: Continue home nortryptiline and trazadone #Chronic pain: Continue prn oxycodone #FEN: IVF PRN/Replete PRN/Transplant low-bacteria diet #ACCESS: L central line #PROPHYLAXIS: -Pain: oxycodone prn -Bowel: prn -GI: prn -DVT: holding lovenox given TCP #CODE: Full #CONTACT: Name of health care proxy: [MASKED] Relationship: Spouse Phone number: [MASKED] #DISPO: to apartments Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon [MASKED] CAP PO TID W/MEALS meals and snacks 4. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Nortriptyline 10 mg PO QHS 7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Medications: 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Prochlorperazine [MASKED] mg PO Q6H:PRN nausea 3. Ranitidine 150 mg PO DAILY:PRN HEARTBURN 4. TraZODone 25 mg PO QHS:PRN insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth @hs prn Disp #*30 Tablet Refills:*0 5. Acyclovir 400 mg PO Q8H 6. colesevelam 625 mg oral BID 7. Creon [MASKED] CAP PO TID W/MEALS meals and snacks 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Nortriptyline 10 mg PO QHS 11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY DO NOT START UNTIL THE OUTPATIENT TEAM TELLS YOU TO DO SO Discharge Disposition: Home Discharge Diagnosis: composite lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED] You were admitted for an autologous stem cell transplant. You had a fever and mouth pain while your blood counts were low. We did a work up including blood testing, urine testing, and chest x rays which did not find a source of infection. You were placed on antibiotics for your fever spikes and your fevers resolved. You also developed nausea, diarrhea and loss of appetite while you were admitted. These are common side effects after transplant and your symptoms continue to improve. Your nausea medications are as follows: 1 zofran 2 ativan 3 compazine You will continue to take acyclovir to prevent infection. You will start to take Bactrim to prevent a certain type of pneumonia once your counts have fully recovered. Your outpatient provider [MASKED] tell you when to start this. Please take your temperature twice a day, and call us if it goes above 100.4. Please be sure to drink at least 2L (64oz) of fluid daily. Call if you are unable to do so, or if you have worsening nausea or watery stools. It has been a pleasure taking care of you. Followup Instructions: [MASKED]
[]
[ "Y92230", "G4700", "F419", "G8929" ]
[ "C8172: Other Hodgkin lymphoma, intrathoracic lymph nodes", "C8334: Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb", "D701: Agranulocytosis secondary to cancer chemotherapy", "K521: Toxic gastroenteritis and colitis", "K8689: Other specified diseases of pancreas", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "E869: Volume depletion, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "R000: Tachycardia, unspecified", "I493: Ventricular premature depolarization", "R5081: Fever presenting with conditions classified elsewhere", "R110: Nausea", "K1231: Oral mucositis (ulcerative) due to antineoplastic therapy", "G4700: Insomnia, unspecified", "F419: Anxiety disorder, unspecified", "G8929: Other chronic pain", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
10,074,556
28,422,591
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: admission for cycle #5 of EPOCH-R Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old male with a recent diagnosis of primary mediastinal lymphoma who is admitted for planned fifth cycle of DA-EPOCH-R. He originally presented for 6 months of symptoms including weight loss night sweats, and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH and is now presenting for cycle 5 of regimen. ROS: Overall, he reports feeling well. Denies nausea, vomiting, diarrhea, fever, chills or rigors. No sick contacts at home. No urinary complaints, rashes, lesions. Has been keeping active and working out. Denies neuropathy, chest pain, dyspnea, cough, palpitations, tremors, or lower extremity weakness. All other ROS negative. Past Medical History: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 ___ -Da-EPOCH C2 at level 2 ___ -Dose #1 Rituxan ___ -Da-EPOCH C3 at level 3 ___ -Dose#2 Rituxan ___ -DA-EPOCH C4 at level 4 ___ -Dose#3 Rituxan ___ -DA-EPOCH C5 at level 4 ___ -Dose #4 Rituxan ___ PAST MEDICAL HISTORY: -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in ___ -GERD -Nephrolithiasis Social History: ___ Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: TC 97.7 PO 127/77 65 18 100%RA WT: 84.14 KG GEN: Pleasant and NAD EYES: Anicteric sclerea, PERLL, EOMI ENT: Oropharynx clear without lesion. JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally with no crackles, wheezes, or rhonchi GI: Normal bowel sounds; non-distended; soft, non-tender without rebound or guarding; no hepatomegaly/splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert/oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes or lesions LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymosis ACCESS: POC on R chest without swelling, erythema or pain DISCHARGE PHYSICAL EXAM: VS: TC 97.9 ___ 95-100%RA I/O: 2963/650 BM x1 WT: 185.69 LBS GEN: Pleasant and NAD HEENT: Anicteric sclerea, PERLL, EOMI. Facial flushing. Oropharynx clear without lesion. JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally with no crackles, wheezes, or rhonchi GI: Normal bowel sounds; non-distended; soft, non-tender without rebound or guarding; no hepatomegaly/splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert/oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes or lesions LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymosis ACCESS: POC on R chest without swelling, erythema or pain Pertinent Results: ADMISSION LABS: ___ 09:50AM PLT SMR-HIGH* PLT COUNT-424*# ___ 09:50AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL TEARDROP-OCCASIONAL ___ 09:50AM NEUTS-64 BANDS-0 ___ MONOS-14* EOS-0 BASOS-0 ___ METAS-1* MYELOS-2* AbsNeut-2.94 AbsLymp-0.87* AbsMono-0.64 AbsEos-0.00* AbsBaso-0.00* ___ 09:50AM WBC-4.6# RBC-3.46* HGB-10.3* HCT-31.0* MCV-90 MCH-29.8 MCHC-33.2 RDW-20.5* RDWSD-65.9* ___ 09:50AM ALBUMIN-4.3 CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-2.0 URIC ACID-6.1 ___ 09:50AM ALT(SGPT)-16 AST(SGOT)-17 LD(LDH)-254* ALK PHOS-78 TOT BILI-0.2 ___ 09:50AM estGFR-Using this ___ 09:50AM UREA N-10 CREAT-1.0 SODIUM-142 POTASSIUM-4.6 ___ 09:50AM GLUCOSE-117* ___ 12:00AM PLT SMR-HIGH* PLT COUNT-432* ___ 12:00AM HYPOCHROM-1+* ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* MICROCYT-1+* POLYCHROM-1+* SPHEROCYT-2+* OVALOCYT-1+* SCHISTOCY-OCCASIONAL TEARDROP-1+* ___ 12:00AM NEUTS-96* BANDS-0 LYMPHS-2* MONOS-1* EOS-0 BASOS-0 ___ MYELOS-1* AbsNeut-5.66 AbsLymp-0.12* AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM WBC-5.9 RBC-3.25* HGB-9.6* HCT-28.8* MCV-89 MCH-29.5 MCHC-33.3 RDW-20.3* RDWSD-64.6* ___ 12:00AM ALBUMIN-4.2 CALCIUM-9.4 PHOSPHATE-2.7 MAGNESIUM-2.0 URIC ACID-5.1 ___ 12:00AM ALT(SGPT)-16 AST(SGOT)-16 LD(LDH)-258* ALK PHOS-75 TOT BILI-0.2 ___ 12:00AM GLUCOSE-136* UREA N-10 CREAT-1.0 SODIUM-143 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15 DISCHARGE LABS: ___ 12:00AM BLOOD WBC-2.6* RBC-3.11* Hgb-9.3* Hct-27.5* MCV-88 MCH-29.9 MCHC-33.8 RDW-19.9* RDWSD-63.7* Plt ___ ___ 12:00AM BLOOD Neuts-86.9* Lymphs-6.2* Monos-5.0 Eos-0.0* Baso-0.0 Im ___ AbsNeut-2.24# AbsLymp-0.16* AbsMono-0.13* AbsEos-0.00* AbsBaso-0.00* ___ 12:00AM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-NORMAL Macrocy-2+* Microcy-NORMAL Polychr-2+* ___ 12:00AM BLOOD Plt ___ ___ 12:00AM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-142 K-4.1 Cl-101 HCO3-27 AnGap-14 ___ 12:00AM BLOOD ALT-16 AST-14 LD(LDH)-165 AlkPhos-56 TotBili-0.6 ___ 12:00AM BLOOD Albumin-3.9 Calcium-9.3 Phos-4.1 Mg-2.___SSESSMENT AND PLAN: ___ is a ___ year old male with a diagnosis of primary mediastinal lymphoma who is admitted for planned fifth cycle of DA-EPOCH-R. #Primary Mediastinal Lymphoma: Most recent PET scan on ___ shows interval increase in FDG avidity of midline epiphrenic mass with decreased size, when compared to the prior study as well as interval stable or decrease in size and FDG avidity of mediastinal and lateral epiphrenic masses. After discussion with primary team, decision was made to continue with EPOCH. He received cycle #5 of EPOCH-R without acute complications. Today is D+5. He continues with his acyclovir and bactrim prophylaxis. His neupogen injections will start on ___ in the afternoon. His outpatient appointment is scheduled on ___. #FVO: Resolved and was mild, attributed to steroid/IVF. Did not require diuresis #Chronic pancreatitis: #Pancreatic divisum: #Pancreatic pseudocyst: No acute issues in-house. Continue creon, colesevelam, and nortriptyline #GERD: No acute exacerbations, received ranitidine BID in-house #Mucositis: No active exacerbations, continue MMW as needed #Constipation: Colace/Senna/Miralax BID, no acute issues in-house ACCESS: POC placed ___ CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: ___ DISPO: Discharged ___. RTC ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon ___ CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 7. Nortriptyline 10 mg PO QHS 8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 9. Polyethylene Glycol 17 g PO DAILY constipation 10. Senna 8.6 mg PO BID 11. Sulfameth/Trimethoprim SS 1 TAB PO QHS 12. Filgrastim-sndz 480 mcg SC Q24H 13. Levofloxacin 500 mg PO Q24H 14. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Ondansetron 8 mg PO Q8H:PRN nausea 17. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 18. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting 19. Ranitidine 150 mg PO DAILY:PRN heartburn Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon ___ CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. Filgrastim-sndz 480 mcg SC Q24H Start first injection on ___ 7. Levofloxacin 500 mg PO Q24H 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting 17. Senna 8.6 mg PO BID 18. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary mediastinal lymphoma 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 receive your fifth cycle of chemotherapy for your lymphoma. You tolerated this very well and will be discharged home today. You gained fluid weight due to the chemotherapy, which improved with decreasing your IV fluids. You will inject neupogen daily starting ___. You will continue this daily injection until you are told to stop. You will continue to take medications to prevent infection: acyclovir and bactrim. Your nausea medications are as follows: 1 zofran 2 ativan Please continue to take colace and senna for the next two weeks as ordered. If your stools become frequent, you may decrease the senna to once daily. If you become constipated despite the colace/senna, please purchase miralax over the counter and use this daily. If you remain constipated despite these medications, please call us. Please drink enough fluids so that your urine is close to clear (this is usually between 48-64 oz of fluid per day). You will follow up in the outpatient clinic as stated below. Please do not hesitate to call in the meantime with any questions or concerns. Followup Instructions: ___
[ "Z5111", "C8332", "K863", "Q453", "K861", "K5900", "R300", "K1230", "K219" ]
Allergies: Penicillins Chief Complaint: admission for cycle #5 of EPOCH-R Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] year old male with a recent diagnosis of primary mediastinal lymphoma who is admitted for planned fifth cycle of DA-EPOCH-R. He originally presented for 6 months of symptoms including weight loss night sweats, and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH and is now presenting for cycle 5 of regimen. ROS: Overall, he reports feeling well. Denies nausea, vomiting, diarrhea, fever, chills or rigors. No sick contacts at home. No urinary complaints, rashes, lesions. Has been keeping active and working out. Denies neuropathy, chest pain, dyspnea, cough, palpitations, tremors, or lower extremity weakness. All other ROS negative. Past Medical History: Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. -EPOCH C1 [MASKED] -Da-EPOCH C2 at level 2 [MASKED] -Dose #1 Rituxan [MASKED] -Da-EPOCH C3 at level 3 [MASKED] -Dose#2 Rituxan [MASKED] -DA-EPOCH C4 at level 4 [MASKED] -Dose#3 Rituxan [MASKED] -DA-EPOCH C5 at level 4 [MASKED] -Dose #4 Rituxan [MASKED] PAST MEDICAL HISTORY: -Pancreas divisum -Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] -GERD -Nephrolithiasis Social History: [MASKED] Family History: Mother and father with hypertension. No family history of other cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS: TC 97.7 PO 127/77 65 18 100%RA WT: 84.14 KG GEN: Pleasant and NAD EYES: Anicteric sclerea, PERLL, EOMI ENT: Oropharynx clear without lesion. JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally with no crackles, wheezes, or rhonchi GI: Normal bowel sounds; non-distended; soft, non-tender without rebound or guarding; no hepatomegaly/splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert/oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes or lesions LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymosis ACCESS: POC on R chest without swelling, erythema or pain DISCHARGE PHYSICAL EXAM: VS: TC 97.9 [MASKED] 95-100%RA I/O: 2963/650 BM x1 WT: 185.69 LBS GEN: Pleasant and NAD HEENT: Anicteric sclerea, PERLL, EOMI. Facial flushing. Oropharynx clear without lesion. JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally with no crackles, wheezes, or rhonchi GI: Normal bowel sounds; non-distended; soft, non-tender without rebound or guarding; no hepatomegaly/splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert/oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes or lesions LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymosis ACCESS: POC on R chest without swelling, erythema or pain Pertinent Results: ADMISSION LABS: [MASKED] 09:50AM PLT SMR-HIGH* PLT COUNT-424*# [MASKED] 09:50AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL TEARDROP-OCCASIONAL [MASKED] 09:50AM NEUTS-64 BANDS-0 [MASKED] MONOS-14* EOS-0 BASOS-0 [MASKED] METAS-1* MYELOS-2* AbsNeut-2.94 AbsLymp-0.87* AbsMono-0.64 AbsEos-0.00* AbsBaso-0.00* [MASKED] 09:50AM WBC-4.6# RBC-3.46* HGB-10.3* HCT-31.0* MCV-90 MCH-29.8 MCHC-33.2 RDW-20.5* RDWSD-65.9* [MASKED] 09:50AM ALBUMIN-4.3 CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-2.0 URIC ACID-6.1 [MASKED] 09:50AM ALT(SGPT)-16 AST(SGOT)-17 LD(LDH)-254* ALK PHOS-78 TOT BILI-0.2 [MASKED] 09:50AM estGFR-Using this [MASKED] 09:50AM UREA N-10 CREAT-1.0 SODIUM-142 POTASSIUM-4.6 [MASKED] 09:50AM GLUCOSE-117* [MASKED] 12:00AM PLT SMR-HIGH* PLT COUNT-432* [MASKED] 12:00AM HYPOCHROM-1+* ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* MICROCYT-1+* POLYCHROM-1+* SPHEROCYT-2+* OVALOCYT-1+* SCHISTOCY-OCCASIONAL TEARDROP-1+* [MASKED] 12:00AM NEUTS-96* BANDS-0 LYMPHS-2* MONOS-1* EOS-0 BASOS-0 [MASKED] MYELOS-1* AbsNeut-5.66 AbsLymp-0.12* AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM WBC-5.9 RBC-3.25* HGB-9.6* HCT-28.8* MCV-89 MCH-29.5 MCHC-33.3 RDW-20.3* RDWSD-64.6* [MASKED] 12:00AM ALBUMIN-4.2 CALCIUM-9.4 PHOSPHATE-2.7 MAGNESIUM-2.0 URIC ACID-5.1 [MASKED] 12:00AM ALT(SGPT)-16 AST(SGOT)-16 LD(LDH)-258* ALK PHOS-75 TOT BILI-0.2 [MASKED] 12:00AM GLUCOSE-136* UREA N-10 CREAT-1.0 SODIUM-143 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15 DISCHARGE LABS: [MASKED] 12:00AM BLOOD WBC-2.6* RBC-3.11* Hgb-9.3* Hct-27.5* MCV-88 MCH-29.9 MCHC-33.8 RDW-19.9* RDWSD-63.7* Plt [MASKED] [MASKED] 12:00AM BLOOD Neuts-86.9* Lymphs-6.2* Monos-5.0 Eos-0.0* Baso-0.0 Im [MASKED] AbsNeut-2.24# AbsLymp-0.16* AbsMono-0.13* AbsEos-0.00* AbsBaso-0.00* [MASKED] 12:00AM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-NORMAL Macrocy-2+* Microcy-NORMAL Polychr-2+* [MASKED] 12:00AM BLOOD Plt [MASKED] [MASKED] 12:00AM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-142 K-4.1 Cl-101 HCO3-27 AnGap-14 [MASKED] 12:00AM BLOOD ALT-16 AST-14 LD(LDH)-165 AlkPhos-56 TotBili-0.6 [MASKED] 12:00AM BLOOD Albumin-3.9 Calcium-9.3 Phos-4.1 Mg-2. SSESSMENT AND PLAN: [MASKED] is a [MASKED] year old male with a diagnosis of primary mediastinal lymphoma who is admitted for planned fifth cycle of DA-EPOCH-R. #Primary Mediastinal Lymphoma: Most recent PET scan on [MASKED] shows interval increase in FDG avidity of midline epiphrenic mass with decreased size, when compared to the prior study as well as interval stable or decrease in size and FDG avidity of mediastinal and lateral epiphrenic masses. After discussion with primary team, decision was made to continue with EPOCH. He received cycle #5 of EPOCH-R without acute complications. Today is D+5. He continues with his acyclovir and bactrim prophylaxis. His neupogen injections will start on [MASKED] in the afternoon. His outpatient appointment is scheduled on [MASKED]. #FVO: Resolved and was mild, attributed to steroid/IVF. Did not require diuresis #Chronic pancreatitis: #Pancreatic divisum: #Pancreatic pseudocyst: No acute issues in-house. Continue creon, colesevelam, and nortriptyline #GERD: No acute exacerbations, received ranitidine BID in-house #Mucositis: No active exacerbations, continue MMW as needed #Constipation: Colace/Senna/Miralax BID, no acute issues in-house ACCESS: POC placed [MASKED] CODE: Full (presumed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: [MASKED] DISPO: Discharged [MASKED]. RTC [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon [MASKED] CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 7. Nortriptyline 10 mg PO QHS 8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 9. Polyethylene Glycol 17 g PO DAILY constipation 10. Senna 8.6 mg PO BID 11. Sulfameth/Trimethoprim SS 1 TAB PO QHS 12. Filgrastim-sndz 480 mcg SC Q24H 13. Levofloxacin 500 mg PO Q24H 14. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Ondansetron 8 mg PO Q8H:PRN nausea 17. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 18. Prochlorperazine [MASKED] mg PO Q6H:PRN nausea/vomiting 19. Ranitidine 150 mg PO DAILY:PRN heartburn Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon [MASKED] CAP PO QID:PRN snacks 4. Creon 12 2 CAP PO TID W/MEALS 5. Docusate Sodium 100 mg PO BID 6. Filgrastim-sndz 480 mcg SC Q24H Start first injection on [MASKED] 7. Levofloxacin 500 mg PO Q24H 8. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 9. Maalox/Diphenhydramine/Lidocaine [MASKED] mL PO QID:PRN mouth irritation 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Nortriptyline 10 mg PO QHS 12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 15. Polyethylene Glycol 17 g PO DAILY constipation 16. Prochlorperazine [MASKED] mg PO Q6H:PRN nausea/vomiting 17. Senna 8.6 mg PO BID 18. Sulfameth/Trimethoprim SS 1 TAB PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary mediastinal lymphoma 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 receive your fifth cycle of chemotherapy for your lymphoma. You tolerated this very well and will be discharged home today. You gained fluid weight due to the chemotherapy, which improved with decreasing your IV fluids. You will inject neupogen daily starting [MASKED]. You will continue this daily injection until you are told to stop. You will continue to take medications to prevent infection: acyclovir and bactrim. Your nausea medications are as follows: 1 zofran 2 ativan Please continue to take colace and senna for the next two weeks as ordered. If your stools become frequent, you may decrease the senna to once daily. If you become constipated despite the colace/senna, please purchase miralax over the counter and use this daily. If you remain constipated despite these medications, please call us. Please drink enough fluids so that your urine is close to clear (this is usually between 48-64 oz of fluid per day). You will follow up in the outpatient clinic as stated below. Please do not hesitate to call in the meantime with any questions or concerns. Followup Instructions: [MASKED]
[]
[ "K5900", "K219" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8332: Diffuse large B-cell lymphoma, intrathoracic lymph nodes", "K863: Pseudocyst of pancreas", "Q453: Other congenital malformations of pancreas and pancreatic duct", "K861: Other chronic pancreatitis", "K5900: Constipation, unspecified", "R300: Dysuria", "K1230: Oral mucositis (ulcerative), unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,074,556
28,530,417
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Scheduled chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of Primary mediastinal lymphoma now classical hodgkin's (s/p 6 cycles of dose adjusted R-EPOCH in ___ with residual disease (CHL) now s/p C1 ICE) who presents for Cycle 2 of ICE Patient noted that since last admission for viral rhinitis, he has been tired with little appetite but is eating a normal amount. He denied fever or chills. Noted that he is without rhinitis, cough, sore throat, nausea, vomiting, abdominal pain, diarrhea, dysuria, rash. He noted that he tolerated last ICE cycle without issue and is hopeful that this one will be tolerated as well. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per Dr ___ clinic note: "Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation ___. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. - EPOCH C1 ___ - DA-R-EPOCH dose level 2 (Rituxan on last day of chemo) ___ - DA-R-EPOCH dose level 3 ___ - DA-R-EPOCH dose level 4 ___ - DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg - DA-R-EPOCH dose level 4 ___- Vincristine cap at 2mg ICE- ___ PAST MEDICAL HISTORY: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in ___ - GERD - Nephrolithiasis - Arrhythmia Social History: ___ Family History: Mother and father with hypertension. No known family history of leukemia or lymphoma. Physical Exam: Admission: GENERAL: sitting in bed, appears comfortable, NAD, pleasant, smiling EYES: PERRLA, anicteric HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR, no increased WOB CV: RRR no m/r/g, normal distal perfusion, no edema ABD: soft, NT, ND, normoactive BS, no rebound or guarding GENITOURINARY: no foley EXT: warm, dry, normal muscle bulk, no deformity SKIN: warm, dry, no rash NEURO: AOx3, fluent speech ACCESS: POrt accessed with dressing c/d/I Discharge: GENERAL: sitting in chair, appears comfortable, NAD, pleasant EYES: PERRLA, anicteric HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR, no increased WOB CV: RRR no m/r/g, normal distal perfusion, no edema ABD: soft, NT, ND, normoactive BS, no rebound or guarding GENITOURINARY: no foley EXT: warm, dry, normal muscle bulk, no deformity SKIN: warm, dry, no rash NEURO: AOx3, fluent speech ACCESS: POrt accessed with dressing c/d/I Pertinent Results: Admission ___ 10:15AM BLOOD WBC-3.7*# RBC-4.23* Hgb-12.5* Hct-36.9* MCV-87 MCH-29.6 MCHC-33.9 RDW-12.6 RDWSD-38.8 Plt ___ ___ 10:15AM BLOOD Glucose-103* UreaN-10 Creat-0.9 Na-140 K-4.8 ___ 10:15AM BLOOD ALT-45* AST-23 LD(LDH)-183 AlkPhos-143* TotBili-<0.2 ___ 10:15AM BLOOD ALT-45* AST-23 LD(LDH)-183 AlkPhos-143* TotBili-<0.2 ___ 10:15AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.0 Mg-2.2 UricAcd-5.4 Discharge: ___ 12:00AM BLOOD WBC-6.3 RBC-3.86* Hgb-11.3* Hct-33.3* MCV-86 MCH-29.3 MCHC-33.9 RDW-12.6 RDWSD-37.7 Plt ___ ___ 12:00AM BLOOD ___ PTT-31.2 ___ ___ 12:00AM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-141 K-4.5 Cl-102 HCO3-25 AnGap-14 ___ 12:00AM BLOOD ALT-31 AST-15 LD(___)-151 AlkPhos-110 TotBili-0.3 ___ 12:00AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0 UricAcd-3.5 Micro: None Imaging: None Brief Hospital Course: ___ PMH of Primary mediastinal lymphoma now classical Hodgkin's (s/p 6 cycles of dose adjusted R-EPOCH in ___ with residual disease (CHL) now s/p C1 ICE) who presents for Cycle 2 of ICE, who tolerated regimen with exception of mild nausea on D2. Patient was discharged with plan to start neupogen >24 hrs after last dose of chemotherapy (to start ___ night or ___ morning), with plan to continue until directed otherwise by Dr ___. Patient was continued on acyclovir and Bactrim prophylaxis and is to have counts re-checked at next followup appointment on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Creon ___ CAP PO QID PRN meals and snacks 3. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Nortriptyline 10 mg PO QHS 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. colesevelam 625 mg oral BID 9. Ondansetron ODT 4 mg PO Q8H:PRN nausea 10. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon ___ CAP PO QID PRN meals and snacks 4. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Nortriptyline 10 mg PO QHS 7. Ondansetron ODT 4 mg PO Q8H:PRN nausea 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary mediastinal lymphoma now classical Hodgkin's here for scheduled chemotherapy with Cycle 2 ICE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr ___, It was a pleasure taking care of you. As you know, you were admitted for cycle 2 of chemotherapy (ICE) which you tolerated well with the exception of some nausea. You are to start neupogen at least 24 hours after chemotherapy finishes (start either ___ night or ___ morning) and are to continue until directed otherwise by Dr. ___. Your next follow-up appointment is on ___ when you will have your labs checked. Remember that if your nausea is problematic at home, you can take both your Zofran and Ativan to help control the symptoms. Followup Instructions: ___
[ "Z5111", "C8198", "K219" ]
Allergies: Penicillins Chief Complaint: Scheduled chemotherapy Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH of Primary mediastinal lymphoma now classical hodgkin's (s/p 6 cycles of dose adjusted R-EPOCH in [MASKED] with residual disease (CHL) now s/p C1 ICE) who presents for Cycle 2 of ICE Patient noted that since last admission for viral rhinitis, he has been tired with little appetite but is eating a normal amount. He denied fever or chills. Noted that he is without rhinitis, cough, sore throat, nausea, vomiting, abdominal pain, diarrhea, dysuria, rash. He noted that he tolerated last ICE cycle without issue and is hopeful that this one will be tolerated as well. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY: As per Dr [MASKED] clinic note: "Patient with roughly 6 months of symptoms including weight loss night sweats and pruritus with tachycardia leading into a GI evaluation [MASKED]. An MRCP that was performed for the evaluation of a history of necrotic pancreatitis demonstrated a large mediastinal mass. CT imaging confirms the presence of a massive mediastinal mass. The tumor extended into the left axilla. Biopsy from that site demonstrated diffuse large B-cell lymphoma. Patient was initiated on therapy with EPOCH as an inpatient. Rituximab was deferred given the concern for tumor flare in the mediastinum. - EPOCH C1 [MASKED] - DA-R-EPOCH dose level 2 (Rituxan on last day of chemo) [MASKED] - DA-R-EPOCH dose level 3 [MASKED] - DA-R-EPOCH dose level 4 [MASKED] - DA-R-EPOCH dose level 4 [MASKED]- Vincristine cap at 2mg - DA-R-EPOCH dose level 4 [MASKED]- Vincristine cap at 2mg ICE- [MASKED] PAST MEDICAL HISTORY: - Pancreas divisum - Acute pancreatitis with necrosis s/p necrosectomy in [MASKED] - GERD - Nephrolithiasis - Arrhythmia Social History: [MASKED] Family History: Mother and father with hypertension. No known family history of leukemia or lymphoma. Physical Exam: Admission: GENERAL: sitting in bed, appears comfortable, NAD, pleasant, smiling EYES: PERRLA, anicteric HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR, no increased WOB CV: RRR no m/r/g, normal distal perfusion, no edema ABD: soft, NT, ND, normoactive BS, no rebound or guarding GENITOURINARY: no foley EXT: warm, dry, normal muscle bulk, no deformity SKIN: warm, dry, no rash NEURO: AOx3, fluent speech ACCESS: POrt accessed with dressing c/d/I Discharge: GENERAL: sitting in chair, appears comfortable, NAD, pleasant EYES: PERRLA, anicteric HEENT: OP clear, MMM NECK: supple LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR, no increased WOB CV: RRR no m/r/g, normal distal perfusion, no edema ABD: soft, NT, ND, normoactive BS, no rebound or guarding GENITOURINARY: no foley EXT: warm, dry, normal muscle bulk, no deformity SKIN: warm, dry, no rash NEURO: AOx3, fluent speech ACCESS: POrt accessed with dressing c/d/I Pertinent Results: Admission [MASKED] 10:15AM BLOOD WBC-3.7*# RBC-4.23* Hgb-12.5* Hct-36.9* MCV-87 MCH-29.6 MCHC-33.9 RDW-12.6 RDWSD-38.8 Plt [MASKED] [MASKED] 10:15AM BLOOD Glucose-103* UreaN-10 Creat-0.9 Na-140 K-4.8 [MASKED] 10:15AM BLOOD ALT-45* AST-23 LD(LDH)-183 AlkPhos-143* TotBili-<0.2 [MASKED] 10:15AM BLOOD ALT-45* AST-23 LD(LDH)-183 AlkPhos-143* TotBili-<0.2 [MASKED] 10:15AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.0 Mg-2.2 UricAcd-5.4 Discharge: [MASKED] 12:00AM BLOOD WBC-6.3 RBC-3.86* Hgb-11.3* Hct-33.3* MCV-86 MCH-29.3 MCHC-33.9 RDW-12.6 RDWSD-37.7 Plt [MASKED] [MASKED] 12:00AM BLOOD [MASKED] PTT-31.2 [MASKED] [MASKED] 12:00AM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-141 K-4.5 Cl-102 HCO3-25 AnGap-14 [MASKED] 12:00AM BLOOD ALT-31 AST-15 LD([MASKED])-151 AlkPhos-110 TotBili-0.3 [MASKED] 12:00AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.0 UricAcd-3.5 Micro: None Imaging: None Brief Hospital Course: [MASKED] PMH of Primary mediastinal lymphoma now classical Hodgkin's (s/p 6 cycles of dose adjusted R-EPOCH in [MASKED] with residual disease (CHL) now s/p C1 ICE) who presents for Cycle 2 of ICE, who tolerated regimen with exception of mild nausea on D2. Patient was discharged with plan to start neupogen >24 hrs after last dose of chemotherapy (to start [MASKED] night or [MASKED] morning), with plan to continue until directed otherwise by Dr [MASKED]. Patient was continued on acyclovir and Bactrim prophylaxis and is to have counts re-checked at next followup appointment on [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Creon [MASKED] CAP PO QID PRN meals and snacks 3. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Nortriptyline 10 mg PO QHS 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. colesevelam 625 mg oral BID 9. Ondansetron ODT 4 mg PO Q8H:PRN nausea 10. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. colesevelam 625 mg oral BID 3. Creon [MASKED] CAP PO QID PRN meals and snacks 4. LORazepam 0.5-1 mg PO Q8H:PRN nausea anxiety insomnia 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Nortriptyline 10 mg PO QHS 7. Ondansetron ODT 4 mg PO Q8H:PRN nausea 8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 10. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Primary mediastinal lymphoma now classical Hodgkin's here for scheduled chemotherapy with Cycle 2 ICE 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 taking care of you. As you know, you were admitted for cycle 2 of chemotherapy (ICE) which you tolerated well with the exception of some nausea. You are to start neupogen at least 24 hours after chemotherapy finishes (start either [MASKED] night or [MASKED] morning) and are to continue until directed otherwise by Dr. [MASKED]. Your next follow-up appointment is on [MASKED] when you will have your labs checked. Remember that if your nausea is problematic at home, you can take both your Zofran and Ativan to help control the symptoms. Followup Instructions: [MASKED]
[]
[ "K219" ]
[ "Z5111: Encounter for antineoplastic chemotherapy", "C8198: Hodgkin lymphoma, unspecified, lymph nodes of multiple sites", "K219: Gastro-esophageal reflux disease without esophagitis" ]
10,074,611
20,663,793
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: cephalexin / Influenza Virus Vaccines Attending: ___. Chief Complaint: back pain Major Surgical or Invasive Procedure: ___ thoracic posterior fusion from T1-T9 for correction of kyphosis with corpectomy at T4 and cement History of Present Illness: Ms. ___ presents to the office for evaluation. She was seen on ___ s/p MVC. She was found ejected from vehicle on road after an MVC. She was found initially awake but confused with worsening mental status leading to intubation in the field by EMS. She was found to have a large laceration to left scalp. She had multiple imaging which showed mutliple injuries including a TBI, C3 anterior inferior endplate fracture, T4 Burst Fracture with minimal retropulsion and involvement of inferior facets; T3 inferior facet fractures. Prevertebral hematoma from T1 to T6; Spinous process fractures (T1 - T4) and Posterior rib fractures (R ___ and L ___. She had a prolong ICU and hospitalization. She had been in acute rehab and now is currently home. She has back pain but manageable on current pain regimen. She has no weakness or paresthesias. She was treated for several months with TLSO brace. Repeat thoracic CT showed progressive kyphosis and collapse of T4 fx. As a result, surgical intervention was recommended. Risks and benefits were discussed in ___ and candid matter. She wishes to proceed Past Medical History: None Social History: ___ Family History: Lives with her husband Physical ___: GENERAL APPEARANCE: in no acute distress, well developed, well nourished with TLSO brace. HEAD: normocephalic, atraumatic. EYES: pupils equal, round, reactive to light and accommodation. NECK/THYROID: neck supple, full range of motion, no cervical lymphadenopathy. SKIN: warm and dry. HEART: no murmurs, regular rate and rhythm, S1, S2 normal. LUNGS: clear to auscultation bilaterally. ABDOMEN: normal, bowel sounds present, soft, nontender, nondistended. BACK: TLSO brace in place. MUSCULOSKELETAL: cervical spine normal, full range of motion, lumbosacral spine normal, no swelling or deformity. EXTREMITIES: Gross motor strength is intact in terms of deltoid, biceps, triceps, wrist extension/flexion, finger extension/flexion and intrinsics, no clubbing, cyanosis, or edema. NEUROLOGIC: Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. 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, 3-2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength: Muscle Right Left Deltoid 5 5 Biceps 5 5 Triceps 5 5 Wrist flexors / Extensors 5 5 Hand Intrisics 5 5 Iliopsaos 5 5 Quadriceps 5 5 Hamstrings 5 5 Dorsiflexion 5 5 Plantarflexion 5 5 ___ 5 5 No pronator drift Sensation: Intact to light touch Reflexes: grossly 2+ throughout Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin No evidence of dysmetria ___ is negative No clonus. postop Exam General: NAD. AAO x3. sitting up in a chair. Skin: warm, dry, no rash Pulm: normal effort Abd: soft, NT/ND, obese Wound: C/D/I. No swelling, redness, or warmth, skin blister/bleeding noted Extremities: calves are soft, no edema Neurologic: Motor Strength: Delt Bi Tri BR WF/WE HI Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 IP Quad Ham TA Gas ___ Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: intact to light touch Pertinent Results: ___ 09:30PM cTropnT-<0.01 ___ 01:25PM TYPE-ART PO2-198* PCO2-40 PH-7.33* TOTAL CO2-22 BASE XS--4 ___ 01:25PM GLUCOSE-157* LACTATE-3.6* NA+-136 K+-4.1 CL--109* ___ 01:25PM HGB-11.1* calcHCT-33 ___ 01:25PM freeCa-1.03* ___ 12:38PM TYPE-ART RATES-/12 TIDAL VOL-500 PO2-252* PCO2-38 PH-7.36 TOTAL CO2-22 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED ___ 12:38PM GLUCOSE-145* LACTATE-3.1* NA+-136 K+-3.9 CL--110* ___ 12:38PM HGB-9.1* calcHCT-27 O2 SAT-99 ___ 12:38PM freeCa-0.97* ___ 11:31AM TYPE-ART PO2-244* PCO2-38 PH-7.38 TOTAL CO2-23 BASE XS--1 ___ 11:31AM GLUCOSE-147* LACTATE-2.4* NA+-135 K+-3.9 CL--109* ___ 11:31AM HGB-9.6* calcHCT-29 O2 SAT-99 ___ 11:31AM freeCa-0.95* ___ 10:10AM TYPE-ART RATES-/12 TIDAL VOL-500 PO2-233* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED ___ 10:10AM GLUCOSE-130* LACTATE-1.7 NA+-136 K+-3.6 CL--105 ___ 10:10AM HGB-8.2* calcHCT-25 O2 SAT-99 ___ 10:10AM freeCa-0.94* ___ 09:00AM TYPE-ART O2-86 PO2-384* PCO2-37 PH-7.42 TOTAL CO2-25 BASE XS-0 AADO2-183 REQ O2-40 INTUBATED-INTUBATED VENT-CONTROLLED ___ 09:00AM LACTATE-1.6 NA+-136 K+-3.6 CL--105 ___ 09:00AM HGB-10.0* calcHCT-30 ___ 09:00AM PLT COUNT-228 ___ 09:00AM ___ PTT-32.1 ___ Brief Hospital Course: Patient was admitted to Orthopedic Spine Service on ___ and underwent the above stated procedure. Please review dictated operative report for details. Patient was extubated without incident and was transferred to PACU then floor in stable condition. During the patient's course ___ were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with oral and IV pain medication. Diet was advanced as tolerated. Hospital course was significant for pain management. She was transition from PCA to oral pain medications. Then MS contin was started for better pain control. On ___ her right EJ central line was removed in routine fashion. Now, Day of Discharge, patient is afebrile, VSS, and neuro intact with improvement of radiculopathy. Patient tolerated a good oral diet and pain was controlled on oral pain medications. Patient ambulated independently. Patient's wound is clean, dry and intact. Patient noted improvement in radicular pain. Patient is set for discharge to rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. Gabapentin 200 mg PO BID 3. Labetalol 300 mg PO TID 4. Verapamil SR 180 mg PO Q24H 5. Docusate Sodium 100 mg PO BID 6. Senna 8.6 mg PO BID 7. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT 8. lifitegrast 5 % ophthalmic (eye) BID 9. Multivitamins W/minerals 1 TAB PO DAILY 10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 11. diclofenac sodium 1 % topical TID 12. Aspirin 81 mg PO DAILY 13. Citalopram 40 mg PO QAM 14. TraZODone 100 mg PO QHS Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY 2. Cyclobenzaprine 5 mg PO TID:PRN spasms 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4-6 Disp #*60 Tablet Refills:*0 4. Morphine SR (MS ___ 15 mg PO Q12H RX *morphine 15 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 5. Acetaminophen 1000 mg PO Q8H 6. Aspirin 81 mg PO DAILY You may resume ASA on ___ 7. Citalopram 40 mg PO QAM 8. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT 9. Docusate Sodium 100 mg PO BID 10. Gabapentin 200 mg PO BID 11. Labetalol 300 mg PO TID 12. lifitegrast 5 % ophthalmic (eye) BID 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Senna 8.6 mg PO BID 15. TraZODone 100 mg PO QHS this was held during your hospitalization 16. Verapamil SR 180 mg PO Q24H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: T4 fracture Thoracic kyphosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Thoracic Decompression With Fusion: You have undergone the following operation: Thoracic Decompression With Fusion Follow-up Appointments •After you are discharged from the hospital and settled at home or rehab, please make sure you have two appointments: 1.2 week post-operative wound check visit after surgery 2.a post-operative visit with your surgeon for ___ weeks after surgery. •You can reach the office at ___ and ask to speak with your surgeon’s surgical coordinator/staff to schedule or confirm your appointments Wound Care •If not already done in the hospital, remove the incision dressing on day 2 after surgery. •You may shower day 3 after surgery. Starting on this ___ day, you should gently cleanse the incision and surrounding area daily with mild soap and water, patting it dry when you are finished. •Some swelling and bruising around the incision is normal. Your muscles have been cut, separated and sewn back together as part of your surgical procedure. You will leave the hospital with back discomfort from the surgical incision. As you become more active and the incision and muscles continue to heal, the swelling and pain will decrease. •Have someone look at the incision daily for 2 weeks. Call the surgeon’s office if you notice any of the following: Increased redness along the length of the incision Increased swelling of the area around your incision Drainage from the incision Weakness of your extremities greater than before surgery Loss of bowel or bladder control Development of severe headache Leg swelling or calf tenderness Fever above 101.5 •Do not soak or immerse your incision in water for 1 month. For example, no tub baths, swimming pools or jacuzzi. Activity Guidelines •You MAY be given a RIGID BRACE that you will wear whenever sitting up, standing, or walking. You will wear it for ___ weeks after surgery. See the last page of these instructions for details on wearing the brace. •Avoid strenuous activity, bending, pushing or holding your breath. For example, do not vacuum, wash the car, do large loads of laundry, or walk the dog until your follow-up visit with your surgeon. •Avoid heavy lifting. Do not lift anything over ___ pounds for the first few weeks that you are home from the hospital. •Increase your activities a little each day. Walking is good exercise. Plan rest periods and try to avoid hills if possible. Remember, exercise should not increase your back pain or cause leg pain. •Reaching: When you have to reach things on or near the floor, always squat (bending the knees), rather than bending over at the waist. •Lying down: when lying on your back, you may find that a pillow under the knees is more comfortable. When on your side, a pillow between the knees will help keep your back straight. •Sitting: should be limited to 40-60 minutes at a time for the first week. Slowly increase the amount of sitting time, remembering that it should not increase your back pain. •Stairs: use stairs only once or twice a day for the first week, or as directed by the surgeon. Climb steps one at a time, placing both feet on the step before moving to the next one. •Driving: you should not drive for ___ weeks after surgery. You should discuss driving with your surgeon /nurse practitioner /physician ___. You may ride in a car for short distances. When in the car, avoid sitting in one position for too long. If you must take long car rides, do not ride for more than 60 minutes without taking a break to stretch (walk for several minutes and change position.). •Sexual activity: you may resume sexual activity ___ weeks after surgery (avoiding pain or stress on the back). •Reduction in symptoms: patients who have experienced back and radiating leg pain for a short window of time before surgery should anticipate a significant decrease in pre-operative symptoms. If the pain has been present for a longer period (months to years), the pre-operative symptoms will recover on a more gradual basis week by week. It is not practical to expect immediate relief of symptoms. Routinely, pain will gradually improve on a weekly basis, weakness on a monthly basis, and numbness in a range of 6 months to ___ year. Physical Therapy •Outpatient Physical Therapy (if appropriate) will not begin until after your post-operative visit with your surgeon. A prescription is needed for formal outpatient therapy. •You may be given simple stretching exercises or a prescription for formal outpatient physical therapy, based on what your needs are after surgery. Medications •You will be given prescriptions for pain medications and stool softeners upon discharge from the hospital. •Pain medications should be taken as prescribed by your surgeon or nurse practitioner/ physician ___. You are allowed to gradually reduce the number of pills you take when the pain begins to subside. •If you are taking more than the recommended dose, please contact the office to discuss this with a practitioner ___ medication may need to be increased or changed). •Constipation: Pain medications (narcotics) may cause constipation. It is important to be aware of your bowel habits so you ___ develop severe constipation that cannot be treated with simple, over the counter laxatives. Most prescription pain medications cannot be called into the pharmacy for renewal. The following are 2 options you may explore to obtain a renewal of your narcotic medications: 1.Call the office ___ days before your prescription runs out and speak with office staff about mailing a prescription to your home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) 2.Call the office 24 hours in advance and speak with our office staff about coming into the office to pick up a prescription. •If you continue to require medications, you may be referred to a pain management specialist or your medical doctor for ongoing management of your pain medications •Avoid NSAIDS for ___ weeks post-operative. These medications include, but are not limited to the following: 1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam, Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, Tolectin, Toradol, Trilisate, Voltarin Blood Clots in the Leg 1.It is not uncommon for patients who recently had surgery to develop blood clots in leg veins. •Symptoms include low-grade fever, and/or redness, swelling, tenderness, and/or an •aching/cramping pain in your calf. •You should call your doctor immediately if you have these symptoms. •To prevent blood clots in legs, try walking and/ or pumping ankles several times during the day. •If the blood clot breaks free from the leg vein, it can travel to the lungs and cause severe breathing difficulty and/or chest pain. If you experience this, call ___ immediately. Questions •Any questions may be directed to your surgeon or physician ___. 1.During normal business hours (8:30am- 5:00pm), you can call the office directly at ___. Turn around time for a phone call is 24 hours. After normal business hours, you can call the on-call service and we will get back to you the next business day. •If you are calling with an urgent medical issue, please tell the coordinator that it is an “urgent issue” and needs to be discussed in less than 24 hours (i.e. pain unrelieved with medications, wound breakdown/infection, or new neurological symptoms). Lumbar Corset or (TLSO) Brace Guidelines •You MAY have been given a rigid brace that you will wear for ___ weeks after surgery. •You should put on your brace as you have been instructed by the orthotist (brace maker). Instructions will be reviewed in the hospital by the nursing staff and Physical Therapist. •It is a good idea to start practicing with your brace before surgery (putting it on/taking it off, sitting, standing, walking, and climbing steps with the brace) so you can assist with your post-operative care in the hospital. •Keep the name and phone number of the person who fitted and dispensed your brace close by in case you need to have the brace checked and/or adjusted. •You should always have a barrier between your surgical incision and the brace. For example, you may want to put on a light t-shirt and then the brace before getting dressed for the day. •During periods of rest, take off the brace and expose the incision to the air by lying on your side for a few hours. This will reduce the chance of your wound breaking down. 1.The brace must be worn at all times with the following 3 exceptions: 1.Lying flat in bed during a rest period or at night to sleep. 2.Getting out of bed at night to go to the bathroom, returning to bed immediately when you are finished. 3.Showering. You may wish to use a shower chair to help prevent bending/twisting while bathing. You should have someone help wash your back and legs. Followup Instructions: ___
[ "M4014", "S22041G", "V499XXD", "Z720", "I10", "Z8541", "F329", "F419" ]
Allergies: cephalexin / Influenza Virus Vaccines Chief Complaint: back pain Major Surgical or Invasive Procedure: [MASKED] thoracic posterior fusion from T1-T9 for correction of kyphosis with corpectomy at T4 and cement History of Present Illness: Ms. [MASKED] presents to the office for evaluation. She was seen on [MASKED] s/p MVC. She was found ejected from vehicle on road after an MVC. She was found initially awake but confused with worsening mental status leading to intubation in the field by EMS. She was found to have a large laceration to left scalp. She had multiple imaging which showed mutliple injuries including a TBI, C3 anterior inferior endplate fracture, T4 Burst Fracture with minimal retropulsion and involvement of inferior facets; T3 inferior facet fractures. Prevertebral hematoma from T1 to T6; Spinous process fractures (T1 - T4) and Posterior rib fractures (R [MASKED] and L [MASKED]. She had a prolong ICU and hospitalization. She had been in acute rehab and now is currently home. She has back pain but manageable on current pain regimen. She has no weakness or paresthesias. She was treated for several months with TLSO brace. Repeat thoracic CT showed progressive kyphosis and collapse of T4 fx. As a result, surgical intervention was recommended. Risks and benefits were discussed in [MASKED] and candid matter. She wishes to proceed Past Medical History: None Social History: [MASKED] Family History: Lives with her husband Physical [MASKED]: GENERAL APPEARANCE: in no acute distress, well developed, well nourished with TLSO brace. HEAD: normocephalic, atraumatic. EYES: pupils equal, round, reactive to light and accommodation. NECK/THYROID: neck supple, full range of motion, no cervical lymphadenopathy. SKIN: warm and dry. HEART: no murmurs, regular rate and rhythm, S1, S2 normal. LUNGS: clear to auscultation bilaterally. ABDOMEN: normal, bowel sounds present, soft, nontender, nondistended. BACK: TLSO brace in place. MUSCULOSKELETAL: cervical spine normal, full range of motion, lumbosacral spine normal, no swelling or deformity. EXTREMITIES: Gross motor strength is intact in terms of deltoid, biceps, triceps, wrist extension/flexion, finger extension/flexion and intrinsics, no clubbing, cyanosis, or edema. NEUROLOGIC: Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [MASKED] objects at 5 minutes. 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, 3-2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength: Muscle Right Left Deltoid 5 5 Biceps 5 5 Triceps 5 5 Wrist flexors / Extensors 5 5 Hand Intrisics 5 5 Iliopsaos 5 5 Quadriceps 5 5 Hamstrings 5 5 Dorsiflexion 5 5 Plantarflexion 5 5 [MASKED] 5 5 No pronator drift Sensation: Intact to light touch Reflexes: grossly 2+ throughout Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin No evidence of dysmetria [MASKED] is negative No clonus. postop Exam General: NAD. AAO x3. sitting up in a chair. Skin: warm, dry, no rash Pulm: normal effort Abd: soft, NT/ND, obese Wound: C/D/I. No swelling, redness, or warmth, skin blister/bleeding noted Extremities: calves are soft, no edema Neurologic: Motor Strength: Delt Bi Tri BR WF/WE HI Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 IP Quad Ham TA Gas [MASKED] Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: intact to light touch Pertinent Results: [MASKED] 09:30PM cTropnT-<0.01 [MASKED] 01:25PM TYPE-ART PO2-198* PCO2-40 PH-7.33* TOTAL CO2-22 BASE XS--4 [MASKED] 01:25PM GLUCOSE-157* LACTATE-3.6* NA+-136 K+-4.1 CL--109* [MASKED] 01:25PM HGB-11.1* calcHCT-33 [MASKED] 01:25PM freeCa-1.03* [MASKED] 12:38PM TYPE-ART RATES-/12 TIDAL VOL-500 PO2-252* PCO2-38 PH-7.36 TOTAL CO2-22 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED [MASKED] 12:38PM GLUCOSE-145* LACTATE-3.1* NA+-136 K+-3.9 CL--110* [MASKED] 12:38PM HGB-9.1* calcHCT-27 O2 SAT-99 [MASKED] 12:38PM freeCa-0.97* [MASKED] 11:31AM TYPE-ART PO2-244* PCO2-38 PH-7.38 TOTAL CO2-23 BASE XS--1 [MASKED] 11:31AM GLUCOSE-147* LACTATE-2.4* NA+-135 K+-3.9 CL--109* [MASKED] 11:31AM HGB-9.6* calcHCT-29 O2 SAT-99 [MASKED] 11:31AM freeCa-0.95* [MASKED] 10:10AM TYPE-ART RATES-/12 TIDAL VOL-500 PO2-233* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-1 INTUBATED-INTUBATED VENT-CONTROLLED [MASKED] 10:10AM GLUCOSE-130* LACTATE-1.7 NA+-136 K+-3.6 CL--105 [MASKED] 10:10AM HGB-8.2* calcHCT-25 O2 SAT-99 [MASKED] 10:10AM freeCa-0.94* [MASKED] 09:00AM TYPE-ART O2-86 PO2-384* PCO2-37 PH-7.42 TOTAL CO2-25 BASE XS-0 AADO2-183 REQ O2-40 INTUBATED-INTUBATED VENT-CONTROLLED [MASKED] 09:00AM LACTATE-1.6 NA+-136 K+-3.6 CL--105 [MASKED] 09:00AM HGB-10.0* calcHCT-30 [MASKED] 09:00AM PLT COUNT-228 [MASKED] 09:00AM [MASKED] PTT-32.1 [MASKED] Brief Hospital Course: Patient was admitted to Orthopedic Spine Service on [MASKED] and underwent the above stated procedure. Please review dictated operative report for details. Patient was extubated without incident and was transferred to PACU then floor in stable condition. During the patient's course [MASKED] were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with oral and IV pain medication. Diet was advanced as tolerated. Hospital course was significant for pain management. She was transition from PCA to oral pain medications. Then MS contin was started for better pain control. On [MASKED] her right EJ central line was removed in routine fashion. Now, Day of Discharge, patient is afebrile, VSS, and neuro intact with improvement of radiculopathy. Patient tolerated a good oral diet and pain was controlled on oral pain medications. Patient ambulated independently. Patient's wound is clean, dry and intact. Patient noted improvement in radicular pain. Patient is set for discharge to rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. Gabapentin 200 mg PO BID 3. Labetalol 300 mg PO TID 4. Verapamil SR 180 mg PO Q24H 5. Docusate Sodium 100 mg PO BID 6. Senna 8.6 mg PO BID 7. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT 8. lifitegrast 5 % ophthalmic (eye) BID 9. Multivitamins W/minerals 1 TAB PO DAILY 10. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate 11. diclofenac sodium 1 % topical TID 12. Aspirin 81 mg PO DAILY 13. Citalopram 40 mg PO QAM 14. TraZODone 100 mg PO QHS Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY 2. Cyclobenzaprine 5 mg PO TID:PRN spasms 3. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate RX *hydromorphone [Dilaudid] 2 mg [MASKED] tablet(s) by mouth Q4-6 Disp #*60 Tablet Refills:*0 4. Morphine SR (MS [MASKED] 15 mg PO Q12H RX *morphine 15 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 5. Acetaminophen 1000 mg PO Q8H 6. Aspirin 81 mg PO DAILY You may resume ASA on [MASKED] 7. Citalopram 40 mg PO QAM 8. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QSAT 9. Docusate Sodium 100 mg PO BID 10. Gabapentin 200 mg PO BID 11. Labetalol 300 mg PO TID 12. lifitegrast 5 % ophthalmic (eye) BID 13. Multivitamins W/minerals 1 TAB PO DAILY 14. Senna 8.6 mg PO BID 15. TraZODone 100 mg PO QHS this was held during your hospitalization 16. Verapamil SR 180 mg PO Q24H Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: T4 fracture Thoracic kyphosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Thoracic Decompression With Fusion: You have undergone the following operation: Thoracic Decompression With Fusion Follow-up Appointments •After you are discharged from the hospital and settled at home or rehab, please make sure you have two appointments: 1.2 week post-operative wound check visit after surgery 2.a post-operative visit with your surgeon for [MASKED] weeks after surgery. •You can reach the office at [MASKED] and ask to speak with your surgeon’s surgical coordinator/staff to schedule or confirm your appointments Wound Care •If not already done in the hospital, remove the incision dressing on day 2 after surgery. •You may shower day 3 after surgery. Starting on this [MASKED] day, you should gently cleanse the incision and surrounding area daily with mild soap and water, patting it dry when you are finished. •Some swelling and bruising around the incision is normal. Your muscles have been cut, separated and sewn back together as part of your surgical procedure. You will leave the hospital with back discomfort from the surgical incision. As you become more active and the incision and muscles continue to heal, the swelling and pain will decrease. •Have someone look at the incision daily for 2 weeks. Call the surgeon’s office if you notice any of the following: Increased redness along the length of the incision Increased swelling of the area around your incision Drainage from the incision Weakness of your extremities greater than before surgery Loss of bowel or bladder control Development of severe headache Leg swelling or calf tenderness Fever above 101.5 •Do not soak or immerse your incision in water for 1 month. For example, no tub baths, swimming pools or jacuzzi. Activity Guidelines •You MAY be given a RIGID BRACE that you will wear whenever sitting up, standing, or walking. You will wear it for [MASKED] weeks after surgery. See the last page of these instructions for details on wearing the brace. •Avoid strenuous activity, bending, pushing or holding your breath. For example, do not vacuum, wash the car, do large loads of laundry, or walk the dog until your follow-up visit with your surgeon. •Avoid heavy lifting. Do not lift anything over [MASKED] pounds for the first few weeks that you are home from the hospital. •Increase your activities a little each day. Walking is good exercise. Plan rest periods and try to avoid hills if possible. Remember, exercise should not increase your back pain or cause leg pain. •Reaching: When you have to reach things on or near the floor, always squat (bending the knees), rather than bending over at the waist. •Lying down: when lying on your back, you may find that a pillow under the knees is more comfortable. When on your side, a pillow between the knees will help keep your back straight. •Sitting: should be limited to 40-60 minutes at a time for the first week. Slowly increase the amount of sitting time, remembering that it should not increase your back pain. •Stairs: use stairs only once or twice a day for the first week, or as directed by the surgeon. Climb steps one at a time, placing both feet on the step before moving to the next one. •Driving: you should not drive for [MASKED] weeks after surgery. You should discuss driving with your surgeon /nurse practitioner /physician [MASKED]. You may ride in a car for short distances. When in the car, avoid sitting in one position for too long. If you must take long car rides, do not ride for more than 60 minutes without taking a break to stretch (walk for several minutes and change position.). •Sexual activity: you may resume sexual activity [MASKED] weeks after surgery (avoiding pain or stress on the back). •Reduction in symptoms: patients who have experienced back and radiating leg pain for a short window of time before surgery should anticipate a significant decrease in pre-operative symptoms. If the pain has been present for a longer period (months to years), the pre-operative symptoms will recover on a more gradual basis week by week. It is not practical to expect immediate relief of symptoms. Routinely, pain will gradually improve on a weekly basis, weakness on a monthly basis, and numbness in a range of 6 months to [MASKED] year. Physical Therapy •Outpatient Physical Therapy (if appropriate) will not begin until after your post-operative visit with your surgeon. A prescription is needed for formal outpatient therapy. •You may be given simple stretching exercises or a prescription for formal outpatient physical therapy, based on what your needs are after surgery. Medications •You will be given prescriptions for pain medications and stool softeners upon discharge from the hospital. •Pain medications should be taken as prescribed by your surgeon or nurse practitioner/ physician [MASKED]. You are allowed to gradually reduce the number of pills you take when the pain begins to subside. •If you are taking more than the recommended dose, please contact the office to discuss this with a practitioner [MASKED] medication may need to be increased or changed). •Constipation: Pain medications (narcotics) may cause constipation. It is important to be aware of your bowel habits so you [MASKED] develop severe constipation that cannot be treated with simple, over the counter laxatives. Most prescription pain medications cannot be called into the pharmacy for renewal. The following are 2 options you may explore to obtain a renewal of your narcotic medications: 1.Call the office [MASKED] days before your prescription runs out and speak with office staff about mailing a prescription to your home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) 2.Call the office 24 hours in advance and speak with our office staff about coming into the office to pick up a prescription. •If you continue to require medications, you may be referred to a pain management specialist or your medical doctor for ongoing management of your pain medications •Avoid NSAIDS for [MASKED] weeks post-operative. These medications include, but are not limited to the following: 1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam, Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, Tolectin, Toradol, Trilisate, Voltarin Blood Clots in the Leg 1.It is not uncommon for patients who recently had surgery to develop blood clots in leg veins. •Symptoms include low-grade fever, and/or redness, swelling, tenderness, and/or an •aching/cramping pain in your calf. •You should call your doctor immediately if you have these symptoms. •To prevent blood clots in legs, try walking and/ or pumping ankles several times during the day. •If the blood clot breaks free from the leg vein, it can travel to the lungs and cause severe breathing difficulty and/or chest pain. If you experience this, call [MASKED] immediately. Questions •Any questions may be directed to your surgeon or physician [MASKED]. 1.During normal business hours (8:30am- 5:00pm), you can call the office directly at [MASKED]. Turn around time for a phone call is 24 hours. After normal business hours, you can call the on-call service and we will get back to you the next business day. •If you are calling with an urgent medical issue, please tell the coordinator that it is an “urgent issue” and needs to be discussed in less than 24 hours (i.e. pain unrelieved with medications, wound breakdown/infection, or new neurological symptoms). Lumbar Corset or (TLSO) Brace Guidelines •You MAY have been given a rigid brace that you will wear for [MASKED] weeks after surgery. •You should put on your brace as you have been instructed by the orthotist (brace maker). Instructions will be reviewed in the hospital by the nursing staff and Physical Therapist. •It is a good idea to start practicing with your brace before surgery (putting it on/taking it off, sitting, standing, walking, and climbing steps with the brace) so you can assist with your post-operative care in the hospital. •Keep the name and phone number of the person who fitted and dispensed your brace close by in case you need to have the brace checked and/or adjusted. •You should always have a barrier between your surgical incision and the brace. For example, you may want to put on a light t-shirt and then the brace before getting dressed for the day. •During periods of rest, take off the brace and expose the incision to the air by lying on your side for a few hours. This will reduce the chance of your wound breaking down. 1.The brace must be worn at all times with the following 3 exceptions: 1.Lying flat in bed during a rest period or at night to sleep. 2.Getting out of bed at night to go to the bathroom, returning to bed immediately when you are finished. 3.Showering. You may wish to use a shower chair to help prevent bending/twisting while bathing. You should have someone help wash your back and legs. Followup Instructions: [MASKED]
[]
[ "I10", "F329", "F419" ]
[ "M4014: Other secondary kyphosis, thoracic region", "S22041G: Stable burst fracture of fourth thoracic vertebra, subsequent encounter for fracture with delayed healing", "V499XXD: Car occupant (driver) (passenger) injured in unspecified traffic accident, subsequent encounter", "Z720: Tobacco use", "I10: Essential (primary) hypertension", "Z8541: Personal history of malignant neoplasm of cervix uteri", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]
10,074,611
23,494,296
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: cephalexin / Influenza Virus Vaccines Attending: ___. Chief Complaint: MVC resulting in T4 burst Fx, T5 osteophyte Fx,T1-T4 SP fx, Rt 1st rib Fx with displacement, extensive scalp lac, right distal clavicular fx Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female ___ presented to the hospital after an MVC in which she ws ejected from the vehicle. She was speaking initially upon arrival of EMS. However she had a mental status change so she was intubated. Blood pressure was 130 systolic and her heart rate was 139. She has a degloving injury to the scalp. She was started on hypertonic saline. She was intubated with a 7.5 endotracheal tube. Past Medical History: None Social History: ___ Family History: Lives with her husband Physical ___: PHYSICAL EXAMINATION upon admission: ___: ============================================== HR: 140 BP: 140/ O(2)Sat: 100 Constitutional: Degloving injury to the scalp HEENT: Pupils equal, round and reactive to light Cervical collar was placed upon arrival Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, obese, multiple abrasions over the anterior abdomen Extr/Back: Left hand ecchymosis no obvious deformity. Left thigh anterolateral ecchymosis no obvious deformity. Bilateral knee abrasions, bilateral medial ankle ecchymosis. Pulses are intact of both upper and lower extremities. There are no obvious deformities. The patient was rolled and has no obvious back injuries Neuro: Unresponsive DISCHARGE PHYSCIAL EXAM: ======================== Gen: NAD, Comfortable HEENT: Repaired laceration on scalp, c/d/i; EOMI, PERRAL, MMM Neck: Supple CV: RRR, normal S1&S2, no MRG Lung: Non-labored breathing Abd: Soft, NT, ND Ext: No c/e/e Pertinent Results: ADMISSION LABS: =============== ___ 06:42PM BLOOD WBC-20.1* RBC-3.18* Hgb-10.4* Hct-31.2* MCV-98 MCH-32.7* MCHC-33.3 RDW-13.8 RDWSD-48.9* Plt ___ ___ 06:42PM BLOOD ___ PTT-23.1* ___ ___ 11:34PM BLOOD Glucose-146* UreaN-11 Creat-0.5 Na-147 K-4.2 Cl-113* HCO3-21* AnGap-13 ___ 11:34PM BLOOD ALT-46* AST-51* LD(LDH)-378* AlkPhos-51 TotBili-<0.2 ___ 06:42PM BLOOD Lipase-109* ___ 11:34PM BLOOD Albumin-3.2* Calcium-7.1* Phos-3.5 Mg-1.7 ___ 06:42PM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:49PM BLOOD ___ pO2-90 pCO2-47* pH-7.30* calTCO2-24 Base XS--3 Comment-GREEN TOP ___ 06:49PM BLOOD Glucose-142* Na-148* K-4.3 Cl-110* ___ 11:57PM BLOOD freeCa-1.01* ___ 07:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 07:40PM URINE Blood-SM* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM* ___ 07:40PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 ___ 07:40PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG INTERIM PERTINENT LABS: ======================= ___ 11:57PM BLOOD Type-ART pO2-117* pCO2-46* pH-7.29* calTCO2-23 Base XS--4 ___ 04:37AM BLOOD Type-ART pO2-113* pCO2-40 pH-7.35 calTCO2-23 Base XS--3 ___ 12:06PM BLOOD Type-ART pO2-103 pCO2-37 pH-7.38 calTCO2-23 Base XS--2 ___ 05:44PM BLOOD Type-ART pO2-92 pCO2-36 pH-7.44 calTCO2-25 Base XS-0 ___ 12:58AM BLOOD pH-7.43 ___ 06:11AM BLOOD Type-ART pO2-94 pCO2-38 pH-7.42 calTCO2-25 Base XS-0 ___ 11:57PM BLOOD Glucose-141* Lactate-2.9* ___ 04:37AM BLOOD Glucose-132* Lactate-3.4* ___ 12:06PM BLOOD Lactate-2.8* ___ 05:44PM BLOOD Lactate-3.0* ___ 12:58AM BLOOD Lactate-2.4* ___ 06:11AM BLOOD Lactate-1.9 DISCHARGE LABS: =============== ___ 09:23AM BLOOD WBC-12.6* RBC-2.96* Hgb-9.2* Hct-29.2* MCV-99* MCH-31.1 MCHC-31.5* RDW-15.0 RDWSD-53.8* Plt ___ ___ 09:23AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-136 K-4.7 Cl-96 HCO3-25 AnGap-15 ___ 09:23AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2 MICROBIOLOGY: ============= ___ 7:40 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 6:12 pm BLOOD CULTURE Source: Line-aline. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:05 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 6:21 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 9:15 pm Mini-BAL **FINAL REPORT ___ GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. ~6000 CFU/mL. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. MORAXELLA CATARRHALIS. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S IMAGING/STUDIES: ================ NCHCT ___: 1. Large left frontoparietal laceration/degloving injury of the scalp without underlying fracture identified. 2. No intracranial hemorrhage identified. C-Spine w/o Contrast ___: IMPRESSION: Tiny calcific density and adjacent to the anterior inferior endplate of C3. While this could be degenerative, in light of adjacent prevertebral edema, an acute avulsion fracture/anterior ligamentous injury is possible. Suggest MRI. No traumatic malalignment. Acute T1 and T2 spinous process fractures. CT CHEST W/CONTRAST ___: 1. Burst fracture of T4 with anterior displacement of the fracture fragments and surrounding prevertebral hematoma, as described above, with no significant bony spinal canal narrowing identified. 2. T1 through T4 spinous process fractures with the T3 and T4 fractures extending to the inferior articular facets bilaterally. Suspected nondisplaced right first posterior rib fracture. Fracture at the base of an endplate osteophyte at the right superolateral aspect of the T5 vertebral body. 3. No acute solid organ injury identified within the chest, abdomen, or pelvis. 4. A 2.9 cm right adnexal cyst can be further assessed by nonurgent pelvic ultrasound when clinically feasible. MR CERVICAL SPINE W/O CONTRAST ___: 1. Mild disc degenerative changes identified C5-C6 level, no focal or diffuse lesions are noted throughout the cervical spinal cord. 2. Burst fracture identified at T4 vertebral body with mild retropulsion causing anterior thecal sac deformity, with no evidence of cord compression or underlying signal abnormalities within the thoracic spinal cord. 3. Posterior soft tissue edema in the cervical and upper thoracic region, suggestive of ligamentous injury more significant from C4 through T5 vertebral levels. 4. Fractures of the spinous processes from T1 through T5 vertebral bodies are better depicted in the prior CT chest. Unchanged prevertebral soft tissue edema. Bilateral pleural effusion is new since the prior CT chest, more significant on the right. Schmorl's node at T10 superior endplate and heterogeneous signal at multiple thoracic and lumbar vertebral bodies are consistent with fatty hemangiomas. 5. Disc degenerative changes identified in the lower lumbar spine consistent disc protrusion at L4-5 and diffuse disc bulge at L5-S1 level. CTA NECK W&W/O CONTRAST ___: 1. No evidence of vascular injury within the carotid and vertebral arteries or their major branches. 2. Redemonstration of a T4 burst fracture with anterior displacement, no change in a prevertebral hematoma. T1-T5 spinous process fractures are unchanged. Nondisplaced right first posterior rib fracture and probable nondisplaced right mid to distal clavicular fracture. 3. Interval increase in mediastinal hematoma size, no airway compression noted. 4. Persistent bilateral pulmonary effusions with a hemorrhagic component and overlying atelectasis, worse on the right and partially imaged. CXR ___: Comparison with prior study there is persistent low lung volumes with bronchovascular crowding and bibasilar atelectasis. ETT terminates in the mid thoracic trachea, unchanged. NG tube courses below the diaphragm terminating in the left upper quadrant unchanged from prior. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is unchanged. IMPRESSION: 1. No significant changed from prior study with persistent bibasilar atelectasis. 2. Unchanged positioning of support devices, as described above. CXR ___: Mild left basilar opacity likely reflects atelectasis although underlying pneumonia is difficult to exclude. Brief Hospital Course: ___ ejected from MV at 40 mph. Patient was confused on scene but speaking, significant head laceration noted. Patient was intubated for confusion/agitation and received 150 fent, 2mg midaz, 75 ketamine en-route to hospital. Patient was hemodynamically stable upon evaluation. Injuries include T4 burst Fx, T5 osteophyte Fx,T1-T4 SP fx, Rt 1st rib Fx with displacement, extensive scalp lac, right distal clavicular fx. Her scalp laceration was stapled in the ED. Ortho Spine recommended nonoperative management w/ cervical collar on at all times, ___ brace while out of bed. On hospital day 0, patient was started on phenobarbital taper and transitioned to precede gtt. MRI Head negative, MRI spine showed posterior soft tissue edema c/w ligamentous injury from C4-T5, T4 burst fracture w/ mild retropulsion without cord compression. CTA Neck negative for vascular injury. She spike a fever to 102.5, blood, urine and mini BAL sent (BAL grew 3+ GNRs later found to be Moraxella catarrhalis). Her Hct was down to 20.5 and she was transfused 1U pRBC, her Hct responded to 25.2. By Hospital day 2, patient was moving all extremities and following instructions and so she was extubated. Patient was able to ventilate well on face mask afterwards. On Hospital Day 3, patient passed her speech/swallow evaluation and so the NGT was removed. Psychiatry was consulted for passive SI and depression, recommended starting Citalopram 40 mg QD. Her Foley was removed and she voided. On Hospital Day 4 the patient was transferred to the floor where she continued to work w/ physical therapy, which recommended rehab. On the floor, she continued tolerate a normal diet, was voiding independently but required pain control titration. She was started on Bactrim for a 7 day course for her M. catarrhalis CAP and initiated on Macrobid for a UTI as defined by a UA. By day of discharge, her pain was well controlled, she was eating, voiding, and eliminating independently, and her cough was controlled with inhalers and antibiotics. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyclobenzaprine 5 mg PO TID:PRN back spasms 2. TraMADol 50-100 mg PO Q6H:PRN Pain - Mild 3. Sulindac 200 mg PO QHS:PRN back swelling 4. TraZODone 50-100 mg PO QHS:PRN insomnia 5. Verapamil SR 180 mg PO Q24H hypertension 6. Xiidra (lifitegrast) 1 DROP BOTH EYES BID dry eyes Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol 0.083% Neb Soln ___ NEB IH Q6H:PRN SOB 3. Citalopram 40 mg PO DAILY 4. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWED 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 200 mg PO BID 7. Ipratropium Bromide Neb ___ NEB IH Q6H:PRN SOB 8. Labetalol 300 mg PO TID 9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 Days 10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX *oxycodone 10 mg 1 tablet(s) by mouth every three (3) hours Disp #*8 Tablet Refills:*0 11. Senna 8.6 mg PO BID:PRN Constipation 12. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 7 Days 13. Cyclobenzaprine 5 mg PO TID:PRN back spasms 14. Sulindac 200 mg PO QHS:PRN back swelling 15. TraZODone 50-100 mg PO QHS:PRN insomnia 16. Verapamil SR 180 mg PO Q24H hypertension 17. Xiidra (lifitegrast) 1 DROP BOTH EYES BID dry eyes Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Trauma: MVC Burst T4 vertebral body w/ mild retrop C4-T5 posterior soft tissue swelling spinous processes from T1 through T5 right 1st rib Fracture with displacement scalp laceration right clavicular fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear ___, You were admitted to the hospital after being involved in a MVC. You sustained fractures to your cervical and thoracic spine, in addition to a rib fracture and a right clavicle fracture. You were fitted for a special brace for stabilization of your neck and spine. You also sustained a laceration to your scalp which was staples. You had an airway placed to assist with your breathing and you were monitored in the intensive care unit. Because of your injuries, you were evaluated by the Spine and orthopedic services. You were evaluated by physical therapy and recommendations made for discharge to a rehabilitation center to further improve your mobililty. You are being discharged with the following instructions: ** Rib Fracture * Your injury caused a right 1st rib fracture which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * Non-steroidal anti-inflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn). * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). ** Spine Fractures * Bracing: Rigid cervical collar at all times. * ___ brace when walking. You can put it on at edge of bed. * Please follow-up in the Concussion Clinic as needed. ** Clavicle Fracture * Please wear arm sling until you follow up in surgery clinic. ** General Recommendations * 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. - 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. Thank you for allowing us to be a part of your care. Sincerely, Your ___ Surgery Care Team Followup Instructions: ___
[ "S22041A", "S140XXA", "R402212", "S06890A", "S240XXA", "J9600", "J158", "S2231XA", "D62", "F10239", "F10221", "N390", "S22018A", "S22028A", "S22038A", "S22058A", "S42031A", "V892XXA", "Y92410", "S0101XA", "F17210", "R402142", "R402362", "E669", "I10", "F329", "D696", "G4700", "B9689" ]
Allergies: cephalexin / Influenza Virus Vaccines Chief Complaint: MVC resulting in T4 burst Fx, T5 osteophyte Fx,T1-T4 SP fx, Rt 1st rib Fx with displacement, extensive scalp lac, right distal clavicular fx Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old female [MASKED] presented to the hospital after an MVC in which she ws ejected from the vehicle. She was speaking initially upon arrival of EMS. However she had a mental status change so she was intubated. Blood pressure was 130 systolic and her heart rate was 139. She has a degloving injury to the scalp. She was started on hypertonic saline. She was intubated with a 7.5 endotracheal tube. Past Medical History: None Social History: [MASKED] Family History: Lives with her husband Physical [MASKED]: PHYSICAL EXAMINATION upon admission: [MASKED]: ============================================== HR: 140 BP: 140/ O(2)Sat: 100 Constitutional: Degloving injury to the scalp HEENT: Pupils equal, round and reactive to light Cervical collar was placed upon arrival Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, obese, multiple abrasions over the anterior abdomen Extr/Back: Left hand ecchymosis no obvious deformity. Left thigh anterolateral ecchymosis no obvious deformity. Bilateral knee abrasions, bilateral medial ankle ecchymosis. Pulses are intact of both upper and lower extremities. There are no obvious deformities. The patient was rolled and has no obvious back injuries Neuro: Unresponsive DISCHARGE PHYSCIAL EXAM: ======================== Gen: NAD, Comfortable HEENT: Repaired laceration on scalp, c/d/i; EOMI, PERRAL, MMM Neck: Supple CV: RRR, normal S1&S2, no MRG Lung: Non-labored breathing Abd: Soft, NT, ND Ext: No c/e/e Pertinent Results: ADMISSION LABS: =============== [MASKED] 06:42PM BLOOD WBC-20.1* RBC-3.18* Hgb-10.4* Hct-31.2* MCV-98 MCH-32.7* MCHC-33.3 RDW-13.8 RDWSD-48.9* Plt [MASKED] [MASKED] 06:42PM BLOOD [MASKED] PTT-23.1* [MASKED] [MASKED] 11:34PM BLOOD Glucose-146* UreaN-11 Creat-0.5 Na-147 K-4.2 Cl-113* HCO3-21* AnGap-13 [MASKED] 11:34PM BLOOD ALT-46* AST-51* LD(LDH)-378* AlkPhos-51 TotBili-<0.2 [MASKED] 06:42PM BLOOD Lipase-109* [MASKED] 11:34PM BLOOD Albumin-3.2* Calcium-7.1* Phos-3.5 Mg-1.7 [MASKED] 06:42PM BLOOD ASA-NEG [MASKED] Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 06:49PM BLOOD [MASKED] pO2-90 pCO2-47* pH-7.30* calTCO2-24 Base XS--3 Comment-GREEN TOP [MASKED] 06:49PM BLOOD Glucose-142* Na-148* K-4.3 Cl-110* [MASKED] 11:57PM BLOOD freeCa-1.01* [MASKED] 07:40PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 07:40PM URINE Blood-SM* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM* [MASKED] 07:40PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 [MASKED] 07:40PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG INTERIM PERTINENT LABS: ======================= [MASKED] 11:57PM BLOOD Type-ART pO2-117* pCO2-46* pH-7.29* calTCO2-23 Base XS--4 [MASKED] 04:37AM BLOOD Type-ART pO2-113* pCO2-40 pH-7.35 calTCO2-23 Base XS--3 [MASKED] 12:06PM BLOOD Type-ART pO2-103 pCO2-37 pH-7.38 calTCO2-23 Base XS--2 [MASKED] 05:44PM BLOOD Type-ART pO2-92 pCO2-36 pH-7.44 calTCO2-25 Base XS-0 [MASKED] 12:58AM BLOOD pH-7.43 [MASKED] 06:11AM BLOOD Type-ART pO2-94 pCO2-38 pH-7.42 calTCO2-25 Base XS-0 [MASKED] 11:57PM BLOOD Glucose-141* Lactate-2.9* [MASKED] 04:37AM BLOOD Glucose-132* Lactate-3.4* [MASKED] 12:06PM BLOOD Lactate-2.8* [MASKED] 05:44PM BLOOD Lactate-3.0* [MASKED] 12:58AM BLOOD Lactate-2.4* [MASKED] 06:11AM BLOOD Lactate-1.9 DISCHARGE LABS: =============== [MASKED] 09:23AM BLOOD WBC-12.6* RBC-2.96* Hgb-9.2* Hct-29.2* MCV-99* MCH-31.1 MCHC-31.5* RDW-15.0 RDWSD-53.8* Plt [MASKED] [MASKED] 09:23AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-136 K-4.7 Cl-96 HCO3-25 AnGap-15 [MASKED] 09:23AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2 MICROBIOLOGY: ============= [MASKED] 7:40 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 6:12 pm BLOOD CULTURE Source: Line-aline. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 6:05 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 6:21 pm URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 9:15 pm Mini-BAL **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ [MASKED] per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [MASKED]: Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. ~6000 CFU/mL. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. MORAXELLA CATARRHALIS. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S IMAGING/STUDIES: ================ NCHCT [MASKED]: 1. Large left frontoparietal laceration/degloving injury of the scalp without underlying fracture identified. 2. No intracranial hemorrhage identified. C-Spine w/o Contrast [MASKED]: IMPRESSION: Tiny calcific density and adjacent to the anterior inferior endplate of C3. While this could be degenerative, in light of adjacent prevertebral edema, an acute avulsion fracture/anterior ligamentous injury is possible. Suggest MRI. No traumatic malalignment. Acute T1 and T2 spinous process fractures. CT CHEST W/CONTRAST [MASKED]: 1. Burst fracture of T4 with anterior displacement of the fracture fragments and surrounding prevertebral hematoma, as described above, with no significant bony spinal canal narrowing identified. 2. T1 through T4 spinous process fractures with the T3 and T4 fractures extending to the inferior articular facets bilaterally. Suspected nondisplaced right first posterior rib fracture. Fracture at the base of an endplate osteophyte at the right superolateral aspect of the T5 vertebral body. 3. No acute solid organ injury identified within the chest, abdomen, or pelvis. 4. A 2.9 cm right adnexal cyst can be further assessed by nonurgent pelvic ultrasound when clinically feasible. MR CERVICAL SPINE W/O CONTRAST [MASKED]: 1. Mild disc degenerative changes identified C5-C6 level, no focal or diffuse lesions are noted throughout the cervical spinal cord. 2. Burst fracture identified at T4 vertebral body with mild retropulsion causing anterior thecal sac deformity, with no evidence of cord compression or underlying signal abnormalities within the thoracic spinal cord. 3. Posterior soft tissue edema in the cervical and upper thoracic region, suggestive of ligamentous injury more significant from C4 through T5 vertebral levels. 4. Fractures of the spinous processes from T1 through T5 vertebral bodies are better depicted in the prior CT chest. Unchanged prevertebral soft tissue edema. Bilateral pleural effusion is new since the prior CT chest, more significant on the right. Schmorl's node at T10 superior endplate and heterogeneous signal at multiple thoracic and lumbar vertebral bodies are consistent with fatty hemangiomas. 5. Disc degenerative changes identified in the lower lumbar spine consistent disc protrusion at L4-5 and diffuse disc bulge at L5-S1 level. CTA NECK W&W/O CONTRAST [MASKED]: 1. No evidence of vascular injury within the carotid and vertebral arteries or their major branches. 2. Redemonstration of a T4 burst fracture with anterior displacement, no change in a prevertebral hematoma. T1-T5 spinous process fractures are unchanged. Nondisplaced right first posterior rib fracture and probable nondisplaced right mid to distal clavicular fracture. 3. Interval increase in mediastinal hematoma size, no airway compression noted. 4. Persistent bilateral pulmonary effusions with a hemorrhagic component and overlying atelectasis, worse on the right and partially imaged. CXR [MASKED]: Comparison with prior study there is persistent low lung volumes with bronchovascular crowding and bibasilar atelectasis. ETT terminates in the mid thoracic trachea, unchanged. NG tube courses below the diaphragm terminating in the left upper quadrant unchanged from prior. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is unchanged. IMPRESSION: 1. No significant changed from prior study with persistent bibasilar atelectasis. 2. Unchanged positioning of support devices, as described above. CXR [MASKED]: Mild left basilar opacity likely reflects atelectasis although underlying pneumonia is difficult to exclude. Brief Hospital Course: [MASKED] ejected from MV at 40 mph. Patient was confused on scene but speaking, significant head laceration noted. Patient was intubated for confusion/agitation and received 150 fent, 2mg midaz, 75 ketamine en-route to hospital. Patient was hemodynamically stable upon evaluation. Injuries include T4 burst Fx, T5 osteophyte Fx,T1-T4 SP fx, Rt 1st rib Fx with displacement, extensive scalp lac, right distal clavicular fx. Her scalp laceration was stapled in the ED. Ortho Spine recommended nonoperative management w/ cervical collar on at all times, [MASKED] brace while out of bed. On hospital day 0, patient was started on phenobarbital taper and transitioned to precede gtt. MRI Head negative, MRI spine showed posterior soft tissue edema c/w ligamentous injury from C4-T5, T4 burst fracture w/ mild retropulsion without cord compression. CTA Neck negative for vascular injury. She spike a fever to 102.5, blood, urine and mini BAL sent (BAL grew 3+ GNRs later found to be Moraxella catarrhalis). Her Hct was down to 20.5 and she was transfused 1U pRBC, her Hct responded to 25.2. By Hospital day 2, patient was moving all extremities and following instructions and so she was extubated. Patient was able to ventilate well on face mask afterwards. On Hospital Day 3, patient passed her speech/swallow evaluation and so the NGT was removed. Psychiatry was consulted for passive SI and depression, recommended starting Citalopram 40 mg QD. Her Foley was removed and she voided. On Hospital Day 4 the patient was transferred to the floor where she continued to work w/ physical therapy, which recommended rehab. On the floor, she continued tolerate a normal diet, was voiding independently but required pain control titration. She was started on Bactrim for a 7 day course for her M. catarrhalis CAP and initiated on Macrobid for a UTI as defined by a UA. By day of discharge, her pain was well controlled, she was eating, voiding, and eliminating independently, and her cough was controlled with inhalers and antibiotics. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cyclobenzaprine 5 mg PO TID:PRN back spasms 2. TraMADol 50-100 mg PO Q6H:PRN Pain - Mild 3. Sulindac 200 mg PO QHS:PRN back swelling 4. TraZODone 50-100 mg PO QHS:PRN insomnia 5. Verapamil SR 180 mg PO Q24H hypertension 6. Xiidra (lifitegrast) 1 DROP BOTH EYES BID dry eyes Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol 0.083% Neb Soln [MASKED] NEB IH Q6H:PRN SOB 3. Citalopram 40 mg PO DAILY 4. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QWED 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 200 mg PO BID 7. Ipratropium Bromide Neb [MASKED] NEB IH Q6H:PRN SOB 8. Labetalol 300 mg PO TID 9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 Days 10. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe RX *oxycodone 10 mg 1 tablet(s) by mouth every three (3) hours Disp #*8 Tablet Refills:*0 11. Senna 8.6 mg PO BID:PRN Constipation 12. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 7 Days 13. Cyclobenzaprine 5 mg PO TID:PRN back spasms 14. Sulindac 200 mg PO QHS:PRN back swelling 15. TraZODone 50-100 mg PO QHS:PRN insomnia 16. Verapamil SR 180 mg PO Q24H hypertension 17. Xiidra (lifitegrast) 1 DROP BOTH EYES BID dry eyes Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Trauma: MVC Burst T4 vertebral body w/ mild retrop C4-T5 posterior soft tissue swelling spinous processes from T1 through T5 right 1st rib Fracture with displacement scalp laceration right clavicular fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear [MASKED], You were admitted to the hospital after being involved in a MVC. You sustained fractures to your cervical and thoracic spine, in addition to a rib fracture and a right clavicle fracture. You were fitted for a special brace for stabilization of your neck and spine. You also sustained a laceration to your scalp which was staples. You had an airway placed to assist with your breathing and you were monitored in the intensive care unit. Because of your injuries, you were evaluated by the Spine and orthopedic services. You were evaluated by physical therapy and recommendations made for discharge to a rehabilitation center to further improve your mobililty. You are being discharged with the following instructions: ** Rib Fracture * Your injury caused a right 1st rib fracture which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * Non-steroidal anti-inflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn). * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). ** Spine Fractures * Bracing: Rigid cervical collar at all times. * [MASKED] brace when walking. You can put it on at edge of bed. * Please follow-up in the Concussion Clinic as needed. ** Clavicle Fracture * Please wear arm sling until you follow up in surgery clinic. ** General Recommendations * 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. - 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. Thank you for allowing us to be a part of your care. Sincerely, Your [MASKED] Surgery Care Team Followup Instructions: [MASKED]
[]
[ "D62", "N390", "F17210", "E669", "I10", "F329", "D696", "G4700" ]
[ "S22041A: Stable burst fracture of fourth thoracic vertebra, initial encounter for closed fracture", "S140XXA: Concussion and edema of cervical spinal cord, initial encounter", "R402212: Coma scale, best verbal response, none, at arrival to emergency department", "S06890A: Other specified intracranial injury without loss of consciousness, initial encounter", "S240XXA: Concussion and edema of thoracic spinal cord, initial encounter", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "J158: Pneumonia due to other specified bacteria", "S2231XA: Fracture of one rib, right side, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "F10239: Alcohol dependence with withdrawal, unspecified", "F10221: Alcohol dependence with intoxication delirium", "N390: Urinary tract infection, site not specified", "S22018A: Other fracture of first thoracic vertebra, initial encounter for closed fracture", "S22028A: Other fracture of second thoracic vertebra, initial encounter for closed fracture", "S22038A: Other fracture of third thoracic vertebra, initial encounter for closed fracture", "S22058A: Other fracture of T5-T6 vertebra, initial encounter for closed fracture", "S42031A: Displaced fracture of lateral end of right clavicle, initial encounter for closed fracture", "V892XXA: Person injured in unspecified motor-vehicle accident, traffic, initial encounter", "Y92410: Unspecified street and highway as the place of occurrence of the external cause", "S0101XA: Laceration without foreign body of scalp, initial encounter", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "E669: Obesity, unspecified", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "D696: Thrombocytopenia, unspecified", "G4700: Insomnia, unspecified", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere" ]
10,074,649
28,167,262
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: heavy vaginal bleeding Major Surgical or Invasive Procedure: Total vaginal hysterectomy, bilateral partial salpingectomy, cystoscopy Physical Exam: Gen: NAD CV: RRR Pulm: breathing comfortably on RA Abd: soft, appropriately mildly TTP, no rebound or guarding GU: minimal staining on pad, foley in place Ext: WWP, mild TTP on lateral dorsal aspect of right ankle and foot, no erythema or edema Pertinent Results: ___ 03:30AM BLOOD WBC-15.0* RBC-3.34* Hgb-9.6* Hct-29.8* MCV-89 MCH-28.7 MCHC-32.2 RDW-14.1 RDWSD-46.1 Plt ___ Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service after undergoing transvaginal hysterectomy, bilateral salpingectomy and cystoscopy for abnormal uterine bleeding. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. Her Foley was removed and she was voiding independently. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hours. RX *acetaminophen 500 mg ___ tablet(s) by mouth Every 6 hours as needed Disp #*40 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Can take while using oxycodone to prevent severe constipation. RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice per day as needed Disp #*28 Tablet Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN Pain Please take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #*40 Tablet Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Do not operative heavy machinery or drink while using. RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #*12 Tablet Refills:*0 5. Amitriptyline 25 mg PO QHS 6. Gabapentin 100 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: excessive menstruation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink ___ liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener ___ times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
[ "N920", "N800", "N879", "G43909", "E663", "Z6828", "Z87891" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: heavy vaginal bleeding Major Surgical or Invasive Procedure: Total vaginal hysterectomy, bilateral partial salpingectomy, cystoscopy Physical Exam: Gen: NAD CV: RRR Pulm: breathing comfortably on RA Abd: soft, appropriately mildly TTP, no rebound or guarding GU: minimal staining on pad, foley in place Ext: WWP, mild TTP on lateral dorsal aspect of right ankle and foot, no erythema or edema Pertinent Results: [MASKED] 03:30AM BLOOD WBC-15.0* RBC-3.34* Hgb-9.6* Hct-29.8* MCV-89 MCH-28.7 MCHC-32.2 RDW-14.1 RDWSD-46.1 Plt [MASKED] Brief Hospital Course: On [MASKED], Ms. [MASKED] was admitted to the gynecology service after undergoing transvaginal hysterectomy, bilateral salpingectomy and cystoscopy for abnormal uterine bleeding. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid and toradol. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. Her Foley was removed and she was voiding independently. She was then discharged home in stable condition with outpatient follow-up scheduled. Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever Do not exceed 4000mg in 24 hours. RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth Every 6 hours as needed Disp #*40 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line Can take while using oxycodone to prevent severe constipation. RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice per day as needed Disp #*28 Tablet Refills:*0 3. Ibuprofen 600 mg PO Q6H:PRN Pain Please take with food. RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #*40 Tablet Refills:*0 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Do not operative heavy machinery or drink while using. RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed Disp #*12 Tablet Refills:*0 5. Amitriptyline 25 mg PO QHS 6. Gabapentin 100 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: excessive menstruation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. [MASKED] office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 3 months. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Constipation: * Drink [MASKED] liters of water every day. * Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include: Whole grain breads, Bran cereal, Prune juice, Fresh fruits and vegetables, Dried fruits such as dried apricots and prunes, Legumes, Nuts/seeds. * Take Colace stool softener [MASKED] times daily. * Use Dulcolax suppository daily as needed. * Take Miralax laxative powder daily as needed. * Stop constipation medications if you are having loose stools or diarrhea. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [MASKED]. Followup Instructions: [MASKED]
[]
[ "Z87891" ]
[ "N920: Excessive and frequent menstruation with regular cycle", "N800: Endometriosis of uterus", "N879: Dysplasia of cervix uteri, unspecified", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "E663: Overweight", "Z6828: Body mass index [BMI] 28.0-28.9, adult", "Z87891: Personal history of nicotine dependence" ]
10,074,869
28,600,840
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: ___ Coronary artery bypass grafting x 5 with the left internal mammary artery to left anterior descending artery, reverse saphenous vein graft to the posterolateral branch artery, a diagonal artery, and sequential reverse saphenous vein graft to the first and second obtuse marginal artery. History of Present Illness: ___ year old male with past medical history of hypertension, diabetes mellitus type 2, hyperlipidemia, and prostate cancer who presented to ___ with chest pain. The pain was described as ___, pressure-like chest pain, retrosternal, radiating to his neck with associated nausea. He felt that he could not swallow and thought his symptoms might have been related to some gastric gas pain. He had a cup of water and belched with slight improvement in his pain so he went back to his bed. Less than 15 minutes later, the pain recurred at the same severity. He repeated the drinking and belching cycle over for two additional times with the same effect. Shortly after he heard some gurgling in his stomach and went to have a BM which was normal and went back to sleep. At 5 am, he felt that his left arm was numb but was able to lift it above his head. Later when his wife woke up around 8am, he told her the story and she insisted that he go to the ED. The pain was alleviated by nitroglycerin x2 and belching in the ED. He reports a similar presentation two weeks ago but did not seek medical advice. He underwent cardiac catheterization which demonstrated multi-vessel coronary artery disease. He was transferred to ___ for coronary artery bypass graft evaluation. Past Medical History: Hypertension Hyperlipidemia Diabetes mellitus type 2 Prostate CA- in remission Coronary artery disease Arthritis ruptured achilles left Past Surgical History: bilat cataract removal laser surg eyes cyst removal left lateral neck cyst removal left chest wall/under breast Social History: ___ Family History: Father passed from ___ Brother had CABG at ___ yo All siblings have HTN Physical Exam: T 98.0 HR 73 BP 166/74 RR 20 O2sat 99% RA B/P Right: 125/64 Left: Height: 64 in Weight: 174 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] MMM, Neck: Supple [x] Full ROM [x] no jvd Chest: Lungs clear bilaterally [x] Heart: RRR [x] no M/R/G Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: + Left: + DP Right: Left: ___ Right: + Left: + Radial Right: + Left: + Carotid Bruit: none appreciated Discharge Exam Pertinent Results: ___ 04:36AM BLOOD WBC-14.3* RBC-2.69* Hgb-8.6* Hct-25.3* MCV-94 MCH-32.0 MCHC-34.0 RDW-13.4 RDWSD-45.6 Plt ___ ___ 02:29AM BLOOD WBC-13.6* RBC-2.43* Hgb-7.9* Hct-23.0* MCV-95 MCH-32.5* MCHC-34.3 RDW-13.6 RDWSD-46.7* Plt ___ ___ 12:40PM BLOOD Hct-24.7* ___ 02:29AM BLOOD ___ PTT-26.7 ___ ___ 02:25AM BLOOD ___ PTT-27.0 ___ ___ 03:02AM BLOOD ___ PTT-24.9* ___ ___ 04:36AM BLOOD Glucose-156* UreaN-20 Creat-0.9 Na-138 K-4.0 Cl-97 HCO3-30 AnGap-11 ___ 12:25PM BLOOD K-3.9 ___ 02:29AM BLOOD Glucose-86 UreaN-22* Creat-0.8 Na-139 K-3.9 Cl-101 HCO3-27 AnGap-11 ___ 12:40PM BLOOD UreaN-23* Creat-0.9 K-3.9 TEE ___ Pre Bypass: The left atrium is mildly dilated. The left atrium is elongated. No mass/thrombus is seen in the left atrium or left atrial appendage. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%) with anteroapical hypokinesis. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild to moderate (___) aortic regurgitation is seen. The aortic regurgitation jet is eccentric and a pressure half time could not be obtained. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Post Bypass: Patient is A paced on phenylepherine infusion. Biventricular function is preserved. Aortic insufficiency is unchanged. Aortic contours intact after cannula removal. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. Brief Hospital Course: The patient was brought to the Operating Room on ___ where the patient underwent Coronary artery bypass grafting x 5 with the left internal mammary artery to left anterior descending artery, reverse saphenous vein graft to the posterolateral branch artery, a diagonal artery, and sequential reverse saphenous vein graft to the first and second obtuse marginal artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He had brief episode of atrial fibrillation which converted to normal sinus rhythm with IV Lopressor and increased oral Lopressor. The patient was transferred to the telemetry floor for further recovery. Lisinopril was started at lower dose than home regimen and is to be titrated up as blood pressure allows. Home Diabetes meds were restarted. 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 with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: antiox.mv ___ 2 tab PO DAILY atenolol 25 mg PO DAILY atorvastatin 40 mg PO DAILY glipizide 10 mg PO daily hydrochlorothiazide 25 mg PO DAILY -hold lisinopril 40 mg PO DAILY Meds at ___: Tylenol ___ Q6/prn ASA 81 mg daily Atenolol 25 mg Daily Atorvastatin 40 mg daily NTG 0.4 prn Trazadone 25 mg QHS/prn Glipizide 10 mg daily Lisinopril 40 mg daily-hold Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 4. Furosemide 40 mg PO DAILY Duration: 10 Days RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 5. Metoprolol Tartrate 50 mg PO Q8H RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 6. Potassium Chloride 40 mEq PO DAILY Duration: 10 Days RX *potassium chloride 20 mEq 2 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 7. Ranitidine 150 mg PO BID Duration: 30 Days RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Senna 17.2 mg PO BID:PRN Constipation - First Line RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day Disp #*30 Tablet Refills:*0 9. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. GlipiZIDE XL 10 mg PO DAILY RX *glipizide 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 12. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 13. Atorvastatin 40 mg PO QPM 14. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until talking with your PCP ___: Home With Service Facility: ___ Discharge Diagnosis: Hypertension Hyperlipidemia Diabetes mellitus type 2 Prostate CA- in remission Coronary artery disease Arthritis ruptured achilles left Past Surgical History: bilat cataract removal laser surg eyes cyst removal left lateral neck cyst removal left chest wall/under breast 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 **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
[ "I2510", "D62", "I2582", "I4891", "I10", "E785", "E119", "D72829", "Z8546", "Z8249" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED] Coronary artery bypass grafting x 5 with the left internal mammary artery to left anterior descending artery, reverse saphenous vein graft to the posterolateral branch artery, a diagonal artery, and sequential reverse saphenous vein graft to the first and second obtuse marginal artery. History of Present Illness: [MASKED] year old male with past medical history of hypertension, diabetes mellitus type 2, hyperlipidemia, and prostate cancer who presented to [MASKED] with chest pain. The pain was described as [MASKED], pressure-like chest pain, retrosternal, radiating to his neck with associated nausea. He felt that he could not swallow and thought his symptoms might have been related to some gastric gas pain. He had a cup of water and belched with slight improvement in his pain so he went back to his bed. Less than 15 minutes later, the pain recurred at the same severity. He repeated the drinking and belching cycle over for two additional times with the same effect. Shortly after he heard some gurgling in his stomach and went to have a BM which was normal and went back to sleep. At 5 am, he felt that his left arm was numb but was able to lift it above his head. Later when his wife woke up around 8am, he told her the story and she insisted that he go to the ED. The pain was alleviated by nitroglycerin x2 and belching in the ED. He reports a similar presentation two weeks ago but did not seek medical advice. He underwent cardiac catheterization which demonstrated multi-vessel coronary artery disease. He was transferred to [MASKED] for coronary artery bypass graft evaluation. Past Medical History: Hypertension Hyperlipidemia Diabetes mellitus type 2 Prostate CA- in remission Coronary artery disease Arthritis ruptured achilles left Past Surgical History: bilat cataract removal laser surg eyes cyst removal left lateral neck cyst removal left chest wall/under breast Social History: [MASKED] Family History: Father passed from [MASKED] Brother had CABG at [MASKED] yo All siblings have HTN Physical Exam: T 98.0 HR 73 BP 166/74 RR 20 O2sat 99% RA B/P Right: 125/64 Left: Height: 64 in Weight: 174 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] MMM, Neck: Supple [x] Full ROM [x] no jvd Chest: Lungs clear bilaterally [x] Heart: RRR [x] no M/R/G Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: + Left: + DP Right: Left: [MASKED] Right: + Left: + Radial Right: + Left: + Carotid Bruit: none appreciated Discharge Exam Pertinent Results: [MASKED] 04:36AM BLOOD WBC-14.3* RBC-2.69* Hgb-8.6* Hct-25.3* MCV-94 MCH-32.0 MCHC-34.0 RDW-13.4 RDWSD-45.6 Plt [MASKED] [MASKED] 02:29AM BLOOD WBC-13.6* RBC-2.43* Hgb-7.9* Hct-23.0* MCV-95 MCH-32.5* MCHC-34.3 RDW-13.6 RDWSD-46.7* Plt [MASKED] [MASKED] 12:40PM BLOOD Hct-24.7* [MASKED] 02:29AM BLOOD [MASKED] PTT-26.7 [MASKED] [MASKED] 02:25AM BLOOD [MASKED] PTT-27.0 [MASKED] [MASKED] 03:02AM BLOOD [MASKED] PTT-24.9* [MASKED] [MASKED] 04:36AM BLOOD Glucose-156* UreaN-20 Creat-0.9 Na-138 K-4.0 Cl-97 HCO3-30 AnGap-11 [MASKED] 12:25PM BLOOD K-3.9 [MASKED] 02:29AM BLOOD Glucose-86 UreaN-22* Creat-0.8 Na-139 K-3.9 Cl-101 HCO3-27 AnGap-11 [MASKED] 12:40PM BLOOD UreaN-23* Creat-0.9 K-3.9 TEE [MASKED] Pre Bypass: The left atrium is mildly dilated. The left atrium is elongated. No mass/thrombus is seen in the left atrium or left atrial appendage. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%) with anteroapical hypokinesis. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild to moderate ([MASKED]) aortic regurgitation is seen. The aortic regurgitation jet is eccentric and a pressure half time could not be obtained. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Post Bypass: Patient is A paced on phenylepherine infusion. Biventricular function is preserved. Aortic insufficiency is unchanged. Aortic contours intact after cannula removal. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. Brief Hospital Course: The patient was brought to the Operating Room on [MASKED] where the patient underwent Coronary artery bypass grafting x 5 with the left internal mammary artery to left anterior descending artery, reverse saphenous vein graft to the posterolateral branch artery, a diagonal artery, and sequential reverse saphenous vein graft to the first and second obtuse marginal artery. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He had brief episode of atrial fibrillation which converted to normal sinus rhythm with IV Lopressor and increased oral Lopressor. The patient was transferred to the telemetry floor for further recovery. Lisinopril was started at lower dose than home regimen and is to be titrated up as blood pressure allows. Home Diabetes meds were restarted. 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 with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: antiox.mv [MASKED] 2 tab PO DAILY atenolol 25 mg PO DAILY atorvastatin 40 mg PO DAILY glipizide 10 mg PO daily hydrochlorothiazide 25 mg PO DAILY -hold lisinopril 40 mg PO DAILY Meds at [MASKED]: Tylenol [MASKED] Q6/prn ASA 81 mg daily Atenolol 25 mg Daily Atorvastatin 40 mg daily NTG 0.4 prn Trazadone 25 mg QHS/prn Glipizide 10 mg daily Lisinopril 40 mg daily-hold Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Aspirin EC 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 4. Furosemide 40 mg PO DAILY Duration: 10 Days RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 5. Metoprolol Tartrate 50 mg PO Q8H RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 6. Potassium Chloride 40 mEq PO DAILY Duration: 10 Days RX *potassium chloride 20 mEq 2 tablet(s) by mouth once a day Disp #*10 Tablet Refills:*0 7. Ranitidine 150 mg PO BID Duration: 30 Days RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Senna 17.2 mg PO BID:PRN Constipation - First Line RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day Disp #*30 Tablet Refills:*0 9. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 11. GlipiZIDE XL 10 mg PO DAILY RX *glipizide 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 12. Lisinopril 10 mg PO DAILY RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1 13. Atorvastatin 40 mg PO QPM 14. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until talking with your PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: Hypertension Hyperlipidemia Diabetes mellitus type 2 Prostate CA- in remission Coronary artery disease Arthritis ruptured achilles left Past Surgical History: bilat cataract removal laser surg eyes cyst removal left lateral neck cyst removal left chest wall/under breast 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 **Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours** Followup Instructions: [MASKED]
[]
[ "I2510", "D62", "I4891", "I10", "E785", "E119" ]
[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "D62: Acute posthemorrhagic anemia", "I2582: Chronic total occlusion of coronary artery", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "D72829: Elevated white blood cell count, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]
10,074,908
27,875,313
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: seafood Attending: ___. Chief Complaint: Hydrocephalus Major Surgical or Invasive Procedure: ___ - Placement of VP Shunt by Dr ___ ___ of Present Illness: Mr. ___ is a ___ y/o female with hydrocephalus who presents for elective placement of a VP shunt. The risks and benefits of VP shunt placement were discussed and consent was obtained. Past Medical History: Type II DM h/o cerebellar meningioma neurocognitive decline Social History: ___ Family History: NC. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: EO spont, ___ speaking. PERRL ___, EOMI. Face symmetric at rest. Moves all extremities antigravity, mimics. PHYSICAL EXAMINATION ON DISCHARGE: EO spontaneously, ___ speaking. PERRL ___, EOMI. Difficulty following commands, mimics. Face symmetric. Moves all extremities antigravity, ambulates with assistance. Pertinent Results: CT Head W/O Contrast ___ 1. The patient is status-post right frontal approach VP shunt placement with expected postsurgical changes that includes pneumocephalus, subcutaneous emphysema, and subcutaneous edema and/or hematoma. No significant intracranial hemorrhage. 2. Stable large extra-axial right posterior fossa mass, most likely consistent with meningioma. CT Head W/O Contrast ___ 1. The right frontal approach VP shunt catheter is unchanged in position. Ventricular dilation is unchanged. 2. Stable large extra-axial right posterior fossa mass, most consistent with a meningioma. Brief Hospital Course: The patient was taken to the operating room on the day of admission, ___ and underwent placement of a right frontal VP shunt. She tolerated the procedure well and was extubated in the operating room. She was then transferred to the PACU in stable condition for close monitoring. On ___ the patent remained neurologically stable. The patients potassium was repleated and speech and swallow evaluated the patient for concerns of aspiration. She was cleared for a puree diet with thin liquids and 1:1 supervision with all feeds. The patient worked with OT and ___ for dispo planning. On ___ the patient remained neurologically and hemodynamically stable. She was awake and alert, as well as mimics and moving all extremities spontaneously against gravity. The incision site was clean, dry and intact. At one point the family was concerned that she may be more lethargic, upon further examination the patient appeared fatigued but easily arousable with no changes in her neuro exam. ___ and OT are involved for dispo planning as well as social work for family support. On ___, the patient was neurologically stable. On ___, The patient was noted to be lethargic by family and nursing at approximately 2 pm and the patient was sent for a Stat NCHCT which was stable. The patient woke up to her baseline neurological status on her way to the CT scanner. The patient was moving all extremities. Eyes were open spontaneously. pupils were equal and reactive. A urine analysis was sent and was negative for UTI. From ___, patient remains neurologically and hemodynamically stable. She was re-evaluated by physical therapy who recommended rehab. She was tolerating house diet, ambulating with assistance and voiding without difficulty. VP Shunt setting was confirmed prior to discharge and set at 1.5. Medications on Admission: alendronate 70mg, 1 tablet q week liptor 80mg q day flexeril 5mg po TID PRN calcium carbonate-vitamin D3 1 tablet PO BID lisinopril 5mg tablet q day Namenda 5mg tablet PO q day Metformin 500mg PO BID omega 3 fatty acids 1 capsule PO q day Discharge Medications: 1. Acetaminophen 325-650 mg PO Q8H:PRN headache 2. Atorvastatin 80 mg PO QPM 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. Codeine Sulfate 15 mg PO Q4H:PRN headache 5. Docusate Sodium 100 mg PO BID 6. Heparin 5000 UNIT SC BID 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 8. Lisinopril 5 mg PO DAILY ___ hold for SBP < 100. 9. Memantine 5 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 17.2 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Hydrocephalus. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Ventriculoperitoneal Shunt Surgery • You had a VP shunt placed for hydrocephalus. Your incisions should be kept dry until sutures or staples are removed. • Your shunt is a ___ Strata Valve which is programmable. This will need to be readjusted after all MRIs or exposure to large magnets. Your shunt is programmed to 1.5. • t 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. • No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: • Headache or pain along your incision. • Some neck tenderness along the shunt tubing. • 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: ___
[ "G912", "F0390", "E119", "I10", "E785", "M810", "R269", "Z794" ]
Allergies: seafood Chief Complaint: Hydrocephalus Major Surgical or Invasive Procedure: [MASKED] - Placement of VP Shunt by Dr [MASKED] [MASKED] of Present Illness: Mr. [MASKED] is a [MASKED] y/o female with hydrocephalus who presents for elective placement of a VP shunt. The risks and benefits of VP shunt placement were discussed and consent was obtained. Past Medical History: Type II DM h/o cerebellar meningioma neurocognitive decline Social History: [MASKED] Family History: NC. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: EO spont, [MASKED] speaking. PERRL [MASKED], EOMI. Face symmetric at rest. Moves all extremities antigravity, mimics. PHYSICAL EXAMINATION ON DISCHARGE: EO spontaneously, [MASKED] speaking. PERRL [MASKED], EOMI. Difficulty following commands, mimics. Face symmetric. Moves all extremities antigravity, ambulates with assistance. Pertinent Results: CT Head W/O Contrast [MASKED] 1. The patient is status-post right frontal approach VP shunt placement with expected postsurgical changes that includes pneumocephalus, subcutaneous emphysema, and subcutaneous edema and/or hematoma. No significant intracranial hemorrhage. 2. Stable large extra-axial right posterior fossa mass, most likely consistent with meningioma. CT Head W/O Contrast [MASKED] 1. The right frontal approach VP shunt catheter is unchanged in position. Ventricular dilation is unchanged. 2. Stable large extra-axial right posterior fossa mass, most consistent with a meningioma. Brief Hospital Course: The patient was taken to the operating room on the day of admission, [MASKED] and underwent placement of a right frontal VP shunt. She tolerated the procedure well and was extubated in the operating room. She was then transferred to the PACU in stable condition for close monitoring. On [MASKED] the patent remained neurologically stable. The patients potassium was repleated and speech and swallow evaluated the patient for concerns of aspiration. She was cleared for a puree diet with thin liquids and 1:1 supervision with all feeds. The patient worked with OT and [MASKED] for dispo planning. On [MASKED] the patient remained neurologically and hemodynamically stable. She was awake and alert, as well as mimics and moving all extremities spontaneously against gravity. The incision site was clean, dry and intact. At one point the family was concerned that she may be more lethargic, upon further examination the patient appeared fatigued but easily arousable with no changes in her neuro exam. [MASKED] and OT are involved for dispo planning as well as social work for family support. On [MASKED], the patient was neurologically stable. On [MASKED], The patient was noted to be lethargic by family and nursing at approximately 2 pm and the patient was sent for a Stat NCHCT which was stable. The patient woke up to her baseline neurological status on her way to the CT scanner. The patient was moving all extremities. Eyes were open spontaneously. pupils were equal and reactive. A urine analysis was sent and was negative for UTI. From [MASKED], patient remains neurologically and hemodynamically stable. She was re-evaluated by physical therapy who recommended rehab. She was tolerating house diet, ambulating with assistance and voiding without difficulty. VP Shunt setting was confirmed prior to discharge and set at 1.5. Medications on Admission: alendronate 70mg, 1 tablet q week liptor 80mg q day flexeril 5mg po TID PRN calcium carbonate-vitamin D3 1 tablet PO BID lisinopril 5mg tablet q day Namenda 5mg tablet PO q day Metformin 500mg PO BID omega 3 fatty acids 1 capsule PO q day Discharge Medications: 1. Acetaminophen 325-650 mg PO Q8H:PRN headache 2. Atorvastatin 80 mg PO QPM 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. Codeine Sulfate 15 mg PO Q4H:PRN headache 5. Docusate Sodium 100 mg PO BID 6. Heparin 5000 UNIT SC BID 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 8. Lisinopril 5 mg PO DAILY [MASKED] hold for SBP < 100. 9. Memantine 5 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 17.2 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Hydrocephalus. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Ventriculoperitoneal Shunt Surgery • You had a VP shunt placed for hydrocephalus. Your incisions should be kept dry until sutures or staples are removed. • Your shunt is a [MASKED] Strata Valve which is programmable. This will need to be readjusted after all MRIs or exposure to large magnets. Your shunt is programmed to 1.5. • t 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. • No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience: • Headache or pain along your incision. • Some neck tenderness along the shunt tubing. • 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]
[]
[ "E119", "I10", "E785", "Z794" ]
[ "G912: (Idiopathic) normal pressure hydrocephalus", "F0390: Unspecified dementia without behavioral disturbance", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "R269: Unspecified abnormalities of gait and mobility", "Z794: Long term (current) use of insulin" ]
10,074,908
29,170,411
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: seafood Attending: ___. Chief Complaint: Weakness, Jaw Pain Major Surgical or Invasive Procedure: ___: Extraoral L parapharyngeal abscess I&D with ___ drain placement; Extraction of teeth 3, 9, 12, 18 Endotracheal Intubation History of Present Illness: ___ year old ___ speaking female with DMII, dementia, ___, with 2 days of left submandibular swelling and pain, decreased PO intake. Family reports she complained of pain in the throat yesterday, and today complained of pain in the left jaw. She also had a subjective fever today, and was referred to ED by her PCP. Of note, patient was last hospitalized ___ for elective placement of VP shunt for NPH. In the ED, initial vitals: T99.2 HR89 BP180/152 RR16 O297% RA - Her exam was notable for somnolence, asymmetric tense swelling to the left mandibular angle tender to palpation, trismus with 3-4cm of opening, poor dentition apparent, foul smelling breath. Pulmonary exam notable for coarse breath sounds radiating through bilateral lung fields. - Examination by OMFS showed: "OC/OP shows floor of mouth soft + pus along sulcus/duct. Left neck swelling. FOE shows moderate epiglottis edema. VC visualized and without edema." - Labs were notable for: WBC 9.1 (80% PMNs), Hbg 13.9, Plts 300, lactate 1.4,with normal chem10. - ENT and Anesthesia were requested. - CT neck with contrast showed a 1.4 x 1.0 cm hypodense lesion with internal foci of air is identified in the left parapharyngeal space (02:37, 602b:38), concerning for phlegmon/ early abscess. - Patient was given cefepime 2g and dexamethasone 10mg. Patient was taken to OR and is now s/p extraoral I&D left submandibular space with associated extraction of 4 teeth (3 maxillary, 1 mandibular). 1 ___ was placed (extra-oral to intra-oral) with 4x4 gauze dressing placed. Procedure was otherwise uncomplicated and lasted 13 minutes. Patient was intubated and paralyzed during procedure. On arrival to the MICU, patient was intubated and sedated, inability to follow commands. He was noted to have 6.5ETT with no cuff leak. ENT recommended keeping intubated overnight with plans for extubation in the morning after scope and with backup from anesthesia/ENT. Anesthesia also note that intubation was not difficult but they did use glidescope for intubation. Past Medical History: DEMENTIA H/O CEREBELLAR MENINGIOMA, calcified, q6 mo MRI; with residual right sided weakness HYDROCEPHALUS S/P VP SHUNT DIABETES TYPE II ___ DISEASE FRONTAL CORTEX DEMENTIA, OVER THE LAST ___ YEARS Social History: ___ Family History: Adopted in ___ Physical Exam: Admission Physical Exam: ========================== Vitals: T97.5 HR80 BP128/79 RR29 100% Vent: 40%FiO2 Peep5 CMV 400 RR14 GENERAL: intubated, sedated, pinpoint pupils HEENT: bite block in place NECK: bandaging left side of neck with overlying dressing, c/d/i LUNGS: ctab, mechanical breath sounds CV: rrr, no m/r/g ABD: soft, nondistended, nontender, normoactive bs EXT: no ___ edema NEURO: not following commands ACCESS: 18g, 20g Discharge Physical Exam: ======================== Vitals: T 98 HR 79 BP 107/66 RR 20 SpO2 99% on RA General: Alert, making good eye contact and smiling in response to my smile, no acute distress HEENT: L jaw without palpable fluctuance, crepitus, or tension. L jaw operative site is clean/dry/intact. No purulent drainage or surrounding erythema. Lungs: Poor inspiratory effort, but clear to auscultation anteriorly/laterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs/rubs/gallops Abdomen: Soft, non-tender to palpation, non-distended, bowel sounds normoactive, no guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin: No new rashes or lesions Neuro: Moving all four extremities spontaneously. CN II-XII grossly intact. Pertinent Results: >> Admission Labs: ==================== ___ 02:47PM BLOOD WBC-9.1 RBC-4.49 Hgb-13.9 Hct-39.4 MCV-88 MCH-31.0 MCHC-35.3 RDW-12.0 RDWSD-38.5 Plt ___ ___ 02:47PM BLOOD Neuts-80.1* Lymphs-12.2* Monos-7.0 Eos-0.1* Baso-0.3 Im ___ AbsNeut-7.30*# AbsLymp-1.11* AbsMono-0.64 AbsEos-0.01* AbsBaso-0.03 ___ 02:47PM BLOOD ___ PTT-28.9 ___ ___ 02:47PM BLOOD Glucose-144* UreaN-7 Creat-0.6 Na-137 K-5.0 Cl-99 HCO3-23 AnGap-20 ___ 02:47PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8 ___ 11:07PM BLOOD Type-ART Temp-36.5 FiO2-40 pO2-193* pCO2-28* pH-7.47* calTCO2-21 Base XS--1 Intubat-INTUBATED ___ 03:00PM BLOOD Lactate-1.4 >> Discharge Labs: ================== ___ 07:00AM BLOOD WBC-3.6* RBC-4.37 Hgb-13.2 Hct-38.6 MCV-88 MCH-30.2 MCHC-34.2 RDW-12.0 RDWSD-38.9 Plt ___ ___ 07:00AM BLOOD Glucose-169* UreaN-10 Creat-0.5 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-16 >> Pertinent Reports: ===================== ___ Imaging CHEST (PORTABLE AP) Compared to chest radiographs since ___, most recently ___ at 01:18. Endotracheal tube has been repositioned, now in standard placement. Lungs clear. Cardiomediastinal and hilar silhouettes and pleural surfaces normal. Transesophageal drainage tube passes into the nondistended stomach and out of view. ___ Imaging CHEST (PORTABLE AP) ET tube indwelling he ET tube tip less than a cm from carina should be withdrawn 2 or 3 cm. Lungs fully expanded and clear. Normal cardiomediastinal and hilar silhouettes and pleural surfaces. Nasogastric tube passes into the stomach and out of view. ___ Imaging CHEST (PORTABLE AP) Lungs grossly clear. Heart size normal. Esophageal drainage catheter passes into the stomach and out of view. An identified catheter, perhaps a ventriculoperitoneal shunt, traverses the right neck chest and upper abdomen, also passing of view. ___ Imaging CT NECK W/CONTRAST 1. 1.4 x 1.0 x 0.9 cm hypodense area within the left parapharyngeal space at the level of the angle of the mandible containing foci of gas with peripheral enhancement and extensive adjacent inflammatory changes most compatible with phlegmon and early abscess formation. 2. Re- demonstration of extensive periapical lucencies within maxillary and mandibular teeth bilaterally, likely reflective of periodontal disease, but these are not adjacent to the area of phlegmon/ early abscess. 3. 3.2 cm calcified right posterior fossa mass is unchanged, consistent with a meningioma. Brief Hospital Course: ___ year old female with DMII, dementia, ___ presented with 2 days of left submandibular swelling and pain, decreased PO intake, found to have parapharyngeal space abscess, s/p drainage and antibiotics. ACTIVE ISSUES ============== # Left submandibular space/odontogenic infection: CT neck demonstrating a 1.4 x 1.0 cm hypodense lesion with internal foci of air identified in the left parapharyngeal space concerning for phlegmon/early abscess. On ___, patient underwent extraoral I&D left submandibular space with associated extraction of 4 teeth (3 maxillary, 1 mandibular) with placement of ___. Patient was given 4 doses of Decadron for concern of airway swelling. She was extubated within 24 hours. She was maintained on peridex mouthrinse BID and Unasyn from ___, whereupon she was switched to clindamycin for a 7 day course (ending ___. ___ was discontinued on ___ per OMFS. CHRONIC ISSUES ================ # NPH s/p VP Shunt/frontotemporal dementia: Baseline dementia. # Hypertension: Home lisinopril was held in the setting of soft pressures on admission. # Diabetes: Home metformin was held and patient was started on ISS while hospitalized. # ___ Disease: Patient was maintained on home carbidopa-levodopa. TRANSITIONAL ISSUES ================== # PARAPHARYNGYEAL SPACE ABSCESS: antibiotics (clindamycin) to continue until ___ # LEUKOPENIA: noted on labs at discharge. Would recommend repeat CBC in 1 week after completing antibiotics and work up as necessary. # Communication: Husband ___ ___ # Code: FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Lisinopril 5 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Carbidopa-Levodopa (___) 1 TAB PO TID 6. Alendronate Sodium 70 mg PO QSUN 7. Cyclobenzaprine 5 mg PO TID:PRN pain 8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY Discharge Medications: 1. Alendronate Sodium 70 mg PO QSUN 2. Atorvastatin 80 mg PO QPM 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 5. Cyclobenzaprine 5 mg PO TID:PRN pain 6. Lisinopril 5 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Clindamycin 300 mg PO Q6H Duration: 7 Days Final day of antibiotics: ___. 9. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Parapharyngeal abscess Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to the ___ because you had two days of decreased appetite and jaw/throat pain. You were found to have an infection in an area around your left jaw. Our oral/ maxillofacial surgeons were able to drain this abscess, as well as remove four teeth that may have been a source of this infection. We treated you with antibiotics and monitored your blood for signs of infection. We are sending you home with clindamycin pills to help get rid of this infection. You will be completing a 7-day course, with the last day of your antibiotics to complete on ___. Warm regards, Your ___ Team Followup Instructions: ___
[ "J390", "K658", "G20", "J384", "G8191", "E8339", "K122", "B9561", "Z1623", "Z1629", "F0280", "D320", "I10", "Z9181", "W06XXXA", "Y92230", "E8351", "E876", "Z982" ]
Allergies: seafood Chief Complaint: Weakness, Jaw Pain Major Surgical or Invasive Procedure: [MASKED]: Extraoral L parapharyngeal abscess I&D with [MASKED] drain placement; Extraction of teeth 3, 9, 12, 18 Endotracheal Intubation History of Present Illness: [MASKED] year old [MASKED] speaking female with DMII, dementia, [MASKED], with 2 days of left submandibular swelling and pain, decreased PO intake. Family reports she complained of pain in the throat yesterday, and today complained of pain in the left jaw. She also had a subjective fever today, and was referred to ED by her PCP. Of note, patient was last hospitalized [MASKED] for elective placement of VP shunt for NPH. In the ED, initial vitals: T99.2 HR89 BP180/152 RR16 O297% RA - Her exam was notable for somnolence, asymmetric tense swelling to the left mandibular angle tender to palpation, trismus with 3-4cm of opening, poor dentition apparent, foul smelling breath. Pulmonary exam notable for coarse breath sounds radiating through bilateral lung fields. - Examination by OMFS showed: "OC/OP shows floor of mouth soft + pus along sulcus/duct. Left neck swelling. FOE shows moderate epiglottis edema. VC visualized and without edema." - Labs were notable for: WBC 9.1 (80% PMNs), Hbg 13.9, Plts 300, lactate 1.4,with normal chem10. - ENT and Anesthesia were requested. - CT neck with contrast showed a 1.4 x 1.0 cm hypodense lesion with internal foci of air is identified in the left parapharyngeal space (02:37, 602b:38), concerning for phlegmon/ early abscess. - Patient was given cefepime 2g and dexamethasone 10mg. Patient was taken to OR and is now s/p extraoral I&D left submandibular space with associated extraction of 4 teeth (3 maxillary, 1 mandibular). 1 [MASKED] was placed (extra-oral to intra-oral) with 4x4 gauze dressing placed. Procedure was otherwise uncomplicated and lasted 13 minutes. Patient was intubated and paralyzed during procedure. On arrival to the MICU, patient was intubated and sedated, inability to follow commands. He was noted to have 6.5ETT with no cuff leak. ENT recommended keeping intubated overnight with plans for extubation in the morning after scope and with backup from anesthesia/ENT. Anesthesia also note that intubation was not difficult but they did use glidescope for intubation. Past Medical History: DEMENTIA H/O CEREBELLAR MENINGIOMA, calcified, q6 mo MRI; with residual right sided weakness HYDROCEPHALUS S/P VP SHUNT DIABETES TYPE II [MASKED] DISEASE FRONTAL CORTEX DEMENTIA, OVER THE LAST [MASKED] YEARS Social History: [MASKED] Family History: Adopted in [MASKED] Physical Exam: Admission Physical Exam: ========================== Vitals: T97.5 HR80 BP128/79 RR29 100% Vent: 40%FiO2 Peep5 CMV 400 RR14 GENERAL: intubated, sedated, pinpoint pupils HEENT: bite block in place NECK: bandaging left side of neck with overlying dressing, c/d/i LUNGS: ctab, mechanical breath sounds CV: rrr, no m/r/g ABD: soft, nondistended, nontender, normoactive bs EXT: no [MASKED] edema NEURO: not following commands ACCESS: 18g, 20g Discharge Physical Exam: ======================== Vitals: T 98 HR 79 BP 107/66 RR 20 SpO2 99% on RA General: Alert, making good eye contact and smiling in response to my smile, no acute distress HEENT: L jaw without palpable fluctuance, crepitus, or tension. L jaw operative site is clean/dry/intact. No purulent drainage or surrounding erythema. Lungs: Poor inspiratory effort, but clear to auscultation anteriorly/laterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs/rubs/gallops Abdomen: Soft, non-tender to palpation, non-distended, bowel sounds normoactive, no guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Skin: No new rashes or lesions Neuro: Moving all four extremities spontaneously. CN II-XII grossly intact. Pertinent Results: >> Admission Labs: ==================== [MASKED] 02:47PM BLOOD WBC-9.1 RBC-4.49 Hgb-13.9 Hct-39.4 MCV-88 MCH-31.0 MCHC-35.3 RDW-12.0 RDWSD-38.5 Plt [MASKED] [MASKED] 02:47PM BLOOD Neuts-80.1* Lymphs-12.2* Monos-7.0 Eos-0.1* Baso-0.3 Im [MASKED] AbsNeut-7.30*# AbsLymp-1.11* AbsMono-0.64 AbsEos-0.01* AbsBaso-0.03 [MASKED] 02:47PM BLOOD [MASKED] PTT-28.9 [MASKED] [MASKED] 02:47PM BLOOD Glucose-144* UreaN-7 Creat-0.6 Na-137 K-5.0 Cl-99 HCO3-23 AnGap-20 [MASKED] 02:47PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8 [MASKED] 11:07PM BLOOD Type-ART Temp-36.5 FiO2-40 pO2-193* pCO2-28* pH-7.47* calTCO2-21 Base XS--1 Intubat-INTUBATED [MASKED] 03:00PM BLOOD Lactate-1.4 >> Discharge Labs: ================== [MASKED] 07:00AM BLOOD WBC-3.6* RBC-4.37 Hgb-13.2 Hct-38.6 MCV-88 MCH-30.2 MCHC-34.2 RDW-12.0 RDWSD-38.9 Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-169* UreaN-10 Creat-0.5 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-16 >> Pertinent Reports: ===================== [MASKED] Imaging CHEST (PORTABLE AP) Compared to chest radiographs since [MASKED], most recently [MASKED] at 01:18. Endotracheal tube has been repositioned, now in standard placement. Lungs clear. Cardiomediastinal and hilar silhouettes and pleural surfaces normal. Transesophageal drainage tube passes into the nondistended stomach and out of view. [MASKED] Imaging CHEST (PORTABLE AP) ET tube indwelling he ET tube tip less than a cm from carina should be withdrawn 2 or 3 cm. Lungs fully expanded and clear. Normal cardiomediastinal and hilar silhouettes and pleural surfaces. Nasogastric tube passes into the stomach and out of view. [MASKED] Imaging CHEST (PORTABLE AP) Lungs grossly clear. Heart size normal. Esophageal drainage catheter passes into the stomach and out of view. An identified catheter, perhaps a ventriculoperitoneal shunt, traverses the right neck chest and upper abdomen, also passing of view. [MASKED] Imaging CT NECK W/CONTRAST 1. 1.4 x 1.0 x 0.9 cm hypodense area within the left parapharyngeal space at the level of the angle of the mandible containing foci of gas with peripheral enhancement and extensive adjacent inflammatory changes most compatible with phlegmon and early abscess formation. 2. Re- demonstration of extensive periapical lucencies within maxillary and mandibular teeth bilaterally, likely reflective of periodontal disease, but these are not adjacent to the area of phlegmon/ early abscess. 3. 3.2 cm calcified right posterior fossa mass is unchanged, consistent with a meningioma. Brief Hospital Course: [MASKED] year old female with DMII, dementia, [MASKED] presented with 2 days of left submandibular swelling and pain, decreased PO intake, found to have parapharyngeal space abscess, s/p drainage and antibiotics. ACTIVE ISSUES ============== # Left submandibular space/odontogenic infection: CT neck demonstrating a 1.4 x 1.0 cm hypodense lesion with internal foci of air identified in the left parapharyngeal space concerning for phlegmon/early abscess. On [MASKED], patient underwent extraoral I&D left submandibular space with associated extraction of 4 teeth (3 maxillary, 1 mandibular) with placement of [MASKED]. Patient was given 4 doses of Decadron for concern of airway swelling. She was extubated within 24 hours. She was maintained on peridex mouthrinse BID and Unasyn from [MASKED], whereupon she was switched to clindamycin for a 7 day course (ending [MASKED]. [MASKED] was discontinued on [MASKED] per OMFS. CHRONIC ISSUES ================ # NPH s/p VP Shunt/frontotemporal dementia: Baseline dementia. # Hypertension: Home lisinopril was held in the setting of soft pressures on admission. # Diabetes: Home metformin was held and patient was started on ISS while hospitalized. # [MASKED] Disease: Patient was maintained on home carbidopa-levodopa. TRANSITIONAL ISSUES ================== # PARAPHARYNGYEAL SPACE ABSCESS: antibiotics (clindamycin) to continue until [MASKED] # LEUKOPENIA: noted on labs at discharge. Would recommend repeat CBC in 1 week after completing antibiotics and work up as necessary. # Communication: Husband [MASKED] [MASKED] # Code: FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Lisinopril 5 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 6. Alendronate Sodium 70 mg PO QSUN 7. Cyclobenzaprine 5 mg PO TID:PRN pain 8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY Discharge Medications: 1. Alendronate Sodium 70 mg PO QSUN 2. Atorvastatin 80 mg PO QPM 3. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 4. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral DAILY 5. Cyclobenzaprine 5 mg PO TID:PRN pain 6. Lisinopril 5 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Clindamycin 300 mg PO Q6H Duration: 7 Days Final day of antibiotics: [MASKED]. 9. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Parapharyngeal abscess Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the [MASKED] because you had two days of decreased appetite and jaw/throat pain. You were found to have an infection in an area around your left jaw. Our oral/ maxillofacial surgeons were able to drain this abscess, as well as remove four teeth that may have been a source of this infection. We treated you with antibiotics and monitored your blood for signs of infection. We are sending you home with clindamycin pills to help get rid of this infection. You will be completing a 7-day course, with the last day of your antibiotics to complete on [MASKED]. Warm regards, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I10", "Y92230" ]
[ "J390: Retropharyngeal and parapharyngeal abscess", "K658: Other peritonitis", "G20: Parkinson's disease", "J384: Edema of larynx", "G8191: Hemiplegia, unspecified affecting right dominant side", "E8339: Other disorders of phosphorus metabolism", "K122: Cellulitis and abscess of mouth", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "Z1623: Resistance to quinolones and fluoroquinolones", "Z1629: Resistance to other single specified antibiotic", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "D320: Benign neoplasm of cerebral meninges", "I10: Essential (primary) hypertension", "Z9181: History of falling", "W06XXXA: Fall from bed, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "E8351: Hypocalcemia", "E876: Hypokalemia", "Z982: Presence of cerebrospinal fluid drainage device" ]
10,075,035
27,908,665
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: chloroquine Attending: ___. Chief Complaint: right scapula GCT Major Surgical or Invasive Procedure: right partial scapulectomy ___ History of Present Illness: Mr. ___ is a very pleasant ___ right-hand dominant gentleman who started having pain in his scapular region back in after a fall in ___. He had a hard time with medical access at that time and so he eventually did though come in for evaluation with the team at ___ in ___ and ___ and was found to have a very large giant cell tumor of bone involving his right scapula. He has been treated with denosumab from ___ through ___ and had a good response in terms of increased mineralization within the mass, but no decrease in size. He then went to ___ for ozone treatment with no noticeable change in his mass that he has noted. Past Medical History: malaria Social History: ___ Family History: Significant for a blood disorder of some type in his sister, which he is not sure. Physical Exam: RUE--SILT ax/m/u/r ___ EPL/IO/FDP 2+ radial pulse inc c/d/i Brief Hospital Course: Admitted to the floor postop in stable condition. His pain was controlled with a nerve catheter and he was transitioned to oral pain medications. He tolerated an oral diet. He ambulated safely with ___ and worked with OT. He was discharged to home in stable condition. FICU Course =========== ___ with a history of benign giant cell tumor of the right scapula presenting after partial scapular resection for persistent hypotension requiring pressors likely secondary to operative blood loss. Patient was transferred to the FICU on phenylephrine which was weaned out. He was transfused 3 units pRBC prior to transfer and his H/H remained stable without further need for transfusions. He completed 3 doses of cefazolin and pain control was continued with APAP, oxycodone and dilaudid. He was transferred to the floor in a stable condition. After transfer to the floor he remained hemodynamically stable. Hematocrit was checked daily and found to be stable. He was able to ambulate without any dizziness or lightheadedness. Drain was removed POD3. Dressing was changed daily and wound was clean and dry. He remained stable with no further issues. He was discharged home on POD 4. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 1500 mg PO DAILY 2. Vitamin D 400 UNIT PO DAILY 3. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H prn pain 2. Docusate Sodium 100 mg PO BID while on narcotics 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain 4. Calcium Carbonate 1500 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Vitamin D 400 UNIT PO DAILY 7. ferrous sulfate 325mg daily x 3 weeks Discharge Disposition: Home Discharge Diagnosis: right scapula GCT Discharge Condition: stable 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. Please keep your incision clean and dry. Ok to shower now with dressing in place but don't scrub around dressing. Remove current dressing in 2 days. If incision dry leave open to air. Ok to shower with incision uncovered at that time but do not submerge. Check wound regularly for signs of infection such as redness or thick yellow drainage. 8. ACTIVITY: Weight bearing as tolerated on the operative extremity. Sling for comfort. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently Followup Instructions: ___
[ "D480", "D62", "G893", "I9581" ]
Allergies: chloroquine Chief Complaint: right scapula GCT Major Surgical or Invasive Procedure: right partial scapulectomy [MASKED] History of Present Illness: Mr. [MASKED] is a very pleasant [MASKED] right-hand dominant gentleman who started having pain in his scapular region back in after a fall in [MASKED]. He had a hard time with medical access at that time and so he eventually did though come in for evaluation with the team at [MASKED] in [MASKED] and [MASKED] and was found to have a very large giant cell tumor of bone involving his right scapula. He has been treated with denosumab from [MASKED] through [MASKED] and had a good response in terms of increased mineralization within the mass, but no decrease in size. He then went to [MASKED] for ozone treatment with no noticeable change in his mass that he has noted. Past Medical History: malaria Social History: [MASKED] Family History: Significant for a blood disorder of some type in his sister, which he is not sure. Physical Exam: RUE--SILT ax/m/u/r [MASKED] EPL/IO/FDP 2+ radial pulse inc c/d/i Brief Hospital Course: Admitted to the floor postop in stable condition. His pain was controlled with a nerve catheter and he was transitioned to oral pain medications. He tolerated an oral diet. He ambulated safely with [MASKED] and worked with OT. He was discharged to home in stable condition. FICU Course =========== [MASKED] with a history of benign giant cell tumor of the right scapula presenting after partial scapular resection for persistent hypotension requiring pressors likely secondary to operative blood loss. Patient was transferred to the FICU on phenylephrine which was weaned out. He was transfused 3 units pRBC prior to transfer and his H/H remained stable without further need for transfusions. He completed 3 doses of cefazolin and pain control was continued with APAP, oxycodone and dilaudid. He was transferred to the floor in a stable condition. After transfer to the floor he remained hemodynamically stable. Hematocrit was checked daily and found to be stable. He was able to ambulate without any dizziness or lightheadedness. Drain was removed POD3. Dressing was changed daily and wound was clean and dry. He remained stable with no further issues. He was discharged home on POD 4. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 1500 mg PO DAILY 2. Vitamin D 400 UNIT PO DAILY 3. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H prn pain 2. Docusate Sodium 100 mg PO BID while on narcotics 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain 4. Calcium Carbonate 1500 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Vitamin D 400 UNIT PO DAILY 7. ferrous sulfate 325mg daily x 3 weeks Discharge Disposition: Home Discharge Diagnosis: right scapula GCT Discharge Condition: stable 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. Please keep your incision clean and dry. Ok to shower now with dressing in place but don't scrub around dressing. Remove current dressing in 2 days. If incision dry leave open to air. Ok to shower with incision uncovered at that time but do not submerge. Check wound regularly for signs of infection such as redness or thick yellow drainage. 8. ACTIVITY: Weight bearing as tolerated on the operative extremity. Sling for comfort. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently Followup Instructions: [MASKED]
[]
[ "D62" ]
[ "D480: Neoplasm of uncertain behavior of bone and articular cartilage", "D62: Acute posthemorrhagic anemia", "G893: Neoplasm related pain (acute) (chronic)", "I9581: Postprocedural hypotension" ]
10,075,053
26,259,455
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: generalized pain s/p MVC with rollover Major Surgical or Invasive Procedure: none History of Present Illness: ___ with no PMHx presents to the ED intoxicated (EtOH) and s/p MVC. The patient was the unrestrained passenger involved in an MVC with rollover at unknown speed-- Estimated to be high by EMS, as the vehicle rolled over on ___, found significantly deformed about 100 feet away from the street. Patient entrapped in vehicle, which took ___ minutes to extract. Past Medical History: none Social History: ___ Family History: non-contributory Physical Exam: SUBJECTIVE: Patient endorsing full body pain. Denies chest pain, SOB, fever, chills, N/V. OBJECTIVE: Vitals: Temp: 98.1 BP: 100/65 HR: 58, RR: 18, O2 sat: 95%, O2 delivery: Ra Gen: A&Ox3 ___: RRR assessed peripherally Pulm: non-labored breathing on room air MSK: RUE: diffuse soreness/pain limits fulls strength ___ motor intact to shoulder abduction/shrug ___ elbow flexion/extension; wrist flexion/extension but limited secondary to pain; r/u/m nerve distributions intact about hand Sensation diffusely intact to RUE including ax/r/m/u nerve distributions Tenderness to palpation diffusely RUE, especially about Right ulnar styloid, no significant pain to snuff box DRUJ assessed and comparable to contralateral (left) side palpable radial pulse w/brisk cap refill distally LUE: diffuse soreness/pain limits fulls strength ___ motor intact to shoulder abduction/shrug ___ elbow flexion/extension; wrist flexion/extension but limited secondary to pain; r/u/m nerve distributions intact about hand Sensation diffusely intact to RUE including ax/r/m/u nerve distributions Tenderness to palpation diffusely RUE Palpable radial pulse w/brisk cap refill distally RLE: Scattered superficial abrasions about thigh and leg Minor knee effusion, no obvious deformities Motor intact to thigh ext/flexion; knee extension and flexion and ___ intact Sensation diffusely intact about thigh, leg, foot (SPN and DPN) Brisk cap refill distally LLE: Scattered superficial abrasions about thigh and leg Minor knee effusion, no obvious deformities Motor intact to thigh ext/flexion; knee extension and flexion and ___ intact Sensation diffusely intact about thigh, leg, foot (SPN and DPN) Brisk cap refill distally Pertinent Results: ___ 02:20AM BLOOD WBC-8.0 RBC-4.07* Hgb-12.4* Hct-38.1* MCV-94 MCH-30.5 MCHC-32.5 RDW-12.7 RDWSD-43.5 Plt ___ ___ 02:20AM BLOOD Plt ___ ___ 04:23AM BLOOD ___ PTT-26.2 ___ ___ 02:20AM BLOOD Glucose-137* UreaN-14 Creat-0.9 Na-141 K-4.2 Cl-104 HCO3-27 AnGap-10 ___ 02:15AM BLOOD ALT-183* AST-225* AlkPhos-50 TotBili-0.2 ___ 02:15AM BLOOD Albumin-4.4 Calcium-9.2 Phos-4.0 Mg-2.0 ___ 02:15AM BLOOD ASA-NEG ___ Acetmnp-NEG Tricycl-NEG RIGHT WRIST: There is a mildly displaced fracture through the ulnar styloid. Deformity of the fourth metacarpal most likely represents a healed fracture. There are no significant degenerative changes. Carpal bones are well aligned. Mineralization is normal. There are no erosions. Diffuse soft tissue swelling is seen around the wrist. There is an intravenous line along the dorsal aspect of the wrist. Brief Hospital Course: Mr ___ presented to ___ Department early in the morning on ___ s/p MCV accident with EtOH intoxication. Upon arrival to ED the patient was assessed and managed via trauma protocols. The patient was found to be hemodynamically stable and not in respiratory distress. He was assessed with an EFAST US scan, trauma X-rays of the chest and pelvis, and pan scanned with CT which showed evidence of possible pulmonary contusions, but no injuries that warranted immediate surgery. Given findings, the patient was taken not to the operating room but instead managed conservatively with pain management and close monitoring. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with IV medications and then quickly transitioned to oral tylenol, ibuprofen, and oxycodone once tolerating oral diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. 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. MSK: Due to generalized pain and superficial injuries, after initial X-rays and CT pan scan, patinet recived additional xrays of his R elbow, hand, wrist, ankle, bilateral knees, L tib/fib. All of which were noncerning for acute processes of fxs with the notable exception of the R wrist: There is a mildly displaced fracture through the ulnar styloid. Deformity of the fourth metacarpal most likely represents a healed fracture. There are no significant degenerative changes. Carpal bones are well aligned. Mineralization is normal. There are no erosions. Diffuse soft tissue swelling is seen around the wrist. There is an intravenous line along the dorsal aspect of the wrist. During his stay, Mr. ___ was seen by OT, Social work, as well as Spiritual Care given the traumatic nature of the mechanism of his injuries. 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. Patient agreed to follow-up with the ortho hand clinic for further assessment and management of his wrist fracture and well as follow-up with ACS. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Do not exceed 3000 mg in 24 hours. Do not take with alcohol 2. Ibuprofen 600 mg PO Q6H 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe Duration: 3 Days Take only the minimum amount needed for severe pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Bilateral pulmonary contusions right ulnar styloid fracture 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 were involved in a car accident. Upon assessment here at ___, you were noted to have sustained bruising (contusions) to both your lungs. It will resolve on its own and requires no medical intervention. You have been seen by social work and occupational therapy because you do not remember the accident. You have been cleared to go home to continue your recovery. Please follow the discharge instructions 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. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
[ "S27322A", "S52611A", "V892XXA", "Y92410", "Z23", "F10129" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: generalized pain s/p MVC with rollover Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with no PMHx presents to the ED intoxicated (EtOH) and s/p MVC. The patient was the unrestrained passenger involved in an MVC with rollover at unknown speed-- Estimated to be high by EMS, as the vehicle rolled over on [MASKED], found significantly deformed about 100 feet away from the street. Patient entrapped in vehicle, which took [MASKED] minutes to extract. Past Medical History: none Social History: [MASKED] Family History: non-contributory Physical Exam: SUBJECTIVE: Patient endorsing full body pain. Denies chest pain, SOB, fever, chills, N/V. OBJECTIVE: Vitals: Temp: 98.1 BP: 100/65 HR: 58, RR: 18, O2 sat: 95%, O2 delivery: Ra Gen: A&Ox3 [MASKED]: RRR assessed peripherally Pulm: non-labored breathing on room air MSK: RUE: diffuse soreness/pain limits fulls strength [MASKED] motor intact to shoulder abduction/shrug [MASKED] elbow flexion/extension; wrist flexion/extension but limited secondary to pain; r/u/m nerve distributions intact about hand Sensation diffusely intact to RUE including ax/r/m/u nerve distributions Tenderness to palpation diffusely RUE, especially about Right ulnar styloid, no significant pain to snuff box DRUJ assessed and comparable to contralateral (left) side palpable radial pulse w/brisk cap refill distally LUE: diffuse soreness/pain limits fulls strength [MASKED] motor intact to shoulder abduction/shrug [MASKED] elbow flexion/extension; wrist flexion/extension but limited secondary to pain; r/u/m nerve distributions intact about hand Sensation diffusely intact to RUE including ax/r/m/u nerve distributions Tenderness to palpation diffusely RUE Palpable radial pulse w/brisk cap refill distally RLE: Scattered superficial abrasions about thigh and leg Minor knee effusion, no obvious deformities Motor intact to thigh ext/flexion; knee extension and flexion and [MASKED] intact Sensation diffusely intact about thigh, leg, foot (SPN and DPN) Brisk cap refill distally LLE: Scattered superficial abrasions about thigh and leg Minor knee effusion, no obvious deformities Motor intact to thigh ext/flexion; knee extension and flexion and [MASKED] intact Sensation diffusely intact about thigh, leg, foot (SPN and DPN) Brisk cap refill distally Pertinent Results: [MASKED] 02:20AM BLOOD WBC-8.0 RBC-4.07* Hgb-12.4* Hct-38.1* MCV-94 MCH-30.5 MCHC-32.5 RDW-12.7 RDWSD-43.5 Plt [MASKED] [MASKED] 02:20AM BLOOD Plt [MASKED] [MASKED] 04:23AM BLOOD [MASKED] PTT-26.2 [MASKED] [MASKED] 02:20AM BLOOD Glucose-137* UreaN-14 Creat-0.9 Na-141 K-4.2 Cl-104 HCO3-27 AnGap-10 [MASKED] 02:15AM BLOOD ALT-183* AST-225* AlkPhos-50 TotBili-0.2 [MASKED] 02:15AM BLOOD Albumin-4.4 Calcium-9.2 Phos-4.0 Mg-2.0 [MASKED] 02:15AM BLOOD ASA-NEG [MASKED] Acetmnp-NEG Tricycl-NEG RIGHT WRIST: There is a mildly displaced fracture through the ulnar styloid. Deformity of the fourth metacarpal most likely represents a healed fracture. There are no significant degenerative changes. Carpal bones are well aligned. Mineralization is normal. There are no erosions. Diffuse soft tissue swelling is seen around the wrist. There is an intravenous line along the dorsal aspect of the wrist. Brief Hospital Course: Mr [MASKED] presented to [MASKED] Department early in the morning on [MASKED] s/p MCV accident with EtOH intoxication. Upon arrival to ED the patient was assessed and managed via trauma protocols. The patient was found to be hemodynamically stable and not in respiratory distress. He was assessed with an EFAST US scan, trauma X-rays of the chest and pelvis, and pan scanned with CT which showed evidence of possible pulmonary contusions, but no injuries that warranted immediate surgery. Given findings, the patient was taken not to the operating room but instead managed conservatively with pain management and close monitoring. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with IV medications and then quickly transitioned to oral tylenol, ibuprofen, and oxycodone once tolerating oral diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. 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. MSK: Due to generalized pain and superficial injuries, after initial X-rays and CT pan scan, patinet recived additional xrays of his R elbow, hand, wrist, ankle, bilateral knees, L tib/fib. All of which were noncerning for acute processes of fxs with the notable exception of the R wrist: There is a mildly displaced fracture through the ulnar styloid. Deformity of the fourth metacarpal most likely represents a healed fracture. There are no significant degenerative changes. Carpal bones are well aligned. Mineralization is normal. There are no erosions. Diffuse soft tissue swelling is seen around the wrist. There is an intravenous line along the dorsal aspect of the wrist. During his stay, Mr. [MASKED] was seen by OT, Social work, as well as Spiritual Care given the traumatic nature of the mechanism of his injuries. 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. Patient agreed to follow-up with the ortho hand clinic for further assessment and management of his wrist fracture and well as follow-up with ACS. Medications on Admission: none Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Do not exceed 3000 mg in 24 hours. Do not take with alcohol 2. Ibuprofen 600 mg PO Q6H 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe Duration: 3 Days Take only the minimum amount needed for severe pain RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Bilateral pulmonary contusions right ulnar styloid fracture 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 were involved in a car accident. Upon assessment here at [MASKED], you were noted to have sustained bruising (contusions) to both your lungs. It will resolve on its own and requires no medical intervention. You have been seen by social work and occupational therapy because you do not remember the accident. You have been cleared to go home to continue your recovery. Please follow the discharge instructions 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. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: [MASKED]
[]
[]
[ "S27322A: Contusion of lung, bilateral, initial encounter", "S52611A: Displaced fracture of right ulna styloid process, initial encounter for closed fracture", "V892XXA: Person injured in unspecified motor-vehicle accident, traffic, initial encounter", "Y92410: Unspecified street and highway as the place of occurrence of the external cause", "Z23: Encounter for immunization", "F10129: Alcohol abuse with intoxication, unspecified" ]
10,075,148
22,304,013
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Flagyl / metformin / Statins-Hmg-Coa Reductase Inhibitors / lisinopril / atenolol / hayfever Attending: ___ Chief Complaint: Hypertension chest pain Major Surgical or Invasive Procedure: Coronary angiogram with drug-eluting stent x1 to the OM. History of Present Illness: Brief HPI: ___ w/hx of hypertension, hyperlipidemia(intolerant to statins), diabetes on oral hypoglycemics, CAD status post RCA and OM1 DES in ___ on ASA 81mg and Brilinta BID, presented with 2 weeks history of progressive chest pain. She mentioned that about 2 weeks ago she started experiencing progressive exertional chest pain which resolved with rest. She was seen as an outpatient and had an treadmill exercise testing which was significant for hypertensive response on walking ___ minutes on ___ protocol with ST depressions in inferolateral leads. She was scheduled to have an outpatient stress test with imaging for further evaluation. Last night, she had persistent resting chest pain manifesting as " someone sitting on the chest", nonradiating, no association with dyspnea, dizziness, nausea, lightheadedness, palpitation. The chest pain lasted for about ___ minutes resolved after taking sublingual nitroglycerin. This prompted her to come to the hospital for further evaluation. On arrival to the ED, she was noted to have hypertensive urgency with systolic blood pressure ~200 mmHg. She was started on IV nitroglycerin. Her initial cardiac biomarkers have been negative. Currently not complaining of chest pain and denies SOB, DOE, palpitations, lightheadedness, nausea, or vomiting. Past Medical History: CAD s/p DES to RCA and OM1 in ___ High Cholesterol, intolerant to statin HTN DM GERD CVA CKD OSA Social History: ___ Family History: Mother: CVA in her ___ Father: Unknown Physical ___: On admission: ___ Temp: 98.1 PO BP: 136/88 HR: 81 RR: 17 O2 sat: 96% O2 delivery: Ra Constitutional: Appears comfortable. Denies any chest pain dyspnea. NAD Head/Eyes: NCAT, PERRL, no conjunctival injection ENT: Atraumatic external nose and ears, MMM. Neck: Supple, trachea midline Resp: No respiratory distress, CTAB Cards: RRR. s1,s2. no MRG, 2+ extremity pulses Abd: S/NT/ND, no HSM Skin: Warm, dry, no rash Ext: No c/c/e, extremities w/no gross deformity Neuro: speech fluent, sensation grossly intact, no focal lateralizing neurologic deficit Psych: Alert and oriented, normal mood . Pertinent Results: ADmission: ___ 11:58AM BLOOD WBC-9.9 RBC-4.93 Hgb-12.7 Hct-40.1 MCV-81* MCH-25.8* MCHC-31.7* RDW-15.1 RDWSD-45.0 Plt ___ ___ 11:58AM BLOOD Plt ___ ___ 11:58AM BLOOD Glucose-99 UreaN-17 Creat-1.0 Na-143 K-4.1 Cl-104 HCO3-27 AnGap-12 ___ 03:52AM BLOOD CK(CPK)-132 ___ 03:52AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:58AM BLOOD cTropnT-<0.01 ___ 10:07PM BLOOD %HbA1c-7.3* eAG-163* . On DC: ___ 06:40AM BLOOD WBC-13.0* RBC-4.77 Hgb-12.3 Hct-38.6 MCV-81* MCH-25.8* MCHC-31.9* RDW-15.5 RDWSD-44.7 Plt ___ ___ 06:40AM BLOOD Glucose-109* UreaN-12 Creat-1.1 Na-144 K-4.1 Cl-105 HCO3-22 AnGap-17 . Cardiac cath ___: Coronary Description The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 40% stenosis in the proximal and mid segments. The ___ Diagonal, arising from the proximal segment, is a medium caliber vessel. The ___ Diagonal, arising from the mid segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. There is a 90% stenosis in the ostium. There is a stent in the proximal and mid segments. The Inferior lateral of the OM, arising from the proximal segment, is a medium caliber vessel. There is a 60% stenosis in the proximal and mid segments. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 30% stenosis in the proximal segment. There is a stent in the proximal segment. There is a stent in the mid and distal segments. There is a stent in the distal segment. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. Interventional Details Percutaneous Coronary Intervention: Percutaneous coronary intervention (PCI) was performed on an ad hoc basis based on the coronary angiographic findings from the diagnostic portion of this procedure. A 6 ___ EBU3.75 guide provided adequate support. Crossed with a Prowater wire into the distal OM. We also placed a Sion blue wire in the AV groove branch to protect this branch Predilated with a 2.5 mm balloon and then deployed a 3.5 mm x 24 mm DES, extending from the proximal LCx into the OM1 branch. We pulled the wire out of the AV groove branch, flow remained intact in this branch. Postdilated with a 3.5 mm balloon, 18 ATM in the distal stent and 20 ATM in the proximal stent. (this stent overlapped distally with the prior 3.0 DES placed in the mid OM1 branch in ___ Final angiography revealed normal flow, no dissection and 0% residual stenosis. Complications: There were no clinically significant complications. Impression • Widely patent RCA stents and in the Mid OM1 • Ostial OM 90% stenosis (proximal to OM1 stent), Rxed successfully with 3.5 mm DES, flow intact in jailed AV groove branch of the ___ Recommendations • Continue DAPT with ASA 81mg and Ticagrelor • Aggressive secondary risk factor modification • Further recommendations as per in patient Cardiology Service Brief Hospital Course: Assessment/Plan: ___ woman with CAD s/p DES, HTN, HLD, recent positive stress test presented to ER with gradually escalating exertional dyspnea and now chest pain at rest. # Chest pain/UA/Positive ETT/CAD: History of prior CAD status post drug-eluting stent to OM1 and RCA in ___ now presenting with progressive chest pain on exertion, now occurring at rest. Stress test with markedly lower exercise tolerance. Cardiac catheterization showed a 90% ostial OM lesion proximal to the OM1 stent. This was successfully treated with a 3.5 mm drug-eluting stent, flow was intact and the jailed AV groove branch of the left circumflex so no further intervention was needed. Of note patient triggered for hypertension and confusion and neatly after the cardiac catheterization and responded well to Haldol and blood pressure medicines. Patient was continued on her aspirin and Brilinta and had no chest pain after the procedure. Is recommended that she attend cardiac rehab after she is cleared by her cardiologist, Dr. ___. She was also started on Repatha after prior authorization was obtained for this medicine. She agrees to inject this once every other week. # HTN: Hypertensive urgency on presentation with systolic blood pressure~200 mmHg. Medication reconciliation was difficult but patient appeared to be on on losartan and carvedilol on admission. She was started on chlorthalidone, spironolactone, and amlodipine during this hospital stay with some improvement of her blood pressure. Her carvedilol was also increased to 25 mg twice a day. Patient is reluctant to take all these medicines so a lot of tissue was done about her high risk for stroke and importance of maintaining a lower blood pressure. She was encouraged to get a blood pressure cuff at home to use and record blood pressures to better titrate her medicines. # HLD: Intolerant to multiple statins. Rec'd PA for Repatha done and patient will start this tomorrow. # DM: A1C 7.4. Pt states it has been 10 in the past. Unclear about insulin dosing but Atrius record says 20 in am and 50 in pm. These medicines were continued at discharge. Jardiance prior authorization was confirmed and this can be considered as an outpatient if patient agrees. # GERD: On pantoprazole # CVA: On aspirin and ticagrelor # CKD: Stage ___. Most recent creat 0.9. Regularly sees a nephrologist at ___. # OSA: Mild. Recently diagnosed with OSA.No CPAP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CARVedilol 12.5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. TiCAGRELOR 90 mg PO BID 4. Benicar (olmesartan) 40 mg oral DAILY daily 5. Pantoprazole 40 mg PO Q24H 6. glimepiride 2 mg oral BID 7. Glargine 20 Units Breakfast Glargine 50 Units Bedtime 8. melatonin 1 mg oral Other bedtime 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Repatha SureClick (evolocumab) 140 mg/mL subcutaneous every 2 weeks 4. Spironolactone 25 mg PO DAILY 5. CARVedilol 25 mg PO BID 6. Glargine 20 Units Breakfast Glargine 50 Units Bedtime 7. Aspirin 81 mg PO DAILY 8. Benicar (olmesartan) 40 mg oral DAILY daily 9. glimepiride 2 mg oral BID 10. melatonin 1 mg oral Other bedtime 11. Pantoprazole 40 mg PO Q24H 12. TiCAGRELOR 90 mg PO BID 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: CAD hyperlidipemia Hypertensive urgency Diabetes GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted following your cardiac catheterization in which a drug coated stent was placed to open a blockage in your coronary artery. Instructions regarding care of the access site are included with your discharge information. Please continue your current medications with the following changes: - continue Aspirin 81mg daily, lifelong. - continue Brillinta daily, you should take this for a minimum of one year and ONLY stop when told by a cardiologist specifically. - Continue nitroglycerin as needed for chest pain. Take 1 tab under the tongue as needed for chest pain. You may repeat this every 5 mintues for continued chest pain for a total of 3 doses. If chest pain persists after 3 doses, call ___. It is important to sit or lie down if you are taking this medication because it can cause a drop in blood pressure and could cause you to pass out if blood pressure drops too low. It is very important to take all of your heart healthy medications. In particular, Aspirin and Brillinta help keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. If you stop these medications or miss ___ dose, a blood clot could form in your heart stent which could cause a life threatening heart attack. Please do not stop taking either medication without taking to your heart doctor, even if another doctor tells you to stop the medications. You were started on 3 new medicines for your blood pressure. Please take these medicines every day. Check your blood pressure at home once a day and record it so that you can bring it to doctor's appointments. This will help to adjust your medicines so you are not on too much or too little. It is strongly recommended that you attend a cardiac rehab program in the near future. A referral form was provided to you that lists the locations of these programs. Please bring this with you to your follow up visit with your cardiologist, and they will inform you when it is safe to begin a program. If you were given any prescriptions on discharge, any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. If you have any urgent questions that are related to your recovery from your hospitalization or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call ___ or your Doctor's office. It has been a pleasure to have participated in your care and we wish you the best with your health. Your ___ Cardiac Care Team Followup Instructions: ___
[ "I25110", "Z87891", "E785", "K219", "G4733", "Z8673", "E1122", "I129", "I160", "Z7982", "N182", "Z794" ]
Allergies: Flagyl / metformin / Statins-Hmg-Coa Reductase Inhibitors / lisinopril / atenolol / hayfever Chief Complaint: Hypertension chest pain Major Surgical or Invasive Procedure: Coronary angiogram with drug-eluting stent x1 to the OM. History of Present Illness: Brief HPI: [MASKED] w/hx of hypertension, hyperlipidemia(intolerant to statins), diabetes on oral hypoglycemics, CAD status post RCA and OM1 DES in [MASKED] on ASA 81mg and Brilinta BID, presented with 2 weeks history of progressive chest pain. She mentioned that about 2 weeks ago she started experiencing progressive exertional chest pain which resolved with rest. She was seen as an outpatient and had an treadmill exercise testing which was significant for hypertensive response on walking [MASKED] minutes on [MASKED] protocol with ST depressions in inferolateral leads. She was scheduled to have an outpatient stress test with imaging for further evaluation. Last night, she had persistent resting chest pain manifesting as " someone sitting on the chest", nonradiating, no association with dyspnea, dizziness, nausea, lightheadedness, palpitation. The chest pain lasted for about [MASKED] minutes resolved after taking sublingual nitroglycerin. This prompted her to come to the hospital for further evaluation. On arrival to the ED, she was noted to have hypertensive urgency with systolic blood pressure ~200 mmHg. She was started on IV nitroglycerin. Her initial cardiac biomarkers have been negative. Currently not complaining of chest pain and denies SOB, DOE, palpitations, lightheadedness, nausea, or vomiting. Past Medical History: CAD s/p DES to RCA and OM1 in [MASKED] High Cholesterol, intolerant to statin HTN DM GERD CVA CKD OSA Social History: [MASKED] Family History: Mother: CVA in her [MASKED] Father: Unknown Physical [MASKED]: On admission: [MASKED] Temp: 98.1 PO BP: 136/88 HR: 81 RR: 17 O2 sat: 96% O2 delivery: Ra Constitutional: Appears comfortable. Denies any chest pain dyspnea. NAD Head/Eyes: NCAT, PERRL, no conjunctival injection ENT: Atraumatic external nose and ears, MMM. Neck: Supple, trachea midline Resp: No respiratory distress, CTAB Cards: RRR. s1,s2. no MRG, 2+ extremity pulses Abd: S/NT/ND, no HSM Skin: Warm, dry, no rash Ext: No c/c/e, extremities w/no gross deformity Neuro: speech fluent, sensation grossly intact, no focal lateralizing neurologic deficit Psych: Alert and oriented, normal mood . Pertinent Results: ADmission: [MASKED] 11:58AM BLOOD WBC-9.9 RBC-4.93 Hgb-12.7 Hct-40.1 MCV-81* MCH-25.8* MCHC-31.7* RDW-15.1 RDWSD-45.0 Plt [MASKED] [MASKED] 11:58AM BLOOD Plt [MASKED] [MASKED] 11:58AM BLOOD Glucose-99 UreaN-17 Creat-1.0 Na-143 K-4.1 Cl-104 HCO3-27 AnGap-12 [MASKED] 03:52AM BLOOD CK(CPK)-132 [MASKED] 03:52AM BLOOD CK-MB-2 cTropnT-<0.01 [MASKED] 11:58AM BLOOD cTropnT-<0.01 [MASKED] 10:07PM BLOOD %HbA1c-7.3* eAG-163* . On DC: [MASKED] 06:40AM BLOOD WBC-13.0* RBC-4.77 Hgb-12.3 Hct-38.6 MCV-81* MCH-25.8* MCHC-31.9* RDW-15.5 RDWSD-44.7 Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-109* UreaN-12 Creat-1.1 Na-144 K-4.1 Cl-105 HCO3-22 AnGap-17 . Cardiac cath [MASKED]: Coronary Description The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 40% stenosis in the proximal and mid segments. The [MASKED] Diagonal, arising from the proximal segment, is a medium caliber vessel. The [MASKED] Diagonal, arising from the mid segment, is a medium caliber vessel. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. There is a 90% stenosis in the ostium. There is a stent in the proximal and mid segments. The Inferior lateral of the OM, arising from the proximal segment, is a medium caliber vessel. There is a 60% stenosis in the proximal and mid segments. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. There is a 30% stenosis in the proximal segment. There is a stent in the proximal segment. There is a stent in the mid and distal segments. There is a stent in the distal segment. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. Interventional Details Percutaneous Coronary Intervention: Percutaneous coronary intervention (PCI) was performed on an ad hoc basis based on the coronary angiographic findings from the diagnostic portion of this procedure. A 6 [MASKED] EBU3.75 guide provided adequate support. Crossed with a Prowater wire into the distal OM. We also placed a Sion blue wire in the AV groove branch to protect this branch Predilated with a 2.5 mm balloon and then deployed a 3.5 mm x 24 mm DES, extending from the proximal LCx into the OM1 branch. We pulled the wire out of the AV groove branch, flow remained intact in this branch. Postdilated with a 3.5 mm balloon, 18 ATM in the distal stent and 20 ATM in the proximal stent. (this stent overlapped distally with the prior 3.0 DES placed in the mid OM1 branch in [MASKED] Final angiography revealed normal flow, no dissection and 0% residual stenosis. Complications: There were no clinically significant complications. Impression • Widely patent RCA stents and in the Mid OM1 • Ostial OM 90% stenosis (proximal to OM1 stent), Rxed successfully with 3.5 mm DES, flow intact in jailed AV groove branch of the [MASKED] Recommendations • Continue DAPT with ASA 81mg and Ticagrelor • Aggressive secondary risk factor modification • Further recommendations as per in patient Cardiology Service Brief Hospital Course: Assessment/Plan: [MASKED] woman with CAD s/p DES, HTN, HLD, recent positive stress test presented to ER with gradually escalating exertional dyspnea and now chest pain at rest. # Chest pain/UA/Positive ETT/CAD: History of prior CAD status post drug-eluting stent to OM1 and RCA in [MASKED] now presenting with progressive chest pain on exertion, now occurring at rest. Stress test with markedly lower exercise tolerance. Cardiac catheterization showed a 90% ostial OM lesion proximal to the OM1 stent. This was successfully treated with a 3.5 mm drug-eluting stent, flow was intact and the jailed AV groove branch of the left circumflex so no further intervention was needed. Of note patient triggered for hypertension and confusion and neatly after the cardiac catheterization and responded well to Haldol and blood pressure medicines. Patient was continued on her aspirin and Brilinta and had no chest pain after the procedure. Is recommended that she attend cardiac rehab after she is cleared by her cardiologist, Dr. [MASKED]. She was also started on Repatha after prior authorization was obtained for this medicine. She agrees to inject this once every other week. # HTN: Hypertensive urgency on presentation with systolic blood pressure~200 mmHg. Medication reconciliation was difficult but patient appeared to be on on losartan and carvedilol on admission. She was started on chlorthalidone, spironolactone, and amlodipine during this hospital stay with some improvement of her blood pressure. Her carvedilol was also increased to 25 mg twice a day. Patient is reluctant to take all these medicines so a lot of tissue was done about her high risk for stroke and importance of maintaining a lower blood pressure. She was encouraged to get a blood pressure cuff at home to use and record blood pressures to better titrate her medicines. # HLD: Intolerant to multiple statins. Rec'd PA for Repatha done and patient will start this tomorrow. # DM: A1C 7.4. Pt states it has been 10 in the past. Unclear about insulin dosing but Atrius record says 20 in am and 50 in pm. These medicines were continued at discharge. Jardiance prior authorization was confirmed and this can be considered as an outpatient if patient agrees. # GERD: On pantoprazole # CVA: On aspirin and ticagrelor # CKD: Stage [MASKED]. Most recent creat 0.9. Regularly sees a nephrologist at [MASKED]. # OSA: Mild. Recently diagnosed with OSA.No CPAP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CARVedilol 12.5 mg PO BID 2. Aspirin 81 mg PO DAILY 3. TiCAGRELOR 90 mg PO BID 4. Benicar (olmesartan) 40 mg oral DAILY daily 5. Pantoprazole 40 mg PO Q24H 6. glimepiride 2 mg oral BID 7. Glargine 20 Units Breakfast Glargine 50 Units Bedtime 8. melatonin 1 mg oral Other bedtime 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. amLODIPine 5 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Repatha SureClick (evolocumab) 140 mg/mL subcutaneous every 2 weeks 4. Spironolactone 25 mg PO DAILY 5. CARVedilol 25 mg PO BID 6. Glargine 20 Units Breakfast Glargine 50 Units Bedtime 7. Aspirin 81 mg PO DAILY 8. Benicar (olmesartan) 40 mg oral DAILY daily 9. glimepiride 2 mg oral BID 10. melatonin 1 mg oral Other bedtime 11. Pantoprazole 40 mg PO Q24H 12. TiCAGRELOR 90 mg PO BID 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: CAD hyperlidipemia Hypertensive urgency Diabetes GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted following your cardiac catheterization in which a drug coated stent was placed to open a blockage in your coronary artery. Instructions regarding care of the access site are included with your discharge information. Please continue your current medications with the following changes: - continue Aspirin 81mg daily, lifelong. - continue Brillinta daily, you should take this for a minimum of one year and ONLY stop when told by a cardiologist specifically. - Continue nitroglycerin as needed for chest pain. Take 1 tab under the tongue as needed for chest pain. You may repeat this every 5 mintues for continued chest pain for a total of 3 doses. If chest pain persists after 3 doses, call [MASKED]. It is important to sit or lie down if you are taking this medication because it can cause a drop in blood pressure and could cause you to pass out if blood pressure drops too low. It is very important to take all of your heart healthy medications. In particular, Aspirin and Brillinta help keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. If you stop these medications or miss [MASKED] dose, a blood clot could form in your heart stent which could cause a life threatening heart attack. Please do not stop taking either medication without taking to your heart doctor, even if another doctor tells you to stop the medications. You were started on 3 new medicines for your blood pressure. Please take these medicines every day. Check your blood pressure at home once a day and record it so that you can bring it to doctor's appointments. This will help to adjust your medicines so you are not on too much or too little. It is strongly recommended that you attend a cardiac rehab program in the near future. A referral form was provided to you that lists the locations of these programs. Please bring this with you to your follow up visit with your cardiologist, and they will inform you when it is safe to begin a program. If you were given any prescriptions on discharge, any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. If you have any urgent questions that are related to your recovery from your hospitalization or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call [MASKED] or your Doctor's office. It has been a pleasure to have participated in your care and we wish you the best with your health. Your [MASKED] Cardiac Care Team Followup Instructions: [MASKED]
[]
[ "Z87891", "E785", "K219", "G4733", "Z8673", "E1122", "I129", "Z794" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I160: Hypertensive urgency", "Z7982: Long term (current) use of aspirin", "N182: Chronic kidney disease, stage 2 (mild)", "Z794: Long term (current) use of insulin" ]
10,075,709
20,137,578
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with mild asthma, HTN, hypothyroidism, GERD, vitiligo, allergies, who presented with an episode of lightheadedness and syncope on background of N/V/D and abdominal pain. She was in her usual state of good health until ___ at 1AM when she awoke with abdominal pain. It was focused in her low abdomen, moderate, gas-like, nonradiating. She tried some seltzer water thinking it was gas but this did not help. The pain then became colicky, more diffuse, and progressively worsened. At around 5AM, she went to the bathroom and experienced an uncontrollable bout of vomiting and diarrhea. She returned to bed, pain ever worsening, and noted sweats. About an hour later she got up to go to the bathroom again, experienced a severe wave of pain, and then felt lightheaded and briefly passed out, hitting her cheek and right knee. She proceeded to go again to the bathroom where she experienced multiple waves of vomiting and diarrhea. She eventually called her friend and neighbor who brought her to the ED. In the ED, she had stable vital signs. Labs showed leukocytosis and hypokalemia, mild LFT elevation. Imaging with CTAP showed colitis. EKG with some nonspecific TW changes and possibly prolonged QT. She was given potassium, morphine, IVF, and admission was requested. Past Medical History: Asthma HTN Hypothyroidism (s/p treatment for Grave's) GERD Vitiligo Seasonal allergies Social History: ___ Family History: + for IBD in her mother, who was diagnosed at a late age. Sister had bowel obstruction recently. Family history was reviewed and is thought otherwise impertinent to current presentation. Physical Exam: Admission PHYSICAL EXAM Vitals: 97.8 126 / ___ Gen: NAD, sitting up in bed Eyes: EOMI, sclerae anicteric HENT: NCAT, MMM, OP clear, hearing adequate Cardiovasc: RRR, no obvious MRG. Full pulses, no edema. Resp: normal effort, breathing unlabored, no accessory muscle use, lungs CTA ___ without adventitious sounds. GI: Fairly tender to deep palpation diffusely, worst in LLQ, with some voluntary guarding. No rebound or guarding. Soft, ND, BS hyperactive. HSM deferred due to tenderness. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Vitiligo noted. Neuro: AAOx3. No facial droop. Moves all extremities. Psych: Full range of affect. Thought linear. GU: No foley Discharge physical exam: Gen: Lying in bed in no apparent distress. Vitiligo present HEENT: Anicteric, eyes conjugate, MMM, no JVD Cardiovascular: RRR no MRG, nl. S1 and S2 Pulmonary: Lung fields clear to auscultation throughout Gastroinestinal: Soft, non-tender, non-distended, bowel sounds present, no HSM MSK: No edema Skin: No rashes or ulcerations evident Neurological: Alert, interactive, speech fluent, face symmetric, moving all extremities Psychiatric: pleasant, appropriate affect Pertinent Results: ___ 05:59PM BLOOD WBC-11.3* RBC-4.59 Hgb-13.7 Hct-40.5 MCV-88 MCH-29.8 MCHC-33.8 RDW-12.7 RDWSD-40.7 Plt ___ ___ 06:40AM BLOOD WBC-9.2 RBC-3.86* Hgb-11.7 Hct-34.4 MCV-89 MCH-30.3 MCHC-34.0 RDW-12.7 RDWSD-41.3 Plt ___ ___ 06:55AM BLOOD WBC-6.1 RBC-3.65* Hgb-11.1* Hct-32.9* MCV-90 MCH-30.4 MCHC-33.7 RDW-12.5 RDWSD-41.4 Plt ___ ___ 05:59PM BLOOD Neuts-83.2* Lymphs-8.6* Monos-7.2 Eos-0.1* Baso-0.3 Im ___ AbsNeut-9.43* AbsLymp-0.97* AbsMono-0.82* AbsEos-0.01* AbsBaso-0.03 ___ 05:59PM BLOOD ALT-66* AST-52* AlkPhos-75 TotBili-0.5 ___ 06:40AM BLOOD ALT-64* AST-48* AlkPhos-62 TotBili-0.4 ___ 06:55AM BLOOD ALT-62* AST-40 AlkPhos-56 TotBili-0.2 ___ 06:12PM BLOOD Lactate-2.6* CT A/P: Colitis involving the distal transverse and descending colon, no perforation, pneumatosis, drainable fluid collection, or obstruction. Probable hepatic steatosis CXR: No acute intrathoracic process Right knee x-ray: No acute findings Brief Hospital Course: This is a ___ with mild asthma, HTN, hypothyroidism, GERD, vitiligo, allergies, who presented with an episode of lightheadedness and syncope on background of N/V/D and abdominal pain, found to have colitis on CT. #Abdominal pain, colitis: Most likely to be infectious based on the time course and her age. Inflammatory colitis is a much less likely secondary possibility, only really considered due to her family history of ulcerative colitis. Patient improved rapidly with IV ciprofloxacin and Flagyl, and by hospital day #2 was tolerating a full diet with no further diarrhea or significant abdominal pain. She was able to tolerate pills without difficulty, and was converted to oral ciprofloxacin and Flagyl to complete a total 7 day course of antibiotics. She has a colonoscopy already scheduled for ___, which may also help evaluate the possibility of underlying inflammatory bowel disease. She was instructed to follow-up with her PCP only if her symptoms fail to improve as expected. # Syncope: Very likely be orthostatic, due to her diarrhea and poor p.o. intake. Her lightheadedness improved/resolved with IV fluids, and again by hospital day 2 she was taking a full diet and excellent fluid intake. #Hypertension: Due to some mild hypokalemia, her hydrochlorothiazide will be held on discharge until she follows up with her PCP. Her blood pressures are main under excellent control during her entire hospital stay. #Right knee pain: Occurred after her fall at home. There is no evidence of fracture on films, and her pain improved with symptomatic management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ipratropium bromide 0.06 % nasal QID:PRN 2. amLODIPine 5 mg PO DAILY 3. beclomethasone dipropionate 80 mcg/actuation inhalation BID 4. Omeprazole 20 mg PO DAILY 5. Cetirizine 10 mg PO DAILY 6. Hydrochlorothiazide 50 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY 9. clotrimazole-betamethasone ___ % topical BID Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg ___ tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 2. Ciprofloxacin HCl 500 mg PO BID Duration: 5 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*16 Tablet Refills:*0 4. amLODIPine 5 mg PO DAILY 5. beclomethasone dipropionate 80 mcg/actuation inhalation BID 6. Cetirizine 10 mg PO DAILY 7. clotrimazole-betamethasone ___ % topical BID 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY 9. ipratropium bromide 0.06 % nasal QID:PRN 10. Levothyroxine Sodium 112 mcg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. HELD- Hydrochlorothiazide 50 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until you speak with your PCP ___: Home Discharge Diagnosis: Infectious Colitis (Mild) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure caring for you. You were admitted with lightheadedness, abdominal pain and Vomiting/Diarrhea. You were found to have mild Colitis on CT Scan. You were also found to be dehydrated. You improved significantly with IV fluids and IV antibiotics. We suspect this colitis is most likely due to a bacterial infection, but given your family history of Ulcerative Colitis, it would be reasonable to undergo a colonoscopy to make sure you don't also have this condition. You already have a colonoscopy scheduled for later in the year, which is perfect. On discharge, continue to take your oral antibiotics for a total of 7 days (e.g. through ___. You may continue to eat a regular diet. If your condition does not fully resolve, please call your PCP to schedule ___ follow-up appointment for further evaluation. Followup Instructions: ___
[ "A09", "E039", "D72829", "I10", "J45998", "K219", "L80", "J302", "M25561", "E876", "R1084", "R112", "R42", "R55", "Z87891" ]
Allergies: Penicillins / Cephalosporins Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] with mild asthma, HTN, hypothyroidism, GERD, vitiligo, allergies, who presented with an episode of lightheadedness and syncope on background of N/V/D and abdominal pain. She was in her usual state of good health until [MASKED] at 1AM when she awoke with abdominal pain. It was focused in her low abdomen, moderate, gas-like, nonradiating. She tried some seltzer water thinking it was gas but this did not help. The pain then became colicky, more diffuse, and progressively worsened. At around 5AM, she went to the bathroom and experienced an uncontrollable bout of vomiting and diarrhea. She returned to bed, pain ever worsening, and noted sweats. About an hour later she got up to go to the bathroom again, experienced a severe wave of pain, and then felt lightheaded and briefly passed out, hitting her cheek and right knee. She proceeded to go again to the bathroom where she experienced multiple waves of vomiting and diarrhea. She eventually called her friend and neighbor who brought her to the ED. In the ED, she had stable vital signs. Labs showed leukocytosis and hypokalemia, mild LFT elevation. Imaging with CTAP showed colitis. EKG with some nonspecific TW changes and possibly prolonged QT. She was given potassium, morphine, IVF, and admission was requested. Past Medical History: Asthma HTN Hypothyroidism (s/p treatment for Grave's) GERD Vitiligo Seasonal allergies Social History: [MASKED] Family History: + for IBD in her mother, who was diagnosed at a late age. Sister had bowel obstruction recently. Family history was reviewed and is thought otherwise impertinent to current presentation. Physical Exam: Admission PHYSICAL EXAM Vitals: 97.8 126 / [MASKED] Gen: NAD, sitting up in bed Eyes: EOMI, sclerae anicteric HENT: NCAT, MMM, OP clear, hearing adequate Cardiovasc: RRR, no obvious MRG. Full pulses, no edema. Resp: normal effort, breathing unlabored, no accessory muscle use, lungs CTA [MASKED] without adventitious sounds. GI: Fairly tender to deep palpation diffusely, worst in LLQ, with some voluntary guarding. No rebound or guarding. Soft, ND, BS hyperactive. HSM deferred due to tenderness. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Vitiligo noted. Neuro: AAOx3. No facial droop. Moves all extremities. Psych: Full range of affect. Thought linear. GU: No foley Discharge physical exam: Gen: Lying in bed in no apparent distress. Vitiligo present HEENT: Anicteric, eyes conjugate, MMM, no JVD Cardiovascular: RRR no MRG, nl. S1 and S2 Pulmonary: Lung fields clear to auscultation throughout Gastroinestinal: Soft, non-tender, non-distended, bowel sounds present, no HSM MSK: No edema Skin: No rashes or ulcerations evident Neurological: Alert, interactive, speech fluent, face symmetric, moving all extremities Psychiatric: pleasant, appropriate affect Pertinent Results: [MASKED] 05:59PM BLOOD WBC-11.3* RBC-4.59 Hgb-13.7 Hct-40.5 MCV-88 MCH-29.8 MCHC-33.8 RDW-12.7 RDWSD-40.7 Plt [MASKED] [MASKED] 06:40AM BLOOD WBC-9.2 RBC-3.86* Hgb-11.7 Hct-34.4 MCV-89 MCH-30.3 MCHC-34.0 RDW-12.7 RDWSD-41.3 Plt [MASKED] [MASKED] 06:55AM BLOOD WBC-6.1 RBC-3.65* Hgb-11.1* Hct-32.9* MCV-90 MCH-30.4 MCHC-33.7 RDW-12.5 RDWSD-41.4 Plt [MASKED] [MASKED] 05:59PM BLOOD Neuts-83.2* Lymphs-8.6* Monos-7.2 Eos-0.1* Baso-0.3 Im [MASKED] AbsNeut-9.43* AbsLymp-0.97* AbsMono-0.82* AbsEos-0.01* AbsBaso-0.03 [MASKED] 05:59PM BLOOD ALT-66* AST-52* AlkPhos-75 TotBili-0.5 [MASKED] 06:40AM BLOOD ALT-64* AST-48* AlkPhos-62 TotBili-0.4 [MASKED] 06:55AM BLOOD ALT-62* AST-40 AlkPhos-56 TotBili-0.2 [MASKED] 06:12PM BLOOD Lactate-2.6* CT A/P: Colitis involving the distal transverse and descending colon, no perforation, pneumatosis, drainable fluid collection, or obstruction. Probable hepatic steatosis CXR: No acute intrathoracic process Right knee x-ray: No acute findings Brief Hospital Course: This is a [MASKED] with mild asthma, HTN, hypothyroidism, GERD, vitiligo, allergies, who presented with an episode of lightheadedness and syncope on background of N/V/D and abdominal pain, found to have colitis on CT. #Abdominal pain, colitis: Most likely to be infectious based on the time course and her age. Inflammatory colitis is a much less likely secondary possibility, only really considered due to her family history of ulcerative colitis. Patient improved rapidly with IV ciprofloxacin and Flagyl, and by hospital day #2 was tolerating a full diet with no further diarrhea or significant abdominal pain. She was able to tolerate pills without difficulty, and was converted to oral ciprofloxacin and Flagyl to complete a total 7 day course of antibiotics. She has a colonoscopy already scheduled for [MASKED], which may also help evaluate the possibility of underlying inflammatory bowel disease. She was instructed to follow-up with her PCP only if her symptoms fail to improve as expected. # Syncope: Very likely be orthostatic, due to her diarrhea and poor p.o. intake. Her lightheadedness improved/resolved with IV fluids, and again by hospital day 2 she was taking a full diet and excellent fluid intake. #Hypertension: Due to some mild hypokalemia, her hydrochlorothiazide will be held on discharge until she follows up with her PCP. Her blood pressures are main under excellent control during her entire hospital stay. #Right knee pain: Occurred after her fall at home. There is no evidence of fracture on films, and her pain improved with symptomatic management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ipratropium bromide 0.06 % nasal QID:PRN 2. amLODIPine 5 mg PO DAILY 3. beclomethasone dipropionate 80 mcg/actuation inhalation BID 4. Omeprazole 20 mg PO DAILY 5. Cetirizine 10 mg PO DAILY 6. Hydrochlorothiazide 50 mg PO DAILY 7. Levothyroxine Sodium 112 mcg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY 9. clotrimazole-betamethasone [MASKED] % topical BID Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg [MASKED] tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 2. Ciprofloxacin HCl 500 mg PO BID Duration: 5 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO TID RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #*16 Tablet Refills:*0 4. amLODIPine 5 mg PO DAILY 5. beclomethasone dipropionate 80 mcg/actuation inhalation BID 6. Cetirizine 10 mg PO DAILY 7. clotrimazole-betamethasone [MASKED] % topical BID 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY 9. ipratropium bromide 0.06 % nasal QID:PRN 10. Levothyroxine Sodium 112 mcg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. HELD- Hydrochlorothiazide 50 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until you speak with your PCP [MASKED]: Home Discharge Diagnosis: Infectious Colitis (Mild) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a pleasure caring for you. You were admitted with lightheadedness, abdominal pain and Vomiting/Diarrhea. You were found to have mild Colitis on CT Scan. You were also found to be dehydrated. You improved significantly with IV fluids and IV antibiotics. We suspect this colitis is most likely due to a bacterial infection, but given your family history of Ulcerative Colitis, it would be reasonable to undergo a colonoscopy to make sure you don't also have this condition. You already have a colonoscopy scheduled for later in the year, which is perfect. On discharge, continue to take your oral antibiotics for a total of 7 days (e.g. through [MASKED]. You may continue to eat a regular diet. If your condition does not fully resolve, please call your PCP to schedule [MASKED] follow-up appointment for further evaluation. Followup Instructions: [MASKED]
[]
[ "E039", "I10", "K219", "Z87891" ]
[ "A09: Infectious gastroenteritis and colitis, unspecified", "E039: Hypothyroidism, unspecified", "D72829: Elevated white blood cell count, unspecified", "I10: Essential (primary) hypertension", "J45998: Other asthma", "K219: Gastro-esophageal reflux disease without esophagitis", "L80: Vitiligo", "J302: Other seasonal allergic rhinitis", "M25561: Pain in right knee", "E876: Hypokalemia", "R1084: Generalized abdominal pain", "R112: Nausea with vomiting, unspecified", "R42: Dizziness and giddiness", "R55: Syncope and collapse", "Z87891: Personal history of nicotine dependence" ]
10,075,900
23,749,709
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: latex Attending: ___. Chief Complaint: seizure, hyponatremia Major Surgical or Invasive Procedure: RIJ line placement ___ History of Present Illness: This is a ___ female who presents with concern for hyponatremic seizures. Per her family, she has had ___ witnessed episodes of staring off + chewing repeating, without remembering the episode, and with associated fatigue afterwards. Husband notes they typically take place in the morning, and they've been seeming less frequent. Husband says they only last a matter of seconds. Husband notes that patient drinks a ton of water, when pressed to quantify noted ___ bottles of water (possibly more like 7) every day. She constantly craves and ingests a ton of salt. She also is noted to frequently urinate ___ per day including ___. Last night, patient had about 4 glasses of wine, but did not seem more altered (and husband says has tolerated this without incident multiple times in the past.) She complained of increased fatigue this morning. She ate slices of ham (with high sodium). Later, the husband found her in bed with some swelling in mouth/face, episode of urinary incontinence, briefly unresponsive followed by responsive to pain only with severe fatigue. She was seen at ___ where she was noted to be hyponatremic to 116 and had a witnessed tonic clonic sz at CAT scan. She got 100mL 3% and Ativan with improvement. She got 15mL 3% on route. In the helicopter, she became increasingly altered, vomited, and was intubated for airway protection. On arrival she was noted to be having twitching of the bilateral hands, and received an additional 100 milliliter 3% saline bolus and was loaded with fosphenytoin. A right internal jugular line was placed. Nephrology was consulted and recommended correction of sodium to greater than 120. The sodium value was 123 on recheck, and no further correction was pursued. Given concern for prior seizure activity, neurology was consulted. In ED initial VS: 100.4, intubated, 68, 82/31, 16 Labs significant for: NA 117, WBC 20, SCr 0.4 Patient was given: ___ 21:18 IV DRIP Propofol ___ mcg/kg/min ordered) ___ 21:18 IVF Sodium Chloride 3% (Hypertonic) ___ 22:04 IV Fosphenytoin 1000 mg ___ 22:04 IV Fentanyl Citrate 100 mcg ___ 00:02 IV Magnesium Sulfate 2 gm Imaging notable for: CXr with ETT well positioned, no clear PNA Consults: Neuro- load with PHT Renal- Hypertonic saline until Na >120 On arrival to the MICU, pt intubated and sedated REVIEW OF SYSTEMS: unable to obtain as pt intubated and sedated Past Medical History: Panic disorder Generalized Anxiety Disorder Depression/PTSD from Childhood Social History: ___ Family History: Generalized Anxiety Disorder in mother Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Reviewed in metavision 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 rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No visible skin lesions NEURO: Intubated, follows commands with 4 extremities DISCHARGE PHYSICAL EXAM: VITALS: 97.8PO, 119 / 80, 94, 18, 97 RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, RIJ in place 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 EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No visible skin lesions NEURO: Awake, responsive, grossly normal exam Pertinent Results: ADMISSION LABS: =============== ___ 09:10PM BLOOD WBC-20.3* RBC-3.74* Hgb-11.6 Hct-32.0* MCV-86 MCH-31.0 MCHC-36.3 RDW-12.6 RDWSD-39.1 Plt ___ ___ 09:10PM BLOOD Neuts-79.3* Lymphs-17.4* Monos-2.2* Eos-0.0* Baso-0.3 Im ___ AbsNeut-16.13* AbsLymp-3.53 AbsMono-0.45 AbsEos-0.00* AbsBaso-0.06 ___ 09:10PM BLOOD ___ PTT-27.0 ___ ___ 09:10PM BLOOD Glucose-151* UreaN-4* Creat-0.4 Na-123* K-3.7 Cl-87* HCO3-20* AnGap-16 ___ 09:10PM BLOOD ALT-15 AST-24 CK(CPK)-337* AlkPhos-48 TotBili-0.9 ___ 09:10PM BLOOD Albumin-3.8 Calcium-7.0* Phos-1.7* Mg-1.4* Cholest-149 ___ 09:10PM BLOOD Triglyc-84 HDL-81 CHOL/HD-1.8 LDLcalc-51 ___ 10:15PM BLOOD Osmolal-248* ___ 09:10PM BLOOD TSH-0.75 ___ 09:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:24PM BLOOD Type-CENTRAL VE pO2-57* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 ___ 09:23PM BLOOD Lactate-1.7 RELEVANT LABS: ============== ___ 07:55AM BLOOD Cortsol-9.7 ___ 02:58AM BLOOD Lactate-1.0 Na-122* ___ 04:03AM BLOOD Na-123* ___ 06:12AM BLOOD Na-125* ___ 06:42AM BLOOD Na-126* ___ 08:15AM BLOOD Na-126* ___ 10:36AM BLOOD Na-125* ___ 11:56AM BLOOD Na-125* ___ 03:17PM BLOOD Na-123* ___ 08:40PM BLOOD Na-123* ___ 04:14AM BLOOD Na-128* ___ 09:14AM BLOOD Na-137 ___ 02:52PM BLOOD Na-136 ___ 06:19AM BLOOD Na-132* ___ 03:52PM BLOOD Na-136 ___ 06:54AM BLOOD Na-138 ___ 06:00AM URINE Hours-RANDOM Creat-89 Na-40 ___ 06:00AM URINE Osmolal-311 ___ 02:16AM URINE Hours-RANDOM Na-<20 ___ 02:16AM URINE Osmolal-122 ___ 10:15PM URINE Hours-RANDOM Creat-68 Na-81 Cl-90 ___ 10:15PM URINE Osmolal-559 DISCHARGE LABS: =============== ___ 06:25AM BLOOD WBC-8.7 RBC-3.46* Hgb-10.6* Hct-31.7* MCV-92 MCH-30.6 MCHC-33.4 RDW-13.9 RDWSD-46.5* Plt ___ ___ 06:25AM BLOOD Glucose-97 UreaN-<3* Creat-0.5 Na-140 K-4.0 Cl-103 HCO3-28 AnGap-9* ___ 06:25AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8 ___ 06:54AM BLOOD Na-138 MICROBIOLOGY: ============= ___ blood culture x2: pending ___ urine culture: negative ___ 09:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:00PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-150* Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 09:00PM URINE RBC-9* WBC-3 Bacteri-FEW* Yeast-NONE Epi-<1 ___ 09:00PM URINE CastHy-1* STUDIES: ======== ___ Neurophysiology EEG : pending report EEG Study Date of ___ IMPRESSION: This is an abnormal continuous video EEG monitoring study because of intermittent focal slowing in the left temporal region, consistent with focal subcortical dysfunction. The background activity otherwise reaches normal alpha frequency. Diffuse beta activity seen is most likely due to medication effects, typically associated with benzodiazepines or barbiturates. There are no epileptiform discharges or electrographic seizures. Compared to the prior day's recording, there is no significant change. MRI ROUTINE SEIZURE PROTOCOL W&W/O CONTRAST Study Date of ___ 1. No acute findings. Specifically no epileptogenic focus is identified. Brief Hospital Course: ___ year old woman with history of generalized anxiety disorder, who was transferred to ___ with tonic clonic seizures and possible partial seizures with hyponatremia. She was intubated for airway protection, fosphenytoin loaded and started on keppra. ACUTE ISSUES: #Tonic-Clonic Seizures: She presented to ___ after a tonic clonic seizure, and there had witnessed tonic clonic seizures with possible partial seizure activity. Seizures were most likely in the setting of severe hyponatremia, to 116 on presentation. She was intubated briefly for airway protection in the setting of altered mental status. NCHCT was negative. She was loaded with fosphenytoin and subsequently switched to keppra 750 BID. EEG was negative. MRI brain negative. She will follow up with neurology as an outpatient. Per MA law, no driving and can discuss further at outpatient neuro follow-up. #Hyponatremia: She was hyponatremic to 116 on presentation. Urine lytes were consistent with SIADH. Etiology was somewhat unclear but thought to be multifactorial related to chronic abdominal pain and nausea causing SIADH, tea and toast diet, and polydipsia. She initially required hypertonic saline, after which her sodium overcorrected and she required DDAVP. Sodium on discharge was: 140. She was discharged on a 2L fluid restriction. She will follow up with renal. CHRONIC ISSUES: # Anxiety: continued home Alprazolam 0.5 mg TID:PRN anxiety. TRANSITIONAL ISSUES: ==================== - Na on discharge is 140 on chemistry. - Will have neurology follow up appointment scheduled; likely downtitration of keppra as outpatient. - Fluid restriction to 2L daily. - She has been counseled on a high solute, high protein diet. - Lab draw ordered for ___, to be sent to PCP, BMP for monitoring of sodium levels. - She has significant anxiety and was previously on an SSRI. Please monitor mood and psych medication management as outpatient. - New meds: keppra - Changed meds: none - Stopped meds: none - Communication: HCP: Husband, ___ ___ - Code: Full, presumed Greater than 30 minutes spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO TID:PRN anxiety Discharge Medications: 1. LevETIRAcetam 750 mg PO BID RX *levetiracetam 750 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 2. ALPRAZolam 0.5 mg PO TID:PRN anxiety 3.Outpatient Lab Work DATE: ___. LAB: BMP. ICD-10: ___.1 Hyponatremia. CONTACT: ___. MD. PHONE: ___. FAX: ___. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Hyponatremia Seizure SECONDARY DIAGNOSIS: Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure to care for you at ___ ___. WHY WERE YOU ADMITTED? - You had seizures and were confused. WHAT HAPPENED IN THE HOSPITAL? - The sodium levels in your blood were found to be very low, which may have caused your seizures. - You were seen by the neurologists for your seizures, and by the renal doctors for your ___ sodium levels. - Your sodium levels corrected to normal this admission. - You were started on an anti-seizure medication (keppra). - Your EEG did not show any active seizure activity. WHAT SHOULD YOU DO ON DISCHARGE? - Please go to your follow up appointments. - Your primary care doctor ___ call you with an appointment time. If you do not hear back, please call Dr. ___ at: ___. - The neurologists will call you with an appointment time. If you do not hear back, please call them at: ___ - Please limit your fluid intake to 2L daily. Please try to eat a high protein diet. This will help prevent future low sodium levels. - Please have labwork drawn on ___ or ___ an faxed to Dr. ___. He should review these labs to ensure that your sodium is stable. - Please take your medications as written. We wish you the best, Your ___ team Followup Instructions: ___
[ "E222", "G4089", "F329", "F419" ]
Allergies: latex Chief Complaint: seizure, hyponatremia Major Surgical or Invasive Procedure: RIJ line placement [MASKED] History of Present Illness: This is a [MASKED] female who presents with concern for hyponatremic seizures. Per her family, she has had [MASKED] witnessed episodes of staring off + chewing repeating, without remembering the episode, and with associated fatigue afterwards. Husband notes they typically take place in the morning, and they've been seeming less frequent. Husband says they only last a matter of seconds. Husband notes that patient drinks a ton of water, when pressed to quantify noted [MASKED] bottles of water (possibly more like 7) every day. She constantly craves and ingests a ton of salt. She also is noted to frequently urinate [MASKED] per day including [MASKED]. Last night, patient had about 4 glasses of wine, but did not seem more altered (and husband says has tolerated this without incident multiple times in the past.) She complained of increased fatigue this morning. She ate slices of ham (with high sodium). Later, the husband found her in bed with some swelling in mouth/face, episode of urinary incontinence, briefly unresponsive followed by responsive to pain only with severe fatigue. She was seen at [MASKED] where she was noted to be hyponatremic to 116 and had a witnessed tonic clonic sz at CAT scan. She got 100mL 3% and Ativan with improvement. She got 15mL 3% on route. In the helicopter, she became increasingly altered, vomited, and was intubated for airway protection. On arrival she was noted to be having twitching of the bilateral hands, and received an additional 100 milliliter 3% saline bolus and was loaded with fosphenytoin. A right internal jugular line was placed. Nephrology was consulted and recommended correction of sodium to greater than 120. The sodium value was 123 on recheck, and no further correction was pursued. Given concern for prior seizure activity, neurology was consulted. In ED initial VS: 100.4, intubated, 68, 82/31, 16 Labs significant for: NA 117, WBC 20, SCr 0.4 Patient was given: [MASKED] 21:18 IV DRIP Propofol [MASKED] mcg/kg/min ordered) [MASKED] 21:18 IVF Sodium Chloride 3% (Hypertonic) [MASKED] 22:04 IV Fosphenytoin 1000 mg [MASKED] 22:04 IV Fentanyl Citrate 100 mcg [MASKED] 00:02 IV Magnesium Sulfate 2 gm Imaging notable for: CXr with ETT well positioned, no clear PNA Consults: Neuro- load with PHT Renal- Hypertonic saline until Na >120 On arrival to the MICU, pt intubated and sedated REVIEW OF SYSTEMS: unable to obtain as pt intubated and sedated Past Medical History: Panic disorder Generalized Anxiety Disorder Depression/PTSD from Childhood Social History: [MASKED] Family History: Generalized Anxiety Disorder in mother Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: Reviewed in metavision 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 rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No visible skin lesions NEURO: Intubated, follows commands with 4 extremities DISCHARGE PHYSICAL EXAM: VITALS: 97.8PO, 119 / 80, 94, 18, 97 RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, RIJ in place 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 EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No visible skin lesions NEURO: Awake, responsive, grossly normal exam Pertinent Results: ADMISSION LABS: =============== [MASKED] 09:10PM BLOOD WBC-20.3* RBC-3.74* Hgb-11.6 Hct-32.0* MCV-86 MCH-31.0 MCHC-36.3 RDW-12.6 RDWSD-39.1 Plt [MASKED] [MASKED] 09:10PM BLOOD Neuts-79.3* Lymphs-17.4* Monos-2.2* Eos-0.0* Baso-0.3 Im [MASKED] AbsNeut-16.13* AbsLymp-3.53 AbsMono-0.45 AbsEos-0.00* AbsBaso-0.06 [MASKED] 09:10PM BLOOD [MASKED] PTT-27.0 [MASKED] [MASKED] 09:10PM BLOOD Glucose-151* UreaN-4* Creat-0.4 Na-123* K-3.7 Cl-87* HCO3-20* AnGap-16 [MASKED] 09:10PM BLOOD ALT-15 AST-24 CK(CPK)-337* AlkPhos-48 TotBili-0.9 [MASKED] 09:10PM BLOOD Albumin-3.8 Calcium-7.0* Phos-1.7* Mg-1.4* Cholest-149 [MASKED] 09:10PM BLOOD Triglyc-84 HDL-81 CHOL/HD-1.8 LDLcalc-51 [MASKED] 10:15PM BLOOD Osmolal-248* [MASKED] 09:10PM BLOOD TSH-0.75 [MASKED] 09:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 10:24PM BLOOD Type-CENTRAL VE pO2-57* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 [MASKED] 09:23PM BLOOD Lactate-1.7 RELEVANT LABS: ============== [MASKED] 07:55AM BLOOD Cortsol-9.7 [MASKED] 02:58AM BLOOD Lactate-1.0 Na-122* [MASKED] 04:03AM BLOOD Na-123* [MASKED] 06:12AM BLOOD Na-125* [MASKED] 06:42AM BLOOD Na-126* [MASKED] 08:15AM BLOOD Na-126* [MASKED] 10:36AM BLOOD Na-125* [MASKED] 11:56AM BLOOD Na-125* [MASKED] 03:17PM BLOOD Na-123* [MASKED] 08:40PM BLOOD Na-123* [MASKED] 04:14AM BLOOD Na-128* [MASKED] 09:14AM BLOOD Na-137 [MASKED] 02:52PM BLOOD Na-136 [MASKED] 06:19AM BLOOD Na-132* [MASKED] 03:52PM BLOOD Na-136 [MASKED] 06:54AM BLOOD Na-138 [MASKED] 06:00AM URINE Hours-RANDOM Creat-89 Na-40 [MASKED] 06:00AM URINE Osmolal-311 [MASKED] 02:16AM URINE Hours-RANDOM Na-<20 [MASKED] 02:16AM URINE Osmolal-122 [MASKED] 10:15PM URINE Hours-RANDOM Creat-68 Na-81 Cl-90 [MASKED] 10:15PM URINE Osmolal-559 DISCHARGE LABS: =============== [MASKED] 06:25AM BLOOD WBC-8.7 RBC-3.46* Hgb-10.6* Hct-31.7* MCV-92 MCH-30.6 MCHC-33.4 RDW-13.9 RDWSD-46.5* Plt [MASKED] [MASKED] 06:25AM BLOOD Glucose-97 UreaN-<3* Creat-0.5 Na-140 K-4.0 Cl-103 HCO3-28 AnGap-9* [MASKED] 06:25AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8 [MASKED] 06:54AM BLOOD Na-138 MICROBIOLOGY: ============= [MASKED] blood culture x2: pending [MASKED] urine culture: negative [MASKED] 09:00PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 09:00PM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-150* Ketone-80* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 09:00PM URINE RBC-9* WBC-3 Bacteri-FEW* Yeast-NONE Epi-<1 [MASKED] 09:00PM URINE CastHy-1* STUDIES: ======== [MASKED] Neurophysiology EEG : pending report EEG Study Date of [MASKED] IMPRESSION: This is an abnormal continuous video EEG monitoring study because of intermittent focal slowing in the left temporal region, consistent with focal subcortical dysfunction. The background activity otherwise reaches normal alpha frequency. Diffuse beta activity seen is most likely due to medication effects, typically associated with benzodiazepines or barbiturates. There are no epileptiform discharges or electrographic seizures. Compared to the prior day's recording, there is no significant change. MRI ROUTINE SEIZURE PROTOCOL W&W/O CONTRAST Study Date of [MASKED] 1. No acute findings. Specifically no epileptogenic focus is identified. Brief Hospital Course: [MASKED] year old woman with history of generalized anxiety disorder, who was transferred to [MASKED] with tonic clonic seizures and possible partial seizures with hyponatremia. She was intubated for airway protection, fosphenytoin loaded and started on keppra. ACUTE ISSUES: #Tonic-Clonic Seizures: She presented to [MASKED] after a tonic clonic seizure, and there had witnessed tonic clonic seizures with possible partial seizure activity. Seizures were most likely in the setting of severe hyponatremia, to 116 on presentation. She was intubated briefly for airway protection in the setting of altered mental status. NCHCT was negative. She was loaded with fosphenytoin and subsequently switched to keppra 750 BID. EEG was negative. MRI brain negative. She will follow up with neurology as an outpatient. Per MA law, no driving and can discuss further at outpatient neuro follow-up. #Hyponatremia: She was hyponatremic to 116 on presentation. Urine lytes were consistent with SIADH. Etiology was somewhat unclear but thought to be multifactorial related to chronic abdominal pain and nausea causing SIADH, tea and toast diet, and polydipsia. She initially required hypertonic saline, after which her sodium overcorrected and she required DDAVP. Sodium on discharge was: 140. She was discharged on a 2L fluid restriction. She will follow up with renal. CHRONIC ISSUES: # Anxiety: continued home Alprazolam 0.5 mg TID:PRN anxiety. TRANSITIONAL ISSUES: ==================== - Na on discharge is 140 on chemistry. - Will have neurology follow up appointment scheduled; likely downtitration of keppra as outpatient. - Fluid restriction to 2L daily. - She has been counseled on a high solute, high protein diet. - Lab draw ordered for [MASKED], to be sent to PCP, BMP for monitoring of sodium levels. - She has significant anxiety and was previously on an SSRI. Please monitor mood and psych medication management as outpatient. - New meds: keppra - Changed meds: none - Stopped meds: none - Communication: HCP: Husband, [MASKED] [MASKED] - Code: Full, presumed Greater than 30 minutes spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.5 mg PO TID:PRN anxiety Discharge Medications: 1. LevETIRAcetam 750 mg PO BID RX *levetiracetam 750 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 2. ALPRAZolam 0.5 mg PO TID:PRN anxiety 3.Outpatient Lab Work DATE: [MASKED]. LAB: BMP. ICD-10: [MASKED].1 Hyponatremia. CONTACT: [MASKED]. MD. PHONE: [MASKED]. FAX: [MASKED]. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Hyponatremia Seizure SECONDARY DIAGNOSIS: Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a pleasure to care for you at [MASKED] [MASKED]. WHY WERE YOU ADMITTED? - You had seizures and were confused. WHAT HAPPENED IN THE HOSPITAL? - The sodium levels in your blood were found to be very low, which may have caused your seizures. - You were seen by the neurologists for your seizures, and by the renal doctors for your [MASKED] sodium levels. - Your sodium levels corrected to normal this admission. - You were started on an anti-seizure medication (keppra). - Your EEG did not show any active seizure activity. WHAT SHOULD YOU DO ON DISCHARGE? - Please go to your follow up appointments. - Your primary care doctor [MASKED] call you with an appointment time. If you do not hear back, please call Dr. [MASKED] at: [MASKED]. - The neurologists will call you with an appointment time. If you do not hear back, please call them at: [MASKED] - Please limit your fluid intake to 2L daily. Please try to eat a high protein diet. This will help prevent future low sodium levels. - Please have labwork drawn on [MASKED] or [MASKED] an faxed to Dr. [MASKED]. He should review these labs to ensure that your sodium is stable. - Please take your medications as written. We wish you the best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "F329", "F419" ]
[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "G4089: Other seizures", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]
10,075,925
20,739,229
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / Iodinated Contrast- Oral and IV Dye Attending: ___. Chief Complaint: dysuria Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH HTN, HFpEF, IDDM, ESRD due to DM s/p LURT ___ (living donor: husband), with recent diagnosis of adenocarcinoma of the lung during her prior hospitalization, who presents now for dysuria and ___. Patient first noticed pain with urination about 2 days ago. Urine smelled abnormal, and looked discolored/whitish. No fevers, back pain, abdominal/suprapubic pain. Feels dehydrated, and has not been eating and drinking her normal amount. Has been taking her medications, including tacro and insulin; remains on a long prednisone taper. Reports symptoms in her L eye have been a little better. Also noted to have elevated FSG to 400, which after insulin administration led to an episode of hypoglycemia. Per report, ___ visited today, and collected urine samples and preliminary labs, which showed an ___. Patient recently had a prolonged hospitalization for shortness of breath, ___ in the setting of diuresis as an outpatient, persistent pleural effusions, and persistent pericardial effusion, and was diagnosed with stage IV adenocarcinoma of the lung, without option for curative treatment. Patient and family decided to focus on comfort on discharge and indicated that they would go home with ___ and move to hospice when indicated. Also on a prolonged prednisone taper for bullous choroidal effusion of the left eye: ___: 20 mg/day, ___: 10 mg/day, ___ and on: 5 mg/day. While in the ED on this admission, family meeting was had with patient, husband/HCP ___, Dr. ___ (attending from her prior hospitalization), Dr. ___ Dr. ___ ___ team). Meeting involved discussing recent diagnosis of widely metastatic adenocarcinoma of the lung in the setting of multiple chronic medical problems (OSA, CHF, renal transplant, IDDM) resulting in multiple hospitalizations of recent, limited prognosis, and current functional status being unable to tolerate or benefit from palliative cancer-directed therapies. As a result, patient is now DNR/DNI, will be transitioned to hospice care after this hospitalization, and will not be re-hospitalized after this admission. On this admission, goals of care involve better management of acute medical issues (e.g. better insulin management and treatment of UTI), while arranging for hospice services on discharge. In the ED: Initial vital signs were notable for: 98.3 84 135/79 16 100% 3L NC Labs were notable for: WBC 14.3, H/H 8.2/28.4, BUN/Cr 50/1.6 (improved to 1.3), Glc 143, UA 108 WBC, many bacteria, lg leuks, tacro 11.9 Studies performed include: Renal transplant US: Unchanged top-normal resistive indices of the intrarenal arteries. CXR: Marked cardiomegaly in this patient with known pericardial effusion. Right hilar mass with right perifissural opacity likely representing tumor and partially collapsed right upper lung. No gross signs of a superimposed pneumonia. Patient was given: ___ 23:52 IVF NS ___ Started ___ 01:17 PO Tacrolimus 2.5 mg ___ ___ 02:50 IVF NS 1000 mL ___ Stopped (2h ___ ___ 03:59 IV CefTRIAXone ___ Started ___ 04:23 IV CefTRIAXone 1 gm ___ Stopped (___) ___ 08:00 SC Insulin ___ Not Given ___ 08:33 SC Insulin ___ Not Given ___ 09:00 SC Insulin ___ Not Given ___ 09:17 PO/NG PredniSONE 20 mg ___ ___ 09:17 PO/NG amLODIPine 10 mg ___ ___ 09:17 PO/NG Labetalol 200 mg ___ ___ 11:16 SC Insulin 10 UNIT ___ ___ 13:58 SC Insulin 2 UNIT ___ ___ 13:58 SC Insulin 3 Units ___ ___ 16:08 PO Tacrolimus 2.5 mg Consults: Renal transplant, Heme/Onc, ___ Vitals on transfer: 98.6 90 145/72 16 96% 3L NC Upon arrival to the floor, patient is asleep and denies any pain or shortness of breath. She does not answer additional questions but is arousable to voice. REVIEW OF SYSTEMS: Unable to obtain complete ROS as above Past Medical History: Hypertension Heart failure with preserved ejection fraction (HFpEF) Type 1 diabetes mellitus End stage renal disease (ESRD) Living donor renal transplant from her husband (___) Pericardial effusion (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: 98.2PO 152 / 82 86 18 91% 3L GENERAL: Alert and arousable to voice. Sleeping. In no acute distress. HEENT: NCAT. MMM. NECK: Supple CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. NEUROLOGIC: moves extremities with purpose, deferred full neuro exam as asleep DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated ___ @ 427) Temp: 98.1 (Tm 98.5), BP: 152/94 (144-156/84-94), HR: 90 (81-90), RR: 16 (___), O2 sat: 92% (92-95), O2 delivery: 3L GENERAL: Alert and arousable to voice. Sleeping. In no acute distress. HEENT: NCAT. MMM. LUNGS: breathing comfortably without evidence of increased work of breathing. ABDOMEN: softly distended NEUROLOGIC: moves extremities with purpose, deferred full neuro exam as asleep Note: Exam limited as patient asked not to be examined further. Pertinent Results: ADMISSION LABS: ============== ___ 08:17PM BLOOD WBC-14.3* RBC-3.35* Hgb-8.2* Hct-28.4* MCV-85 MCH-24.5* MCHC-28.9* RDW-17.2* RDWSD-53.3* Plt ___ ___ 08:17PM BLOOD Neuts-95.0* Lymphs-1.5* Monos-2.5* Eos-0.1* Baso-0.1 Im ___ AbsNeut-13.57* AbsLymp-0.22* AbsMono-0.35 AbsEos-0.01* AbsBaso-0.01 ___ 08:17PM BLOOD Glucose-143* UreaN-50* Creat-1.6* Na-137 K-4.9 Cl-87* HCO3-34* AnGap-16 ___ 10:13PM BLOOD Lactate-2.1* DISCHARGE LABS: ============== ___ 06:07AM BLOOD WBC-12.7* RBC-3.27* Hgb-8.0* Hct-28.4* MCV-87 MCH-24.5* MCHC-28.2* RDW-16.9* RDWSD-53.9* Plt ___ ___ 06:07AM BLOOD Glucose-111* UreaN-38* Creat-1.2* Na-139 K-4.4 Cl-91* HCO3-34* AnGap-14 ___ 01:42AM BLOOD Lactate-1.4 K-4.7 RENAL TRANSPLANT U/S - ___: ========================= FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.73 to 0.80, previously 0.70 to 0.83. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 80.4. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Unchanged top-normal resistive indices of the intrarenal arteries. CHEST XRAY - ___: ================= FINDINGS: PA and lateral views of the chest provided. Multiple overlying EKG leads are present. Frontal view is somewhat limited given partial exclusion of the lateral CP recess. The heart appears markedly enlarged. Please note patient is noted to have a large pericardial effusion on recent CT exam. A right hilar mass is associated with partial collapse of the right upper lobe and the overall appearance is similar. There is no definite evidence for pneumonia. Left lung appears relatively clear. Bony structures are intact. IMPRESSION: Marked cardiomegaly in this patient with known pericardial effusion. Right hilar mass with right perifissural opacity likely representing tumor and partially collapsed right upper lung. No gross signs of a superimposed pneumonia. Brief Hospital Course: BRIEF HOSPITAL COURSE: ====================== ___ PMH HTN, HFpEF, IDDM, ESRD due to DM s/p LURT ___ (living donor: husband), with recent diagnosis of NSCLC with metastases to the liver and bones during her prior hospitalization, who presents now for dysuria and ___. # Goals of care. # Widely metastatic lung adenocarcinoma. Extensive goals of care/advanced directives meeting was had between patient's husband/HCP, Dr. ___, Dr. ___ Dr. ___ team). Meeting involved discussing recent diagnosis of widely metastatic adenocarcinoma of the lung in the setting of multiple chronic medical problems (OSA, CHF, renal transplant, IDDM) resulting in multiple hospitalizations of recent, limited prognosis, and current functional status being unable to tolerate or benefit from palliative cancer-directed therapies. As a result, patient is now DNR/DNI, will be transitioned to hospice care after this hospitalization, and will not be re-hospitalized after this admission. To help patient and patient's family better manage patient's chronic medical conditions, patient's endocrinologist, ___, was contacted and made aware of patient's care plan. Patient will be able to contact Dr. ___ with any questions regarding insulin titration. Patient's renal transplant doctors were also ___ who confirmed tacrolimus dosing. As patient and patient's family wish to make patient as comfortable as possible for the remainder of her life, patient will not have lab work drawn at home. # Dysuria # UTI. Patient presented with dysuria, suprapubic tenderness. UA obtained on this admission was concerning for infection, with cultures growing gram negative rods (speciation and sensitivities pending). Patient has prior urine culture history of amp/macrobid/Bactrim resistant klebsiella. Thus, patient was started on ceftriaxone while inpatient. She was discharged on Bactrim with plan to f/u urine cultures and narrow abx pending sensitivities. # ___ # ESRD s/p LURT. Patient with baseline Cr ~1. On presentation Cr elevated to 1.6, with resolution after administration of IV fluids, likely reflecting pre-renal physiology in the setting of diuretic use with poor PO intake. As patient PO intake has decreased substantially and patient was without evidence of hypervolemia on exam, we held patient's torsemide on discharge, with instructions to hospice care to consider reintroduction if evidence of volume overload. Patient's tacrolimus level was maintained at 2.5 mg q 12 hrs with input from renal transplant. In line with patient care goals, tacrolimus levels will no longer be measured as outpatient. # Hyperglycemia # Variable BG control # Type I DM. Patient presented after recent hyperglycemic episode with correction leading to hypoglycemic episode. Hyperglycemia was likely exacerbated by current infection plus prolonged steroid taper superimposed on previously known labile glycemic control. Patient has had variable BG control in recent days with hypoglycemia overnight (in 40-50mg/dL) requiring EMS treatment due to stacking of Humalog insulin to treat persisting hyperglycemia. Patient endocrinologist, ___, was contacted who will continue to provide care for patient at home with clear plan for patient as to when to contact Dr. ___ ___ staff for titration of insulin regimen. #Hallucinations Likely delirium ___ infection/hospitalizations vs metastatic spread of disease to brain. Patient AAOx3 with nonfocal neuro exam. Patient endorsed hallucination of husband in her room. Patient seems comforted and not distressed by the hallucination. As such, further intervention was considered outside of patient's goals of care. # Bullous choroidal effusion of the left eye. Patient recently initiated on prednisone taper for bullous choroidal effusion of the left eye diagnosed on most recent hospitalization. Patient's prednisone taper was continued while inpatient along with Atropine Sulfate drops. # Anemia. Patient with prior ___ with duodenal ulcer. H/H stable during this hospitalization, without active blood loss. Patient's PPI was continued while inpatient and at discharge. CHRONIC ISSUES ============== # Hypertension. Patient's amlodipine and labetalol were continued while inpatient. # Insomnia. Patient's trazadone was continued while inpatient. TRANSITIONAL ISSUES : ================== [ ] For any questions moving forward, primary contact for hospice is PCP, ___ (___) [ ] Patient to follow up with endocrinologist, ___, should BG move outside of target range (target BG: 100-300mg/dL). See below for current insulin regimen recommendations, with understanding that this may need to be adjusted with the help of Dr. ___ (or another on call MD) who can be reached at ___. [ ] Patient's husband may submit blood sugar logs to ___ ___ at ___ should they find this helpful to patient's care. [ ] Please do not continue to draw patient labs as this is outside of patient's goals of care [ ] Please continue tacrolimus at current dose (2.5 mg q 12 hrs) in line with renal transplant recommendations [ ] Should patient experience hallucinations that appear distressing to patient, please contact patient PCP [ ] Should patient appear hypervolemic/volume overload please reintroduce low dose home torsemide (currently held in the setting of poor PO intake and recent ___ [ ] Please continue antibiotic regimen for UTI (Bactrim 5 day course; D1 ___ [ ] Please drain PleurX 3x a week (last drainage on ___ Insulin regimen at discharge: 22 glargine QHS 2 Humalog standing with meals sliding scale as below Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose ___ mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 3 Units 3 Units 0 Units 201-250 mg/dL 4 Units 5 Units 5 Units 0 Units 251-300 mg/dL 6 Units 7 Units 7 Units 2 Units 301-350 mg/dL 8 Units 9 Units 9 Units 3 Units 351-400 mg/dL 10 Units 11 Units 11 Units 4 Units > 400 mg/dL ___ M.D. ___ M.D. ___ M.D. ___ M.D. CORE MEASURES ============= #CODE: DNR/DNI, Do not re-hospitalize #CONTACT: HCP/Husband ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 4. Labetalol 200 mg PO BID 5. Tacrolimus 2.5 mg PO Q12H 6. Torsemide 40 mg PO EVERY OTHER DAY 7. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 8. Pantoprazole 40 mg PO Q24H 9. PredniSONE 20 mg PO DAILY 10. PredniSONE 10 mg PO DAILY 11. PredniSONE 5 mg PO DAILY 12. TraZODone 25 mg PO QHS:PRN insomnia 13. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 14. Glargine 34 Units Bedtime Humalog 2 Units Breakfast Humalog 8 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Phenazopyridine 100 mg PO TID:PRN urinary tract pain Duration: 3 Days RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a day as needed Disp #*30 Tablet Refills:*0 2. Sulfameth/Trimethoprim DS 1 TAB PO BID urinary tract infection Duration: 10 Doses RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*9 Tablet Refills:*0 3. Glargine 22 Units Bedtime Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 5. amLODIPine 10 mg PO DAILY 6. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 7. Docusate Sodium 100 mg PO BID 8. Labetalol 200 mg PO BID 9. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 10. Pantoprazole 40 mg PO Q24H 11. PredniSONE 10 mg PO DAILY 12. PredniSONE 5 mg PO DAILY 13. PredniSONE 20 mg PO DAILY 14. Tacrolimus 2.5 mg PO Q12H 15. TraZODone 25 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses: ============== Urinary Tract Infection Acute Kidney Injury (Prerenal) Secondary Diagnoses: ================= ___ - Stage IV DMI HTN Pericardial effusion ESRD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear , It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? - You came to the hospital because you had pain with urination and lab work that indicated there was an injury to your kidney. What did you receive in the hospital? - You received intravenous fluids and your diuretics were held which led to improvement in your kidney function. - You received antibiotics for your urinary tract infection. What should you do once you leave the hospital? - Complete your antibiotic course for your urinary tract infection. - Continue to spend time with your warm and wonderful family. We wish you the best! Your ___ Care Team Followup Instructions: ___
[ "N390", "N179", "C3401", "C7931", "E1022", "I132", "I5032", "N186", "Z940", "I313", "Z993", "E1065", "R441", "H318", "D649", "G4700", "Z23", "Z66", "Z794", "E669", "Z6832", "E10319", "H409" ]
Allergies: Lisinopril / Iodinated Contrast- Oral and IV Dye Chief Complaint: dysuria Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH HTN, HFpEF, IDDM, ESRD due to DM s/p LURT [MASKED] (living donor: husband), with recent diagnosis of adenocarcinoma of the lung during her prior hospitalization, who presents now for dysuria and [MASKED]. Patient first noticed pain with urination about 2 days ago. Urine smelled abnormal, and looked discolored/whitish. No fevers, back pain, abdominal/suprapubic pain. Feels dehydrated, and has not been eating and drinking her normal amount. Has been taking her medications, including tacro and insulin; remains on a long prednisone taper. Reports symptoms in her L eye have been a little better. Also noted to have elevated FSG to 400, which after insulin administration led to an episode of hypoglycemia. Per report, [MASKED] visited today, and collected urine samples and preliminary labs, which showed an [MASKED]. Patient recently had a prolonged hospitalization for shortness of breath, [MASKED] in the setting of diuresis as an outpatient, persistent pleural effusions, and persistent pericardial effusion, and was diagnosed with stage IV adenocarcinoma of the lung, without option for curative treatment. Patient and family decided to focus on comfort on discharge and indicated that they would go home with [MASKED] and move to hospice when indicated. Also on a prolonged prednisone taper for bullous choroidal effusion of the left eye: [MASKED]: 20 mg/day, [MASKED]: 10 mg/day, [MASKED] and on: 5 mg/day. While in the ED on this admission, family meeting was had with patient, husband/HCP [MASKED], Dr. [MASKED] (attending from her prior hospitalization), Dr. [MASKED] Dr. [MASKED] [MASKED] team). Meeting involved discussing recent diagnosis of widely metastatic adenocarcinoma of the lung in the setting of multiple chronic medical problems (OSA, CHF, renal transplant, IDDM) resulting in multiple hospitalizations of recent, limited prognosis, and current functional status being unable to tolerate or benefit from palliative cancer-directed therapies. As a result, patient is now DNR/DNI, will be transitioned to hospice care after this hospitalization, and will not be re-hospitalized after this admission. On this admission, goals of care involve better management of acute medical issues (e.g. better insulin management and treatment of UTI), while arranging for hospice services on discharge. In the ED: Initial vital signs were notable for: 98.3 84 135/79 16 100% 3L NC Labs were notable for: WBC 14.3, H/H 8.2/28.4, BUN/Cr 50/1.6 (improved to 1.3), Glc 143, UA 108 WBC, many bacteria, lg leuks, tacro 11.9 Studies performed include: Renal transplant US: Unchanged top-normal resistive indices of the intrarenal arteries. CXR: Marked cardiomegaly in this patient with known pericardial effusion. Right hilar mass with right perifissural opacity likely representing tumor and partially collapsed right upper lung. No gross signs of a superimposed pneumonia. Patient was given: [MASKED] 23:52 IVF NS [MASKED] Started [MASKED] 01:17 PO Tacrolimus 2.5 mg [MASKED] [MASKED] 02:50 IVF NS 1000 mL [MASKED] Stopped (2h [MASKED] [MASKED] 03:59 IV CefTRIAXone [MASKED] Started [MASKED] 04:23 IV CefTRIAXone 1 gm [MASKED] Stopped ([MASKED]) [MASKED] 08:00 SC Insulin [MASKED] Not Given [MASKED] 08:33 SC Insulin [MASKED] Not Given [MASKED] 09:00 SC Insulin [MASKED] Not Given [MASKED] 09:17 PO/NG PredniSONE 20 mg [MASKED] [MASKED] 09:17 PO/NG amLODIPine 10 mg [MASKED] [MASKED] 09:17 PO/NG Labetalol 200 mg [MASKED] [MASKED] 11:16 SC Insulin 10 UNIT [MASKED] [MASKED] 13:58 SC Insulin 2 UNIT [MASKED] [MASKED] 13:58 SC Insulin 3 Units [MASKED] [MASKED] 16:08 PO Tacrolimus 2.5 mg Consults: Renal transplant, Heme/Onc, [MASKED] Vitals on transfer: 98.6 90 145/72 16 96% 3L NC Upon arrival to the floor, patient is asleep and denies any pain or shortness of breath. She does not answer additional questions but is arousable to voice. REVIEW OF SYSTEMS: Unable to obtain complete ROS as above Past Medical History: Hypertension Heart failure with preserved ejection fraction (HFpEF) Type 1 diabetes mellitus End stage renal disease (ESRD) Living donor renal transplant from her husband ([MASKED]) Pericardial effusion ([MASKED]) Social History: [MASKED] Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: 98.2PO 152 / 82 86 18 91% 3L GENERAL: Alert and arousable to voice. Sleeping. In no acute distress. HEENT: NCAT. MMM. NECK: Supple CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. NEUROLOGIC: moves extremities with purpose, deferred full neuro exam as asleep DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated [MASKED] @ 427) Temp: 98.1 (Tm 98.5), BP: 152/94 (144-156/84-94), HR: 90 (81-90), RR: 16 ([MASKED]), O2 sat: 92% (92-95), O2 delivery: 3L GENERAL: Alert and arousable to voice. Sleeping. In no acute distress. HEENT: NCAT. MMM. LUNGS: breathing comfortably without evidence of increased work of breathing. ABDOMEN: softly distended NEUROLOGIC: moves extremities with purpose, deferred full neuro exam as asleep Note: Exam limited as patient asked not to be examined further. Pertinent Results: ADMISSION LABS: ============== [MASKED] 08:17PM BLOOD WBC-14.3* RBC-3.35* Hgb-8.2* Hct-28.4* MCV-85 MCH-24.5* MCHC-28.9* RDW-17.2* RDWSD-53.3* Plt [MASKED] [MASKED] 08:17PM BLOOD Neuts-95.0* Lymphs-1.5* Monos-2.5* Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-13.57* AbsLymp-0.22* AbsMono-0.35 AbsEos-0.01* AbsBaso-0.01 [MASKED] 08:17PM BLOOD Glucose-143* UreaN-50* Creat-1.6* Na-137 K-4.9 Cl-87* HCO3-34* AnGap-16 [MASKED] 10:13PM BLOOD Lactate-2.1* DISCHARGE LABS: ============== [MASKED] 06:07AM BLOOD WBC-12.7* RBC-3.27* Hgb-8.0* Hct-28.4* MCV-87 MCH-24.5* MCHC-28.2* RDW-16.9* RDWSD-53.9* Plt [MASKED] [MASKED] 06:07AM BLOOD Glucose-111* UreaN-38* Creat-1.2* Na-139 K-4.4 Cl-91* HCO3-34* AnGap-14 [MASKED] 01:42AM BLOOD Lactate-1.4 K-4.7 RENAL TRANSPLANT U/S - [MASKED]: ========================= FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.73 to 0.80, previously 0.70 to 0.83. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 80.4. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Unchanged top-normal resistive indices of the intrarenal arteries. CHEST XRAY - [MASKED]: ================= FINDINGS: PA and lateral views of the chest provided. Multiple overlying EKG leads are present. Frontal view is somewhat limited given partial exclusion of the lateral CP recess. The heart appears markedly enlarged. Please note patient is noted to have a large pericardial effusion on recent CT exam. A right hilar mass is associated with partial collapse of the right upper lobe and the overall appearance is similar. There is no definite evidence for pneumonia. Left lung appears relatively clear. Bony structures are intact. IMPRESSION: Marked cardiomegaly in this patient with known pericardial effusion. Right hilar mass with right perifissural opacity likely representing tumor and partially collapsed right upper lung. No gross signs of a superimposed pneumonia. Brief Hospital Course: BRIEF HOSPITAL COURSE: ====================== [MASKED] PMH HTN, HFpEF, IDDM, ESRD due to DM s/p LURT [MASKED] (living donor: husband), with recent diagnosis of NSCLC with metastases to the liver and bones during her prior hospitalization, who presents now for dysuria and [MASKED]. # Goals of care. # Widely metastatic lung adenocarcinoma. Extensive goals of care/advanced directives meeting was had between patient's husband/HCP, Dr. [MASKED], Dr. [MASKED] Dr. [MASKED] team). Meeting involved discussing recent diagnosis of widely metastatic adenocarcinoma of the lung in the setting of multiple chronic medical problems (OSA, CHF, renal transplant, IDDM) resulting in multiple hospitalizations of recent, limited prognosis, and current functional status being unable to tolerate or benefit from palliative cancer-directed therapies. As a result, patient is now DNR/DNI, will be transitioned to hospice care after this hospitalization, and will not be re-hospitalized after this admission. To help patient and patient's family better manage patient's chronic medical conditions, patient's endocrinologist, [MASKED], was contacted and made aware of patient's care plan. Patient will be able to contact Dr. [MASKED] with any questions regarding insulin titration. Patient's renal transplant doctors were also [MASKED] who confirmed tacrolimus dosing. As patient and patient's family wish to make patient as comfortable as possible for the remainder of her life, patient will not have lab work drawn at home. # Dysuria # UTI. Patient presented with dysuria, suprapubic tenderness. UA obtained on this admission was concerning for infection, with cultures growing gram negative rods (speciation and sensitivities pending). Patient has prior urine culture history of amp/macrobid/Bactrim resistant klebsiella. Thus, patient was started on ceftriaxone while inpatient. She was discharged on Bactrim with plan to f/u urine cultures and narrow abx pending sensitivities. # [MASKED] # ESRD s/p LURT. Patient with baseline Cr ~1. On presentation Cr elevated to 1.6, with resolution after administration of IV fluids, likely reflecting pre-renal physiology in the setting of diuretic use with poor PO intake. As patient PO intake has decreased substantially and patient was without evidence of hypervolemia on exam, we held patient's torsemide on discharge, with instructions to hospice care to consider reintroduction if evidence of volume overload. Patient's tacrolimus level was maintained at 2.5 mg q 12 hrs with input from renal transplant. In line with patient care goals, tacrolimus levels will no longer be measured as outpatient. # Hyperglycemia # Variable BG control # Type I DM. Patient presented after recent hyperglycemic episode with correction leading to hypoglycemic episode. Hyperglycemia was likely exacerbated by current infection plus prolonged steroid taper superimposed on previously known labile glycemic control. Patient has had variable BG control in recent days with hypoglycemia overnight (in 40-50mg/dL) requiring EMS treatment due to stacking of Humalog insulin to treat persisting hyperglycemia. Patient endocrinologist, [MASKED], was contacted who will continue to provide care for patient at home with clear plan for patient as to when to contact Dr. [MASKED] [MASKED] staff for titration of insulin regimen. #Hallucinations Likely delirium [MASKED] infection/hospitalizations vs metastatic spread of disease to brain. Patient AAOx3 with nonfocal neuro exam. Patient endorsed hallucination of husband in her room. Patient seems comforted and not distressed by the hallucination. As such, further intervention was considered outside of patient's goals of care. # Bullous choroidal effusion of the left eye. Patient recently initiated on prednisone taper for bullous choroidal effusion of the left eye diagnosed on most recent hospitalization. Patient's prednisone taper was continued while inpatient along with Atropine Sulfate drops. # Anemia. Patient with prior [MASKED] with duodenal ulcer. H/H stable during this hospitalization, without active blood loss. Patient's PPI was continued while inpatient and at discharge. CHRONIC ISSUES ============== # Hypertension. Patient's amlodipine and labetalol were continued while inpatient. # Insomnia. Patient's trazadone was continued while inpatient. TRANSITIONAL ISSUES : ================== [ ] For any questions moving forward, primary contact for hospice is PCP, [MASKED] ([MASKED]) [ ] Patient to follow up with endocrinologist, [MASKED], should BG move outside of target range (target BG: 100-300mg/dL). See below for current insulin regimen recommendations, with understanding that this may need to be adjusted with the help of Dr. [MASKED] (or another on call MD) who can be reached at [MASKED]. [ ] Patient's husband may submit blood sugar logs to [MASKED] [MASKED] at [MASKED] should they find this helpful to patient's care. [ ] Please do not continue to draw patient labs as this is outside of patient's goals of care [ ] Please continue tacrolimus at current dose (2.5 mg q 12 hrs) in line with renal transplant recommendations [ ] Should patient experience hallucinations that appear distressing to patient, please contact patient PCP [ ] Should patient appear hypervolemic/volume overload please reintroduce low dose home torsemide (currently held in the setting of poor PO intake and recent [MASKED] [ ] Please continue antibiotic regimen for UTI (Bactrim 5 day course; D1 [MASKED] [ ] Please drain PleurX 3x a week (last drainage on [MASKED] Insulin regimen at discharge: 22 glargine QHS 2 Humalog standing with meals sliding scale as below Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose [MASKED] mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 3 Units 3 Units 0 Units 201-250 mg/dL 4 Units 5 Units 5 Units 0 Units 251-300 mg/dL 6 Units 7 Units 7 Units 2 Units 301-350 mg/dL 8 Units 9 Units 9 Units 3 Units 351-400 mg/dL 10 Units 11 Units 11 Units 4 Units > 400 mg/dL [MASKED] M.D. [MASKED] M.D. [MASKED] M.D. [MASKED] M.D. CORE MEASURES ============= #CODE: DNR/DNI, Do not re-hospitalize #CONTACT: HCP/Husband [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 4. Labetalol 200 mg PO BID 5. Tacrolimus 2.5 mg PO Q12H 6. Torsemide 40 mg PO EVERY OTHER DAY 7. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 8. Pantoprazole 40 mg PO Q24H 9. PredniSONE 20 mg PO DAILY 10. PredniSONE 10 mg PO DAILY 11. PredniSONE 5 mg PO DAILY 12. TraZODone 25 mg PO QHS:PRN insomnia 13. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 14. Glargine 34 Units Bedtime Humalog 2 Units Breakfast Humalog 8 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Phenazopyridine 100 mg PO TID:PRN urinary tract pain Duration: 3 Days RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a day as needed Disp #*30 Tablet Refills:*0 2. Sulfameth/Trimethoprim DS 1 TAB PO BID urinary tract infection Duration: 10 Doses RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*9 Tablet Refills:*0 3. Glargine 22 Units Bedtime Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 5. amLODIPine 10 mg PO DAILY 6. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 7. Docusate Sodium 100 mg PO BID 8. Labetalol 200 mg PO BID 9. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate 10. Pantoprazole 40 mg PO Q24H 11. PredniSONE 10 mg PO DAILY 12. PredniSONE 5 mg PO DAILY 13. PredniSONE 20 mg PO DAILY 14. Tacrolimus 2.5 mg PO Q12H 15. TraZODone 25 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnoses: ============== Urinary Tract Infection Acute Kidney Injury (Prerenal) Secondary Diagnoses: ================= [MASKED] - Stage IV DMI HTN Pericardial effusion ESRD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear , It was a pleasure to care for you at the [MASKED] [MASKED]. Why did you come to the hospital? - You came to the hospital because you had pain with urination and lab work that indicated there was an injury to your kidney. What did you receive in the hospital? - You received intravenous fluids and your diuretics were held which led to improvement in your kidney function. - You received antibiotics for your urinary tract infection. What should you do once you leave the hospital? - Complete your antibiotic course for your urinary tract infection. - Continue to spend time with your warm and wonderful family. We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "N390", "N179", "I5032", "D649", "G4700", "Z66", "Z794", "E669" ]
[ "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "C3401: Malignant neoplasm of right main bronchus", "C7931: Secondary malignant neoplasm of brain", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5032: Chronic diastolic (congestive) heart failure", "N186: End stage renal disease", "Z940: Kidney transplant status", "I313: Pericardial effusion (noninflammatory)", "Z993: Dependence on wheelchair", "E1065: Type 1 diabetes mellitus with hyperglycemia", "R441: Visual hallucinations", "H318: Other specified disorders of choroid", "D649: Anemia, unspecified", "G4700: Insomnia, unspecified", "Z23: Encounter for immunization", "Z66: Do not resuscitate", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "H409: Unspecified glaucoma" ]
10,075,925
21,574,077
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with h/o HTN, HFpEF, DM2, s/p Living donor renal transplant ___, who presented with one week of worsening dyspnea and leg edema, found to be hypoxemic to 70% on RA in ED. Patient notes she was caring for her father who also has a bronchitis or PNA. She has been progressively dyspneic with rest and ambulation. She denies orthopnea, however does endorse PND. Endorses weight gain and leg edema and abdominal bloating. Per our records she has gained 24lbs since ___. She has only been taking 10mg Lasix at home and reportedly her nephrologist asked her to increase, but patient was worried it would hurt her kidneys so she did not increase. Denies chest pain/pressure, palpitations, syncope, presyncope, sputum production, fevers, chills, sweats. Denies n/v, abdominal pain. Denies recent surgery or immobilization, or hemoptysis. In ED initial VS: ___ 70 122/54 20 70% RA Labs significant for: whole K 7.4, Cr 1.3 (baseline ___, Normal WBC. Lactate 3.3 Patient was given: Vanc/Cefepime. Dextrose, insulin, calcium gluconate. NO FLUIDS. Imaging notable for: CXR with known cardiomegaly and diffuse interstitial edema with right pleural effusion. Difficult to r/o focal infiltrate. Consults: Nephrology transplant VS prior to transfer: ___ 80 133/79 20 95% 5L NC On arrival to the MICU, patient notes her breathing is somewhat better. However still dyspneic, especially with activity. Denies chest pain, palpitations, pre-syncope. REVIEW OF SYSTEMS: Otherwise negative review. Past Medical History: HTN HFpEF DM2 Living donor renal transplant from her husband (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION EXAM GENERAL: Alert, oriented, in NAD. Pleasant. Obese. Cushingoid features. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: JVD elevated to earlobe at 90 degrees LUNGS: Bilateral crackles in lower to mid lung fields. No wheezing, rhonchi. CV: Tachycardic, Regular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Obese, soft, non-tender, bowel sounds present, no rebound tenderness or guarding EXT: WARM, WELL perfused in upper and lower extremities. 1+ pitting edema bilaterally. Some edema in arms. SKIN: No rashes. Bronze skin. NEURO: AAx0x3. Moves all extremities with purpose. DISCHARGE EXAM ___ 1132 Temp: 98.0 PO BP: 117/75 HR: 80 RR: 18 O2 sat: 100% O2 delivery: neb FSBG: 205 GENERAL: Comfortable, in NAD HEENT: NC/AT, PERRLA, EOMI NECK: Supple, no lymphadenopathy, unable to assess JVD given neck pannus CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNGS: Decreased breath sounds throughout. No wheezes, rales, rhonchi ABDOMEN: Soft, NT/ND. Normoactive bowel sounds. No evidence of organomegaly EXTREMITIES: No lower extremity edema. NEUROLOGIC: CN II-XII intact. No focal neurological deficits SKIN: No obvious skin rashes, ulceration, or skin breakdown. Pertinent Results: ADMISSION LABS ___ 05:50PM BLOOD WBC-9.1 RBC-4.70 Hgb-14.0 Hct-46.0* MCV-98 MCH-29.8 MCHC-30.4* RDW-20.1* RDWSD-69.6* Plt ___ ___ 05:50PM BLOOD ___ PTT-28.7 ___ ___ 05:50PM BLOOD Glucose-197* UreaN-42* Creat-1.3* Na-133* K->10.0* Cl-93* HCO3-25 AnGap-15 ___ 07:52PM BLOOD proBNP-708* ___ 12:05AM BLOOD CK-MB-9 cTropnT-0.03* ___ 05:50PM BLOOD Calcium-9.4 Phos-5.6* ___ 05:59PM BLOOD ___ pO2-87 pCO2-55* pH-7.30* calTCO2-28 Base XS-0 ___ 05:59PM BLOOD Lactate-3.3* K-7.4* INTERVAL LABS ___ 12:05AM BLOOD ALT-24 AST-16 CK(CPK)-191 AlkPhos-80 TotBili-0.6 ___ 02:56AM BLOOD %HbA1c-6.4* eAG-137* ___ 12:17AM BLOOD ___ pO2-48* pCO2-55* pH-7.30* calTCO2-28 Base XS-0 ___ 04:02PM BLOOD ___ pO2-47* pCO2-75* pH-7.31* calTCO2-40* Base XS-7 ___ 04:02PM BLOOD Glucose-302* Lactate-2.0 K-4.6 DISCHARGE LABS ___ 06:26AM BLOOD WBC-7.9 RBC-4.96 Hgb-14.6 Hct-47.2* MCV-95 MCH-29.4 MCHC-30.9* RDW-17.4* RDWSD-59.9* Plt ___ ___ 06:26AM BLOOD Glucose-235* UreaN-35* Creat-1.1 Na-137 K-4.5 Cl-90* HCO3-29 AnGap-18 ___ 06:26AM BLOOD Calcium-10.5* Phos-3.7 Mg-2.0 ___ 06:26AM BLOOD PTH-PND ___ 03:05AM BLOOD 25VitD-PND ___ 06:26AM BLOOD tacroFK-6.7 MICROBIOLOGY Blood Culture, Routine (Final ___: NO GROWTH. URINE CULTURE (Final ___: NO GROWTH. IMAGING CHEST X-RAY ___: Severe cardiomegaly with vascular congestion and moderate interstitial edema and a trace right-sided effusion. Superimposed infection would be difficult to exclude in the appropriate clinical context. TTE ___: Small to moderate pericardial effusion without echocardiographic evidence of tamponade. Mild symmetric left ventricular hypertrophy with preserved biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Compared with the prior study (images reviewed) of ___, the size of the pericardial effusion is likely similar (suboptimal apical images on the prior study preclude definitive comparison). CXR ___: Cardiac silhouette is enlarged. There is again seen diffuse interstitial opacities bilaterally. There is worsening of opacities at the right base. Again, findings can be seen with pulmonary edema; however, given the diuresis, infection should also be considered. CXR ___: Mild to moderate pulmonary edema has improved since ___, particularly at the base of the right lung. Small pleural effusions, moderate cardiomegaly and dilatation of the pulmonary arteries have improved as well. No pneumothorax. Indentation of the trachea from the left at the thoracic inlet is long-standing, usually due to an enlarged thyroid. Clinical evaluation recommended. Brief Hospital Course: Ms. ___ is a ___ female with history of hypertension, HFpEF, DM2, ESRD ___ DM s/p LURT (___) maintained on cellcept and tacrolimus, who presented with dyspnea, lower extremity edema and weight gain, found to be hypoxemic on admission with O2 70% on RA in the ED, admitted for acute on chronic HFpEF exacerbation to the ICU, requiring BiPAP, diuresed with IV Lasix, subsequently weaned to room air and transitioned to PO Lasix 30mg daily, likely with central and obstructive sleep apnea. # Mixed Hypoxemic Respiratory Failure # Acute on chronic HFpEF - Patient initially presented with a one-week history of worsening dyspnea on exertion and at rest, also with 20 pound weight gain since ___ and worsening abdominal distention, on admission was hypoxic to 70%, with BNP 700. CXR showed pulmonary edema, requiring ICU admission for BiPAP. She initially received vancomycin and cefepime to cover possible PNA, continued on ceftriaxone and azithromycin in the ICU, however antibiotics were subsequently discontinued given the low suspicion for pneumonia. She was diuresed with IV lasix 80mg boluses, subsequently transitioned to PO Lasix 30 mg daily, increased from her home dose 10 mg. Trigger for acute on chronic HFpEF exacerbation was unclear, given no obvious underlying infection, troponin 0.03 on admission with flat CK-MB within her baseline the setting of ESRD status post LURT. Reported adherence to home PO Lasix, possibly dietary discretion. Discharge weight 91.2 kg, 201.06 lbs. # Apnea # Acute on chronic respiratory acidosis - Of note, with chronic respiratory acidosis and observed to have apneic episodes overnight with desaturations to the ___. She likely has underlying obstructive sleep apnea and probable central apnea. When awakened, she recovers her tidal volume and oxygenation. Her CO2 improved with high settings on the Trilogy mask. She had intermittent apnea episodes while sleeping, but easily recovers. She was counseled on the need for sleep medicine followup and consideration of different options for her apnea, given that she would like to avoid CPAP. On the floor, she was weaned to room air. With ambulation she maintained O2 sats of 90-96%. # ESRD s/p LURT - History of ESRD ___ DM s/p LURT (___). She was continued on home cellcept 500mg BID and tacrolimus 1.5mg BID with goal trough ___. # HTN - Was continued on home amlodipine 10mg daily, home valsartan 160 mg PO BID, home labetalol 300 BID, and home chlorthalidone 25mg. Furosemide was increased from 10 mg daily to 30 mg daily. # DM2 - Home glargine was increased from 30 units to 34 units given hyperglycemia. # CAD primary prevention - Continued home Aspirin 81 mg PO DAILY and atorvastatin 20 mg PO QPM # UTI prophylaxis - Continued home macrobid ___ daily TRANSITIONAL ISSUES [ ] New/Changed Medications: - Lasix increased from 10 to 30 mg daily - Glargine increased from 30 units to 34 units [ ] Discharge diuretic: 30 mg furosemide daily [ ] Discharge weight: Discharge weight 91.2 kg, 201.06 lbs. [ ] Please ensure that patient goes to outpatient pulmonary appointment that has been scheduled. [ ] Please check CHEM 10 at hospital discharge follow up appointment. Please monitor weight and volume status at outpatient follow up. Please titrate furosemide as needed. [ ] Calcium was slightly elevated upon discharge. Please follow up PTH and Vitamin D level, which are pending at discharge. [ ] Please ensure follow up with outpatient endocrinologist. We have emailed to assist with follow up appointment. # CODE: Full, CONFIRMED # CONTACT: ___ (Husband/HCP): ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Chlorthalidone 25 mg PO DAILY 5. Labetalol 300 mg PO BID 6. Mycophenolate Mofetil 500 mg PO BID 7. Tacrolimus 1.5 mg PO Q12H 8. Valsartan 160 mg PO BID 9. Furosemide 10 mg PO DAILY 10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 11. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 13. Docusate Sodium 100 mg PO BID 14. Fish Oil (Omega 3) 1000 mg PO DAILY 15. Vitamin D 1400 UNIT PO DAILY Discharge Medications: 1. Furosemide 30 mg PO DAILY RX *furosemide 20 mg 1.5 tablet(s) by mouth daily Disp #*45 Tablet Refills:*0 2. Glargine 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Chlorthalidone 25 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Labetalol 300 mg PO BID 11. Mycophenolate Mofetil 500 mg PO BID 12. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 13. Tacrolimus 1.5 mg PO Q12H 14. Valsartan 160 mg PO BID 15. Vitamin D 1400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS - Acute on Chronic HFpEF - Apnea - Acute on chronic respiratory acidosis SECONDARY DIAGNOSIS - ESRD s/p LURT - HTN - DM - Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. Why did you come to the hospital? - You initially came to the hospital because of difficulty breathing What happened during your hospitalization? - You were initially admitted to the ICU for assistance breathing with a BIPAP mask - You received medications through your IV to help from extra fluid from your lungs - Your oxygen levels decreased at night and you also had low oxygen levels during the day WHEN YOU GO HOME: - Your medications and follow up appointmets are below. - You will need a sleep study and we have scheduled you to see a pulmonologist. - Weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. -Please make sure to make your appointment at Healthcare Associates on ___ at 2:55 pm. It was a pleasure taking care of you. -Your ___ Team Followup Instructions: ___
[ "I130", "I5033", "J9621", "J9622", "Z940", "E872", "J9811", "E669", "E1122", "G4733", "I2510", "E1165", "E785", "N189", "Z87891", "E875", "D649", "Z794", "H409" ]
Allergies: Lisinopril Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] yo F with h/o HTN, HFpEF, DM2, s/p Living donor renal transplant [MASKED], who presented with one week of worsening dyspnea and leg edema, found to be hypoxemic to 70% on RA in ED. Patient notes she was caring for her father who also has a bronchitis or PNA. She has been progressively dyspneic with rest and ambulation. She denies orthopnea, however does endorse PND. Endorses weight gain and leg edema and abdominal bloating. Per our records she has gained 24lbs since [MASKED]. She has only been taking 10mg Lasix at home and reportedly her nephrologist asked her to increase, but patient was worried it would hurt her kidneys so she did not increase. Denies chest pain/pressure, palpitations, syncope, presyncope, sputum production, fevers, chills, sweats. Denies n/v, abdominal pain. Denies recent surgery or immobilization, or hemoptysis. In ED initial VS: [MASKED] 70 122/54 20 70% RA Labs significant for: whole K 7.4, Cr 1.3 (baseline [MASKED], Normal WBC. Lactate 3.3 Patient was given: Vanc/Cefepime. Dextrose, insulin, calcium gluconate. NO FLUIDS. Imaging notable for: CXR with known cardiomegaly and diffuse interstitial edema with right pleural effusion. Difficult to r/o focal infiltrate. Consults: Nephrology transplant VS prior to transfer: [MASKED] 80 133/79 20 95% 5L NC On arrival to the MICU, patient notes her breathing is somewhat better. However still dyspneic, especially with activity. Denies chest pain, palpitations, pre-syncope. REVIEW OF SYSTEMS: Otherwise negative review. Past Medical History: HTN HFpEF DM2 Living donor renal transplant from her husband ([MASKED]) Social History: [MASKED] Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION EXAM GENERAL: Alert, oriented, in NAD. Pleasant. Obese. Cushingoid features. HEENT: Sclera anicteric, MMM, oropharynx clear NECK: JVD elevated to earlobe at 90 degrees LUNGS: Bilateral crackles in lower to mid lung fields. No wheezing, rhonchi. CV: Tachycardic, Regular rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Obese, soft, non-tender, bowel sounds present, no rebound tenderness or guarding EXT: WARM, WELL perfused in upper and lower extremities. 1+ pitting edema bilaterally. Some edema in arms. SKIN: No rashes. Bronze skin. NEURO: AAx0x3. Moves all extremities with purpose. DISCHARGE EXAM [MASKED] 1132 Temp: 98.0 PO BP: 117/75 HR: 80 RR: 18 O2 sat: 100% O2 delivery: neb FSBG: 205 GENERAL: Comfortable, in NAD HEENT: NC/AT, PERRLA, EOMI NECK: Supple, no lymphadenopathy, unable to assess JVD given neck pannus CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops LUNGS: Decreased breath sounds throughout. No wheezes, rales, rhonchi ABDOMEN: Soft, NT/ND. Normoactive bowel sounds. No evidence of organomegaly EXTREMITIES: No lower extremity edema. NEUROLOGIC: CN II-XII intact. No focal neurological deficits SKIN: No obvious skin rashes, ulceration, or skin breakdown. Pertinent Results: ADMISSION LABS [MASKED] 05:50PM BLOOD WBC-9.1 RBC-4.70 Hgb-14.0 Hct-46.0* MCV-98 MCH-29.8 MCHC-30.4* RDW-20.1* RDWSD-69.6* Plt [MASKED] [MASKED] 05:50PM BLOOD [MASKED] PTT-28.7 [MASKED] [MASKED] 05:50PM BLOOD Glucose-197* UreaN-42* Creat-1.3* Na-133* K->10.0* Cl-93* HCO3-25 AnGap-15 [MASKED] 07:52PM BLOOD proBNP-708* [MASKED] 12:05AM BLOOD CK-MB-9 cTropnT-0.03* [MASKED] 05:50PM BLOOD Calcium-9.4 Phos-5.6* [MASKED] 05:59PM BLOOD [MASKED] pO2-87 pCO2-55* pH-7.30* calTCO2-28 Base XS-0 [MASKED] 05:59PM BLOOD Lactate-3.3* K-7.4* INTERVAL LABS [MASKED] 12:05AM BLOOD ALT-24 AST-16 CK(CPK)-191 AlkPhos-80 TotBili-0.6 [MASKED] 02:56AM BLOOD %HbA1c-6.4* eAG-137* [MASKED] 12:17AM BLOOD [MASKED] pO2-48* pCO2-55* pH-7.30* calTCO2-28 Base XS-0 [MASKED] 04:02PM BLOOD [MASKED] pO2-47* pCO2-75* pH-7.31* calTCO2-40* Base XS-7 [MASKED] 04:02PM BLOOD Glucose-302* Lactate-2.0 K-4.6 DISCHARGE LABS [MASKED] 06:26AM BLOOD WBC-7.9 RBC-4.96 Hgb-14.6 Hct-47.2* MCV-95 MCH-29.4 MCHC-30.9* RDW-17.4* RDWSD-59.9* Plt [MASKED] [MASKED] 06:26AM BLOOD Glucose-235* UreaN-35* Creat-1.1 Na-137 K-4.5 Cl-90* HCO3-29 AnGap-18 [MASKED] 06:26AM BLOOD Calcium-10.5* Phos-3.7 Mg-2.0 [MASKED] 06:26AM BLOOD PTH-PND [MASKED] 03:05AM BLOOD 25VitD-PND [MASKED] 06:26AM BLOOD tacroFK-6.7 MICROBIOLOGY Blood Culture, Routine (Final [MASKED]: NO GROWTH. URINE CULTURE (Final [MASKED]: NO GROWTH. IMAGING CHEST X-RAY [MASKED]: Severe cardiomegaly with vascular congestion and moderate interstitial edema and a trace right-sided effusion. Superimposed infection would be difficult to exclude in the appropriate clinical context. TTE [MASKED]: Small to moderate pericardial effusion without echocardiographic evidence of tamponade. Mild symmetric left ventricular hypertrophy with preserved biventricular systolic function. No clinically significant valvular regurgitation or stenosis. Compared with the prior study (images reviewed) of [MASKED], the size of the pericardial effusion is likely similar (suboptimal apical images on the prior study preclude definitive comparison). CXR [MASKED]: Cardiac silhouette is enlarged. There is again seen diffuse interstitial opacities bilaterally. There is worsening of opacities at the right base. Again, findings can be seen with pulmonary edema; however, given the diuresis, infection should also be considered. CXR [MASKED]: Mild to moderate pulmonary edema has improved since [MASKED], particularly at the base of the right lung. Small pleural effusions, moderate cardiomegaly and dilatation of the pulmonary arteries have improved as well. No pneumothorax. Indentation of the trachea from the left at the thoracic inlet is long-standing, usually due to an enlarged thyroid. Clinical evaluation recommended. Brief Hospital Course: Ms. [MASKED] is a [MASKED] female with history of hypertension, HFpEF, DM2, ESRD [MASKED] DM s/p LURT ([MASKED]) maintained on cellcept and tacrolimus, who presented with dyspnea, lower extremity edema and weight gain, found to be hypoxemic on admission with O2 70% on RA in the ED, admitted for acute on chronic HFpEF exacerbation to the ICU, requiring BiPAP, diuresed with IV Lasix, subsequently weaned to room air and transitioned to PO Lasix 30mg daily, likely with central and obstructive sleep apnea. # Mixed Hypoxemic Respiratory Failure # Acute on chronic HFpEF - Patient initially presented with a one-week history of worsening dyspnea on exertion and at rest, also with 20 pound weight gain since [MASKED] and worsening abdominal distention, on admission was hypoxic to 70%, with BNP 700. CXR showed pulmonary edema, requiring ICU admission for BiPAP. She initially received vancomycin and cefepime to cover possible PNA, continued on ceftriaxone and azithromycin in the ICU, however antibiotics were subsequently discontinued given the low suspicion for pneumonia. She was diuresed with IV lasix 80mg boluses, subsequently transitioned to PO Lasix 30 mg daily, increased from her home dose 10 mg. Trigger for acute on chronic HFpEF exacerbation was unclear, given no obvious underlying infection, troponin 0.03 on admission with flat CK-MB within her baseline the setting of ESRD status post LURT. Reported adherence to home PO Lasix, possibly dietary discretion. Discharge weight 91.2 kg, 201.06 lbs. # Apnea # Acute on chronic respiratory acidosis - Of note, with chronic respiratory acidosis and observed to have apneic episodes overnight with desaturations to the [MASKED]. She likely has underlying obstructive sleep apnea and probable central apnea. When awakened, she recovers her tidal volume and oxygenation. Her CO2 improved with high settings on the Trilogy mask. She had intermittent apnea episodes while sleeping, but easily recovers. She was counseled on the need for sleep medicine followup and consideration of different options for her apnea, given that she would like to avoid CPAP. On the floor, she was weaned to room air. With ambulation she maintained O2 sats of 90-96%. # ESRD s/p LURT - History of ESRD [MASKED] DM s/p LURT ([MASKED]). She was continued on home cellcept 500mg BID and tacrolimus 1.5mg BID with goal trough [MASKED]. # HTN - Was continued on home amlodipine 10mg daily, home valsartan 160 mg PO BID, home labetalol 300 BID, and home chlorthalidone 25mg. Furosemide was increased from 10 mg daily to 30 mg daily. # DM2 - Home glargine was increased from 30 units to 34 units given hyperglycemia. # CAD primary prevention - Continued home Aspirin 81 mg PO DAILY and atorvastatin 20 mg PO QPM # UTI prophylaxis - Continued home macrobid [MASKED] daily TRANSITIONAL ISSUES [ ] New/Changed Medications: - Lasix increased from 10 to 30 mg daily - Glargine increased from 30 units to 34 units [ ] Discharge diuretic: 30 mg furosemide daily [ ] Discharge weight: Discharge weight 91.2 kg, 201.06 lbs. [ ] Please ensure that patient goes to outpatient pulmonary appointment that has been scheduled. [ ] Please check CHEM 10 at hospital discharge follow up appointment. Please monitor weight and volume status at outpatient follow up. Please titrate furosemide as needed. [ ] Calcium was slightly elevated upon discharge. Please follow up PTH and Vitamin D level, which are pending at discharge. [ ] Please ensure follow up with outpatient endocrinologist. We have emailed to assist with follow up appointment. # CODE: Full, CONFIRMED # CONTACT: [MASKED] (Husband/HCP): [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Chlorthalidone 25 mg PO DAILY 5. Labetalol 300 mg PO BID 6. Mycophenolate Mofetil 500 mg PO BID 7. Tacrolimus 1.5 mg PO Q12H 8. Valsartan 160 mg PO BID 9. Furosemide 10 mg PO DAILY 10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 11. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 13. Docusate Sodium 100 mg PO BID 14. Fish Oil (Omega 3) 1000 mg PO DAILY 15. Vitamin D 1400 UNIT PO DAILY Discharge Medications: 1. Furosemide 30 mg PO DAILY RX *furosemide 20 mg 1.5 tablet(s) by mouth daily Disp #*45 Tablet Refills:*0 2. Glargine 34 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Chlorthalidone 25 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. Fish Oil (Omega 3) 1000 mg PO DAILY 10. Labetalol 300 mg PO BID 11. Mycophenolate Mofetil 500 mg PO BID 12. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 13. Tacrolimus 1.5 mg PO Q12H 14. Valsartan 160 mg PO BID 15. Vitamin D 1400 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS - Acute on Chronic HFpEF - Apnea - Acute on chronic respiratory acidosis SECONDARY DIAGNOSIS - ESRD s/p LURT - HTN - DM - Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. Why did you come to the hospital? - You initially came to the hospital because of difficulty breathing What happened during your hospitalization? - You were initially admitted to the ICU for assistance breathing with a BIPAP mask - You received medications through your IV to help from extra fluid from your lungs - Your oxygen levels decreased at night and you also had low oxygen levels during the day WHEN YOU GO HOME: - Your medications and follow up appointmets are below. - You will need a sleep study and we have scheduled you to see a pulmonologist. - Weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. -Please make sure to make your appointment at Healthcare Associates on [MASKED] at 2:55 pm. It was a pleasure taking care of you. -Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "I130", "E872", "E669", "E1122", "G4733", "I2510", "E1165", "E785", "N189", "Z87891", "D649", "Z794" ]
[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "J9621: Acute and chronic respiratory failure with hypoxia", "J9622: Acute and chronic respiratory failure with hypercapnia", "Z940: Kidney transplant status", "E872: Acidosis", "J9811: Atelectasis", "E669: Obesity, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E785: Hyperlipidemia, unspecified", "N189: Chronic kidney disease, unspecified", "Z87891: Personal history of nicotine dependence", "E875: Hyperkalemia", "D649: Anemia, unspecified", "Z794: Long term (current) use of insulin", "H409: Unspecified glaucoma" ]
10,075,925
23,788,833
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / Iodinated Contrast- Oral and IV Dye Attending: ___. Chief Complaint: Shortness of Breath and fatigue Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD) - ___ Colonoscopy - ___ Bronchoscopy with transbronchial biopsy - ___ Right chest tube ___ TPC Placement ___ History of Present Illness: Mrs. ___ is a ___ year-old lady with end stsge renal disease secondary to type one diabetes mellitus status post living donor renal transplant in ___ (donor: husband; maintained on MMF and tacrolimus), HFpEF, chronic pericardial effusion (___), hypertension, who presents on ___ to the hospital with one week history of lethargy, drowsiness, orthopnea and increasing shortness of breath. The patient has 3 recent hospital admission due to heart failure exacerbations. During last hospital admission (discharged ___, she was intubated for respiratory distress and diuresed with IV Lasix, and discharged on torsemide 40 mg. The patient also had urosepsis with Klebsellia and GNR. She was discharged on ciprofloxacin for 14 days, last dose was ___. On admission, patient was found to have acute kidney injury (___) (Cr of 2.8 up from 1.6 on ___. She was also found to have anemia with hemoglobin drop from 11.5 on ___ to 8.0 on ___. Past Medical History: Hypertension Heart failure with preserved ejection fraction (HFpEF) Type 1 diabetes mellitus End stage renal disease (ESRD) Living donor renal transplant from her husband (___) Pericardial effusion (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ============================ ADMISSION PHYSICAL EXAMINATION ============================ 24 HR Data (last updated ___ @ 1720) Temp: 98.0 (Tm 98.5), BP: 122/77 (100-122/66-77), HR: 83, RR: 18 (___), O2 sat: 97% (85-97), O2 delivery: 1LNC, Wt: 191.58 lb/86.9 kg General: Alert, oriented, looks tired and dyspneic at times. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar crepitations - Good air entry bilaterally Abdomen: Soft, Bruises at heparin injection sites, obese, bowel sounds present, no organomegaly, no rebound or guarding Ext: No lower limbs edema; feet has what appears like fungal infection Neuro: grossly intact. Tremor noticed ============================ DISCHARGE PHYSICAL EXAMINATION ============================ VITALS: 24 HR Data (last updated ___ @ 1214) Temp: 98.5 (Tm 99.9), BP: 149/93 (114-155/64-93), HR: 85 (85-89), RR: 18 (___), O2 sat: 96% (91-100), O2 delivery: 2,5L (2l-3l), Wt: 164.8 lb/74.75 kg GEN: Patient is lying down in bed on her right side with CPAP off. She is very withdrawn and barely responds to questions. HEENT: PERRLA CARDIAC: RRR, no audible murmurs. LUNGS: Diminished breath sounds bilaterally L>R ABDOMEN: softly distended EXTREMITIES: trace edema BLE GEN: Patient is lying down in bed on her right side with CPAP off. She is very withdrawn and barely responds to questions. HEENT: PERRLA CARDIAC: RRR, no audible murmurs. LUNGS: Diminished breath sounds bilaterally L>R ABDOMEN: softly distended EXTREMITIES: trace edema BLE Pertinent Results: ADMISSION LABS: ================ ___ 09:33AM BLOOD WBC-13.8* RBC-2.77* Hgb-8.0* Hct-25.5* MCV-92 MCH-28.9 MCHC-31.4* RDW-17.6* RDWSD-58.2* Plt ___ ___ 07:40PM BLOOD ___ PTT-22.7* ___ ___ 05:06PM BLOOD ___ ___ 05:06PM BLOOD Ret Aut-5.6* Abs Ret-0.17* ___ 09:33AM BLOOD Glucose-247* UreaN-184* Creat-2.8*# Na-127* K-6.6* Cl-77* HCO3-29 AnGap-21* ___ 07:40PM BLOOD ALT-11 AST-11 LD(LDH)-196 AlkPhos-54 TotBili-0.4 ___ 09:33AM BLOOD cTropnT-0.08* proBNP-1603* ___ 09:33AM BLOOD Calcium-10.1 Phos-4.7* Mg-1.7 ___ 09:33AM BLOOD Hapto-181 ___ 07:10AM BLOOD tacroFK-6.8 ___ 09:47AM BLOOD ___ pO2-33* pCO2-57* pH-7.43 calTCO2-39* Base XS-10 ___ 02:36AM BLOOD Lactate-1.0 DISCHARGE LABS =============== ___ 07:19AM BLOOD WBC-13.2* RBC-3.19* Hgb-8.1* Hct-28.0* MCV-88 MCH-25.4* MCHC-28.9* RDW-17.5* RDWSD-56.6* Plt ___ ___ 07:19AM BLOOD Plt ___ ___ 07:19AM BLOOD Glucose-58* UreaN-47* Creat-1.2* Na-141 K-4.1 Cl-91* HCO3-37* AnGap-13 ___ 07:19AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.8 ___ 07:19AM BLOOD tacroFK-4.9* IMAGING: ======== -RENAL TRANSPLANT U/S - ___ Normal appearing transplant kidney with unchanged slight increase in the resistance index at the interpolar region. -Transthoracic Echocardiography (TTE) - ___ Moderate to large, predominantly lateral pericardial effusion with evidence of possible early tamponade physiology. Very little fluid anterior to the right ventricle or apex. Clinical correlation and continued serial scans are suggested. -Transthoracic Echocardiography (TTE) - ___ Large circumferential serous pericardial effusion with echocardiographic signs of low pressure tamponade. Compared to prior, findings are similar. -CT ABDOMEN & PELVIS W/O CONTRAST - ___ 1. No evidence of acute trauma identified on this noncontrast CT of the abdomen and pelvis. Specifically, no fracture or significant hematoma identified. 2. 8.3 cm indeterminate mass arising from the native left kidney. Differential includes hyperdense cyst, oncocytoma, and renal cell carcinoma. Recommend further evaluation with dedicated renal CT or MRI depending on patient's renal function. 3. Cholelithiasis without CT evidence of cholecystitis. 4. Stable right adnexal/pelvic mass presumably representing an exophytic fibroid. 5. Additional chronic changes as detailed above. -CT CHEST W/O CONTAST - ___ Right suprahilar masslike consolidation with occlusion of the right upper lobe bronchus. Although this could represent bronchopneumonia in the setting of mucous plugging appearance raises suspicion for primary lung malignancy. There is nodular airspace disease noted distally within the right upper lobe suggestive of a postobstructive pneumonia/pneumonitis. Recommend pulmonology consultation and bronchoscopic correlation. Mediastinal and probable right hilar lymphadenopathy as detailed above could be reactive to infectious/inflammatory process or could represent metastatic disease. Redemonstration of known moderate to large pericardial effusion, small right pleural effusion, and trace left pleural effusion. -CT CHEST W/O CONTAST - ___ Again noted is a right central right upper lobe mass with postobstructive pneumopathy. Degree of postobstructive atelectasis of the anterior segment of the right upper lobe appears increased since the prior chest CT. Extensive mediastinal lymphadenopathy as well as right supraclavicular lymphadenopathy are unchanged. Interval placement of a chest tube with interval decrease in size of the previously noted right pleural effusion and right base atelectasis. There is extensive peribronchial nodular opacities involving all lobes, but most marked in the right lower lobe which is new/increased compared to prior and is concerning for aspiration or broncho pneumonia. Substantial increase in extent of left lower lobe atelectasis, now mostly collapsed. Unchanged large pericardial effusion. Interstitial septal thickening in the lung apices and bases suggest interstitial pulmonary edema. Partly imaged hyperdense lesion along the left kidney. Dedicated CT or MR may be helpful to evaluate further although ultraound may prove useful as a possible way of demonstrating and characterizing a complex cyst, which is more likely than a solid mass. Esophagogastroduodenoscopy (EGD) ___ Normal esophageal mucosa. Erythema in the antrum compatible with gastritis. Large, 1cm deep cratered ulcer in the duodenal bulb with surrounding hyperemia and edema. The base of the ulcer was clean. No visible vessel or active bleeding. The second part of the duodenum there was small erosions and two more small clean-based ulcers. COLONOSCOPY ___: Mucosa not visualized adequately due to high residual material. Otherwise, normal mucosa in the colon. CXR ___: New pleural effusions, mild to moderate pulmonary edema and increasing right basilar parenchymal opacification probably due to atelectasis. Although partly obscured, likely persistent atelectasis of the anterior segment of the right upper lobe including possibility of a malignancy. CT HEAD W/ CONTRAST ___: FINDINGS: There is no evidence of large territorial infarction, hemorrhage, edema, or mass. The ventricles and sulci are age-appropriate. Mild calcified atherosclerotic disease is demonstrated at the bilateral carotid siphons. There is no intracranial abnormal enhancement on post contrast images. There is interval increased osseous erosion of the left sphenoid (series 2, image 9 and 10) with soft tissue density, extending into the left sphenoid sinus (series 603, image 37). Erosion through the floor of the left middle cranial fossa (series 603, image 39) is identified, with dural thickening. No definite involvement of the adjacent temporal lobe. The lesion erodes through the medial aspect of the left foramen ovale and inferior aspect of the left foramen rotundum (series 603, image 37 and 41). The visualized portions of the maxillary sinuses, ethmoid air cells and frontal sinuses are essentially clear. Hyperdensity along the posterior aspect of the left globe is compatible with choroidal effusion or scleral detachment. Left lens replacement identified. The right orbit is grossly unremarkable. Mastoid air cells middle ears arm ties and clear. IMPRESSION: 1. No evidence of intracranial metastatic disease within confines of contrast enhanced CT examination at this time. 2. Soft tissue lesion centered in the left sphenoid wing with interval osseous erosion, extending into the left sphenoid sinus is new from prior examination of ___. This is worrisome for osseous metastatic disease. There is erosion through the floor of the left middle cranial fossa, with associated dural thickening. No definite involvement of the brain parenchyma, however examination is not optimized for such evaluation. 3. Additional findings described above. CTA CHEST - ___: ================= FINDINGS: CHEST: PULMONARY ARTERIES: The study is of slightly suboptimal technical quality for evaluation of acute PE (density in the main PA 189 ___ units). Infiltrative tumor around the right hilum is causing significant narrowing of the right upper lobe artery but there is a thin column of flow present. There is also focal narrowing of the right middle lobe artery but flow is seen distally. There is no significant narrowing of the right lower lobe artery. No filling defects concerning for pulmonary emboli are demonstrated within the limits of the study. The pulmonary trunk is dilated at 3.6 cm, suggesting pulmonary hypertension. HEART AND VASCULATURE: There is a large pericardial effusion. The left atrium is dilated. Multivessel coronary calcifications are present. The thoracic aorta is within normal limits of caliber. AXILLA, HILA, AND MEDIASTINUM: There is a large amount of infiltrative enhancing soft tissue around the right hilum, surrounding the hilar bronchovascular structures. This is contiguous with the right upper lobe lung mass and associated atelectasis/consolidation. There is patency of the major right upper lobe bronchial structures but narrowing of pulmonary arteries as noted above, as well as branches of the superior pulmonary veins. There may be invasion of the main and lobar prominently arteries. There is extensive bilateral mediastinal adenopathy consisting of irregular, heterogeneously enhancing nodes in keeping with metastases. Individual nodes are difficult to measure but 1 nodal mass is 2.2 cm in the right paratracheal region. There are also multiple small bilateral abnormal supraclavicular nodes measuring slightly greater than 1 cm on the right. There is no axillary adenopathy. The thyroid is diffusely heterogeneous and there are multifocal calcifications in the bulky left lobe. This is likely related to goiter. PLEURAL SPACES: There is a small left pleural effusion and a small to moderate right pleural effusion. A pleural drain is present on the right. LUNGS/AIRWAYS: Right upper lobe mass as noted above. There are multiple spiculated nodular opacities throughout the right upper lobe, mostly in the subcentimeter range. There are also a few in the right middle and lower lobes. Interlobular septal thickening in the right upper and lower lobes appears slightly nodular in some areas, raising the possibility of lymphangitic carcinomatosis, versus lymphovascular congestion due to hilar masses. There is nodular thickening of the bilateral major fissures and there is mild left-sided pleural nodularity, in keeping with metastases. There is abnormal tissue tracking in the right lower lobe along the bronchovascular structures, also in keeping with tumor spread. ABDOMEN AND PELVIS: HEPATOBILIARY: There multiple ill-defined liver hypodensities measuring less than 2 cm, in keeping with metastases. The largest lesions in the right lobe are in segments 6 and 7 measuring 1.7 cm, and the largest in the left lobe is in segment ___ measuring 1.6 cm. There is no biliary dilation. The gallbladder contains small stones without wall thickening or surrounding inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout without evidence of focal lesion. ADRENALS: Both adrenal glands are diffusely bulky and mildly nodular, likely related to hyperplasia as opposed to metastases. URINARY: Both native kidneys are severely atrophic. There is an 8.5 cm simple cyst arising from the lower pole of the left kidney. There is a transplant kidney in the right iliac fossa. This contains a few subcentimeter cortical hypodensities, likely benign cysts. There is no hydronephrosis. The urinary bladder is distended but otherwise unremarkable. GASTROINTESTINAL: The stomach is unremarkable aside from a small hiatal hernia. The small bowel appears within normal limits. There is a large stool load throughout the colon. There is no free fluid or free air in the abdomen or pelvis. REPRODUCTIVE ORGANS: There is a circumscribed 4.9 x 4.0 cm intermediate density right adnexal lesion demonstrating a small focal mural calcifications. This is likely ovarian in nature and is incompletely evaluated on CT, but probably benign. The there is a 1.4 cm left adnexal cystic lesion. The uterus is unremarkable aside from a 1.5 cm intramural fibroid. LYMPH NODES: There is no retroperitoneal, mesenteric, pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Extensive atherosclerotic disease is noted. BONES: There is a nondisplaced, mildly comminuted fracture of the right lateral seventh rib, associated with questionable underlying lucency. This is suspicious for pathologic fracture secondary to metastasis. Sclerotic change in the left T7 transverse process could represent a metastasis. A 2.1 cm sclerotic marginated lucency in the left anterior iliac crest is likely a metastasis. Soft tissues: A small fat containing periumbilical hernia is noted. Subcutaneous soft tissue stranding in the anterior upper abdominal wall is presumably related to contusion or fibrosis. Associated calcifications within this region on the left are nonspecific but probably related to a prior inflammatory process or fat infarct. IMPRESSION: 1. Technically suboptimal study, but no evidence of acute PE. 2. Large right upper lobe mass contiguous with infiltrative right hilar soft tissue compromising pulmonary arterial structures as described, particularly the right upper lobe arteries. Major airways remain patent. 3. Extensive bilateral mediastinal and supraclavicular lymphadenopathy. Multiple intrapulmonary metastases in the right lung, as well as probable lymphangitic carcinomatosis. Bilateral pleural metastases. 4. Small left pleural effusion and small to moderate right pleural effusion with associated passive atelectasis. 5. Large pericardial effusion could be malignant. 6. Multiple liver metastases. 7. Probable left iliac crest metastasis. Two other bone lesions, including 1 associated with a fracture of the right seventh rib are most likely metastatic. PATHOLOGY ========== TRANSBRONCHIAL BIOPSY - ___ LUNG ADENOCARCINOMA. See note. Note: By immunohistochemistry, tumor cells show the following staining profile: - Positive: TTF-1, Napsin. - Negative: p40. Brief Hospital Course: BRIEF HOSPITAL COURSE: ======================= Mrs. ___ is a lovely ___ year-old lady with end stage renal disease secondary to type one diabetes mellitus status post living donor renal transplant in ___ (donor: husband; maintained on MMF and tacrolimus), HFpEF, chronic pericardial effusion (___), who initially was admitted on ___ with pre-renal acute kidney injury. Her hospital course was complicated by hypoxia requiring MICU stay and new diagnosis of stage IV lung adenocarcinoma (NSCLC) with metastases to the bone and liver. ACTIVE ISSUES ============ #Hypoxemic respiratory failure #Bilateral Pleural Effusion #OSA Patient underwent CXR in the setting of hypoxia and was found to have a new right lung opacity. CT chest was then obtained on ___ which demonstrated a mass-like consolidation in RUL for which she had bronchoscopy on ___. Transbronchial biopsy showed adenocarcinoma. On ___, patient was transferred to MICU with worsening shortness of breath and hypoxia. Chest x-rays (___) revealed bilateral pleural effusions with R>L. Subsequently, a right ___ Fr chest tube was placed by interventional pulmonology team on ___ with lymphocytic predominant transudative fluid evacuated and negative cytology. She was initially started on broad spectrum antibiotics for a presumed hospital acquired infection (HAP),; however, these were discontinued on presentation to the unit. While on the floor, she was originally maintained on high flow O2 and face mask, but was able to be weaned down to nasal cannula. At night she was placed on CPAP, which improved hypoxia in the setting of likely OSA. Upon transfer to the floor, patient was satting well on ___ NC, with continued drainage from her chest tube. Chest tube was removed in the setting of decreased output and patient was begun on ceftazadine and flagyl for possible obstructive PNA. Hypoxia was difficult to manage on the floor with patient requiring frequent IV diuresis with only moderate improvement and O2 requirements reaching as high as 8L NC during the day and 15L on CPAP overnight. Repeat CXR on ___ demonstrated recurrence of pulmonary effusion, with interventional pulmonology stating effusion likely malignant due to speed of reaccumulation despite negative cytology. On ___ a R tunneled pleural catheter was placed with high output drainage and improvement in O2 requirements to ___ via NC. Patient was discharged satting in the mid to high 90's on ___ L NC and plan for home sleep study to obtain CPAP machine. Note: ___ between MD and Patient agreeing to Home O2 in the setting of chronic hypoxia with diuresis and pleural drains insufficient to eliminate the need for O2. Pt requires long-term home and portable oxygen therapy to improve hypoxia-related symptoms. #Lung adenocarcinoma - ___ Patient underwent CXR in the setting of hypoxia and was found to have a new right lung opacity. CT chest was then obtained on ___ which demonstrated a mass-like consolidation in RUL for which she had bronchoscopy on ___. Transbronchial biopsy showed adenocarcinoma. Cellcept was stopped and prednisone 5mg was started in anticipation for chemotherapy. Prednisone 5mg was later stopped iso new prednisnone 60 mg for choroidal effusion. Due to patient's prolonged hospitalization and need for staging imaging, we obtained CT head w/ and w/o contrast and CTA C/A/P on ___ which demonstrated heavy disease burden with metastases to the bone and liver, indicating stage IV disease. Genetic testing did not demonstrate a target for immunotherapy. Per oncology, patient treatment options included home with hospice, or chemotherapy and possible radiation. However, patient's poor clinical status portended likely poor outcome. Radiation oncology was consulted who felt that palliative radiation was likely inappropriate as patient did not complain of pain at a particular metastatic site. Additionally, as patient had significant claustrophobia and anxiety, it was thought that the mapping necessary to proceed with radiation therapy would be too challenging to complete. Goals of care conversations were initiated with palliative care, social work, oncology, radiation oncology and primary medical team involved. These conversations took place with patient's husband who then relayed information to patient as patient's anxiety was too great to participate in conversations and preferred that all information be communicated to her husband. Patient and family decided to focus on comfort at this time and indicated that they would go home with ___ and move to hospice when indicated ___ provider also provides hospice). Patient was provided with contact information of primary medical team and palliative care team as well as follow up with medical oncology. #Pericardial Effusion Patient has a chronic pericardial effusion (since ___. TTE performed on ___ demonstrated worsening pericardial effusion, with repeat TTE on ___ similar to prior. In the MICU, cardiology team recommended pericardial window; however, the patient family declined this at the time being. CTA chest on ___ with large pericardial effusion present, possibly increased in size. However, pt was clinically stable. After staging imaging, hematology/oncology discussed possibility of pericardial effusion to prevent complications in the setting of possible plan for chemotherapy. Patient's husband initially expressed interest in learning more about what this procedure would entail, but was concerned about putting patient through more procedures and decided to focus on comfort with patient deferring procedure and moving towards home with ___ services. #New onset bullous choroidal effusion in the left eye: Patient noted decreased vision in left eye for which she was seen by ophtho on ___. ___ evaluation revealed new onset bullous choroidal effusion for which patient was begun on 60 mg prednisone. On reevaluation by optho, patient endorsed some improvement in vision and prednisone taper was planned (see outlined below). Patient was maintained on PPI. Bactrim ppx for PCP was deferred. ___ was contacted during hospitalization to aid in titrating insulin dosing in the setting of steroid administration. Recommendations for altered regimen were provided on the day prior to discharge with plan for patient to continue to monitor blood sugars at home. Per ophthalmology, patient should follow up with outpatient ophthalmologist, Dr. ___, in ___ weeks upon discharge. Prednisone Taper: ___: 40 mg/day ___: 20 mg/day ___: 10 mg/day ___ and on: 5 mg/day # End stage renal disease # Living donor kidney transplant # ___ (resolved) Patient arrived with Cr of 2.8 on ___ up from 1.6 on ___. ___ appeared to be prerenal in the setting of over diuresis and resolved after stopping home torsemide. Cr on discharge is 1.2, with patient taking good PO intake. During this admission, Cellcept was stopped and prednisone 5mg was started in anticipation of starting chemotherapy. Prednisone was increased in the setting of ophthalmology evaluation and findings (see above). Chemotherapy was not pursued as family decided to focus on comfort as noted above. Tacrolimus was continued throughout the hospitalization, with levels adjusted per renal transplant for goal tacrolimus level ___. # Anemia Hgb 8 on admission down from 15. EGD and colonoscopy on ___ showed a 1cm, non-bleeding, deep cratered ulcer in the duodenal bulb. H. Pylori negative. Patient was continued on a PPI, with Hgb remaining stable through rest of hospitalization. #Hyperkalemia: Patient demonstrated intermittent hyperkalemia of unclear etiology despite Lasix administration. Thought possibly related to intermittent constipation with improvement after bowel movements. Will check BMP to be ordered during visit with Dr. ___. #Mood/Depression Patient began to appear quite lethargic, somnolent, and depressed. She also has significant anxiety regarding her own medical care, and did not wish to have any medical information relayed to her; she preferred that all medical information be relayed to her husband. No prior diagnosis of a mood disorder, but may have manifested in setting of new diagnosis and multiple recent hospitalizations. Palliative care evaluated, and did not feel starting medications were appropriate in the acute setting and would continue to monitor going forward. Patient has excellent support network with husband, daughter, father living in her home. She has a large group of friends and a sister who visits her during the hospitalization. CHRONIC/STABLE PROBLEMS: ======================= #Type 1 diabetes Patient was followed by ___ throughout hospitalization, with insulin levels adjusted per their recommendations. She was discharged on 34 U glargine at bedtime, 2 units Humalog at breakfast, 8 units Humalog at lunch, 10 units Humalog at dinner. #Hypertension Patient was continued on her home regimen of labetalol 200mg BID, amlodipine 10mg, and ASA 81mg daily during hospitalization. ASA 81 mg was discontinued prior to discharge given patient diagnosis and decision to move towards comfort care. #Hyperlipidemia Continued home atorvastatin 20mg qPM during hospitalization but discontinued prior to discharge given patient diagnosis and decision to move towards comfort care. TRANSITIONAL ISSUES ================== [ ] BMP should be obtained during visit with Dr. ___ [ ] ___ service to evaluate for home needs. [ ] Patient should continue to monitor blood sugars. Current ___ regimen in place for 40 mg prednisone dose, but prednisone taper ordered which may alter needs. [ ] Patient should call O2 company when home to order home O2. [ ] Renal transplant to arrange for standing labs to be completed as outpatient, including tacrolimus level monitoring (goal ___ [ ] Patient to follow up with Dr. ___ (heme/onc fellow) as primary medical contact as patient does not have primary care physician ___ [ ] Palliative care doctor, ___, MD, can be contacted if you have additional questions or concerns regarding improving patient comfort [ ] Home sleep study ordered, in order to obtain home CPAP for patient. Please contact ___ if you do not hear from them within 3 days of discharge. [ ] Wheelchair for home ordered. [ ] Patient to continue with home ___ ordered at discharge. [] Please monitor renal function and volume status closely, to titrate her home torsemide dosing accordingly (torsemide 40 qOD) [] Please continue ongoing ___ conversations with patient's husband and patient. They will likely transition to hospice as an outpatient at some point. Code: Full with limited trial of life sustaining measures Contact: Name of health care proxy: ___ Relationship: Husband Phone number: ___ ___ on Admission: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Labetalol 200 mg PO BID 7. Tacrolimus 1 mg PO Q12H 8. Mycophenolate Mofetil 500 mg PO BID 9. Vitamin D 1400 UNIT PO DAILY 10. Ciprofloxacin HCl 500 mg PO Q12H 11. Torsemide 40 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID RX *atropine 1 % 1 drop in the left eye twice daily Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours as needed Disp #*10 Tablet Refills:*0 3. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. PredniSONE 20 mg PO DAILY Duration: 7 Days RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 5. PredniSONE 10 mg PO DAILY Duration: 7 Days RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 6. PredniSONE 5 mg PO DAILY RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. PredniSONE 40 mg PO DAILY Duration: 7 Days RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet Refills:*0 8. TraZODone 25 mg PO QHS:PRN insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth nightly as needed Disp #*15 Tablet Refills:*0 9. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as needed Disp #*60 Tablet Refills:*0 10. Glargine 34 Units Bedtime Humalog 2 Units Breakfast Humalog 8 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Tacrolimus 2.5 mg PO Q12H RX *tacrolimus 0.5 mg 5 capsule(s) by mouth daily Disp #*150 Capsule Refills:*0 12. Torsemide 40 mg PO EVERY OTHER DAY RX *torsemide 20 mg 2 tablet(s) by mouth every other day Disp #*60 Tablet Refills:*0 13. amLODIPine 10 mg PO DAILY 14. Docusate Sodium 100 mg PO BID 15. Labetalol 200 mg PO BID 16.Outpatient Physical Therapy Physical Therapy Outpatient Dx: metastatic NSCLC Px: Poor ___: 13 mos ICD10: C34.90 17.Wheelchair Dx: metastatic NSCLC Px: Poor ___ mos ICD10: C34.90 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: ================== Stage IV NSCLC Hypoxic respiratory failure Secondary Diagnoses: ==================== HTN HFpEF DM2 Living donor renal transplant ESRD Pericardial effusion (___) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear ___, ___ was a pleasure to care for you at the ___ ___. Why did you come to the hospital? - You came to the hospital because you were feeling tired and fatigued. You also had shortness of breath and almost fell. What did you receive in the hospital? - You were found to have worsening kidney function. You water pill (torsemide) was held, and your kidney function returned to normal so we were able to reinitiate your torsemide on discharge. - You were found to have low blood levels (hemoglobin), for which you underwent EGD and colonoscopy (check below) - You underwent a procedure called Esophagogastroduodenoscopy (EGD), where a thin flexible tube (a "scope") that can be looked through or seen on a TV monitor was passed down your mouth to visualize your upper gut. You were found to have an ulcer in the first part of your small intestine (duodenum) - You underwent a procedure called colonoscopy, where a thin flexible tube (a "scope") that can be looked through or seen on a TV monitor was passed down to visualize your lower gut (colon) - You had CT scan for your chest on ___. It showed a mass in your upper right lung. You subsequently, underwent a procedure called bronchoscopy, where a a thin flexible tube (a "scope") that can be looked through or seen on a TV monitor was passed down your mouth to visualize your airways and take samples. - Samples from your lung showed non small cell lung cancer. - Additional CT imaging showed metastases in the liver and bone. - We discussed your goals of care and found that the best treatment for you at this point is to spend time with your family and feel comfortable at home. What should you do once you leave the hospital? - Continue to enjoy your wonderful family and call us if any questions should arise. We wish you the best! Your ___ Care Team Followup Instructions: ___
[ "C3411", "I5033", "N170", "J189", "J9601", "I130", "I313", "C787", "Z940", "E871", "N390", "D62", "J9811", "J90", "C7951", "H31421", "K269", "N189", "Z794", "E669", "Z6837", "R2681", "G4733", "E1021", "K2960", "E10319", "E860", "E875", "E1022" ]
Allergies: Lisinopril / Iodinated Contrast- Oral and IV Dye Chief Complaint: Shortness of Breath and fatigue Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD) - [MASKED] Colonoscopy - [MASKED] Bronchoscopy with transbronchial biopsy - [MASKED] Right chest tube [MASKED] TPC Placement [MASKED] History of Present Illness: Mrs. [MASKED] is a [MASKED] year-old lady with end stsge renal disease secondary to type one diabetes mellitus status post living donor renal transplant in [MASKED] (donor: husband; maintained on MMF and tacrolimus), HFpEF, chronic pericardial effusion ([MASKED]), hypertension, who presents on [MASKED] to the hospital with one week history of lethargy, drowsiness, orthopnea and increasing shortness of breath. The patient has 3 recent hospital admission due to heart failure exacerbations. During last hospital admission (discharged [MASKED], she was intubated for respiratory distress and diuresed with IV Lasix, and discharged on torsemide 40 mg. The patient also had urosepsis with Klebsellia and GNR. She was discharged on ciprofloxacin for 14 days, last dose was [MASKED]. On admission, patient was found to have acute kidney injury ([MASKED]) (Cr of 2.8 up from 1.6 on [MASKED]. She was also found to have anemia with hemoglobin drop from 11.5 on [MASKED] to 8.0 on [MASKED]. Past Medical History: Hypertension Heart failure with preserved ejection fraction (HFpEF) Type 1 diabetes mellitus End stage renal disease (ESRD) Living donor renal transplant from her husband ([MASKED]) Pericardial effusion ([MASKED]) Social History: [MASKED] Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ============================ ADMISSION PHYSICAL EXAMINATION ============================ 24 HR Data (last updated [MASKED] @ 1720) Temp: 98.0 (Tm 98.5), BP: 122/77 (100-122/66-77), HR: 83, RR: 18 ([MASKED]), O2 sat: 97% (85-97), O2 delivery: 1LNC, Wt: 191.58 lb/86.9 kg General: Alert, oriented, looks tired and dyspneic at times. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar crepitations - Good air entry bilaterally Abdomen: Soft, Bruises at heparin injection sites, obese, bowel sounds present, no organomegaly, no rebound or guarding Ext: No lower limbs edema; feet has what appears like fungal infection Neuro: grossly intact. Tremor noticed ============================ DISCHARGE PHYSICAL EXAMINATION ============================ VITALS: 24 HR Data (last updated [MASKED] @ 1214) Temp: 98.5 (Tm 99.9), BP: 149/93 (114-155/64-93), HR: 85 (85-89), RR: 18 ([MASKED]), O2 sat: 96% (91-100), O2 delivery: 2,5L (2l-3l), Wt: 164.8 lb/74.75 kg GEN: Patient is lying down in bed on her right side with CPAP off. She is very withdrawn and barely responds to questions. HEENT: PERRLA CARDIAC: RRR, no audible murmurs. LUNGS: Diminished breath sounds bilaterally L>R ABDOMEN: softly distended EXTREMITIES: trace edema BLE GEN: Patient is lying down in bed on her right side with CPAP off. She is very withdrawn and barely responds to questions. HEENT: PERRLA CARDIAC: RRR, no audible murmurs. LUNGS: Diminished breath sounds bilaterally L>R ABDOMEN: softly distended EXTREMITIES: trace edema BLE Pertinent Results: ADMISSION LABS: ================ [MASKED] 09:33AM BLOOD WBC-13.8* RBC-2.77* Hgb-8.0* Hct-25.5* MCV-92 MCH-28.9 MCHC-31.4* RDW-17.6* RDWSD-58.2* Plt [MASKED] [MASKED] 07:40PM BLOOD [MASKED] PTT-22.7* [MASKED] [MASKED] 05:06PM BLOOD [MASKED] [MASKED] 05:06PM BLOOD Ret Aut-5.6* Abs Ret-0.17* [MASKED] 09:33AM BLOOD Glucose-247* UreaN-184* Creat-2.8*# Na-127* K-6.6* Cl-77* HCO3-29 AnGap-21* [MASKED] 07:40PM BLOOD ALT-11 AST-11 LD(LDH)-196 AlkPhos-54 TotBili-0.4 [MASKED] 09:33AM BLOOD cTropnT-0.08* proBNP-1603* [MASKED] 09:33AM BLOOD Calcium-10.1 Phos-4.7* Mg-1.7 [MASKED] 09:33AM BLOOD Hapto-181 [MASKED] 07:10AM BLOOD tacroFK-6.8 [MASKED] 09:47AM BLOOD [MASKED] pO2-33* pCO2-57* pH-7.43 calTCO2-39* Base XS-10 [MASKED] 02:36AM BLOOD Lactate-1.0 DISCHARGE LABS =============== [MASKED] 07:19AM BLOOD WBC-13.2* RBC-3.19* Hgb-8.1* Hct-28.0* MCV-88 MCH-25.4* MCHC-28.9* RDW-17.5* RDWSD-56.6* Plt [MASKED] [MASKED] 07:19AM BLOOD Plt [MASKED] [MASKED] 07:19AM BLOOD Glucose-58* UreaN-47* Creat-1.2* Na-141 K-4.1 Cl-91* HCO3-37* AnGap-13 [MASKED] 07:19AM BLOOD Calcium-9.5 Phos-4.0 Mg-1.8 [MASKED] 07:19AM BLOOD tacroFK-4.9* IMAGING: ======== -RENAL TRANSPLANT U/S - [MASKED] Normal appearing transplant kidney with unchanged slight increase in the resistance index at the interpolar region. -Transthoracic Echocardiography (TTE) - [MASKED] Moderate to large, predominantly lateral pericardial effusion with evidence of possible early tamponade physiology. Very little fluid anterior to the right ventricle or apex. Clinical correlation and continued serial scans are suggested. -Transthoracic Echocardiography (TTE) - [MASKED] Large circumferential serous pericardial effusion with echocardiographic signs of low pressure tamponade. Compared to prior, findings are similar. -CT ABDOMEN & PELVIS W/O CONTRAST - [MASKED] 1. No evidence of acute trauma identified on this noncontrast CT of the abdomen and pelvis. Specifically, no fracture or significant hematoma identified. 2. 8.3 cm indeterminate mass arising from the native left kidney. Differential includes hyperdense cyst, oncocytoma, and renal cell carcinoma. Recommend further evaluation with dedicated renal CT or MRI depending on patient's renal function. 3. Cholelithiasis without CT evidence of cholecystitis. 4. Stable right adnexal/pelvic mass presumably representing an exophytic fibroid. 5. Additional chronic changes as detailed above. -CT CHEST W/O CONTAST - [MASKED] Right suprahilar masslike consolidation with occlusion of the right upper lobe bronchus. Although this could represent bronchopneumonia in the setting of mucous plugging appearance raises suspicion for primary lung malignancy. There is nodular airspace disease noted distally within the right upper lobe suggestive of a postobstructive pneumonia/pneumonitis. Recommend pulmonology consultation and bronchoscopic correlation. Mediastinal and probable right hilar lymphadenopathy as detailed above could be reactive to infectious/inflammatory process or could represent metastatic disease. Redemonstration of known moderate to large pericardial effusion, small right pleural effusion, and trace left pleural effusion. -CT CHEST W/O CONTAST - [MASKED] Again noted is a right central right upper lobe mass with postobstructive pneumopathy. Degree of postobstructive atelectasis of the anterior segment of the right upper lobe appears increased since the prior chest CT. Extensive mediastinal lymphadenopathy as well as right supraclavicular lymphadenopathy are unchanged. Interval placement of a chest tube with interval decrease in size of the previously noted right pleural effusion and right base atelectasis. There is extensive peribronchial nodular opacities involving all lobes, but most marked in the right lower lobe which is new/increased compared to prior and is concerning for aspiration or broncho pneumonia. Substantial increase in extent of left lower lobe atelectasis, now mostly collapsed. Unchanged large pericardial effusion. Interstitial septal thickening in the lung apices and bases suggest interstitial pulmonary edema. Partly imaged hyperdense lesion along the left kidney. Dedicated CT or MR may be helpful to evaluate further although ultraound may prove useful as a possible way of demonstrating and characterizing a complex cyst, which is more likely than a solid mass. Esophagogastroduodenoscopy (EGD) [MASKED] Normal esophageal mucosa. Erythema in the antrum compatible with gastritis. Large, 1cm deep cratered ulcer in the duodenal bulb with surrounding hyperemia and edema. The base of the ulcer was clean. No visible vessel or active bleeding. The second part of the duodenum there was small erosions and two more small clean-based ulcers. COLONOSCOPY [MASKED]: Mucosa not visualized adequately due to high residual material. Otherwise, normal mucosa in the colon. CXR [MASKED]: New pleural effusions, mild to moderate pulmonary edema and increasing right basilar parenchymal opacification probably due to atelectasis. Although partly obscured, likely persistent atelectasis of the anterior segment of the right upper lobe including possibility of a malignancy. CT HEAD W/ CONTRAST [MASKED]: FINDINGS: There is no evidence of large territorial infarction, hemorrhage, edema, or mass. The ventricles and sulci are age-appropriate. Mild calcified atherosclerotic disease is demonstrated at the bilateral carotid siphons. There is no intracranial abnormal enhancement on post contrast images. There is interval increased osseous erosion of the left sphenoid (series 2, image 9 and 10) with soft tissue density, extending into the left sphenoid sinus (series 603, image 37). Erosion through the floor of the left middle cranial fossa (series 603, image 39) is identified, with dural thickening. No definite involvement of the adjacent temporal lobe. The lesion erodes through the medial aspect of the left foramen ovale and inferior aspect of the left foramen rotundum (series 603, image 37 and 41). The visualized portions of the maxillary sinuses, ethmoid air cells and frontal sinuses are essentially clear. Hyperdensity along the posterior aspect of the left globe is compatible with choroidal effusion or scleral detachment. Left lens replacement identified. The right orbit is grossly unremarkable. Mastoid air cells middle ears arm ties and clear. IMPRESSION: 1. No evidence of intracranial metastatic disease within confines of contrast enhanced CT examination at this time. 2. Soft tissue lesion centered in the left sphenoid wing with interval osseous erosion, extending into the left sphenoid sinus is new from prior examination of [MASKED]. This is worrisome for osseous metastatic disease. There is erosion through the floor of the left middle cranial fossa, with associated dural thickening. No definite involvement of the brain parenchyma, however examination is not optimized for such evaluation. 3. Additional findings described above. CTA CHEST - [MASKED]: ================= FINDINGS: CHEST: PULMONARY ARTERIES: The study is of slightly suboptimal technical quality for evaluation of acute PE (density in the main PA 189 [MASKED] units). Infiltrative tumor around the right hilum is causing significant narrowing of the right upper lobe artery but there is a thin column of flow present. There is also focal narrowing of the right middle lobe artery but flow is seen distally. There is no significant narrowing of the right lower lobe artery. No filling defects concerning for pulmonary emboli are demonstrated within the limits of the study. The pulmonary trunk is dilated at 3.6 cm, suggesting pulmonary hypertension. HEART AND VASCULATURE: There is a large pericardial effusion. The left atrium is dilated. Multivessel coronary calcifications are present. The thoracic aorta is within normal limits of caliber. AXILLA, HILA, AND MEDIASTINUM: There is a large amount of infiltrative enhancing soft tissue around the right hilum, surrounding the hilar bronchovascular structures. This is contiguous with the right upper lobe lung mass and associated atelectasis/consolidation. There is patency of the major right upper lobe bronchial structures but narrowing of pulmonary arteries as noted above, as well as branches of the superior pulmonary veins. There may be invasion of the main and lobar prominently arteries. There is extensive bilateral mediastinal adenopathy consisting of irregular, heterogeneously enhancing nodes in keeping with metastases. Individual nodes are difficult to measure but 1 nodal mass is 2.2 cm in the right paratracheal region. There are also multiple small bilateral abnormal supraclavicular nodes measuring slightly greater than 1 cm on the right. There is no axillary adenopathy. The thyroid is diffusely heterogeneous and there are multifocal calcifications in the bulky left lobe. This is likely related to goiter. PLEURAL SPACES: There is a small left pleural effusion and a small to moderate right pleural effusion. A pleural drain is present on the right. LUNGS/AIRWAYS: Right upper lobe mass as noted above. There are multiple spiculated nodular opacities throughout the right upper lobe, mostly in the subcentimeter range. There are also a few in the right middle and lower lobes. Interlobular septal thickening in the right upper and lower lobes appears slightly nodular in some areas, raising the possibility of lymphangitic carcinomatosis, versus lymphovascular congestion due to hilar masses. There is nodular thickening of the bilateral major fissures and there is mild left-sided pleural nodularity, in keeping with metastases. There is abnormal tissue tracking in the right lower lobe along the bronchovascular structures, also in keeping with tumor spread. ABDOMEN AND PELVIS: HEPATOBILIARY: There multiple ill-defined liver hypodensities measuring less than 2 cm, in keeping with metastases. The largest lesions in the right lobe are in segments 6 and 7 measuring 1.7 cm, and the largest in the left lobe is in segment [MASKED] measuring 1.6 cm. There is no biliary dilation. The gallbladder contains small stones without wall thickening or surrounding inflammation. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout without evidence of focal lesion. ADRENALS: Both adrenal glands are diffusely bulky and mildly nodular, likely related to hyperplasia as opposed to metastases. URINARY: Both native kidneys are severely atrophic. There is an 8.5 cm simple cyst arising from the lower pole of the left kidney. There is a transplant kidney in the right iliac fossa. This contains a few subcentimeter cortical hypodensities, likely benign cysts. There is no hydronephrosis. The urinary bladder is distended but otherwise unremarkable. GASTROINTESTINAL: The stomach is unremarkable aside from a small hiatal hernia. The small bowel appears within normal limits. There is a large stool load throughout the colon. There is no free fluid or free air in the abdomen or pelvis. REPRODUCTIVE ORGANS: There is a circumscribed 4.9 x 4.0 cm intermediate density right adnexal lesion demonstrating a small focal mural calcifications. This is likely ovarian in nature and is incompletely evaluated on CT, but probably benign. The there is a 1.4 cm left adnexal cystic lesion. The uterus is unremarkable aside from a 1.5 cm intramural fibroid. LYMPH NODES: There is no retroperitoneal, mesenteric, pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. Extensive atherosclerotic disease is noted. BONES: There is a nondisplaced, mildly comminuted fracture of the right lateral seventh rib, associated with questionable underlying lucency. This is suspicious for pathologic fracture secondary to metastasis. Sclerotic change in the left T7 transverse process could represent a metastasis. A 2.1 cm sclerotic marginated lucency in the left anterior iliac crest is likely a metastasis. Soft tissues: A small fat containing periumbilical hernia is noted. Subcutaneous soft tissue stranding in the anterior upper abdominal wall is presumably related to contusion or fibrosis. Associated calcifications within this region on the left are nonspecific but probably related to a prior inflammatory process or fat infarct. IMPRESSION: 1. Technically suboptimal study, but no evidence of acute PE. 2. Large right upper lobe mass contiguous with infiltrative right hilar soft tissue compromising pulmonary arterial structures as described, particularly the right upper lobe arteries. Major airways remain patent. 3. Extensive bilateral mediastinal and supraclavicular lymphadenopathy. Multiple intrapulmonary metastases in the right lung, as well as probable lymphangitic carcinomatosis. Bilateral pleural metastases. 4. Small left pleural effusion and small to moderate right pleural effusion with associated passive atelectasis. 5. Large pericardial effusion could be malignant. 6. Multiple liver metastases. 7. Probable left iliac crest metastasis. Two other bone lesions, including 1 associated with a fracture of the right seventh rib are most likely metastatic. PATHOLOGY ========== TRANSBRONCHIAL BIOPSY - [MASKED] LUNG ADENOCARCINOMA. See note. Note: By immunohistochemistry, tumor cells show the following staining profile: - Positive: TTF-1, Napsin. - Negative: p40. Brief Hospital Course: BRIEF HOSPITAL COURSE: ======================= Mrs. [MASKED] is a lovely [MASKED] year-old lady with end stage renal disease secondary to type one diabetes mellitus status post living donor renal transplant in [MASKED] (donor: husband; maintained on MMF and tacrolimus), HFpEF, chronic pericardial effusion ([MASKED]), who initially was admitted on [MASKED] with pre-renal acute kidney injury. Her hospital course was complicated by hypoxia requiring MICU stay and new diagnosis of stage IV lung adenocarcinoma (NSCLC) with metastases to the bone and liver. ACTIVE ISSUES ============ #Hypoxemic respiratory failure #Bilateral Pleural Effusion #OSA Patient underwent CXR in the setting of hypoxia and was found to have a new right lung opacity. CT chest was then obtained on [MASKED] which demonstrated a mass-like consolidation in RUL for which she had bronchoscopy on [MASKED]. Transbronchial biopsy showed adenocarcinoma. On [MASKED], patient was transferred to MICU with worsening shortness of breath and hypoxia. Chest x-rays ([MASKED]) revealed bilateral pleural effusions with R>L. Subsequently, a right [MASKED] Fr chest tube was placed by interventional pulmonology team on [MASKED] with lymphocytic predominant transudative fluid evacuated and negative cytology. She was initially started on broad spectrum antibiotics for a presumed hospital acquired infection (HAP),; however, these were discontinued on presentation to the unit. While on the floor, she was originally maintained on high flow O2 and face mask, but was able to be weaned down to nasal cannula. At night she was placed on CPAP, which improved hypoxia in the setting of likely OSA. Upon transfer to the floor, patient was satting well on [MASKED] NC, with continued drainage from her chest tube. Chest tube was removed in the setting of decreased output and patient was begun on ceftazadine and flagyl for possible obstructive PNA. Hypoxia was difficult to manage on the floor with patient requiring frequent IV diuresis with only moderate improvement and O2 requirements reaching as high as 8L NC during the day and 15L on CPAP overnight. Repeat CXR on [MASKED] demonstrated recurrence of pulmonary effusion, with interventional pulmonology stating effusion likely malignant due to speed of reaccumulation despite negative cytology. On [MASKED] a R tunneled pleural catheter was placed with high output drainage and improvement in O2 requirements to [MASKED] via NC. Patient was discharged satting in the mid to high 90's on [MASKED] L NC and plan for home sleep study to obtain CPAP machine. Note: [MASKED] between MD and Patient agreeing to Home O2 in the setting of chronic hypoxia with diuresis and pleural drains insufficient to eliminate the need for O2. Pt requires long-term home and portable oxygen therapy to improve hypoxia-related symptoms. #Lung adenocarcinoma - [MASKED] Patient underwent CXR in the setting of hypoxia and was found to have a new right lung opacity. CT chest was then obtained on [MASKED] which demonstrated a mass-like consolidation in RUL for which she had bronchoscopy on [MASKED]. Transbronchial biopsy showed adenocarcinoma. Cellcept was stopped and prednisone 5mg was started in anticipation for chemotherapy. Prednisone 5mg was later stopped iso new prednisnone 60 mg for choroidal effusion. Due to patient's prolonged hospitalization and need for staging imaging, we obtained CT head w/ and w/o contrast and CTA C/A/P on [MASKED] which demonstrated heavy disease burden with metastases to the bone and liver, indicating stage IV disease. Genetic testing did not demonstrate a target for immunotherapy. Per oncology, patient treatment options included home with hospice, or chemotherapy and possible radiation. However, patient's poor clinical status portended likely poor outcome. Radiation oncology was consulted who felt that palliative radiation was likely inappropriate as patient did not complain of pain at a particular metastatic site. Additionally, as patient had significant claustrophobia and anxiety, it was thought that the mapping necessary to proceed with radiation therapy would be too challenging to complete. Goals of care conversations were initiated with palliative care, social work, oncology, radiation oncology and primary medical team involved. These conversations took place with patient's husband who then relayed information to patient as patient's anxiety was too great to participate in conversations and preferred that all information be communicated to her husband. Patient and family decided to focus on comfort at this time and indicated that they would go home with [MASKED] and move to hospice when indicated [MASKED] provider also provides hospice). Patient was provided with contact information of primary medical team and palliative care team as well as follow up with medical oncology. #Pericardial Effusion Patient has a chronic pericardial effusion (since [MASKED]. TTE performed on [MASKED] demonstrated worsening pericardial effusion, with repeat TTE on [MASKED] similar to prior. In the MICU, cardiology team recommended pericardial window; however, the patient family declined this at the time being. CTA chest on [MASKED] with large pericardial effusion present, possibly increased in size. However, pt was clinically stable. After staging imaging, hematology/oncology discussed possibility of pericardial effusion to prevent complications in the setting of possible plan for chemotherapy. Patient's husband initially expressed interest in learning more about what this procedure would entail, but was concerned about putting patient through more procedures and decided to focus on comfort with patient deferring procedure and moving towards home with [MASKED] services. #New onset bullous choroidal effusion in the left eye: Patient noted decreased vision in left eye for which she was seen by ophtho on [MASKED]. [MASKED] evaluation revealed new onset bullous choroidal effusion for which patient was begun on 60 mg prednisone. On reevaluation by optho, patient endorsed some improvement in vision and prednisone taper was planned (see outlined below). Patient was maintained on PPI. Bactrim ppx for PCP was deferred. [MASKED] was contacted during hospitalization to aid in titrating insulin dosing in the setting of steroid administration. Recommendations for altered regimen were provided on the day prior to discharge with plan for patient to continue to monitor blood sugars at home. Per ophthalmology, patient should follow up with outpatient ophthalmologist, Dr. [MASKED], in [MASKED] weeks upon discharge. Prednisone Taper: [MASKED]: 40 mg/day [MASKED]: 20 mg/day [MASKED]: 10 mg/day [MASKED] and on: 5 mg/day # End stage renal disease # Living donor kidney transplant # [MASKED] (resolved) Patient arrived with Cr of 2.8 on [MASKED] up from 1.6 on [MASKED]. [MASKED] appeared to be prerenal in the setting of over diuresis and resolved after stopping home torsemide. Cr on discharge is 1.2, with patient taking good PO intake. During this admission, Cellcept was stopped and prednisone 5mg was started in anticipation of starting chemotherapy. Prednisone was increased in the setting of ophthalmology evaluation and findings (see above). Chemotherapy was not pursued as family decided to focus on comfort as noted above. Tacrolimus was continued throughout the hospitalization, with levels adjusted per renal transplant for goal tacrolimus level [MASKED]. # Anemia Hgb 8 on admission down from 15. EGD and colonoscopy on [MASKED] showed a 1cm, non-bleeding, deep cratered ulcer in the duodenal bulb. H. Pylori negative. Patient was continued on a PPI, with Hgb remaining stable through rest of hospitalization. #Hyperkalemia: Patient demonstrated intermittent hyperkalemia of unclear etiology despite Lasix administration. Thought possibly related to intermittent constipation with improvement after bowel movements. Will check BMP to be ordered during visit with Dr. [MASKED]. #Mood/Depression Patient began to appear quite lethargic, somnolent, and depressed. She also has significant anxiety regarding her own medical care, and did not wish to have any medical information relayed to her; she preferred that all medical information be relayed to her husband. No prior diagnosis of a mood disorder, but may have manifested in setting of new diagnosis and multiple recent hospitalizations. Palliative care evaluated, and did not feel starting medications were appropriate in the acute setting and would continue to monitor going forward. Patient has excellent support network with husband, daughter, father living in her home. She has a large group of friends and a sister who visits her during the hospitalization. CHRONIC/STABLE PROBLEMS: ======================= #Type 1 diabetes Patient was followed by [MASKED] throughout hospitalization, with insulin levels adjusted per their recommendations. She was discharged on 34 U glargine at bedtime, 2 units Humalog at breakfast, 8 units Humalog at lunch, 10 units Humalog at dinner. #Hypertension Patient was continued on her home regimen of labetalol 200mg BID, amlodipine 10mg, and ASA 81mg daily during hospitalization. ASA 81 mg was discontinued prior to discharge given patient diagnosis and decision to move towards comfort care. #Hyperlipidemia Continued home atorvastatin 20mg qPM during hospitalization but discontinued prior to discharge given patient diagnosis and decision to move towards comfort care. TRANSITIONAL ISSUES ================== [ ] BMP should be obtained during visit with Dr. [MASKED] [ ] [MASKED] service to evaluate for home needs. [ ] Patient should continue to monitor blood sugars. Current [MASKED] regimen in place for 40 mg prednisone dose, but prednisone taper ordered which may alter needs. [ ] Patient should call O2 company when home to order home O2. [ ] Renal transplant to arrange for standing labs to be completed as outpatient, including tacrolimus level monitoring (goal [MASKED] [ ] Patient to follow up with Dr. [MASKED] (heme/onc fellow) as primary medical contact as patient does not have primary care physician [MASKED] [ ] Palliative care doctor, [MASKED], MD, can be contacted if you have additional questions or concerns regarding improving patient comfort [ ] Home sleep study ordered, in order to obtain home CPAP for patient. Please contact [MASKED] if you do not hear from them within 3 days of discharge. [ ] Wheelchair for home ordered. [ ] Patient to continue with home [MASKED] ordered at discharge. [] Please monitor renal function and volume status closely, to titrate her home torsemide dosing accordingly (torsemide 40 qOD) [] Please continue ongoing [MASKED] conversations with patient's husband and patient. They will likely transition to hospice as an outpatient at some point. Code: Full with limited trial of life sustaining measures Contact: Name of health care proxy: [MASKED] Relationship: Husband Phone number: [MASKED] [MASKED] on Admission: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Fish Oil (Omega 3) 1000 mg PO DAILY 6. Labetalol 200 mg PO BID 7. Tacrolimus 1 mg PO Q12H 8. Mycophenolate Mofetil 500 mg PO BID 9. Vitamin D 1400 UNIT PO DAILY 10. Ciprofloxacin HCl 500 mg PO Q12H 11. Torsemide 40 mg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID RX *atropine 1 % 1 drop in the left eye twice daily Refills:*0 2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours as needed Disp #*10 Tablet Refills:*0 3. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. PredniSONE 20 mg PO DAILY Duration: 7 Days RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 5. PredniSONE 10 mg PO DAILY Duration: 7 Days RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 6. PredniSONE 5 mg PO DAILY RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. PredniSONE 40 mg PO DAILY Duration: 7 Days RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet Refills:*0 8. TraZODone 25 mg PO QHS:PRN insomnia RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth nightly as needed Disp #*15 Tablet Refills:*0 9. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as needed Disp #*60 Tablet Refills:*0 10. Glargine 34 Units Bedtime Humalog 2 Units Breakfast Humalog 8 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 11. Tacrolimus 2.5 mg PO Q12H RX *tacrolimus 0.5 mg 5 capsule(s) by mouth daily Disp #*150 Capsule Refills:*0 12. Torsemide 40 mg PO EVERY OTHER DAY RX *torsemide 20 mg 2 tablet(s) by mouth every other day Disp #*60 Tablet Refills:*0 13. amLODIPine 10 mg PO DAILY 14. Docusate Sodium 100 mg PO BID 15. Labetalol 200 mg PO BID 16.Outpatient Physical Therapy Physical Therapy Outpatient Dx: metastatic NSCLC Px: Poor [MASKED]: 13 mos ICD10: C34.90 17.Wheelchair Dx: metastatic NSCLC Px: Poor [MASKED] mos ICD10: C34.90 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: ================== Stage IV NSCLC Hypoxic respiratory failure Secondary Diagnoses: ==================== HTN HFpEF DM2 Living donor renal transplant ESRD Pericardial effusion ([MASKED]) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear [MASKED], [MASKED] was a pleasure to care for you at the [MASKED] [MASKED]. Why did you come to the hospital? - You came to the hospital because you were feeling tired and fatigued. You also had shortness of breath and almost fell. What did you receive in the hospital? - You were found to have worsening kidney function. You water pill (torsemide) was held, and your kidney function returned to normal so we were able to reinitiate your torsemide on discharge. - You were found to have low blood levels (hemoglobin), for which you underwent EGD and colonoscopy (check below) - You underwent a procedure called Esophagogastroduodenoscopy (EGD), where a thin flexible tube (a "scope") that can be looked through or seen on a TV monitor was passed down your mouth to visualize your upper gut. You were found to have an ulcer in the first part of your small intestine (duodenum) - You underwent a procedure called colonoscopy, where a thin flexible tube (a "scope") that can be looked through or seen on a TV monitor was passed down to visualize your lower gut (colon) - You had CT scan for your chest on [MASKED]. It showed a mass in your upper right lung. You subsequently, underwent a procedure called bronchoscopy, where a a thin flexible tube (a "scope") that can be looked through or seen on a TV monitor was passed down your mouth to visualize your airways and take samples. - Samples from your lung showed non small cell lung cancer. - Additional CT imaging showed metastases in the liver and bone. - We discussed your goals of care and found that the best treatment for you at this point is to spend time with your family and feel comfortable at home. What should you do once you leave the hospital? - Continue to enjoy your wonderful family and call us if any questions should arise. We wish you the best! Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "J9601", "I130", "E871", "N390", "D62", "N189", "Z794", "E669", "G4733" ]
[ "C3411: Malignant neoplasm of upper lobe, right bronchus or lung", "I5033: Acute on chronic diastolic (congestive) heart failure", "N170: Acute kidney failure with tubular necrosis", "J189: Pneumonia, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I313: Pericardial effusion (noninflammatory)", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "Z940: Kidney transplant status", "E871: Hypo-osmolality and hyponatremia", "N390: Urinary tract infection, site not specified", "D62: Acute posthemorrhagic anemia", "J9811: Atelectasis", "J90: Pleural effusion, not elsewhere classified", "C7951: Secondary malignant neoplasm of bone", "H31421: Serous choroidal detachment, right eye", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "N189: Chronic kidney disease, unspecified", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "R2681: Unsteadiness on feet", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "K2960: Other gastritis without bleeding", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E860: Dehydration", "E875: Hyperkalemia", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease" ]
10,075,925
24,184,489
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: SOB Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo F with h/o HTN, dCHF, DM2, s/p renal transplant, admitted on ___ with a several day h/o dyspnea with exertion, progressive, called EMS and found to have hypoxemia to the 50's. Pt with mild CP on admission (resolved). She reports 9 lb weight gain over six months (wt 209 lbs on admission). In the ED, started on BiPAP. She was treated with empiric abx (for possible PNA) and bid furosemide (for possible pulm edema), with marked improvement. She is now sitting in bed, conversant, on 5L O2, with her husband and daughter at the bedside. She is being transferred to the medical service from the ICU for further care. She currently has no SOB (on O2). She has no HA, f/c, N/V, CP, abd pain. [X] 10 point review of symptoms negative except as noted above. Past Medical History: HTN/dCHF DM2 Living donor renal transplant from her husband (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: HMED ADMISSION EXAM: Afeb 83 160/74 RR 12 SaO2 95% (5L NC) NAD RRR Scattered wheezes/rhonchi +BS, soft, NT, ND No ___ edema A+Ox3 . . HMED DISCHARGE EXAM: VS: 24 HR Data (last updated ___ @ 1457) Temp: 98.0 (Tm 98.5), BP: 132/84 (112-159/58-84), HR: 74 (74-88), RR: 18 (___), O2 sat: 95% (93-98), O2 delivery: RA Wt: 90 kg (198.4 lbs) on standing scale Gen: NAD, disheveled, +cushingoid appearance HEENT: EOMI, MMM Neck: obese, unable to visualize any JVP/JVD Cards: RR Chest: trace LLL crackles, no wheezing, normal WOB Abd: obese, S, NT, ND, BS+ Skin: acanthosis nigricans in various places on the back, thickening of skin Ext: no ___ edema, grossly normal strength in arms/legs Neuro: awake, alert, conversant Psych: calm, cooperative Pertinent Results: ADMISSION LABS: ================= ___ 07:08AM BLOOD WBC-10.4* RBC-4.87 Hgb-14.3 Hct-47.8* MCV-98 MCH-29.4 MCHC-29.9* RDW-18.4* RDWSD-61.6* Plt ___ ___ 07:08AM BLOOD Neuts-81.3* Lymphs-9.1* Monos-8.2 Eos-0.5* Baso-0.2 NRBC-0.5* Im ___ AbsNeut-8.48* AbsLymp-0.95* AbsMono-0.85* AbsEos-0.05 AbsBaso-0.02 ___ 07:08AM BLOOD ___ PTT-27.7 ___ ___ 07:08AM BLOOD Glucose-106* UreaN-31* Creat-1.1 Na-135 K-8.6* Cl-94* HCO3-25 AnGap-16 ___ 07:08AM BLOOD ALT-<5 AST-58* CK(CPK)-182 AlkPhos-70 TotBili-0.6 ___ 07:08AM BLOOD CK-MB-7 proBNP-1020* ___ 07:08AM BLOOD cTropnT-0.05* ___ 07:08AM BLOOD Albumin-4.4 ___ 05:02PM BLOOD Calcium-10.0 Phos-3.8 Mg-2.0 ___ 07:15AM BLOOD ___ pO2-51* pCO2-53* pH-7.32* calTCO2-29 Base XS-0 Intubat-NOT INTUBA Comment-ADDED TO A ___ 07:15AM BLOOD K-5.0 . . NOTABLE LABS WHILE INPATIENT: ============================= ___ 07:08AM BLOOD CK-MB-7 proBNP-1020* ___ 07:08AM BLOOD cTropnT-0.05* ___ 05:02PM BLOOD CK-MB-9 cTropnT-0.06* ___ 06:17AM BLOOD CK-MB-5 cTropnT-0.08* ___ 09:00AM BLOOD tacroFK-5.2 ___ 10:35AM BLOOD tacroFK-7.4 . . DISCHARGE LABS: ================ ___ 07:10AM BLOOD WBC-9.0 RBC-4.91 Hgb-14.4 Hct-46.9* MCV-96 MCH-29.3 MCHC-30.7* RDW-16.4* RDWSD-56.7* Plt ___ ___ 07:10AM BLOOD Glucose-248* UreaN-41* Creat-1.1 Na-136 K-4.9 Cl-90* HCO3-31 AnGap-15 ___ 07:10AM BLOOD Calcium-9.7 Phos-2.4* Mg-2.5 . . MICRO: ======= Flu - negative Resp viral screen - negative Resp viral Cx - pending ___ Blood culture x2 - pending . . IMAGING: ======== ___ CXR: IMPRESSION: Hypoinflated lungs with moderate pulmonary edema and probable small bilateral pleural effusions. Retrocardiac opacities may represent atelectasis, however, superimposed pneumonia cannot be excluded in the appropriate clinical setting. . ___ CXR: IMPRESSION: In comparison with study of ___, there again are low lung volumes with substantial enlargement of the cardiac silhouette and moderate pulmonary edema. Increased opacity at the right base with silhouetting of the hemidiaphragm is consistent with pleural effusion and volume loss in the left lower lobe. The left hemidiaphragm is better seen, suggesting some improvement in atelectatic changes and pleural effusion. In the appropriate clinical setting, it would be impossible to exclude superimposed pneumonia/aspiration, given the findings described above in the absence of a lateral view. . ___ TTE: EF 66%; Small-moderate circumferential pericardial effusion without evidence for hemodynamic compromise. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Brief Hospital Course: Active Problem list: ===================== # Acute hypoxic respiratory failure # Possible community-acquired pneumonia # Acute HFpEF exacerbation # Type II NSTEMI (demand ischemia i/s/o CKD) # Small-to-moderate circumferential pericardial effusion # Mechanical fall while hospitalized # ___ on CKD # Hx of renal transplant on chronic immunosuppression # HTN # IDDM # OSA - untreated . . Hospital Course: ================= # Acute hypoxic respiratory failure # Acute on chronic HFpEF # Possible CAP -Presented with acute hypoxic respiratory failure from HFpEF +/- CAP -SOB and hypoxia responded well to BIPAP and IV Lasix initially in ED and ICU, was over 7 L net negative in ICU. -On transfer to the floor, her O2 sats remained low (w/ 4 L O2 requirement) despite developing signs of contraction alkalosis and intravascular hypovolemia, so she was continued on CAP treatment w/ cefepime and given gentle IVF with resolution of the contraction alkalosis, intravascular hypovolemia and gradual resolution of her hypoxia. -Received total course of 5 days of cefepime for CAP, last dose on ___ . # HFpEF w/ acute exacerbation -TTE on ___ showing normal LVEF, significant LVH, ___ ___ - suggestive of hypertensive heart disease and consistent with chronic HFpEF; presentation with severe hypoxia that responded to BIPAP plus IV Lasix with large volume UOP -Being discharged on her prior home dose of Lasix (10 mg daily), this may ultimately need to be increased to keep her weights stable -She was counseled on the importance of daily weights, sodium restriction, and fluid restriction for CHF management and instructed to notify her MD if increasing daily weights or developing signs/symptoms of volume overload/CHF -Discharge weight: 90 kg (198.4 lbs) . # Small-to-medium pericardial effusion w/o evidence for tamponade: unclear etiology; she resolved clinically back to her baseline with diuresis and abx for possible CAP. [] Consider outpatient cardiology referral or interval cardiac imaging for assessment of small-to-moderate pericardial effusion noted on ___ TTE. . # Hx of renal transplant -Renal transplant service actively followed the patient while she was hospitalized. Her home tacro/MMF doses were not changed during this hospitalization. . # Fall: mechanical fall while hospitalized, tripped on roommate's luggage. No clinical sequelae of fall. ___ evaluated patient and found her to be independent in all activities. . # HTN: on 5-drug regimen for BP control at home. Possible that untreated OSA may be contributing to her recalcitrant hypertension; could also be related to renovascular causes I/s/o renal transplant. Discussed with ___ fellow, no changes to her home regiment made while inpatient. . # DM2, uncontrolled with complications - continued insulin . # OSA: endorses prior Dx, says she wasn't able to wear the CPAP/BIPAP mask due to claustrophobia "a long time ago." [] consider outpatient sleep study to evaluate other/new mask types . . Transitional issues: ======================= -Discharge standing weight: 90 kg -Advised patient to call to schedule PCP ___ within ___ days to follow-up on this hospitalization. [] Consider outpatient cardiology referral or interval cardiac imaging for assessment of small-to-moderate pericardial effusion noted on ___ TTE. [] Consider outpatient sleep study to evaluate other/new mask types so that she might be started on treatment for OSA. . . . Time in care: Greater than 45 minutes in patient care, patient counseling, care coordination and other discharge-related activities today. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Chlorthalidone 25 mg PO DAILY 4. Furosemide 10 mg PO DAILY 5. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Labetalol 300 mg PO BID 7. Mycophenolate Mofetil 500 mg PO BID 8. Tacrolimus 1.5 mg PO Q12H 9. Valsartan 160 mg PO BID 10. Aspirin 81 mg PO DAILY 11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY Discharge Medications: 1. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Chlorthalidone 25 mg PO DAILY 6. Furosemide 10 mg PO DAILY 7. Labetalol 300 mg PO BID 8. Mycophenolate Mofetil 500 mg PO BID 9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 10. Tacrolimus 1.5 mg PO Q12H 11. Valsartan 160 mg PO BID Discharge Disposition: Home Discharge Diagnosis: # Acute hypoxic respiratory failure # Possible community-acquired pneumonia # Acute HFpEF exacerbation # Type II NSTEMI (demand ischemia i/s/o CKD) # Small-to-moderate circumferential pericardial effusion # Mechanical fall while hospitalized # ___ on CKD # Hx of renal transplant on chronic immunosuppression # HTN # IDDM # OSA - untreated Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms ___, You were admitted to the hospital with shortness of breath and very low oxygen levels (hypoxia). You were treated initially with BIPAP, diuretics to help you pee out excess fluid, and IV antibiotics for possible pneumonia. With these interventions your shortness of breath improved rapidly and your oxygen levels improved more gradually, but have now returned to normal levels. You have completed a 5 day course of antibiotics for possible pneumonia and are doing well. However, if in the next ___ days you develop fevers or shaking chills, worsening shortness of breath, cough, or sputum production, please return to the ___ emergency department immediately, as you may need more antibiotics. You are being discharged back on your regular diuretic regimen (Furosemide 10 mg daily). It is VERY IMPORTANT that you weigh yourself each day, at approximately the same time of day, and notify your doctor if your weight is increases by more than 3 lbs from your current weight. If your weight is increasing, you may need to take more of the furosemide (Lasix). It was a pleasure caring for you while you were in the hospital, and we wish you a full and speedy recovery. Sincerely, The ___ Medicine Team Followup Instructions: ___
[ "I110", "J9601", "I21A1", "E861", "E873", "I313", "J189", "E1121", "Z940", "I5033", "Z794", "G4733", "Z9181", "E11319" ]
Allergies: Lisinopril Chief Complaint: SOB Major Surgical or Invasive Procedure: None. History of Present Illness: [MASKED] yo F with h/o HTN, dCHF, DM2, s/p renal transplant, admitted on [MASKED] with a several day h/o dyspnea with exertion, progressive, called EMS and found to have hypoxemia to the 50's. Pt with mild CP on admission (resolved). She reports 9 lb weight gain over six months (wt 209 lbs on admission). In the ED, started on BiPAP. She was treated with empiric abx (for possible PNA) and bid furosemide (for possible pulm edema), with marked improvement. She is now sitting in bed, conversant, on 5L O2, with her husband and daughter at the bedside. She is being transferred to the medical service from the ICU for further care. She currently has no SOB (on O2). She has no HA, f/c, N/V, CP, abd pain. [X] 10 point review of symptoms negative except as noted above. Past Medical History: HTN/dCHF DM2 Living donor renal transplant from her husband ([MASKED]) Social History: [MASKED] Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: HMED ADMISSION EXAM: Afeb 83 160/74 RR 12 SaO2 95% (5L NC) NAD RRR Scattered wheezes/rhonchi +BS, soft, NT, ND No [MASKED] edema A+Ox3 . . HMED DISCHARGE EXAM: VS: 24 HR Data (last updated [MASKED] @ 1457) Temp: 98.0 (Tm 98.5), BP: 132/84 (112-159/58-84), HR: 74 (74-88), RR: 18 ([MASKED]), O2 sat: 95% (93-98), O2 delivery: RA Wt: 90 kg (198.4 lbs) on standing scale Gen: NAD, disheveled, +cushingoid appearance HEENT: EOMI, MMM Neck: obese, unable to visualize any JVP/JVD Cards: RR Chest: trace LLL crackles, no wheezing, normal WOB Abd: obese, S, NT, ND, BS+ Skin: acanthosis nigricans in various places on the back, thickening of skin Ext: no [MASKED] edema, grossly normal strength in arms/legs Neuro: awake, alert, conversant Psych: calm, cooperative Pertinent Results: ADMISSION LABS: ================= [MASKED] 07:08AM BLOOD WBC-10.4* RBC-4.87 Hgb-14.3 Hct-47.8* MCV-98 MCH-29.4 MCHC-29.9* RDW-18.4* RDWSD-61.6* Plt [MASKED] [MASKED] 07:08AM BLOOD Neuts-81.3* Lymphs-9.1* Monos-8.2 Eos-0.5* Baso-0.2 NRBC-0.5* Im [MASKED] AbsNeut-8.48* AbsLymp-0.95* AbsMono-0.85* AbsEos-0.05 AbsBaso-0.02 [MASKED] 07:08AM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 07:08AM BLOOD Glucose-106* UreaN-31* Creat-1.1 Na-135 K-8.6* Cl-94* HCO3-25 AnGap-16 [MASKED] 07:08AM BLOOD ALT-<5 AST-58* CK(CPK)-182 AlkPhos-70 TotBili-0.6 [MASKED] 07:08AM BLOOD CK-MB-7 proBNP-1020* [MASKED] 07:08AM BLOOD cTropnT-0.05* [MASKED] 07:08AM BLOOD Albumin-4.4 [MASKED] 05:02PM BLOOD Calcium-10.0 Phos-3.8 Mg-2.0 [MASKED] 07:15AM BLOOD [MASKED] pO2-51* pCO2-53* pH-7.32* calTCO2-29 Base XS-0 Intubat-NOT INTUBA Comment-ADDED TO A [MASKED] 07:15AM BLOOD K-5.0 . . NOTABLE LABS WHILE INPATIENT: ============================= [MASKED] 07:08AM BLOOD CK-MB-7 proBNP-1020* [MASKED] 07:08AM BLOOD cTropnT-0.05* [MASKED] 05:02PM BLOOD CK-MB-9 cTropnT-0.06* [MASKED] 06:17AM BLOOD CK-MB-5 cTropnT-0.08* [MASKED] 09:00AM BLOOD tacroFK-5.2 [MASKED] 10:35AM BLOOD tacroFK-7.4 . . DISCHARGE LABS: ================ [MASKED] 07:10AM BLOOD WBC-9.0 RBC-4.91 Hgb-14.4 Hct-46.9* MCV-96 MCH-29.3 MCHC-30.7* RDW-16.4* RDWSD-56.7* Plt [MASKED] [MASKED] 07:10AM BLOOD Glucose-248* UreaN-41* Creat-1.1 Na-136 K-4.9 Cl-90* HCO3-31 AnGap-15 [MASKED] 07:10AM BLOOD Calcium-9.7 Phos-2.4* Mg-2.5 . . MICRO: ======= Flu - negative Resp viral screen - negative Resp viral Cx - pending [MASKED] Blood culture x2 - pending . . IMAGING: ======== [MASKED] CXR: IMPRESSION: Hypoinflated lungs with moderate pulmonary edema and probable small bilateral pleural effusions. Retrocardiac opacities may represent atelectasis, however, superimposed pneumonia cannot be excluded in the appropriate clinical setting. . [MASKED] CXR: IMPRESSION: In comparison with study of [MASKED], there again are low lung volumes with substantial enlargement of the cardiac silhouette and moderate pulmonary edema. Increased opacity at the right base with silhouetting of the hemidiaphragm is consistent with pleural effusion and volume loss in the left lower lobe. The left hemidiaphragm is better seen, suggesting some improvement in atelectatic changes and pleural effusion. In the appropriate clinical setting, it would be impossible to exclude superimposed pneumonia/aspiration, given the findings described above in the absence of a lateral view. . [MASKED] TTE: EF 66%; Small-moderate circumferential pericardial effusion without evidence for hemodynamic compromise. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Brief Hospital Course: Active Problem list: ===================== # Acute hypoxic respiratory failure # Possible community-acquired pneumonia # Acute HFpEF exacerbation # Type II NSTEMI (demand ischemia i/s/o CKD) # Small-to-moderate circumferential pericardial effusion # Mechanical fall while hospitalized # [MASKED] on CKD # Hx of renal transplant on chronic immunosuppression # HTN # IDDM # OSA - untreated . . Hospital Course: ================= # Acute hypoxic respiratory failure # Acute on chronic HFpEF # Possible CAP -Presented with acute hypoxic respiratory failure from HFpEF +/- CAP -SOB and hypoxia responded well to BIPAP and IV Lasix initially in ED and ICU, was over 7 L net negative in ICU. -On transfer to the floor, her O2 sats remained low (w/ 4 L O2 requirement) despite developing signs of contraction alkalosis and intravascular hypovolemia, so she was continued on CAP treatment w/ cefepime and given gentle IVF with resolution of the contraction alkalosis, intravascular hypovolemia and gradual resolution of her hypoxia. -Received total course of 5 days of cefepime for CAP, last dose on [MASKED] . # HFpEF w/ acute exacerbation -TTE on [MASKED] showing normal LVEF, significant LVH, [MASKED] [MASKED] - suggestive of hypertensive heart disease and consistent with chronic HFpEF; presentation with severe hypoxia that responded to BIPAP plus IV Lasix with large volume UOP -Being discharged on her prior home dose of Lasix (10 mg daily), this may ultimately need to be increased to keep her weights stable -She was counseled on the importance of daily weights, sodium restriction, and fluid restriction for CHF management and instructed to notify her MD if increasing daily weights or developing signs/symptoms of volume overload/CHF -Discharge weight: 90 kg (198.4 lbs) . # Small-to-medium pericardial effusion w/o evidence for tamponade: unclear etiology; she resolved clinically back to her baseline with diuresis and abx for possible CAP. [] Consider outpatient cardiology referral or interval cardiac imaging for assessment of small-to-moderate pericardial effusion noted on [MASKED] TTE. . # Hx of renal transplant -Renal transplant service actively followed the patient while she was hospitalized. Her home tacro/MMF doses were not changed during this hospitalization. . # Fall: mechanical fall while hospitalized, tripped on roommate's luggage. No clinical sequelae of fall. [MASKED] evaluated patient and found her to be independent in all activities. . # HTN: on 5-drug regimen for BP control at home. Possible that untreated OSA may be contributing to her recalcitrant hypertension; could also be related to renovascular causes I/s/o renal transplant. Discussed with [MASKED] fellow, no changes to her home regiment made while inpatient. . # DM2, uncontrolled with complications - continued insulin . # OSA: endorses prior Dx, says she wasn't able to wear the CPAP/BIPAP mask due to claustrophobia "a long time ago." [] consider outpatient sleep study to evaluate other/new mask types . . Transitional issues: ======================= -Discharge standing weight: 90 kg -Advised patient to call to schedule PCP [MASKED] within [MASKED] days to follow-up on this hospitalization. [] Consider outpatient cardiology referral or interval cardiac imaging for assessment of small-to-moderate pericardial effusion noted on [MASKED] TTE. [] Consider outpatient sleep study to evaluate other/new mask types so that she might be started on treatment for OSA. . . . Time in care: Greater than 45 minutes in patient care, patient counseling, care coordination and other discharge-related activities today. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Chlorthalidone 25 mg PO DAILY 4. Furosemide 10 mg PO DAILY 5. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Labetalol 300 mg PO BID 7. Mycophenolate Mofetil 500 mg PO BID 8. Tacrolimus 1.5 mg PO Q12H 9. Valsartan 160 mg PO BID 10. Aspirin 81 mg PO DAILY 11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY Discharge Medications: 1. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Chlorthalidone 25 mg PO DAILY 6. Furosemide 10 mg PO DAILY 7. Labetalol 300 mg PO BID 8. Mycophenolate Mofetil 500 mg PO BID 9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 10. Tacrolimus 1.5 mg PO Q12H 11. Valsartan 160 mg PO BID Discharge Disposition: Home Discharge Diagnosis: # Acute hypoxic respiratory failure # Possible community-acquired pneumonia # Acute HFpEF exacerbation # Type II NSTEMI (demand ischemia i/s/o CKD) # Small-to-moderate circumferential pericardial effusion # Mechanical fall while hospitalized # [MASKED] on CKD # Hx of renal transplant on chronic immunosuppression # HTN # IDDM # OSA - untreated 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 the hospital with shortness of breath and very low oxygen levels (hypoxia). You were treated initially with BIPAP, diuretics to help you pee out excess fluid, and IV antibiotics for possible pneumonia. With these interventions your shortness of breath improved rapidly and your oxygen levels improved more gradually, but have now returned to normal levels. You have completed a 5 day course of antibiotics for possible pneumonia and are doing well. However, if in the next [MASKED] days you develop fevers or shaking chills, worsening shortness of breath, cough, or sputum production, please return to the [MASKED] emergency department immediately, as you may need more antibiotics. You are being discharged back on your regular diuretic regimen (Furosemide 10 mg daily). It is VERY IMPORTANT that you weigh yourself each day, at approximately the same time of day, and notify your doctor if your weight is increases by more than 3 lbs from your current weight. If your weight is increasing, you may need to take more of the furosemide (Lasix). It was a pleasure caring for you while you were in the hospital, and we wish you a full and speedy recovery. Sincerely, The [MASKED] Medicine Team Followup Instructions: [MASKED]
[]
[ "I110", "J9601", "Z794", "G4733" ]
[ "I110: Hypertensive heart disease with heart failure", "J9601: Acute respiratory failure with hypoxia", "I21A1: Myocardial infarction type 2", "E861: Hypovolemia", "E873: Alkalosis", "I313: Pericardial effusion (noninflammatory)", "J189: Pneumonia, unspecified organism", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "Z940: Kidney transplant status", "I5033: Acute on chronic diastolic (congestive) heart failure", "Z794: Long term (current) use of insulin", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z9181: History of falling", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema" ]
10,075,925
25,211,602
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril / Iodinated Contrast- Oral and IV Dye Attending: ___. Chief Complaint: R arm fracture, respiratory failure, metastatic cancer Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with a past medical history pertinent for HTN, HFpEF, IDDM, ESRD due to DM s/p LURT ___ (living donor: husband), widely metastatic adenocarcinoma of the lung (bones, liver) who was recently discharged to home hospice ___ with home nursing, including tri- or bi-weekly drainage of R chest Pleurex, who now presented ___t home from bed leading to a left midshaft humerus fracture. Ortho saw patient and placed her arm in a coaptation splint. She was subsequently triaged for admission to hospital medicine to facilitate inpatient hospice arrangement. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Metastic Lung Cancer Hypertension Heart failure with preserved ejection fraction (HFpEF) Type 1 diabetes mellitus End stage renal disease (ESRD) Living donor renal transplant from her husband (___) Pericardial effusion (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Chronically ill woman lying in bed with rebreather mask on, right arm splinted and wrapped, husband at bedside, in no apparent distress. EYES: PERRL. EOMI. Anicteric sclerae. ENT: Ears and nose without visible erythema, masses, or trauma. Posterior oropharynx without erythema or exudate, uvula midline. CV: Regular rate and rhythm. Normal S1 S2, no S3, no S4. No murmur. No JVD. PULM: Breathing comfortably with rebreather mask on. Bilateral crackles and wheezes, right chest Pleurex in place with site c/d/i. GI: Bowel sounds reduced. Abdomen non-distended, soft, non-tender to palpation. GU: No suprapubic fullness or tenderness to palpation. EXTR: Right arm in splint and wrapped extensively. No lower extremity edema. Distal extremity pulses palpable throughout. SKIN: No rashes, ulcerations, scars noted. NEURO: Lethargic but arousable to voice. Oriented to self and husband, not clear on place or details of situation. Face symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all limbs spontaneously. No tremors, asterixis, or other involuntary movements observed. PSYCH: Very lethargic. Denies pain or distress. Answers simple questions appropriately. Appropriate affect. DISCHARGE: T97.7 BP 126/75 HR84 RR20 90% on 6L NC Gen: lethargic woman resting in bed with NC, NAD. HEENT: anicteric sclera, EOMI, OP clear Lungs: Bilateral crackles R > L. Right pleurex in place. Cards: RRR no m/r/g Abd: soft, NTND Ext: well perfused, no edema Neuro: very lethargic, responsive to voice but not following commands nor answering questions appropriately. Pertinent Results: IMAGING: ======= HUMERUS (AP & LAT) ___ There is an oblique fracture through the midshaft of the right humerus with lateral displacement and apparent apex dorsal angulation of the distal fracture fragment. Evaluation of alignment is limited on this single projection. There is prominent surrounding soft tissue swelling. Limited view of the elbow joint is unremarkable. There is no definite displaced rib fracture in the right chest cage on limited assessment. IMPRESSION: Oblique fracture through the midshaft of the right humerus with displacement and probable angulation as described. Brief Hospital Course: Ms. ___ is a ___ woman with a past medical history pertinent for HTN, HFpEF, IDDM, ESRD due to DM s/p LURT ___ (living donor: husband), widely metastatic adenocarcinoma of the lung (bones, liver) who was recently discharged to home hospice ___ with home nursing, including tri- or bi-weekly drainage of R chest Pleurex, who now presented ___t home from bed leading to a left midshaft humerus fracture. Ortho saw patient and placed her arm in a coaptation splint. She was subsequently triaged for admission to hospital medicine to facilitate inpatient hospice arrangement. # Widely metastatic lung adenocarcinoma # Home to inpatient hospice transition Discharged to home hospice last admission. Unfortunately, experienced fall with resultant humerus fracture. After discussion with family/HCP, felt that inpatient hospice would provide optimal care. She has a right pleurex catheter that has been getting drained bi- to tri-weekly, last drained ___ for 550cc. # Right humerus fracture: Presented with right arm pain after fall and found to have an oblique fracture through the midshaft of the right humerus on x-ray. Her injury was deemed inoperable and she was placed in a coaptation splint. She is to be nonweightbearing on the right side. She would need follow up in ___ clinic in ___ weeks but expect her life expectancy to be more limited. # ESRD s/p LURT. Patient unable to take home tacrolimus 2.5 mg BID, so this was discontinued. # DM1: Previously on 22u lantus qHS, has been cut back drastically by husband in setting of poor to no PO intake. Received 8u lantus + 2u correction insulin ___ and was hypoglycemic morning of ___ with FSBG of 50. Discharging on 5u lantus to maintain basal insulin level and prevent precipitation of DKA. # TRANSITIONAL ISSUES: ===================== [] Please continue draining R. pleurex catheter as needed for comfort (previously getting drained ___ per week. [] Recommend continuing some level of basal insulin to prevent DKA. [] If patient again able to take PO meds, would consider restarting tacrolimus to prevent rejection of kidney transplant (which would cause avoidable discomfort). [] As above, right humerus to be kept in coaptation splint and she is non-weoghtbearing on that extremity. Greater than 30 minutes spent coordinating discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Labetalol 200 mg PO BID 3. Glargine 22 Units Bedtime Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Docusate Sodium 100 mg PO BID 5. Tacrolimus 2.5 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever 2. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions 3. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q15MIN:PRN moderate-severe pain or respiratory distress 4. LORazepam 0.5-2 mg IV Q2H:PRN anxiety This is a new medication for comfort. 5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q1H:PRN pain 6. Glargine 5 Units Bedtime Discharge Disposition: Extended Care Discharge Diagnosis: # Stage IV Lung Cancer: # End of life care: Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___, It was a privilege to care for you at the ___ ___. You were admitted to the hospital after a fall at home. You are now ready for discharge to an ___ facility for ongoing care. Sincerely, Your ___ team Followup Instructions: ___
[ "S42331A", "W06XXXA", "Y92009", "C3490", "C787", "C7951", "J9690", "I132", "I5032", "N186", "E1022", "Z940", "Z794", "Z66", "E1021", "E10319", "E785" ]
Allergies: Lisinopril / Iodinated Contrast- Oral and IV Dye Chief Complaint: R arm fracture, respiratory failure, metastatic cancer Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] woman with a past medical history pertinent for HTN, HFpEF, IDDM, ESRD due to DM s/p LURT [MASKED] (living donor: husband), widely metastatic adenocarcinoma of the lung (bones, liver) who was recently discharged to home hospice [MASKED] with home nursing, including tri- or bi-weekly drainage of R chest Pleurex, who now presented t home from bed leading to a left midshaft humerus fracture. Ortho saw patient and placed her arm in a coaptation splint. She was subsequently triaged for admission to hospital medicine to facilitate inpatient hospice arrangement. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: Metastic Lung Cancer Hypertension Heart failure with preserved ejection fraction (HFpEF) Type 1 diabetes mellitus End stage renal disease (ESRD) Living donor renal transplant from her husband ([MASKED]) Pericardial effusion ([MASKED]) Social History: [MASKED] Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION: VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Chronically ill woman lying in bed with rebreather mask on, right arm splinted and wrapped, husband at bedside, in no apparent distress. EYES: PERRL. EOMI. Anicteric sclerae. ENT: Ears and nose without visible erythema, masses, or trauma. Posterior oropharynx without erythema or exudate, uvula midline. CV: Regular rate and rhythm. Normal S1 S2, no S3, no S4. No murmur. No JVD. PULM: Breathing comfortably with rebreather mask on. Bilateral crackles and wheezes, right chest Pleurex in place with site c/d/i. GI: Bowel sounds reduced. Abdomen non-distended, soft, non-tender to palpation. GU: No suprapubic fullness or tenderness to palpation. EXTR: Right arm in splint and wrapped extensively. No lower extremity edema. Distal extremity pulses palpable throughout. SKIN: No rashes, ulcerations, scars noted. NEURO: Lethargic but arousable to voice. Oriented to self and husband, not clear on place or details of situation. Face symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all limbs spontaneously. No tremors, asterixis, or other involuntary movements observed. PSYCH: Very lethargic. Denies pain or distress. Answers simple questions appropriately. Appropriate affect. DISCHARGE: T97.7 BP 126/75 HR84 RR20 90% on 6L NC Gen: lethargic woman resting in bed with NC, NAD. HEENT: anicteric sclera, EOMI, OP clear Lungs: Bilateral crackles R > L. Right pleurex in place. Cards: RRR no m/r/g Abd: soft, NTND Ext: well perfused, no edema Neuro: very lethargic, responsive to voice but not following commands nor answering questions appropriately. Pertinent Results: IMAGING: ======= HUMERUS (AP & LAT) [MASKED] There is an oblique fracture through the midshaft of the right humerus with lateral displacement and apparent apex dorsal angulation of the distal fracture fragment. Evaluation of alignment is limited on this single projection. There is prominent surrounding soft tissue swelling. Limited view of the elbow joint is unremarkable. There is no definite displaced rib fracture in the right chest cage on limited assessment. IMPRESSION: Oblique fracture through the midshaft of the right humerus with displacement and probable angulation as described. Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with a past medical history pertinent for HTN, HFpEF, IDDM, ESRD due to DM s/p LURT [MASKED] (living donor: husband), widely metastatic adenocarcinoma of the lung (bones, liver) who was recently discharged to home hospice [MASKED] with home nursing, including tri- or bi-weekly drainage of R chest Pleurex, who now presented t home from bed leading to a left midshaft humerus fracture. Ortho saw patient and placed her arm in a coaptation splint. She was subsequently triaged for admission to hospital medicine to facilitate inpatient hospice arrangement. # Widely metastatic lung adenocarcinoma # Home to inpatient hospice transition Discharged to home hospice last admission. Unfortunately, experienced fall with resultant humerus fracture. After discussion with family/HCP, felt that inpatient hospice would provide optimal care. She has a right pleurex catheter that has been getting drained bi- to tri-weekly, last drained [MASKED] for 550cc. # Right humerus fracture: Presented with right arm pain after fall and found to have an oblique fracture through the midshaft of the right humerus on x-ray. Her injury was deemed inoperable and she was placed in a coaptation splint. She is to be nonweightbearing on the right side. She would need follow up in [MASKED] clinic in [MASKED] weeks but expect her life expectancy to be more limited. # ESRD s/p LURT. Patient unable to take home tacrolimus 2.5 mg BID, so this was discontinued. # DM1: Previously on 22u lantus qHS, has been cut back drastically by husband in setting of poor to no PO intake. Received 8u lantus + 2u correction insulin [MASKED] and was hypoglycemic morning of [MASKED] with FSBG of 50. Discharging on 5u lantus to maintain basal insulin level and prevent precipitation of DKA. # TRANSITIONAL ISSUES: ===================== [] Please continue draining R. pleurex catheter as needed for comfort (previously getting drained [MASKED] per week. [] Recommend continuing some level of basal insulin to prevent DKA. [] If patient again able to take PO meds, would consider restarting tacrolimus to prevent rejection of kidney transplant (which would cause avoidable discomfort). [] As above, right humerus to be kept in coaptation splint and she is non-weoghtbearing on that extremity. Greater than 30 minutes spent coordinating discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Labetalol 200 mg PO BID 3. Glargine 22 Units Bedtime Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Docusate Sodium 100 mg PO BID 5. Tacrolimus 2.5 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever 2. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions 3. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q15MIN:PRN moderate-severe pain or respiratory distress 4. LORazepam 0.5-2 mg IV Q2H:PRN anxiety This is a new medication for comfort. 5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL [MASKED] mg PO Q1H:PRN pain 6. Glargine 5 Units Bedtime Discharge Disposition: Extended Care Discharge Diagnosis: # Stage IV Lung Cancer: # End of life care: Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [MASKED], It was a privilege to care for you at the [MASKED] [MASKED]. You were admitted to the hospital after a fall at home. You are now ready for discharge to an [MASKED] facility for ongoing care. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "I5032", "Z794", "Z66", "E785" ]
[ "S42331A: Displaced oblique fracture of shaft of humerus, right arm, initial encounter for closed fracture", "W06XXXA: Fall from bed, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7951: Secondary malignant neoplasm of bone", "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5032: Chronic diastolic (congestive) heart failure", "N186: End stage renal disease", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "Z940: Kidney transplant status", "Z794: Long term (current) use of insulin", "Z66: Do not resuscitate", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E785: Hyperlipidemia, unspecified" ]
10,075,925
26,160,109
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril Attending: ___. Chief Complaint: B/L Leg Swelling Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ hx renal transplant ___, living unrelated donor) on MMF, tacrolimus who presented with acute onset of R>L lower extremity swelling overnight. Patient reports noncompliance with low sodium diet recently and over the holidays. She denies recent travel, fever/chills, CP, SOB. In the ED, initial vitals: 97.8 79 175/66 18 94% RA Labs were significant for normal CBC: WBC 9.8 H/H 14.1/45, Plt 256 Chemistry panel unremarkable: Na 140 K 4.9 Cl 100 HCO3 27 BUN 29 Cr 1.1 LFTs normal Trop T: 0.02 -> 0.01 proBNP 369. CXR showed new mild pulmonary vascular congestion with mild/moderate interstitial pulmonary edema and increased mild cardiomegaly without focal consolidation. Renal transplant ultrasound normal. Pt received 40 mg IV Lasix. Currently, Patient denies CP, SOB, abdominal pain. States that her leg swelling has improved. ROS: 10- point review of systems reviewed and negative Past Medical History: 1. Urinary tract infection in ___ treated with Levo. She had a urinary tract infection in ___, which was Levo resistant. 2. Insulin dependent diabetes. 3. Hypertension. PAST SURGICAL HISTORY: Living donor kidney transplant from her husband in ___. Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION EXAM: =============== VS: 99.1 152/59 80 20 98%RA GEN: Alert, sitting upright in bed in NAD HEENT: Cushingoid face. MMM. NECK: Supple PULM: CTAB COR: RRR (+)S1/S2 no m/r/g ABD: Soft, nontender, nondistended. EXTREM: R>L 1+ edema in the lower extremities to the knee. Extremities warm NEURO: CN II-XII grossly intact, AAOx3 DISCHARGE EXAM: =============== Vitals: 98.6 150s/50s-60s ___ 20 95%RA GEN: Alert, sitting upright in bed in NAD HEENT: Cushingoid face. MMM. NECK: Supple PULM: CTAB COR: RRR (+)S1/S2 no m/r/g ABD: Soft, nontender, nondistended. EXTREM: Improved ___ edema. Extremities warm NEURO: CN II-XII grossly intact, AAOx3 Pertinent Results: ADMISSION LABS: =============== ___ 09:05AM cTropnT-0.01 ___ 04:25AM URINE HOURS-RANDOM CREAT-32 TOT PROT-7 PROT/CREA-0.2 ___ 04:25AM URINE HOURS-RANDOM ___ 04:25AM URINE UCG-NEGATIVE ___ 04:25AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 04:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 11:50PM GLUCOSE-82 UREA N-29* CREAT-1.1 SODIUM-140 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-18 ___ 11:50PM estGFR-Using this ___ 11:50PM ALT(SGPT)-21 AST(SGOT)-20 ALK PHOS-57 TOT BILI-0.3 ___ 11:50PM cTropnT-0.02* ___ 11:50PM proBNP-369* ___ 11:50PM WBC-9.8 RBC-4.71 HGB-14.1 HCT-45.0 MCV-96 MCH-29.9 MCHC-31.3* RDW-15.5 RDWSD-55.2* ___ 11:50PM NEUTS-74.1* LYMPHS-12.5* MONOS-11.3 EOS-1.3 BASOS-0.4 IM ___ AbsNeut-7.26* AbsLymp-1.23 AbsMono-1.11* AbsEos-0.13 AbsBaso-0.04 ___ 11:50PM PLT COUNT-256 MICRO: ====== ___ 4:25 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. DISCHARGE LABS: =============== ___ 07:45AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.2 Hct-46.1* MCV-95 MCH-29.3 MCHC-30.8* RDW-15.1 RDWSD-52.9* Plt ___ ___ 07:45AM BLOOD Glucose-268* UreaN-26* Creat-1.0 Na-136 K-5.1 Cl-95* HCO3-28 AnGap-18 ___ 07:45AM BLOOD Calcium-10.9* Phos-3.7 Mg-1.8 IMAGING/STUDIES: ================ + ECG Study Date of ___ 11:35:33 ___ Clinical indication for EKG: Localized edema Sinus rhythm. Poor R wave progression across the precordium. Small Q wave in lead III of unknown significance. Non-specific ST-T wave abnormalities which are unchanged compared to the previous tracing of ___. Intervals Axes Rate PR QRS QT QTc (___) P QRS T 80 135 86 ___ + ___ Imaging UNILAT LOWER EXT VEINS IMPRESSION: 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Moderate right lower extremity edema. + ___ Imaging CHEST (PA & LAT) IMPRESSION: New mild pulmonary vascular congestion with mild to moderate interstitial pulmonary edema and increased mild cardiomegaly. No focal consolidation. + ___ Cardiovascular ECHO Conclusions The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate circumferential pericardial effusion with no echocardiographic signs of tamponade. Mild symmetric left ventricular hypertrophy with preserved regional/global systolic function. Moderate diastolic dysfunction with elevated PCWP. Compared with the report of the prior study (images unavailable for review) of ___, the effusion is new. There are signs of diastolic dysfunction. Brief Hospital Course: ___ hx renal transplant ___, living unrelated donor) on MMF, tacrolimus who presented with acute onset of R>L lower extremity swelling overnight. # Lower extremity edema: The patient had lower extremity Doppler which showed no evidence of RLE DVT. She had a chest xray which showed mild pulmonary edema and so she was diuresed with 40 mg IV Lasix, and by the next day her lower extremity swelling improved. She had a TTE which showed grade II diastolic dysfunction, normal EF (70-75%) and a small/moderate pericardial effusion without evidence of tamponade. The patient was not hypotensive. Because of this, the patient was started on Lasix 10 mg PO daily. # ESRD s/p transplant: Patient had no evidence of allograft dysfunction as creatinine was at baseline and renal transplant ultrasound was normal. She continued on home tacrolimus and mycophenolate mofetil. # Diabetes, insulin-dependent: Patient continued on home lantus 40 mg qHS and Humalog sliding scale. # HTN: Patient continued on home valsartan, chlorthalidone. # Hx recurrent UTIs: Continued home nitrofurantoin. TRANSITIONAL ISSUES: - Discharge weight: 93.9 kg [] Patient has follow up with new PCP, ___ ___. Please order a repeat TTE at this visit in order to evaluate for interval change in pericardial effusion. Please also check chemistry panel given initiation of Lasix. [] Patient was discharged on Lasix 10 mg PO daily. [] Patient diagnosed with new diastolic dysfunction has follow up with cardiology on ___. # CODE STATUS: Full (confirmed) # CONTACT: Husband / HCT ___ ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 20 mg PO QPM 2. Chlorthalidone 25 mg PO DAILY 3. Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Labetalol 300 mg PO BID 5. Mycophenolate Mofetil 500 mg PO BID 6. Tacrolimus 1 mg PO Q12H 7. Valsartan 160 mg PO BID 8. Nitrofurantoin (Macrodantin) 100 mg PO QHS Discharge Medications: 1. Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 2. Labetalol 300 mg PO BID 3. Mycophenolate Mofetil 500 mg PO BID 4. Nitrofurantoin (Macrodantin) 100 mg PO QHS 5. Tacrolimus 1 mg PO Q12H 6. Valsartan 160 mg PO BID 7. Atorvastatin 20 mg PO QPM 8. Chlorthalidone 25 mg PO DAILY 9. Furosemide 10 mg PO DAILY RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth Daily Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Diastolic dysfunction Secondary diagnoses: ESRD s/p renal transplant Insulin-dependent diabetes 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 ___ because you were having right leg swelling. You had an ultrasound of your leg which did not show a DVT, or blood clot. You had a chest xray which showed mild fluid overload in your lungs. You were given a dose of a diuretic medication and your swelling decreased. While you were here, you had an echocardiogram of your heart which showed that you have diastolic heart failure, meaning that your heart is still and has caused some fluid to back up into your lungs and legs. You were started on a water pill which will help keep fluid from building up. You also had a little bit of fluid around your heart. It is very important that you see your new PCP next week and have a repeat echo to make sure the fluid has gone away. You should also weigh yourself daily and call your doctor if you gain more than 3 pounds in a few days. You have been given a new PCP at ___. Please follow up with Dr. ___ below). We have also set you up with a cardiologist (see below). Thank you for allowing us to participate in your care. Sincerely, Your ___ Team Followup Instructions: ___
[ "I5033", "J811", "I313", "I120", "N186", "Z940", "Z992", "E119", "Z794", "E669", "Z6841", "H409", "I272", "Z87440", "Z9111" ]
Allergies: Lisinopril Chief Complaint: B/L Leg Swelling Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] hx renal transplant [MASKED], living unrelated donor) on MMF, tacrolimus who presented with acute onset of R>L lower extremity swelling overnight. Patient reports noncompliance with low sodium diet recently and over the holidays. She denies recent travel, fever/chills, CP, SOB. In the ED, initial vitals: 97.8 79 175/66 18 94% RA Labs were significant for normal CBC: WBC 9.8 H/H 14.1/45, Plt 256 Chemistry panel unremarkable: Na 140 K 4.9 Cl 100 HCO3 27 BUN 29 Cr 1.1 LFTs normal Trop T: 0.02 -> 0.01 proBNP 369. CXR showed new mild pulmonary vascular congestion with mild/moderate interstitial pulmonary edema and increased mild cardiomegaly without focal consolidation. Renal transplant ultrasound normal. Pt received 40 mg IV Lasix. Currently, Patient denies CP, SOB, abdominal pain. States that her leg swelling has improved. ROS: 10- point review of systems reviewed and negative Past Medical History: 1. Urinary tract infection in [MASKED] treated with Levo. She had a urinary tract infection in [MASKED], which was Levo resistant. 2. Insulin dependent diabetes. 3. Hypertension. PAST SURGICAL HISTORY: Living donor kidney transplant from her husband in [MASKED]. Social History: [MASKED] Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION EXAM: =============== VS: 99.1 152/59 80 20 98%RA GEN: Alert, sitting upright in bed in NAD HEENT: Cushingoid face. MMM. NECK: Supple PULM: CTAB COR: RRR (+)S1/S2 no m/r/g ABD: Soft, nontender, nondistended. EXTREM: R>L 1+ edema in the lower extremities to the knee. Extremities warm NEURO: CN II-XII grossly intact, AAOx3 DISCHARGE EXAM: =============== Vitals: 98.6 150s/50s-60s [MASKED] 20 95%RA GEN: Alert, sitting upright in bed in NAD HEENT: Cushingoid face. MMM. NECK: Supple PULM: CTAB COR: RRR (+)S1/S2 no m/r/g ABD: Soft, nontender, nondistended. EXTREM: Improved [MASKED] edema. Extremities warm NEURO: CN II-XII grossly intact, AAOx3 Pertinent Results: ADMISSION LABS: =============== [MASKED] 09:05AM cTropnT-0.01 [MASKED] 04:25AM URINE HOURS-RANDOM CREAT-32 TOT PROT-7 PROT/CREA-0.2 [MASKED] 04:25AM URINE HOURS-RANDOM [MASKED] 04:25AM URINE UCG-NEGATIVE [MASKED] 04:25AM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 04:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 11:50PM GLUCOSE-82 UREA N-29* CREAT-1.1 SODIUM-140 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-27 ANION GAP-18 [MASKED] 11:50PM estGFR-Using this [MASKED] 11:50PM ALT(SGPT)-21 AST(SGOT)-20 ALK PHOS-57 TOT BILI-0.3 [MASKED] 11:50PM cTropnT-0.02* [MASKED] 11:50PM proBNP-369* [MASKED] 11:50PM WBC-9.8 RBC-4.71 HGB-14.1 HCT-45.0 MCV-96 MCH-29.9 MCHC-31.3* RDW-15.5 RDWSD-55.2* [MASKED] 11:50PM NEUTS-74.1* LYMPHS-12.5* MONOS-11.3 EOS-1.3 BASOS-0.4 IM [MASKED] AbsNeut-7.26* AbsLymp-1.23 AbsMono-1.11* AbsEos-0.13 AbsBaso-0.04 [MASKED] 11:50PM PLT COUNT-256 MICRO: ====== [MASKED] 4:25 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. DISCHARGE LABS: =============== [MASKED] 07:45AM BLOOD WBC-8.1 RBC-4.84 Hgb-14.2 Hct-46.1* MCV-95 MCH-29.3 MCHC-30.8* RDW-15.1 RDWSD-52.9* Plt [MASKED] [MASKED] 07:45AM BLOOD Glucose-268* UreaN-26* Creat-1.0 Na-136 K-5.1 Cl-95* HCO3-28 AnGap-18 [MASKED] 07:45AM BLOOD Calcium-10.9* Phos-3.7 Mg-1.8 IMAGING/STUDIES: ================ + ECG Study Date of [MASKED] 11:35:33 [MASKED] Clinical indication for EKG: Localized edema Sinus rhythm. Poor R wave progression across the precordium. Small Q wave in lead III of unknown significance. Non-specific ST-T wave abnormalities which are unchanged compared to the previous tracing of [MASKED]. Intervals Axes Rate PR QRS QT QTc ([MASKED]) P QRS T 80 135 86 [MASKED] + [MASKED] Imaging UNILAT LOWER EXT VEINS IMPRESSION: 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Moderate right lower extremity edema. + [MASKED] Imaging CHEST (PA & LAT) IMPRESSION: New mild pulmonary vascular congestion with mild to moderate interstitial pulmonary edema and increased mild cardiomegaly. No focal consolidation. + [MASKED] Cardiovascular ECHO Conclusions The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Small to moderate circumferential pericardial effusion with no echocardiographic signs of tamponade. Mild symmetric left ventricular hypertrophy with preserved regional/global systolic function. Moderate diastolic dysfunction with elevated PCWP. Compared with the report of the prior study (images unavailable for review) of [MASKED], the effusion is new. There are signs of diastolic dysfunction. Brief Hospital Course: [MASKED] hx renal transplant [MASKED], living unrelated donor) on MMF, tacrolimus who presented with acute onset of R>L lower extremity swelling overnight. # Lower extremity edema: The patient had lower extremity Doppler which showed no evidence of RLE DVT. She had a chest xray which showed mild pulmonary edema and so she was diuresed with 40 mg IV Lasix, and by the next day her lower extremity swelling improved. She had a TTE which showed grade II diastolic dysfunction, normal EF (70-75%) and a small/moderate pericardial effusion without evidence of tamponade. The patient was not hypotensive. Because of this, the patient was started on Lasix 10 mg PO daily. # ESRD s/p transplant: Patient had no evidence of allograft dysfunction as creatinine was at baseline and renal transplant ultrasound was normal. She continued on home tacrolimus and mycophenolate mofetil. # Diabetes, insulin-dependent: Patient continued on home lantus 40 mg qHS and Humalog sliding scale. # HTN: Patient continued on home valsartan, chlorthalidone. # Hx recurrent UTIs: Continued home nitrofurantoin. TRANSITIONAL ISSUES: - Discharge weight: 93.9 kg [] Patient has follow up with new PCP, [MASKED] [MASKED]. Please order a repeat TTE at this visit in order to evaluate for interval change in pericardial effusion. Please also check chemistry panel given initiation of Lasix. [] Patient was discharged on Lasix 10 mg PO daily. [] Patient diagnosed with new diastolic dysfunction has follow up with cardiology on [MASKED]. # CODE STATUS: Full (confirmed) # CONTACT: Husband / HCT [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Atorvastatin 20 mg PO QPM 2. Chlorthalidone 25 mg PO DAILY 3. Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Labetalol 300 mg PO BID 5. Mycophenolate Mofetil 500 mg PO BID 6. Tacrolimus 1 mg PO Q12H 7. Valsartan 160 mg PO BID 8. Nitrofurantoin (Macrodantin) 100 mg PO QHS Discharge Medications: 1. Glargine 40 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 2. Labetalol 300 mg PO BID 3. Mycophenolate Mofetil 500 mg PO BID 4. Nitrofurantoin (Macrodantin) 100 mg PO QHS 5. Tacrolimus 1 mg PO Q12H 6. Valsartan 160 mg PO BID 7. Atorvastatin 20 mg PO QPM 8. Chlorthalidone 25 mg PO DAILY 9. Furosemide 10 mg PO DAILY RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth Daily Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Diastolic dysfunction Secondary diagnoses: ESRD s/p renal transplant Insulin-dependent diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the [MASKED] because you were having right leg swelling. You had an ultrasound of your leg which did not show a DVT, or blood clot. You had a chest xray which showed mild fluid overload in your lungs. You were given a dose of a diuretic medication and your swelling decreased. While you were here, you had an echocardiogram of your heart which showed that you have diastolic heart failure, meaning that your heart is still and has caused some fluid to back up into your lungs and legs. You were started on a water pill which will help keep fluid from building up. You also had a little bit of fluid around your heart. It is very important that you see your new PCP next week and have a repeat echo to make sure the fluid has gone away. You should also weigh yourself daily and call your doctor if you gain more than 3 pounds in a few days. You have been given a new PCP at [MASKED]. Please follow up with Dr. [MASKED] below). We have also set you up with a cardiologist (see below). Thank you for allowing us to participate in your care. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "E119", "Z794", "E669" ]
[ "I5033: Acute on chronic diastolic (congestive) heart failure", "J811: Chronic pulmonary edema", "I313: Pericardial effusion (noninflammatory)", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "Z940: Kidney transplant status", "Z992: Dependence on renal dialysis", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "H409: Unspecified glaucoma", "I272: Other secondary pulmonary hypertension", "Z87440: Personal history of urinary (tract) infections", "Z9111: Patient's noncompliance with dietary regimen" ]
10,075,925
29,287,496
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Lisinopril Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history of hypertension, HFpEF, DM2, ESRD ___ DM s/p LURT (___) maintained on cellcept and tacrolimus who presents from home with dyspnea for 7 days, admitted to the CCU in setting of hypercarbic hypoxic respiratory failure. History obtained from her husband. He notes over past 7 days has been increasingly lethargic. Denies fevers, chills, sick contacts. Notes this time no preceding cough, lower extremity edema but marked fatigue. She has been taking her furosemide 30mg daily as well as tacro/MMF without issue. Mr. ___ believes her urine output was stable while at home. Given the progression of her symptoms, ultimately family called EMS. Of note patient was admitted from ___ for mixed hypoxemic hypercarbic respiratory failure requiring MICU admission for BiPAP. At that time this was attributed to an acute on chronic HFpEF exacerbation as well as OSA +/- central apnea. She was diuresed extensively and discharged on a higher dose of Lasix. ED Course notable for: Initial vital signs were notable for: T 97.8 HR 64 BP 114/64 RR22 O2 Sat 93% on RA Exam notable for: Labs were notable for: K 5.9, Cr 2.3, BUN 110, glucose 60, proBNP 4042, trop-t .06 Studies performed include: CT head: 1. No acute intracranial findings. 2. Extensive atherosclerotic disease. 3. Periapical lucencies in the first and third left upper molars are concerning for underlying periodontal infection. Non urgent dental consultation is recommended. CXR: Marked cardiomegaly, congestion with mild to moderate pulmonary edema and probable small pleural effusions. Patient was given: -40mg IV Lasix -50g Dextrose, 10 units insulin The patient was placed on BiPAP for question of altered mental status. On arrival to the CCU, Ms. ___ was rousable, oriented to person and place. Reports ongoing fatigue. REVIEW OF SYSTEMS: 10-point ROS negative except as noted in HPI Past Medical History: HTN HFpEF DM2 Living donor renal transplant from her husband (___) Social History: ___ Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION PHYSICAL EXAM ========================= VITALS: Reviewed in Metavision GENERAL: No acute distress, intermittently alert HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, unable to appreciate JVD due to body habitus and positioning LUNGS: Bibasilar crackles to mid lung fields, no wheezes, accessory muscle use. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding EXT: Warm, well perfused, 2+ pulses, no pitting edema appreciated SKIN: no obvious skin defects NEURO: CN2-12 grossly intact DISCHARGE PHYSICAL EXAM ========================== 24 HR Data (last updated ___ @ 500) Temp: 98.8 (Tm 98.8), BP: 121/69 (107-146/64-74), HR: 89 (82-90), RR: 18, O2 sat: 93% (89-95), O2 delivery: RA GENERAL: No acute distress, alert and orientd x3 HEENT: Sclera anicteric, LUNGS: NO increased work of breathing on RA. No crackles, , no wheezes, accessory muscle use. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, mildly distended,no rebound tenderness or guarding EXT: Warm, well perfused, 2+ pulses, no pitting edema appreciated Pertinent Results: Admission Labs ================ ___ 04:09PM BLOOD WBC-9.0 RBC-4.53 Hgb-12.5 Hct-43.8 MCV-97 MCH-27.6 MCHC-28.5* RDW-18.8* RDWSD-65.1* Plt ___ ___ 04:09PM BLOOD Neuts-80.9* Lymphs-7.2* Monos-11.2 Eos-0.1* Baso-0.2 Im ___ AbsNeut-7.29* AbsLymp-0.65* AbsMono-1.01* AbsEos-0.01* AbsBaso-0.02 ___ 02:32AM BLOOD ___ PTT-30.2 ___ ___ 04:09PM BLOOD Glucose-60* UreaN-110* Creat-2.3*# Na-138 K-5.9* Cl-100 HCO3-25 AnGap-13 ___ 04:09PM BLOOD CK-MB-5 proBNP-4042* ___ 04:09PM BLOOD cTropnT-0.06* ___ 02:32AM BLOOD CK-MB-4 cTropnT-0.04* ___ 04:09PM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.4 Mg-3.3* ___ 02:32AM BLOOD Calcium-8.2* Phos-4.9* Mg-3.0* ___ 04:09PM BLOOD Osmolal-321* ___ 02:32AM BLOOD TSH-1.3 ___ 05:13PM BLOOD tacroFK-14.1 ___ 04:15PM BLOOD ___ pO2-37* pCO2-58* pH-7.28* calTCO2-28 Base XS-0 ___ 04:15PM BLOOD Lactate-1.4 Pertinent Labs ================ ___ 10:32PM BLOOD Type-ART pO2-108* pCO2-64* pH-7.23* calTCO2-28 Base XS--2 ___ 03:23PM BLOOD ___ pO2-34* pCO2-55* pH-7.32* calTCO2-30 Base XS-0 Micro ================ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 4 R Imaging ================ N/A Brief Hospital Course: SUMMARY ========== Ms. ___ is a ___ female with history of hypertension, OSA, HFpEF, DM2, ESRD ___ DM s/p LURT (___) maintained on cellcept and tacrolimus who presents from home with dyspnea, found to have hypoxemic hypercarbic respiratory failure likely secondary to acute HFpEF exacerbation and unmanaged OSA. ACUTE ISSUES ============== #Acute decompensated heart failure with preserved ejection fraction (diastolic): Patient with known diastolic dysfunction, last EF 55% in ___. Possible triggers include acute complicated cystitis and unmanaged OSA. She initially was intubated for respiratory distress in the setting of acute heart failure exacerbation and was diuresed with IV Lasix. Patient was then transitioned to PO torsemide 40mg daily which she was discharged on. #GNR Bacteremia #Sepsis #Acute Complicated Cystitis growing Klebsiella: Urine sample on presentation with minimal epithelial cells, WBC and bacteria. BCx growing GNR, was broadened with cefepime (___) and then narrowed to ceftriaxone (___) and discharged on ciprofloxacin which should end after ___ for a ___SRD s/p LURT #Acute kidney injury Baseline Cr 1.1. Presenting with Cr 2.3, likely in setting of cardiorenal syndrome as Cr has improved with diuresis. Urine lytes suggest prerenal which would be consistent with cardiorenal. Renal Transplant US completed was normal. Renal transplant consulted and followed patient throughout hospitalization. Losartan and chlorthalidone were held during her hospitalization and will need to be followed up on as an outpatient. Continued tacro and MMF throughout hospitalization. #Hypertension: Continued on amlodipine and labetalol during hospitalization. Held losartan and chlorthalidone in the setting of ___. #Obstructive Sleep Apnea: Patient ordered for CPAP while in the hospital. She should follow up with sleep medicine as an outpatient. #Altered Mental Status: likely secondary to uremia hypercarbia. Patient initially admitted with severe altered mental status thought to be secondary to infection and hypercarbia. This has improved with diuresis and treatment of infection. At baseline patient alert and oriented times 3, presents with acute depression in mental status per family collateral. Notably CT head on admission negative for acute process. #Respiratory + Metabolic Acidosis: resolved Patient initially presented with respiratory and metabolic acidosis thought to be secondary to CO2 retention and acute uremia. #Pericardial Effusion: Patient with known pericardial effusion as documented in ___. Per bedside US by Cardiology team, effusion stable from prior. Pulsus negative on presentation. Differential for effusion includes uremia (most likely) vs infection vs less likely malignancy. Echo without evidence of tamponade physiology. #Acute mixed hypoxemic hypercarbic respiratory failure: Occurred in the setting of acute decompensated heart failure with acute on chronic hypercarbia I/s/o obesity and OSA. Her oxygenation has improved with diuresis and she was extubated and then has been able to wean off of Bipap to nasal cannula. She was further weaned to room air. Chronic Issues: ================= #UTI prophylaxis: Home macrobid held in the setting of acute kidney injury. #T2DM: Glargine 40 Units Bedtime, SSI TRANSITIONAL ISSUES ==================== [] Losartan and chlorthalidone were held in the setting of ___. Consider restarting if needed for BP and if Cr is improved. [] Patient should have Cr, K monitored in the next week given increased diuretic dose [] Macrobid was held in the setting ___ - patient takes for UTI ppx. Consider restarting when Cr improves. [] Please go to the appointments we have scheduled for you. [] Follow up with sleep medicine for a sleep study [] Follow up with Dr. ___ in cardiology ___ Cr: 1.6 Discharge Weight: 85.0 kg (187.39 lb) # CONTACT: ___ (Husband/HCP): ___ # Code: Full, confirmed with HCP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fish Oil (Omega 3) 1000 mg PO DAILY 2. Labetalol 300 mg PO BID 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Mycophenolate Mofetil 500 mg PO BID 9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 10. Tacrolimus 1.5 mg PO Q12H 11. Vitamin D 1400 UNIT PO DAILY 12. Chlorthalidone 25 mg PO DAILY 13. Furosemide 30 mg PO DAILY 14. Losartan Potassium 100 mg PO DAILY 15. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Doses RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth Twice a day Disp #*9 Tablet Refills:*0 2. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*0 5. Tacrolimus 1 mg PO Q12H RX *tacrolimus 1 mg 1 capsule(s) by mouth Twice a day Disp #*60 Capsule Refills:*0 6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Docusate Sodium 100 mg PO BID 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. Mycophenolate Mofetil 500 mg PO BID 13. Vitamin D 1400 UNIT PO DAILY 14. HELD- Chlorthalidone 25 mg PO DAILY This medication was held. Do not restart Chlorthalidone until you follow up with your cardiologist. 15. HELD- Losartan Potassium 100 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you follow up with your cardiologist. 16. HELD- Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY This medication was held. Do not restart Nitrofurantoin Monohyd (MacroBID) until you follow up with your primary care doctor. 17.Outpatient Lab Work Please draw CHEM10. ICD9: 428.0 Name/contact: Please fax to ___ Fax number ___ and ___ ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS =================== ACUTE ON CHRONIC HEART FAILURE WITH PRESERVED EJECTION FRACTION APNEA SECONDARY DIAGNOSIS ==================== ESRD s/p LURT HTN DM HYPERLIPIDEMIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. WHY WAS I ADMITTED TO THE HOSPITAL? ==================================== - You were initially admitted to the hospital because of difficulty breathing. WHAT HAPPENED DURING YOUR HOSPITALIZATION =========================================== - You were initially admitted to the intensive care unit because you needed to be intubated in order to help you breathe. - You received medications through your IV to help remove extra fluid from your lungs. - You were treated for an infection in your urine and in your blood. WHAT SHOULD I DO WHEN I GO HOME? ================================= - Your medications and follow up appointments are below. - You will need a sleep study and we have scheduled you to see a pulmonologist. - Weigh yourself every morning, call your doctor if weight goes up more than 2 lbs. We wish you the best of luck! Your ___ Team Followup Instructions: ___
[ "A4159", "I5033", "J9601", "G92", "J9602", "I130", "N3000", "Z940", "E874", "I313", "N179", "Z1611", "Z1629", "N189", "E1122", "E1165", "Z794", "Z87891", "G4733", "E669", "E785", "Z781", "B961", "E875" ]
Allergies: Lisinopril Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female with history of hypertension, HFpEF, DM2, ESRD [MASKED] DM s/p LURT ([MASKED]) maintained on cellcept and tacrolimus who presents from home with dyspnea for 7 days, admitted to the CCU in setting of hypercarbic hypoxic respiratory failure. History obtained from her husband. He notes over past 7 days has been increasingly lethargic. Denies fevers, chills, sick contacts. Notes this time no preceding cough, lower extremity edema but marked fatigue. She has been taking her furosemide 30mg daily as well as tacro/MMF without issue. Mr. [MASKED] believes her urine output was stable while at home. Given the progression of her symptoms, ultimately family called EMS. Of note patient was admitted from [MASKED] for mixed hypoxemic hypercarbic respiratory failure requiring MICU admission for BiPAP. At that time this was attributed to an acute on chronic HFpEF exacerbation as well as OSA +/- central apnea. She was diuresed extensively and discharged on a higher dose of Lasix. ED Course notable for: Initial vital signs were notable for: T 97.8 HR 64 BP 114/64 RR22 O2 Sat 93% on RA Exam notable for: Labs were notable for: K 5.9, Cr 2.3, BUN 110, glucose 60, proBNP 4042, trop-t .06 Studies performed include: CT head: 1. No acute intracranial findings. 2. Extensive atherosclerotic disease. 3. Periapical lucencies in the first and third left upper molars are concerning for underlying periodontal infection. Non urgent dental consultation is recommended. CXR: Marked cardiomegaly, congestion with mild to moderate pulmonary edema and probable small pleural effusions. Patient was given: -40mg IV Lasix -50g Dextrose, 10 units insulin The patient was placed on BiPAP for question of altered mental status. On arrival to the CCU, Ms. [MASKED] was rousable, oriented to person and place. Reports ongoing fatigue. REVIEW OF SYSTEMS: 10-point ROS negative except as noted in HPI Past Medical History: HTN HFpEF DM2 Living donor renal transplant from her husband ([MASKED]) Social History: [MASKED] Family History: Sister with DM, HTN, HLD. No renal disease in family. Physical Exam: ADMISSION PHYSICAL EXAM ========================= VITALS: Reviewed in Metavision GENERAL: No acute distress, intermittently alert HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, unable to appreciate JVD due to body habitus and positioning LUNGS: Bibasilar crackles to mid lung fields, no wheezes, accessory muscle use. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding EXT: Warm, well perfused, 2+ pulses, no pitting edema appreciated SKIN: no obvious skin defects NEURO: CN2-12 grossly intact DISCHARGE PHYSICAL EXAM ========================== 24 HR Data (last updated [MASKED] @ 500) Temp: 98.8 (Tm 98.8), BP: 121/69 (107-146/64-74), HR: 89 (82-90), RR: 18, O2 sat: 93% (89-95), O2 delivery: RA GENERAL: No acute distress, alert and orientd x3 HEENT: Sclera anicteric, LUNGS: NO increased work of breathing on RA. No crackles, , no wheezes, accessory muscle use. CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, mildly distended,no rebound tenderness or guarding EXT: Warm, well perfused, 2+ pulses, no pitting edema appreciated Pertinent Results: Admission Labs ================ [MASKED] 04:09PM BLOOD WBC-9.0 RBC-4.53 Hgb-12.5 Hct-43.8 MCV-97 MCH-27.6 MCHC-28.5* RDW-18.8* RDWSD-65.1* Plt [MASKED] [MASKED] 04:09PM BLOOD Neuts-80.9* Lymphs-7.2* Monos-11.2 Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-7.29* AbsLymp-0.65* AbsMono-1.01* AbsEos-0.01* AbsBaso-0.02 [MASKED] 02:32AM BLOOD [MASKED] PTT-30.2 [MASKED] [MASKED] 04:09PM BLOOD Glucose-60* UreaN-110* Creat-2.3*# Na-138 K-5.9* Cl-100 HCO3-25 AnGap-13 [MASKED] 04:09PM BLOOD CK-MB-5 proBNP-4042* [MASKED] 04:09PM BLOOD cTropnT-0.06* [MASKED] 02:32AM BLOOD CK-MB-4 cTropnT-0.04* [MASKED] 04:09PM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.4 Mg-3.3* [MASKED] 02:32AM BLOOD Calcium-8.2* Phos-4.9* Mg-3.0* [MASKED] 04:09PM BLOOD Osmolal-321* [MASKED] 02:32AM BLOOD TSH-1.3 [MASKED] 05:13PM BLOOD tacroFK-14.1 [MASKED] 04:15PM BLOOD [MASKED] pO2-37* pCO2-58* pH-7.28* calTCO2-28 Base XS-0 [MASKED] 04:15PM BLOOD Lactate-1.4 Pertinent Labs ================ [MASKED] 10:32PM BLOOD Type-ART pO2-108* pCO2-64* pH-7.23* calTCO2-28 Base XS--2 [MASKED] 03:23PM BLOOD [MASKED] pO2-34* pCO2-55* pH-7.32* calTCO2-30 Base XS-0 Micro ================ URINE CULTURE (Final [MASKED]: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 4 R Imaging ================ N/A Brief Hospital Course: SUMMARY ========== Ms. [MASKED] is a [MASKED] female with history of hypertension, OSA, HFpEF, DM2, ESRD [MASKED] DM s/p LURT ([MASKED]) maintained on cellcept and tacrolimus who presents from home with dyspnea, found to have hypoxemic hypercarbic respiratory failure likely secondary to acute HFpEF exacerbation and unmanaged OSA. ACUTE ISSUES ============== #Acute decompensated heart failure with preserved ejection fraction (diastolic): Patient with known diastolic dysfunction, last EF 55% in [MASKED]. Possible triggers include acute complicated cystitis and unmanaged OSA. She initially was intubated for respiratory distress in the setting of acute heart failure exacerbation and was diuresed with IV Lasix. Patient was then transitioned to PO torsemide 40mg daily which she was discharged on. #GNR Bacteremia #Sepsis #Acute Complicated Cystitis growing Klebsiella: Urine sample on presentation with minimal epithelial cells, WBC and bacteria. BCx growing GNR, was broadened with cefepime ([MASKED]) and then narrowed to ceftriaxone ([MASKED]) and discharged on ciprofloxacin which should end after [MASKED] for a SRD s/p LURT #Acute kidney injury Baseline Cr 1.1. Presenting with Cr 2.3, likely in setting of cardiorenal syndrome as Cr has improved with diuresis. Urine lytes suggest prerenal which would be consistent with cardiorenal. Renal Transplant US completed was normal. Renal transplant consulted and followed patient throughout hospitalization. Losartan and chlorthalidone were held during her hospitalization and will need to be followed up on as an outpatient. Continued tacro and MMF throughout hospitalization. #Hypertension: Continued on amlodipine and labetalol during hospitalization. Held losartan and chlorthalidone in the setting of [MASKED]. #Obstructive Sleep Apnea: Patient ordered for CPAP while in the hospital. She should follow up with sleep medicine as an outpatient. #Altered Mental Status: likely secondary to uremia hypercarbia. Patient initially admitted with severe altered mental status thought to be secondary to infection and hypercarbia. This has improved with diuresis and treatment of infection. At baseline patient alert and oriented times 3, presents with acute depression in mental status per family collateral. Notably CT head on admission negative for acute process. #Respiratory + Metabolic Acidosis: resolved Patient initially presented with respiratory and metabolic acidosis thought to be secondary to CO2 retention and acute uremia. #Pericardial Effusion: Patient with known pericardial effusion as documented in [MASKED]. Per bedside US by Cardiology team, effusion stable from prior. Pulsus negative on presentation. Differential for effusion includes uremia (most likely) vs infection vs less likely malignancy. Echo without evidence of tamponade physiology. #Acute mixed hypoxemic hypercarbic respiratory failure: Occurred in the setting of acute decompensated heart failure with acute on chronic hypercarbia I/s/o obesity and OSA. Her oxygenation has improved with diuresis and she was extubated and then has been able to wean off of Bipap to nasal cannula. She was further weaned to room air. Chronic Issues: ================= #UTI prophylaxis: Home macrobid held in the setting of acute kidney injury. #T2DM: Glargine 40 Units Bedtime, SSI TRANSITIONAL ISSUES ==================== [] Losartan and chlorthalidone were held in the setting of [MASKED]. Consider restarting if needed for BP and if Cr is improved. [] Patient should have Cr, K monitored in the next week given increased diuretic dose [] Macrobid was held in the setting [MASKED] - patient takes for UTI ppx. Consider restarting when Cr improves. [] Please go to the appointments we have scheduled for you. [] Follow up with sleep medicine for a sleep study [] Follow up with Dr. [MASKED] in cardiology [MASKED] Cr: 1.6 Discharge Weight: 85.0 kg (187.39 lb) # CONTACT: [MASKED] (Husband/HCP): [MASKED] # Code: Full, confirmed with HCP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fish Oil (Omega 3) 1000 mg PO DAILY 2. Labetalol 300 mg PO BID 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Mycophenolate Mofetil 500 mg PO BID 9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY 10. Tacrolimus 1.5 mg PO Q12H 11. Vitamin D 1400 UNIT PO DAILY 12. Chlorthalidone 25 mg PO DAILY 13. Furosemide 30 mg PO DAILY 14. Losartan Potassium 100 mg PO DAILY 15. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Doses RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth Twice a day Disp #*9 Tablet Refills:*0 2. Torsemide 40 mg PO DAILY RX *torsemide 20 mg 2 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*0 5. Tacrolimus 1 mg PO Q12H RX *tacrolimus 1 mg 1 capsule(s) by mouth Twice a day Disp #*60 Capsule Refills:*0 6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 7. amLODIPine 10 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Docusate Sodium 100 mg PO BID 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. Mycophenolate Mofetil 500 mg PO BID 13. Vitamin D 1400 UNIT PO DAILY 14. HELD- Chlorthalidone 25 mg PO DAILY This medication was held. Do not restart Chlorthalidone until you follow up with your cardiologist. 15. HELD- Losartan Potassium 100 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you follow up with your cardiologist. 16. HELD- Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY This medication was held. Do not restart Nitrofurantoin Monohyd (MacroBID) until you follow up with your primary care doctor. 17.Outpatient Lab Work Please draw CHEM10. ICD9: 428.0 Name/contact: Please fax to [MASKED] Fax number [MASKED] and [MASKED] [MASKED]. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS =================== ACUTE ON CHRONIC HEART FAILURE WITH PRESERVED EJECTION FRACTION APNEA SECONDARY DIAGNOSIS ==================== ESRD s/p LURT HTN DM HYPERLIPIDEMIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? ==================================== - You were initially admitted to the hospital because of difficulty breathing. WHAT HAPPENED DURING YOUR HOSPITALIZATION =========================================== - You were initially admitted to the intensive care unit because you needed to be intubated in order to help you breathe. - You received medications through your IV to help remove extra fluid from your lungs. - You were treated for an infection in your urine and in your blood. WHAT SHOULD I DO WHEN I GO HOME? ================================= - Your medications and follow up appointments are below. - You will need a sleep study and we have scheduled you to see a pulmonologist. - Weigh yourself every morning, call your doctor if weight goes up more than 2 lbs. We wish you the best of luck! Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "J9601", "I130", "N179", "N189", "E1122", "E1165", "Z794", "Z87891", "G4733", "E669", "E785" ]
[ "A4159: Other Gram-negative sepsis", "I5033: Acute on chronic diastolic (congestive) heart failure", "J9601: Acute respiratory failure with hypoxia", "G92: Toxic encephalopathy", "J9602: Acute respiratory failure with hypercapnia", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N3000: Acute cystitis without hematuria", "Z940: Kidney transplant status", "E874: Mixed disorder of acid-base balance", "I313: Pericardial effusion (noninflammatory)", "N179: Acute kidney failure, unspecified", "Z1611: Resistance to penicillins", "Z1629: Resistance to other single specified antibiotic", "N189: Chronic kidney disease, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E669: Obesity, unspecified", "E785: Hyperlipidemia, unspecified", "Z781: Physical restraint status", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "E875: Hyperkalemia" ]
10,076,144
20,119,544
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Fosamax / Peach / cherries / fresh fruit Attending: ___. Chief Complaint: constipation Major Surgical or Invasive Procedure: None History of Present Illness: ___ h/o CHF, prostate ca s/p resection and chemo (remote) and fistula-in-ano presents with constipation x3 weeks. Patient reports that approximately 4 weeks ago, he had 5 days of loose stools. He did not have any fever/chills, abdominal pain, nausea or vomiting. Following those 5 days, he had 3 weeks of constipation. After about ___ days of constipation, he tried a fleet enema and had some watery stool. ___ days later, he tried mag citrate with a similar result. After speaking to his PCP, he tried dulcolax suppositories the day prior to and the day of presentation again with a modest amount of watery stool. He continues to pass gas and denies any accompanying abdominal pain, nausea of vomiting. He continues to pass flatus. Prior to this month, he had a normal, solid bowel movement every ___ days, taking miralax daily. In the ED, initial vitals were: 98.7 74 181/63 18 99% RA Labs notable for WBC 14.3, Hgb 11.6, Cr 1.4 c/w recent baseline CT A/P shows large stool burden and rectal thickening c/w proctitis and known fistula He received flagyl. On the floor, he endorsed mild abdominal pain and distention. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies cough, increased shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting or abdominal pain. No dysuria. Denies arthralgias or myalgias. Past Medical History: COLONIC POLYPS GASTROESOPHAGEAL REFLUX HYPERLIPIDEMIA MACULAR DEGENERATION PROSTATE CANCER SCIATICA HYPERTENSION RECTAL BLEEDING HERPES ZOSTER FISTULA-IN-ANO, COMPLEX ___ ABSCESS Social History: ___ Family History: His father had tongue carcinoma. No history of prostate cancer. His mother had coronary artery disease. Hypertension in his brother and his mother. No diabetes. Physical Exam: ADMISSION PHYSICAL EXAM ========================= Vital Signs: 98.1 67 133/63 18 98RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM 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, distended, tympanic to percussion, no rebound or guarding GU: No foley Rectal: Fistulae visible perianally, DRE with minimal brown stool in rectum streaked with scant red blood. Non-tender. Normal tone. DISCHARGE PHYSICAL EXAM ======================== VS: 98.0PO 109/40 70 18 96 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM 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, distended with interval improvement, tympanic to percussion, no rebound or guarding GU: No foley Neuro: Alert+oriented x3 Pertinent Results: ADMISSION LABS =============== ___ 07:23PM BLOOD WBC-14.3*# RBC-4.18* Hgb-11.6* Hct-37.0* MCV-89 MCH-27.8 MCHC-31.4* RDW-14.6 RDWSD-46.9* Plt ___ ___ 07:23PM BLOOD Plt Smr-NORMAL Plt ___ ___ 09:12AM BLOOD ___ PTT-28.7 ___ ___ 07:23PM BLOOD Glucose-120* UreaN-32* Creat-1.4* Na-136 K-4.3 Cl-101 HCO3-27 AnGap-12 ___ 07:23PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.7* DISCHARGE LABS ================ ___ 07:25AM BLOOD WBC-10.5* RBC-4.03* Hgb-11.1* Hct-35.3* MCV-88 MCH-27.5 MCHC-31.4* RDW-14.5 RDWSD-46.2 Plt ___ ___ 07:25AM BLOOD Plt ___ ___ 07:25AM BLOOD Glucose-85 UreaN-26* Creat-1.3* Na-140 K-3.8 Cl-98 HCO3-29 AnGap-17 ___ 07:25AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 IMAGING ======== CT ABD/PELVIS ___ 1. Moderate-to-severe colonic stool burden particularly in the rectum and sigmoid colon with circumferential wall-thickening of the distal rectum and mild surrounding fat-stranding. Limited assessment on this unenhanced scan but could suggest proctitis/stercocolitis. 2. Known perianal fistula best assessed on the recent MR pelvis. This exam is not dedicated to assess for fistula and sinus tracts. 3. Persistent distal esophageal wall thickening can be seen with chronic reflux. Direct visualization if clinically indicated could be performed to further evaluate. Brief Hospital Course: ___ with prostate cancer s/p prostatectomy and radiation presenting with 3 weeks of constipation and colitis on CT. ACTIVE ISSUES =============== #Constipation: 3 weeks without normal BM, significant stool burden on CT. Patient has some chronic constipation with BM q1-3 days with miralax, but has never had an episode like this in the past. No obvious precipitant. Preceding diarrhea may have been post-obstructive or may have been early colitis progressing to constipation. No recent antibiotics. No other signs or symptoms of infectious colitis. Constipation was treated with an aggressive bowel regimen and had resolved on the day of discharge. He will f/u outpatient with his PCP. #Colitis/Proctitis: Seen on CT and felt to be most likely ___ constipation. He received abx with cipro/flagyl initially but these were then discontinued once constipation resolved. CHRONIC ISSUES ============== #HTN: Continued amlodipine #CHF: Continued home lasix #CKD: Creatinine at recent baseline, 1.3. TRANSITIONAL ISSUES ==================== - Cdiff negative, stool culture pending on discharge - Discharged with more aggressive bowel regimen including colace, senna and bisacodyl prn, milk of magnesia and miralax. Also given a prescription for moviprep to take in case of severe constipation. - Consider further work-up for obstructive process as cause of severe constipation as indicated if symptoms do not improve, particularly given history of cancer. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PR QHS:PRN constipation 2. Docusate Sodium 100 mg PO DAILY 3. amLODIPine 7.5 mg PO DAILY 4. Furosemide 20 mg PO EVERY OTHER DAY 5. Omeprazole 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Ascorbic Acid ___ mg PO DAILY Discharge Medications: 1. amLODIPine 7.5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Furosemide 20 mg PO EVERY OTHER DAY 5. Omeprazole 20 mg PO DAILY 6. Bisacodyl 10 mg PR QHS:PRN constipation 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 15 ml by mouth four times a day Refills:*0 8. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30 Tablet Refills:*0 9. Ascorbic Acid ___ mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 11. MoviPrep 1 L PO ONCE Duration: 1 Dose Take if you have no bowel movement for 5days. Drink 1L over 1 hour. RX *peg 3350-electrolytes-vit C [MoviPrep] 100 gram-7.5 gram-2.691 gram-1.015 gram-5.9 gram-4.7 gram 1 package by mouth once Disp #*1 Packet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Constipation Secondary Diagnosis: prostate ca s/p resection and chemo, CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came into the hospital because you were having severe constipation. You were given strong laxative medications and had several bowel movements and your belly became less distended. You were given medications to take at home to continue to treat your constipation. If you continue to have severe constipation and haven't had a bowel movement in 5 days, please drink ___ Liter of moviprep and call your PCP. Once you leave the hospital it is important that you follow-up with your primary care provider. It was a pleasure being involved in your care, Your ___ Care Team Followup Instructions: ___
[ "K5900", "I509", "Z8546", "K603", "K219", "E785", "I129", "N189", "K529" ]
Allergies: Penicillins / Fosamax / Peach / cherries / fresh fruit Chief Complaint: constipation Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] h/o CHF, prostate ca s/p resection and chemo (remote) and fistula-in-ano presents with constipation x3 weeks. Patient reports that approximately 4 weeks ago, he had 5 days of loose stools. He did not have any fever/chills, abdominal pain, nausea or vomiting. Following those 5 days, he had 3 weeks of constipation. After about [MASKED] days of constipation, he tried a fleet enema and had some watery stool. [MASKED] days later, he tried mag citrate with a similar result. After speaking to his PCP, he tried dulcolax suppositories the day prior to and the day of presentation again with a modest amount of watery stool. He continues to pass gas and denies any accompanying abdominal pain, nausea of vomiting. He continues to pass flatus. Prior to this month, he had a normal, solid bowel movement every [MASKED] days, taking miralax daily. In the ED, initial vitals were: 98.7 74 181/63 18 99% RA Labs notable for WBC 14.3, Hgb 11.6, Cr 1.4 c/w recent baseline CT A/P shows large stool burden and rectal thickening c/w proctitis and known fistula He received flagyl. On the floor, he endorsed mild abdominal pain and distention. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies cough, increased shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting or abdominal pain. No dysuria. Denies arthralgias or myalgias. Past Medical History: COLONIC POLYPS GASTROESOPHAGEAL REFLUX HYPERLIPIDEMIA MACULAR DEGENERATION PROSTATE CANCER SCIATICA HYPERTENSION RECTAL BLEEDING HERPES ZOSTER FISTULA-IN-ANO, COMPLEX [MASKED] ABSCESS Social History: [MASKED] Family History: His father had tongue carcinoma. No history of prostate cancer. His mother had coronary artery disease. Hypertension in his brother and his mother. No diabetes. Physical Exam: ADMISSION PHYSICAL EXAM ========================= Vital Signs: 98.1 67 133/63 18 98RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM 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, distended, tympanic to percussion, no rebound or guarding GU: No foley Rectal: Fistulae visible perianally, DRE with minimal brown stool in rectum streaked with scant red blood. Non-tender. Normal tone. DISCHARGE PHYSICAL EXAM ======================== VS: 98.0PO 109/40 70 18 96 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM 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, distended with interval improvement, tympanic to percussion, no rebound or guarding GU: No foley Neuro: Alert+oriented x3 Pertinent Results: ADMISSION LABS =============== [MASKED] 07:23PM BLOOD WBC-14.3*# RBC-4.18* Hgb-11.6* Hct-37.0* MCV-89 MCH-27.8 MCHC-31.4* RDW-14.6 RDWSD-46.9* Plt [MASKED] [MASKED] 07:23PM BLOOD Plt Smr-NORMAL Plt [MASKED] [MASKED] 09:12AM BLOOD [MASKED] PTT-28.7 [MASKED] [MASKED] 07:23PM BLOOD Glucose-120* UreaN-32* Creat-1.4* Na-136 K-4.3 Cl-101 HCO3-27 AnGap-12 [MASKED] 07:23PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.7* DISCHARGE LABS ================ [MASKED] 07:25AM BLOOD WBC-10.5* RBC-4.03* Hgb-11.1* Hct-35.3* MCV-88 MCH-27.5 MCHC-31.4* RDW-14.5 RDWSD-46.2 Plt [MASKED] [MASKED] 07:25AM BLOOD Plt [MASKED] [MASKED] 07:25AM BLOOD Glucose-85 UreaN-26* Creat-1.3* Na-140 K-3.8 Cl-98 HCO3-29 AnGap-17 [MASKED] 07:25AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 IMAGING ======== CT ABD/PELVIS [MASKED] 1. Moderate-to-severe colonic stool burden particularly in the rectum and sigmoid colon with circumferential wall-thickening of the distal rectum and mild surrounding fat-stranding. Limited assessment on this unenhanced scan but could suggest proctitis/stercocolitis. 2. Known perianal fistula best assessed on the recent MR pelvis. This exam is not dedicated to assess for fistula and sinus tracts. 3. Persistent distal esophageal wall thickening can be seen with chronic reflux. Direct visualization if clinically indicated could be performed to further evaluate. Brief Hospital Course: [MASKED] with prostate cancer s/p prostatectomy and radiation presenting with 3 weeks of constipation and colitis on CT. ACTIVE ISSUES =============== #Constipation: 3 weeks without normal BM, significant stool burden on CT. Patient has some chronic constipation with BM q1-3 days with miralax, but has never had an episode like this in the past. No obvious precipitant. Preceding diarrhea may have been post-obstructive or may have been early colitis progressing to constipation. No recent antibiotics. No other signs or symptoms of infectious colitis. Constipation was treated with an aggressive bowel regimen and had resolved on the day of discharge. He will f/u outpatient with his PCP. #Colitis/Proctitis: Seen on CT and felt to be most likely [MASKED] constipation. He received abx with cipro/flagyl initially but these were then discontinued once constipation resolved. CHRONIC ISSUES ============== #HTN: Continued amlodipine #CHF: Continued home lasix #CKD: Creatinine at recent baseline, 1.3. TRANSITIONAL ISSUES ==================== - Cdiff negative, stool culture pending on discharge - Discharged with more aggressive bowel regimen including colace, senna and bisacodyl prn, milk of magnesia and miralax. Also given a prescription for moviprep to take in case of severe constipation. - Consider further work-up for obstructive process as cause of severe constipation as indicated if symptoms do not improve, particularly given history of cancer. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PR QHS:PRN constipation 2. Docusate Sodium 100 mg PO DAILY 3. amLODIPine 7.5 mg PO DAILY 4. Furosemide 20 mg PO EVERY OTHER DAY 5. Omeprazole 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Ascorbic Acid [MASKED] mg PO DAILY Discharge Medications: 1. amLODIPine 7.5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Furosemide 20 mg PO EVERY OTHER DAY 5. Omeprazole 20 mg PO DAILY 6. Bisacodyl 10 mg PR QHS:PRN constipation 7. Milk of Magnesia 30 mL PO Q6H:PRN constipation RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 15 ml by mouth four times a day Refills:*0 8. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30 Tablet Refills:*0 9. Ascorbic Acid [MASKED] mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily Disp #*30 Packet Refills:*0 11. MoviPrep 1 L PO ONCE Duration: 1 Dose Take if you have no bowel movement for 5days. Drink 1L over 1 hour. RX *peg 3350-electrolytes-vit C [MoviPrep] 100 gram-7.5 gram-2.691 gram-1.015 gram-5.9 gram-4.7 gram 1 package by mouth once Disp #*1 Packet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Constipation Secondary Diagnosis: prostate ca s/p resection and chemo, CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You came into the hospital because you were having severe constipation. You were given strong laxative medications and had several bowel movements and your belly became less distended. You were given medications to take at home to continue to treat your constipation. If you continue to have severe constipation and haven't had a bowel movement in 5 days, please drink [MASKED] Liter of moviprep and call your PCP. Once you leave the hospital it is important that you follow-up with your primary care provider. It was a pleasure being involved in your care, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "K5900", "K219", "E785", "I129", "N189" ]
[ "K5900: Constipation, unspecified", "I509: Heart failure, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "K603: Anal fistula", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "K529: Noninfective gastroenteritis and colitis, unspecified" ]
10,076,144
23,965,952
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Fosamax / Peach / cherries / fresh fruit / cats Attending: ___. Chief Complaint: Hand swelling, pain, erythema Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with chief complaint of cellulitis. He was recently seen in ED for cellulitis of his hand. It developed following ___ surgery of the left hand for a squamous cell carcinoma on ___. In the ED, he was given Vanco with clinical improvement. He was discharged on doxycycline which he has been tolerating. However, swelling is worsening and erythema is spreading down his arm which suggests that doxycycline may not be sufficient. In the ED, labs notable for elevated CRP, no elevated WBC or left shift, s/p Vancomycin. Dermatology following patient, will see Hand C/S as an inpatient. No f/c, n/v, CP/SOB. On arrival to the floor, in no apparent distress. Past Medical History: COLONIC POLYPS GASTROESOPHAGEAL REFLUX HYPERLIPIDEMIA MACULAR DEGENERATION PROSTATE CANCER SCIATICA HYPERTENSION RECTAL BLEEDING HERPES ZOSTER FISTULA-IN-ANO, COMPLEX ___ ABSCESS Social History: ___ Family History: His father had tongue carcinoma. No history of prostate cancer. His mother had coronary artery disease. Hypertension in his brother and his mother. No diabetes. Physical Exam: ADMISSION Gen: Lying in bed in no apparent distress Vitals: T: 98.1, 140/70, 56, 20, 95% RA; ambulatory sats 96-98% HEENT: Anicteric, eyes conjugate, MMM, no JVD Cor: RRR no MRG, nl. S1 and S2 Chest: Lung fields clear to auscultation throughout Abd: Soft, non-tender, non-distended, bowel sounds present Ext: LUE: erythema and swelling improved, denies TTP; Skin: No rashes or ulcerations evident Neuro: Alert, interactive, speech fluent, face symmetric, moving all extremities DISCHARGE VS: T98.4 120/60 ___ GEN: Pleasant older male in no distress, ambulatory HEENT: No scleral icterus HEART: RRR, normal S1 S2, no murmurs LUNGS: Clear, no wheezes or rales ABD: Soft, NT ND, normal BS EXT: ~2x3cm elliptical surgical wound on the mid-ulnar dorsum of the hand with surrounding granulation tissue, sutures in place, no gross purulence, decreased sensation to light touch Pertinent Results: ADMISSION LABS ___ 08:30PM BLOOD WBC-8.4 RBC-3.85* Hgb-11.0* Hct-33.9* MCV-88 MCH-28.6 MCHC-32.4 RDW-14.2 RDWSD-45.2 Plt ___ ___ 08:30PM BLOOD Neuts-43.6 ___ Monos-14.1* Eos-14.5* Baso-0.7 Im ___ AbsNeut-3.67 AbsLymp-2.27 AbsMono-1.19* AbsEos-1.22* AbsBaso-0.06 ___ 08:30PM BLOOD Glucose-87 UreaN-30* Creat-1.2 Na-138 K-4.3 Cl-102 HCO3-24 AnGap-16 ___ 07:30AM BLOOD ALT-7 AST-10 AlkPhos-59 TotBili-0.4 ___ 07:40AM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1 ___ 07:40AM BLOOD TSH-3.2 ___ 08:30PM BLOOD CRP-38.5* ___ 08:42PM BLOOD Lactate-0.8 DISCHARGE LABS ___ 07:30AM BLOOD WBC-8.4 RBC-4.05* Hgb-11.6* Hct-35.5* MCV-88 MCH-28.6 MCHC-32.7 RDW-13.8 RDWSD-44.1 Plt ___ ___ 07:30AM BLOOD Neuts-42.0 ___ Monos-13.7* Eos-18.7* Baso-1.1* Im ___ AbsNeut-3.53 AbsLymp-2.02 AbsMono-1.15* AbsEos-1.57* AbsBaso-0.09* ___ 07:30AM BLOOD Glucose-92 UreaN-28* Creat-1.3* Na-138 K-4.4 Cl-102 HCO3-28 AnGap-12 IMAGING: ___ LEFT HAND XRAY No fracture or dislocation. Significant degenerative changes are noted involving the majority of the PIP and DIP joints of the left hand with loss of joint space, subchondral sclerosis with articular surface irregularity. Degenerative changes at the first carpometacarpal joint and triscaphe joint also noted with loss of joint space and marginal osteophytosis. Soft tissue swelling is noted diffusely most notable dorsally. No convincing signs of osteomyelitis. ___ LEFT HAND XRAY There is no acute fracture or dislocation. No bony erosions or periostitis. All interphalangeal joint spaces are affected by is degenerative changes, although with more pronounced joint space narrowing at the distal interphalangeal joints. There is also first MCP and triscaphe joint osteoarthritis. No concerning lytic or sclerotic lesion identified. Generalized soft tissue edema over the dorsum of the left hand. A nonspecific linear radiolucency over the dorsum may represent the site of prior surgery. IMPRESSION: No radiographic evidence of osteomyelitis. ___ CXR Cardiomediastinal contours are normal. The lungs are clear. There is no pneumothorax or pleural effusion. The osseous structures are unremarkable IMPRESSION: No acute cardiopulmonary abnormalities ___ BCx NGTD Brief Hospital Course: ___ with history of SCC of the left dorsal hand s/p Mohs procedure 8 days prior to admission presents with swelling and erythema with cellulitis due to antibiotic resistance to PO doxycycline. # Left hand cellulitis. Evaluated by Derm and Plastic Surgery. This is unlikely a deep soft tissue infection. No evidence of necrosis or abscess. No fever or elevation of WBC. He was given two doses of Vancomycin on ___ and ___ and then transitioned to Clindamycin 300 mg QID to a complete total 7-day course. Follow up with dermatologist as scheduled. Wound care includes vaseline to surgical site, cover with gauze, and secure with non-adhesive tape. # Asthma. ECG and CXR unremarkable. He had mild congestion, SOB, ambulatory sats 96-98% and his breathing improved with initiation of Symbicort which he had not started since his pulmonary appointment. He will follow up with Pulmonary. # Hypertension. Cont amlodipine. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Desonide 0.05% Cream 1 Appl TP PRN DAILY irritation 2. Bisacodyl 10 mg PR QHS:PRN constipation 3. Docusate Sodium 100 mg PO DAILY 4. Senna 8.6 mg PO DAILY 5. amLODIPine 7.5 mg PO DAILY 6. Furosemide 20 mg PO EVERY OTHER DAY 7. Omeprazole 20 mg PO DAILY:PRN GERD 8. Aspirin 81 mg PO DAILY 9. Ascorbic Acid ___ mg PO DAILY 10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. amLODIPine 7.5 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Bisacodyl 10 mg PR QHS:PRN constipation 6. Desonide 0.05% Cream 1 Appl TP PRN DAILY irritation 7. Docusate Sodium 100 mg PO DAILY 8. Furosemide 20 mg PO EVERY OTHER DAY 9. Omeprazole 20 mg PO DAILY:PRN GERD 10. Senna 8.6 mg PO DAILY 11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 12. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #*20 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Hand cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for intravenous antibiotics for a hand cellulitis. This improved and you were transitioned to oral antibiotics. Please continue the rest of the antibiotic prescription and follow up with your dermatologist. Keep the hand clean and dry with regular dressing changes. Followup Instructions: ___
[ "T814XXA", "L03114", "I10", "K219", "E785", "Z8546", "Y848", "Y929", "J45909" ]
Allergies: Penicillins / Fosamax / Peach / cherries / fresh fruit / cats Chief Complaint: Hand swelling, pain, erythema Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old male with chief complaint of cellulitis. He was recently seen in ED for cellulitis of his hand. It developed following [MASKED] surgery of the left hand for a squamous cell carcinoma on [MASKED]. In the ED, he was given Vanco with clinical improvement. He was discharged on doxycycline which he has been tolerating. However, swelling is worsening and erythema is spreading down his arm which suggests that doxycycline may not be sufficient. In the ED, labs notable for elevated CRP, no elevated WBC or left shift, s/p Vancomycin. Dermatology following patient, will see Hand C/S as an inpatient. No f/c, n/v, CP/SOB. On arrival to the floor, in no apparent distress. Past Medical History: COLONIC POLYPS GASTROESOPHAGEAL REFLUX HYPERLIPIDEMIA MACULAR DEGENERATION PROSTATE CANCER SCIATICA HYPERTENSION RECTAL BLEEDING HERPES ZOSTER FISTULA-IN-ANO, COMPLEX [MASKED] ABSCESS Social History: [MASKED] Family History: His father had tongue carcinoma. No history of prostate cancer. His mother had coronary artery disease. Hypertension in his brother and his mother. No diabetes. Physical Exam: ADMISSION Gen: Lying in bed in no apparent distress Vitals: T: 98.1, 140/70, 56, 20, 95% RA; ambulatory sats 96-98% HEENT: Anicteric, eyes conjugate, MMM, no JVD Cor: RRR no MRG, nl. S1 and S2 Chest: Lung fields clear to auscultation throughout Abd: Soft, non-tender, non-distended, bowel sounds present Ext: LUE: erythema and swelling improved, denies TTP; Skin: No rashes or ulcerations evident Neuro: Alert, interactive, speech fluent, face symmetric, moving all extremities DISCHARGE VS: T98.4 120/60 [MASKED] GEN: Pleasant older male in no distress, ambulatory HEENT: No scleral icterus HEART: RRR, normal S1 S2, no murmurs LUNGS: Clear, no wheezes or rales ABD: Soft, NT ND, normal BS EXT: ~2x3cm elliptical surgical wound on the mid-ulnar dorsum of the hand with surrounding granulation tissue, sutures in place, no gross purulence, decreased sensation to light touch Pertinent Results: ADMISSION LABS [MASKED] 08:30PM BLOOD WBC-8.4 RBC-3.85* Hgb-11.0* Hct-33.9* MCV-88 MCH-28.6 MCHC-32.4 RDW-14.2 RDWSD-45.2 Plt [MASKED] [MASKED] 08:30PM BLOOD Neuts-43.6 [MASKED] Monos-14.1* Eos-14.5* Baso-0.7 Im [MASKED] AbsNeut-3.67 AbsLymp-2.27 AbsMono-1.19* AbsEos-1.22* AbsBaso-0.06 [MASKED] 08:30PM BLOOD Glucose-87 UreaN-30* Creat-1.2 Na-138 K-4.3 Cl-102 HCO3-24 AnGap-16 [MASKED] 07:30AM BLOOD ALT-7 AST-10 AlkPhos-59 TotBili-0.4 [MASKED] 07:40AM BLOOD cTropnT-<0.01 [MASKED] 07:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1 [MASKED] 07:40AM BLOOD TSH-3.2 [MASKED] 08:30PM BLOOD CRP-38.5* [MASKED] 08:42PM BLOOD Lactate-0.8 DISCHARGE LABS [MASKED] 07:30AM BLOOD WBC-8.4 RBC-4.05* Hgb-11.6* Hct-35.5* MCV-88 MCH-28.6 MCHC-32.7 RDW-13.8 RDWSD-44.1 Plt [MASKED] [MASKED] 07:30AM BLOOD Neuts-42.0 [MASKED] Monos-13.7* Eos-18.7* Baso-1.1* Im [MASKED] AbsNeut-3.53 AbsLymp-2.02 AbsMono-1.15* AbsEos-1.57* AbsBaso-0.09* [MASKED] 07:30AM BLOOD Glucose-92 UreaN-28* Creat-1.3* Na-138 K-4.4 Cl-102 HCO3-28 AnGap-12 IMAGING: [MASKED] LEFT HAND XRAY No fracture or dislocation. Significant degenerative changes are noted involving the majority of the PIP and DIP joints of the left hand with loss of joint space, subchondral sclerosis with articular surface irregularity. Degenerative changes at the first carpometacarpal joint and triscaphe joint also noted with loss of joint space and marginal osteophytosis. Soft tissue swelling is noted diffusely most notable dorsally. No convincing signs of osteomyelitis. [MASKED] LEFT HAND XRAY There is no acute fracture or dislocation. No bony erosions or periostitis. All interphalangeal joint spaces are affected by is degenerative changes, although with more pronounced joint space narrowing at the distal interphalangeal joints. There is also first MCP and triscaphe joint osteoarthritis. No concerning lytic or sclerotic lesion identified. Generalized soft tissue edema over the dorsum of the left hand. A nonspecific linear radiolucency over the dorsum may represent the site of prior surgery. IMPRESSION: No radiographic evidence of osteomyelitis. [MASKED] CXR Cardiomediastinal contours are normal. The lungs are clear. There is no pneumothorax or pleural effusion. The osseous structures are unremarkable IMPRESSION: No acute cardiopulmonary abnormalities [MASKED] BCx NGTD Brief Hospital Course: [MASKED] with history of SCC of the left dorsal hand s/p Mohs procedure 8 days prior to admission presents with swelling and erythema with cellulitis due to antibiotic resistance to PO doxycycline. # Left hand cellulitis. Evaluated by Derm and Plastic Surgery. This is unlikely a deep soft tissue infection. No evidence of necrosis or abscess. No fever or elevation of WBC. He was given two doses of Vancomycin on [MASKED] and [MASKED] and then transitioned to Clindamycin 300 mg QID to a complete total 7-day course. Follow up with dermatologist as scheduled. Wound care includes vaseline to surgical site, cover with gauze, and secure with non-adhesive tape. # Asthma. ECG and CXR unremarkable. He had mild congestion, SOB, ambulatory sats 96-98% and his breathing improved with initiation of Symbicort which he had not started since his pulmonary appointment. He will follow up with Pulmonary. # Hypertension. Cont amlodipine. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Desonide 0.05% Cream 1 Appl TP PRN DAILY irritation 2. Bisacodyl 10 mg PR QHS:PRN constipation 3. Docusate Sodium 100 mg PO DAILY 4. Senna 8.6 mg PO DAILY 5. amLODIPine 7.5 mg PO DAILY 6. Furosemide 20 mg PO EVERY OTHER DAY 7. Omeprazole 20 mg PO DAILY:PRN GERD 8. Aspirin 81 mg PO DAILY 9. Ascorbic Acid [MASKED] mg PO DAILY 10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 2. amLODIPine 7.5 mg PO DAILY 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Bisacodyl 10 mg PR QHS:PRN constipation 6. Desonide 0.05% Cream 1 Appl TP PRN DAILY irritation 7. Docusate Sodium 100 mg PO DAILY 8. Furosemide 20 mg PO EVERY OTHER DAY 9. Omeprazole 20 mg PO DAILY:PRN GERD 10. Senna 8.6 mg PO DAILY 11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 12. Clindamycin 300 mg PO Q6H RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) hours Disp #*20 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Hand cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for intravenous antibiotics for a hand cellulitis. This improved and you were transitioned to oral antibiotics. Please continue the rest of the antibiotic prescription and follow up with your dermatologist. Keep the hand clean and dry with regular dressing changes. Followup Instructions: [MASKED]
[]
[ "I10", "K219", "E785", "Y929", "J45909" ]
[ "T814XXA: Infection following a procedure", "L03114: Cellulitis of left upper limb", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "J45909: Unspecified asthma, uncomplicated" ]
10,076,144
24,347,474
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Fosamax / Peach / cherries / fresh fruit / cats Attending: ___. Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None TTE - The left atrium is mildly dilated. The left atrial volume index is moderately increased. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. IMPRESSION: Low normal LV function with beat to beat variability in the LVEF. Moderately thicked aortic valve leaflets with mild AS and trace AI. Mild MR ___ TR. ___ is mild pulmonary artery systolic hypertension. Abdominal US IMPRESSION: The patient ate recently in the gallbladder is not distended however there is no gross evidence of gallbladder wall thickening. There is no ascites. History of Present Illness: HPI: ___ with h/o COPD, HTN, ?CHF. here with fever of ___ and 5 days of worsening shortness of breath. He reports being in usual health till 5 days ago when he started having cold like symptoms including cough/mucus, sore throat. Next day he started having low grade temps. His symptoms slowly progressed and he presented today to his PCP who sent him here after a negative flu test. He reports yellow sputum with cough. His dyspnea had progressed to even at rest. He had sick contact in office about a week ago. Has known COPD for at least ___ but no h/o exacerbation. In ED he was noted to be wheezing, received nebs, solumedrol, Lasix 20mg IV and azithromycin for COPD exacerbation. His symptoms have now resolved and he feels back to baseline. He was also noted to have afib in ED, which is a new diagnosis to him. he reports h/o CHF and takes Lasix 20 QOD but does not remember having fluid build up in past. No chest pain, abdominal pain, diarrhea, dysuria or leg swelling or rashes. ROS: negative for 10 systems except as mentioned above Past Medical History: COLONIC POLYPS GASTROESOPHAGEAL REFLUX HYPERLIPIDEMIA MACULAR DEGENERATION PROSTATE CANCER SCIATICA HYPERTENSION RECTAL BLEEDING HERPES ZOSTER FISTULA-IN-ANO, COMPLEX ___ ABSCESS Social History: ___ Family History: His father had tongue carcinoma. No history of prostate cancer. His mother had coronary artery disease. Hypertension in his brother and his mother. No diabetes. Physical Exam: Admission Exam Vitals:98.5PO 125 / 68L Sitting ___ RA General: well build gentleman in no distress HEENT: no pallor. no icterus, moist mucosa Chest: b/l CTA ___ normal. irregular rhythm, tachyacrdic ___: soft, nt, nd, nabs Ext: no c/c/e Skin: no rash Neuro: non focal. normal speech Psych: mood appropriate Pertinent Results: Admission labs ___ 12:26PM BLOOD WBC-7.6 RBC-4.42* Hgb-12.2* Hct-37.9* MCV-86 MCH-27.6 MCHC-32.2 RDW-14.0 RDWSD-43.9 Plt ___ ___ 12:26PM BLOOD Glucose-128* UreaN-30* Creat-1.5* Na-137 K-4.8 Cl-99 HCO3-21* AnGap-17 ___ 12:26PM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1 ___ 12:47PM BLOOD Lactate-1.4 Imaging: CxR: ___: no acute cardio-pulmonary process Ekg: afib with HR 108bpm ___ 06:56AM BLOOD Glucose-117* UreaN-44* Creat-1.6* Na-144 K-4.7 Cl-103 HCO3-26 AnGap-15 ___ 06:30AM BLOOD WBC-9.5 RBC-4.28* Hgb-11.9* Hct-36.8* MCV-86 MCH-27.8 MCHC-32.3 RDW-13.9 RDWSD-43.0 Plt ___ Brief Hospital Course: Impression/plan: ___ with h/o COPD, HTN, ?CHF, presenting with a fever and shortness of breath c/w viral illness and COPD exacerbation found to have new atrial fibrillation. #COPD Exacerbation in the setting of #Pneumonia Was flu negative. Repeat CXR with possible pneumonia. Will place on levofloxacin today -Prednsione 40 mg x5 day -Levofloxacin for 5 day course - Standing Duonebs today and wean as able - Tylenol as needed for fever -recheck ambulatory sats #Atrial fibrillation New diagnosis. Could be in the setting of above exacerbation but could also be new process. His TSH was normal. His echo is with low normal EF and with dilated LA and increased PCWP>18mmHg . His BNP was elevated, wonder if component of CHF is also contributing. -Increase metoprolol 37.5mg po bid for rate control - Apixiban #Acute diastolic HFpEF with echo showing dilated LA and increased PCWP>18mmHg with increased shortness of breath will trial a dose of IV Lasix. Lasix 20 mg IV metoprolol as above Daily weights #Elevated troponin could be NSTEMI type II in the setting of COPD exacerbation. He denies chest pain. He will likely need a stress test once recovered from this acute illness. repeat trop was negative. ___ Update - patient stabilized on current regimen, dc on steroid taper without levaquin, PCP and cardiology follow up, continue apixaban, abdominal US performed without ascites or other findings, patient had elevated troponins which were believed to be due to cardiac stress. Recommend outpatient stress test >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Furosemide 20 mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. amLODIPine 7.5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY:PRN gastritis 6. Ascorbic Acid ___ mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Docusate Sodium 100 mg PO DAILY constipation Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID copd RX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/dose 1 inhalation orally twice a day Disp #*1 Disk Refills:*1 3. Metoprolol Tartrate 37.5 mg PO BID RX *metoprolol tartrate 37.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. PredniSONE 40 mg PO DAILY copd Duration: 2 Doses Start: Tomorrow - ___, First Dose: First Routine Administration Time This is dose # 1 of 3 tapered doses RX *prednisone 10 mg 1 (One) tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*8 Tablet Refills:*0 5. PredniSONE 20 mg PO DAILY copd Duration: 2 Doses Start: After 40 mg DAILY tapered dose This is dose # 2 of 3 tapered doses RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 6. PredniSONE 10 mg PO DAILY copd Duration: 2 Doses Start: After 20 mg DAILY tapered dose This is dose # 3 of 3 tapered doses RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 7. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Ascorbic Acid ___ mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO DAILY constipation 11. Omeprazole 20 mg PO DAILY:PRN gastritis 12. Tiotropium Bromide 1 CAP IH DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. HELD- amLODIPine 7.5 mg PO DAILY This medication was held. Do not restart amLODIPine until follow up with PCP. Blood pressure controlled without. Discharge Disposition: Home with Service Facility: ___ Discharge Diagnosis: COPD Exacerbation Heart failure exacerbation Pneumonia Type II NSTEMI w/ troponin leak due to CHF exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Why You were admitted You were admitted after you began to have severe shortness of breath. What we did for you? You were found to be in a COPD exacerbation for this you were treated with prednisone, azithromycin, and new inhalers. You were also found to have a possible pneumonia and were started on an antibiotics called levofloxacin. You were noted to be in a new heart rhythm called atrial fibrillation for this you were started on two new medications one called metoprolol and one called apixiban. You had COPD exacerbation and pneumonia. You received antibiotics and steroids. You improved. You had congestive heart failure, you received Lasix for diuresis, and you improved. Please follow up with PCP ___ ___ weeks Please monitor your weight Please take medications as prescribed We wish you the best Your ___ Team Followup Instructions: ___
[ "J441", "J189", "I5033", "I21A1", "J440", "K219", "E785", "I4891", "I110", "Z8546", "Z7722", "Z808", "Z7901" ]
Allergies: Penicillins / Fosamax / Peach / cherries / fresh fruit / cats Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None TTE - The left atrium is mildly dilated. The left atrial volume index is moderately increased. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. IMPRESSION: Low normal LV function with beat to beat variability in the LVEF. Moderately thicked aortic valve leaflets with mild AS and trace AI. Mild MR [MASKED] TR. [MASKED] is mild pulmonary artery systolic hypertension. Abdominal US IMPRESSION: The patient ate recently in the gallbladder is not distended however there is no gross evidence of gallbladder wall thickening. There is no ascites. History of Present Illness: HPI: [MASKED] with h/o COPD, HTN, ?CHF. here with fever of [MASKED] and 5 days of worsening shortness of breath. He reports being in usual health till 5 days ago when he started having cold like symptoms including cough/mucus, sore throat. Next day he started having low grade temps. His symptoms slowly progressed and he presented today to his PCP who sent him here after a negative flu test. He reports yellow sputum with cough. His dyspnea had progressed to even at rest. He had sick contact in office about a week ago. Has known COPD for at least [MASKED] but no h/o exacerbation. In ED he was noted to be wheezing, received nebs, solumedrol, Lasix 20mg IV and azithromycin for COPD exacerbation. His symptoms have now resolved and he feels back to baseline. He was also noted to have afib in ED, which is a new diagnosis to him. he reports h/o CHF and takes Lasix 20 QOD but does not remember having fluid build up in past. No chest pain, abdominal pain, diarrhea, dysuria or leg swelling or rashes. ROS: negative for 10 systems except as mentioned above Past Medical History: COLONIC POLYPS GASTROESOPHAGEAL REFLUX HYPERLIPIDEMIA MACULAR DEGENERATION PROSTATE CANCER SCIATICA HYPERTENSION RECTAL BLEEDING HERPES ZOSTER FISTULA-IN-ANO, COMPLEX [MASKED] ABSCESS Social History: [MASKED] Family History: His father had tongue carcinoma. No history of prostate cancer. His mother had coronary artery disease. Hypertension in his brother and his mother. No diabetes. Physical Exam: Admission Exam Vitals:98.5PO 125 / 68L Sitting [MASKED] RA General: well build gentleman in no distress HEENT: no pallor. no icterus, moist mucosa Chest: b/l CTA [MASKED] normal. irregular rhythm, tachyacrdic [MASKED]: soft, nt, nd, nabs Ext: no c/c/e Skin: no rash Neuro: non focal. normal speech Psych: mood appropriate Pertinent Results: Admission labs [MASKED] 12:26PM BLOOD WBC-7.6 RBC-4.42* Hgb-12.2* Hct-37.9* MCV-86 MCH-27.6 MCHC-32.2 RDW-14.0 RDWSD-43.9 Plt [MASKED] [MASKED] 12:26PM BLOOD Glucose-128* UreaN-30* Creat-1.5* Na-137 K-4.8 Cl-99 HCO3-21* AnGap-17 [MASKED] 12:26PM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1 [MASKED] 12:47PM BLOOD Lactate-1.4 Imaging: CxR: [MASKED]: no acute cardio-pulmonary process Ekg: afib with HR 108bpm [MASKED] 06:56AM BLOOD Glucose-117* UreaN-44* Creat-1.6* Na-144 K-4.7 Cl-103 HCO3-26 AnGap-15 [MASKED] 06:30AM BLOOD WBC-9.5 RBC-4.28* Hgb-11.9* Hct-36.8* MCV-86 MCH-27.8 MCHC-32.3 RDW-13.9 RDWSD-43.0 Plt [MASKED] Brief Hospital Course: Impression/plan: [MASKED] with h/o COPD, HTN, ?CHF, presenting with a fever and shortness of breath c/w viral illness and COPD exacerbation found to have new atrial fibrillation. #COPD Exacerbation in the setting of #Pneumonia Was flu negative. Repeat CXR with possible pneumonia. Will place on levofloxacin today -Prednsione 40 mg x5 day -Levofloxacin for 5 day course - Standing Duonebs today and wean as able - Tylenol as needed for fever -recheck ambulatory sats #Atrial fibrillation New diagnosis. Could be in the setting of above exacerbation but could also be new process. His TSH was normal. His echo is with low normal EF and with dilated LA and increased PCWP>18mmHg . His BNP was elevated, wonder if component of CHF is also contributing. -Increase metoprolol 37.5mg po bid for rate control - Apixiban #Acute diastolic HFpEF with echo showing dilated LA and increased PCWP>18mmHg with increased shortness of breath will trial a dose of IV Lasix. Lasix 20 mg IV metoprolol as above Daily weights #Elevated troponin could be NSTEMI type II in the setting of COPD exacerbation. He denies chest pain. He will likely need a stress test once recovered from this acute illness. repeat trop was negative. [MASKED] Update - patient stabilized on current regimen, dc on steroid taper without levaquin, PCP and cardiology follow up, continue apixaban, abdominal US performed without ascites or other findings, patient had elevated troponins which were believed to be due to cardiac stress. Recommend outpatient stress test >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tiotropium Bromide 1 CAP IH DAILY 2. Furosemide 20 mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. amLODIPine 7.5 mg PO DAILY 5. Omeprazole 20 mg PO DAILY:PRN gastritis 6. Ascorbic Acid [MASKED] mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. Docusate Sodium 100 mg PO DAILY constipation Discharge Medications: 1. Apixaban 2.5 mg PO BID RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID copd RX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/dose 1 inhalation orally twice a day Disp #*1 Disk Refills:*1 3. Metoprolol Tartrate 37.5 mg PO BID RX *metoprolol tartrate 37.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. PredniSONE 40 mg PO DAILY copd Duration: 2 Doses Start: Tomorrow - [MASKED], First Dose: First Routine Administration Time This is dose # 1 of 3 tapered doses RX *prednisone 10 mg 1 (One) tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*8 Tablet Refills:*0 5. PredniSONE 20 mg PO DAILY copd Duration: 2 Doses Start: After 40 mg DAILY tapered dose This is dose # 2 of 3 tapered doses RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 6. PredniSONE 10 mg PO DAILY copd Duration: 2 Doses Start: After 20 mg DAILY tapered dose This is dose # 3 of 3 tapered doses RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 7. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Ascorbic Acid [MASKED] mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Docusate Sodium 100 mg PO DAILY constipation 11. Omeprazole 20 mg PO DAILY:PRN gastritis 12. Tiotropium Bromide 1 CAP IH DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. HELD- amLODIPine 7.5 mg PO DAILY This medication was held. Do not restart amLODIPine until follow up with PCP. Blood pressure controlled without. Discharge Disposition: Home with Service Facility: [MASKED] Discharge Diagnosis: COPD Exacerbation Heart failure exacerbation Pneumonia Type II NSTEMI w/ troponin leak due to CHF exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Why You were admitted You were admitted after you began to have severe shortness of breath. What we did for you? You were found to be in a COPD exacerbation for this you were treated with prednisone, azithromycin, and new inhalers. You were also found to have a possible pneumonia and were started on an antibiotics called levofloxacin. You were noted to be in a new heart rhythm called atrial fibrillation for this you were started on two new medications one called metoprolol and one called apixiban. You had COPD exacerbation and pneumonia. You received antibiotics and steroids. You improved. You had congestive heart failure, you received Lasix for diuresis, and you improved. Please follow up with PCP [MASKED] [MASKED] weeks Please monitor your weight Please take medications as prescribed We wish you the best Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "K219", "E785", "I4891", "I110", "Z7901" ]
[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J189: Pneumonia, unspecified organism", "I5033: Acute on chronic diastolic (congestive) heart failure", "I21A1: Myocardial infarction type 2", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "I4891: Unspecified atrial fibrillation", "I110: Hypertensive heart disease with heart failure", "Z8546: Personal history of malignant neoplasm of prostate", "Z7722: Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)", "Z808: Family history of malignant neoplasm of other organs or systems", "Z7901: Long term (current) use of anticoagulants" ]
10,076,263
25,448,079
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___ Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: R IJ placement (___) Diagnostic Paracentesis (___) Upper Endoscopy (___) R PICC Placement (___) History of Present Illness: ___ history of EtOH abuse, EtOH pancreatitis, and recently diagnosed cirrhosis in addition to a recent hospitalization which identified b/l Tubo-ovarian abscesses and multiple intraabdominal abscesses which underwent ___ guided drainage and grew ___ and actinomyces presents with altered mental status, dizzyness and right sided abdominal pain. During that hospitalization, she also required intubation for hypoxic respiratory failure in the setting of pulmonary edema and hepatopulmonary syndrome. The patient was unable to provide history at time of interview. Most of HPI was gathered from emergency department. Per notes, the patient was recently discharged from ___ on ___ for the above mentioned hospitalization with a PICC line for IV ertapenem and fluconazole. Per patient's fiancé, the patient had not been herself since discharge and has been complaining of dizziness x1 day and weakness for the last 10 days. The patient has not been able to take PO. No reported n/v/d. Of note, her PICC line had been taken out by ___ recently for suspicion of a line infection given that it was not being capped properly. Plan was for midline placement ___ as outpt but pt unable to make appt due to weakness. While in the ED, the patient was noted to have a post void residual of 300-400cc and was complaining of low back pain for which a code cord was called over concern for spinal abscess. MRI was obtained and no spinal compression was noted. In addition, the while in the ED a right sided IJ was placed due to poor IV access. This was uncomplicated. Her initial exam was notable for: HR 112, otherwise VS WNL. A&O x3. Dry MM. Tachy with regular rhythm. Abdomen soft, ND, NT. The patient was given 2L IV NS, 1g IV ertapenem, 400 mg IV fluconazole given and Azithro IV 500 mg oxycodone 5 and lorazepam 0.5 - Patient was given: ___ 14:42 PO/NG Acetaminophen 1000 mg ___ 14:42 PO/NG OxyCODONE (Immediate Release) 5 mg ___ 14:42 PO/NG LORazepam .5 mg - Labs notable for: Lactate:2.1 ALT: 11 AP: 467 Tbili: 2.1 Alb: 2.6 AST: 83 WBC 18.6 Hgb 9.3 Plt 333 - Imaging was notable for: ___ 15:44 Chest (Portable Ap) Right IJ terminates in the right atrium. No evidence of pneumothorax. Low lung volumes and left base consolidation worrisome for pneumonia. MRI ___: Disc bulge at L5-S1 mildly impresses on the spinal cord at this level without critical stenosis. Degenerative changes at L4-L5 and L5-S1 result in mild bilateral neuroforaminal narrowing. No abnormal signal changes to suggest cord ischemia or contusion. No evidence of spinal epidural abscess, diskitis or osteomyelitis. ___ 18:51 Skull No radio-opaque foreign body is detected over the orbits. Upon arrival to the floor, patient is AAOx2 and lethargic though able to follow commands REVIEW OF SYSTEMS: unable to obtain Past Medical History: cirrhosis EtOH pancreatitis EtOH abuse/dependence Asthma HTN Depression Social History: ___ Family History: Father with hx of HTN but otherwise healthy. Mother healthy. Three of four children have asthma, otherwise healthy. Denies FH of pancreatitis, pancreatic or GB malignancy. Physical Exam: ADMISSION EXAM: ================ Vital Signs: T 97.5 BP 153/98 HR 88 R 20 SpO2 90 Ra GEN: Lethargic, following commands, cachetic HEENT: sclerae anicteric, +temporal wasting, pupils dilated but reactive ___: RRR no MRG RESP: No increased WOB, bibasilar crackles, no wheezing or rhonchi ABD: Distended, with caput. Small, rubbery nodules RLQ and LLQ. ___, np guarding. EXT: Warm, without edema NEURO: moves all 4 extremities, no tongue deviation, no facial droop, pupils dilated but reactive. No asterixis. DISCHARGE EXAM =============== Vital Signs: 98.2 127/85 114 22 90%RA GEN: A+O x 3, cachectic, alert and interactive HEENT: pupils dilated and minimally reactive (stable from admission), mucous membranes moist, sclerae icteric, +temporal wasting, ___: S1S2 tachycardic; no appreciable murmurs. No carotid bruits auscultated. Tenderness on palpation of right anterior chest. RESP: No increased WOB, lungs clear to auscultation although limited exam based on patient positing ABD: Soft, mildly distended, nontender to palpation EXT: Warm, without edema, cord palpated in R upper extremity MSK: No spinal tenderness to palpation, Positive for tenderness to palpation of the R lower back. NEURO: CNII-XII intact, sensation equal bilaterally, ___ strength in upper extremities, ___ strength in lower extremities, pupils are dilated and minimally reactive, no asterixis, gait testing deferred. SKIN: extremely dry, no tenting, no wounds seen on the extremities, old hyperkeratotic scar on L shin. GU: No suprapubic tenderness. Foley in place. Pertinent Results: ADMISSION LABS: =============== ___ 12:30PM BLOOD WBC-18.6* RBC-2.90* Hgb-9.3* Hct-28.9* MCV-100* MCH-32.1* MCHC-32.2 RDW-19.6* RDWSD-70.9* Plt ___ ___ 12:30PM BLOOD Neuts-83* Bands-0 Lymphs-11* Monos-4* Eos-1 Baso-1 ___ Myelos-0 AbsNeut-15.44* AbsLymp-2.05 AbsMono-0.74 AbsEos-0.19 AbsBaso-0.19* ___ 12:30PM BLOOD Glucose-108* UreaN-8 Creat-0.9 Na-135 K-3.2* Cl-95* HCO3-24 AnGap-19 ___ 12:30PM BLOOD ALT-11 AST-83* AlkPhos-467* TotBili-2.1* ___ 12:30PM BLOOD Lipase-47 ___ 12:30PM BLOOD Albumin-2.6* Calcium-13.0* Phos-5.9* Mg-1.1* ___ 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:57PM BLOOD ___ pO2-36* pCO2-39 pH-7.46* calTCO2-29 Base XS-3 ___ 12:46PM BLOOD Lactate-2.1* OTHER PERTINENT LABS: ===================== ___ 08:15AM BLOOD ___ PTT-52.7* ___ ___ 12:17PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 05:54PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 05:42AM BLOOD Albumin-2.8* Calcium-9.6 Phos-4.8* Mg-2.3 ___ 05:00AM BLOOD TSH-13* ___ 05:00AM BLOOD Free T4-1.0 ___ 06:10AM BLOOD PTH-17 ___ 06:10AM BLOOD PEP-POLYCLONAL DISCHARGE LABS: ================ ___ 01:48PM BLOOD WBC-14.4* RBC-2.40* Hgb-7.4* Hct-23.2* MCV-97 MCH-30.8 MCHC-31.9* RDW-17.7* RDWSD-60.7* Plt ___ ___ 02:13AM BLOOD ___ PTT-73.3* ___ ___ 11:47AM BLOOD Glucose-153* UreaN-5* Creat-0.7 Na-136 K-3.6 Cl-102 HCO3-22 AnGap-16 ___ 02:13AM BLOOD ALT-8 AST-41* AlkPhos-340* TotBili-1.3 ___ 11:47AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2 URINE STUDIES: =============== ___ 06:51PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-8.0 Leuks-NEG ___ 01:07PM URINE Color-Yellow Appear-Clear Sp ___ ___ 01:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR ___ 01:07PM URINE RBC-<1 WBC-4 Bacteri-NONE Yeast-NONE Epi-2 ASCITES STUDIES: ================= ___ 02:29PM ASCITES TNC-165* RBC-143* Polys-1* Lymphs-63* Monos-23* Macroph-13* ___ 02:29PM ASCITES TotPro-2.6 Albumin-1.0 ___ Cytology: NEGATIVE FOR MALIGNANT CELLS. MICROBIOLOGY: =============== ___ 12:00AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 1:07 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 3:45 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:05 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:05 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 8:15 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 2:11 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. Time Taken Not Noted Log-In Date/Time: ___ 2:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT ___ Fluid Culture in Bottles (Final ___: NO GROWTH. ___ 6:07 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Pending): No growth to date ___ 6:51 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 7:02 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date ___ 8:35 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). IMAGING/STUDIES: ================= CXR (___): Right IJ terminates in the right atrium. No evidence of pneumothorax. Low lung volumes and left base consolidation worrisome for pneumonia. Skull Trauma XRay (___): No radio-opaque foreign body is detected over the orbits. Dental amalgam with wires within the mouth likely reflect dental hardware. MR ___ ___ 1. No spinal cord signal abnormality, spinal cord or nerve root compression. 2. No epidural collection or evidence of infection. 3. Mild degenerative changes, as described, without significant spinal canal or high-grade neural foraminal narrowing. 4. Nonspecific lumbar paraspinal muscular edema, which may be related to strain. 5. Moderate left and small right pleural effusions. 6. Small volume ascites. 7. Nonspecific decreased T1 signal of the visualized osseous structures which can be seen in the setting of anemia. CXR (___): Right central venous catheter tip terminates near the cavoatrial junction/proximal right atrium. No relevant change since prior study Liver U/S w/ Doppler (___): 1. Patent hepatic vasculature with appropriate waveforms. 2. Cirrhotic liver morphology without focal lesion identified. 3. Mild ascites. CTA Chest/CT Abdomen (___): 1. Right upper lobe segmental pulmonary embolism. 2. Moderate nonhemorrhagic left pleural effusion with associated compressive atelectasis. 3. Mild dependent pulmonary edema. 4. Interval decrease in the size of the bilateral adnexal fluid collections. 5. Previously seen smaller fluid collections in the right pericolic gutter and adjacent to the right inferior abdominal wall now appear mostly as enhancing soft tissue, and are slightly increased in size. 6. Large volume abdominal and pelvic ascites, similar to prior. Right upper extremity Ultrasound (___): No evidence of deep vein thrombosis in the right upper extremity, noting that the internal jugular vein could not be evaluated secondary to difficulty with patient positioning. Right cephalic vein not seen. Upper Endoscopy (___): No esophageal varices. Erythema, congestion and mosaic appearance in the stomach No gastric varices. An NG tube was placed after the procedure and visualized in the esophagus. Otherwise normal EGD to third part of the duodenum KUB (___): Multiple loops of prominent small bowel, which can be seen in the setting of ileus or early obstruction CXR (___): Prominent loops of bowel in the upper and mid abdomen, minimally improved compared with previous. This may represent ileus or obstruction. KUB (___): Prominent loops of bowel in the upper and mid abdomen, minimally improved compared with previous. This may represent ileus or obstruction. ECHO (___): Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. A right pleural effusion is present. Ascites is present. IMPRESSION: Normal global biventricular systolic function. Ascites and right pleural effusion. KUB (___): Nonspecific loops of bowel in the upper and mid left abdomen, with distension of these loops improved from prior. Brief Hospital Course: Ms. ___ is a ___ with recently diagnosed ETOH cirrhosis and recent prolonged treatment for multiple intra-abdominal and pelvic tuboovarian abscesses growing ___ and actinomyces on IV fluconazole/ertapenem as an outpatient who presented with progressive weakness and recurrent abdominal pain. She was subsequently found to be confused concerning for hepatic encephalopathy. Initially presented with confusion and mumbling consistent with encephalopathy in the setting of likely ileus vs early small obstruction. In the Emergency Department she also was noted to have urinary retention and given difficult historian a Code Cord was called. MRI was performed without evidence of spinal cord compression. A foley was placed successfully. For her encephalopathy, she was given lactulose enemas and NGT was placed to suction with improvement in her mental status. Initially started on broad antibiotics, although infectious work-up including blood cultures, urine cultures, paracentesis and CXR without new evidence of infection. A CTA torso was performed, which demonstrated interval decrease in the size of bilateral adnexal fluid collections and new segmental pulmonary embolism. Infectious disease was consulted and recommended Unasyn/Fluconazole as she was felt not to have failed therapy but may have had inconsistent use of antibiotics at home. For her pulmonary embolism, she was treated with a heparin gtt. Remained hemodynamically stable. Echo performed without evidence of strain and ECG without acute changes. She was having intermittent right sided chest pain that was felt to be musculoskeletal. After ileus resolved, she was transitioned to apixaban for treatment of pulmonary embolism. A KUB of her abdomen was obtained for increased abdominal distention and demonstrated findings consistent with early SBO vs ileus. An NGT was placed to suction and she was hydrated with albumin. Her abdominal exam improved and her tube feeds were advanced. She was having evidence of refeeding syndrome requiring frequent electrolyte repletions, however continued to tolerate feeds. ACTIVE ISSUES: ====================== # Altered Mental Status # Hepatic encephalopathy: Initially presented with confusion, mumbling, and unable to give history. Felt to be most consistent with hepatic encephalopathy given asterixis on admission. Likely triggers include constipation, urinary retention, new acute pulmonary embolism, and possibly due to missed treatments of her known intraabdominal abscesses. Work-up included a negative serum tox, urine tox, a normal noncontrast head CT. Infectious work-up included a CXR without evidence of pnuemonia, and negative urine and blood cultures. Paracentesis was performed which demonstrated no evidence of SBP. She was resumed on home rifaxamin and given lactulose enemas with improvement in her mental status. Given resolving ileus as outlined below, her po lactulose was held. This can be resumed once her po intake improves if with any further confusion. # Malutrition # Refeeding syndrome: While at home the patient reports having very little to no po intake. This was due to nausea/vomiting at home and likely encephalopathy. Due to persistent abdominal pain and ileus, she was unable to keep up with nutritional needs. An NG tube was placed to help supplement nutrition and she was started on Jevity 1.5 feeds with goal of 50cc/hr. Given her poor po intake, she needed BID lytes for repletion of potassium and magnesium. On discharge she was tolerating small amounts of po intake. As she is able to tolerate more, her NG tube feeds can be discontinued. # Ileus: After initiating tube feeds, noted to have increased abdominal distention and abdominal pain. KUB demonstrated likely ileus vs early small bowel obstruction. She continued to have bowel movements, so felt more likely to be due to ileus. C. difficile was sent and found to be negative. NGT was placed to suction and she was placed on bowel rest. Given Albumin 50g boluses/day. Her abdominal pain improved, and tube feeds were advanced. She was able to reach goal tube fees on ___. # Pulmonary embolism: On presentation underwent a CTA that demonstrated a right upper lobe segmental pulmonary embolism. She remained hemodynamically stable throughout admission. An ECG demosntrated sinus tachycardia without evidence of right heart strain. Trops were negative x 2. Echo demonstrated no findings of right heart strain. While she had an ileus she was kept on heparin gtt. This was transitioned to apixaban on ___ for ongoing treatement. She should take apixaban 10mg po BID x 7 days (last day ___, and then transition to apixaban 5mg po BID for ongoing treatment. Of note, cord palpated at old ___ line though no DVT found on ultrasound. # Abdominal Pain # Tuboovarian Abscesses: On admission noted to have abdominal pain felt to be due to known abscesses vs urinary retention as listed below. Patient recently discharged from ___ where she was found to have cirrhosis and multiple intraabdominal abscesses growing ___ and actinomyces. Patient discharged during last hospitalization with ___ line with IV ertapenem and PO fluconazole. PICC line was removed as an outpatient given concern for line infection, and patient did not follow up with mid-line placement. There was concern she was missing doses at home and not adequately treating her infection. Antibiotics were originally supposed to continue through ___. Given her noncompliance with outpatient antibiotic therapy, Infectious Disease was consulted. Recommended IV Unasyn 3g IV q6h and po fluconazole (new day ___ for ___ weeks of treatment. She will then need to be transitioned to po antibiotics if stable. Repeat CT abdomen demonstrated improved abscesses during admission. Will need weekly BMP, CBCD, AST/ALT, AP to be faxed to ___ clinic at ___. # Cirrhosis c/b hepatic encephalopathy and ascites # ETOH use: Cirrhosis felt to be seconary to ETOH cirrhosis given 1L of vodka intake daily while at home. Decompensated on admission with hepatic encephalopathy as outlined above. Diagnosed paracentesis without evidence of SBP. She underwent upper endoscopy on ___ that demonstrated portal gastropathy without evidence of esophageal varices. LFTs near baseline with AST/ALT about ___ during admission. Bilirubin mildly trending up to 1.9, although improved to 1.3 on discharge. She was continued on home spironolactone and Lasix during admission. # Anemia, resolved: During admission had anemia with H/H around ___. On ___, her hgb dropped to 6.9 so she was transfused 1U of PRBCs with improvement. Likely secondary to chronic disease. No evidence of bleeding throughout admission. Please recheck CBC on ___ to ensure stability. # Urinary retention: On presentation noted to have urinary retention and foley was placed. PVR 400cc in ED. Likely secondary to intraabdominal infection. On arrival to the ED given poor historian, concerned for Cord compression. A Code Cord was called and MRI of the ___ was obtained without evidence of spinal stenosis. The patient's fiance notes that she has this issue at home where she holds her urine in because she does not want to get out of bed. Will need voiding trial when she is able to use the bed pan. # Hypercalcemia: During hospitalization noted to have elevated calcium with peak 11.9. PTH 17, Hypothyroidism ruled out, SPEP/UPEP without M spike. Possibly due to outpatient Tums use for abdominal pain, although unclear. Improved during hospitalization. # ETOH abuse: Reports drinking 1L vodka daily. Last use on ___. She was monitored on CIWA scale during admission and required minimal doses without evidence of withdrawal. She was continued on multivitamin, thiamine, and folic acid during admission. CHRONIC ISSUES: ====================== #Asthma: Stable during admission. Continued on home nebs. #Depression: On admission, held amitriptyline and quetiapine given AMS. When her mental status improved she was restarted on amitriptyline and quetiapine 50mg po daily prn. Attempted to restart her home quetiapine 100mg po qhs although became more sedated so this was held. Could consider restarting as outpatient. Her venlfaxine was continued. #Chronic Pain: Patient has chronic low back pain. MRI negative as above. For pain she was continued on lidocaine patch. Her gabapentin dose was held on admission, and restarted at a lower dose at 100mg TID given somnolence. Cyclobenzaprine was also started at a lower dose given sleepiness. Could consider further uptitration as an outpatient. ***TRANSITIONAL ISSUES*** - Please monitor electrolytes daily and replete as needed given persistent hypokalemia and hypomagnesemia in the setting of likely refeeding syndrome - Advance diet as tolerated, and once she is able to support her diet she can discontinue her tube feeds - For her pulmonary embolism she was started on apixaban 10mg po BID. This should be transitioned to 5mg po BID on ___ for continued treatment of acute PE - Please check CBC on ___ to monitor for anemia; She required 1U of PRBCs (given on ___ during her hospitalization. - Please continue to advised ETOH cessation - Will need follow-up with liver clinic in ___ weeks - Will need follow-up with ___ clinic - Please obtain weekly labs (starting ___: BMP, CBC w/diff, AST/ALT, AP and fax to ___ clinic at ___ - Patient should continue on IV Unasyn/fluticasone through ___, and will then need to be transitioned to PO antibiotics as outlined by Infectious Disease. - Lactulose was held on discharge as patient was having frequent bowel movements and when given was giving increased abdominal distention; please consider restarting if she develops confusion - Home Quetiapine 100mg po qhs was held on admission due to sleepiness; consider restarting at lower dose if continues to have poor mood - Patient with foley in place for urinary retention; Will need voiding trial when able to use bed pan - Code: full - Contact: ___ (sister/HCP) Phone number: ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ertapenem Sodium 1 g IV 1X 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 3. Amitriptyline 10 mg PO QHS 4. FoLIC Acid 1 mg PO DAILY 5. Gabapentin 300 mg PO TID 6. Lactulose 30 mL PO TID 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Multivitamins 1 TAB PO DAILY 9. QUEtiapine Fumarate 100 mg PO QHS 10. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 11. Thiamine 100 mg PO DAILY 12. Venlafaxine XR 37.5 mg PO DAILY 13. Lidocaine 5% Patch 1 PTCH TD QPM back pain 14. Pantoprazole 40 mg PO Q24H 15. Rifaximin 550 mg PO BID 16. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation 17. Cyclobenzaprine 10 mg PO HS:PRN spasm 18. Magnesium Oxide 400 mg PO DAILY 19. Fluconazole 400 mg PO Q24H 20. Spironolactone 100 mg PO DAILY 21. Furosemide 60 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Ampicillin-Sulbactam 3 g IV Q6H Continue through ___ or as otherwise instructed by your Infectious Disease doctors 3. Apixaban 10 mg PO BID Duration: 7 Days please continue through ___. Apixaban 5 mg PO BID Please start on ___ and continue until instructed by your primary care physician 5. Nicotine Patch 14 mg TD DAILY 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Cyclobenzaprine 5 mg PO BID:PRN spasm 8. Gabapentin 100 mg PO TID Back pain 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 10. Amitriptyline 10 mg PO QHS 11. Fluconazole 400 mg PO Q24H Continue through ___ or as otherwise instructed by your Infectious Disease doctors 12. FoLIC Acid 1 mg PO DAILY 13. Furosemide 60 mg PO DAILY 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Lidocaine 5% Patch 1 PTCH TD QPM back pain 16. Magnesium Oxide 400 mg PO DAILY 17. Multivitamins 1 TAB PO DAILY 18. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation 19. Pantoprazole 40 mg PO Q24H 20. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 21. Rifaximin 550 mg PO BID 22. Spironolactone 100 mg PO DAILY 23. Thiamine 100 mg PO DAILY 24. Venlafaxine XR 37.5 mg PO DAILY 25. HELD- Lactulose 30 mL PO TID This medication was held. Do not restart Lactulose until your abdominal distension has completely resolved; can restart if increasingly confused 26. HELD- QUEtiapine Fumarate 100 mg PO QHS This medication was held. Do not restart QUEtiapine Fumarate until instructed by your primary care physician 27.Outpatient Lab Work Please obtain weekly labs (starting ___: BMP, CBC w/diff, AST/ALT, AP and fax to ___ clinic at ___ ICD10: ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Hepatic Encephalopathy; Failure to thrive Secondary Diagnosis: Pulmonary embolism, ETOH cirrhosis, malnutrition, ileus, tuboovarian abscesses, refeeding syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for inability to eat and worsening abdominal pain. On admission you were found to be confused, which we felt was due to hepatic encephalopathy. This improved during your admission. During your admission you were also found to have an ileus, which is when your gut doesn't move food through properly. This was likely due to your infection in your abdomen. You were continued on your IV medications to treat your abdominal abscesses and this should continue for the next few weeks. Due to malnutrition, a tube was placed in your nose to help support your nutrition. Please follow-up with the Infectious Disease team and the Liver team in the next ___ weeks. We wish you the best, Your ___ Team Followup Instructions: ___
[ "K7290", "K651", "I2699", "E43", "E8342", "K766", "E8352", "K567", "Z781", "F17210", "K7031", "R627", "Z6820", "F1020", "J45909", "I10", "F329", "R339", "G8929", "E876", "K3189", "D638", "N7093", "Z7902", "R0789" ]
Allergies: lisinopril Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: R IJ placement ([MASKED]) Diagnostic Paracentesis ([MASKED]) Upper Endoscopy ([MASKED]) R PICC Placement ([MASKED]) History of Present Illness: [MASKED] history of EtOH abuse, EtOH pancreatitis, and recently diagnosed cirrhosis in addition to a recent hospitalization which identified b/l Tubo-ovarian abscesses and multiple intraabdominal abscesses which underwent [MASKED] guided drainage and grew [MASKED] and actinomyces presents with altered mental status, dizzyness and right sided abdominal pain. During that hospitalization, she also required intubation for hypoxic respiratory failure in the setting of pulmonary edema and hepatopulmonary syndrome. The patient was unable to provide history at time of interview. Most of HPI was gathered from emergency department. Per notes, the patient was recently discharged from [MASKED] on [MASKED] for the above mentioned hospitalization with a PICC line for IV ertapenem and fluconazole. Per patient's fiancé, the patient had not been herself since discharge and has been complaining of dizziness x1 day and weakness for the last 10 days. The patient has not been able to take PO. No reported n/v/d. Of note, her PICC line had been taken out by [MASKED] recently for suspicion of a line infection given that it was not being capped properly. Plan was for midline placement [MASKED] as outpt but pt unable to make appt due to weakness. While in the ED, the patient was noted to have a post void residual of 300-400cc and was complaining of low back pain for which a code cord was called over concern for spinal abscess. MRI was obtained and no spinal compression was noted. In addition, the while in the ED a right sided IJ was placed due to poor IV access. This was uncomplicated. Her initial exam was notable for: HR 112, otherwise VS WNL. A&O x3. Dry MM. Tachy with regular rhythm. Abdomen soft, ND, NT. The patient was given 2L IV NS, 1g IV ertapenem, 400 mg IV fluconazole given and Azithro IV 500 mg oxycodone 5 and lorazepam 0.5 - Patient was given: [MASKED] 14:42 PO/NG Acetaminophen 1000 mg [MASKED] 14:42 PO/NG OxyCODONE (Immediate Release) 5 mg [MASKED] 14:42 PO/NG LORazepam .5 mg - Labs notable for: Lactate:2.1 ALT: 11 AP: 467 Tbili: 2.1 Alb: 2.6 AST: 83 WBC 18.6 Hgb 9.3 Plt 333 - Imaging was notable for: [MASKED] 15:44 Chest (Portable Ap) Right IJ terminates in the right atrium. No evidence of pneumothorax. Low lung volumes and left base consolidation worrisome for pneumonia. MRI [MASKED]: Disc bulge at L5-S1 mildly impresses on the spinal cord at this level without critical stenosis. Degenerative changes at L4-L5 and L5-S1 result in mild bilateral neuroforaminal narrowing. No abnormal signal changes to suggest cord ischemia or contusion. No evidence of spinal epidural abscess, diskitis or osteomyelitis. [MASKED] 18:51 Skull No radio-opaque foreign body is detected over the orbits. Upon arrival to the floor, patient is AAOx2 and lethargic though able to follow commands REVIEW OF SYSTEMS: unable to obtain Past Medical History: cirrhosis EtOH pancreatitis EtOH abuse/dependence Asthma HTN Depression Social History: [MASKED] Family History: Father with hx of HTN but otherwise healthy. Mother healthy. Three of four children have asthma, otherwise healthy. Denies FH of pancreatitis, pancreatic or GB malignancy. Physical Exam: ADMISSION EXAM: ================ Vital Signs: T 97.5 BP 153/98 HR 88 R 20 SpO2 90 Ra GEN: Lethargic, following commands, cachetic HEENT: sclerae anicteric, +temporal wasting, pupils dilated but reactive [MASKED]: RRR no MRG RESP: No increased WOB, bibasilar crackles, no wheezing or rhonchi ABD: Distended, with caput. Small, rubbery nodules RLQ and LLQ. [MASKED], np guarding. EXT: Warm, without edema NEURO: moves all 4 extremities, no tongue deviation, no facial droop, pupils dilated but reactive. No asterixis. DISCHARGE EXAM =============== Vital Signs: 98.2 127/85 114 22 90%RA GEN: A+O x 3, cachectic, alert and interactive HEENT: pupils dilated and minimally reactive (stable from admission), mucous membranes moist, sclerae icteric, +temporal wasting, [MASKED]: S1S2 tachycardic; no appreciable murmurs. No carotid bruits auscultated. Tenderness on palpation of right anterior chest. RESP: No increased WOB, lungs clear to auscultation although limited exam based on patient positing ABD: Soft, mildly distended, nontender to palpation EXT: Warm, without edema, cord palpated in R upper extremity MSK: No spinal tenderness to palpation, Positive for tenderness to palpation of the R lower back. NEURO: CNII-XII intact, sensation equal bilaterally, [MASKED] strength in upper extremities, [MASKED] strength in lower extremities, pupils are dilated and minimally reactive, no asterixis, gait testing deferred. SKIN: extremely dry, no tenting, no wounds seen on the extremities, old hyperkeratotic scar on L shin. GU: No suprapubic tenderness. Foley in place. Pertinent Results: ADMISSION LABS: =============== [MASKED] 12:30PM BLOOD WBC-18.6* RBC-2.90* Hgb-9.3* Hct-28.9* MCV-100* MCH-32.1* MCHC-32.2 RDW-19.6* RDWSD-70.9* Plt [MASKED] [MASKED] 12:30PM BLOOD Neuts-83* Bands-0 Lymphs-11* Monos-4* Eos-1 Baso-1 [MASKED] Myelos-0 AbsNeut-15.44* AbsLymp-2.05 AbsMono-0.74 AbsEos-0.19 AbsBaso-0.19* [MASKED] 12:30PM BLOOD Glucose-108* UreaN-8 Creat-0.9 Na-135 K-3.2* Cl-95* HCO3-24 AnGap-19 [MASKED] 12:30PM BLOOD ALT-11 AST-83* AlkPhos-467* TotBili-2.1* [MASKED] 12:30PM BLOOD Lipase-47 [MASKED] 12:30PM BLOOD Albumin-2.6* Calcium-13.0* Phos-5.9* Mg-1.1* [MASKED] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 03:57PM BLOOD [MASKED] pO2-36* pCO2-39 pH-7.46* calTCO2-29 Base XS-3 [MASKED] 12:46PM BLOOD Lactate-2.1* OTHER PERTINENT LABS: ===================== [MASKED] 08:15AM BLOOD [MASKED] PTT-52.7* [MASKED] [MASKED] 12:17PM BLOOD CK-MB-<1 cTropnT-<0.01 [MASKED] 05:54PM BLOOD CK-MB-<1 cTropnT-<0.01 [MASKED] 05:42AM BLOOD Albumin-2.8* Calcium-9.6 Phos-4.8* Mg-2.3 [MASKED] 05:00AM BLOOD TSH-13* [MASKED] 05:00AM BLOOD Free T4-1.0 [MASKED] 06:10AM BLOOD PTH-17 [MASKED] 06:10AM BLOOD PEP-POLYCLONAL DISCHARGE LABS: ================ [MASKED] 01:48PM BLOOD WBC-14.4* RBC-2.40* Hgb-7.4* Hct-23.2* MCV-97 MCH-30.8 MCHC-31.9* RDW-17.7* RDWSD-60.7* Plt [MASKED] [MASKED] 02:13AM BLOOD [MASKED] PTT-73.3* [MASKED] [MASKED] 11:47AM BLOOD Glucose-153* UreaN-5* Creat-0.7 Na-136 K-3.6 Cl-102 HCO3-22 AnGap-16 [MASKED] 02:13AM BLOOD ALT-8 AST-41* AlkPhos-340* TotBili-1.3 [MASKED] 11:47AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2 URINE STUDIES: =============== [MASKED] 06:51PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 06:51PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-8.0 Leuks-NEG [MASKED] 01:07PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 01:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR [MASKED] 01:07PM URINE RBC-<1 WBC-4 Bacteri-NONE Yeast-NONE Epi-2 ASCITES STUDIES: ================= [MASKED] 02:29PM ASCITES TNC-165* RBC-143* Polys-1* Lymphs-63* Monos-23* Macroph-13* [MASKED] 02:29PM ASCITES TotPro-2.6 Albumin-1.0 [MASKED] Cytology: NEGATIVE FOR MALIGNANT CELLS. MICROBIOLOGY: =============== [MASKED] 12:00AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 1:07 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 3:45 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 5:05 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 5:05 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 8:15 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. [MASKED] 2:11 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. Time Taken Not Noted Log-In Date/Time: [MASKED] 2:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT [MASKED] Fluid Culture in Bottles (Final [MASKED]: NO GROWTH. [MASKED] 6:07 pm BLOOD CULTURE Source: Line-PICC. Blood Culture, Routine (Pending): No growth to date [MASKED] 6:51 pm URINE Source: Catheter. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 7:02 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date [MASKED] 8:35 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. (Reference Range-Negative). IMAGING/STUDIES: ================= CXR ([MASKED]): Right IJ terminates in the right atrium. No evidence of pneumothorax. Low lung volumes and left base consolidation worrisome for pneumonia. Skull Trauma XRay ([MASKED]): No radio-opaque foreign body is detected over the orbits. Dental amalgam with wires within the mouth likely reflect dental hardware. MR [MASKED] [MASKED] 1. No spinal cord signal abnormality, spinal cord or nerve root compression. 2. No epidural collection or evidence of infection. 3. Mild degenerative changes, as described, without significant spinal canal or high-grade neural foraminal narrowing. 4. Nonspecific lumbar paraspinal muscular edema, which may be related to strain. 5. Moderate left and small right pleural effusions. 6. Small volume ascites. 7. Nonspecific decreased T1 signal of the visualized osseous structures which can be seen in the setting of anemia. CXR ([MASKED]): Right central venous catheter tip terminates near the cavoatrial junction/proximal right atrium. No relevant change since prior study Liver U/S w/ Doppler ([MASKED]): 1. Patent hepatic vasculature with appropriate waveforms. 2. Cirrhotic liver morphology without focal lesion identified. 3. Mild ascites. CTA Chest/CT Abdomen ([MASKED]): 1. Right upper lobe segmental pulmonary embolism. 2. Moderate nonhemorrhagic left pleural effusion with associated compressive atelectasis. 3. Mild dependent pulmonary edema. 4. Interval decrease in the size of the bilateral adnexal fluid collections. 5. Previously seen smaller fluid collections in the right pericolic gutter and adjacent to the right inferior abdominal wall now appear mostly as enhancing soft tissue, and are slightly increased in size. 6. Large volume abdominal and pelvic ascites, similar to prior. Right upper extremity Ultrasound ([MASKED]): No evidence of deep vein thrombosis in the right upper extremity, noting that the internal jugular vein could not be evaluated secondary to difficulty with patient positioning. Right cephalic vein not seen. Upper Endoscopy ([MASKED]): No esophageal varices. Erythema, congestion and mosaic appearance in the stomach No gastric varices. An NG tube was placed after the procedure and visualized in the esophagus. Otherwise normal EGD to third part of the duodenum KUB ([MASKED]): Multiple loops of prominent small bowel, which can be seen in the setting of ileus or early obstruction CXR ([MASKED]): Prominent loops of bowel in the upper and mid abdomen, minimally improved compared with previous. This may represent ileus or obstruction. KUB ([MASKED]): Prominent loops of bowel in the upper and mid abdomen, minimally improved compared with previous. This may represent ileus or obstruction. ECHO ([MASKED]): Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. A right pleural effusion is present. Ascites is present. IMPRESSION: Normal global biventricular systolic function. Ascites and right pleural effusion. KUB ([MASKED]): Nonspecific loops of bowel in the upper and mid left abdomen, with distension of these loops improved from prior. Brief Hospital Course: Ms. [MASKED] is a [MASKED] with recently diagnosed ETOH cirrhosis and recent prolonged treatment for multiple intra-abdominal and pelvic tuboovarian abscesses growing [MASKED] and actinomyces on IV fluconazole/ertapenem as an outpatient who presented with progressive weakness and recurrent abdominal pain. She was subsequently found to be confused concerning for hepatic encephalopathy. Initially presented with confusion and mumbling consistent with encephalopathy in the setting of likely ileus vs early small obstruction. In the Emergency Department she also was noted to have urinary retention and given difficult historian a Code Cord was called. MRI was performed without evidence of spinal cord compression. A foley was placed successfully. For her encephalopathy, she was given lactulose enemas and NGT was placed to suction with improvement in her mental status. Initially started on broad antibiotics, although infectious work-up including blood cultures, urine cultures, paracentesis and CXR without new evidence of infection. A CTA torso was performed, which demonstrated interval decrease in the size of bilateral adnexal fluid collections and new segmental pulmonary embolism. Infectious disease was consulted and recommended Unasyn/Fluconazole as she was felt not to have failed therapy but may have had inconsistent use of antibiotics at home. For her pulmonary embolism, she was treated with a heparin gtt. Remained hemodynamically stable. Echo performed without evidence of strain and ECG without acute changes. She was having intermittent right sided chest pain that was felt to be musculoskeletal. After ileus resolved, she was transitioned to apixaban for treatment of pulmonary embolism. A KUB of her abdomen was obtained for increased abdominal distention and demonstrated findings consistent with early SBO vs ileus. An NGT was placed to suction and she was hydrated with albumin. Her abdominal exam improved and her tube feeds were advanced. She was having evidence of refeeding syndrome requiring frequent electrolyte repletions, however continued to tolerate feeds. ACTIVE ISSUES: ====================== # Altered Mental Status # Hepatic encephalopathy: Initially presented with confusion, mumbling, and unable to give history. Felt to be most consistent with hepatic encephalopathy given asterixis on admission. Likely triggers include constipation, urinary retention, new acute pulmonary embolism, and possibly due to missed treatments of her known intraabdominal abscesses. Work-up included a negative serum tox, urine tox, a normal noncontrast head CT. Infectious work-up included a CXR without evidence of pnuemonia, and negative urine and blood cultures. Paracentesis was performed which demonstrated no evidence of SBP. She was resumed on home rifaxamin and given lactulose enemas with improvement in her mental status. Given resolving ileus as outlined below, her po lactulose was held. This can be resumed once her po intake improves if with any further confusion. # Malutrition # Refeeding syndrome: While at home the patient reports having very little to no po intake. This was due to nausea/vomiting at home and likely encephalopathy. Due to persistent abdominal pain and ileus, she was unable to keep up with nutritional needs. An NG tube was placed to help supplement nutrition and she was started on Jevity 1.5 feeds with goal of 50cc/hr. Given her poor po intake, she needed BID lytes for repletion of potassium and magnesium. On discharge she was tolerating small amounts of po intake. As she is able to tolerate more, her NG tube feeds can be discontinued. # Ileus: After initiating tube feeds, noted to have increased abdominal distention and abdominal pain. KUB demonstrated likely ileus vs early small bowel obstruction. She continued to have bowel movements, so felt more likely to be due to ileus. C. difficile was sent and found to be negative. NGT was placed to suction and she was placed on bowel rest. Given Albumin 50g boluses/day. Her abdominal pain improved, and tube feeds were advanced. She was able to reach goal tube fees on [MASKED]. # Pulmonary embolism: On presentation underwent a CTA that demonstrated a right upper lobe segmental pulmonary embolism. She remained hemodynamically stable throughout admission. An ECG demosntrated sinus tachycardia without evidence of right heart strain. Trops were negative x 2. Echo demonstrated no findings of right heart strain. While she had an ileus she was kept on heparin gtt. This was transitioned to apixaban on [MASKED] for ongoing treatement. She should take apixaban 10mg po BID x 7 days (last day [MASKED], and then transition to apixaban 5mg po BID for ongoing treatment. Of note, cord palpated at old [MASKED] line though no DVT found on ultrasound. # Abdominal Pain # Tuboovarian Abscesses: On admission noted to have abdominal pain felt to be due to known abscesses vs urinary retention as listed below. Patient recently discharged from [MASKED] where she was found to have cirrhosis and multiple intraabdominal abscesses growing [MASKED] and actinomyces. Patient discharged during last hospitalization with [MASKED] line with IV ertapenem and PO fluconazole. PICC line was removed as an outpatient given concern for line infection, and patient did not follow up with mid-line placement. There was concern she was missing doses at home and not adequately treating her infection. Antibiotics were originally supposed to continue through [MASKED]. Given her noncompliance with outpatient antibiotic therapy, Infectious Disease was consulted. Recommended IV Unasyn 3g IV q6h and po fluconazole (new day [MASKED] for [MASKED] weeks of treatment. She will then need to be transitioned to po antibiotics if stable. Repeat CT abdomen demonstrated improved abscesses during admission. Will need weekly BMP, CBCD, AST/ALT, AP to be faxed to [MASKED] clinic at [MASKED]. # Cirrhosis c/b hepatic encephalopathy and ascites # ETOH use: Cirrhosis felt to be seconary to ETOH cirrhosis given 1L of vodka intake daily while at home. Decompensated on admission with hepatic encephalopathy as outlined above. Diagnosed paracentesis without evidence of SBP. She underwent upper endoscopy on [MASKED] that demonstrated portal gastropathy without evidence of esophageal varices. LFTs near baseline with AST/ALT about [MASKED] during admission. Bilirubin mildly trending up to 1.9, although improved to 1.3 on discharge. She was continued on home spironolactone and Lasix during admission. # Anemia, resolved: During admission had anemia with H/H around [MASKED]. On [MASKED], her hgb dropped to 6.9 so she was transfused 1U of PRBCs with improvement. Likely secondary to chronic disease. No evidence of bleeding throughout admission. Please recheck CBC on [MASKED] to ensure stability. # Urinary retention: On presentation noted to have urinary retention and foley was placed. PVR 400cc in ED. Likely secondary to intraabdominal infection. On arrival to the ED given poor historian, concerned for Cord compression. A Code Cord was called and MRI of the [MASKED] was obtained without evidence of spinal stenosis. The patient's fiance notes that she has this issue at home where she holds her urine in because she does not want to get out of bed. Will need voiding trial when she is able to use the bed pan. # Hypercalcemia: During hospitalization noted to have elevated calcium with peak 11.9. PTH 17, Hypothyroidism ruled out, SPEP/UPEP without M spike. Possibly due to outpatient Tums use for abdominal pain, although unclear. Improved during hospitalization. # ETOH abuse: Reports drinking 1L vodka daily. Last use on [MASKED]. She was monitored on CIWA scale during admission and required minimal doses without evidence of withdrawal. She was continued on multivitamin, thiamine, and folic acid during admission. CHRONIC ISSUES: ====================== #Asthma: Stable during admission. Continued on home nebs. #Depression: On admission, held amitriptyline and quetiapine given AMS. When her mental status improved she was restarted on amitriptyline and quetiapine 50mg po daily prn. Attempted to restart her home quetiapine 100mg po qhs although became more sedated so this was held. Could consider restarting as outpatient. Her venlfaxine was continued. #Chronic Pain: Patient has chronic low back pain. MRI negative as above. For pain she was continued on lidocaine patch. Her gabapentin dose was held on admission, and restarted at a lower dose at 100mg TID given somnolence. Cyclobenzaprine was also started at a lower dose given sleepiness. Could consider further uptitration as an outpatient. ***TRANSITIONAL ISSUES*** - Please monitor electrolytes daily and replete as needed given persistent hypokalemia and hypomagnesemia in the setting of likely refeeding syndrome - Advance diet as tolerated, and once she is able to support her diet she can discontinue her tube feeds - For her pulmonary embolism she was started on apixaban 10mg po BID. This should be transitioned to 5mg po BID on [MASKED] for continued treatment of acute PE - Please check CBC on [MASKED] to monitor for anemia; She required 1U of PRBCs (given on [MASKED] during her hospitalization. - Please continue to advised ETOH cessation - Will need follow-up with liver clinic in [MASKED] weeks - Will need follow-up with [MASKED] clinic - Please obtain weekly labs (starting [MASKED]: BMP, CBC w/diff, AST/ALT, AP and fax to [MASKED] clinic at [MASKED] - Patient should continue on IV Unasyn/fluticasone through [MASKED], and will then need to be transitioned to PO antibiotics as outlined by Infectious Disease. - Lactulose was held on discharge as patient was having frequent bowel movements and when given was giving increased abdominal distention; please consider restarting if she develops confusion - Home Quetiapine 100mg po qhs was held on admission due to sleepiness; consider restarting at lower dose if continues to have poor mood - Patient with foley in place for urinary retention; Will need voiding trial when able to use bed pan - Code: full - Contact: [MASKED] (sister/HCP) Phone number: [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ertapenem Sodium 1 g IV 1X 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 3. Amitriptyline 10 mg PO QHS 4. FoLIC Acid 1 mg PO DAILY 5. Gabapentin 300 mg PO TID 6. Lactulose 30 mL PO TID 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Multivitamins 1 TAB PO DAILY 9. QUEtiapine Fumarate 100 mg PO QHS 10. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 11. Thiamine 100 mg PO DAILY 12. Venlafaxine XR 37.5 mg PO DAILY 13. Lidocaine 5% Patch 1 PTCH TD QPM back pain 14. Pantoprazole 40 mg PO Q24H 15. Rifaximin 550 mg PO BID 16. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation 17. Cyclobenzaprine 10 mg PO HS:PRN spasm 18. Magnesium Oxide 400 mg PO DAILY 19. Fluconazole 400 mg PO Q24H 20. Spironolactone 100 mg PO DAILY 21. Furosemide 60 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Ampicillin-Sulbactam 3 g IV Q6H Continue through [MASKED] or as otherwise instructed by your Infectious Disease doctors 3. Apixaban 10 mg PO BID Duration: 7 Days please continue through [MASKED]. Apixaban 5 mg PO BID Please start on [MASKED] and continue until instructed by your primary care physician 5. Nicotine Patch 14 mg TD DAILY 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Cyclobenzaprine 5 mg PO BID:PRN spasm 8. Gabapentin 100 mg PO TID Back pain 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 10. Amitriptyline 10 mg PO QHS 11. Fluconazole 400 mg PO Q24H Continue through [MASKED] or as otherwise instructed by your Infectious Disease doctors 12. FoLIC Acid 1 mg PO DAILY 13. Furosemide 60 mg PO DAILY 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Lidocaine 5% Patch 1 PTCH TD QPM back pain 16. Magnesium Oxide 400 mg PO DAILY 17. Multivitamins 1 TAB PO DAILY 18. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation 19. Pantoprazole 40 mg PO Q24H 20. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 21. Rifaximin 550 mg PO BID 22. Spironolactone 100 mg PO DAILY 23. Thiamine 100 mg PO DAILY 24. Venlafaxine XR 37.5 mg PO DAILY 25. HELD- Lactulose 30 mL PO TID This medication was held. Do not restart Lactulose until your abdominal distension has completely resolved; can restart if increasingly confused 26. HELD- QUEtiapine Fumarate 100 mg PO QHS This medication was held. Do not restart QUEtiapine Fumarate until instructed by your primary care physician 27.Outpatient Lab Work Please obtain weekly labs (starting [MASKED]: BMP, CBC w/diff, AST/ALT, AP and fax to [MASKED] clinic at [MASKED] ICD10: [MASKED] Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: Hepatic Encephalopathy; Failure to thrive Secondary Diagnosis: Pulmonary embolism, ETOH cirrhosis, malnutrition, ileus, tuboovarian abscesses, refeeding syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] for inability to eat and worsening abdominal pain. On admission you were found to be confused, which we felt was due to hepatic encephalopathy. This improved during your admission. During your admission you were also found to have an ileus, which is when your gut doesn't move food through properly. This was likely due to your infection in your abdomen. You were continued on your IV medications to treat your abdominal abscesses and this should continue for the next few weeks. Due to malnutrition, a tube was placed in your nose to help support your nutrition. Please follow-up with the Infectious Disease team and the Liver team in the next [MASKED] weeks. We wish you the best, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "F17210", "J45909", "I10", "F329", "G8929", "Z7902" ]
[ "K7290: Hepatic failure, unspecified without coma", "K651: Peritoneal abscess", "I2699: Other pulmonary embolism without acute cor pulmonale", "E43: Unspecified severe protein-calorie malnutrition", "E8342: Hypomagnesemia", "K766: Portal hypertension", "E8352: Hypercalcemia", "K567: Ileus, unspecified", "Z781: Physical restraint status", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K7031: Alcoholic cirrhosis of liver with ascites", "R627: Adult failure to thrive", "Z6820: Body mass index [BMI] 20.0-20.9, adult", "F1020: Alcohol dependence, uncomplicated", "J45909: Unspecified asthma, uncomplicated", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "R339: Retention of urine, unspecified", "G8929: Other chronic pain", "E876: Hypokalemia", "K3189: Other diseases of stomach and duodenum", "D638: Anemia in other chronic diseases classified elsewhere", "N7093: Salpingitis and oophoritis, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R0789: Other chest pain" ]
10,076,263
25,634,900
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril Attending: ___ Chief Complaint: Right sided abdominal pain Major Surgical or Invasive Procedure: ___ drainage of tubo-ovarian and intra-abdominal abscesses ___ Diagnostic and therapeutic paracentesis ___ and ___ History of Present Illness: ___ year old woman with PMHx of EtOH abuse, EtOH pancreatitis, HTN, cirrhosis presenting complaining of right-sided abdominal/flank pain. Patient states she has had the pain for the past 5 days. She is tender and also has left intermittent thigh pain. She has been having nonbloody nausea and vomiting over the past week. No diarrhea or dark black stool. She reports chills, weakness, fatigue. No fevers. She denies recent travel. She denies IV drug use. Denies history of kidney stone. She continued to drink alcohol last drink on ___ prior to coming to hospital ___ pint of vodka. She has a history of withdrawal and seizures years ago. She has been having had increasing SOB and worsening of her asthma symptoms over the past couple weeks. No chest pain. *Of note the patient reports she has been sleeping with her gas oven on because her apartment is not warm enough. In ED initial vitals 99.4 100 109/55 17 98% RA. HR peaked at 116. Low of BP 98/58. Exam: Right flank tenderness palpation, no CVA tenderness, rectal brown guaiac neg stool Labs notable for: WBC 24.5 H/H 7.3/21.8 -> 20.1 Plt 349 N80.2 131 91 10 ------------- 107 AGap=25 3.4 18 1.7 ___: 18.5 PTT: 40.8 INR: 1.7 Lactate:2.7 Alp 236 ALT<5 AST33 UCG Negative UA Hazy, pH 6.0 Urobilin 4, Leuk Lg, Bld Neg, Nitrates Neg, Protein 30, Glucose Neg, Ket Neg, Rbc 2, WBC 26, Few Bacteria, None Yeast, Epi 4. Cast Hy 58. IMAGING: CTU 1. No convincing evidence of acute intra-abdominal process. Specifically, no hydronephrosis or nephrolithiasis. 2. New, right infrahepatic and right pelvic omental soft tissue nodules. Findings are incompletely characterized on this noncontrast CT examination,and are indeterminate. Further characterization by contrast-enhanced CT examination with Visipaque following IV hydration is recommended. Alternatively, direct tissue sampling could be considered. 3. Bilateral adnexal hypodensities are suboptimally evaluated on this noncontrast CT examination. Recommend pelvic ultrasound for further evaluation. 4. Enlarged and irregular appearing liver, compatible with patient's known cirrhosis. Small volume perihepatic free fluid. Patient was given: ___ 15:05 IV Ketorolac 30 mg ___ 15:05 IVF NS ___ 16:31 IV CeftriaXONE ___ 16:37 IVF NS 1 mL ___ 17:25 IV CeftriaXONE 1 gm ___ 19:30 IVF NS 1 mL ___ 21:13 IV Morphine Sulfate 2 mg ___ 22:00 IVF NS ___ 00:34 PO Thiamine 100 mg ___ 00:34 PO/NG Acetaminophen 325 mg ___ 01:30 IVF NS 1 mL ___ 01:43 IV Morphine Sulfate 2 mg ___ 04:51 TD Nicotine Patch 21 mg ___ 04:51 IH Albuterol Inhaler 2 PUFF Patient initially refused PRBC transfusion and then agreed and then given 1U of PRBC Transfer vitals: 98.9 109 107/68 19 93% On arrival to the MICU, patient states she feels well. Reports chills and right sided flank pain. Past Medical History: EtOH pancreatitis EtOH abuse/dependence Asthma HTN Depression Social History: ___ Family History: Father with hx of HTN but otherwise healthy. Mother healthy. Three of four children have asthma, otherwise healthy. Denies FH of pancreatitis, pancreatic or GB malignancy. Physical Exam: Admission: VITALS: 98.4 114 124/90 22 99%RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM NECK: supple, 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, minimal tenderness over right side of abdomen/flank, non-distended, bowel sounds present, no rebound tenderness or guarding, EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: warm, no evidence of jaundice NEURO: AOx3, no asterixis, grossly normal strength and sensation DISCHARGE EXAM: Vitals: 98.0 113 / 79 100 18 93 /RA-1L General: Thin, chronically ill-appearing woman in NAD HEENT: Sclera anicteric, MMM, oropharynx clear. JVP 1-2cm above clavicle at 90 degrees. Lungs: Decreased breath sounds ___, no W/R/C CV: Tachycardic, loud heart sounds, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: moderately distended,soft, non-tender. Normoactive bowel sounds, no rebound tenderness or guarding. Ext: Warm, well perfused, 1+ ___ edema up to midshin b/l Neuro: AO x 3. No asterixis. Pertinent Results: ============== ADMISSION LABS =============== ___ 07:50PM ___ PO2-38* PCO2-33* PH-7.39 TOTAL CO2-21 BASE XS--3 ___ 07:50PM LACTATE-1.5 ___ 07:50PM HGB-8.5* calcHCT-26 ___ 07:42PM WBC-23.8* RBC-2.40* HGB-8.2* HCT-24.8* MCV-103* MCH-34.2* MCHC-33.1 RDW-15.8* RDWSD-59.6* ___ 07:42PM PLT COUNT-267 ___ 07:42PM ___ PTT-48.6* ___ ___ 01:35PM ___ PO2-158* PCO2-29* PH-7.43 TOTAL CO2-20* BASE XS--3 ___ 01:35PM LACTATE-1.4 ___ 01:35PM O2 SAT-97 CARBOXYHB-2 ___ 07:45AM LACTATE-3.2* ___ 07:41AM GLUCOSE-89 UREA N-10 CREAT-1.0 SODIUM-133 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-17* ANION GAP-20 ___ 07:41AM ALT(SGPT)-<5 AST(SGOT)-27 ALK PHOS-230* TOT BILI-0.9 ___ 07:41AM CALCIUM-7.4* PHOSPHATE-3.3 MAGNESIUM-1.2* ___ 07:41AM WBC-27.4* RBC-2.70*# HGB-9.2*# HCT-28.7*# MCV-106* MCH-34.1* MCHC-32.1 RDW-15.5 RDWSD-59.4* ___ 07:41AM NEUTS-80.6* LYMPHS-12.0* MONOS-5.3 EOS-0.3* BASOS-0.3 NUC RBCS-0.1* IM ___ AbsNeut-22.04* AbsLymp-3.29 AbsMono-1.45* AbsEos-0.07 AbsBaso-0.09* ___ 07:41AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ___ 07:41AM PLT COUNT-299 ___ 07:41AM ___ PTT-43.1* ___ ___ 07:41AM RET AUT-3.0* ABS RET-0.08 ___ 07:00PM HCT-20.1* ___ 04:33PM LACTATE-2.7* ___ 03:54PM ___ PTT-40.8* ___ ___ 03:00PM GLUCOSE-107* UREA N-10 CREAT-1.7*# SODIUM-131* POTASSIUM-3.4 CHLORIDE-91* TOTAL CO2-18* ANION GAP-25* ___ 03:00PM estGFR-Using this ___ 03:00PM ALT(SGPT)-<5 AST(SGOT)-33 ALK PHOS-236* TOT BILI-0.7 ___ 03:00PM LIPASE-6 ___ 03:00PM ALBUMIN-2.3* ___ 03:00PM WBC-24.5*# RBC-2.10*# HGB-7.3*# HCT-21.8*# MCV-104*# MCH-34.8* MCHC-33.5 RDW-14.6 RDWSD-55.2* ___ 03:00PM NEUTS-80.2* LYMPHS-12.4* MONOS-5.6 EOS-0.2* BASOS-0.2 IM ___ AbsNeut-19.64* AbsLymp-3.05 AbsMono-1.38* AbsEos-0.04 AbsBaso-0.05 ___ 03:00PM WBC-24.5*# RBC-2.10*# HGB-7.3*# HCT-21.8*# MCV-104*# MCH-34.8* MCHC-33.5 RDW-14.6 RDWSD-55.2* ___ 03:00PM PLT COUNT-349# ___ 02:00PM URINE HOURS-RANDOM ___ 02:00PM URINE UCG-NEGATIVE ___ 02:00PM URINE UHOLD-HOLD ___ 02:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-LG ___ 02:00PM URINE RBC-2 WBC-26* BACTERIA-FEW YEAST-NONE EPI-4 ___ 02:00PM URINE HYALINE-58* ___ 02:00PM URINE MUCOUS-FEW ========================== DISCHARGE LABS ========================== ___ 05:23AM BLOOD WBC-26.0* RBC-2.35* Hgb-7.5* Hct-23.7* MCV-101* MCH-31.9 MCHC-31.6* RDW-21.2* RDWSD-75.5* Plt ___ ___ 05:23AM BLOOD Neuts-72* Bands-0 Lymphs-18* Monos-4* Eos-1 Baso-1 Atyps-2* Metas-2* Myelos-0 AbsNeut-18.72* AbsLymp-5.20* AbsMono-1.04* AbsEos-0.26 AbsBaso-0.26* ___ 05:23AM BLOOD ___ PTT-53.9* ___ ___ 05:23AM BLOOD Plt ___ ___ 01:00PM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-134 K-4.4 Cl-97 HCO3-23 AnGap-18 ___ 05:23AM BLOOD ALT-10 AST-69* LD(LDH)-207 AlkPhos-508* TotBili-2.0* ___ 01:00PM BLOOD Calcium-9.0 Phos-4.1 Mg-2.7* ___ 09:45PM BLOOD Vanco-25.6* ___ 03:27PM BLOOD CRP-99.0* ___ 07:41AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* IgM HBc-Negative ___ 10:45AM BLOOD AMA-NEGATIVE ___ 08:15AM BLOOD Cortsol-14.7 ___ 04:55AM BLOOD T4-4.6 ___ 05:54AM BLOOD TSH-5.3* ___ 08:55AM BLOOD Type-ART pO2-61* pCO2-38 pH-7.48* calTCO2-29 Base XS-4 ___ 08:55AM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-90 ================ MICROBIOLOGY ================ __________________________________________________________ ___ 2:47 pm STOOL CONSISTENCY: WATERY Source: Stool. FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Pending): __________________________________________________________ ___ 5:58 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. __________________________________________________________ ___ 1:10 pm BLOOD CULTURE #2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 8:42 am BLOOD CULTURE Source: Line-PICC #1. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:40 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 1:09 pm BLOOD CULTURE Source: Line-PICC 1 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 12:53 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 2:23 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 1:30 pm BLOOD CULTURE INCUBATE 10 DAYS FOR RULE/OUT ACTINOMYCES PER ___ ___ ___. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 11:50 am BLOOD CULTURE Source: Line-PICC #1. INCUBATE 10 DAYS FOR RULE/OUT ACTINOMYCES PER ___ ___ ___. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 2:22 pm ABSCESS Source: pelvic abscess. HOLD 14 DAYS FOR ACTINOMYCES . GRAM STAIN (Final ___: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). BEADED/ BRANCHING GRAM POSITIVE ROD(S) ___. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): ANAEROBIC GRAM NEGATIVE ROD(S). SPARSE GROWTH. MIXED BACTERIAL FLORA. Mixed bacteria are present, which may include anaerobes and/or facultative anaerobes. Bacterial growth was screened for the presence of B.fragilis, C.perfringenes, and C.septicum. None of these species was found. ACTINOMYCES ___. SPARSE GROWTH. BEADED BRANCHING POSITIVE ROD. SENT TO ___ LAB FOR IDENTIFICATION AND SUSCEPTIBILITY TESTING. ID PERFORMED BY ___. ============ IMAGING ============= Imaging: Lower extremity ultrasound ___: No evidence of deep venous thrombosis in the right or left lower extremity veins. CT Abd/Pelvis ___: -Minimal interval decrease in size of bilateral tubo-ovarian abscesses and the rim enhancing collection along the right pericolic gutter. -Cirrhosis with sequela of portal hypertension with moderate ascites, decreased since prior exam. -Bilateral, nonhemorrhagic pleural effusions, right greater than left. CT Abd/Pelvis ___: 1. Interval decrease in size of bilateral tubo-ovarian abscesses and the rim enhancing collection along the right paracolic gutter. 2. Cirrhosis with sequela of portal hypertension with moderate ascites, increased since the prior exam. CT Chest ___: 1. Improved pulmonary edema compared to the prior study. 2. Persistent lingular consolidation, though probably slightly improved compared to the prior exam remains concerning for infection. 3. Improved left lower lobe consolidation consistent with atelectasis. 4. Small bilateral pleural effusions, increased compared to the prior study. CTA Chest and CT abdomen ___: 1. Interval decrease in size of bilateral tubo-ovarian abscesses. 2. Interval decrease in the loculated collection along the right pericolic gutter, now measuring up to 1.5 cm. 3. Stigmata of cirrhosis and portal hypertension. Moderate volume ascites, worsened since prior. 4. No evidence for pulmonary embolism. 5. Worsened lingular consolidation, concerning for infection. 6. Improved pleural effusions. Left lower lobe consolidation is stable, likely component of atelectasis, component of infection cannot be excluded. 7. Interval improvement in pulmonary edema. CT Chest ___: Interval rapid development of primarily alveolar opacities in the upper lobes with central distribution, concerning for pulmonary edema. Multifocal infection is a possibility. Definitely concerning for infection left lower lobe consolidation. Interval increase in left and development of right pleural effusion, small. Both effusions are nonhemorrhagic. Reactive mediastinal lymph nodes. For assessment of the upper abdomen please review CT abdomen and pelvis and the corresponding report Underlying emphysema, unchanged. RUQ Ultrasound ___: 1. Cirrhotic liver, with similar moderate volume ascites. 2. Decompressed gallbladder with sludge within it. Transthoracic echo ___: The left atrium and right atrium are normal in cavity size. Late saline contrast is seen in left heart suggesting intrapulmonary shunting. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: 1) There is crossing of late bubbles into the ___ of pulmonary AV malformations. 2) Moderate elevation of pulmonary systolic arterial pressure with normal RV size/function and ___ size. CTA Chest and CT Abdomen ___: 1. Interval decrease in size of bilateral tubo-ovarian abscesses. 2. Interval decrease in the loculated collection along the right pericolic gutter, now measuring up to 1.5 cm. 3. Stigmata of cirrhosis and portal hypertension. Moderate volume ascites, worsened since prior. 4. No evidence for pulmonary embolism. 5. Worsened lingular consolidation, concerning for infection. 6. Improved pleural effusions. Left lower lobe consolidation is stable, likely component of atelectasis, component of infection cannot be excluded. 7. Interval improvement in pulmonary edema. CTA Abd/Pelvis ___: 1. No evidence of active bleed or hematoma in the abdomen or pelvis. 2. Redemonstration of dilated tubular structures in the bilateral adnexa, in keeping with hydrosalpinges, slightly decreased in size compared to CT of the abdomen/pelvis from ___. Ultrasound-guided aspiration yielded pus. 3. 2.5 x 2.1 cm rim enhancing lesion in the right lower abdomen lateral to the right hepatic tip and a 1.9 x 1.3 cm soft tissue nodule in the anterior right pelvis, most concerning for abscesses. However attention on follow-up imaging after treatment of the infection is recommended to exclude the possibility of metastatic implants. 4. Small amount of abdominopelvic ascites, measuring higher than simple fluid density, suggestive of internal complexity. 5. Small bilateral pleural effusions with associated compressive atelectasis. 6. Ground-glass opacity in the lingula may be infectious or inflammatory. CT Abd/Pelvis ___: 1. Multiple fluid-filled cystic structures in the mid-pelvis are most concerning for tubo-ovarian abscess and pyosalpinx given the patient's clinical history of leukocytosis and septic physiology. The largest collection measures 3.3 x 5.3 x 3.6 cm, and likely represents a collection within the right fallopian tube. 2. Round discrete fluid collection with rim enhancement along the right abdominal wall measuring 1.9 x 1.7 x 2.3 cm may represent an additional abscess. This is atypical for ___ and differential diagnosis incudes metastasis. 3. An additional small rim enhancing fluid collection adjacent to the right inferior abdominal wall measures 1.4 x 1.7 by 1.0 cm. 4. Interval increase in the degree of simple fluid ascites throughout the abdomen and pelvis. 5. Diffuse anasarca. 6. Enlarged liver with irregular borders is compatible with the patient's history of cirrhosis. 7. Please see chest CT from the same date for thoracic findings. CT Chest ___: 1. Bilateral small non-hemorrhagic pleural effusions with adjacent atelectasis and likely aspiration/infection in the right lower lobe given provided history. 2. Right upper lobe peribronchovascular nodules and ground glass with diffuse peribronchiolar wall thickening suggests infection. 3. Moderate centrilobular and paraseptal emphysema, worse in the upper lungs. 4. No organized fluid collections in the thorax or evidence of septic pulmonary emboli. Pelvic Ultrasound ___: Bilateral heterogeneous, internally hypovascular lesions measuring up to 6.6 cm. These have a non-specific appearance, but appear to be bilateral thick-walled cystic lesions with internal debris. In the setting of leukocytosis and abdominal pain, these may represent tubo-ovarian abscesses. MRI can be obtained either for follow-up after treatment to assure improvement if the patient is being treated conservatively, or for further evaluation/characterization if interventional is considered. RUQ Ultrasound ___: 1. Heterogeneous nodular hepatic architecture. The parenchyma echogenicity suggests the presence of steatosis. No focal liver lesion is identified. 2. No gallstones and no sonographic sign of cholecystitis. Sludge is noted in the gallbladder. 3. Scant trace ascites predominantly in the perihepatic space. CTU Abd/Pelvis ___ 1. No convincing evidence of acute intra-abdominal process. Specifically, no hydronephrosis or nephrolithiasis. 2. New, right infrahepatic and right pelvic omental soft tissue nodules. Findings are incompletely characterized on this noncontrast CT examination,and are indeterminate. Further characterization by contrast-enhanced CT examination with Visipaque following IV hydration is recommended. Alternatively, direct tissue sampling could be considered. 3. Bilateral adnexal hypodensities are suboptimally evaluated on this noncontrast CT examination. Recommend pelvic ultrasound for further evaluation. 4. Enlarged and irregular appearing liver, compatible with patient's known cirrhosis. Small volume perihepatic free fluid. Pelvic ultrasound ___: Bilateral heterogeneous, internally hypovascular lesions measuring up to 6.6 cm. These have a non-specific appearance, but appear to be bilateral thick-walled cystic lesions with internal debris. In the setting of leukocytosis and abdominal pain, these may represent tubo-ovarian abscesses. MRI can be obtained either for follow-up after treatment to assure improvement if the patient is being treated conservatively, or for further evaluation/characterization if interventional is considered. Brief Hospital Course: SUMMARY: ___ h/o EtOH abuse, EtOH pancreatitis, HTN, HCV, who initially presented with right-sided abdominopelvic pain and was found to have new dx of cirrhosis, bilateral tubo-ovarian abscesses and additional intra-abdominal abscesses. She was treated initially in the MICU with broad-spectrum antibiotics including vancomycin, ceftazidime, doxycycline, and flagyl. She also underwent drainages by ___, in total three ___, ___, to provide source control for her abscesses. After additional culture data returned there was a high suspicion for actinomyces (ultimately confirmed to be actinomyces ___. Additionally there was ___ growing in one of the abscesses, and she was transitioned to ___. Her hospital course was complicated by: - Hypoxemic respiratory failure requiring intubation, thought to be a combination of pulmonary edema and hepatopulmonary syndrome. Stabilized with diuresis. - Hepatic encephalopathy - Ascites - Severe malnutrition. A dobhoff tube was placed on two separate occasions but was self-discontinued. At end of admission she declined to have the dobhoff replaced despite poor PO intake. - Nausea/vomiting and rising alk phos, which were thought to be related to fluconazole. #Tubo-ovarian abscess: Patient presented with leukocytosis, flank pain, fever, tachycardia and positive UA. Hx of pansensitive ecoli growing in prior UTIs. Initially started on Ceftriaxone for UTI but pelvic ultrasound demonstrated b/l inguinal structures likely tubo-ovarian abscesses. She was then broadened to vanc/ceftaz/flagyl as of ___. Cultures grew gram positive branching filamentous rods concerning for actinomyces so Vancomycin/Meropenem was initiated. OB/GYN was consulted and they removed the IUD, which the patient had had in place for ___ years. She subsequently underwent a total of three ___ drainages of abscesses. She was monitored with serial CT scans and over the course of several weeks her abscesses were noted to be decreasing in size. OB/GYN and Hepatology were consulted to consider surgery, but she was estimated to have >80% mortality from intra-abdominal surgery due to her advanced cirrhosis. One of her abscesses was noted to be growing ___, and she was broadened to fluconazole as well. Her cultures were ultimately growing anaerobic GNRs as well as actinomyces. She was discharged on a regimen of ertapenem and fluconazole. Final sensitivities were sent to an outside micro lab at ___ and were pending at time of discharge. Procedures: ___ drainage ___ on ___ and ___ ___ perihepatic abscess drainage on ___eftriaxone (___) Ceftazidime (___) Unasyn (___) Cefepime (___) Flagyl (___) Doxycycline (___) Vancomycin (___) Meropenem (___) Fluconazole (___) Ertapenem (___) # Severe malnutrition: Patient noted to have poor PO intake. On two different instances she had a Dobhoff tube placed but both times it came out. Extensive discussions were held with the patient detailing the risks of her malnutrition; however, patient declined having a Dobhoff tube placed and stated that she would like to continue with PO intake only. # Rising alk phos: Patient was noted to have elevated LFTs but she appeared to have a sustained isolated increase in her alk phos. This peaked at 569 and downtrended to 508 at time of discharge. Hepatology was consulted and believed that this was likely due to her fluconazole. Her fluconazole was continued and she was monitored clinically. RUQ ultrasounds were performed and were unremarkable other than biliary sludge. ID recommended continuation of fluconazole. # Nausea/vomiting: Patient had several episodes of nausea and vomiting. These were thought to be a combination of poor tolerance, possible adverse effect of fluconazole and ascites. # Acute hypoxemic respiratory failure: # Pulmonary edema # Hepatopulmonary syndrome After initial transfer to floor, patient developed respiratory distress in the setting of new pneumonia and volume overload. She was treated for HCAP with broad-spectrum antibiotics as above. She was initially stabilized on 50% facemask but during the ___ procedure she had to be intubated. She was quickly extubated and oxygen therapy was weaned to ___ prior to discharge. Volume overload in the setting of cirrhosis was thought to be the primary contributor to her acute failure, and she improved with diuresis (boluses of 40-80mg IV furosemide with 100 mg PO spironolactone daily) and was transitioned to PO diuretics (furosemide 60mg PO and spironolactone 100mg daily) before discharge. She also had an echo performed that showed "crossing of late bubbles into the ___ of pulmonary AV malformations" which is concerning for hepatopulmonary syndrome. She was ultimately discharged to home with home oxygen PRN. #Acute hepatic encephalopathy: after being extubated, the patient became more confused, agitated, and required precedex and haldol for sedation. This was likely in the setting of inability to take lactulose po. She had a NGT placed and lactulose was given. Subsequently her mental status was improved. After transfer back to regular medical floor she continued taking lactulose regularly and her mental status was stable. # Anemia: Patient with previous H/H ___ in ___ declining to Hb of 7. She intermittently required pRBC transfusions during this hospitalization (5U total). Iron studies and hemolysis labs were unremarkable. Her anemia was thought to be in the setting of occult GI bleeding, acute inflammation, and frequent phlebotomy. She will require EGD for workup of varices as outpatient. # Cirrhosis: Patient with known diagnosis of cirrhosis and has been on lactulose. - Hepatic encephalopathy: Continued lactulose and started rifaximin. - Ascites: Patient had 3 ___, ___ therapeutic paracenteses done during this admission. She was discharged on PO furosemide 60mg and spironolactone 100mg daily. - Varices: No workup has been done, patient will need EGD as outpatient. Patient started on PO pantoprazole 40mg q24h. #Sinus tach: Patient consistently with HR in the 100-110 range throughout admission. This was thought to be in the setting of ongoing infection. #ETOH abuse: last drink ___. Initiated thiamine, folate, MVI, and monitored for EtOH withdrawal which she did not show signs of. #Hx of Domestic abuse reported in prior discharge summary, social work consulted. CHRONIC ISSUES: #Depression/Mood disorder: continued home regimen of Seroquel and Amitriptyline and dose adjust gabapentin 300mg BID #Hypertension: Held losartan given ___, normotension and initiation of diuretics. Held her verapamil as well. TRANSITIONAL ISSUES: - Please ensure TSH repeat as outpatient (5.3 with normal free T4 during admission) - Consider MRI abdomen and malignancy workup - Please ensure EGD, ___ screening and Hepatology follow-up - Per discussion with Dr. ___ at the ___ ___ (covering for PCP), a referral to the res___ house was offered to the patient in case she felt that she had difficulty managing home O2 and IV antibiotics at home - Discharge Hb: 7.5, discharge WBC: 26.0, discharge Alk phos: 508 - For hepatic encephalopathy, discharged on lactulose/rifaximin - For ascites and pulmonary edema, discharged on furosemide 60mg / spironolactone 100mg daily - For actinomyces and gram-negative infection, she was discharged on IV ertapenem 1gm q24h with plan to continue through ___ and further management to be decided by ID team in ___ clinic - Home verapamil and losartan were held in setting of normotension and new initiation of diuretics - Pantoprazole 40mg daily started for GERD symptoms - Will be treated on IV ertapenem 1gm q24h with follow up in ___ clinic - Will need weekly labs: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS - Planned for 6-week course of Ertapenem with transition to PO antibiotics afterwards for up to 6 months - Also discharged on PO fluconazole 400mg daily to cover ___ - ID will determine duration of fluconazole - Please assess volume status and consider further diuresis +/- therapeutic paracentesis - Noted to have hypokalemia and hypomagnesemia prior to discharge which were repleted. Please re-check electrolytes on ___ to ensure stability - Patient noted to be severely malnourished and not meeting PO intake goals. However, patient continuously declined re-placement of dobhoff tube. Please continue to monitor her nutrition and discuss Dobhoff tube as needed. - Hypoxia: Patient with desaturations to 86% with ambulation. She does have mild abdominal distension and ___ edema in setting of cirrhosis in addition to hepatopulmonary syndrome. Patient was discharged with O2 to be used PRN dyspnea. - Given b/l tubo-ovarian abscesses, would recommend workup of malignancy (colonoscopy, other age-appropriate screening) as an outpatient. - Please ensure ongoing down-trend of leukocytosis - Please ensure follow-up abdominal imaging to exclude less likely possibility of malignancy - On CTU ___: "There are bilateral adnexal lesions which appear new from the prior exam with areas of hypodensity poorly characterized on this unenhanced exam. There is a soft tissue nodule along the right anterior pelvis seen best on series 2, image 63 measuring 1.7 x 1.4 cm. This lesion may represent an omental nodule though evaluation is incomplete." A contrast CT was recommended to r/o malignancy. Subsequently multiple CT scans were more consistent with infection but, as above, follow-up MRI abdomen/pelvis may be warranted to confirm absence of malignancy. - Please note, IUD removed, please discuss alternative methods of contraception - Please note, question of intimate partner violence, please continue to involve social work - patient declined further counseling during this admission - Please note CA 125 61 (upper limit 35) - as above, please ensure repeat ovarian imaging after resolution of infection Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Thiamine 100 mg PO DAILY 2. Verapamil SR 240 mg PO Q24H 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 4. Venlafaxine XR 37.5 mg PO DAILY 5. QUEtiapine Fumarate 100 mg PO QHS 6. Omeprazole 20 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Magnesium Oxide 400 mg PO DAILY 9. Losartan Potassium 25 mg PO DAILY 10. Lactulose 30 mL PO BID 11. Gabapentin 300 mg PO TID 12. FoLIC Acid 1 mg PO DAILY 13. Cyclobenzaprine 10 mg PO HS:PRN spasm 14. Amitriptyline 10 mg PO QHS 15. Lidocaine 5% Patch 1 PTCH TD QAM 16. K-Phos No 2 (potassium,sodium monobas phos) 305-700 mg oral QID 17. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation 18. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose Please take Q24H through ___. RX *ertapenem [Invanz] 1 gram 1 g IV Q24H Disp #*18 Vial Refills:*0 2. Fluconazole 400 mg PO Q24H RX *fluconazole 200 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. Furosemide 60 mg PO DAILY RX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 4. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Spironolactone 100 mg PO DAILY RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Lactulose 30 mL PO TID RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day Refills:*0 8. Lidocaine 5% Patch 1 PTCH TD QPM back pain 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 10. Amitriptyline 10 mg PO QHS 11. Cyclobenzaprine 10 mg PO HS:PRN spasm 12. FoLIC Acid 1 mg PO DAILY 13. Gabapentin 300 mg PO TID 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Magnesium Oxide 400 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation 18. QUEtiapine Fumarate 100 mg PO QHS 19. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 20. Thiamine 100 mg PO DAILY 21. Venlafaxine XR 37.5 mg PO DAILY 22.Cane Standard cane Diagnosis: Cirrhosis ICD10 K74.60 Length of need 13 months Prognosis = good 23.Outpatient Lab Work WEEKLY LABS. Please draw every week: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, CRP Please fax to: ATTN: ___ CLINIC - FAX: ___ ICD-10 Actinomyces. A___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Cirrhosis Actinomyces infection Tubo-ovarian abscesses Ascites Hepatic encephalopathy Pneumonia Pulmonary edema SECONDARY DIAGNOSIS: Hypertension Depression 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. ___: WHAT HAPPENED TO YOU IN THE HOSPITAL? ====================================== - You were extremely sick when you came to the hospital. You were found to have abscesses, or pockets of infection, in your ovaries and abdomen - Our Interventional Radiology team drained these pockets three times to help address the infection - You were also found to have scarring of your liver, called cirrhosis. We put you on medications to help move your bowels and urinate to prevent buildup of toxins and fluids. - We thought that your infection was caused by a bacteria called actinomyces WHAT WILL HAPPEN TO YOU AFTER YOU LEAVE THE HOSPITAL? ====================================================== - It is very important that you increase your nutrition -- please try to eat as much as possible - You will need to see a hepatologist and infectious disease doctor in clinic. YOU MUST MAKE IT TO ALL YOUR FOLLOW UP APPOINTMENTS. - If you are having nausea and throwing up, please call your doctor and discuss reducing the amount of fluconazole that you are taking - You will need to be on IV antibiotics with ertapenem at least through ___. You must also get blood tests checked every week - You have many new medications. Please review carefully Please call The ___ ___ House: ___ if you feel that you need more support at home. At this facility you would have more support with your health issues, but also more freedom compared to a normal rehab facility. We wish you all the best. - Your ___ care team Followup Instructions: ___
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Allergies: lisinopril Chief Complaint: Right sided abdominal pain Major Surgical or Invasive Procedure: [MASKED] drainage of tubo-ovarian and intra-abdominal abscesses [MASKED] Diagnostic and therapeutic paracentesis [MASKED] and [MASKED] History of Present Illness: [MASKED] year old woman with PMHx of EtOH abuse, EtOH pancreatitis, HTN, cirrhosis presenting complaining of right-sided abdominal/flank pain. Patient states she has had the pain for the past 5 days. She is tender and also has left intermittent thigh pain. She has been having nonbloody nausea and vomiting over the past week. No diarrhea or dark black stool. She reports chills, weakness, fatigue. No fevers. She denies recent travel. She denies IV drug use. Denies history of kidney stone. She continued to drink alcohol last drink on [MASKED] prior to coming to hospital [MASKED] pint of vodka. She has a history of withdrawal and seizures years ago. She has been having had increasing SOB and worsening of her asthma symptoms over the past couple weeks. No chest pain. *Of note the patient reports she has been sleeping with her gas oven on because her apartment is not warm enough. In ED initial vitals 99.4 100 109/55 17 98% RA. HR peaked at 116. Low of BP 98/58. Exam: Right flank tenderness palpation, no CVA tenderness, rectal brown guaiac neg stool Labs notable for: WBC 24.5 H/H 7.3/21.8 -> 20.1 Plt 349 N80.2 131 91 10 ------------- 107 AGap=25 3.4 18 1.7 [MASKED]: 18.5 PTT: 40.8 INR: 1.7 Lactate:2.7 Alp 236 ALT<5 AST33 UCG Negative UA Hazy, pH 6.0 Urobilin 4, Leuk Lg, Bld Neg, Nitrates Neg, Protein 30, Glucose Neg, Ket Neg, Rbc 2, WBC 26, Few Bacteria, None Yeast, Epi 4. Cast Hy 58. IMAGING: CTU 1. No convincing evidence of acute intra-abdominal process. Specifically, no hydronephrosis or nephrolithiasis. 2. New, right infrahepatic and right pelvic omental soft tissue nodules. Findings are incompletely characterized on this noncontrast CT examination,and are indeterminate. Further characterization by contrast-enhanced CT examination with Visipaque following IV hydration is recommended. Alternatively, direct tissue sampling could be considered. 3. Bilateral adnexal hypodensities are suboptimally evaluated on this noncontrast CT examination. Recommend pelvic ultrasound for further evaluation. 4. Enlarged and irregular appearing liver, compatible with patient's known cirrhosis. Small volume perihepatic free fluid. Patient was given: [MASKED] 15:05 IV Ketorolac 30 mg [MASKED] 15:05 IVF NS [MASKED] 16:31 IV CeftriaXONE [MASKED] 16:37 IVF NS 1 mL [MASKED] 17:25 IV CeftriaXONE 1 gm [MASKED] 19:30 IVF NS 1 mL [MASKED] 21:13 IV Morphine Sulfate 2 mg [MASKED] 22:00 IVF NS [MASKED] 00:34 PO Thiamine 100 mg [MASKED] 00:34 PO/NG Acetaminophen 325 mg [MASKED] 01:30 IVF NS 1 mL [MASKED] 01:43 IV Morphine Sulfate 2 mg [MASKED] 04:51 TD Nicotine Patch 21 mg [MASKED] 04:51 IH Albuterol Inhaler 2 PUFF Patient initially refused PRBC transfusion and then agreed and then given 1U of PRBC Transfer vitals: 98.9 109 107/68 19 93% On arrival to the MICU, patient states she feels well. Reports chills and right sided flank pain. Past Medical History: EtOH pancreatitis EtOH abuse/dependence Asthma HTN Depression Social History: [MASKED] Family History: Father with hx of HTN but otherwise healthy. Mother healthy. Three of four children have asthma, otherwise healthy. Denies FH of pancreatitis, pancreatic or GB malignancy. Physical Exam: Admission: VITALS: 98.4 114 124/90 22 99%RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM NECK: supple, 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, minimal tenderness over right side of abdomen/flank, non-distended, bowel sounds present, no rebound tenderness or guarding, EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: warm, no evidence of jaundice NEURO: AOx3, no asterixis, grossly normal strength and sensation DISCHARGE EXAM: Vitals: 98.0 113 / 79 100 18 93 /RA-1L General: Thin, chronically ill-appearing woman in NAD HEENT: Sclera anicteric, MMM, oropharynx clear. JVP 1-2cm above clavicle at 90 degrees. Lungs: Decreased breath sounds [MASKED], no W/R/C CV: Tachycardic, loud heart sounds, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: moderately distended,soft, non-tender. Normoactive bowel sounds, no rebound tenderness or guarding. Ext: Warm, well perfused, 1+ [MASKED] edema up to midshin b/l Neuro: AO x 3. No asterixis. Pertinent Results: ============== ADMISSION LABS =============== [MASKED] 07:50PM [MASKED] PO2-38* PCO2-33* PH-7.39 TOTAL CO2-21 BASE XS--3 [MASKED] 07:50PM LACTATE-1.5 [MASKED] 07:50PM HGB-8.5* calcHCT-26 [MASKED] 07:42PM WBC-23.8* RBC-2.40* HGB-8.2* HCT-24.8* MCV-103* MCH-34.2* MCHC-33.1 RDW-15.8* RDWSD-59.6* [MASKED] 07:42PM PLT COUNT-267 [MASKED] 07:42PM [MASKED] PTT-48.6* [MASKED] [MASKED] 01:35PM [MASKED] PO2-158* PCO2-29* PH-7.43 TOTAL CO2-20* BASE XS--3 [MASKED] 01:35PM LACTATE-1.4 [MASKED] 01:35PM O2 SAT-97 CARBOXYHB-2 [MASKED] 07:45AM LACTATE-3.2* [MASKED] 07:41AM GLUCOSE-89 UREA N-10 CREAT-1.0 SODIUM-133 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-17* ANION GAP-20 [MASKED] 07:41AM ALT(SGPT)-<5 AST(SGOT)-27 ALK PHOS-230* TOT BILI-0.9 [MASKED] 07:41AM CALCIUM-7.4* PHOSPHATE-3.3 MAGNESIUM-1.2* [MASKED] 07:41AM WBC-27.4* RBC-2.70*# HGB-9.2*# HCT-28.7*# MCV-106* MCH-34.1* MCHC-32.1 RDW-15.5 RDWSD-59.4* [MASKED] 07:41AM NEUTS-80.6* LYMPHS-12.0* MONOS-5.3 EOS-0.3* BASOS-0.3 NUC RBCS-0.1* IM [MASKED] AbsNeut-22.04* AbsLymp-3.29 AbsMono-1.45* AbsEos-0.07 AbsBaso-0.09* [MASKED] 07:41AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [MASKED] 07:41AM PLT COUNT-299 [MASKED] 07:41AM [MASKED] PTT-43.1* [MASKED] [MASKED] 07:41AM RET AUT-3.0* ABS RET-0.08 [MASKED] 07:00PM HCT-20.1* [MASKED] 04:33PM LACTATE-2.7* [MASKED] 03:54PM [MASKED] PTT-40.8* [MASKED] [MASKED] 03:00PM GLUCOSE-107* UREA N-10 CREAT-1.7*# SODIUM-131* POTASSIUM-3.4 CHLORIDE-91* TOTAL CO2-18* ANION GAP-25* [MASKED] 03:00PM estGFR-Using this [MASKED] 03:00PM ALT(SGPT)-<5 AST(SGOT)-33 ALK PHOS-236* TOT BILI-0.7 [MASKED] 03:00PM LIPASE-6 [MASKED] 03:00PM ALBUMIN-2.3* [MASKED] 03:00PM WBC-24.5*# RBC-2.10*# HGB-7.3*# HCT-21.8*# MCV-104*# MCH-34.8* MCHC-33.5 RDW-14.6 RDWSD-55.2* [MASKED] 03:00PM NEUTS-80.2* LYMPHS-12.4* MONOS-5.6 EOS-0.2* BASOS-0.2 IM [MASKED] AbsNeut-19.64* AbsLymp-3.05 AbsMono-1.38* AbsEos-0.04 AbsBaso-0.05 [MASKED] 03:00PM WBC-24.5*# RBC-2.10*# HGB-7.3*# HCT-21.8*# MCV-104*# MCH-34.8* MCHC-33.5 RDW-14.6 RDWSD-55.2* [MASKED] 03:00PM PLT COUNT-349# [MASKED] 02:00PM URINE HOURS-RANDOM [MASKED] 02:00PM URINE UCG-NEGATIVE [MASKED] 02:00PM URINE UHOLD-HOLD [MASKED] 02:00PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-LG [MASKED] 02:00PM URINE RBC-2 WBC-26* BACTERIA-FEW YEAST-NONE EPI-4 [MASKED] 02:00PM URINE HYALINE-58* [MASKED] 02:00PM URINE MUCOUS-FEW ========================== DISCHARGE LABS ========================== [MASKED] 05:23AM BLOOD WBC-26.0* RBC-2.35* Hgb-7.5* Hct-23.7* MCV-101* MCH-31.9 MCHC-31.6* RDW-21.2* RDWSD-75.5* Plt [MASKED] [MASKED] 05:23AM BLOOD Neuts-72* Bands-0 Lymphs-18* Monos-4* Eos-1 Baso-1 Atyps-2* Metas-2* Myelos-0 AbsNeut-18.72* AbsLymp-5.20* AbsMono-1.04* AbsEos-0.26 AbsBaso-0.26* [MASKED] 05:23AM BLOOD [MASKED] PTT-53.9* [MASKED] [MASKED] 05:23AM BLOOD Plt [MASKED] [MASKED] 01:00PM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-134 K-4.4 Cl-97 HCO3-23 AnGap-18 [MASKED] 05:23AM BLOOD ALT-10 AST-69* LD(LDH)-207 AlkPhos-508* TotBili-2.0* [MASKED] 01:00PM BLOOD Calcium-9.0 Phos-4.1 Mg-2.7* [MASKED] 09:45PM BLOOD Vanco-25.6* [MASKED] 03:27PM BLOOD CRP-99.0* [MASKED] 07:41AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* IgM HBc-Negative [MASKED] 10:45AM BLOOD AMA-NEGATIVE [MASKED] 08:15AM BLOOD Cortsol-14.7 [MASKED] 04:55AM BLOOD T4-4.6 [MASKED] 05:54AM BLOOD TSH-5.3* [MASKED] 08:55AM BLOOD Type-ART pO2-61* pCO2-38 pH-7.48* calTCO2-29 Base XS-4 [MASKED] 08:55AM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-90 ================ MICROBIOLOGY ================ [MASKED] [MASKED] 2:47 pm STOOL CONSISTENCY: WATERY Source: Stool. FECAL CULTURE (Final [MASKED]: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Pending): [MASKED] [MASKED] 5:58 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. [MASKED] [MASKED] 1:10 pm BLOOD CULTURE #2. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 8:42 am BLOOD CULTURE Source: Line-PICC #1. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 7:40 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 1:09 pm BLOOD CULTURE Source: Line-PICC 1 OF 2. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 12:53 pm URINE Source: [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 2:23 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 1:30 pm BLOOD CULTURE INCUBATE 10 DAYS FOR RULE/OUT ACTINOMYCES PER [MASKED] [MASKED] [MASKED]. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 11:50 am BLOOD CULTURE Source: Line-PICC #1. INCUBATE 10 DAYS FOR RULE/OUT ACTINOMYCES PER [MASKED] [MASKED] [MASKED]. **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 2:22 pm ABSCESS Source: pelvic abscess. HOLD 14 DAYS FOR ACTINOMYCES . GRAM STAIN (Final [MASKED]: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). BEADED/ BRANCHING GRAM POSITIVE ROD(S) [MASKED]. FLUID CULTURE (Final [MASKED]: NO GROWTH. ANAEROBIC CULTURE (Preliminary): ANAEROBIC GRAM NEGATIVE ROD(S). SPARSE GROWTH. MIXED BACTERIAL FLORA. Mixed bacteria are present, which may include anaerobes and/or facultative anaerobes. Bacterial growth was screened for the presence of B.fragilis, C.perfringenes, and C.septicum. None of these species was found. ACTINOMYCES [MASKED]. SPARSE GROWTH. BEADED BRANCHING POSITIVE ROD. SENT TO [MASKED] LAB FOR IDENTIFICATION AND SUSCEPTIBILITY TESTING. ID PERFORMED BY [MASKED]. ============ IMAGING ============= Imaging: Lower extremity ultrasound [MASKED]: No evidence of deep venous thrombosis in the right or left lower extremity veins. CT Abd/Pelvis [MASKED]: -Minimal interval decrease in size of bilateral tubo-ovarian abscesses and the rim enhancing collection along the right pericolic gutter. -Cirrhosis with sequela of portal hypertension with moderate ascites, decreased since prior exam. -Bilateral, nonhemorrhagic pleural effusions, right greater than left. CT Abd/Pelvis [MASKED]: 1. Interval decrease in size of bilateral tubo-ovarian abscesses and the rim enhancing collection along the right paracolic gutter. 2. Cirrhosis with sequela of portal hypertension with moderate ascites, increased since the prior exam. CT Chest [MASKED]: 1. Improved pulmonary edema compared to the prior study. 2. Persistent lingular consolidation, though probably slightly improved compared to the prior exam remains concerning for infection. 3. Improved left lower lobe consolidation consistent with atelectasis. 4. Small bilateral pleural effusions, increased compared to the prior study. CTA Chest and CT abdomen [MASKED]: 1. Interval decrease in size of bilateral tubo-ovarian abscesses. 2. Interval decrease in the loculated collection along the right pericolic gutter, now measuring up to 1.5 cm. 3. Stigmata of cirrhosis and portal hypertension. Moderate volume ascites, worsened since prior. 4. No evidence for pulmonary embolism. 5. Worsened lingular consolidation, concerning for infection. 6. Improved pleural effusions. Left lower lobe consolidation is stable, likely component of atelectasis, component of infection cannot be excluded. 7. Interval improvement in pulmonary edema. CT Chest [MASKED]: Interval rapid development of primarily alveolar opacities in the upper lobes with central distribution, concerning for pulmonary edema. Multifocal infection is a possibility. Definitely concerning for infection left lower lobe consolidation. Interval increase in left and development of right pleural effusion, small. Both effusions are nonhemorrhagic. Reactive mediastinal lymph nodes. For assessment of the upper abdomen please review CT abdomen and pelvis and the corresponding report Underlying emphysema, unchanged. RUQ Ultrasound [MASKED]: 1. Cirrhotic liver, with similar moderate volume ascites. 2. Decompressed gallbladder with sludge within it. Transthoracic echo [MASKED]: The left atrium and right atrium are normal in cavity size. Late saline contrast is seen in left heart suggesting intrapulmonary shunting. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: 1) There is crossing of late bubbles into the [MASKED] of pulmonary AV malformations. 2) Moderate elevation of pulmonary systolic arterial pressure with normal RV size/function and [MASKED] size. CTA Chest and CT Abdomen [MASKED]: 1. Interval decrease in size of bilateral tubo-ovarian abscesses. 2. Interval decrease in the loculated collection along the right pericolic gutter, now measuring up to 1.5 cm. 3. Stigmata of cirrhosis and portal hypertension. Moderate volume ascites, worsened since prior. 4. No evidence for pulmonary embolism. 5. Worsened lingular consolidation, concerning for infection. 6. Improved pleural effusions. Left lower lobe consolidation is stable, likely component of atelectasis, component of infection cannot be excluded. 7. Interval improvement in pulmonary edema. CTA Abd/Pelvis [MASKED]: 1. No evidence of active bleed or hematoma in the abdomen or pelvis. 2. Redemonstration of dilated tubular structures in the bilateral adnexa, in keeping with hydrosalpinges, slightly decreased in size compared to CT of the abdomen/pelvis from [MASKED]. Ultrasound-guided aspiration yielded pus. 3. 2.5 x 2.1 cm rim enhancing lesion in the right lower abdomen lateral to the right hepatic tip and a 1.9 x 1.3 cm soft tissue nodule in the anterior right pelvis, most concerning for abscesses. However attention on follow-up imaging after treatment of the infection is recommended to exclude the possibility of metastatic implants. 4. Small amount of abdominopelvic ascites, measuring higher than simple fluid density, suggestive of internal complexity. 5. Small bilateral pleural effusions with associated compressive atelectasis. 6. Ground-glass opacity in the lingula may be infectious or inflammatory. CT Abd/Pelvis [MASKED]: 1. Multiple fluid-filled cystic structures in the mid-pelvis are most concerning for tubo-ovarian abscess and pyosalpinx given the patient's clinical history of leukocytosis and septic physiology. The largest collection measures 3.3 x 5.3 x 3.6 cm, and likely represents a collection within the right fallopian tube. 2. Round discrete fluid collection with rim enhancement along the right abdominal wall measuring 1.9 x 1.7 x 2.3 cm may represent an additional abscess. This is atypical for [MASKED] and differential diagnosis incudes metastasis. 3. An additional small rim enhancing fluid collection adjacent to the right inferior abdominal wall measures 1.4 x 1.7 by 1.0 cm. 4. Interval increase in the degree of simple fluid ascites throughout the abdomen and pelvis. 5. Diffuse anasarca. 6. Enlarged liver with irregular borders is compatible with the patient's history of cirrhosis. 7. Please see chest CT from the same date for thoracic findings. CT Chest [MASKED]: 1. Bilateral small non-hemorrhagic pleural effusions with adjacent atelectasis and likely aspiration/infection in the right lower lobe given provided history. 2. Right upper lobe peribronchovascular nodules and ground glass with diffuse peribronchiolar wall thickening suggests infection. 3. Moderate centrilobular and paraseptal emphysema, worse in the upper lungs. 4. No organized fluid collections in the thorax or evidence of septic pulmonary emboli. Pelvic Ultrasound [MASKED]: Bilateral heterogeneous, internally hypovascular lesions measuring up to 6.6 cm. These have a non-specific appearance, but appear to be bilateral thick-walled cystic lesions with internal debris. In the setting of leukocytosis and abdominal pain, these may represent tubo-ovarian abscesses. MRI can be obtained either for follow-up after treatment to assure improvement if the patient is being treated conservatively, or for further evaluation/characterization if interventional is considered. RUQ Ultrasound [MASKED]: 1. Heterogeneous nodular hepatic architecture. The parenchyma echogenicity suggests the presence of steatosis. No focal liver lesion is identified. 2. No gallstones and no sonographic sign of cholecystitis. Sludge is noted in the gallbladder. 3. Scant trace ascites predominantly in the perihepatic space. CTU Abd/Pelvis [MASKED] 1. No convincing evidence of acute intra-abdominal process. Specifically, no hydronephrosis or nephrolithiasis. 2. New, right infrahepatic and right pelvic omental soft tissue nodules. Findings are incompletely characterized on this noncontrast CT examination,and are indeterminate. Further characterization by contrast-enhanced CT examination with Visipaque following IV hydration is recommended. Alternatively, direct tissue sampling could be considered. 3. Bilateral adnexal hypodensities are suboptimally evaluated on this noncontrast CT examination. Recommend pelvic ultrasound for further evaluation. 4. Enlarged and irregular appearing liver, compatible with patient's known cirrhosis. Small volume perihepatic free fluid. Pelvic ultrasound [MASKED]: Bilateral heterogeneous, internally hypovascular lesions measuring up to 6.6 cm. These have a non-specific appearance, but appear to be bilateral thick-walled cystic lesions with internal debris. In the setting of leukocytosis and abdominal pain, these may represent tubo-ovarian abscesses. MRI can be obtained either for follow-up after treatment to assure improvement if the patient is being treated conservatively, or for further evaluation/characterization if interventional is considered. Brief Hospital Course: SUMMARY: [MASKED] h/o EtOH abuse, EtOH pancreatitis, HTN, HCV, who initially presented with right-sided abdominopelvic pain and was found to have new dx of cirrhosis, bilateral tubo-ovarian abscesses and additional intra-abdominal abscesses. She was treated initially in the MICU with broad-spectrum antibiotics including vancomycin, ceftazidime, doxycycline, and flagyl. She also underwent drainages by [MASKED], in total three [MASKED], [MASKED], to provide source control for her abscesses. After additional culture data returned there was a high suspicion for actinomyces (ultimately confirmed to be actinomyces [MASKED]. Additionally there was [MASKED] growing in one of the abscesses, and she was transitioned to [MASKED]. Her hospital course was complicated by: - Hypoxemic respiratory failure requiring intubation, thought to be a combination of pulmonary edema and hepatopulmonary syndrome. Stabilized with diuresis. - Hepatic encephalopathy - Ascites - Severe malnutrition. A dobhoff tube was placed on two separate occasions but was self-discontinued. At end of admission she declined to have the dobhoff replaced despite poor PO intake. - Nausea/vomiting and rising alk phos, which were thought to be related to fluconazole. #Tubo-ovarian abscess: Patient presented with leukocytosis, flank pain, fever, tachycardia and positive UA. Hx of pansensitive ecoli growing in prior UTIs. Initially started on Ceftriaxone for UTI but pelvic ultrasound demonstrated b/l inguinal structures likely tubo-ovarian abscesses. She was then broadened to vanc/ceftaz/flagyl as of [MASKED]. Cultures grew gram positive branching filamentous rods concerning for actinomyces so Vancomycin/Meropenem was initiated. OB/GYN was consulted and they removed the IUD, which the patient had had in place for [MASKED] years. She subsequently underwent a total of three [MASKED] drainages of abscesses. She was monitored with serial CT scans and over the course of several weeks her abscesses were noted to be decreasing in size. OB/GYN and Hepatology were consulted to consider surgery, but she was estimated to have >80% mortality from intra-abdominal surgery due to her advanced cirrhosis. One of her abscesses was noted to be growing [MASKED], and she was broadened to fluconazole as well. Her cultures were ultimately growing anaerobic GNRs as well as actinomyces. She was discharged on a regimen of ertapenem and fluconazole. Final sensitivities were sent to an outside micro lab at [MASKED] and were pending at time of discharge. Procedures: [MASKED] drainage [MASKED] on [MASKED] and [MASKED] [MASKED] perihepatic abscess drainage on eftriaxone ([MASKED]) Ceftazidime ([MASKED]) Unasyn ([MASKED]) Cefepime ([MASKED]) Flagyl ([MASKED]) Doxycycline ([MASKED]) Vancomycin ([MASKED]) Meropenem ([MASKED]) Fluconazole ([MASKED]) Ertapenem ([MASKED]) # Severe malnutrition: Patient noted to have poor PO intake. On two different instances she had a Dobhoff tube placed but both times it came out. Extensive discussions were held with the patient detailing the risks of her malnutrition; however, patient declined having a Dobhoff tube placed and stated that she would like to continue with PO intake only. # Rising alk phos: Patient was noted to have elevated LFTs but she appeared to have a sustained isolated increase in her alk phos. This peaked at 569 and downtrended to 508 at time of discharge. Hepatology was consulted and believed that this was likely due to her fluconazole. Her fluconazole was continued and she was monitored clinically. RUQ ultrasounds were performed and were unremarkable other than biliary sludge. ID recommended continuation of fluconazole. # Nausea/vomiting: Patient had several episodes of nausea and vomiting. These were thought to be a combination of poor tolerance, possible adverse effect of fluconazole and ascites. # Acute hypoxemic respiratory failure: # Pulmonary edema # Hepatopulmonary syndrome After initial transfer to floor, patient developed respiratory distress in the setting of new pneumonia and volume overload. She was treated for HCAP with broad-spectrum antibiotics as above. She was initially stabilized on 50% facemask but during the [MASKED] procedure she had to be intubated. She was quickly extubated and oxygen therapy was weaned to [MASKED] prior to discharge. Volume overload in the setting of cirrhosis was thought to be the primary contributor to her acute failure, and she improved with diuresis (boluses of 40-80mg IV furosemide with 100 mg PO spironolactone daily) and was transitioned to PO diuretics (furosemide 60mg PO and spironolactone 100mg daily) before discharge. She also had an echo performed that showed "crossing of late bubbles into the [MASKED] of pulmonary AV malformations" which is concerning for hepatopulmonary syndrome. She was ultimately discharged to home with home oxygen PRN. #Acute hepatic encephalopathy: after being extubated, the patient became more confused, agitated, and required precedex and haldol for sedation. This was likely in the setting of inability to take lactulose po. She had a NGT placed and lactulose was given. Subsequently her mental status was improved. After transfer back to regular medical floor she continued taking lactulose regularly and her mental status was stable. # Anemia: Patient with previous H/H [MASKED] in [MASKED] declining to Hb of 7. She intermittently required pRBC transfusions during this hospitalization (5U total). Iron studies and hemolysis labs were unremarkable. Her anemia was thought to be in the setting of occult GI bleeding, acute inflammation, and frequent phlebotomy. She will require EGD for workup of varices as outpatient. # Cirrhosis: Patient with known diagnosis of cirrhosis and has been on lactulose. - Hepatic encephalopathy: Continued lactulose and started rifaximin. - Ascites: Patient had 3 [MASKED], [MASKED] therapeutic paracenteses done during this admission. She was discharged on PO furosemide 60mg and spironolactone 100mg daily. - Varices: No workup has been done, patient will need EGD as outpatient. Patient started on PO pantoprazole 40mg q24h. #Sinus tach: Patient consistently with HR in the 100-110 range throughout admission. This was thought to be in the setting of ongoing infection. #ETOH abuse: last drink [MASKED]. Initiated thiamine, folate, MVI, and monitored for EtOH withdrawal which she did not show signs of. #Hx of Domestic abuse reported in prior discharge summary, social work consulted. CHRONIC ISSUES: #Depression/Mood disorder: continued home regimen of Seroquel and Amitriptyline and dose adjust gabapentin 300mg BID #Hypertension: Held losartan given [MASKED], normotension and initiation of diuretics. Held her verapamil as well. TRANSITIONAL ISSUES: - Please ensure TSH repeat as outpatient (5.3 with normal free T4 during admission) - Consider MRI abdomen and malignancy workup - Please ensure EGD, [MASKED] screening and Hepatology follow-up - Per discussion with Dr. [MASKED] at the [MASKED] [MASKED] (covering for PCP), a referral to the res house was offered to the patient in case she felt that she had difficulty managing home O2 and IV antibiotics at home - Discharge Hb: 7.5, discharge WBC: 26.0, discharge Alk phos: 508 - For hepatic encephalopathy, discharged on lactulose/rifaximin - For ascites and pulmonary edema, discharged on furosemide 60mg / spironolactone 100mg daily - For actinomyces and gram-negative infection, she was discharged on IV ertapenem 1gm q24h with plan to continue through [MASKED] and further management to be decided by ID team in [MASKED] clinic - Home verapamil and losartan were held in setting of normotension and new initiation of diuretics - Pantoprazole 40mg daily started for GERD symptoms - Will be treated on IV ertapenem 1gm q24h with follow up in [MASKED] clinic - Will need weekly labs: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS - Planned for 6-week course of Ertapenem with transition to PO antibiotics afterwards for up to 6 months - Also discharged on PO fluconazole 400mg daily to cover [MASKED] - ID will determine duration of fluconazole - Please assess volume status and consider further diuresis +/- therapeutic paracentesis - Noted to have hypokalemia and hypomagnesemia prior to discharge which were repleted. Please re-check electrolytes on [MASKED] to ensure stability - Patient noted to be severely malnourished and not meeting PO intake goals. However, patient continuously declined re-placement of dobhoff tube. Please continue to monitor her nutrition and discuss Dobhoff tube as needed. - Hypoxia: Patient with desaturations to 86% with ambulation. She does have mild abdominal distension and [MASKED] edema in setting of cirrhosis in addition to hepatopulmonary syndrome. Patient was discharged with O2 to be used PRN dyspnea. - Given b/l tubo-ovarian abscesses, would recommend workup of malignancy (colonoscopy, other age-appropriate screening) as an outpatient. - Please ensure ongoing down-trend of leukocytosis - Please ensure follow-up abdominal imaging to exclude less likely possibility of malignancy - On CTU [MASKED]: "There are bilateral adnexal lesions which appear new from the prior exam with areas of hypodensity poorly characterized on this unenhanced exam. There is a soft tissue nodule along the right anterior pelvis seen best on series 2, image 63 measuring 1.7 x 1.4 cm. This lesion may represent an omental nodule though evaluation is incomplete." A contrast CT was recommended to r/o malignancy. Subsequently multiple CT scans were more consistent with infection but, as above, follow-up MRI abdomen/pelvis may be warranted to confirm absence of malignancy. - Please note, IUD removed, please discuss alternative methods of contraception - Please note, question of intimate partner violence, please continue to involve social work - patient declined further counseling during this admission - Please note CA 125 61 (upper limit 35) - as above, please ensure repeat ovarian imaging after resolution of infection Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Thiamine 100 mg PO DAILY 2. Verapamil SR 240 mg PO Q24H 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 4. Venlafaxine XR 37.5 mg PO DAILY 5. QUEtiapine Fumarate 100 mg PO QHS 6. Omeprazole 20 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Magnesium Oxide 400 mg PO DAILY 9. Losartan Potassium 25 mg PO DAILY 10. Lactulose 30 mL PO BID 11. Gabapentin 300 mg PO TID 12. FoLIC Acid 1 mg PO DAILY 13. Cyclobenzaprine 10 mg PO HS:PRN spasm 14. Amitriptyline 10 mg PO QHS 15. Lidocaine 5% Patch 1 PTCH TD QAM 16. K-Phos No 2 (potassium,sodium monobas phos) 305-700 mg oral QID 17. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation 18. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety Discharge Medications: 1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose Please take Q24H through [MASKED]. RX *ertapenem [Invanz] 1 gram 1 g IV Q24H Disp #*18 Vial Refills:*0 2. Fluconazole 400 mg PO Q24H RX *fluconazole 200 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. Furosemide 60 mg PO DAILY RX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 4. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Spironolactone 100 mg PO DAILY RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. Lactulose 30 mL PO TID RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day Refills:*0 8. Lidocaine 5% Patch 1 PTCH TD QPM back pain 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 10. Amitriptyline 10 mg PO QHS 11. Cyclobenzaprine 10 mg PO HS:PRN spasm 12. FoLIC Acid 1 mg PO DAILY 13. Gabapentin 300 mg PO TID 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Magnesium Oxide 400 mg PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. Nicotine Polacrilex 2 mg PO Q2H:PRN smoking cessation 18. QUEtiapine Fumarate 100 mg PO QHS 19. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 20. Thiamine 100 mg PO DAILY 21. Venlafaxine XR 37.5 mg PO DAILY 22.Cane Standard cane Diagnosis: Cirrhosis ICD10 K74.60 Length of need 13 months Prognosis = good 23.Outpatient Lab Work WEEKLY LABS. Please draw every week: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, CRP Please fax to: ATTN: [MASKED] CLINIC - FAX: [MASKED] ICD-10 Actinomyces. A Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Cirrhosis Actinomyces infection Tubo-ovarian abscesses Ascites Hepatic encephalopathy Pneumonia Pulmonary edema SECONDARY DIAGNOSIS: Hypertension Depression 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]: WHAT HAPPENED TO YOU IN THE HOSPITAL? ====================================== - You were extremely sick when you came to the hospital. You were found to have abscesses, or pockets of infection, in your ovaries and abdomen - Our Interventional Radiology team drained these pockets three times to help address the infection - You were also found to have scarring of your liver, called cirrhosis. We put you on medications to help move your bowels and urinate to prevent buildup of toxins and fluids. - We thought that your infection was caused by a bacteria called actinomyces WHAT WILL HAPPEN TO YOU AFTER YOU LEAVE THE HOSPITAL? ====================================================== - It is very important that you increase your nutrition -- please try to eat as much as possible - You will need to see a hepatologist and infectious disease doctor in clinic. YOU MUST MAKE IT TO ALL YOUR FOLLOW UP APPOINTMENTS. - If you are having nausea and throwing up, please call your doctor and discuss reducing the amount of fluconazole that you are taking - You will need to be on IV antibiotics with ertapenem at least through [MASKED]. You must also get blood tests checked every week - You have many new medications. Please review carefully Please call The [MASKED] [MASKED] House: [MASKED] if you feel that you need more support at home. At this facility you would have more support with your health issues, but also more freedom compared to a normal rehab facility. We wish you all the best. - Your [MASKED] care team Followup Instructions: [MASKED]
[]
[ "J9601", "I110", "J45909", "F17210" ]
[ "A419: Sepsis, unspecified organism", "E43: Unspecified severe protein-calorie malnutrition", "J9601: Acute respiratory failure with hypoxia", "K7200: Acute and subacute hepatic failure without coma", "R6521: Severe sepsis with septic shock", "G92: Toxic encephalopathy", "J189: Pneumonia, unspecified organism", "I5031: Acute diastolic (congestive) heart failure", "K8520: Alcohol induced acute pancreatitis without necrosis or infection", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "I110: Hypertensive heart disease with heart failure", "K7681: Hepatopulmonary syndrome", "K7031: Alcoholic cirrhosis of liver with ascites", "J45909: Unspecified asthma, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
10,076,263
29,064,377
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / Risperdal Attending: ___ Chief Complaint: Abd pain, ETOH Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ ETOH abuse, h/o ETOH pancreatitis, ETOH cirrhosis, recent hospitalization for intra-abdominal infection and b/l ___ with Actinomyces, ___, and other polymicrobial infection s/p drainage, and PE (___) p/w 1 wk of abdominal pain. Patient presenting with a 1 wk history of epigastric abdominal pain ___ radiating to back associated with abdominal distension and decreased PO w/ N/V during the past 3 days. Right before going to the ED she noticed blood in her vomit. Patient also reports a 3 day history of dark black stools but of normal volume and frequency. Patient also expresses suicidal ideation saying that she is in so much pain she thinks she may want to die; patient later recanted this remark saying that she wanted pain medication, no longer endorses SI. Patient is an active drinker and drank half pint of vodka right before admission for pain relief but states that she has not drank any other alcohol in the past 3 days. An EGD performed in ___ was negative for esophageal varices in this patient. She completed a course of fluconazole and her unasyn was switched to augmentin at her ___ appointment (___) and she is to be maintained on this for ___ months. In the ED, initial VS were: T 98.7 HR 99 BP 109/77 RR 17 98% RA Exam notable for: Teary, distended abdomen, NTTP, negative guaiac, +HSM, passive SI due to pain, but later recanted. Labs showed: wbc 9.5, hgb 12.1 (MCV 110), plt 137, Na 130, Cr 1.2 (baseline is 0.7-0.8), AST 206, ALT 70, AP 378, tbili 0.6, alb 4.4, UA normal. Imaging showed: CTAP w/ con showed multiple prominent fluid-filled loops of small bowel without transition point, may represent an ileus or gastroenteritis, resolution of ascites and b/l adnexal collections. Received: 1 L NS, morphine sulfate 2 mg + 4 mg IV GI was consulted and recommended NPO status, infectious studies and c.diff, no opioids, IVF bolus for ___ and admission to medicine. On arrival to the floor, patient reports ___ abdominal pain, but feels like she could eat something. She notes b/l lower quadrant pain and RUQ pain. Denies N/V/D/CP/SOB. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: cirrhosis EtOH pancreatitis EtOH abuse/dependence Asthma HTN Depression Social History: ___ Family History: Father with hx of HTN but otherwise healthy. Mother healthy. Three of four children have asthma, otherwise healthy. Denies FH of pancreatitis, pancreatic or GB malignancy Physical Exam: ADMISSION PHYSICAL: VS: T 98.6 BP 115/80 HR 98 RR 20 97% ra GENERAL: mild distress, crying HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, hair loss 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, TTP LUQ, ? palpable spleen, NBS, soft, without rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP/radial pulses bilaterally NEURO: A&Ox3, CN II-XII intact, ___ b/l wrist, biceps, triceps, hips, ankles. Sensation intact to light touch distal extremities. DISCHARGE PHYSICAL: Vitals: 97.9 PO 146 / 89 R Lying 73 18 94 Ra General: alert, oriented, nad HEENT: scleral icterus, pink mmm Neck: supple, no jvd Lungs: ctab, no wheezes, no crackles CV: regular rate and rhythm, no murmurs Abd: mild ascites, nondistended, +BS, no tenderness to palpation, Ext: 2+ dp pulses, no edema Neuro: CN II-XII intact, grossly moving all extremities, slurred speech at baseline Skin: warm and well perfused Pertinent Results: ADMISSION LABS: ___ 11:03AM LACTATE-2.9* ___ 10:35AM GLUCOSE-144* UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-18 ___ 10:35AM ALT(SGPT)-84* AST(SGOT)-319* LD(LDH)-428* ALK PHOS-387* TOT BILI-0.6 ___ 10:35AM ALBUMIN-4.0 CALCIUM-9.5 PHOSPHATE-3.6 MAGNESIUM-1.5* ___ 10:35AM WBC-6.5 RBC-3.24* HGB-11.8 HCT-35.8 MCV-111* MCH-36.4* MCHC-33.0 RDW-13.3 RDWSD-54.4* ___ 10:35AM PLT COUNT-109* ___ 10:35AM ___ PTT-38.0* ___ ___ 06:30PM URINE HOURS-RANDOM ___ 06:30PM URINE UHOLD-HOLD ___ 06:30PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 05:40PM GLUCOSE-103* UREA N-18 CREAT-1.2* SODIUM-130* POTASSIUM-4.7 CHLORIDE-86* TOTAL CO2-24 ANION GAP-25* ___ 05:40PM estGFR-Using this ___ 05:40PM ALT(SGPT)-70* AST(SGOT)-206* ALK PHOS-378* TOT BILI-0.6 ___ 05:40PM LIPASE-17 ___ 05:40PM ALBUMIN-4.4 CALCIUM-10.2 PHOSPHATE-4.0 MAGNESIUM-1.9 ___ 05:40PM WBC-9.5 RBC-3.33*# HGB-12.1# HCT-36.5# MCV-110*# MCH-36.3*# MCHC-33.2 RDW-13.2 RDWSD-53.9* ___ 05:40PM NEUTS-64.0 ___ MONOS-1.9* EOS-1.0 BASOS-0.3 IM ___ AbsNeut-6.06 AbsLymp-3.07 AbsMono-0.18* AbsEos-0.09 AbsBaso-0.03 ___ 05:40PM PLT COUNT-137* DISCHARGE LABS: ___ 08:15AM BLOOD WBC-6.6 RBC-2.99* Hgb-10.7* Hct-33.4* MCV-112* MCH-35.8* MCHC-32.0 RDW-13.2 RDWSD-53.9* Plt ___ ___ 08:15AM BLOOD Plt ___ ___ 08:15AM BLOOD ___ PTT-36.5 ___ ___ 08:15AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-136 K-4.2 Cl-99 HCO3-25 AnGap-16 ___ 08:15AM BLOOD ALT-65* AST-172* LD(LDH)-262* AlkPhos-355* TotBili-0.5 ___ 08:15AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.1 PERTINENT IMAGING ___ CT ABDOMEN/PELVIS 1. Multiple prominent fluid-filled loops of small bowel, without a transition point, may reflect ileus or gastroenteritis. 2. Interval resolution of ascites, with minimal residual inflammatory changes seen in the subhepatic region. 3. Interval resolution of bilateral adnexal collections. No new intra-abdominal or pelvic fluid collection. 4. Cholelithiasis, with no evidence of acute cholecystitis. MICROBIOLOGY ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. Brief Hospital Course: ___ w/ ETOH abuse, h/o ETOH pancreatitis, ETOH cirrhosis, recent hospitalization for intra-abdominal infection and b/l ___ with polymicrobial infection s/p drainage on suppressive amoxicillin, also with history of recent PE (___) who presented with 1 week of abdominal pain. On admission, a CT scan showed multiple, prominent fluid-filled loops of small bowel concerning for gastritis or ileus. Her clinical presentation was most consistent with gastritis, potentially secondary to recent, ongoing alcohol use. She was initially made NPO and treated with tramadol for pain and her symptoms improved. She continued to have regular non-bloody bowel movements throughout her hospitalization and tolerated a regular diet without pain, nausea or vomiting prior to discharge. ACUTE ISSUES ============ #Abdominal pain: Patient presented with 1 week of abdominal pain and nausea/vomiting in the setting of ongoing EtOH abuse and ETOH cirrhosis. CTAP w/o pancreatitis, but concerning for ileus vs enteritis. Infectious workup including urine cx, blood cx, and cdiff were negative. Patient remained afebrile without leukocytosis. Due to concern for ileus, patient was initially kept NPO but diet was advanced as tolerated with no further nausea/vomiting. #Cirrhosis/#ETOH use: Ongoing alcohol abuse with alcoholic cirrhosis complicated previously by HE, ascites w/o SBP, and EGD w/o esophageal varices (showed gastropathy). On admission, AST/ALT 206/70, tbili wnl, INR 1.2. Patient was kept on CIWA protocol and continued on rifaximin and lactulose. Home lasix and spironolactone were held in the setting of n/v and poor PO intake. CHRONIC ISSUES ============== #h/o Actinomyces infection: Stable. CTAP on admission confirmed resolving adnexal collections. Continued on home amoxicillin 875 mg BID. Per ID ___ need to be on this for ___ months. #h/o PE: History of PE ___. Patient was continued on home Apixaban 5 mg PO BID. #Smoking: Current smoker ___ ppd. Continued on nicotine patch inpatient. #Back pain: Stable. Continued on gabapentin and lidocaine. #Asthma: Stable. Continued albuterol inhaler prn. #Depression: Stable. Continued on amitriptyline, venlafaxine XR, quetiapine prn TRANSITIONAL ISSUES: ==================== [] Patient reports missing doses of Amoxicillin at home. This medication was given while in the hospital. Please ensure this medication continues per Infectious Disease recommendations (minimum ___ months from ___ [] Please ensure patient follows-up with both hepatology and infectious disease going forward [] Please continue to counsel patient on importance of alcohol cessation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Amoxicillin 875 mg PO Q12H 3. Cholestyramine 2 gm PO DAILY 4. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 5. Apixaban 5 mg PO BID 6. FoLIC Acid 1 mg PO DAILY 7. Furosemide 80 mg PO DAILY 8. Gabapentin 300 mg PO TID 9. Lactulose 15 mL PO BID 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. Magnesium Oxide 400 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Naproxen 500 mg PO Q12H:PRN Pain - Mild 14. QUEtiapine Fumarate 100 mg PO QHS 15. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 16. Sarna Lotion 1 Appl TP TID:PRN itching 17. Spironolactone 100 mg PO DAILY 18. Venlafaxine XR 37.5 mg PO DAILY 19. Thiamine 100 mg PO DAILY 20. Rifaximin 550 mg PO BID 21. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 2. Amitriptyline 10 mg PO QHS 3. Amoxicillin 875 mg PO Q12H 4. Apixaban 5 mg PO BID 5. Cholestyramine 2 gm PO DAILY 6. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 7. FoLIC Acid 1 mg PO DAILY 8. Furosemide 80 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. Lactulose 15 mL PO BID 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Magnesium Oxide 400 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Naproxen 500 mg PO Q12H:PRN Pain - Mild 15. QUEtiapine Fumarate 100 mg PO QHS 16. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 17. Rifaximin 550 mg PO BID 18. Sarna Lotion 1 Appl TP TID:PRN itching 19. Spironolactone 100 mg PO DAILY 20. Thiamine 100 mg PO DAILY 21. Venlafaxine XR 37.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcoholic Gastritis Secondary Diagnosis: Alcohol abuse, Cirrhosis, Tubo-Ovarian Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you at ___ ___. You were admitted with pain in your abdomen. You were found to have fluid-filled loops of small bowel on a CT scan, that was most concerning for gastritis, potentially related to your alcohol use. We trialed bowel rest and medications for your pain and this improved. You will be discharged home today to continue your usual medications - including Amoxicillin - and to follow-up with your Primary Care Physician. Best wishes, Your ___ Team Followup Instructions: ___
[ "K2920", "K7031", "N7093", "F419", "Z86711", "F17210", "M549", "J45909", "F329", "A429", "Z7902" ]
Allergies: lisinopril / Risperdal Chief Complaint: Abd pain, ETOH Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] w/ ETOH abuse, h/o ETOH pancreatitis, ETOH cirrhosis, recent hospitalization for intra-abdominal infection and b/l [MASKED] with Actinomyces, [MASKED], and other polymicrobial infection s/p drainage, and PE ([MASKED]) p/w 1 wk of abdominal pain. Patient presenting with a 1 wk history of epigastric abdominal pain [MASKED] radiating to back associated with abdominal distension and decreased PO w/ N/V during the past 3 days. Right before going to the ED she noticed blood in her vomit. Patient also reports a 3 day history of dark black stools but of normal volume and frequency. Patient also expresses suicidal ideation saying that she is in so much pain she thinks she may want to die; patient later recanted this remark saying that she wanted pain medication, no longer endorses SI. Patient is an active drinker and drank half pint of vodka right before admission for pain relief but states that she has not drank any other alcohol in the past 3 days. An EGD performed in [MASKED] was negative for esophageal varices in this patient. She completed a course of fluconazole and her unasyn was switched to augmentin at her [MASKED] appointment ([MASKED]) and she is to be maintained on this for [MASKED] months. In the ED, initial VS were: T 98.7 HR 99 BP 109/77 RR 17 98% RA Exam notable for: Teary, distended abdomen, NTTP, negative guaiac, +HSM, passive SI due to pain, but later recanted. Labs showed: wbc 9.5, hgb 12.1 (MCV 110), plt 137, Na 130, Cr 1.2 (baseline is 0.7-0.8), AST 206, ALT 70, AP 378, tbili 0.6, alb 4.4, UA normal. Imaging showed: CTAP w/ con showed multiple prominent fluid-filled loops of small bowel without transition point, may represent an ileus or gastroenteritis, resolution of ascites and b/l adnexal collections. Received: 1 L NS, morphine sulfate 2 mg + 4 mg IV GI was consulted and recommended NPO status, infectious studies and c.diff, no opioids, IVF bolus for [MASKED] and admission to medicine. On arrival to the floor, patient reports [MASKED] abdominal pain, but feels like she could eat something. She notes b/l lower quadrant pain and RUQ pain. Denies N/V/D/CP/SOB. REVIEW OF SYSTEMS: (+)PER HPI Past Medical History: cirrhosis EtOH pancreatitis EtOH abuse/dependence Asthma HTN Depression Social History: [MASKED] Family History: Father with hx of HTN but otherwise healthy. Mother healthy. Three of four children have asthma, otherwise healthy. Denies FH of pancreatitis, pancreatic or GB malignancy Physical Exam: ADMISSION PHYSICAL: VS: T 98.6 BP 115/80 HR 98 RR 20 97% ra GENERAL: mild distress, crying HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, hair loss 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, TTP LUQ, ? palpable spleen, NBS, soft, without rebound/guarding EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP/radial pulses bilaterally NEURO: A&Ox3, CN II-XII intact, [MASKED] b/l wrist, biceps, triceps, hips, ankles. Sensation intact to light touch distal extremities. DISCHARGE PHYSICAL: Vitals: 97.9 PO 146 / 89 R Lying 73 18 94 Ra General: alert, oriented, nad HEENT: scleral icterus, pink mmm Neck: supple, no jvd Lungs: ctab, no wheezes, no crackles CV: regular rate and rhythm, no murmurs Abd: mild ascites, nondistended, +BS, no tenderness to palpation, Ext: 2+ dp pulses, no edema Neuro: CN II-XII intact, grossly moving all extremities, slurred speech at baseline Skin: warm and well perfused Pertinent Results: ADMISSION LABS: [MASKED] 11:03AM LACTATE-2.9* [MASKED] 10:35AM GLUCOSE-144* UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-18 [MASKED] 10:35AM ALT(SGPT)-84* AST(SGOT)-319* LD(LDH)-428* ALK PHOS-387* TOT BILI-0.6 [MASKED] 10:35AM ALBUMIN-4.0 CALCIUM-9.5 PHOSPHATE-3.6 MAGNESIUM-1.5* [MASKED] 10:35AM WBC-6.5 RBC-3.24* HGB-11.8 HCT-35.8 MCV-111* MCH-36.4* MCHC-33.0 RDW-13.3 RDWSD-54.4* [MASKED] 10:35AM PLT COUNT-109* [MASKED] 10:35AM [MASKED] PTT-38.0* [MASKED] [MASKED] 06:30PM URINE HOURS-RANDOM [MASKED] 06:30PM URINE UHOLD-HOLD [MASKED] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 05:40PM GLUCOSE-103* UREA N-18 CREAT-1.2* SODIUM-130* POTASSIUM-4.7 CHLORIDE-86* TOTAL CO2-24 ANION GAP-25* [MASKED] 05:40PM estGFR-Using this [MASKED] 05:40PM ALT(SGPT)-70* AST(SGOT)-206* ALK PHOS-378* TOT BILI-0.6 [MASKED] 05:40PM LIPASE-17 [MASKED] 05:40PM ALBUMIN-4.4 CALCIUM-10.2 PHOSPHATE-4.0 MAGNESIUM-1.9 [MASKED] 05:40PM WBC-9.5 RBC-3.33*# HGB-12.1# HCT-36.5# MCV-110*# MCH-36.3*# MCHC-33.2 RDW-13.2 RDWSD-53.9* [MASKED] 05:40PM NEUTS-64.0 [MASKED] MONOS-1.9* EOS-1.0 BASOS-0.3 IM [MASKED] AbsNeut-6.06 AbsLymp-3.07 AbsMono-0.18* AbsEos-0.09 AbsBaso-0.03 [MASKED] 05:40PM PLT COUNT-137* DISCHARGE LABS: [MASKED] 08:15AM BLOOD WBC-6.6 RBC-2.99* Hgb-10.7* Hct-33.4* MCV-112* MCH-35.8* MCHC-32.0 RDW-13.2 RDWSD-53.9* Plt [MASKED] [MASKED] 08:15AM BLOOD Plt [MASKED] [MASKED] 08:15AM BLOOD [MASKED] PTT-36.5 [MASKED] [MASKED] 08:15AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-136 K-4.2 Cl-99 HCO3-25 AnGap-16 [MASKED] 08:15AM BLOOD ALT-65* AST-172* LD(LDH)-262* AlkPhos-355* TotBili-0.5 [MASKED] 08:15AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.1 PERTINENT IMAGING [MASKED] CT ABDOMEN/PELVIS 1. Multiple prominent fluid-filled loops of small bowel, without a transition point, may reflect ileus or gastroenteritis. 2. Interval resolution of ascites, with minimal residual inflammatory changes seen in the subhepatic region. 3. Interval resolution of bilateral adnexal collections. No new intra-abdominal or pelvic fluid collection. 4. Cholelithiasis, with no evidence of acute cholecystitis. MICROBIOLOGY [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. Brief Hospital Course: [MASKED] w/ ETOH abuse, h/o ETOH pancreatitis, ETOH cirrhosis, recent hospitalization for intra-abdominal infection and b/l [MASKED] with polymicrobial infection s/p drainage on suppressive amoxicillin, also with history of recent PE ([MASKED]) who presented with 1 week of abdominal pain. On admission, a CT scan showed multiple, prominent fluid-filled loops of small bowel concerning for gastritis or ileus. Her clinical presentation was most consistent with gastritis, potentially secondary to recent, ongoing alcohol use. She was initially made NPO and treated with tramadol for pain and her symptoms improved. She continued to have regular non-bloody bowel movements throughout her hospitalization and tolerated a regular diet without pain, nausea or vomiting prior to discharge. ACUTE ISSUES ============ #Abdominal pain: Patient presented with 1 week of abdominal pain and nausea/vomiting in the setting of ongoing EtOH abuse and ETOH cirrhosis. CTAP w/o pancreatitis, but concerning for ileus vs enteritis. Infectious workup including urine cx, blood cx, and cdiff were negative. Patient remained afebrile without leukocytosis. Due to concern for ileus, patient was initially kept NPO but diet was advanced as tolerated with no further nausea/vomiting. #Cirrhosis/#ETOH use: Ongoing alcohol abuse with alcoholic cirrhosis complicated previously by HE, ascites w/o SBP, and EGD w/o esophageal varices (showed gastropathy). On admission, AST/ALT 206/70, tbili wnl, INR 1.2. Patient was kept on CIWA protocol and continued on rifaximin and lactulose. Home lasix and spironolactone were held in the setting of n/v and poor PO intake. CHRONIC ISSUES ============== #h/o Actinomyces infection: Stable. CTAP on admission confirmed resolving adnexal collections. Continued on home amoxicillin 875 mg BID. Per ID [MASKED] need to be on this for [MASKED] months. #h/o PE: History of PE [MASKED]. Patient was continued on home Apixaban 5 mg PO BID. #Smoking: Current smoker [MASKED] ppd. Continued on nicotine patch inpatient. #Back pain: Stable. Continued on gabapentin and lidocaine. #Asthma: Stable. Continued albuterol inhaler prn. #Depression: Stable. Continued on amitriptyline, venlafaxine XR, quetiapine prn TRANSITIONAL ISSUES: ==================== [] Patient reports missing doses of Amoxicillin at home. This medication was given while in the hospital. Please ensure this medication continues per Infectious Disease recommendations (minimum [MASKED] months from [MASKED] [] Please ensure patient follows-up with both hepatology and infectious disease going forward [] Please continue to counsel patient on importance of alcohol cessation Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Amoxicillin 875 mg PO Q12H 3. Cholestyramine 2 gm PO DAILY 4. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 5. Apixaban 5 mg PO BID 6. FoLIC Acid 1 mg PO DAILY 7. Furosemide 80 mg PO DAILY 8. Gabapentin 300 mg PO TID 9. Lactulose 15 mL PO BID 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. Magnesium Oxide 400 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Naproxen 500 mg PO Q12H:PRN Pain - Mild 14. QUEtiapine Fumarate 100 mg PO QHS 15. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 16. Sarna Lotion 1 Appl TP TID:PRN itching 17. Spironolactone 100 mg PO DAILY 18. Venlafaxine XR 37.5 mg PO DAILY 19. Thiamine 100 mg PO DAILY 20. Rifaximin 550 mg PO BID 21. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 2. Amitriptyline 10 mg PO QHS 3. Amoxicillin 875 mg PO Q12H 4. Apixaban 5 mg PO BID 5. Cholestyramine 2 gm PO DAILY 6. Cyclobenzaprine 10 mg PO HS:PRN muscle spasms 7. FoLIC Acid 1 mg PO DAILY 8. Furosemide 80 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. Lactulose 15 mL PO BID 11. Lidocaine 5% Patch 1 PTCH TD QAM 12. Magnesium Oxide 400 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Naproxen 500 mg PO Q12H:PRN Pain - Mild 15. QUEtiapine Fumarate 100 mg PO QHS 16. QUEtiapine Fumarate 50 mg PO DAILY:PRN anxiety 17. Rifaximin 550 mg PO BID 18. Sarna Lotion 1 Appl TP TID:PRN itching 19. Spironolactone 100 mg PO DAILY 20. Thiamine 100 mg PO DAILY 21. Venlafaxine XR 37.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcoholic Gastritis Secondary Diagnosis: Alcohol abuse, Cirrhosis, Tubo-Ovarian Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure to care for you at [MASKED] [MASKED]. You were admitted with pain in your abdomen. You were found to have fluid-filled loops of small bowel on a CT scan, that was most concerning for gastritis, potentially related to your alcohol use. We trialed bowel rest and medications for your pain and this improved. You will be discharged home today to continue your usual medications - including Amoxicillin - and to follow-up with your Primary Care Physician. Best wishes, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "F419", "F17210", "J45909", "F329", "Z7902" ]
[ "K2920: Alcoholic gastritis without bleeding", "K7031: Alcoholic cirrhosis of liver with ascites", "N7093: Salpingitis and oophoritis, unspecified", "F419: Anxiety disorder, unspecified", "Z86711: Personal history of pulmonary embolism", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M549: Dorsalgia, unspecified", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "A429: Actinomycosis, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
10,076,272
21,537,202
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / Sulfa (Sulfonamide Antibiotics) / ciprofloxacin / lisinopril / Penicillins / metoprolol Attending: ___. Chief Complaint: rectal pain Major Surgical or Invasive Procedure: None History of Present Illness: PCP: Name: ___. Location: ___ Address: ___, ___ Phone: ___ Fax: ___ HPI: ___ yo F s/p laparoscopic total abdominal colectomy with partial proctectomy and end-ileostomy ___ for medically refractory UC, HTN, pst DVT/PE and latent TB, presents with drainage from anus, mucous discharge, as well as ankle pain. The patient complains of progressively worse mucous discharge from her anus in the setting of rectal bleeding and rectal pain prior to defecation. She has tried various enemas with no effect: mesalamine and hydrocortisone. She was hospitalized recently to ___ and treated with hydrocortisone enemas. her symptoms continue despite this. Also, she complains of diffuse joint pains. Specifically, she complains of migratory arthritis in her neck, shoulder, back and now right ankle. She is to see Rheumatology for this. in the ED, CRS consulted. Her ankle was aspirated for CPPD. 10 point review of systems reviewed, otherwise negative except as listed above Past Medical History: Ulcerative Colitis s/p subtotal colectomy with end-ileostomy HTN Urinary frequency Latent TB s/p treatment Squamous cell skin cancer Provoked PE/DVT s/p 3 months treatment Social History: ___ Family History: nephew with UC niece with ___ Physical Exam: VS: AVSS GEN: well appearing in NAD HEENT: MMM OP clear NECK: neck supple HEART: RRR no mrg LUNG: CTAB ABD: soft NT/ND +BS, brown ostomy output EXT: warm, trace edema. Swelling over R ankle with decreased ROM, no erythema. No other joint swelling SKIN: no rash NEURO: no focal deficits Pertinent Results: ___ 08:14AM JOINT FLUID ___ POLYS-84* ___ ___ 08:14AM JOINT FLUID NUMBER-MOD SHAPE-RHOMBOID LOCATION-I/E BIREFRI-POS COMMENT-c/w calciu ___ 09:41PM GLUCOSE-139* UREA N-19 CREAT-0.7 SODIUM-134 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-26 ANION GAP-14 ___ 09:41PM estGFR-Using this ___ 09:41PM WBC-7.8 RBC-3.63* HGB-10.6* HCT-33.0* MCV-91# MCH-29.2# MCHC-32.1 RDW-13.7 RDWSD-45.9 ___ 09:41PM NEUTS-60.7 ___ MONOS-12.3 EOS-0.9* BASOS-0.5 IM ___ AbsNeut-4.71 AbsLymp-1.95 AbsMono-0.95* AbsEos-0.07 AbsBaso-0.04 ___ 09:41PM PLT COUNT-412* ___ 09:41PM ___ PTT-24.2* ___ ___ 09:26PM URINE HOURS-RANDOM ___ 09:26PM URINE UHOLD-HOLD ___ 09:26PM URINE GR HOLD-HOLD ___ 09:26PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 09:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___: negative for DVT: ANKLE XRAY: IMPRESSION: 1. There is moderate edema throughout the superficial soft tissues of the ankle, however no acute fracture or dislocation. 2. A density within the fat pad of the heel likely represents a foreign body versus soft tissue calcification . 3. Small tibiotalar joint effusion. Brief Hospital Course: ___ with refractory UC s/p total colectomy, partial proctectomy with end ileostomy, presents with rectal pain with mucous/bloody discharge and poly arthritis. UC with rectal pain due to diversion proctitis Felt to be residual proctitis. C. diff negative. Symptoms ongoing and not relieved with various enemas. Hospitalized at discretion of primary GI for evaluation. GI and colorectal surgery consulted and case reviewed with outpatient GI. Cortifoam enemas were started. Ultimately, it was felt that the patient would likely need surgery and completion proctectomy, which the patient was amenable to. She will follow up closely with Dr. ___ to make plans for this. She was started on iron supplementation on discharge and will need monitoring of her Hct. Polyarthritis/CPPD: Ankle aspiration confirms CPPD. No signs of infection. ___ also have poly arthritis due to IBD. Given colchicine in addition to Tylenol, Tramadol, and Ice with improvement. Discharged on short course of Colchicine with the above analgesics and home ___ Essential HTN: Stable Medications on Admission: traMADol 50 mg tablet Take 1 tablet by mouth every 6 hours as needed for pain. No more than 6 tablets per day oxybutynin 5 mg tablet extended release 24hr SR 24 Hr Take 1 tablet by mouth daily hydrocortisone 100 mg/60 mL Enema Insert 1 enema rectally pantoprazole 40 mg tablet,delayed release (___) Take 1 tablet by mouth every evening OTHER MEDICATION, , 60-ml enema containing acetate: 60 mmol/liter; propionate: 30 mmol/liter; and N-butyrate: 40 mmol/liter. One per rectum q hs. pyridoxine (B-6) 50 mg tablet Take 1 tablet by mouth every evening for 9 months while on INH therapy. fluticasone 50 mcg/actuation Spray, Suspension Apply 2 sprays to each nostril daily azelastine (OPTIVAR) 0.05 % Drops Instill 1 drop in both eyes twice daily cholecalciferol, vitamin D3, (VITAMIN D) 1,000 unit capsule Take by mouth daily ascorbic acid (ASCORBIC ACID WITH ROSE HIPS) 500 mg tablet Take by mouth daily multivitamin Oral capsule Take 1 capsule by mouth daily CALCIUM CARBONATE/VITAMIN D2 (CALCIUM 500 WITH VITAMIN D ORAL) Take 1 tablet by mouth daily acetaminophen 500 mg Oral tablet 2 tabs tid Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Ascorbic Acid ___ mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Oxybutynin 5 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Pyridoxine 50 mg PO DAILY 7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth four times a day Disp #*28 Tablet Refills:*0 8. azelastine 0.05 % ophthalmic DAILY 9. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 10. Hydrocortisone Acetate 10% Foam 1 Appl PR TID RX *hydrocortisone acetate [Cortifoam] 10 % 1 foam(s) rectally three times a day Refills:*0 11. Colchicine 0.6 mg PO DAILY RX *colchicine 0.6 mg 1 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 12. Outpatient Lab Work Please check your CBC, complete blood count, when you follow up with your doctor 13. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Diversion proctitis Ulcerative colitis Rectal bleeding Acute Pseudogout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of continued rectal bleeding and pain. After review with Dr. ___ the GI team, we have decided to start making plans for surgery. In the meantime, please continue the CortiFoam enemas three times a day. Please take iron supplement as well. Also, we found "Pseudogout" in your ankle. You have improved with pain control and ice. Please continue this regimen and follow up closely with your PCP ___: ___
[ "K5120", "K625", "R710", "K6289", "Z9049", "M1389", "Z932", "M25579", "M11279", "I10", "R350", "R7611", "Z85828", "Z86718" ]
Allergies: aspirin / Sulfa (Sulfonamide Antibiotics) / ciprofloxacin / lisinopril / Penicillins / metoprolol Chief Complaint: rectal pain Major Surgical or Invasive Procedure: None History of Present Illness: PCP: Location: [MASKED] Address: [MASKED], [MASKED] Phone: [MASKED] Fax: [MASKED] HPI: [MASKED] yo F s/p laparoscopic total abdominal colectomy with partial proctectomy and end-ileostomy [MASKED] for medically refractory UC, HTN, pst DVT/PE and latent TB, presents with drainage from anus, mucous discharge, as well as ankle pain. The patient complains of progressively worse mucous discharge from her anus in the setting of rectal bleeding and rectal pain prior to defecation. She has tried various enemas with no effect: mesalamine and hydrocortisone. She was hospitalized recently to [MASKED] and treated with hydrocortisone enemas. her symptoms continue despite this. Also, she complains of diffuse joint pains. Specifically, she complains of migratory arthritis in her neck, shoulder, back and now right ankle. She is to see Rheumatology for this. in the ED, CRS consulted. Her ankle was aspirated for CPPD. 10 point review of systems reviewed, otherwise negative except as listed above Past Medical History: Ulcerative Colitis s/p subtotal colectomy with end-ileostomy HTN Urinary frequency Latent TB s/p treatment Squamous cell skin cancer Provoked PE/DVT s/p 3 months treatment Social History: [MASKED] Family History: nephew with UC niece with [MASKED] Physical Exam: VS: AVSS GEN: well appearing in NAD HEENT: MMM OP clear NECK: neck supple HEART: RRR no mrg LUNG: CTAB ABD: soft NT/ND +BS, brown ostomy output EXT: warm, trace edema. Swelling over R ankle with decreased ROM, no erythema. No other joint swelling SKIN: no rash NEURO: no focal deficits Pertinent Results: [MASKED] 08:14AM JOINT FLUID [MASKED] POLYS-84* [MASKED] [MASKED] 08:14AM JOINT FLUID NUMBER-MOD SHAPE-RHOMBOID LOCATION-I/E BIREFRI-POS COMMENT-c/w calciu [MASKED] 09:41PM GLUCOSE-139* UREA N-19 CREAT-0.7 SODIUM-134 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-26 ANION GAP-14 [MASKED] 09:41PM estGFR-Using this [MASKED] 09:41PM WBC-7.8 RBC-3.63* HGB-10.6* HCT-33.0* MCV-91# MCH-29.2# MCHC-32.1 RDW-13.7 RDWSD-45.9 [MASKED] 09:41PM NEUTS-60.7 [MASKED] MONOS-12.3 EOS-0.9* BASOS-0.5 IM [MASKED] AbsNeut-4.71 AbsLymp-1.95 AbsMono-0.95* AbsEos-0.07 AbsBaso-0.04 [MASKED] 09:41PM PLT COUNT-412* [MASKED] 09:41PM [MASKED] PTT-24.2* [MASKED] [MASKED] 09:26PM URINE HOURS-RANDOM [MASKED] 09:26PM URINE UHOLD-HOLD [MASKED] 09:26PM URINE GR HOLD-HOLD [MASKED] 09:26PM URINE COLOR-Yellow APPEAR-Clear SP [MASKED] [MASKED] 09:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [MASKED]: negative for DVT: ANKLE XRAY: IMPRESSION: 1. There is moderate edema throughout the superficial soft tissues of the ankle, however no acute fracture or dislocation. 2. A density within the fat pad of the heel likely represents a foreign body versus soft tissue calcification . 3. Small tibiotalar joint effusion. Brief Hospital Course: [MASKED] with refractory UC s/p total colectomy, partial proctectomy with end ileostomy, presents with rectal pain with mucous/bloody discharge and poly arthritis. UC with rectal pain due to diversion proctitis Felt to be residual proctitis. C. diff negative. Symptoms ongoing and not relieved with various enemas. Hospitalized at discretion of primary GI for evaluation. GI and colorectal surgery consulted and case reviewed with outpatient GI. Cortifoam enemas were started. Ultimately, it was felt that the patient would likely need surgery and completion proctectomy, which the patient was amenable to. She will follow up closely with Dr. [MASKED] to make plans for this. She was started on iron supplementation on discharge and will need monitoring of her Hct. Polyarthritis/CPPD: Ankle aspiration confirms CPPD. No signs of infection. [MASKED] also have poly arthritis due to IBD. Given colchicine in addition to Tylenol, Tramadol, and Ice with improvement. Discharged on short course of Colchicine with the above analgesics and home [MASKED] Essential HTN: Stable Medications on Admission: traMADol 50 mg tablet Take 1 tablet by mouth every 6 hours as needed for pain. No more than 6 tablets per day oxybutynin 5 mg tablet extended release 24hr SR 24 Hr Take 1 tablet by mouth daily hydrocortisone 100 mg/60 mL Enema Insert 1 enema rectally pantoprazole 40 mg tablet,delayed release ([MASKED]) Take 1 tablet by mouth every evening OTHER MEDICATION, , 60-ml enema containing acetate: 60 mmol/liter; propionate: 30 mmol/liter; and N-butyrate: 40 mmol/liter. One per rectum q hs. pyridoxine (B-6) 50 mg tablet Take 1 tablet by mouth every evening for 9 months while on INH therapy. fluticasone 50 mcg/actuation Spray, Suspension Apply 2 sprays to each nostril daily azelastine (OPTIVAR) 0.05 % Drops Instill 1 drop in both eyes twice daily cholecalciferol, vitamin D3, (VITAMIN D) 1,000 unit capsule Take by mouth daily ascorbic acid (ASCORBIC ACID WITH ROSE HIPS) 500 mg tablet Take by mouth daily multivitamin Oral capsule Take 1 capsule by mouth daily CALCIUM CARBONATE/VITAMIN D2 (CALCIUM 500 WITH VITAMIN D ORAL) Take 1 tablet by mouth daily acetaminophen 500 mg Oral tablet 2 tabs tid Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Ascorbic Acid [MASKED] mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Oxybutynin 5 mg PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Pyridoxine 50 mg PO DAILY 7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth four times a day Disp #*28 Tablet Refills:*0 8. azelastine 0.05 % ophthalmic DAILY 9. Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY 10. Hydrocortisone Acetate 10% Foam 1 Appl PR TID RX *hydrocortisone acetate [Cortifoam] 10 % 1 foam(s) rectally three times a day Refills:*0 11. Colchicine 0.6 mg PO DAILY RX *colchicine 0.6 mg 1 tablet(s) by mouth once a day Disp #*4 Tablet Refills:*0 12. Outpatient Lab Work Please check your CBC, complete blood count, when you follow up with your doctor 13. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Diversion proctitis Ulcerative colitis Rectal bleeding Acute Pseudogout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for evaluation of continued rectal bleeding and pain. After review with Dr. [MASKED] the GI team, we have decided to start making plans for surgery. In the meantime, please continue the CortiFoam enemas three times a day. Please take iron supplement as well. Also, we found "Pseudogout" in your ankle. You have improved with pain control and ice. Please continue this regimen and follow up closely with your PCP [MASKED]: [MASKED]
[]
[ "I10", "Z86718" ]
[ "K5120: Ulcerative (chronic) proctitis without complications", "K625: Hemorrhage of anus and rectum", "R710: Precipitous drop in hematocrit", "K6289: Other specified diseases of anus and rectum", "Z9049: Acquired absence of other specified parts of digestive tract", "M1389: Other specified arthritis, multiple sites", "Z932: Ileostomy status", "M25579: Pain in unspecified ankle and joints of unspecified foot", "M11279: Other chondrocalcinosis, unspecified ankle and foot", "I10: Essential (primary) hypertension", "R350: Frequency of micturition", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis", "Z85828: Personal history of other malignant neoplasm of skin", "Z86718: Personal history of other venous thrombosis and embolism" ]
10,076,272
28,524,353
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: aspirin / Sulfa (Sulfonamide Antibiotics) / ciprofloxacin / lisinopril / Penicillins / metoprolol Attending: ___ ___ Complaint: Ulcerative Colitis, retained rectum after colectomy with on going pain and bleeding Major Surgical or Invasive Procedure: Completion Proctectomy History of Present Illness: ___ year old lovely female patient followed by Dr. ___ the colorectal surgery team who is s/p colectomy and end ileostomy with continued pain and ulcerative colitis symtpoms in her retained rectum. She was evaluated in clinic. Plans for surgical removal of remaining rectum were arranged and Past Medical History: Ulcerative Colitis s/p subtotal colectomy with end-ileostomy HTN Urinary frequency Latent TB s/p treatment Squamous cell skin cancer Provoked PE/DVT s/p 3 months treatment Social History: ___ Family History: nephew with UC niece with ___ Physical Exam: General:NAD Neuro: A&OX3 Cardio/Pulm: RRR, nl breathing effort Abd/perineum: soft, NT/ND, perineal wound with mild SS drainage, intact ___ edema Pertinent Results: ___ 08:19AM BLOOD WBC-5.6 RBC-3.39* Hgb-9.9* Hct-31.5* MCV-93 MCH-29.2 MCHC-31.4* RDW-15.5 RDWSD-52.8* Plt ___ ___ 05:18PM BLOOD Hct-34.3 ___ 08:19AM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-139 K-4.1 Cl-109* HCO3-23 AnGap-11 ___ 05:18PM BLOOD Na-141 K-3.5 Cl-107 ___ 08:19AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.8 ___ 05:18PM BLOOD Mg-1.9 Brief Hospital Course: Mrs. ___ was admitted to the inpatient Colorectal Surgery Service after completion proctectomy with diverting ileostomy. She was doing quite well on post-operative day one. Her pain was controlled with a pca and she was hydrated intravenously. She tolerated clear liquids without issue and intravenous fluids were discontinued. She was advanced to a slow regular diet as the ileostomy had more output which was tolerated well. All of he medications were transitioned to oral which controlled her pain without issue. The surgical incisions were clean and intact. The ileostomy was pink and had liquid green output. The ___ incision was intact. She was ambulating with the nursing staff and discharged to home on ___ Medications on Admission: Acetaminophen 1000 mg PO TID Ascorbic Acid ___ mg PO DAILY Fluticasone Propionate NASAL 2 SPRY NU DAILY Oxybutynin 5 mg PO DAILY Pantoprazole 40 mg PO Q24H Pyridoxine 50 mg PO DAILY azelastine 0.05 % ophthalmic DAILY Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO TID do not take more than 3000mg of tylenol in 24 hours or drink alcohol while taking 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY 3. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medicaton 4. Ascorbic Acid ___ mg PO DAILY 5. Oxybutynin 5 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Pyridoxine 50 mg PO DAILY 8. azelastine 0.05 % ophthalmic DAILY 9. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral DAILY 10. Colchicine 0.6 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ulcerative Colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ were admitted to the inpatient Colorectal Surgery Service after a completion proctectomy to remove the remaining amount of rectum left in place after the colectomy done to treat your Ulcerative Colitis. Your ileostomy was redone. ___ have recovered and have tolerated a regular diet. ___ may return home to finish your recovery. ___ have an ileostomy. The most common complication from a ileostomy is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. ___ must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If ___ find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if ___ notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If ___ notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. ___ may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to ___ by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. ___ stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as ___ have been instructed by the wound/ostomy nurses. ___ will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. ___ will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until ___ are comfortable caring for it on your own. Please monitor your bowel function closely. If ___ have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. ___ will be prescribed a small amount of the pain medication Thank ___ for allowing us to participate in your care! Our hope is that ___ will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___
[ "K51211", "I10", "Z9049", "R350", "R7611", "Z85828", "Z86711", "Z86718", "Z87891" ]
Allergies: aspirin / Sulfa (Sulfonamide Antibiotics) / ciprofloxacin / lisinopril / Penicillins / metoprolol [MASKED] Complaint: Ulcerative Colitis, retained rectum after colectomy with on going pain and bleeding Major Surgical or Invasive Procedure: Completion Proctectomy History of Present Illness: [MASKED] year old lovely female patient followed by Dr. [MASKED] the colorectal surgery team who is s/p colectomy and end ileostomy with continued pain and ulcerative colitis symtpoms in her retained rectum. She was evaluated in clinic. Plans for surgical removal of remaining rectum were arranged and Past Medical History: Ulcerative Colitis s/p subtotal colectomy with end-ileostomy HTN Urinary frequency Latent TB s/p treatment Squamous cell skin cancer Provoked PE/DVT s/p 3 months treatment Social History: [MASKED] Family History: nephew with UC niece with [MASKED] Physical Exam: General:NAD Neuro: A&OX3 Cardio/Pulm: RRR, nl breathing effort Abd/perineum: soft, NT/ND, perineal wound with mild SS drainage, intact [MASKED] edema Pertinent Results: [MASKED] 08:19AM BLOOD WBC-5.6 RBC-3.39* Hgb-9.9* Hct-31.5* MCV-93 MCH-29.2 MCHC-31.4* RDW-15.5 RDWSD-52.8* Plt [MASKED] [MASKED] 05:18PM BLOOD Hct-34.3 [MASKED] 08:19AM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-139 K-4.1 Cl-109* HCO3-23 AnGap-11 [MASKED] 05:18PM BLOOD Na-141 K-3.5 Cl-107 [MASKED] 08:19AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.8 [MASKED] 05:18PM BLOOD Mg-1.9 Brief Hospital Course: Mrs. [MASKED] was admitted to the inpatient Colorectal Surgery Service after completion proctectomy with diverting ileostomy. She was doing quite well on post-operative day one. Her pain was controlled with a pca and she was hydrated intravenously. She tolerated clear liquids without issue and intravenous fluids were discontinued. She was advanced to a slow regular diet as the ileostomy had more output which was tolerated well. All of he medications were transitioned to oral which controlled her pain without issue. The surgical incisions were clean and intact. The ileostomy was pink and had liquid green output. The [MASKED] incision was intact. She was ambulating with the nursing staff and discharged to home on [MASKED] Medications on Admission: Acetaminophen 1000 mg PO TID Ascorbic Acid [MASKED] mg PO DAILY Fluticasone Propionate NASAL 2 SPRY NU DAILY Oxybutynin 5 mg PO DAILY Pantoprazole 40 mg PO Q24H Pyridoxine 50 mg PO DAILY azelastine 0.05 % ophthalmic DAILY Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO TID do not take more than 3000mg of tylenol in 24 hours or drink alcohol while taking 2. Fluticasone Propionate NASAL 2 SPRY NU DAILY 3. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medicaton 4. Ascorbic Acid [MASKED] mg PO DAILY 5. Oxybutynin 5 mg PO DAILY 6. Pantoprazole 40 mg PO Q24H 7. Pyridoxine 50 mg PO DAILY 8. azelastine 0.05 % ophthalmic DAILY 9. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit oral DAILY 10. Colchicine 0.6 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Ulcerative Colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [MASKED] were admitted to the inpatient Colorectal Surgery Service after a completion proctectomy to remove the remaining amount of rectum left in place after the colectomy done to treat your Ulcerative Colitis. Your ileostomy was redone. [MASKED] have recovered and have tolerated a regular diet. [MASKED] may return home to finish your recovery. [MASKED] have an ileostomy. The most common complication from a ileostomy is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. [MASKED] must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If [MASKED] find that your output has become too much or too little, please call the office for advice. The office nurse or nurse practitioner can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if [MASKED] notice your ileostomy output increasing, take in more electrolyte drink such as Gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If [MASKED] notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. [MASKED] may eat a regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to [MASKED] by the ostomy nurses. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. [MASKED] stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for bulging or signs of infection listed above. Please care for the ostomy as [MASKED] have been instructed by the wound/ostomy nurses. [MASKED] will be able to make an appointment with the ostomy nurse in the clinic 7 days after surgery. [MASKED] will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until [MASKED] are comfortable caring for it on your own. Please monitor your bowel function closely. If [MASKED] have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. [MASKED] will be prescribed a small amount of the pain medication Thank [MASKED] for allowing us to participate in your care! Our hope is that [MASKED] will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]
[]
[ "I10", "Z86718", "Z87891" ]
[ "K51211: Ulcerative (chronic) proctitis with rectal bleeding", "I10: Essential (primary) hypertension", "Z9049: Acquired absence of other specified parts of digestive tract", "R350: Frequency of micturition", "R7611: Nonspecific reaction to tuberculin skin test without active tuberculosis", "Z85828: Personal history of other malignant neoplasm of skin", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence" ]
10,076,362
24,641,199
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / Losartan Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ Cardiac catheterization History of Present Illness: ___ with history of HTN, anxiety and significant family history of CAD who is transferred from ___ with unstable angina. She has had similar anginal symptoms in the past, and was evaluated with a nuclear stress test in ___ with an essentially normal study. She was walking yesterday and developed left arm pain radiating to her chest and jaw associated with dyspnea but no nausea and vomiting. This resolved with rest, but then recurred when walking around her house. She therefore presented to ___. There she had troponin T tested twice within two hours, both negative, and an unconcerning EKG. She was tachycardic to the 120s that improved after getting her home atenolol, which she had not taken due to running out of the pills. At ___ she got 81 mg aspirin, 100 mg atenolol, nitro and amlodipine. A CXR showed no acute abnormality. ___ cardiology was consulted in ___ and recommended transfer to ___ for diagnostic catheterization. In the ED, initial vital signs were: 98.0 61 130/85 18 96% RA - Labs were notable for: CBC WNL, coags WNL, trop < 0.01 x 1, U/A with small leuk esterase and few bacteria but nitrite negative - Imaging: EKG with sinus rhythm and no ischemic changes - The patient was given: nothing - Consults: ___ cardiology who recommended admission to ___ service Vitals prior to transfer were: 98 64 123/70 18 98% RA Upon arrival to the floor, she is chest pain free and endorses the above story. She states that she has medication reactions with colonoscopy sedating meds, and would like this passed on in case she undergoes catheterization. Denies dysuria. Past Medical History: - Anxiety - Depression - Hyperlipidemia - ADHD - allergic rhinitis - obesity - hypertension - left patellofemoral syndrome - colon adenoma - iron deficienty anemia - GERD - osteoporosis - primary hyperparathyroidism - s/p cholecystectomy - appendiceal polyp - hiatal hernia - s/p ovarian cystectomy Social History: ___ Family History: - father with HTN, HLD, MI in ___ requiring CABG - mother with MY in ___ - brother with MI at age ___, died of complications prior to heart transplant ___ years later Physical Exam: ON ADMISSION: VITALS: 98 165/89 68 16 99% RA GENERAL: NAD HEENT - MM somewhat dry, anicteric sclera, oropharynx clear NECK: Supple, no LAD, JVP flat CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: A&Ox3, no motor deficit ON DISCHARGE: VITALS: 98.2 100s-130s/50s-70s ___ 95-98% RA GENERAL: NAD HEENT - MM somewhat dry, anicteric sclera, oropharynx clear NECK: Supple, no LAD, JVP flat CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. R radial access site c/d/I without hematoma or bruising SKIN: Without rash. NEUROLOGIC: A&Ox3, no motor deficit Pertinent Results: ON ADMISSION: ___ 08:00PM BLOOD WBC-6.1 RBC-3.89* Hgb-12.2 Hct-36.4 MCV-94 MCH-31.4 MCHC-33.5 RDW-13.8 RDWSD-46.7* Plt ___ ___ 08:00PM BLOOD Neuts-46.0 ___ Monos-9.8 Eos-5.7 Baso-1.0 Im ___ AbsNeut-2.82 AbsLymp-2.28 AbsMono-0.60 AbsEos-0.35 AbsBaso-0.06 ___ 08:00PM BLOOD ___ PTT-32.5 ___ ___ 08:00PM BLOOD Glucose-99 UreaN-6 Creat-1.0 Na-140 K-4.1 Cl-105 HCO3-28 AnGap-11 ___ 08:00PM BLOOD cTropnT-<0.01 ___ 06:30AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9 ON DISCHARGE: ___ 06:00AM BLOOD WBC-7.3 RBC-3.65* Hgb-11.0* Hct-34.9 MCV-96 MCH-30.1 MCHC-31.5* RDW-20.3* RDWSD-70.3* Plt ___ ___ 06:00AM BLOOD Glucose-80 UreaN-16 Creat-0.9 Na-141 K-3.7 Cl-109* HCO3-23 AnGap-13 ___ 06:00AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.9 OTHER STUDIES: ___ ECG: Baseline artifact. Sinus rhythm. Early R wave progression. No previous tracing available for comparison. Brief Hospital Course: ___ yoF with h/o hypertension, hyperlipidemia, and significant family history of CAD with approximately one year history of intermittent chest pain who initially presented to ___ with left arm pain radiating to her chest and jaw as well as dyspnea. EKG showed no ischemic changes and troponins were negative x2. She was transferred to ___ for cardiac catheterization for unstable angina. Cardiac catheterization was via right radial access, and showed moderate 3 vessel disease. Findings appeared underwhelming given classic ACS symptoms. Patient was medically managed with ASA 81, metoprolol, and atorvastatin. Her home amlodipine and atenolol were discontinued. Her blood pressure remained under good control. She was chest pain free during her admission. CHRONIC ISSUES: # Normocytic anemia: Hgb 11 (from 12.2), unclear baseline. Denies melena, BRBPR or lightheadedness/dizziness. Continued on home ferrous sulfate # Anxiety: Continued home clonazepam # Depression: Continued home amitriptyline # Asymptomatic pyuria: No antibiotics. TRANSITIONAL ISSUES: - New medications: ASA 81 qd, atorvastatin 80 qd, metoprolol succinate 50 qd - Discontinued medications: Amlodipine, atenolol - Please continue to monitor blood pressure. ___ consider restarting amlodipine or adding an ace inhibitor if she is persistently hypertensive - Code status: Full - ___ (sister) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. Amlodipine 7.5 mg PO DAILY 3. Amitriptyline 100 mg PO QHS 4. ClonazePAM 0.5 mg PO QAM 5. ClonazePAM 1 mg PO QHS 6. Vitamin D 3000 UNIT PO DAILY 7. Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. Amitriptyline 100 mg PO QHS 2. Vitamin D 3000 UNIT PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. ClonazePAM 0.5 mg PO QAM 5. ClonazePAM 1 mg PO QHS 6. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 2 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Unstable angina SECONDARY: Mild-moderate coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. You were admitted because you were experiencing chest pain. You underwent cardiac catheterization, which showed mild-moderate coronary artery disease not requiring intervention. You were started on new medications to better manage your coronary artery disease and prevent future heart attacks. Please see your medication list for changes to your regimen. Please see below for your scheduled or pending appointments with your PCP and cardiology. We wish you the best, Your ___ Care Team Followup Instructions: ___
[ "I25110", "D509", "F419", "N390", "F329", "E669", "Z8249", "Z6838" ]
Allergies: lisinopril / Losartan Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED] Cardiac catheterization History of Present Illness: [MASKED] with history of HTN, anxiety and significant family history of CAD who is transferred from [MASKED] with unstable angina. She has had similar anginal symptoms in the past, and was evaluated with a nuclear stress test in [MASKED] with an essentially normal study. She was walking yesterday and developed left arm pain radiating to her chest and jaw associated with dyspnea but no nausea and vomiting. This resolved with rest, but then recurred when walking around her house. She therefore presented to [MASKED]. There she had troponin T tested twice within two hours, both negative, and an unconcerning EKG. She was tachycardic to the 120s that improved after getting her home atenolol, which she had not taken due to running out of the pills. At [MASKED] she got 81 mg aspirin, 100 mg atenolol, nitro and amlodipine. A CXR showed no acute abnormality. [MASKED] cardiology was consulted in [MASKED] and recommended transfer to [MASKED] for diagnostic catheterization. In the ED, initial vital signs were: 98.0 61 130/85 18 96% RA - Labs were notable for: CBC WNL, coags WNL, trop < 0.01 x 1, U/A with small leuk esterase and few bacteria but nitrite negative - Imaging: EKG with sinus rhythm and no ischemic changes - The patient was given: nothing - Consults: [MASKED] cardiology who recommended admission to [MASKED] service Vitals prior to transfer were: 98 64 123/70 18 98% RA Upon arrival to the floor, she is chest pain free and endorses the above story. She states that she has medication reactions with colonoscopy sedating meds, and would like this passed on in case she undergoes catheterization. Denies dysuria. Past Medical History: - Anxiety - Depression - Hyperlipidemia - ADHD - allergic rhinitis - obesity - hypertension - left patellofemoral syndrome - colon adenoma - iron deficienty anemia - GERD - osteoporosis - primary hyperparathyroidism - s/p cholecystectomy - appendiceal polyp - hiatal hernia - s/p ovarian cystectomy Social History: [MASKED] Family History: - father with HTN, HLD, MI in [MASKED] requiring CABG - mother with MY in [MASKED] - brother with MI at age [MASKED], died of complications prior to heart transplant [MASKED] years later Physical Exam: ON ADMISSION: VITALS: 98 165/89 68 16 99% RA GENERAL: NAD HEENT - MM somewhat dry, anicteric sclera, oropharynx clear NECK: Supple, no LAD, JVP flat CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: A&Ox3, no motor deficit ON DISCHARGE: VITALS: 98.2 100s-130s/50s-70s [MASKED] 95-98% RA GENERAL: NAD HEENT - MM somewhat dry, anicteric sclera, oropharynx clear NECK: Supple, no LAD, JVP flat CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops. PULMONARY: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, no organomegaly. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. R radial access site c/d/I without hematoma or bruising SKIN: Without rash. NEUROLOGIC: A&Ox3, no motor deficit Pertinent Results: ON ADMISSION: [MASKED] 08:00PM BLOOD WBC-6.1 RBC-3.89* Hgb-12.2 Hct-36.4 MCV-94 MCH-31.4 MCHC-33.5 RDW-13.8 RDWSD-46.7* Plt [MASKED] [MASKED] 08:00PM BLOOD Neuts-46.0 [MASKED] Monos-9.8 Eos-5.7 Baso-1.0 Im [MASKED] AbsNeut-2.82 AbsLymp-2.28 AbsMono-0.60 AbsEos-0.35 AbsBaso-0.06 [MASKED] 08:00PM BLOOD [MASKED] PTT-32.5 [MASKED] [MASKED] 08:00PM BLOOD Glucose-99 UreaN-6 Creat-1.0 Na-140 K-4.1 Cl-105 HCO3-28 AnGap-11 [MASKED] 08:00PM BLOOD cTropnT-<0.01 [MASKED] 06:30AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9 ON DISCHARGE: [MASKED] 06:00AM BLOOD WBC-7.3 RBC-3.65* Hgb-11.0* Hct-34.9 MCV-96 MCH-30.1 MCHC-31.5* RDW-20.3* RDWSD-70.3* Plt [MASKED] [MASKED] 06:00AM BLOOD Glucose-80 UreaN-16 Creat-0.9 Na-141 K-3.7 Cl-109* HCO3-23 AnGap-13 [MASKED] 06:00AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.9 OTHER STUDIES: [MASKED] ECG: Baseline artifact. Sinus rhythm. Early R wave progression. No previous tracing available for comparison. Brief Hospital Course: [MASKED] yoF with h/o hypertension, hyperlipidemia, and significant family history of CAD with approximately one year history of intermittent chest pain who initially presented to [MASKED] with left arm pain radiating to her chest and jaw as well as dyspnea. EKG showed no ischemic changes and troponins were negative x2. She was transferred to [MASKED] for cardiac catheterization for unstable angina. Cardiac catheterization was via right radial access, and showed moderate 3 vessel disease. Findings appeared underwhelming given classic ACS symptoms. Patient was medically managed with ASA 81, metoprolol, and atorvastatin. Her home amlodipine and atenolol were discontinued. Her blood pressure remained under good control. She was chest pain free during her admission. CHRONIC ISSUES: # Normocytic anemia: Hgb 11 (from 12.2), unclear baseline. Denies melena, BRBPR or lightheadedness/dizziness. Continued on home ferrous sulfate # Anxiety: Continued home clonazepam # Depression: Continued home amitriptyline # Asymptomatic pyuria: No antibiotics. TRANSITIONAL ISSUES: - New medications: ASA 81 qd, atorvastatin 80 qd, metoprolol succinate 50 qd - Discontinued medications: Amlodipine, atenolol - Please continue to monitor blood pressure. [MASKED] consider restarting amlodipine or adding an ace inhibitor if she is persistently hypertensive - Code status: Full - [MASKED] (sister) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 100 mg PO DAILY 2. Amlodipine 7.5 mg PO DAILY 3. Amitriptyline 100 mg PO QHS 4. ClonazePAM 0.5 mg PO QAM 5. ClonazePAM 1 mg PO QHS 6. Vitamin D 3000 UNIT PO DAILY 7. Ferrous Sulfate 325 mg PO BID Discharge Medications: 1. Amitriptyline 100 mg PO QHS 2. Vitamin D 3000 UNIT PO DAILY 3. Ferrous Sulfate 325 mg PO BID 4. ClonazePAM 0.5 mg PO QAM 5. ClonazePAM 1 mg PO QHS 6. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 2 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 8. Atorvastatin 80 mg PO QPM RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Unstable angina SECONDARY: Mild-moderate coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at [MASKED]. You were admitted because you were experiencing chest pain. You underwent cardiac catheterization, which showed mild-moderate coronary artery disease not requiring intervention. You were started on new medications to better manage your coronary artery disease and prevent future heart attacks. Please see your medication list for changes to your regimen. Please see below for your scheduled or pending appointments with your PCP and cardiology. We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "D509", "F419", "N390", "F329", "E669" ]
[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "D509: Iron deficiency anemia, unspecified", "F419: Anxiety disorder, unspecified", "N390: Urinary tract infection, site not specified", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "Z6838: Body mass index [BMI] 38.0-38.9, adult" ]
10,076,506
20,946,164
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: codeine Attending: ___. Chief Complaint: CC: fever; malaise REASON FOR MICU: respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ female with no significant PMH presenting as a transfer from ___ in the setting of acute respiratory failure. Patient had plans to travel to ___ in the next month or so and was administered oral typhoid vaccine last week. She received 4 doses, last dose administered on ___. She presented to her PCP ___ ___ with c/o of one day of fevers as high as ___ with associated body aches, joint pain of her ankles/knees/wrists/and elbows, and fatigue without neck stiffness, abdominal pain, headache, or rash. She had no respiratory symptoms at that time. Arthralgias/myalgias had started 2 days prior. There was no history of known tick bite and had very little outdoor activity. Vitals at ___'s office were notable for T103, HR137s with BP128/62 99%RA. U/A was noted to be negative. Physical exam showed nontoxic appearance with supple neck, no respiratory distress, no pericardial rub, no rash, but with somewhat stiff gait. There were no inflammatory changes on her wrists, elbows, hands, knees, or ankles but with some pain with ROM in those areas. CBC showed: 13.94 (88.9%)/13.6/40/287. CXR was within normal limits. Her PCP prescribed doxycycline (100mg BID X 14 days), prednisone (60mg X 4 days, 40 pills X next 4 days, 20mg X last 4 days), acetaminophen-codeine tabs. Per family, she had never taken doxycycline due to concern for interaction with typhoid vaccine brought up by her local pharmacist. Labs were also sent for anaplasia antibodies neg, malaria/babesia neg, ___ screen (positive 1:160), CPK ___ ___ to ___ CK594), ESR50, CRP117, RF negative, Lyme disease Ab negat , and urine HCG negative. At 0330 the morning of presentation to ___ ED, patient was having dizziness with associated whole body myalgias as well as fever to ___. This prompted her to come to ___ ED. Vitals were notable for tachycardia and labs were notable only for elevated CK. Patient was admitted to ED observation unit and patient was administered IVF. On the morning of ___ at 0730, patient c/o of pleuritic chest pain and abdominal pain. She was found to have T102.9 with HR 150s. Exam was reportedly notable for lack of meningeal signs. Family notes that splotchy red rash on patient's lower back, feet, knees, and hands had appeared the evening prior and progressed to white splotches that morning. Labs were notable for rising lactate from 2 to 3.3. 1 set of troponins negative. CXR and u/a were reportedly negative. She was started on vanc/cefipeme. ID was consulted and doxycycline and clindamycin were added for coverage of tick-borne illnesses and ?toxic shock syndrome (though patient had not had c/o of sore throat and had not been wearing a tampon). She was sent for CT torso during which her blood pressures dropped to ___ and patient became hypoxic to 85% with HR140s. She was intubated. Imaging was notable for b/l infiltrates on CT chest (in the setting of administration of 6L IVF) with no evidence of PE. Pressures improved to 130s/80s with IVF with no pressor requirement. Labs from ___ were notable for: ___ chem10: ___ CBC17.7/11.4/34.5/254 ___: 12.5/___/35.___/291) Lactic acid 3.3 --> 1.4 LFTs wnl On arrival to the MICU, patient was intubated and sedated, unable to follow commands. Bronchoscopy with petechial hemorrhage along airways and thin clear secretions throughout but no purulence or evidence of DAH. Alveolar lavage was cloudy pale without blood. Little evidence of active infection. Review of systems: (+) Per HPI Unable to obtain Past Medical History: Received Hep A/B vaccines 1 month ago History of varciella Anxiety Lumbar Strain Overweight Hx ovarian cysts, managed conservatively Social History: ___ Family History: No hx of immune deficiency other than nephew with ulcerative colitis Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T98.3 HR120s BP122/65 RR19 100% Vent settings: CMV 40%FIO2 PEEP10 TV370 RR18 GENERAL: Intubated, sedated HEENT: Sclera anicteric, dry MM, ETT in place NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, mechanical breath sounds CV: tachycardic, no m/r/g 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; no rash noted Pertinent Results: ADMISSION LABS ___ 05:47PM BLOOD WBC-17.2* RBC-3.92 Hgb-11.6 Hct-36.4 MCV-93 MCH-29.6 MCHC-31.9* RDW-13.1 RDWSD-44.8 Plt ___ ___ 05:47PM BLOOD Neuts-82.6* Lymphs-12.3* Monos-3.0* Eos-1.5 Baso-0.1 Im ___ AbsNeut-14.19* AbsLymp-2.12 AbsMono-0.52 AbsEos-0.26 AbsBaso-0.02 ___ 05:47PM BLOOD ___ PTT-25.5 ___ ___ 05:47PM BLOOD Glucose-101* UreaN-8 Creat-0.7 Na-140 K-3.9 Cl-111* HCO3-22 AnGap-11 ___ 05:47PM BLOOD ALT-18 AST-19 CK(CPK)-85 AlkPhos-48 TotBili-0.2 ___ 05:47PM BLOOD Calcium-7.5* Phos-3.5 Mg-1.6 ___ 05:47PM BLOOD HIV Ab-Negative ___ 05:31PM BLOOD Type-ART pO2-168* pCO2-38 pH-7.36 calTCO2-22 Base XS--3 Intubat-INTUBATED ___ 05:31PM BLOOD Lactate-1.1 ___ 05:47PM URINE Color-Straw Appear-Hazy Sp ___ ___ 05:47PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 05:47PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE Epi-0 ___ 06:00PM OTHER BODY FLUID Polys-26* Lymphs-2* Monos-0 Macro-19* Other-53* ___ 06:00PM OTHER BODY FLUID Polys-56* ___ Monos-1* Macro-14* Other-29* MICROBIOLOGY ___ URINE CX PENDING ___ BAL PENDING ___ RESPIRATORY VIRAL SCREEN PERTINENT IMAGING ___ CXR 1. Tip of the ET tube situated 5.7 cm above the carina. Care should be taken not to withdraw it further. Tip of the enteric tube is below the diaphragm but not included in the field-of-view. 2. Focal right basilar opacity concerning for pneumonia. 3. Small left pleural effusion and adjacent atelectasis. 4. Heterogeneous opacity overlying the right upper lobe peripherally is likely due to external equipment. Removal of all overlying hardware, if possible, is recommended for the next evaluation Brief Hospital Course: This is a ___ female with no significant PMH presenting as a transfer from ___ in the setting of acute respiratory failure and history of acute myalgias, arthralgias, and rash shortly after completing course of oral typhoid vaccine. # Systemic inflammatory syndrome: Initially with high fever, myalgias and subsequent tachycardia and hypotension requiring fluid resuscitation. Highest concern for vaccine related reaction. It is unclear, but highly unlikely that the patient actually contracted typhoid infection from vaccine. Infectious etiologies possible, though tick-borne illness, systemic bacteremia, endocarditis, and pulmonary bacterial and viral process were either definitively ruled out or seem less likely. Several microbiologic studies pending at time of discharge. ID was consulted while inpatient, they helped guide infectious work-up. Autoimmune etiologies very unlikely, but a broad serologic work-up was sent upon initial arrival to ___. Plan for hospitalist service and infectious disease to follow-up on pending microbiologic and autoimmune serologies and contact patient with results. All symptoms had completely resolved at time of discharge, and patient had been stable for more than 48 hours. Will continue empiric levaquin for seven days and doxycycline for up to 14 days, or at least until repeat tick borne serologies are negative (will be contacted about this by ID). Recommend outpatient ID follow-up and consideration of rheumatology consultation. Of note, CT scan at OSH showed bilateral pulmonary nodules without clear explanation. TTE without evidence of endocarditis, arguing against these nodules being septic emboli. CT scan ought to be repeated in three months or sooner as indicated by symptoms. # Diarrhea: Noted on day of discharge. These were not consistent with c. diff infection, and patient was educated that this was likely secondary to antibiotics. # Respiratory failure: Hypoxemic respiratory failure at ___ ___ leading to intubation. Unclear etiology, differential included ARDS from typhoid vaccine systemic reaction versus volume overload from fluid resuscitation (LVEF 59% on TTE). Patient extubated upon arrival to ___. Was fluid overloaded somewhat, received 1x dose of furosemide with improvement in leg swelling. # H/O Anxiety: Managed with Ativan prn TRANSITIONAL ISSUES: ==================== - levaquin 750 mg daily until ___ - doxycycline 100 mg BID until ___, pending results of tick-borne illness serologies (will be contacted by ID, per ID consultation service) - repeat CT scan of chest to trend pulmonary nodules in follow-up, no later than three months from discharge - low dose lorazepam prescribed on discharge prn to help with anxiety surrounding this critical illness - Outpatient ID follow-up and possible rheumatology consultation at the discretion of the PCP ___ on ___: The Preadmission Medication list is accurate and complete. 1. Cyclobenzaprine 10 mg PO TID:PRN pain 2. ___ (21) (norethindrone ac-eth estradiol) 1.5-30 mg-mcg oral DAILY 3. Selenium Sulfide 2.5 mL TP ONCE MR1 Discharge Medications: 1. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 2. LORazepam 0.5 mg PO Q8H:PRN anxiety RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 3. ___ (21) (norethindrone ac-eth estradiol) 1.5-30 mg-mcg oral DAILY 4. Selenium Sulfide 2.5 mL TP ONCE MR1 5. Cyclobenzaprine 10 mg PO TID:PRN pain pending follow-up with PCP, no refills given while inpatient 6. Levofloxacin 750 mg PO Q24H Duration: 3 Doses RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: systemic inflammatory response acute hypoxemic respiratory failure possible anaphylactic reaction fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ has been a pleasure participating in your care at ___. You came in with a breathing tube after developing respiratory distress at an outside hospital. Fortunately, we were able to remove the breathing tube and you have done quite well since. We are not entirely sure what caused your fever, high heart rate, and low blood pressure. We are suspicious that this may have been a very atypical reaction to the typhoid vaccine you were taking, but there are many tests still pending from an infectious and autoimmune standpoint. We are very glad that you are doing better. Please follow-up with your PCP as scheduled. You will take levofloxacin and doxycycline for now. The total course for levofloxacin will be from ___ through ___ (last day ___, and you will continue doxycycline for two weeks (to end ___. The infectious disease doctors here ___ you on their follow-up list, and will call you if the repeat tests for tick borne diseases are negative. If those tests are negative, you can stop the doxycycline. Please limit sun exposure (Wear sunscreen, long sleeves) while on doxycycline. Please feel free to resume light activity such as walking, but limit significant exertion until you see your PCP. If you have significant watery diarrhea, please call your PCP's office to let him know since you have been taking antibiotics. We wish you the best, Your ___ team Followup Instructions: ___
[ "T8059XA", "J9601", "M6282", "K521", "F419", "R509", "R918", "T368X5A", "Y92230", "T50A95A", "Y929" ]
Allergies: codeine Chief Complaint: CC: fever; malaise REASON FOR MICU: respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: This is a [MASKED] female with no significant PMH presenting as a transfer from [MASKED] in the setting of acute respiratory failure. Patient had plans to travel to [MASKED] in the next month or so and was administered oral typhoid vaccine last week. She received 4 doses, last dose administered on [MASKED]. She presented to her PCP [MASKED] [MASKED] with c/o of one day of fevers as high as [MASKED] with associated body aches, joint pain of her ankles/knees/wrists/and elbows, and fatigue without neck stiffness, abdominal pain, headache, or rash. She had no respiratory symptoms at that time. Arthralgias/myalgias had started 2 days prior. There was no history of known tick bite and had very little outdoor activity. Vitals at [MASKED]'s office were notable for T103, HR137s with BP128/62 99%RA. U/A was noted to be negative. Physical exam showed nontoxic appearance with supple neck, no respiratory distress, no pericardial rub, no rash, but with somewhat stiff gait. There were no inflammatory changes on her wrists, elbows, hands, knees, or ankles but with some pain with ROM in those areas. CBC showed: 13.94 (88.9%)/13.6/40/287. CXR was within normal limits. Her PCP prescribed doxycycline (100mg BID X 14 days), prednisone (60mg X 4 days, 40 pills X next 4 days, 20mg X last 4 days), acetaminophen-codeine tabs. Per family, she had never taken doxycycline due to concern for interaction with typhoid vaccine brought up by her local pharmacist. Labs were also sent for anaplasia antibodies neg, malaria/babesia neg, [MASKED] screen (positive 1:160), CPK [MASKED] [MASKED] to [MASKED] CK594), ESR50, CRP117, RF negative, Lyme disease Ab negat , and urine HCG negative. At 0330 the morning of presentation to [MASKED] ED, patient was having dizziness with associated whole body myalgias as well as fever to [MASKED]. This prompted her to come to [MASKED] ED. Vitals were notable for tachycardia and labs were notable only for elevated CK. Patient was admitted to ED observation unit and patient was administered IVF. On the morning of [MASKED] at 0730, patient c/o of pleuritic chest pain and abdominal pain. She was found to have T102.9 with HR 150s. Exam was reportedly notable for lack of meningeal signs. Family notes that splotchy red rash on patient's lower back, feet, knees, and hands had appeared the evening prior and progressed to white splotches that morning. Labs were notable for rising lactate from 2 to 3.3. 1 set of troponins negative. CXR and u/a were reportedly negative. She was started on vanc/cefipeme. ID was consulted and doxycycline and clindamycin were added for coverage of tick-borne illnesses and ?toxic shock syndrome (though patient had not had c/o of sore throat and had not been wearing a tampon). She was sent for CT torso during which her blood pressures dropped to [MASKED] and patient became hypoxic to 85% with HR140s. She was intubated. Imaging was notable for b/l infiltrates on CT chest (in the setting of administration of 6L IVF) with no evidence of PE. Pressures improved to 130s/80s with IVF with no pressor requirement. Labs from [MASKED] were notable for: [MASKED] chem10: [MASKED] CBC17.7/11.4/34.5/254 [MASKED]: 12.5/[MASKED]/35.[MASKED]/291) Lactic acid 3.3 --> 1.4 LFTs wnl On arrival to the MICU, patient was intubated and sedated, unable to follow commands. Bronchoscopy with petechial hemorrhage along airways and thin clear secretions throughout but no purulence or evidence of DAH. Alveolar lavage was cloudy pale without blood. Little evidence of active infection. Review of systems: (+) Per HPI Unable to obtain Past Medical History: Received Hep A/B vaccines 1 month ago History of varciella Anxiety Lumbar Strain Overweight Hx ovarian cysts, managed conservatively Social History: [MASKED] Family History: No hx of immune deficiency other than nephew with ulcerative colitis Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T98.3 HR120s BP122/65 RR19 100% Vent settings: CMV 40%FIO2 PEEP10 TV370 RR18 GENERAL: Intubated, sedated HEENT: Sclera anicteric, dry MM, ETT in place NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, mechanical breath sounds CV: tachycardic, no m/r/g 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; no rash noted Pertinent Results: ADMISSION LABS [MASKED] 05:47PM BLOOD WBC-17.2* RBC-3.92 Hgb-11.6 Hct-36.4 MCV-93 MCH-29.6 MCHC-31.9* RDW-13.1 RDWSD-44.8 Plt [MASKED] [MASKED] 05:47PM BLOOD Neuts-82.6* Lymphs-12.3* Monos-3.0* Eos-1.5 Baso-0.1 Im [MASKED] AbsNeut-14.19* AbsLymp-2.12 AbsMono-0.52 AbsEos-0.26 AbsBaso-0.02 [MASKED] 05:47PM BLOOD [MASKED] PTT-25.5 [MASKED] [MASKED] 05:47PM BLOOD Glucose-101* UreaN-8 Creat-0.7 Na-140 K-3.9 Cl-111* HCO3-22 AnGap-11 [MASKED] 05:47PM BLOOD ALT-18 AST-19 CK(CPK)-85 AlkPhos-48 TotBili-0.2 [MASKED] 05:47PM BLOOD Calcium-7.5* Phos-3.5 Mg-1.6 [MASKED] 05:47PM BLOOD HIV Ab-Negative [MASKED] 05:31PM BLOOD Type-ART pO2-168* pCO2-38 pH-7.36 calTCO2-22 Base XS--3 Intubat-INTUBATED [MASKED] 05:31PM BLOOD Lactate-1.1 [MASKED] 05:47PM URINE Color-Straw Appear-Hazy Sp [MASKED] [MASKED] 05:47PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 05:47PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 06:00PM OTHER BODY FLUID Polys-26* Lymphs-2* Monos-0 Macro-19* Other-53* [MASKED] 06:00PM OTHER BODY FLUID Polys-56* [MASKED] Monos-1* Macro-14* Other-29* MICROBIOLOGY [MASKED] URINE CX PENDING [MASKED] BAL PENDING [MASKED] RESPIRATORY VIRAL SCREEN PERTINENT IMAGING [MASKED] CXR 1. Tip of the ET tube situated 5.7 cm above the carina. Care should be taken not to withdraw it further. Tip of the enteric tube is below the diaphragm but not included in the field-of-view. 2. Focal right basilar opacity concerning for pneumonia. 3. Small left pleural effusion and adjacent atelectasis. 4. Heterogeneous opacity overlying the right upper lobe peripherally is likely due to external equipment. Removal of all overlying hardware, if possible, is recommended for the next evaluation Brief Hospital Course: This is a [MASKED] female with no significant PMH presenting as a transfer from [MASKED] in the setting of acute respiratory failure and history of acute myalgias, arthralgias, and rash shortly after completing course of oral typhoid vaccine. # Systemic inflammatory syndrome: Initially with high fever, myalgias and subsequent tachycardia and hypotension requiring fluid resuscitation. Highest concern for vaccine related reaction. It is unclear, but highly unlikely that the patient actually contracted typhoid infection from vaccine. Infectious etiologies possible, though tick-borne illness, systemic bacteremia, endocarditis, and pulmonary bacterial and viral process were either definitively ruled out or seem less likely. Several microbiologic studies pending at time of discharge. ID was consulted while inpatient, they helped guide infectious work-up. Autoimmune etiologies very unlikely, but a broad serologic work-up was sent upon initial arrival to [MASKED]. Plan for hospitalist service and infectious disease to follow-up on pending microbiologic and autoimmune serologies and contact patient with results. All symptoms had completely resolved at time of discharge, and patient had been stable for more than 48 hours. Will continue empiric levaquin for seven days and doxycycline for up to 14 days, or at least until repeat tick borne serologies are negative (will be contacted about this by ID). Recommend outpatient ID follow-up and consideration of rheumatology consultation. Of note, CT scan at OSH showed bilateral pulmonary nodules without clear explanation. TTE without evidence of endocarditis, arguing against these nodules being septic emboli. CT scan ought to be repeated in three months or sooner as indicated by symptoms. # Diarrhea: Noted on day of discharge. These were not consistent with c. diff infection, and patient was educated that this was likely secondary to antibiotics. # Respiratory failure: Hypoxemic respiratory failure at [MASKED] [MASKED] leading to intubation. Unclear etiology, differential included ARDS from typhoid vaccine systemic reaction versus volume overload from fluid resuscitation (LVEF 59% on TTE). Patient extubated upon arrival to [MASKED]. Was fluid overloaded somewhat, received 1x dose of furosemide with improvement in leg swelling. # H/O Anxiety: Managed with Ativan prn TRANSITIONAL ISSUES: ==================== - levaquin 750 mg daily until [MASKED] - doxycycline 100 mg BID until [MASKED], pending results of tick-borne illness serologies (will be contacted by ID, per ID consultation service) - repeat CT scan of chest to trend pulmonary nodules in follow-up, no later than three months from discharge - low dose lorazepam prescribed on discharge prn to help with anxiety surrounding this critical illness - Outpatient ID follow-up and possible rheumatology consultation at the discretion of the PCP [MASKED] on [MASKED]: The Preadmission Medication list is accurate and complete. 1. Cyclobenzaprine 10 mg PO TID:PRN pain 2. [MASKED] (21) (norethindrone ac-eth estradiol) 1.5-30 mg-mcg oral DAILY 3. Selenium Sulfide 2.5 mL TP ONCE MR1 Discharge Medications: 1. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 2. LORazepam 0.5 mg PO Q8H:PRN anxiety RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 3. [MASKED] (21) (norethindrone ac-eth estradiol) 1.5-30 mg-mcg oral DAILY 4. Selenium Sulfide 2.5 mL TP ONCE MR1 5. Cyclobenzaprine 10 mg PO TID:PRN pain pending follow-up with PCP, no refills given while inpatient 6. Levofloxacin 750 mg PO Q24H Duration: 3 Doses RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: systemic inflammatory response acute hypoxemic respiratory failure possible anaphylactic reaction fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], [MASKED] has been a pleasure participating in your care at [MASKED]. You came in with a breathing tube after developing respiratory distress at an outside hospital. Fortunately, we were able to remove the breathing tube and you have done quite well since. We are not entirely sure what caused your fever, high heart rate, and low blood pressure. We are suspicious that this may have been a very atypical reaction to the typhoid vaccine you were taking, but there are many tests still pending from an infectious and autoimmune standpoint. We are very glad that you are doing better. Please follow-up with your PCP as scheduled. You will take levofloxacin and doxycycline for now. The total course for levofloxacin will be from [MASKED] through [MASKED] (last day [MASKED], and you will continue doxycycline for two weeks (to end [MASKED]. The infectious disease doctors here [MASKED] you on their follow-up list, and will call you if the repeat tests for tick borne diseases are negative. If those tests are negative, you can stop the doxycycline. Please limit sun exposure (Wear sunscreen, long sleeves) while on doxycycline. Please feel free to resume light activity such as walking, but limit significant exertion until you see your PCP. If you have significant watery diarrhea, please call your PCP's office to let him know since you have been taking antibiotics. We wish you the best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "J9601", "F419", "Y92230", "Y929" ]
[ "T8059XA: Anaphylactic reaction due to other serum, initial encounter", "J9601: Acute respiratory failure with hypoxia", "M6282: Rhabdomyolysis", "K521: Toxic gastroenteritis and colitis", "F419: Anxiety disorder, unspecified", "R509: Fever, unspecified", "R918: Other nonspecific abnormal finding of lung field", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "T50A95A: Adverse effect of other bacterial vaccines, initial encounter", "Y929: Unspecified place or not applicable" ]
10,076,617
20,459,993
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin / dapsone Attending: ___. Chief Complaint: Right ___ toe pain Major Surgical or Invasive Procedure: I&D of R ___ toe abscess (___) History of Present Illness: CC: Right ___ ___ Swelling HISTORY OF PRESENT ILLNESS: Mrs ___ is ___ year old woman with a history of IDDM2, pHTN, Sweet syndrome and inflammatory arthritis on prednisone, pHTN admitted with right ___ toe SSTI. Patient reports being in her USOH until approximately 2 weeks ago when she developed a corn on her right ___ toe. This developed into a blister and then became increasingly swollen and painful. Denies any antecedent trauma. She endorsed continued irritation with shoes, requiring padding, and had to rely more on her walker. The pain and swelling have increasingly affected her walking, and she presented to the hospital today at the prompting of her friend. She also has pain to a lesser extent in the left forefoot, although to much less extent than her right. She does not have any systemic symptoms, deniy f/c/n/c. Not lightheaded or dizzy, with normal cardiopulmonary function. She continues to eat well and have normal bowel/urinary function. Patient originally was seen in ___ where she received 1 dose of CTX and subsequently transferred to ___. In the emergency department, she was seen by podiatry who performed a bedside I&D, unroofing a purulent fluid collection was drained. The underlying area probed deeply to bone. Patient was started on antibiotics and a wound culture sent from the aspirate. To note, patient was recently hospitalized with UTI, worsening Sweet syndrome, and inflammatory arthritis 1 month ago. Since discharge, her prednisone was decreased to 15mg and she is close to transitioning to methotrexate. ROS: Positive per above, otherwise comprehensive ROS negative. Past Medical History: - IDDM2 - CKD, stage III - HTN - HLD - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on CPAP (setting unknown) - Sweet's syndrome (dx in 1990s, previously on dapsone, now colchicine/prednisone) - Likely serongative inflammatory arthritis - COPD, PRN supplemental O2 with ambulation (2L NC) - Pulmonary HTN Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION: ========== VS: 98.1 144/83 65 18 98/RA GEN: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: MMM, grossly nl OP CV: RRR nl S1/S2 no g/r/m RESP: CTAB no w/r/r EWOB SIFS GI: soft, NT/ND NABS no r/g/rigidity. GU: No IUC, no suprapubic tenderness/fullness EXT: WWP, no trace ___ edema MSK: MSK: MCP of b/l hands enlarged R>L, DIP/PIP also slightly swollen, thought without erythema, warmth, or tenderness. R ___ toe swollen, erythematous, TTP (recently I&D this AM). No discharge or exudate. Left foot bandage DSD CDI. TTP along ball of foot, but banadage not removed per pt. Capillary fill time ___. SKIN: several nodules, scattered mostly on b/l arms ~1cm slightly erythematous, slighty tender (chronic x weeks per pt) NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs. Strenght ___ in b/l ___ major felxors and extensors, sensation in b/l ___ grossly preserved to fine touch PSYCH: pleasant, appropriate affect DISCHARGE: ========== GENERAL: NAD, sitting comfortably in bed EYES: PERRL, anicteric sclerae ENT: OP clear CV: RRR, nl S1, S2, II/VI SEM, no JVD RESP: CTAB, no crackles, wheezes, or rhonchi GI: obese, + BS, soft, NT, ND, no rebound/guarding, no HSM MSK: mild synovitis of the MCPs and wrists b/l, R>L with soft tissue fullness of the hands b/l; no e/o synovitis or effusions of the knees b/l; lower ext warm without edema NEURO: AOx3, CN II-XII intact, ___ strength in all extremities, sensation grossly intact throughout, gait testing deferred PSYCH: pleasant but anxious SKIN: R ___ pulses palpable; ulcer on lateral R ___ toe s/p I&D without residual purulence/erythema/TTP; superficial blisters on plantar surface LLE w/o erythema or TTP; violacious papule on periungual surface of L index finger with new, painful papules on multiple fingertips and the R olecranon process Pertinent Results: ADMISSION: =========== ___ 07:53PM BLOOD WBC-7.8 RBC-3.85* Hgb-10.8* Hct-34.6 MCV-90 MCH-28.1 MCHC-31.2* RDW-15.9* RDWSD-51.9* Plt ___ ___ 07:53PM BLOOD Plt ___ ___ 06:50AM BLOOD ___ 07:53PM BLOOD Glucose-181* UreaN-17 Creat-1.0 Na-142 K-4.1 Cl-106 HCO3-26 AnGap-10 ___ 07:42AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8 ___ 08:03AM BLOOD %HbA1c-10.6* eAG-258* ___ 07:53PM BLOOD CRP-4.6 ___ 07:53PM BLOOD Lactate-0.7 DISCHARGE: ========== ___ 07:00AM BLOOD WBC-7.9 RBC-3.78* Hgb-10.7* Hct-34.2 MCV-91 MCH-28.3 MCHC-31.3* RDW-15.8* RDWSD-52.2* Plt ___ ___ 07:00AM BLOOD Glucose-131* UreaN-16 Creat-1.0 Na-146 K-3.8 Cl-106 HCO3-29 AnGap-11 ___ 06:57AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 CRP 38.9 (from 4.6) Prior: ------ INR ___ Fibrinogen 310 A1c 10.6% UA: neg bld, neg nit, lg ___, tr prot, 1000 gluc, 122 WBCs, few bact BCX (___): pending x 2 R ___ toe swab (___): 2+ PMNs, no organisms; sparse growth Grp B strep and rare growth of CoNS; mixed flora UCx (___): >100K yeast IMAGING: ======== US L hand (___): No wrist or MCP joint effusion is identified. Trace tenosynovitis of flexor tendons are noted. No focal fluid collection is identified. No significant synovitis is demonstrated in the wrist or MCP joints. US R hand (___): No joint effusion is identified. Soft tissues surrounding the extensor tendons and small finger MCP and PIP joints are suggestive of tenosynovitis/synovitis. MRI R foot w/w/o cont (___): 1. No MRI signs for acute osteomyelitis or soft tissue abscess. There is dorsal forefoot and fifth toe soft tissue swelling. 2. Degenerative changes of PIP joints of the second through fifth toes. ABIs b/l (___): No evidence of arterial insufficiency to the lower extremities bilaterally. R foot plain films (___): 1. No definite destructive lesion. If there is continued clinical concern, MRI would be more sensitive for the detection of osteomyelitis. 2. Swelling of the right fifth digit without evidence of acute bony abnormality. 3. Degenerative changes as described above. Brief Hospital Course: ___ with hx Sweet's syndrome (on prednisone/colchicine), seronegative inflammatory arthritis, IDDM, CKD stage III, HTN, HLD, OSA, pHTN/COPD (intermittent 2L NC) presenting with R ___ toe abscess s/p I&D and likely flare of Sweet's syndrome and inflammatory arthritis. # R ___ toe abscess/cellulitis: Patient p/w R ___ toe abscess with cellulitis, s/p I&D in ED by podiatry, with culture growing Grp B strep, rare CoNS, and mixed flora. Per podiatry, ulcer probed to bone, but plain films without e/o osteomyelitis, CRP initially nl (subsequently rose, attributed to arthritis as below), and MRI foot without radiographic evidence of osteomyelitis. ABIs nl. She was treated with Unasyn initially with significant improvement in her R ___ toe pain and erythema. She was transitioned to Augmentin to complete a 10d course through ___ (was not covered for MRSA given improvement on Unasyn). Wound was treated with betadine dressings daily and a surgical boot for ambulation. She will f/u with outpatient podiatry. # Sweet's Syndrome: Diagnosed in ___, previously followed at ___ and maintained on dapsone (d/c'd for hemolytic anemia). Recently admitted ___ with Sweet's flare, started on cyclosporine (which was d/c'd for insurance reasons), and discharged on increased prednisone dose with plan for taper. Recently tapered from pred 20mg -> 15mg per outpatient dermatologist, Dr. ___, with plan for MTX initiation in near future in conjunction with rheumatology; continues on colchicine. Presents this admission with a flare of her Sweet's, with new lesions on her fingertips and R olecranon. Dermatology was consulted and injected a L index periungual lesion. Prednisone was increased by rheum for her inflammatory arthritis as below, which should also treat Sweet's, and betamethasone ointment to the hands was initiated, with plan for a 2 week course (through ___. She was discharged on prednisone 20mg PO daily and topical steroids with plan for dermatology f/u with Dr. ___ ___ consideration of MTX initiation (appointment requested, pending at discharge). # Likely seronegative inflammatory arthritis: Worked up last admission and seen by rheumatology as outpatient; thought to have seronegative inflammatory arthritis. Per dermatology last admission, arthritis not thought to be attributable to Sweet's, although interestingly flares of the two seem to co-occur. Complained of worsening joint pain ___ with rising CRP, for which rheumatology was consulted. U/S performed at rheum's requests showed evidence of synovitis/tenosynovitis of the R MCP/PIP joints without effusions. Rheum recommended increasing prednisone to 30mg x 3d followed by taper to 20mg daily and outpatient f/u for consideration of DMARD. She will take prednisone 20mg PO daily, with plan for outpatient f/u with Dr. ___ on ___ for consideration of MTX. Pain was improving at discharge. # IDDM2: Hyperglycemic in setting of prednisone for Sweet's. Initiated on NPH qAM last admission ___. A1c 10.6%. Continued home NPH 28u qAM with addition of ISS. # Diarrhea: Likely attributable to antibx. C.diff was negative. # L plantar foot blister: Blister on plantar L foot evaluated by podiatry in ED, s/p I&D without signs of infection. Treated with betadine dressings and surgical boot. She will f/u with outpatient podiatry on ___. # Thrombocytopenia: Plt 138 on ___. Was noted to be thrombocytopenic during recent hospitalization in ___. No e/o bleeding or DIC. Stable at 147 on discharge. # CKD stage III: B/l appears to be 1.0-1.2. F/u with Dr. ___ on ___. # OSA # pHTN: Patient one home O2 (2L) intermittently with exertion. Previously on CPAP at home but has not been using; declined while inpatient. # HLD: Continued home aspirin, statin # Depression: Continued home sertraline # Overactive bladder: Home Vesicare NF, will substituted tolterodine while inpatient. ** TRANSITIONAL ** [ ] prednisone 20mg daily through rheumatology f/u [ ] f/u with rheumatology and dermatology consideration of methotrextate initiation [ ] adjust insulin for improved glycemic control Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Colchicine 0.6 mg PO BID 3. Vesicare (solifenacin) 5 mg oral DAILY 4. Acetaminophen 650 mg PO Q6H 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. PredniSONE 15 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. NPH 28 Units Breakfast 10. triamcinolone acetonide 0.5 % topical daily 11. calcium carbonate-vitamin D3 500 mg calcium- 400 unit/5 mL oral daily Discharge Medications: 1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth every twelve (12) hours Disp #*10 Tablet Refills:*0 2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID RX *betamethasone dipropionate 0.05 % Apply a small amount to affected areas twice a day Refills:*0 3. PredniSONE 20 mg PO DAILY RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*5 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. calcium carbonate-vitamin D3 500 mg calcium- 400 unit/5 mL oral daily 8. Colchicine 0.6 mg PO BID 9. NPH 28 Units Breakfast 10. Multivitamins 1 TAB PO DAILY 11. Sertraline 100 mg PO DAILY 12. triamcinolone acetonide 0.5 % topical daily vaginal application 13. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right ___ toe abscess/cellulitis Sweet's syndrome Seronegative inflammatory arthritis 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 Ms. ___, You were admitted to the hospital with an abscess on your right ___ toe. The abscess was drained by the podiatry team and you were treated with antibiotics. An MRI of your foot showed no evidence of bone infection. You are being discharged on an antibiotic called Augmentin, which you should continue through ___ (10 days total). While here, you were noted to have a flare of your Sweet's syndrome and your arthritis. You were seen by the dermatology and rheumatology teams, and your prednisone dose was increased. Please continue prednisone 20mg PO daily until you see your rheumatology team on ___. Please take your medications as prescribed and follow-up with your outpatient doctors as below. With best wishes, ___ Medicine Followup Instructions: ___
[ "L03031", "L02611", "B951", "L982", "D696", "I129", "E1122", "N183", "G4733", "Z9981", "I2720", "E785", "F329", "N3281", "Z87891", "Z8542", "E669", "Z6836", "S90822A", "M06042", "M06041", "R197", "Z794" ]
Allergies: Clindamycin / dapsone Chief Complaint: Right [MASKED] toe pain Major Surgical or Invasive Procedure: I&D of R [MASKED] toe abscess ([MASKED]) History of Present Illness: CC: Right [MASKED] [MASKED] Swelling HISTORY OF PRESENT ILLNESS: Mrs [MASKED] is [MASKED] year old woman with a history of IDDM2, pHTN, Sweet syndrome and inflammatory arthritis on prednisone, pHTN admitted with right [MASKED] toe SSTI. Patient reports being in her USOH until approximately 2 weeks ago when she developed a corn on her right [MASKED] toe. This developed into a blister and then became increasingly swollen and painful. Denies any antecedent trauma. She endorsed continued irritation with shoes, requiring padding, and had to rely more on her walker. The pain and swelling have increasingly affected her walking, and she presented to the hospital today at the prompting of her friend. She also has pain to a lesser extent in the left forefoot, although to much less extent than her right. She does not have any systemic symptoms, deniy f/c/n/c. Not lightheaded or dizzy, with normal cardiopulmonary function. She continues to eat well and have normal bowel/urinary function. Patient originally was seen in [MASKED] where she received 1 dose of CTX and subsequently transferred to [MASKED]. In the emergency department, she was seen by podiatry who performed a bedside I&D, unroofing a purulent fluid collection was drained. The underlying area probed deeply to bone. Patient was started on antibiotics and a wound culture sent from the aspirate. To note, patient was recently hospitalized with UTI, worsening Sweet syndrome, and inflammatory arthritis 1 month ago. Since discharge, her prednisone was decreased to 15mg and she is close to transitioning to methotrexate. ROS: Positive per above, otherwise comprehensive ROS negative. Past Medical History: - IDDM2 - CKD, stage III - HTN - HLD - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN [MASKED]: no e/o recurrence - OSA on CPAP (setting unknown) - Sweet's syndrome (dx in 1990s, previously on dapsone, now colchicine/prednisone) - Likely serongative inflammatory arthritis - COPD, PRN supplemental O2 with ambulation (2L NC) - Pulmonary HTN Social History: [MASKED] Family History: Father - deceased of MI in his [MASKED] Mother - emphysema, deceased in her [MASKED] No children Physical Exam: ADMISSION: ========== VS: 98.1 144/83 65 18 98/RA GEN: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: MMM, grossly nl OP CV: RRR nl S1/S2 no g/r/m RESP: CTAB no w/r/r EWOB SIFS GI: soft, NT/ND NABS no r/g/rigidity. GU: No IUC, no suprapubic tenderness/fullness EXT: WWP, no trace [MASKED] edema MSK: MSK: MCP of b/l hands enlarged R>L, DIP/PIP also slightly swollen, thought without erythema, warmth, or tenderness. R [MASKED] toe swollen, erythematous, TTP (recently I&D this AM). No discharge or exudate. Left foot bandage DSD CDI. TTP along ball of foot, but banadage not removed per pt. Capillary fill time [MASKED]. SKIN: several nodules, scattered mostly on b/l arms ~1cm slightly erythematous, slighty tender (chronic x weeks per pt) NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs. Strenght [MASKED] in b/l [MASKED] major felxors and extensors, sensation in b/l [MASKED] grossly preserved to fine touch PSYCH: pleasant, appropriate affect DISCHARGE: ========== GENERAL: NAD, sitting comfortably in bed EYES: PERRL, anicteric sclerae ENT: OP clear CV: RRR, nl S1, S2, II/VI SEM, no JVD RESP: CTAB, no crackles, wheezes, or rhonchi GI: obese, + BS, soft, NT, ND, no rebound/guarding, no HSM MSK: mild synovitis of the MCPs and wrists b/l, R>L with soft tissue fullness of the hands b/l; no e/o synovitis or effusions of the knees b/l; lower ext warm without edema NEURO: AOx3, CN II-XII intact, [MASKED] strength in all extremities, sensation grossly intact throughout, gait testing deferred PSYCH: pleasant but anxious SKIN: R [MASKED] pulses palpable; ulcer on lateral R [MASKED] toe s/p I&D without residual purulence/erythema/TTP; superficial blisters on plantar surface LLE w/o erythema or TTP; violacious papule on periungual surface of L index finger with new, painful papules on multiple fingertips and the R olecranon process Pertinent Results: ADMISSION: =========== [MASKED] 07:53PM BLOOD WBC-7.8 RBC-3.85* Hgb-10.8* Hct-34.6 MCV-90 MCH-28.1 MCHC-31.2* RDW-15.9* RDWSD-51.9* Plt [MASKED] [MASKED] 07:53PM BLOOD Plt [MASKED] [MASKED] 06:50AM BLOOD [MASKED] 07:53PM BLOOD Glucose-181* UreaN-17 Creat-1.0 Na-142 K-4.1 Cl-106 HCO3-26 AnGap-10 [MASKED] 07:42AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8 [MASKED] 08:03AM BLOOD %HbA1c-10.6* eAG-258* [MASKED] 07:53PM BLOOD CRP-4.6 [MASKED] 07:53PM BLOOD Lactate-0.7 DISCHARGE: ========== [MASKED] 07:00AM BLOOD WBC-7.9 RBC-3.78* Hgb-10.7* Hct-34.2 MCV-91 MCH-28.3 MCHC-31.3* RDW-15.8* RDWSD-52.2* Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-131* UreaN-16 Creat-1.0 Na-146 K-3.8 Cl-106 HCO3-29 AnGap-11 [MASKED] 06:57AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 CRP 38.9 (from 4.6) Prior: ------ INR [MASKED] Fibrinogen 310 A1c 10.6% UA: neg bld, neg nit, lg [MASKED], tr prot, 1000 gluc, 122 WBCs, few bact BCX ([MASKED]): pending x 2 R [MASKED] toe swab ([MASKED]): 2+ PMNs, no organisms; sparse growth Grp B strep and rare growth of CoNS; mixed flora UCx ([MASKED]): >100K yeast IMAGING: ======== US L hand ([MASKED]): No wrist or MCP joint effusion is identified. Trace tenosynovitis of flexor tendons are noted. No focal fluid collection is identified. No significant synovitis is demonstrated in the wrist or MCP joints. US R hand ([MASKED]): No joint effusion is identified. Soft tissues surrounding the extensor tendons and small finger MCP and PIP joints are suggestive of tenosynovitis/synovitis. MRI R foot w/w/o cont ([MASKED]): 1. No MRI signs for acute osteomyelitis or soft tissue abscess. There is dorsal forefoot and fifth toe soft tissue swelling. 2. Degenerative changes of PIP joints of the second through fifth toes. ABIs b/l ([MASKED]): No evidence of arterial insufficiency to the lower extremities bilaterally. R foot plain films ([MASKED]): 1. No definite destructive lesion. If there is continued clinical concern, MRI would be more sensitive for the detection of osteomyelitis. 2. Swelling of the right fifth digit without evidence of acute bony abnormality. 3. Degenerative changes as described above. Brief Hospital Course: [MASKED] with hx Sweet's syndrome (on prednisone/colchicine), seronegative inflammatory arthritis, IDDM, CKD stage III, HTN, HLD, OSA, pHTN/COPD (intermittent 2L NC) presenting with R [MASKED] toe abscess s/p I&D and likely flare of Sweet's syndrome and inflammatory arthritis. # R [MASKED] toe abscess/cellulitis: Patient p/w R [MASKED] toe abscess with cellulitis, s/p I&D in ED by podiatry, with culture growing Grp B strep, rare CoNS, and mixed flora. Per podiatry, ulcer probed to bone, but plain films without e/o osteomyelitis, CRP initially nl (subsequently rose, attributed to arthritis as below), and MRI foot without radiographic evidence of osteomyelitis. ABIs nl. She was treated with Unasyn initially with significant improvement in her R [MASKED] toe pain and erythema. She was transitioned to Augmentin to complete a 10d course through [MASKED] (was not covered for MRSA given improvement on Unasyn). Wound was treated with betadine dressings daily and a surgical boot for ambulation. She will f/u with outpatient podiatry. # Sweet's Syndrome: Diagnosed in [MASKED], previously followed at [MASKED] and maintained on dapsone (d/c'd for hemolytic anemia). Recently admitted [MASKED] with Sweet's flare, started on cyclosporine (which was d/c'd for insurance reasons), and discharged on increased prednisone dose with plan for taper. Recently tapered from pred 20mg -> 15mg per outpatient dermatologist, Dr. [MASKED], with plan for MTX initiation in near future in conjunction with rheumatology; continues on colchicine. Presents this admission with a flare of her Sweet's, with new lesions on her fingertips and R olecranon. Dermatology was consulted and injected a L index periungual lesion. Prednisone was increased by rheum for her inflammatory arthritis as below, which should also treat Sweet's, and betamethasone ointment to the hands was initiated, with plan for a 2 week course (through [MASKED]. She was discharged on prednisone 20mg PO daily and topical steroids with plan for dermatology f/u with Dr. [MASKED] [MASKED] consideration of MTX initiation (appointment requested, pending at discharge). # Likely seronegative inflammatory arthritis: Worked up last admission and seen by rheumatology as outpatient; thought to have seronegative inflammatory arthritis. Per dermatology last admission, arthritis not thought to be attributable to Sweet's, although interestingly flares of the two seem to co-occur. Complained of worsening joint pain [MASKED] with rising CRP, for which rheumatology was consulted. U/S performed at rheum's requests showed evidence of synovitis/tenosynovitis of the R MCP/PIP joints without effusions. Rheum recommended increasing prednisone to 30mg x 3d followed by taper to 20mg daily and outpatient f/u for consideration of DMARD. She will take prednisone 20mg PO daily, with plan for outpatient f/u with Dr. [MASKED] on [MASKED] for consideration of MTX. Pain was improving at discharge. # IDDM2: Hyperglycemic in setting of prednisone for Sweet's. Initiated on NPH qAM last admission [MASKED]. A1c 10.6%. Continued home NPH 28u qAM with addition of ISS. # Diarrhea: Likely attributable to antibx. C.diff was negative. # L plantar foot blister: Blister on plantar L foot evaluated by podiatry in ED, s/p I&D without signs of infection. Treated with betadine dressings and surgical boot. She will f/u with outpatient podiatry on [MASKED]. # Thrombocytopenia: Plt 138 on [MASKED]. Was noted to be thrombocytopenic during recent hospitalization in [MASKED]. No e/o bleeding or DIC. Stable at 147 on discharge. # CKD stage III: B/l appears to be 1.0-1.2. F/u with Dr. [MASKED] on [MASKED]. # OSA # pHTN: Patient one home O2 (2L) intermittently with exertion. Previously on CPAP at home but has not been using; declined while inpatient. # HLD: Continued home aspirin, statin # Depression: Continued home sertraline # Overactive bladder: Home Vesicare NF, will substituted tolterodine while inpatient. ** TRANSITIONAL ** [ ] prednisone 20mg daily through rheumatology f/u [ ] f/u with rheumatology and dermatology consideration of methotrextate initiation [ ] adjust insulin for improved glycemic control Greater than 30 minutes was spent in care coordination and counseling on the day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Colchicine 0.6 mg PO BID 3. Vesicare (solifenacin) 5 mg oral DAILY 4. Acetaminophen 650 mg PO Q6H 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. PredniSONE 15 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. NPH 28 Units Breakfast 10. triamcinolone acetonide 0.5 % topical daily 11. calcium carbonate-vitamin D3 500 mg calcium- 400 unit/5 mL oral daily Discharge Medications: 1. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth every twelve (12) hours Disp #*10 Tablet Refills:*0 2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID RX *betamethasone dipropionate 0.05 % Apply a small amount to affected areas twice a day Refills:*0 3. PredniSONE 20 mg PO DAILY RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*5 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q6H 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 20 mg PO QPM 7. calcium carbonate-vitamin D3 500 mg calcium- 400 unit/5 mL oral daily 8. Colchicine 0.6 mg PO BID 9. NPH 28 Units Breakfast 10. Multivitamins 1 TAB PO DAILY 11. Sertraline 100 mg PO DAILY 12. triamcinolone acetonide 0.5 % topical daily vaginal application 13. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Right [MASKED] toe abscess/cellulitis Sweet's syndrome Seronegative inflammatory arthritis 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 Ms. [MASKED], You were admitted to the hospital with an abscess on your right [MASKED] toe. The abscess was drained by the podiatry team and you were treated with antibiotics. An MRI of your foot showed no evidence of bone infection. You are being discharged on an antibiotic called Augmentin, which you should continue through [MASKED] (10 days total). While here, you were noted to have a flare of your Sweet's syndrome and your arthritis. You were seen by the dermatology and rheumatology teams, and your prednisone dose was increased. Please continue prednisone 20mg PO daily until you see your rheumatology team on [MASKED]. Please take your medications as prescribed and follow-up with your outpatient doctors as below. With best wishes, [MASKED] Medicine Followup Instructions: [MASKED]
[]
[ "D696", "I129", "E1122", "G4733", "E785", "F329", "Z87891", "E669", "Z794" ]
[ "L03031: Cellulitis of right toe", "L02611: Cutaneous abscess of right foot", "B951: Streptococcus, group B, as the cause of diseases classified elsewhere", "L982: Febrile neutrophilic dermatosis [Sweet]", "D696: Thrombocytopenia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z9981: Dependence on supplemental oxygen", "I2720: Pulmonary hypertension, unspecified", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "N3281: Overactive bladder", "Z87891: Personal history of nicotine dependence", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "S90822A: Blister (nonthermal), left foot, initial encounter", "M06042: Rheumatoid arthritis without rheumatoid factor, left hand", "M06041: Rheumatoid arthritis without rheumatoid factor, right hand", "R197: Diarrhea, unspecified", "Z794: Long term (current) use of insulin" ]
10,076,617
20,598,574
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ___ Allergies: Clindamycin / dapsone Attending: ___ Chief Complaint: Dizziness, hyperglycemia, sweets syndrome worsening Major Surgical or Invasive Procedure: Bedside debridement of sweets lesions over fingers by dermatology History of Present Illness: As per HPI in H&P by Dr. ___ ___: ___ female with history of sweet syndrome, non-insulin-dependent diabetes, frequent urinary tract infections, pulmonary hypertension on home O2, who presents with at least 2 weeks of increasing weakness and dizziness, poor glucose control, and recently diagnosed urinary tract infection. Patient states she has been in and out of ___ with blood sugars over 500, and multiple episodes of DKA. She does not typically use insulin at home. She was recently diagnosed with a urinary tract infection and started on Keflex, last dose was yesterday. She feels that she is also having a sweets flare. On ___, she was taken off of dapsone due to bone marrow suppression, and was started on prednisone. Patient also had a fall about 1 week ago, for which she refused to be seen at the hospital. She sustained a large bruise to the right side of the chest, but feels her symptoms have been improving does not feel that she injured anything else. In the ED, initial vital signs were 98.7 87 ___ 99% on room air. CBC with normal WBC and platelets of 106. MP notable for BUN of 23 and creatinine 1.2. UA grossly positive with large leuk esterase, positive nitrites, however with 4 epis. CXR showed pulmonary vascular congestion without focal consolidation ___ she received 10 units subcu insulin x2, IV ceftriaxone, aspirin, sertraline. She was admitted further for treatment of UTI. Upon arrival to the floor, the patient confirms the story as above. She reports that in ___, she was taken off of dapsone due to hemolytic anemia. She had taken dapsone for many years and feel that it was very effective in treating her sweet syndrome. She was then started on prednisone and colchicine through the works for ___ who is at ___. When she started taking prednisone, she knows her sugars, which she checks twice a day, increased a lot. She began to experience feeling dizzy and unwell. She reports she went to urgent care approximately twice per week to get insulin, although she is never been on insulin before. Because of this, her prednisone was decreased to half a pill per day. In this setting, she has noticed new lesions developing on her hands, as well as a lesion on her nose. She also reports painful lesions on her buttocks. She states in general she was not feeling well. She did experience some urinary symptoms, typically urinary frequency and dysuria. She went to a clinic, where she was given a full course of Macrobid which she completed. She returned to that clinic, she was reportedly told that she still had a urinary tract infection and was prescribed Keflex which she began to take yesterday. She continues to feel unwell, with worsening lightheadedness and mild headache. She otherwise denies abdominal pain. Of note, she did have a mechanical fall in ___, during which time she bruised her right chest. She denies lightheadedness at that time. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. " Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION 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 Chest: Large bruise on right breast RESP: Lungs clear to auscultation with good air movement bilaterally GI: Abdomen soft, non-distended, non-tender to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: + dark ulcer on L middle finger, on right bridge of nose, pinpoint lesions developing on fingertips NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect DISCHARGE EXAM: Vitals reviewed and unremarkable, sugars ranging 132–183. Inputs and outputs reviewed and unremarkable. Obese older woman seated in a chair next to the bed, standing and ambulating without difficulty in the room. Alert, cooperative, NAD. Anicteric, MMM. Equal chest rise, CTAB, no WOB or cough. Heart regular. Abdomen soft, NTND. Extremities warm and well-perfused, no pitting edema. Skin with rashes consistent with healing sweet syndrome, no significant new lesions. She has some red skin on her bilateral middle fingertips, and some scabbed areas on her elbows and a few on her lower extremities. Please see ___ dermatology note for more details. Pertinent Results: ADMISSION LABS: ___ 09:30AM BLOOD WBC-6.3 RBC-4.13 Hgb-11.8 Hct-36.5 MCV-88 MCH-28.6 MCHC-32.3 RDW-12.5 RDWSD-40.2 Plt ___ ___ 09:30AM BLOOD Neuts-75.1* Lymphs-15.3* Monos-6.7 Eos-1.9 Baso-0.5 Im ___ AbsNeut-4.70 AbsLymp-0.96* AbsMono-0.42 AbsEos-0.12 AbsBaso-0.03 ___ 09:30AM BLOOD Glucose-627* UreaN-23* Creat-1.2* Na-137 K-4.8 Cl-98 HCO3-23 AnGap-16 ___ 09:30AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.8 ___ 06:29AM BLOOD ALT-20 AST-13 AlkPhos-67 TotBili-0.3 ___ 09:58AM BLOOD ___ pO2-35* pCO2-44 pH-7.40 calTCO2-28 Base XS-1 ___ 09:58AM BLOOD Glucose-600* Lactate-1.8 K-4.1 PERTINENT LABS: ___ 06:36AM BLOOD %HbA1c-10.8* eAG-263* ___ 06:29AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG ___ 06:29AM BLOOD HCV Ab-NEG ___ 06:29AM BLOOD HCV VL-NOT DETECT ___ 09:00AM BLOOD Cyclspr-32* ___ 08:50AM BLOOD Cyclspr-75* ___ 09:35AM BLOOD Cyclspr-84* MICRO: Stool C.diff PCR (___): negative Wound swab culture (___): MSSA (resistant to clindamycin) BCx (___): No growth x2 UCx (___): Pan-sensitive E.coli IMAGING: CXR PA/Lat (___): IMPRESSION: Pulmonary vascular congestion without focal consolidation. XR bilateral hands (___): IMPRESSION: Mild diffuse soft tissue edema about the bilateral hands and questionable chronic erosions at the right hand long finger DIP and proximal triquetrum and left ulnar styloid process tip. Recommend clinical correlation for inflammatory arthropathy. MR right wrist without contrast (___) - incomplete study: IMPRESSION: 1. Evaluation for synovitis is limited due to motion degradation and lack of IV contrast. 2. Chronic changes related to a combination of likely inflammatory arthritis and osteoarthritis in the carpal bones and at the wrist joints. 3. Small loculated joint effusion in the ulnocarpal joint, fluid in the distal radioulnar joint and nonspecific mild soft tissue edema in the dorsal intercarpal ligament and at the ulnar aspect of the wrist likely relates to chronic synovitis with mild acute inflammatory component not excluded. This could be further evaluated with Doppler ultrasound if MRI contrast is not feasible. 4. Mild tendinosis of the extensor carpi ulnaris with intrasubstance tearing. 5. Mild peritendinitis of the extensor digitorum tendons at the hand, and trace fluid in the ECU, second and third extensor compartment and trace edema about the flexor tendon sheaths in the carpal tunnel, nonspecific but may relate to mild tenosynovitis. This could be further evaluated with Doppler ultrasound if MRI contrast is not feasible. 6. Degenerative tearing of the TFCC. MR right hand without contrast (___) - incomplete study: IMPRESSION: 1. Evaluation for synovitis is limited by lack of IV contrast 2. Chronic cortical changes likely related osteoarthritis with possible superimposed chronic erosive changes. 3. Small joint effusions at the third metacarpophalangeal joint and fifth proximal interphalangeal joints, with mild associated soft tissue no particular at the fifth PIP may represent mild synovitis. Recommend clinical correlation. If clinically warranted, further evaluation with Doppler ultrasound can be performed if contrast-enhanced MRI is not feasible. 4. Mild peritendinitis around the extensor digitorum tendons, similar to prior MRI. Trace fluid in multiple extensor compartment tendon sheaths, trace edema about the flexor tendons in the carpal tunnel, as well as loculated fluid in the ulnar carpal joint space and associated soft tissue edema is nonspecific but mild acute on chronic inflammation is not excluded. Note that overall the soft tissue edema has decreased from prior study of ___ however. 5. Trace nonspecific fluid surrounding the fourth and fifth digit flexor tendons. 6. Please see MRI wrist of same day for additional Findings. DISCHARGE LABS: ___ 04:30AM BLOOD WBC-6.3 RBC-4.09 Hgb-11.5 Hct-36.9 MCV-90 MCH-28.1 MCHC-31.2* RDW-13.3 RDWSD-43.0 Plt ___ ___ 04:30AM BLOOD Glucose-96 UreaN-26* Creat-1.2* Na-139 K-6.4* Cl-106 HCO3-20* AnGap-13 ___ 07:40AM BLOOD ALT-42* AST-29 AlkPhos-85 TotBili-0.4 ___ 07:40AM BLOOD Calcium-9.7 Phos-4.2 Mg-1.6 Brief Hospital Course: SUMMARY: ___ female with history of sweet syndrome, non-insulin-dependent diabetes, frequent urinary tract infections, pulmonary hypertension on home O2, who presented with at least 2 weeks of increasing weakness and dizziness, poor glucose control, and recently diagnosed urinary tract infection & worsening of her Sweets syndrome lesions with course complicated by hyperglycemia in the setting of diabetes mellitus type II requiring initiation of insulin. Seen on the day of discharge, the patient was doing well, no new concerns or issues. The nurses had worked extensively to help her understand her follow-up appointments including once a day, as well as helping arrange her medications and supplies for her transport home with a chair car. She had no questions for me and was looking forward to leaving. HOSPITAL COURSE BY PROBLEM: # Hyperglycemia # Diabetes mellitus, type II Severe hyperglycemia on admission, occurring in the setting of steroids for her Sweet syndrome. FSBG as high as 600, but no other evidence of hyperglycemic-hyperosmolar nonketotic syndrome. Initially, due to worsened joint pain and swelling (related to her Sweet syndrome), prednisone was resumed with plans for a more prolonged taper. However, because of the patient's joint pain/swelling, she does not have enough dexterity to self-administer insulin. On ___, her prednisone was stopped (after cyclosporine had been initiated on ___ with hopes that she would not require insulin to go home. However, her joint pain/swelling worsened dramatically after the prednisone was discontinued and a lower dose was resumed later that night. Because of this she was placed on insulin NPH. Occupational therapy and ___ were consulted to teach the patient strategies for insulin self-administration, especially given that her Hgb A1c is 10.8%. She unfortunately had some hypoglycemia so her glipizide was stopped. Case management arranged for her to have a ___ visit once a day for insulin administration and a morning sugar check. She was discharged on NPH 28 units once daily in the morning. This should be titrated as she tapers down on prednisone. For every 5 mg the prednisone goes down, ___ estimated that the NPH should be decreased 6 units. As a result for a decrease in prednisone from 20 mg daily to 15 mg daily the NPH would go from ___ units. She will follow-up with her primary care doctor regarding her diabetes, and can be referred to ___ if needed by her PCP. Given that the patient could not self administer her insulin nor could she work the glucometer herself, we recommended that she try to find someone who could help her check her sugar once a day after 12 ___. The ___ will help with the morning blood sugar check. She was instructed to bring her fingerstick values to her follow-up appointment. # Sweet Syndrome Patient has a history of Sweet syndrome which has been treated by a dermatologist at ___ (she wants to transfer her care to ___. Her Sweet syndrome was well controlled on dapsone, however she developed hemolysis as a side effect so this was discontinued by hematology. Since discontinuation of dapsone, the patient has noted the appearance of several new painful lesions as well as worsened joint pain and swelling. For workup for possible alternative therapies, QuantGOLD was negative, hepatitis serologies negative, and LFTs wnl. Dermatology was consulted. They recommended starting cyclosporine which was done on ___. Her hospital course was prolonged waiting for a prior authorization for cyclosporine to go through. As above she was also treated with a prolonged prednisone taper. Derm recommended that she use betamethasone ointment for new skin lesions and they will consider intralesional steroid injections as an outpatient. Unfortunately her insurance denied to provide prior authorization for cyclosporine so the plan was made to titrate this off, and go up slightly on her prednisone (from 15 mg to 20 mg, and to continue using the topical steroid as needed. She was provided with a short/quick taper of cyclosporine which will finish on ___. # Likely inflammatory arthritis Dermatology did not think that her arthritis is a manifestation of her Sweet syndrome. Rheumatology was consulted; they will see her in clinic. In the meantime, they recommend a prolonged steroid taper to control her symptoms. MRI was attempted but not able to be completed due to patient discomfort. # E.coli Urinary Tract Infection Patient reported urinary frequency on admission. She was treated with a complete course of Bactrim. # Vertigo - chronic issue, reinitiated meclizine, which has worked for her in the past with improvement in her symptoms. She indicated an interest in following up with ENT as an outpatient, and was provided with their contact information RESOLVED # ___: Admission creatinine of 1.2, improved to baseline 1 after IV fluids and PO hydration. CHRONIC/STABLE PROBLEMS: # Hx of Hemolytic anemia in the setting of dapsone: Patient has a history of low grade anemia for at least ___ years per ___ records. G6PD checked and greater than upper limit of normal. Coombs test negative. Dapsone recently discontinued with improvement in hemolysis parameters. Given inability to tolerate prednisone and appearance of new lesions while taking colcichine, the risk of hemolysis with future use of dapsone was discussed with heme/onc. They recommended against any future use of dapsone in this patient. Interestingly since the improvement in her chronic anemia with discontinuation of dapsone she no longer requires supplemental O2 (she was on home O2 prior to admission). She will follow-up with hematology as an outpatient. # HLD, Primary prevention of coronary artery disease: - Continued Aspirin 81 mg daily - atorvastatin was held while she was on cyclosporine (given a drug drug interaction) and will be restarted once that medication has washed out of her system # Depression: - Continued Sertraline 100 mg daily # Overactive bladder: Vesicare (solifenacin) 5 mg oral DAILY (not formulary) held. TRANSITIONAL ISSUES: [ ] Insulin will need to be adjusted as she tapers down on prednisone. [x] The patient is safe to discharge today, and I spent [ ] <30min; [x] >30min in discharge day management services. ___, MD ___ Pager ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. PredniSONE 10 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. GlipiZIDE 10 mg PO QAM 5. GlipiZIDE 2.5 mg PO QPM 6. Multivitamins 1 TAB PO DAILY 7. Sertraline 100 mg PO DAILY 8. Vesicare (solifenacin) 5 mg oral DAILY 9. Atorvastatin 20 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth Q6H:PRN Disp #*50 Tablet Refills:*0 2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID RX *betamethasone dipropionate 0.05 % 1 Appl twice a day Refills:*1 3. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat RX *benzocaine-menthol [Cepacol Sore Throat ___ 15 mg-3.6 mg ___ lozenges q2h Disp #*48 Lozenge Refills:*0 4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H Take 1 dose on ___ evening, then one dose ___ morning, and 1 dose ___ evening, then stop 5. NPH 28 Units Breakfast RX *blood sugar diagnostic [OneTouch Verio] AS DIR AS DIR Disp #*50 Strip Refills:*0 RX *lancets [Ultra Thin Lancets] 31 gauge AS DIR AS DIR Disp #*100 Each Refills:*0 RX *insulin NPH isoph U-100 human [Humulin N NPH U-100 Insulin] 100 unit/mL AS DIR units SC 28 Units before BKFT; Disp #*1 Vial Refills:*1 RX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine] 31 gauge X ___ AS DIR AS DIR Disp #*90 Syringe Refills:*0 6. PredniSONE 20 mg PO DAILY RX *prednisone 5 mg 4 tablet(s) by mouth DAILY in the morning Disp #*100 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY 8. Colchicine 0.6 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Sertraline 100 mg PO DAILY 11. Vesicare (solifenacin) 5 mg oral DAILY 12. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do not restart Atorvastatin until ___ (4 days after you finish the cyclosporine) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Sweets syndrome, Hyperglycemia 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 because your blood sugars were too high, causing dizziness, you had a urinary tract infection, and your Sweet syndrome had worsened on the decreasing dose of steroids. Since we did not feel dapsone is safe for you, our dermatologists recommended cyclosporine. Unfortunately, your insurance refused to pay for cyclosporine, so we began to taper you off this ___, increased your prednisone dose, and encouraged you to use the topical steroid and follow-up with Dermatology for intra-lesional steroid injections. You should follow-up with Rheumatology about your joint pains (inflammatory arthritis). For your diabetes you were started on NPH insulin once daily in the morning, which will be administered by a visiting nurse. You should follow-up with your primary care doctor about your diabetes and insulin. Call them -- or your PCP -- with any questions about your sugars. They can refer you to ___ if needed. It is important that your sugars be checked at least twice a day. The ___ can help in the morning. Please try to ask a friend, neighbor, or family member to help you check your sugar sometime between 12pm and 10pm each day. Please write down the times you check your sugars, and the values, and bring that information to your follow-up appointment with your PCP. It is important that Dermatology, Rheumatology, and your PCP coordinate your prednisone dose and your insulin dose. As the prednisone goes down, the insulin must go down. For every 5mg the prednisone is decreased, the insulin should go down 6 units, for instance when the prednisone goes from 20 to 15mg, the insulin should go from 28 to 22 units. Please do not restart your atorvastatin until 4 days after finishing cyclosporine. Your other follow-up appointments are listed below. Followup Instructions: ___
[ "E1165", "N390", "N179", "L982", "B9620", "I2720", "I129", "E1122", "N183", "J449", "G4733", "E785", "I951", "D696", "N3281", "F329", "M1990", "Z9981", "Z87891", "Z8542" ]
Allergies: Clindamycin / dapsone Chief Complaint: Dizziness, hyperglycemia, sweets syndrome worsening Major Surgical or Invasive Procedure: Bedside debridement of sweets lesions over fingers by dermatology History of Present Illness: As per HPI in H&P by Dr. [MASKED] [MASKED]: [MASKED] female with history of sweet syndrome, non-insulin-dependent diabetes, frequent urinary tract infections, pulmonary hypertension on home O2, who presents with at least 2 weeks of increasing weakness and dizziness, poor glucose control, and recently diagnosed urinary tract infection. Patient states she has been in and out of [MASKED] with blood sugars over 500, and multiple episodes of DKA. She does not typically use insulin at home. She was recently diagnosed with a urinary tract infection and started on Keflex, last dose was yesterday. She feels that she is also having a sweets flare. On [MASKED], she was taken off of dapsone due to bone marrow suppression, and was started on prednisone. Patient also had a fall about 1 week ago, for which she refused to be seen at the hospital. She sustained a large bruise to the right side of the chest, but feels her symptoms have been improving does not feel that she injured anything else. In the ED, initial vital signs were 98.7 87 [MASKED] 99% on room air. CBC with normal WBC and platelets of 106. MP notable for BUN of 23 and creatinine 1.2. UA grossly positive with large leuk esterase, positive nitrites, however with 4 epis. CXR showed pulmonary vascular congestion without focal consolidation [MASKED] she received 10 units subcu insulin x2, IV ceftriaxone, aspirin, sertraline. She was admitted further for treatment of UTI. Upon arrival to the floor, the patient confirms the story as above. She reports that in [MASKED], she was taken off of dapsone due to hemolytic anemia. She had taken dapsone for many years and feel that it was very effective in treating her sweet syndrome. She was then started on prednisone and colchicine through the works for [MASKED] who is at [MASKED]. When she started taking prednisone, she knows her sugars, which she checks twice a day, increased a lot. She began to experience feeling dizzy and unwell. She reports she went to urgent care approximately twice per week to get insulin, although she is never been on insulin before. Because of this, her prednisone was decreased to half a pill per day. In this setting, she has noticed new lesions developing on her hands, as well as a lesion on her nose. She also reports painful lesions on her buttocks. She states in general she was not feeling well. She did experience some urinary symptoms, typically urinary frequency and dysuria. She went to a clinic, where she was given a full course of Macrobid which she completed. She returned to that clinic, she was reportedly told that she still had a urinary tract infection and was prescribed Keflex which she began to take yesterday. She continues to feel unwell, with worsening lightheadedness and mild headache. She otherwise denies abdominal pain. Of note, she did have a mechanical fall in [MASKED], during which time she bruised her right chest. She denies lightheadedness at that time. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. " Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN [MASKED]: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: [MASKED] Family History: Father - deceased of MI in his [MASKED] Mother - emphysema, deceased in her [MASKED] No children Physical Exam: ADMISSION 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 Chest: Large bruise on right breast RESP: Lungs clear to auscultation with good air movement bilaterally GI: Abdomen soft, non-distended, non-tender to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: + dark ulcer on L middle finger, on right bridge of nose, pinpoint lesions developing on fingertips NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect DISCHARGE EXAM: Vitals reviewed and unremarkable, sugars ranging 132–183. Inputs and outputs reviewed and unremarkable. Obese older woman seated in a chair next to the bed, standing and ambulating without difficulty in the room. Alert, cooperative, NAD. Anicteric, MMM. Equal chest rise, CTAB, no WOB or cough. Heart regular. Abdomen soft, NTND. Extremities warm and well-perfused, no pitting edema. Skin with rashes consistent with healing sweet syndrome, no significant new lesions. She has some red skin on her bilateral middle fingertips, and some scabbed areas on her elbows and a few on her lower extremities. Please see [MASKED] dermatology note for more details. Pertinent Results: ADMISSION LABS: [MASKED] 09:30AM BLOOD WBC-6.3 RBC-4.13 Hgb-11.8 Hct-36.5 MCV-88 MCH-28.6 MCHC-32.3 RDW-12.5 RDWSD-40.2 Plt [MASKED] [MASKED] 09:30AM BLOOD Neuts-75.1* Lymphs-15.3* Monos-6.7 Eos-1.9 Baso-0.5 Im [MASKED] AbsNeut-4.70 AbsLymp-0.96* AbsMono-0.42 AbsEos-0.12 AbsBaso-0.03 [MASKED] 09:30AM BLOOD Glucose-627* UreaN-23* Creat-1.2* Na-137 K-4.8 Cl-98 HCO3-23 AnGap-16 [MASKED] 09:30AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.8 [MASKED] 06:29AM BLOOD ALT-20 AST-13 AlkPhos-67 TotBili-0.3 [MASKED] 09:58AM BLOOD [MASKED] pO2-35* pCO2-44 pH-7.40 calTCO2-28 Base XS-1 [MASKED] 09:58AM BLOOD Glucose-600* Lactate-1.8 K-4.1 PERTINENT LABS: [MASKED] 06:36AM BLOOD %HbA1c-10.8* eAG-263* [MASKED] 06:29AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG [MASKED] 06:29AM BLOOD HCV Ab-NEG [MASKED] 06:29AM BLOOD HCV VL-NOT DETECT [MASKED] 09:00AM BLOOD Cyclspr-32* [MASKED] 08:50AM BLOOD Cyclspr-75* [MASKED] 09:35AM BLOOD Cyclspr-84* MICRO: Stool C.diff PCR ([MASKED]): negative Wound swab culture ([MASKED]): MSSA (resistant to clindamycin) BCx ([MASKED]): No growth x2 UCx ([MASKED]): Pan-sensitive E.coli IMAGING: CXR PA/Lat ([MASKED]): IMPRESSION: Pulmonary vascular congestion without focal consolidation. XR bilateral hands ([MASKED]): IMPRESSION: Mild diffuse soft tissue edema about the bilateral hands and questionable chronic erosions at the right hand long finger DIP and proximal triquetrum and left ulnar styloid process tip. Recommend clinical correlation for inflammatory arthropathy. MR right wrist without contrast ([MASKED]) - incomplete study: IMPRESSION: 1. Evaluation for synovitis is limited due to motion degradation and lack of IV contrast. 2. Chronic changes related to a combination of likely inflammatory arthritis and osteoarthritis in the carpal bones and at the wrist joints. 3. Small loculated joint effusion in the ulnocarpal joint, fluid in the distal radioulnar joint and nonspecific mild soft tissue edema in the dorsal intercarpal ligament and at the ulnar aspect of the wrist likely relates to chronic synovitis with mild acute inflammatory component not excluded. This could be further evaluated with Doppler ultrasound if MRI contrast is not feasible. 4. Mild tendinosis of the extensor carpi ulnaris with intrasubstance tearing. 5. Mild peritendinitis of the extensor digitorum tendons at the hand, and trace fluid in the ECU, second and third extensor compartment and trace edema about the flexor tendon sheaths in the carpal tunnel, nonspecific but may relate to mild tenosynovitis. This could be further evaluated with Doppler ultrasound if MRI contrast is not feasible. 6. Degenerative tearing of the TFCC. MR right hand without contrast ([MASKED]) - incomplete study: IMPRESSION: 1. Evaluation for synovitis is limited by lack of IV contrast 2. Chronic cortical changes likely related osteoarthritis with possible superimposed chronic erosive changes. 3. Small joint effusions at the third metacarpophalangeal joint and fifth proximal interphalangeal joints, with mild associated soft tissue no particular at the fifth PIP may represent mild synovitis. Recommend clinical correlation. If clinically warranted, further evaluation with Doppler ultrasound can be performed if contrast-enhanced MRI is not feasible. 4. Mild peritendinitis around the extensor digitorum tendons, similar to prior MRI. Trace fluid in multiple extensor compartment tendon sheaths, trace edema about the flexor tendons in the carpal tunnel, as well as loculated fluid in the ulnar carpal joint space and associated soft tissue edema is nonspecific but mild acute on chronic inflammation is not excluded. Note that overall the soft tissue edema has decreased from prior study of [MASKED] however. 5. Trace nonspecific fluid surrounding the fourth and fifth digit flexor tendons. 6. Please see MRI wrist of same day for additional Findings. DISCHARGE LABS: [MASKED] 04:30AM BLOOD WBC-6.3 RBC-4.09 Hgb-11.5 Hct-36.9 MCV-90 MCH-28.1 MCHC-31.2* RDW-13.3 RDWSD-43.0 Plt [MASKED] [MASKED] 04:30AM BLOOD Glucose-96 UreaN-26* Creat-1.2* Na-139 K-6.4* Cl-106 HCO3-20* AnGap-13 [MASKED] 07:40AM BLOOD ALT-42* AST-29 AlkPhos-85 TotBili-0.4 [MASKED] 07:40AM BLOOD Calcium-9.7 Phos-4.2 Mg-1.6 Brief Hospital Course: SUMMARY: [MASKED] female with history of sweet syndrome, non-insulin-dependent diabetes, frequent urinary tract infections, pulmonary hypertension on home O2, who presented with at least 2 weeks of increasing weakness and dizziness, poor glucose control, and recently diagnosed urinary tract infection & worsening of her Sweets syndrome lesions with course complicated by hyperglycemia in the setting of diabetes mellitus type II requiring initiation of insulin. Seen on the day of discharge, the patient was doing well, no new concerns or issues. The nurses had worked extensively to help her understand her follow-up appointments including once a day, as well as helping arrange her medications and supplies for her transport home with a chair car. She had no questions for me and was looking forward to leaving. HOSPITAL COURSE BY PROBLEM: # Hyperglycemia # Diabetes mellitus, type II Severe hyperglycemia on admission, occurring in the setting of steroids for her Sweet syndrome. FSBG as high as 600, but no other evidence of hyperglycemic-hyperosmolar nonketotic syndrome. Initially, due to worsened joint pain and swelling (related to her Sweet syndrome), prednisone was resumed with plans for a more prolonged taper. However, because of the patient's joint pain/swelling, she does not have enough dexterity to self-administer insulin. On [MASKED], her prednisone was stopped (after cyclosporine had been initiated on [MASKED] with hopes that she would not require insulin to go home. However, her joint pain/swelling worsened dramatically after the prednisone was discontinued and a lower dose was resumed later that night. Because of this she was placed on insulin NPH. Occupational therapy and [MASKED] were consulted to teach the patient strategies for insulin self-administration, especially given that her Hgb A1c is 10.8%. She unfortunately had some hypoglycemia so her glipizide was stopped. Case management arranged for her to have a [MASKED] visit once a day for insulin administration and a morning sugar check. She was discharged on NPH 28 units once daily in the morning. This should be titrated as she tapers down on prednisone. For every 5 mg the prednisone goes down, [MASKED] estimated that the NPH should be decreased 6 units. As a result for a decrease in prednisone from 20 mg daily to 15 mg daily the NPH would go from [MASKED] units. She will follow-up with her primary care doctor regarding her diabetes, and can be referred to [MASKED] if needed by her PCP. Given that the patient could not self administer her insulin nor could she work the glucometer herself, we recommended that she try to find someone who could help her check her sugar once a day after 12 [MASKED]. The [MASKED] will help with the morning blood sugar check. She was instructed to bring her fingerstick values to her follow-up appointment. # Sweet Syndrome Patient has a history of Sweet syndrome which has been treated by a dermatologist at [MASKED] (she wants to transfer her care to [MASKED]. Her Sweet syndrome was well controlled on dapsone, however she developed hemolysis as a side effect so this was discontinued by hematology. Since discontinuation of dapsone, the patient has noted the appearance of several new painful lesions as well as worsened joint pain and swelling. For workup for possible alternative therapies, QuantGOLD was negative, hepatitis serologies negative, and LFTs wnl. Dermatology was consulted. They recommended starting cyclosporine which was done on [MASKED]. Her hospital course was prolonged waiting for a prior authorization for cyclosporine to go through. As above she was also treated with a prolonged prednisone taper. Derm recommended that she use betamethasone ointment for new skin lesions and they will consider intralesional steroid injections as an outpatient. Unfortunately her insurance denied to provide prior authorization for cyclosporine so the plan was made to titrate this off, and go up slightly on her prednisone (from 15 mg to 20 mg, and to continue using the topical steroid as needed. She was provided with a short/quick taper of cyclosporine which will finish on [MASKED]. # Likely inflammatory arthritis Dermatology did not think that her arthritis is a manifestation of her Sweet syndrome. Rheumatology was consulted; they will see her in clinic. In the meantime, they recommend a prolonged steroid taper to control her symptoms. MRI was attempted but not able to be completed due to patient discomfort. # E.coli Urinary Tract Infection Patient reported urinary frequency on admission. She was treated with a complete course of Bactrim. # Vertigo - chronic issue, reinitiated meclizine, which has worked for her in the past with improvement in her symptoms. She indicated an interest in following up with ENT as an outpatient, and was provided with their contact information RESOLVED # [MASKED]: Admission creatinine of 1.2, improved to baseline 1 after IV fluids and PO hydration. CHRONIC/STABLE PROBLEMS: # Hx of Hemolytic anemia in the setting of dapsone: Patient has a history of low grade anemia for at least [MASKED] years per [MASKED] records. G6PD checked and greater than upper limit of normal. Coombs test negative. Dapsone recently discontinued with improvement in hemolysis parameters. Given inability to tolerate prednisone and appearance of new lesions while taking colcichine, the risk of hemolysis with future use of dapsone was discussed with heme/onc. They recommended against any future use of dapsone in this patient. Interestingly since the improvement in her chronic anemia with discontinuation of dapsone she no longer requires supplemental O2 (she was on home O2 prior to admission). She will follow-up with hematology as an outpatient. # HLD, Primary prevention of coronary artery disease: - Continued Aspirin 81 mg daily - atorvastatin was held while she was on cyclosporine (given a drug drug interaction) and will be restarted once that medication has washed out of her system # Depression: - Continued Sertraline 100 mg daily # Overactive bladder: Vesicare (solifenacin) 5 mg oral DAILY (not formulary) held. TRANSITIONAL ISSUES: [ ] Insulin will need to be adjusted as she tapers down on prednisone. [x] The patient is safe to discharge today, and I spent [ ] <30min; [x] >30min in discharge day management services. [MASKED], MD [MASKED] Pager [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. PredniSONE 10 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. GlipiZIDE 10 mg PO QAM 5. GlipiZIDE 2.5 mg PO QPM 6. Multivitamins 1 TAB PO DAILY 7. Sertraline 100 mg PO DAILY 8. Vesicare (solifenacin) 5 mg oral DAILY 9. Atorvastatin 20 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth Q6H:PRN Disp #*50 Tablet Refills:*0 2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID RX *betamethasone dipropionate 0.05 % 1 Appl twice a day Refills:*1 3. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat RX *benzocaine-menthol [Cepacol Sore Throat [MASKED] 15 mg-3.6 mg [MASKED] lozenges q2h Disp #*48 Lozenge Refills:*0 4. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H Take 1 dose on [MASKED] evening, then one dose [MASKED] morning, and 1 dose [MASKED] evening, then stop 5. NPH 28 Units Breakfast RX *blood sugar diagnostic [OneTouch Verio] AS DIR AS DIR Disp #*50 Strip Refills:*0 RX *lancets [Ultra Thin Lancets] 31 gauge AS DIR AS DIR Disp #*100 Each Refills:*0 RX *insulin NPH isoph U-100 human [Humulin N NPH U-100 Insulin] 100 unit/mL AS DIR units SC 28 Units before BKFT; Disp #*1 Vial Refills:*1 RX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine] 31 gauge X [MASKED] AS DIR AS DIR Disp #*90 Syringe Refills:*0 6. PredniSONE 20 mg PO DAILY RX *prednisone 5 mg 4 tablet(s) by mouth DAILY in the morning Disp #*100 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY 8. Colchicine 0.6 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Sertraline 100 mg PO DAILY 11. Vesicare (solifenacin) 5 mg oral DAILY 12. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do not restart Atorvastatin until [MASKED] (4 days after you finish the cyclosporine) Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Sweets syndrome, Hyperglycemia 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 because your blood sugars were too high, causing dizziness, you had a urinary tract infection, and your Sweet syndrome had worsened on the decreasing dose of steroids. Since we did not feel dapsone is safe for you, our dermatologists recommended cyclosporine. Unfortunately, your insurance refused to pay for cyclosporine, so we began to taper you off this [MASKED], increased your prednisone dose, and encouraged you to use the topical steroid and follow-up with Dermatology for intra-lesional steroid injections. You should follow-up with Rheumatology about your joint pains (inflammatory arthritis). For your diabetes you were started on NPH insulin once daily in the morning, which will be administered by a visiting nurse. You should follow-up with your primary care doctor about your diabetes and insulin. Call them -- or your PCP -- with any questions about your sugars. They can refer you to [MASKED] if needed. It is important that your sugars be checked at least twice a day. The [MASKED] can help in the morning. Please try to ask a friend, neighbor, or family member to help you check your sugar sometime between 12pm and 10pm each day. Please write down the times you check your sugars, and the values, and bring that information to your follow-up appointment with your PCP. It is important that Dermatology, Rheumatology, and your PCP coordinate your prednisone dose and your insulin dose. As the prednisone goes down, the insulin must go down. For every 5mg the prednisone is decreased, the insulin should go down 6 units, for instance when the prednisone goes from 20 to 15mg, the insulin should go from 28 to 22 units. Please do not restart your atorvastatin until 4 days after finishing cyclosporine. Your other follow-up appointments are listed below. Followup Instructions: [MASKED]
[]
[ "E1165", "N390", "N179", "I129", "E1122", "J449", "G4733", "E785", "D696", "F329", "Z87891" ]
[ "E1165: Type 2 diabetes mellitus with hyperglycemia", "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "L982: Febrile neutrophilic dermatosis [Sweet]", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "I2720: Pulmonary hypertension, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "J449: Chronic obstructive pulmonary disease, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E785: Hyperlipidemia, unspecified", "I951: Orthostatic hypotension", "D696: Thrombocytopenia, unspecified", "N3281: Overactive bladder", "F329: Major depressive disorder, single episode, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z9981: Dependence on supplemental oxygen", "Z87891: Personal history of nicotine dependence", "Z8542: Personal history of malignant neoplasm of other parts of uterus" ]
10,076,617
21,474,221
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin Attending: ___. Chief Complaint: fever, weakness, UTI Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ yo F with history of Sweets Syndrome, Type 2 DM, pulmonary hypertension on home oxygen, who presented to the ED on ___ with urinary tract infection and was discharged from the ED who then represented later in the day after she almost collapsed at ___. In the ED, initial vitals: - Exam notable for: 100.4 86 149/110 16 96% on 2 L - Labs notable for: U/a with lg leuks, moderate blood, trace ketones, WBC 10.7 (N predominance), Hb 9.2, Hct 28.7 BUN 32, Cr 1.3, Glc 208, lactate 1.5, flu negative - Imaging notable for: CXR with Re- demonstrated moderate pulmonary edema without definite focal consolidation. Atypical infection is not excluded in the appropriate clinical setting. - Patient given: Tylenol ___ mg PO x1, ibuprofen 400 mg po x1, ceftriazone IV 1 gram, 1000 ml NS at 100 cc/hr - Vitals prior to transfer: 99 80 136/72 20 97% nasal cannula On arrival to the floor, pt reports 1.5 weeks of chills. Says went to urgent care yesterday (___) after she felt dizzy. She received IVF and got a CXR. She returned home and continued to feel poorly. Said she has felt week and very fatigued. She came to the ED today (___) and was diagnosed with UTI. She was then discharged and went to pharmacy to pick up Rx. At pharmacy she felt so weak that she was unable to walk to the car. EMS was called and she was brought back to the ED. Notes that she has been having chills, fatigue and fever. Endorses runny nose, congestion, and mild h/a. No cough. Also reports increased urinary frequency. No dysuria. No abdominal pain, diarrhea, back pain, shortness of breath, chest pain, changes in vision, changes in her skin or skin rash. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION EXAM: Vitals:98.0 107 / 51 80 20 92 ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mouth appears dry Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, systolic murmur heard best at ___ Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Neuro: ___ strength is ___ bilaterally, sensation to touch is intact DISCHARGE EXAM: Vitals:99.4 PO 147 / 81 L Lying 81 20 95 2 L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mouth appears dry Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, systolic murmur heard best at ___ Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Neuro: BLE strength intact, no TTP of knees Skin: hemorrhagic vesicle on left ___ MCP with surrounding erythema. R MCPs mildly erythematous. Faint erythematous papules over extensoral surface of elbows bilaterally. Pertinent Results: ADMISSION LABS: ___ 12:30PM BLOOD WBC-10.7* RBC-3.09* Hgb-9.2* Hct-28.7* MCV-93 MCH-29.8 MCHC-32.1 RDW-13.3 RDWSD-45.8 Plt ___ ___ 12:30PM BLOOD Neuts-82.2* Lymphs-6.9* Monos-10.0 Eos-0.1* Baso-0.3 Im ___ AbsNeut-8.77*# AbsLymp-0.74* AbsMono-1.07* AbsEos-0.01* AbsBaso-0.03 ___ 04:00PM BLOOD ___ PTT-27.5 ___ ___ 12:30PM BLOOD Glucose-208* UreaN-32* Creat-1.3* Na-133 K-4.3 Cl-95* HCO3-23 AnGap-19 ___ 06:08AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9 UricAcd-6.7* Iron-25* ___ 06:08AM BLOOD calTIBC-225* ___ Ferritn-348* TRF-173* ___ 06:08AM BLOOD LD(LDH)-195 ___ 12:50PM BLOOD Lactate-1.5 ___ 01:40PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 01:40PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 01:40PM URINE RBC-17* WBC->182* Bacteri-MANY Yeast-NONE Epi-1 URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ BLOOD CULTURES X2: NO GROWTH TO DATE STUDIES: ___ CXR: Re- demonstrated moderate pulmonary edema without definite focal consolidation. Atypical infection is not excluded in the appropriate clinical setting. ___ KNEE FILMS, BILATERAL: IMPRESSION: Diffuse osteopenia. Moderate to moderately severe osteoarthritis in both knees. No obvious fracture or dislocation identified on these views. No gross effusion detected in either knee. A small joint effusion might not be apparent on the cross-table lateral views. No bone erosion, periostitis, or chondrocalcinosis detected in either knee. DISCHARGE LABS: ___ 07:23AM BLOOD WBC-6.6 RBC-2.61* Hgb-7.6* Hct-24.4* MCV-94 MCH-29.1 MCHC-31.1* RDW-14.1 RDWSD-47.8* Plt ___ ___ 07:23AM BLOOD Glucose-132* UreaN-23* Creat-1.1 Na-138 K-3.6 Cl-103 HCO3-24 AnGap-15 ___ 07:23AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 Brief Hospital Course: Ms ___ is a ___ yo F with history of Sweets Syndrome, Type 2 DM, pulmonary hypertension on home oxygen, who presented to the ED on ___ with symptoms of URI found to have UTI, also with bilateral knee pain that may have been due to manifestation of Sweet's syndrome. #Complicated cystitis: Initially treated with CTX, then bactrim. She will continue bactrim 1 DS BID (total 7d, ___. #Acute bilateral medial knee pain: Resolved by day of discharge. ___ have been due to Sweet's flare, exacerbated by infection. Knee films with moderate-severe osteoarthritis. Evaluated by rheumatology - no effusion to be tapped. She initially was unable to walk due to the pain, but was cleared by ___ on day of discharge. #___ SYNDROME: With apparent flare, precipitated by UTI. She developed characteristic skin lesions on bilateral MCP/elbows. She continued dapsone. #URI : No evidence of PNA on CXR. No cough. Mild symptoms. Treated with supportive care #Acute on chronic kidney disease: Stage ___ CKD at baseline. S/p IVF in the ED. Suspect that this is pre renal in setting of recent illness and decreased PO intake. Cr downtrended to normal. #Acute on chronic anemia: Hgb last 11 in ___. She did have hemolysis during her last admission. Hemolysis labs negative. Transferrin sat 14%, but iron studies suggestive of anemia of chronic disease. #DEPRESSION Continued sertraline TRANSITIONAL ISSUES: ===================== -Knee XRAYS showed diffuse osteopenia; consider DEXA -Last day ABx ___ # CODE STATUS: Full code with limited trial # CONTACT: Name of health care proxy: ___ Relationship: ___ Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Vesicare (solifenacin) 5 mg oral DAILY 2. GlipiZIDE 5 mg PO DAILY 3. Dapsone 100 mg PO DAILY 4. Sertraline 100 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. Dapsone 100 mg PO DAILY 4. GlipiZIDE 5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: complicated urinary tract infection acute viral syndrome acute tendonitis acute on chronic Sweet's syndrome secondary chronic kidney disease type II diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, Why were you here: -You were very weak and almost collapsed -You had a urinary tract infection -You had knee pain likely from a Sweet's flare What was done: -We gave you fluids in your IV and antibiotics. You improved. What to do next: -Take all your medications as prescribed and follow-up at the appointments below. We wish you all the best, Your ___ team Followup Instructions: ___
[ "N3090", "N179", "E1122", "I130", "I509", "I272", "B9620", "B349", "L982", "N183", "Z9981", "J069", "M170", "Z23", "J449", "I350", "Z87891", "E785", "Z9114", "N3281", "G4733", "F329", "M779" ]
Allergies: Clindamycin Chief Complaint: fever, weakness, UTI Major Surgical or Invasive Procedure: None History of Present Illness: Ms [MASKED] is a [MASKED] yo F with history of Sweets Syndrome, Type 2 DM, pulmonary hypertension on home oxygen, who presented to the ED on [MASKED] with urinary tract infection and was discharged from the ED who then represented later in the day after she almost collapsed at [MASKED]. In the ED, initial vitals: - Exam notable for: 100.4 86 149/110 16 96% on 2 L - Labs notable for: U/a with lg leuks, moderate blood, trace ketones, WBC 10.7 (N predominance), Hb 9.2, Hct 28.7 BUN 32, Cr 1.3, Glc 208, lactate 1.5, flu negative - Imaging notable for: CXR with Re- demonstrated moderate pulmonary edema without definite focal consolidation. Atypical infection is not excluded in the appropriate clinical setting. - Patient given: Tylenol [MASKED] mg PO x1, ibuprofen 400 mg po x1, ceftriazone IV 1 gram, 1000 ml NS at 100 cc/hr - Vitals prior to transfer: 99 80 136/72 20 97% nasal cannula On arrival to the floor, pt reports 1.5 weeks of chills. Says went to urgent care yesterday ([MASKED]) after she felt dizzy. She received IVF and got a CXR. She returned home and continued to feel poorly. Said she has felt week and very fatigued. She came to the ED today ([MASKED]) and was diagnosed with UTI. She was then discharged and went to pharmacy to pick up Rx. At pharmacy she felt so weak that she was unable to walk to the car. EMS was called and she was brought back to the ED. Notes that she has been having chills, fatigue and fever. Endorses runny nose, congestion, and mild h/a. No cough. Also reports increased urinary frequency. No dysuria. No abdominal pain, diarrhea, back pain, shortness of breath, chest pain, changes in vision, changes in her skin or skin rash. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN [MASKED]: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: [MASKED] Family History: Father - deceased of MI in his [MASKED] Mother - emphysema, deceased in her [MASKED] No children Physical Exam: ADMISSION EXAM: Vitals:98.0 107 / 51 80 20 92 ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mouth appears dry Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, systolic murmur heard best at [MASKED] Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Neuro: [MASKED] strength is [MASKED] bilaterally, sensation to touch is intact DISCHARGE EXAM: Vitals:99.4 PO 147 / 81 L Lying 81 20 95 2 L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mouth appears dry Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, systolic murmur heard best at [MASKED] Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no cyanosis or edema Neuro: BLE strength intact, no TTP of knees Skin: hemorrhagic vesicle on left [MASKED] MCP with surrounding erythema. R MCPs mildly erythematous. Faint erythematous papules over extensoral surface of elbows bilaterally. Pertinent Results: ADMISSION LABS: [MASKED] 12:30PM BLOOD WBC-10.7* RBC-3.09* Hgb-9.2* Hct-28.7* MCV-93 MCH-29.8 MCHC-32.1 RDW-13.3 RDWSD-45.8 Plt [MASKED] [MASKED] 12:30PM BLOOD Neuts-82.2* Lymphs-6.9* Monos-10.0 Eos-0.1* Baso-0.3 Im [MASKED] AbsNeut-8.77*# AbsLymp-0.74* AbsMono-1.07* AbsEos-0.01* AbsBaso-0.03 [MASKED] 04:00PM BLOOD [MASKED] PTT-27.5 [MASKED] [MASKED] 12:30PM BLOOD Glucose-208* UreaN-32* Creat-1.3* Na-133 K-4.3 Cl-95* HCO3-23 AnGap-19 [MASKED] 06:08AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9 UricAcd-6.7* Iron-25* [MASKED] 06:08AM BLOOD calTIBC-225* [MASKED] Ferritn-348* TRF-173* [MASKED] 06:08AM BLOOD LD(LDH)-195 [MASKED] 12:50PM BLOOD Lactate-1.5 [MASKED] 01:40PM URINE Color-Yellow Appear-Cloudy Sp [MASKED] [MASKED] 01:40PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [MASKED] 01:40PM URINE RBC-17* WBC->182* Bacteri-MANY Yeast-NONE Epi-1 URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] BLOOD CULTURES X2: NO GROWTH TO DATE STUDIES: [MASKED] CXR: Re- demonstrated moderate pulmonary edema without definite focal consolidation. Atypical infection is not excluded in the appropriate clinical setting. [MASKED] KNEE FILMS, BILATERAL: IMPRESSION: Diffuse osteopenia. Moderate to moderately severe osteoarthritis in both knees. No obvious fracture or dislocation identified on these views. No gross effusion detected in either knee. A small joint effusion might not be apparent on the cross-table lateral views. No bone erosion, periostitis, or chondrocalcinosis detected in either knee. DISCHARGE LABS: [MASKED] 07:23AM BLOOD WBC-6.6 RBC-2.61* Hgb-7.6* Hct-24.4* MCV-94 MCH-29.1 MCHC-31.1* RDW-14.1 RDWSD-47.8* Plt [MASKED] [MASKED] 07:23AM BLOOD Glucose-132* UreaN-23* Creat-1.1 Na-138 K-3.6 Cl-103 HCO3-24 AnGap-15 [MASKED] 07:23AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 Brief Hospital Course: Ms [MASKED] is a [MASKED] yo F with history of Sweets Syndrome, Type 2 DM, pulmonary hypertension on home oxygen, who presented to the ED on [MASKED] with symptoms of URI found to have UTI, also with bilateral knee pain that may have been due to manifestation of Sweet's syndrome. #Complicated cystitis: Initially treated with CTX, then bactrim. She will continue bactrim 1 DS BID (total 7d, [MASKED]. #Acute bilateral medial knee pain: Resolved by day of discharge. [MASKED] have been due to Sweet's flare, exacerbated by infection. Knee films with moderate-severe osteoarthritis. Evaluated by rheumatology - no effusion to be tapped. She initially was unable to walk due to the pain, but was cleared by [MASKED] on day of discharge. #[MASKED] SYNDROME: With apparent flare, precipitated by UTI. She developed characteristic skin lesions on bilateral MCP/elbows. She continued dapsone. #URI : No evidence of PNA on CXR. No cough. Mild symptoms. Treated with supportive care #Acute on chronic kidney disease: Stage [MASKED] CKD at baseline. S/p IVF in the ED. Suspect that this is pre renal in setting of recent illness and decreased PO intake. Cr downtrended to normal. #Acute on chronic anemia: Hgb last 11 in [MASKED]. She did have hemolysis during her last admission. Hemolysis labs negative. Transferrin sat 14%, but iron studies suggestive of anemia of chronic disease. #DEPRESSION Continued sertraline TRANSITIONAL ISSUES: ===================== -Knee XRAYS showed diffuse osteopenia; consider DEXA -Last day ABx [MASKED] # CODE STATUS: Full code with limited trial # CONTACT: Name of health care proxy: [MASKED] Relationship: [MASKED] Phone number: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Vesicare (solifenacin) 5 mg oral DAILY 2. GlipiZIDE 5 mg PO DAILY 3. Dapsone 100 mg PO DAILY 4. Sertraline 100 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*7 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. Dapsone 100 mg PO DAILY 4. GlipiZIDE 5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: complicated urinary tract infection acute viral syndrome acute tendonitis acute on chronic Sweet's syndrome secondary chronic kidney disease type II diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], Why were you here: -You were very weak and almost collapsed -You had a urinary tract infection -You had knee pain likely from a Sweet's flare What was done: -We gave you fluids in your IV and antibiotics. You improved. What to do next: -Take all your medications as prescribed and follow-up at the appointments below. We wish you all the best, Your [MASKED] team Followup Instructions: [MASKED]
[]
[ "N179", "E1122", "I130", "J449", "Z87891", "E785", "G4733", "F329" ]
[ "N3090: Cystitis, unspecified without hematuria", "N179: Acute kidney failure, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I509: Heart failure, unspecified", "I272: Other secondary pulmonary hypertension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "B349: Viral infection, unspecified", "L982: Febrile neutrophilic dermatosis [Sweet]", "N183: Chronic kidney disease, stage 3 (moderate)", "Z9981: Dependence on supplemental oxygen", "J069: Acute upper respiratory infection, unspecified", "M170: Bilateral primary osteoarthritis of knee", "Z23: Encounter for immunization", "J449: Chronic obstructive pulmonary disease, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "N3281: Overactive bladder", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F329: Major depressive disorder, single episode, unspecified", "M779: Enthesopathy, unspecified" ]
10,076,617
21,631,538
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin Attending: ___. Chief Complaint: Right hand swelling/erythema Major Surgical or Invasive Procedure: Incision and drainage of right hand collar button abscess. History of Present Illness: ___ female with PMHx of sweets syndrome and pulmonary hypertension on home O2 presents with right hand swelling since for 5 days. The patient symptoms started gradually, and then she thought it was related to her sweets syndrome. She attempted taking 60 mg of prednisone 3 days ago and 120 milligrams of prednisone yesterday without improvement in her symptoms. The patient swelling has progressively worsened over the past 5 days. Patient reports that her range of motion is limited by the swelling, however not limited by pain. She denies fevers, chills, lymphadenopathy, spreading erythema, new rash. Patient reports recent dental procedure with tooth extractions. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: Admission Physical Exam T99 Hr 98 BP 95/48, RR 18, O2 Sat 2L Con: Comfortable HEENT: Normocephalic, atraumatic, Oropharynx within normal limits Resp: No respiratory distress, on nasal cannula CV: Regular Rate and Rhythm, Abd: Non-distended. MSK: Swelling of the right hand over the second and third MCP, with volar erythema and separation of the right second and third digits with swelling between the second and third MCP. Pain on passive extension of the fingers, fingers flexed at rest, tenderness to palpation on the palmar surface of second and third fingers and palm, ___ ___ strength. Distal sensation intact, capillary refill <2 seconds. Strong regular radial pulse Skin: Warm and dry, No petechiae Neuro: speech fluent Psych: Normal mood/mentation Discharge Physical Exam: VITALS: 98.6 BP 127-130/43-57 HR ___ RR20 96% on ___ Tm ___ GENERAL - pleasant, well-appearing, in no acute distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no JVD CARDIAC - regular rate & rhythm, normal S1/S2, II/VI systolic murmur at RUSB. PULMONARY - clear aside from some crackles at bases ABDOMEN - normal BS, soft, NT, ND, Healed scab at midline scar. EXTREMITIES - WWP. Incision clean/dry/intact some peeling skin around wound with ongoing erythema. Good perfusion, sensation of fingers. No appreciable erythema on ___ Erythematous crusted lesion on the patient's right ankle Pertinent Results: ADMISSION LABS: =============== ___ 12:00PM BLOOD WBC-8.7 RBC-3.29* Hgb-9.9* Hct-31.6* MCV-96 MCH-30.1 MCHC-31.3* RDW-14.9 RDWSD-52.3* Plt ___ ___ 12:00PM BLOOD Neuts-71.6* Lymphs-17.6* Monos-9.2 Eos-0.6* Baso-0.7 Im ___ AbsNeut-6.24* AbsLymp-1.53 AbsMono-0.80 AbsEos-0.05 AbsBaso-0.06 ___ 12:00PM BLOOD Plt ___ ___ 06:15AM BLOOD ___ PTT-25.9 ___ ___ 12:00PM BLOOD Glucose-161* UreaN-30* Creat-1.0 Na-138 K-4.3 Cl-100 HCO3-29 AnGap-13 ___ 12:00PM BLOOD estGFR-Using this ___ 06:15AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.9 ___ 12:00PM BLOOD CRP-21* ___ 12:30PM BLOOD Lactate-1.9 ___ 08:19PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 08:19PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG ___ 08:19PM URINE RBC-1 WBC-164* Bacteri-MOD Yeast-NONE Epi-4 ___ 08:19PM URINE CastHy-0 ___ 08:19PM URINE Mucous-RARE OTHER PERTINENT LABS: ===================== ___ 07:45AM BLOOD WBC-7.7 RBC-2.35* Hgb-7.0* Hct-23.4* MCV-100* MCH-29.8 MCHC-29.9* RDW-15.5 RDWSD-55.6* Plt ___ ___ 06:58AM BLOOD Glucose-145* UreaN-17 Creat-1.3* Na-137 K-4.0 Cl-101 HCO3-26 AnGap-14 ___ 08:00AM BLOOD Glucose-151* UreaN-19 Creat-2.1* Na-140 K-3.9 Cl-103 HCO3-26 AnGap-15 ___ 08:15AM BLOOD Glucose-112* UreaN-22* Creat-2.5* Na-142 K-4.3 Cl-110* HCO3-24 AnGap-12 ___ 06:10AM BLOOD Glucose-124* UreaN-22* Creat-2.2* Na-142 K-3.9 Cl-111* HCO3-21* AnGap-14 ___ 08:10AM BLOOD Glucose-138* UreaN-23* Creat-2.2* Na-141 K-4.7 Cl-109* HCO3-21* AnGap-16 ___ 07:45AM BLOOD Glucose-129* UreaN-26* Creat-2.4* Na-139 K-3.9 Cl-106 HCO3-21* AnGap-16 ___ 12:55PM BLOOD ALT-16 AST-27 LD(LDH)-287* AlkPhos-78 TotBili-0.7 ___ 07:45AM BLOOD calTIBC-261 VitB12-617 Ferritn-412* TRF-201 ___ 06:10AM BLOOD Hapto-<5* ___ 07:15AM BLOOD CRP-51.2* ___ 07:02AM BLOOD CRP-38.0* ___ 06:58AM BLOOD CRP-43.9* ___ 07:45AM BLOOD CRP-71.5* ___ 12:55PM BLOOD PEP-NO SPECIFI MICRO: ====== WOUND CULTURE: GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ___ 8:23 pm URINE TAKEN FROM 67428M. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I 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---- =>16 R ___ Blood Culture x2: NO GROWTH ___ Blood Culture x2: NO GROWTH IMAGING: ======== -Hand XR ___ IMPRESSION: Diffuse soft tissue swelling. Degenerative changes as stated. No fracture. -Hand MR ___ 1. Diffuse subcutaneous edema with a more focal area seen in in the palmar/volar subcutaneous tissues at the level of the second-third proximal phalanges. No well-defined fluid collection/ abscess. 2. No evidence of osteomyelitis. 3. Mild tenosynovitis involving the fourth through sixth extensor compartments and second through fourth flexor tendons. The tendons are intact. 4. Multi focal degenerative changes are seen within the carpal joints, carpal/metacarpal joints, and MCP joints. -Hand US ___ IMPRESSION: 3.3 x 1.4 x 2.1 cm subcutaneous fluid collection along the palmar surface of the right hand, oriented along the MCP joints, worrisome for abscess. Along the dorsal surface of the hand there is edema without evidence of dorsal abscess or thrombophlebitis. -Renal US ___ Normal renal ultrasound. No hydronephrosis, nephrolithiasis, or mass lesion. -CXR ___ New, moderate pulmonary edema. -___ TTE: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF = 65%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: no definite vegetations seen (best excludeed by transesophageal echocardiography) DISCHARGE LABS: =============== ___ 07:15AM BLOOD WBC-8.9 RBC-2.53* Hgb-7.5* Hct-25.0* MCV-99* MCH-29.6 MCHC-30.0* RDW-15.6* RDWSD-56.9* Plt ___ ___ 07:15AM BLOOD Glucose-125* UreaN-26* Creat-2.3* Na-139 K-3.7 Cl-103 HCO3-22 AnGap-18 ___ 07:15AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.___ w/ PMH of ___'s syndrome and endometrial cancer presents with R palmar hand subcutaneous abscess s/p I+D. # Right hand palmar subcutaneous abscess: Presenting with 1 week of swelling, tenderness, and erythema of hand, and found to have collection of fluid on the palmar side of the hand on US. Most consistent with a subcutaneous abscess. Risk factors for abscess include her history of diabetes and immunosuppresion with recent prednisone use. Likely entry site in lesion noted on fifth digit. Superficial thrombophlebitis is unlikely given US findings. Unlikely Sweet Syndrome alone given her lesion is not consistent with a violaceous papule or plaque. Recent dental procedure along with heart murmur initially raised suspicion for a septic emboli; however, unlikely given hx of mild aortic stenosis since ___ confirmed by ___ in ___. S/p hand debridement procedure ___. On broad spectrum abx coverage initially, narrowed to nafcillin ___ once cultures returned MSSA and subsequently transitioned to Keflex ___. Should have soapy washes BID and soft dry dressing for an additional week following discharge, and follow up with plastic surgery and dermatology. Treating with Keflex (overall antibiotics ___, plan for 14 day course). Being discharged to rehab for ongoing OT for hand. #Nonoliguric ___: Patient with bump in creatinine to 1.3 from baseline 1.0 on ___, subsequently increased to 2.5 by ___, remaining persistently elevated at 2.2 now. In setting of longstanding vanc/zosyn, recent procedure, and generally not feeling well with poor PO intake, with ongoing diarrhea. Renal US nl. CXR w/ moderate pulmonary edema, increased from prior. Unlikely prerenal given no response to fluids, volume overload on exam. Bland urine sediment, making AIN less likely. Unlikely postrenal given good voiding and low post-void residuals, w/ nl renal ultrasound. Urine sediment inactive. in setting of positive hemolysis labs, concern for HUS, but no schistocytes present on peripheral smear. TTE with some evidence of diastolic dysfunction, and given volume overload on exam (after 4L fluids given for ___, was diuresed w/ 40IV lasix ___. On discharge, creatinine 2.3, not volume overloaded and not discharged on diuretics. #Anemia: Hb decreased to 7.1 acutely ___ AM. Hemolysis labs and Fe deficiency labs most consistent with hemolysis. Has remained slowly downtrending. Initially c/f HUS given concurrent renal failure but no schistocytes. ___ be hemolysis in setting of acute infection, with possible component of decreased production ___ ___ leading to low EPO. Discharge Hgb 7.5. #Diarrhea Patient w/ episode of diarrhea, c.diff negative. With abdominal pain. Not ill appearing enough to be overly concerned for diverticulitis. Improved at present. #URI Patient with cough, cold, congestion. Likely URI. Resolved with supportive care #Nausea, flushing Patient presenting with nausea, flushing, and dizziness on ___. BP 94/40, HR 86. Orthostatics negative. EKG without ischemic changes. Possible vasovagal episode vs anxiety, gave Ativan 1 mg PO x1 and 500cc NS with resolution. #Asymptomatic pyuria and bacteriuria: Patient was nitrite positive and had WBC of 164 with large leukocytes indicative of a urinary tract infection. She currently does not endorse symptoms of UTI including dysuria, frequency, or suprapubic pain. Received empiric coverage with the antibiotic detailed above. # Sweet's syndrome: No current flare evident. Continued dapsone. # DM2: Continued glipizide. # HTN: Held lisinopril in setting of ___. Should resume as outpatient once Cr normalizes. # Pulmonary hypertension: Never had right heart cath, but per her pulmonology notes, this was seen on ECHO and felt to be consistent with her home O2 requirement. Continued 2L home O2. # OSA: Severe on sleep study. Not on CPAP at the moment given her mask has malfunctioned. Nocturnal O2 while inpatient. # Urge incontinence: Solifenacin not on formulary. On oxybutynin while inpatient, but discontinued per patient request. Please follow up need for oxybutynin, but would resume home medication. TRANSITIONAL ISSUES: ===================== -Discharge Hgb/Hct: 7.5, 25, please check for any active bleeding, no evidence in house -Discharge creatinine 2.3 (___) -Please check Basic Metabolic Panel on ___ and fax results to Dr. ___, Fax: ___ -Please monitor volume exam. If volume overload, weight gain >3 lbs, please consider IV ___ Lasix, and closer PCP follow up as no known prior history of heart failure (EF 75%, RA dilated) -Patient needs follow up of moderate pulmonary artery systolic hypertension -Please check with patient to make sure that appointments with hand surgery ___, ___ and nephrology have been finalized. -Continue Keflex (overall antibiotics ___, plan for 14 day course through ___ -Trend H/H; was stably anemic with evidence of hemolysis during this admission -Holding ACEi in the setting of ___ restart ACEi if normalized. # CONTACT: Friend and HCP ___ ___ # CODE STATUS: Full code (confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 2.5 mg PO DAILY 2. solifenacin 5 mg oral DAILY 3. Dapsone 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Sertraline 100 mg PO DAILY 6. GlipiZIDE 5 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Sertraline 100 mg PO DAILY 4. GlipiZIDE 5 mg PO DAILY 5. solifenacin 5 mg oral DAILY 6. Cephalexin 500 mg PO Q8H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Subcutaneous Abscess Acute Kidney Injury Secondary: Sweet's syndrome DM CKD, stage III HTN HLD (not taking prescribed Lipitor) recurrent cystitis, urge incontinence h/o endometrial cancer s/p ex-lap, LAH, TAH, BSO OSA on home BiPAP Pulmonary HTN on home O2 with ambulation Bell's palsy 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. WHY WAS I ADMITTED TO THE HOSPITAL - You had right hand swelling and redness. WHAT HAPPENED IN THE HOSPITAL - Both hand surgery and dermatology teams saw you. - You were treated with antibiotics. - You underwent a surgical drainage of your hand, with subsequent improvement - You were noted to have injury to your kidney, which was improving, and you are recommended to follow up with kidney specialists. WHAT DO I NEED TO DO WHEN I LEAVE THE HOSPITAL - Take all of your medicines as prescribed. Note that you are no longer on the lisinopril because of your kidney injury. - Go to all of your follow-up appointments. - Call your doctor if you have worsening redness, swelling, or pain of the right hand. Sincerely, Your ___ Team Followup Instructions: ___
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Allergies: Clindamycin Chief Complaint: Right hand swelling/erythema Major Surgical or Invasive Procedure: Incision and drainage of right hand collar button abscess. History of Present Illness: [MASKED] female with PMHx of sweets syndrome and pulmonary hypertension on home O2 presents with right hand swelling since for 5 days. The patient symptoms started gradually, and then she thought it was related to her sweets syndrome. She attempted taking 60 mg of prednisone 3 days ago and 120 milligrams of prednisone yesterday without improvement in her symptoms. The patient swelling has progressively worsened over the past 5 days. Patient reports that her range of motion is limited by the swelling, however not limited by pain. She denies fevers, chills, lymphadenopathy, spreading erythema, new rash. Patient reports recent dental procedure with tooth extractions. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN [MASKED]: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: [MASKED] Family History: Father - deceased of MI in his [MASKED] Mother - emphysema, deceased in her [MASKED] No children Physical Exam: Admission Physical Exam T99 Hr 98 BP 95/48, RR 18, O2 Sat 2L Con: Comfortable HEENT: Normocephalic, atraumatic, Oropharynx within normal limits Resp: No respiratory distress, on nasal cannula CV: Regular Rate and Rhythm, Abd: Non-distended. MSK: Swelling of the right hand over the second and third MCP, with volar erythema and separation of the right second and third digits with swelling between the second and third MCP. Pain on passive extension of the fingers, fingers flexed at rest, tenderness to palpation on the palmar surface of second and third fingers and palm, [MASKED] [MASKED] strength. Distal sensation intact, capillary refill <2 seconds. Strong regular radial pulse Skin: Warm and dry, No petechiae Neuro: speech fluent Psych: Normal mood/mentation Discharge Physical Exam: VITALS: 98.6 BP 127-130/43-57 HR [MASKED] RR20 96% on [MASKED] Tm [MASKED] GENERAL - pleasant, well-appearing, in no acute distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no JVD CARDIAC - regular rate & rhythm, normal S1/S2, II/VI systolic murmur at RUSB. PULMONARY - clear aside from some crackles at bases ABDOMEN - normal BS, soft, NT, ND, Healed scab at midline scar. EXTREMITIES - WWP. Incision clean/dry/intact some peeling skin around wound with ongoing erythema. Good perfusion, sensation of fingers. No appreciable erythema on [MASKED] Erythematous crusted lesion on the patient's right ankle Pertinent Results: ADMISSION LABS: =============== [MASKED] 12:00PM BLOOD WBC-8.7 RBC-3.29* Hgb-9.9* Hct-31.6* MCV-96 MCH-30.1 MCHC-31.3* RDW-14.9 RDWSD-52.3* Plt [MASKED] [MASKED] 12:00PM BLOOD Neuts-71.6* Lymphs-17.6* Monos-9.2 Eos-0.6* Baso-0.7 Im [MASKED] AbsNeut-6.24* AbsLymp-1.53 AbsMono-0.80 AbsEos-0.05 AbsBaso-0.06 [MASKED] 12:00PM BLOOD Plt [MASKED] [MASKED] 06:15AM BLOOD [MASKED] PTT-25.9 [MASKED] [MASKED] 12:00PM BLOOD Glucose-161* UreaN-30* Creat-1.0 Na-138 K-4.3 Cl-100 HCO3-29 AnGap-13 [MASKED] 12:00PM BLOOD estGFR-Using this [MASKED] 06:15AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.9 [MASKED] 12:00PM BLOOD CRP-21* [MASKED] 12:30PM BLOOD Lactate-1.9 [MASKED] 08:19PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 08:19PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [MASKED] 08:19PM URINE RBC-1 WBC-164* Bacteri-MOD Yeast-NONE Epi-4 [MASKED] 08:19PM URINE CastHy-0 [MASKED] 08:19PM URINE Mucous-RARE OTHER PERTINENT LABS: ===================== [MASKED] 07:45AM BLOOD WBC-7.7 RBC-2.35* Hgb-7.0* Hct-23.4* MCV-100* MCH-29.8 MCHC-29.9* RDW-15.5 RDWSD-55.6* Plt [MASKED] [MASKED] 06:58AM BLOOD Glucose-145* UreaN-17 Creat-1.3* Na-137 K-4.0 Cl-101 HCO3-26 AnGap-14 [MASKED] 08:00AM BLOOD Glucose-151* UreaN-19 Creat-2.1* Na-140 K-3.9 Cl-103 HCO3-26 AnGap-15 [MASKED] 08:15AM BLOOD Glucose-112* UreaN-22* Creat-2.5* Na-142 K-4.3 Cl-110* HCO3-24 AnGap-12 [MASKED] 06:10AM BLOOD Glucose-124* UreaN-22* Creat-2.2* Na-142 K-3.9 Cl-111* HCO3-21* AnGap-14 [MASKED] 08:10AM BLOOD Glucose-138* UreaN-23* Creat-2.2* Na-141 K-4.7 Cl-109* HCO3-21* AnGap-16 [MASKED] 07:45AM BLOOD Glucose-129* UreaN-26* Creat-2.4* Na-139 K-3.9 Cl-106 HCO3-21* AnGap-16 [MASKED] 12:55PM BLOOD ALT-16 AST-27 LD(LDH)-287* AlkPhos-78 TotBili-0.7 [MASKED] 07:45AM BLOOD calTIBC-261 VitB12-617 Ferritn-412* TRF-201 [MASKED] 06:10AM BLOOD Hapto-<5* [MASKED] 07:15AM BLOOD CRP-51.2* [MASKED] 07:02AM BLOOD CRP-38.0* [MASKED] 06:58AM BLOOD CRP-43.9* [MASKED] 07:45AM BLOOD CRP-71.5* [MASKED] 12:55PM BLOOD PEP-NO SPECIFI MICRO: ====== WOUND CULTURE: GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [MASKED]: STAPH AUREUS COAG +. SPARSE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S [MASKED] 8:23 pm URINE TAKEN FROM 67428M. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I 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---- =>16 R [MASKED] Blood Culture x2: NO GROWTH [MASKED] Blood Culture x2: NO GROWTH IMAGING: ======== -Hand XR [MASKED] IMPRESSION: Diffuse soft tissue swelling. Degenerative changes as stated. No fracture. -Hand MR [MASKED] 1. Diffuse subcutaneous edema with a more focal area seen in in the palmar/volar subcutaneous tissues at the level of the second-third proximal phalanges. No well-defined fluid collection/ abscess. 2. No evidence of osteomyelitis. 3. Mild tenosynovitis involving the fourth through sixth extensor compartments and second through fourth flexor tendons. The tendons are intact. 4. Multi focal degenerative changes are seen within the carpal joints, carpal/metacarpal joints, and MCP joints. -Hand US [MASKED] IMPRESSION: 3.3 x 1.4 x 2.1 cm subcutaneous fluid collection along the palmar surface of the right hand, oriented along the MCP joints, worrisome for abscess. Along the dorsal surface of the hand there is edema without evidence of dorsal abscess or thrombophlebitis. -Renal US [MASKED] Normal renal ultrasound. No hydronephrosis, nephrolithiasis, or mass lesion. -CXR [MASKED] New, moderate pulmonary edema. -[MASKED] TTE: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF = 65%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: no definite vegetations seen (best excludeed by transesophageal echocardiography) DISCHARGE LABS: =============== [MASKED] 07:15AM BLOOD WBC-8.9 RBC-2.53* Hgb-7.5* Hct-25.0* MCV-99* MCH-29.6 MCHC-30.0* RDW-15.6* RDWSD-56.9* Plt [MASKED] [MASKED] 07:15AM BLOOD Glucose-125* UreaN-26* Creat-2.3* Na-139 K-3.7 Cl-103 HCO3-22 AnGap-18 [MASKED] 07:15AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.[MASKED] w/ PMH of [MASKED]'s syndrome and endometrial cancer presents with R palmar hand subcutaneous abscess s/p I+D. # Right hand palmar subcutaneous abscess: Presenting with 1 week of swelling, tenderness, and erythema of hand, and found to have collection of fluid on the palmar side of the hand on US. Most consistent with a subcutaneous abscess. Risk factors for abscess include her history of diabetes and immunosuppresion with recent prednisone use. Likely entry site in lesion noted on fifth digit. Superficial thrombophlebitis is unlikely given US findings. Unlikely Sweet Syndrome alone given her lesion is not consistent with a violaceous papule or plaque. Recent dental procedure along with heart murmur initially raised suspicion for a septic emboli; however, unlikely given hx of mild aortic stenosis since [MASKED] confirmed by [MASKED] in [MASKED]. S/p hand debridement procedure [MASKED]. On broad spectrum abx coverage initially, narrowed to nafcillin [MASKED] once cultures returned MSSA and subsequently transitioned to Keflex [MASKED]. Should have soapy washes BID and soft dry dressing for an additional week following discharge, and follow up with plastic surgery and dermatology. Treating with Keflex (overall antibiotics [MASKED], plan for 14 day course). Being discharged to rehab for ongoing OT for hand. #Nonoliguric [MASKED]: Patient with bump in creatinine to 1.3 from baseline 1.0 on [MASKED], subsequently increased to 2.5 by [MASKED], remaining persistently elevated at 2.2 now. In setting of longstanding vanc/zosyn, recent procedure, and generally not feeling well with poor PO intake, with ongoing diarrhea. Renal US nl. CXR w/ moderate pulmonary edema, increased from prior. Unlikely prerenal given no response to fluids, volume overload on exam. Bland urine sediment, making AIN less likely. Unlikely postrenal given good voiding and low post-void residuals, w/ nl renal ultrasound. Urine sediment inactive. in setting of positive hemolysis labs, concern for HUS, but no schistocytes present on peripheral smear. TTE with some evidence of diastolic dysfunction, and given volume overload on exam (after 4L fluids given for [MASKED], was diuresed w/ 40IV lasix [MASKED]. On discharge, creatinine 2.3, not volume overloaded and not discharged on diuretics. #Anemia: Hb decreased to 7.1 acutely [MASKED] AM. Hemolysis labs and Fe deficiency labs most consistent with hemolysis. Has remained slowly downtrending. Initially c/f HUS given concurrent renal failure but no schistocytes. [MASKED] be hemolysis in setting of acute infection, with possible component of decreased production [MASKED] [MASKED] leading to low EPO. Discharge Hgb 7.5. #Diarrhea Patient w/ episode of diarrhea, c.diff negative. With abdominal pain. Not ill appearing enough to be overly concerned for diverticulitis. Improved at present. #URI Patient with cough, cold, congestion. Likely URI. Resolved with supportive care #Nausea, flushing Patient presenting with nausea, flushing, and dizziness on [MASKED]. BP 94/40, HR 86. Orthostatics negative. EKG without ischemic changes. Possible vasovagal episode vs anxiety, gave Ativan 1 mg PO x1 and 500cc NS with resolution. #Asymptomatic pyuria and bacteriuria: Patient was nitrite positive and had WBC of 164 with large leukocytes indicative of a urinary tract infection. She currently does not endorse symptoms of UTI including dysuria, frequency, or suprapubic pain. Received empiric coverage with the antibiotic detailed above. # Sweet's syndrome: No current flare evident. Continued dapsone. # DM2: Continued glipizide. # HTN: Held lisinopril in setting of [MASKED]. Should resume as outpatient once Cr normalizes. # Pulmonary hypertension: Never had right heart cath, but per her pulmonology notes, this was seen on ECHO and felt to be consistent with her home O2 requirement. Continued 2L home O2. # OSA: Severe on sleep study. Not on CPAP at the moment given her mask has malfunctioned. Nocturnal O2 while inpatient. # Urge incontinence: Solifenacin not on formulary. On oxybutynin while inpatient, but discontinued per patient request. Please follow up need for oxybutynin, but would resume home medication. TRANSITIONAL ISSUES: ===================== -Discharge Hgb/Hct: 7.5, 25, please check for any active bleeding, no evidence in house -Discharge creatinine 2.3 ([MASKED]) -Please check Basic Metabolic Panel on [MASKED] and fax results to Dr. [MASKED], Fax: [MASKED] -Please monitor volume exam. If volume overload, weight gain >3 lbs, please consider IV [MASKED] Lasix, and closer PCP follow up as no known prior history of heart failure (EF 75%, RA dilated) -Patient needs follow up of moderate pulmonary artery systolic hypertension -Please check with patient to make sure that appointments with hand surgery [MASKED], [MASKED] and nephrology have been finalized. -Continue Keflex (overall antibiotics [MASKED], plan for 14 day course through [MASKED] -Trend H/H; was stably anemic with evidence of hemolysis during this admission -Holding ACEi in the setting of [MASKED] restart ACEi if normalized. # CONTACT: Friend and HCP [MASKED] [MASKED] # CODE STATUS: Full code (confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 2.5 mg PO DAILY 2. solifenacin 5 mg oral DAILY 3. Dapsone 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Sertraline 100 mg PO DAILY 6. GlipiZIDE 5 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Sertraline 100 mg PO DAILY 4. GlipiZIDE 5 mg PO DAILY 5. solifenacin 5 mg oral DAILY 6. Cephalexin 500 mg PO Q8H Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary: Subcutaneous Abscess Acute Kidney Injury Secondary: Sweet's syndrome DM CKD, stage III HTN HLD (not taking prescribed Lipitor) recurrent cystitis, urge incontinence h/o endometrial cancer s/p ex-lap, LAH, TAH, BSO OSA on home BiPAP Pulmonary HTN on home O2 with ambulation Bell's palsy 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. WHY WAS I ADMITTED TO THE HOSPITAL - You had right hand swelling and redness. WHAT HAPPENED IN THE HOSPITAL - Both hand surgery and dermatology teams saw you. - You were treated with antibiotics. - You underwent a surgical drainage of your hand, with subsequent improvement - You were noted to have injury to your kidney, which was improving, and you are recommended to follow up with kidney specialists. WHAT DO I NEED TO DO WHEN I LEAVE THE HOSPITAL - Take all of your medicines as prescribed. Note that you are no longer on the lisinopril because of your kidney injury. - Go to all of your follow-up appointments. - Call your doctor if you have worsening redness, swelling, or pain of the right hand. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "N179", "E872", "I129", "E785", "G4733", "J449", "Z87891" ]
[ "L02511: Cutaneous abscess of right hand", "I5031: Acute diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "K521: Toxic gastroenteritis and colitis", "E872: Acidosis", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "D594: Other nonautoimmune hemolytic anemias", "L03113: Cellulitis of right upper limb", "I272: Other secondary pulmonary hypertension", "Z9981: Dependence on supplemental oxygen", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "G4733: Obstructive sleep apnea (adult) (pediatric)", "J449: Chronic obstructive pulmonary disease, unspecified", "Z87891: Personal history of nicotine dependence", "L982: Febrile neutrophilic dermatosis [Sweet]", "N3941: Urge incontinence", "N3090: Cystitis, unspecified without hematuria", "G510: Bell's palsy", "M659: Synovitis and tenosynovitis, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "T3695XA: Adverse effect of unspecified systemic antibiotic, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "J069: Acute upper respiratory infection, unspecified", "R110: Nausea", "R232: Flushing" ]
10,076,617
23,299,601
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with pulmonary HTN, likely OSA, moderate AS, resultant chronic hypoxic respiratory failure on intermittent home O2, DM2, HL, Sweet's syndrome, pyoderma gangrenosum, remote endometrial cancer s/p hysterectomy, remote diverticulitis s/p partial colectomy, overactive bladder on Vesicare, and history of UTI presenting as weakness who presented with weakness. She was in her usual state of health until ___, when she went to the ___ for a wedding. She says she typically has OAB with incontinence, so did not drink any fluids on ___ out of concern for incontinence during the long drive to and from the ___. Over the course of the day, she noticed increasing subjective weakness and unsteadiness on her feet. This continued through ___, getting progressively worse. She decided to come to the ED today after she noticed extreme difficulty getting herself out of bed. In the ED, she had low grade fever but otherwise stable vital signs. She had labs showing mild acute renal failure, mild leukocytosis, and pyuria with bacteriuria (though specimen was contaminated with epis). CXR was performed and was unremarkable. She was given IVF, CTX, and admission was requested. REVIEW OF SYSTEMS A full 10 point review of systems was performed and is otherwise negative except as noted above. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 98.5 122 / 71 83 18 96 4L Gen: NAD, sitting up in bed, very pleasant Eyes: EOMI, sclerae anicteric HENT: NCAT, MMM, OP clear, hearing adequate Cardiovasc: RRR, no obvious MRG. Full pulses, no edema. Resp: normal effort, breathing unlabored, no accessory muscle use, lungs CTA with bilateral fairly coarse crackles. GI: Soft, NT, ND, BS+. No HSM. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Generalized weakness. Psych: Full range of affect. Thought linear. GU: No foley DISCHARGE PHYSICAL EXAM: ======================== VITALS: 98.7 103 / 69 71 18 93 3LNC Gen: NAD, sitting up in bed, very pleasant Eyes: EOMI, sclerae anicteric HENT: NCAT, MMM, OP clear, hearing adequate Cardiovasc: RRR, no obvious MRG. Full pulses, no ___ edema. Resp: normal effort, breathing unlabored, no accessory muscle use, lungs CTA with bilateral fairly coarse crackles - fewer today. GI: Soft, NT, ND, BS+. No HSM. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash on exposed skin. No jaundice. Periumbilical wound - see wound care and nursing notes. Neuro: AAOx3. No facial droop. Generalized weakness. Psych: Full range of affect. Thought linear. GU: No foley Pertinent Results: ADMISSION LABS: =============== ___ 11:40AM BLOOD WBC-10.8*# RBC-3.47* Hgb-10.3* Hct-32.4* MCV-93 MCH-29.7 MCHC-31.8* RDW-13.3 RDWSD-45.3 Plt ___ ___ 11:40AM BLOOD Neuts-81.8* Lymphs-6.7* Monos-10.2 Eos-0.2* Baso-0.5 Im ___ AbsNeut-8.87*# AbsLymp-0.72* AbsMono-1.10* AbsEos-0.02* AbsBaso-0.05 ___ 11:40AM BLOOD Glucose-220* UreaN-22* Creat-1.2* Na-135 K-4.0 Cl-96 HCO3-24 AnGap-15 ___ 08:12AM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 08:12AM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 08:12AM URINE RBC-16* WBC->182* Bacteri-FEW* Yeast-NONE Epi-2 ___ 12:07PM URINE CastHy-22* PERTINENT LABS: =============== ___ 11:40AM BLOOD TSH-1.4 ___ 11:40AM BLOOD CK(CPK)-193 PERTINENT MICRO: ================ ___ 12:07 pm URINE ___. **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Blood culture ___: Pending PERTINENT IMAGING: ================== CXR ___: IMPRESSION: No acute intrathoracic process. Stable mild cardiac enlargement. DISCHARGE LABS: =============== ___ 07:35AM BLOOD WBC-6.0 RBC-3.12* Hgb-9.3* Hct-29.9* MCV-96 MCH-29.8 MCHC-31.1* RDW-13.8 RDWSD-48.2* Plt ___ ___ 07:35AM BLOOD Glucose-149* UreaN-16 Creat-0.9 Na-141 K-4.4 Cl-102 HCO3-26 AnGap-13 ___ 07:35AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.___ with pulmonary HTN, likely OSA, moderate AS, resultant chronic hypoxic respiratory failure on intermittent home O2, DM2, HLD, Sweet's syndrome, pyoderma gangrenosum, remote endometrial cancer s/p hysterectomy, remote diverticulitis s/p partial colectomy, overactive bladder on Vesicare, and history of UTIs which have presented as weakness admitted with weakness in the setting of a UTI. Urine culture grew E. coli that was sensitive to all antibiotics except nitrofurantoin. She was treated for 4 days with Ceftriaxone, and narrowed to Ciprofloxacin PO to complete a total 7 day course gien her systemic symptoms. She was discharged to rehab. TRANSITIONAL ISSUES: ==================== - Patient discharged on Ciprfloxacin 500 mg PO BID for UTI, to be completed on ___ - Her Vesicare (Solifenacin) was stopped, as this may have been increasing urinary stasis and predisposing to UTI. She should follow-up with gynecology or urology as an outpatient. - Patient likely has underlying OSA, would benefit from an outpatient sleep study to determine need for CPAP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Sertraline 100 mg PO DAILY 4. GlipiZIDE 5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Vesicare (solifenacin) 5 mg oral DAILY 7. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Doses last day: ___ 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Dapsone 100 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Sertraline 100 mg PO DAILY 8. HELD- Vesicare (solifenacin) 5 mg oral DAILY This medication was held. Do not restart Vesicare until you discuss use of this medication with your primary care doctor. Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Urinary tract infection Weakness Pulmonary hypertension Moderate aortic stenosis Hyperlipidemia Diabetes Sweet's syndrome Pyoderma gangrenosum Discharge Condition: Quite unsteady on her feet, requiring assistance and supervision - see ___ notes. 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 our pleasure caring for you at ___ ___. You were admitted to the hospital with weakness that was found to be due to a urinary tract infection. You were treated with antibiotics and you improved. You were seen by ___ and they recommended you go to rehab. You are being discharged to rehab to work on getting stronger so you can go home. Thank you for allowing us to participate in your care Followup Instructions: ___
[ "N390", "N179", "J9611", "E1122", "L88", "Z9981", "I350", "E785", "L982", "Z8542", "N3281", "I129", "N183", "G4733", "J449", "Z87891", "B9620", "R531", "R2681", "E861" ]
Allergies: Clindamycin Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] with pulmonary HTN, likely OSA, moderate AS, resultant chronic hypoxic respiratory failure on intermittent home O2, DM2, HL, Sweet's syndrome, pyoderma gangrenosum, remote endometrial cancer s/p hysterectomy, remote diverticulitis s/p partial colectomy, overactive bladder on Vesicare, and history of UTI presenting as weakness who presented with weakness. She was in her usual state of health until [MASKED], when she went to the [MASKED] for a wedding. She says she typically has OAB with incontinence, so did not drink any fluids on [MASKED] out of concern for incontinence during the long drive to and from the [MASKED]. Over the course of the day, she noticed increasing subjective weakness and unsteadiness on her feet. This continued through [MASKED], getting progressively worse. She decided to come to the ED today after she noticed extreme difficulty getting herself out of bed. In the ED, she had low grade fever but otherwise stable vital signs. She had labs showing mild acute renal failure, mild leukocytosis, and pyuria with bacteriuria (though specimen was contaminated with epis). CXR was performed and was unremarkable. She was given IVF, CTX, and admission was requested. REVIEW OF SYSTEMS A full 10 point review of systems was performed and is otherwise negative except as noted above. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN [MASKED]: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: [MASKED] Family History: Father - deceased of MI in his [MASKED] Mother - emphysema, deceased in her [MASKED] No children Physical Exam: ADMISSION PHYSICAL EXAM: ======================== Vitals: 98.5 122 / 71 83 18 96 4L Gen: NAD, sitting up in bed, very pleasant Eyes: EOMI, sclerae anicteric HENT: NCAT, MMM, OP clear, hearing adequate Cardiovasc: RRR, no obvious MRG. Full pulses, no edema. Resp: normal effort, breathing unlabored, no accessory muscle use, lungs CTA with bilateral fairly coarse crackles. GI: Soft, NT, ND, BS+. No HSM. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Generalized weakness. Psych: Full range of affect. Thought linear. GU: No foley DISCHARGE PHYSICAL EXAM: ======================== VITALS: 98.7 103 / 69 71 18 93 3LNC Gen: NAD, sitting up in bed, very pleasant Eyes: EOMI, sclerae anicteric HENT: NCAT, MMM, OP clear, hearing adequate Cardiovasc: RRR, no obvious MRG. Full pulses, no [MASKED] edema. Resp: normal effort, breathing unlabored, no accessory muscle use, lungs CTA with bilateral fairly coarse crackles - fewer today. GI: Soft, NT, ND, BS+. No HSM. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash on exposed skin. No jaundice. Periumbilical wound - see wound care and nursing notes. Neuro: AAOx3. No facial droop. Generalized weakness. Psych: Full range of affect. Thought linear. GU: No foley Pertinent Results: ADMISSION LABS: =============== [MASKED] 11:40AM BLOOD WBC-10.8*# RBC-3.47* Hgb-10.3* Hct-32.4* MCV-93 MCH-29.7 MCHC-31.8* RDW-13.3 RDWSD-45.3 Plt [MASKED] [MASKED] 11:40AM BLOOD Neuts-81.8* Lymphs-6.7* Monos-10.2 Eos-0.2* Baso-0.5 Im [MASKED] AbsNeut-8.87*# AbsLymp-0.72* AbsMono-1.10* AbsEos-0.02* AbsBaso-0.05 [MASKED] 11:40AM BLOOD Glucose-220* UreaN-22* Creat-1.2* Na-135 K-4.0 Cl-96 HCO3-24 AnGap-15 [MASKED] 08:12AM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 08:12AM URINE Blood-SM* Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* [MASKED] 08:12AM URINE RBC-16* WBC->182* Bacteri-FEW* Yeast-NONE Epi-2 [MASKED] 12:07PM URINE CastHy-22* PERTINENT LABS: =============== [MASKED] 11:40AM BLOOD TSH-1.4 [MASKED] 11:40AM BLOOD CK(CPK)-193 PERTINENT MICRO: ================ [MASKED] 12:07 pm URINE [MASKED]. **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Blood culture [MASKED]: Pending PERTINENT IMAGING: ================== CXR [MASKED]: IMPRESSION: No acute intrathoracic process. Stable mild cardiac enlargement. DISCHARGE LABS: =============== [MASKED] 07:35AM BLOOD WBC-6.0 RBC-3.12* Hgb-9.3* Hct-29.9* MCV-96 MCH-29.8 MCHC-31.1* RDW-13.8 RDWSD-48.2* Plt [MASKED] [MASKED] 07:35AM BLOOD Glucose-149* UreaN-16 Creat-0.9 Na-141 K-4.4 Cl-102 HCO3-26 AnGap-13 [MASKED] 07:35AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.[MASKED] with pulmonary HTN, likely OSA, moderate AS, resultant chronic hypoxic respiratory failure on intermittent home O2, DM2, HLD, Sweet's syndrome, pyoderma gangrenosum, remote endometrial cancer s/p hysterectomy, remote diverticulitis s/p partial colectomy, overactive bladder on Vesicare, and history of UTIs which have presented as weakness admitted with weakness in the setting of a UTI. Urine culture grew E. coli that was sensitive to all antibiotics except nitrofurantoin. She was treated for 4 days with Ceftriaxone, and narrowed to Ciprofloxacin PO to complete a total 7 day course gien her systemic symptoms. She was discharged to rehab. TRANSITIONAL ISSUES: ==================== - Patient discharged on Ciprfloxacin 500 mg PO BID for UTI, to be completed on [MASKED] - Her Vesicare (Solifenacin) was stopped, as this may have been increasing urinary stasis and predisposing to UTI. She should follow-up with gynecology or urology as an outpatient. - Patient likely has underlying OSA, would benefit from an outpatient sleep study to determine need for CPAP Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Sertraline 100 mg PO DAILY 4. GlipiZIDE 5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Vesicare (solifenacin) 5 mg oral DAILY 7. Atorvastatin 40 mg PO QPM Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Doses last day: [MASKED] 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Dapsone 100 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Sertraline 100 mg PO DAILY 8. HELD- Vesicare (solifenacin) 5 mg oral DAILY This medication was held. Do not restart Vesicare until you discuss use of this medication with your primary care doctor. Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: Urinary tract infection Weakness Pulmonary hypertension Moderate aortic stenosis Hyperlipidemia Diabetes Sweet's syndrome Pyoderma gangrenosum Discharge Condition: Quite unsteady on her feet, requiring assistance and supervision - see [MASKED] notes. 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 our pleasure caring for you at [MASKED] [MASKED]. You were admitted to the hospital with weakness that was found to be due to a urinary tract infection. You were treated with antibiotics and you improved. You were seen by [MASKED] and they recommended you go to rehab. You are being discharged to rehab to work on getting stronger so you can go home. Thank you for allowing us to participate in your care Followup Instructions: [MASKED]
[]
[ "N390", "N179", "E1122", "E785", "I129", "G4733", "J449", "Z87891" ]
[ "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "J9611: Chronic respiratory failure with hypoxia", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "L88: Pyoderma gangrenosum", "Z9981: Dependence on supplemental oxygen", "I350: Nonrheumatic aortic (valve) stenosis", "E785: Hyperlipidemia, unspecified", "L982: Febrile neutrophilic dermatosis [Sweet]", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "N3281: Overactive bladder", "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)", "G4733: Obstructive sleep apnea (adult) (pediatric)", "J449: Chronic obstructive pulmonary disease, unspecified", "Z87891: Personal history of nicotine dependence", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "R531: Weakness", "R2681: Unsteadiness on feet", "E861: Hypovolemia" ]
10,076,617
25,575,063
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Clindamycin Attending: ___. Chief Complaint: Dyspnea, leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman CKD stage III, hypertension, anxiety, type 2 diabetes, anemia, mild moderate pulmonary hypertension on home oxygen, and a history of Sweet's syndrome who presented to the ED as a transfer from ___ with worsening dyspnea and leg swelling. Notably, patient was seen in CDAC in ___ for moderate pulmonary effusion which was new compared to her prior echo about six months prior. No evidence of tamponade physiology, hemodynamically stable with a normal pulsus paradoxus in the clinic. Follow up TTE showed spontaneous resolution. Three days prior to this admission the patient noticed her right leg becoming more swollen. She has also been feeling increased shortness of breath as well as dizziness. She noted the last day or two that her left leg was starting to swell as well. She denies any headache, chest pain, visual changes, abdominal symptoms. She has a history of Sweet's syndrome and and apparently thought she was having a flare. Regarding the dizziness, pt reports the comes/goes. Has had periods without dizziness. No clear exacerbating factors - denies worsening with standing from seated, head turning, or association with sob. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: 98.9 126/54 80 18 95ra GENERAL: Well developed, well nourished HEENT: Normocephalic atraumatic. CARDIAC: RRR, ___ systolic murmur at RUSB LUNGS: CTAB with no accessory muscle use. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused, trace edema in ankless SKIN: 1cm punched out appearing lesion on right ankle, no drainage or surrounding erythema or warmth DISCHARGE PHYSICAL EXAM: ======================= VITALS: T 98.9 PO BP 118 / 65 HR 84 RR 16 O2 95% RA GENERAL: Obese, well-developed woman NAD HEENT: Normocephalic atraumatic. CARDIAC: RRR, ___ systolic murmur at ___ LUNGS: Course crackles in lower lung fields posteriorly; no wheezes ABDOMEN: Soft, non-tender, non-distended. BS+ EXTREMITIES: Warm, well perfused, non-pitting edema up to knees bilaterally NEURO: no focal neurological deficits; moves all extremities with purpose Pertinent Results: ADMISSION LABS: ====================== ___ 12:45PM BLOOD WBC-6.2 RBC-2.83* Hgb-8.6* Hct-28.4* MCV-100* MCH-30.4 MCHC-30.3* RDW-14.4 RDWSD-53.4* Plt ___ ___ 12:45PM BLOOD Neuts-67.3 ___ Monos-7.7 Eos-2.3 Baso-1.1* Im ___ AbsNeut-4.17 AbsLymp-1.32 AbsMono-0.48 AbsEos-0.14 AbsBaso-0.07 ___ 12:45PM BLOOD ___ PTT-28.3 ___ ___ 12:05PM BLOOD Glucose-119* UreaN-21* Creat-1.0 Na-144 K-4.7 Cl-103 HCO3-25 AnGap-16 ___ 12:05PM BLOOD Calcium-9.6 Phos-3.6 Mg-2.0 ___ 12:45PM BLOOD calTIBC-317 VitB12-709 Folate->20 Hapto-<10* Ferritn-277* TRF-244 DISCHARGE LABS: ================== ___ 08:02AM BLOOD WBC-4.7 RBC-2.58* Hgb-8.0* Hct-26.4* MCV-102* MCH-31.0 MCHC-30.3* RDW-14.6 RDWSD-54.3* Plt ___ ___ 08:02AM BLOOD Glucose-124* UreaN-16 Creat-1.0 Na-145 K-5.0 Cl-105 HCO3-28 AnGap-12 ___ 08:02AM BLOOD ALT-21 AST-24 LD(LDH)-223 AlkPhos-83 TotBili-0.8 ___ 07:20AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0 IMAGING: =============== CHEST CT ___: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Small vessel airway disease and multifocal patchy airspace opacities. Differential considerations include multifocal pneumonia as well as aspiration pneumonitis. Follow-up CT chest in ___ weeks after resolution of symptoms is recommended. 3. Multiple pulmonary nodules as described above. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules bigger than 8mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended. TTE ___: FINDINGS: LEFT ATRIUM (LA)/PULMONARY VEINS: SEVERELY increased LA volume index. RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): Mildly dilated RA. Dilated IVC with normal inspiratory collapse==>RA pressure ___ mmHg. LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity size. Normal regional/global systolic function. The visually estimated left ventricular ejection fraction is 55-60%. Normal cardiac index (>2.5 L/min/m2). No resting outflow tract gradient. Tissue Doppler suggests elevated PCWP. RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall motion. AORTA: Normal sinus diameter for gender. Normal ascending diameter for gender. Normal arch diameter. Normal descending aorta. No coarctation. Focal calcifications in aortic sinus. No coarctation. AORTIC VALVE (AV): Mildly thickend (3) leaflets. Mild stenosis (area 1.5-1.9 cm2). Peak gradient obtained from right parasternal orientation. Trace regurgitation. MITRAL VALVE (MV): Mildly thickened leaflets. No systolic prolapse. Mild MAC. Papillary muscle fibrosis/ calcification. Mild-moderate [___] regurgitation. Central regurgitant jet. Regurgitation severity could be UNDERestimated due to acoustic shadowing. PULMONIC VALVE (PV): Normal leaflets. No stenosis. Physiologic regurgitation. TRICUSPID VALVE (TV): Mildly thickened leaflets. Mild [1+] regurgitation. Mild-moderate pulmonary artery systolic hypertension. PERICARDIUM: No effusion. Anterior fat pad RIGHT LOWER EXTREMITY ULTRASOUND ___: ====================================== IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Brief Hospital Course: PATIENT SUMMARY: ================= ___ with hx of CKD III, DM2, endometrial cancer, mild-moderate AS, presumed Sweet's syndrome, pulmonary HTN presenting with bilateral ___ pain, non-pitting edema, and dyspnea on exertion. ACUTE ISSUES: ================== # ___ discomfort, non-pitting edema: # DOE: Pt reports edema, with minimal pitting on exam, arguing against significant lower extremity interstitial edema. Difficult to assess objective change compared to baseline. TTE essentially unchanged compared to prior. Suspect her DOE is driven primarily by her underlying ILD, for which she is followed by Dr. ___. The constellation of her symptoms - Sweet syndrome, ILD, pyoderma gangrenosum - does point towards some underlying, unifying, systemic process. There are case reports of pulmonary involvement of Sweet syndrome, which would require BAL +/- transbronchial biopsy for diagnosis. Patient was able to ambulate comfortably on 2L of oxygen prior to discharge, which is her baseline. She will need close follow-up with pulmonology. # Hemolytic anemia: Patient has chronic, longstanding, with evidence of low grade anemia for at least ___ years per ___ records. G6PD checked and greater than upper limit of normal. Coombs test negative. Dapsone (without G6PD deficiency) can still cause hemolytic anemia. Per last hematology visit at ___, thought that anemia was in setting of dapsone. Would advise outpatient hematology evaluation, given stability and chronicity of this process. ================ CHRONIC ISSUES: ================ # HLD: Continued Aspirin 81 # Sweet's Syndrome: Continued Dapsone 100 mg, will need age appropriate cancer screening as outpatient given associations with Sweet's Syndrome. Will also need dermatology and hematology followup. # Depression: Continue Sertraline 100 mg. # T2DM: Held GlipiZIDE 5 mg. ISS while inpatient. # Overactive bladder: Vesicare (solifenacin) 5 mg oral DAILY (not formulary) held. TRANSITIONAL ISSUES: ===================== Discharge Hemoglobin: 8.0 Discharge Platelets: 127 Absolute Retic 0.11 Haptoglobin <10 []Patient needs up to date screening for malignancy, especially in setting of presumed Sweet's Syndrome diagnosis. [] Patient needs follow-up with heme in setting of Sweet's syndrome and hemolytic anemia. [] Last biopsy of skin suggestive of Sweet's versus vasculitis. Should follow-up with dermatology. [] CT chest ___ showing multifocal patchy airspace opacities. Recommended follow-up in ___ weeks to check for resolution. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Sertraline 100 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Vesicare (solifenacin) 5 mg oral DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. GlipiZIDE 5 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Sertraline 100 mg PO DAILY 6. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: # ___ discomfort # Dyspnea on exertion # Pulmonary Hypertension # Hemolytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you had worsening swelling in your legs and shortness of breath. WHAT HAPPENED TO ME IN THE HOSPITAL? - We did imaging of your lungs to look for blood clots, imaging of your leg, and imaging of your heart. We also did blood tests to better understand your low red blood cell counts. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - It is extremely important that you call to get your BiPAP setup, and that you use it every day. Your lung pressures are already elevated, and we don't want this to continue to get worse. - Please make sure you go to all of your appointments (listed below). - Please call to get a dermatology appointment. -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
[ "J849", "L88", "D589", "E1122", "I129", "N183", "G4733", "I350", "L982", "I2720", "E785", "E669", "F329", "N3281", "Z9641", "Z9981", "Z8542", "Z87891", "Z6839" ]
Allergies: Clindamycin Chief Complaint: Dyspnea, leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] woman CKD stage III, hypertension, anxiety, type 2 diabetes, anemia, mild moderate pulmonary hypertension on home oxygen, and a history of Sweet's syndrome who presented to the ED as a transfer from [MASKED] with worsening dyspnea and leg swelling. Notably, patient was seen in CDAC in [MASKED] for moderate pulmonary effusion which was new compared to her prior echo about six months prior. No evidence of tamponade physiology, hemodynamically stable with a normal pulsus paradoxus in the clinic. Follow up TTE showed spontaneous resolution. Three days prior to this admission the patient noticed her right leg becoming more swollen. She has also been feeling increased shortness of breath as well as dizziness. She noted the last day or two that her left leg was starting to swell as well. She denies any headache, chest pain, visual changes, abdominal symptoms. She has a history of Sweet's syndrome and and apparently thought she was having a flare. Regarding the dizziness, pt reports the comes/goes. Has had periods without dizziness. No clear exacerbating factors - denies worsening with standing from seated, head turning, or association with sob. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN [MASKED]: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: [MASKED] Family History: Father - deceased of MI in his [MASKED] Mother - emphysema, deceased in her [MASKED] No children Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: 98.9 126/54 80 18 95ra GENERAL: Well developed, well nourished HEENT: Normocephalic atraumatic. CARDIAC: RRR, [MASKED] systolic murmur at RUSB LUNGS: CTAB with no accessory muscle use. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused, trace edema in ankless SKIN: 1cm punched out appearing lesion on right ankle, no drainage or surrounding erythema or warmth DISCHARGE PHYSICAL EXAM: ======================= VITALS: T 98.9 PO BP 118 / 65 HR 84 RR 16 O2 95% RA GENERAL: Obese, well-developed woman NAD HEENT: Normocephalic atraumatic. CARDIAC: RRR, [MASKED] systolic murmur at [MASKED] LUNGS: Course crackles in lower lung fields posteriorly; no wheezes ABDOMEN: Soft, non-tender, non-distended. BS+ EXTREMITIES: Warm, well perfused, non-pitting edema up to knees bilaterally NEURO: no focal neurological deficits; moves all extremities with purpose Pertinent Results: ADMISSION LABS: ====================== [MASKED] 12:45PM BLOOD WBC-6.2 RBC-2.83* Hgb-8.6* Hct-28.4* MCV-100* MCH-30.4 MCHC-30.3* RDW-14.4 RDWSD-53.4* Plt [MASKED] [MASKED] 12:45PM BLOOD Neuts-67.3 [MASKED] Monos-7.7 Eos-2.3 Baso-1.1* Im [MASKED] AbsNeut-4.17 AbsLymp-1.32 AbsMono-0.48 AbsEos-0.14 AbsBaso-0.07 [MASKED] 12:45PM BLOOD [MASKED] PTT-28.3 [MASKED] [MASKED] 12:05PM BLOOD Glucose-119* UreaN-21* Creat-1.0 Na-144 K-4.7 Cl-103 HCO3-25 AnGap-16 [MASKED] 12:05PM BLOOD Calcium-9.6 Phos-3.6 Mg-2.0 [MASKED] 12:45PM BLOOD calTIBC-317 VitB12-709 Folate->20 Hapto-<10* Ferritn-277* TRF-244 DISCHARGE LABS: ================== [MASKED] 08:02AM BLOOD WBC-4.7 RBC-2.58* Hgb-8.0* Hct-26.4* MCV-102* MCH-31.0 MCHC-30.3* RDW-14.6 RDWSD-54.3* Plt [MASKED] [MASKED] 08:02AM BLOOD Glucose-124* UreaN-16 Creat-1.0 Na-145 K-5.0 Cl-105 HCO3-28 AnGap-12 [MASKED] 08:02AM BLOOD ALT-21 AST-24 LD(LDH)-223 AlkPhos-83 TotBili-0.8 [MASKED] 07:20AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0 IMAGING: =============== CHEST CT [MASKED]: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Small vessel airway disease and multifocal patchy airspace opacities. Differential considerations include multifocal pneumonia as well as aspiration pneumonitis. Follow-up CT chest in [MASKED] weeks after resolution of symptoms is recommended. 3. Multiple pulmonary nodules as described above. RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules bigger than 8mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient, with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended. TTE [MASKED]: FINDINGS: LEFT ATRIUM (LA)/PULMONARY VEINS: SEVERELY increased LA volume index. RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): Mildly dilated RA. Dilated IVC with normal inspiratory collapse==>RA pressure [MASKED] mmHg. LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity size. Normal regional/global systolic function. The visually estimated left ventricular ejection fraction is 55-60%. Normal cardiac index (>2.5 L/min/m2). No resting outflow tract gradient. Tissue Doppler suggests elevated PCWP. RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall motion. AORTA: Normal sinus diameter for gender. Normal ascending diameter for gender. Normal arch diameter. Normal descending aorta. No coarctation. Focal calcifications in aortic sinus. No coarctation. AORTIC VALVE (AV): Mildly thickend (3) leaflets. Mild stenosis (area 1.5-1.9 cm2). Peak gradient obtained from right parasternal orientation. Trace regurgitation. MITRAL VALVE (MV): Mildly thickened leaflets. No systolic prolapse. Mild MAC. Papillary muscle fibrosis/ calcification. Mild-moderate [[MASKED]] regurgitation. Central regurgitant jet. Regurgitation severity could be UNDERestimated due to acoustic shadowing. PULMONIC VALVE (PV): Normal leaflets. No stenosis. Physiologic regurgitation. TRICUSPID VALVE (TV): Mildly thickened leaflets. Mild [1+] regurgitation. Mild-moderate pulmonary artery systolic hypertension. PERICARDIUM: No effusion. Anterior fat pad RIGHT LOWER EXTREMITY ULTRASOUND [MASKED]: ====================================== IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. Brief Hospital Course: PATIENT SUMMARY: ================= [MASKED] with hx of CKD III, DM2, endometrial cancer, mild-moderate AS, presumed Sweet's syndrome, pulmonary HTN presenting with bilateral [MASKED] pain, non-pitting edema, and dyspnea on exertion. ACUTE ISSUES: ================== # [MASKED] discomfort, non-pitting edema: # DOE: Pt reports edema, with minimal pitting on exam, arguing against significant lower extremity interstitial edema. Difficult to assess objective change compared to baseline. TTE essentially unchanged compared to prior. Suspect her DOE is driven primarily by her underlying ILD, for which she is followed by Dr. [MASKED]. The constellation of her symptoms - Sweet syndrome, ILD, pyoderma gangrenosum - does point towards some underlying, unifying, systemic process. There are case reports of pulmonary involvement of Sweet syndrome, which would require BAL +/- transbronchial biopsy for diagnosis. Patient was able to ambulate comfortably on 2L of oxygen prior to discharge, which is her baseline. She will need close follow-up with pulmonology. # Hemolytic anemia: Patient has chronic, longstanding, with evidence of low grade anemia for at least [MASKED] years per [MASKED] records. G6PD checked and greater than upper limit of normal. Coombs test negative. Dapsone (without G6PD deficiency) can still cause hemolytic anemia. Per last hematology visit at [MASKED], thought that anemia was in setting of dapsone. Would advise outpatient hematology evaluation, given stability and chronicity of this process. ================ CHRONIC ISSUES: ================ # HLD: Continued Aspirin 81 # Sweet's Syndrome: Continued Dapsone 100 mg, will need age appropriate cancer screening as outpatient given associations with Sweet's Syndrome. Will also need dermatology and hematology followup. # Depression: Continue Sertraline 100 mg. # T2DM: Held GlipiZIDE 5 mg. ISS while inpatient. # Overactive bladder: Vesicare (solifenacin) 5 mg oral DAILY (not formulary) held. TRANSITIONAL ISSUES: ===================== Discharge Hemoglobin: 8.0 Discharge Platelets: 127 Absolute Retic 0.11 Haptoglobin <10 []Patient needs up to date screening for malignancy, especially in setting of presumed Sweet's Syndrome diagnosis. [] Patient needs follow-up with heme in setting of Sweet's syndrome and hemolytic anemia. [] Last biopsy of skin suggestive of Sweet's versus vasculitis. Should follow-up with dermatology. [] CT chest [MASKED] showing multifocal patchy airspace opacities. Recommended follow-up in [MASKED] weeks to check for resolution. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Sertraline 100 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Vesicare (solifenacin) 5 mg oral DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. GlipiZIDE 5 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Sertraline 100 mg PO DAILY 6. Vesicare (solifenacin) 5 mg oral DAILY Discharge Disposition: Home Discharge Diagnosis: # [MASKED] discomfort # Dyspnea on exertion # Pulmonary Hypertension # Hemolytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You were in the hospital because you had worsening swelling in your legs and shortness of breath. WHAT HAPPENED TO ME IN THE HOSPITAL? - We did imaging of your lungs to look for blood clots, imaging of your leg, and imaging of your heart. We also did blood tests to better understand your low red blood cell counts. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - It is extremely important that you call to get your BiPAP setup, and that you use it every day. Your lung pressures are already elevated, and we don't want this to continue to get worse. - Please make sure you go to all of your appointments (listed below). - Please call to get a dermatology appointment. -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]
[]
[ "E1122", "I129", "G4733", "E785", "E669", "F329", "Z87891" ]
[ "J849: Interstitial pulmonary disease, unspecified", "L88: Pyoderma gangrenosum", "D589: Hereditary hemolytic anemia, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I350: Nonrheumatic aortic (valve) stenosis", "L982: Febrile neutrophilic dermatosis [Sweet]", "I2720: Pulmonary hypertension, unspecified", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "F329: Major depressive disorder, single episode, unspecified", "N3281: Overactive bladder", "Z9641: Presence of insulin pump (external) (internal)", "Z9981: Dependence on supplemental oxygen", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "Z87891: Personal history of nicotine dependence", "Z6839: Body mass index [BMI] 39.0-39.9, adult" ]
10,076,617
26,439,893
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Clindamycin Attending: ___ Chief Complaint: Left facial droop Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ F w PMHx of DM, HTN, and HLD who presents to ___ with almost 24hrs of left facial droop. Ms. ___ reports that she noticed her deficits yesterday (___) at around 3PM when they were pointed out by a relative. She is certain that her mouth and eye were working normally earlier in the day when she looked in the mirror to put on her make up. Her relative is a physician and while she told Ms. ___ that she thought she had Bell's Palsy, she did recommend that she go to the ED. Ms. ___ did not seek medical attention until this morning when she went to her primary care clinic. They recommended that she go to the ED to get a CT scan. Ms. ___ does report a dull L sided headache that began yesterday, she does not usually suffer from headaches. She also complains of tenderness to palpation over the L mandibular angle, and a new L ear ache. Ms. ___ denies any recent illnesses including URI or diarrhea. She denies any associated weakness or sensory changes. She denies new bowel and bladder difficulties. She denies any difficulties comprehending speech, though thinks she might be mildly dysarthric due to her facial droop. She denies confusion. She denies dizziness. She denies new auditory symptoms including hyperaccusis. She denies food tasting odd. No history suggestive of possible tick bite. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN ___: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: ___ Family History: Father - deceased of MI in his ___ Mother - emphysema, deceased in her ___ No children Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VS T98.1 HR72 BP112/67 RR16 Sat98%RA GEN - elderly W, talkative, pleasant HEENT - NC/AT, dry mouth, difficulty closing L eye; L TM clear, no vesicles or rash noted NECK - full ROM, does complain of some L sided pain on L rotation CV - RRR RESP - on supplemental O2, normal WOB ABD - obese, soft, NT, ND EXTR - healing sore on R heel, WWP NEUROLOGICAL EXAMINATION MS - Awake, alert, oriented x3. Attention to examiner easily attained and maintained. Concentration maintained when recalling months backwards, but misses ___. Recalls a coherent history. Speech is fluent with normal prosody and no paraphasias. Naming, repetition, comprehension, and reading are all intact. No apraxia. No evidence of hemineglect. No left-right agnosia. CN - [II] PERRL 3->2 brisk. VF full to number counting. [III, IV, VI] ?Incomplete abduction of R eye on R gaze and L eye on L gaze. Denies diplopia. Per patient, long-standing ?lateral gaze limitations. [V] V1-V3 without deficits to light touch or pin-prick bilaterally. [VII] L NLFF at rest with decreased activation of L lower face. Weak L eye closure. Frontalis muscle activation is symmetric. Lower face weakness persists with emotional smile. [VIII] Hearing intact to voice. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline with full ROM. MOTOR - Normal bulk and tone. No pronation, no drift. No orbiting with arm roll. No tremor or asterixis. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [___] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5 4+ 5 5 5 5 5 R 5 5 5 5 5 4+ 5 5 5 5 5 SENSORY - No deficits to light touch or pin-prick throughout. Proprioception intact at B/L great toes. REFLEXES - =[Bic] [Tri] [___] [Quad] [Gastroc] L 2 2 2 2 1 R 2 2 2 2 1 Plantar response flexor on the left, equivocal on the R. COORD - No dysmetria with finger to nose. Good speed and intact cadence with rapid alternating movements. GAIT - Normal initiation. Narrow base. Slightly antalgic and mildly unsteady, ?limping on the LLE. Patient does endorse being slightly unsteady, denies limp. . =========================== DISCHARGE PHYSICAL EXAM =========================== VS 98.1, 107-119/67-73, HR 73-88, RR 18, 96% on RA MS - Alert Cranial nerve - Incomplete L eyelid closure, left facial weakness, left facial droop with NLFF, Asymmetric blink on the left with + Bell's phenomenon. 3mm ___, EOMI, VFF, sensation symmetric, tongue symmetric, palate symmetric, shoulder shrug symmetric strength. Motor - ___ in Deltoid, biceps, triceps, IP, quad, TA No drift. Reflexes - 2+ bic, tric, ___, Quad Pertinent Results: ================ ADMISSION LABS ================ ___ 10:50AM BLOOD WBC-6.4 RBC-3.36* Hgb-10.0* Hct-31.4* MCV-94 MCH-29.8 MCHC-31.8* RDW-14.2 RDWSD-48.4* Plt ___ ___ 10:50AM BLOOD Neuts-64.8 ___ Monos-8.6 Eos-2.5 Baso-1.2* Im ___ AbsNeut-4.16 AbsLymp-1.45 AbsMono-0.55 AbsEos-0.16 AbsBaso-0.08 ___ 10:50AM BLOOD Plt ___ ___ 12:45PM BLOOD ___ PTT-31.0 ___ ___ 10:50AM BLOOD Glucose-153* UreaN-41* Creat-1.4* Na-137 K-4.5 Cl-100 HCO3-23 AnGap-19 ___ 10:50AM BLOOD ALT-27 AST-24 AlkPhos-110* TotBili-0.5 ___ 10:50AM BLOOD Lipase-67* ___ 04:56AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1 Cholest-185 ___ 10:50AM BLOOD Albumin-4.0 ___ 12:45PM BLOOD %HbA1c-5.9 eAG-123 ___ 04:56AM BLOOD Triglyc-90 HDL-55 CHOL/HD-3.4 LDLcalc-112 ___ 12:45PM BLOOD TSH-1.1 ___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:35PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12:35PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 12:35PM URINE RBC-35* WBC->182* Bacteri-MANY Yeast-NONE Epi-6 TransE-2 ___ 12:35PM URINE CastHy-6* ___ 12:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG . URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. INTERPRET RESULTS WITH CAUTION. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL MORPHOLOGIES. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. . . ==================== STUDIES ==================== EKG ___ Sinus rhythm with atrial premature beats. Otherwise, within normal limits. Compared to the previous tracing of ___ wave abnormalities have resolved. . CXR ___ No acute cardiopulmonary process. . CTA HEAD AND NECK ___ 1. No acute intracranial abnormality. 2. No flow limiting stenosis within the vessels of the head and neck. . MRI BRAIN ___ No acute infarct or mass effect. A few small scattered cerebral white matter changes, can relate to small vessel ischemic changes, etc. Mild to moderate diffuse parenchymal volume loss Brief Hospital Course: Ms. ___ is a ___ F w PMHx of DM, HTN, and HLD who presents to ___ with new left facial droop. . By the morning after admission, she had developed significant left facial weakness, both upper and lower face involving eyelid closure which was consistent with peripheral ___ nerve palsy. There were no other concerning findings on neurologic exam. . Her CTA head and neck did not show any significant vessel narrowing and her MRI Brain was negative for acute stroke. Her stroke risk factors were checked and HbA1C and thyroid studies were within normal limits. However, lipid panel was pending on discharge and will need follow up by primary care. . She was incidentally found to have a urinary tract infection on this admission and was treated with Nitrofurantoin for 7 days total. . She was treated for Bell's Palsy with a course of Prednisone 60mg daily and Valacyclovir 1000mg TID for 7 days total on discharge. . She should follow up with primary care - no neurology outpatient follow up is required. . No changes were made to her home medications. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Vesicare (solifenacin) 5 mg oral DAILY 4. Dapsone 100 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Lisinopril 2.5 mg PO DAILY 7. Sertraline 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. GlipiZIDE 5 mg PO DAILY 4. Lisinopril 2.5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. Vesicare (solifenacin) 5 mg oral DAILY 8. PredniSONE 60 mg PO DAILY Duration: 7 Days RX *prednisone 20 mg 3 tablet(s) by mouth DAILY Disp #*21 Tablet Refills:*0 9. ValACYclovir 1000 mg PO TID Duration: 7 Days RX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7 Days RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth twice a day Disp #*12 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1.) Left Bell's Palsy/Left peripheral ___ nerve palsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, You were admitted for left facial droop which we feel is clinically consistent with Bell's Palsy. You had a CT of the vessels going to your brain that do not have any narrowing. You had a Brain MRI that was negative for stroke. You had no other abnormalities on your exam that are suspicious for any other process. We have started treatment for you Bell's Palsy with steroids and an antiviral medication that you should take for 7 days total. You were also found to have a urinary tract infection and will need antibiotics for 6 more days as prescribed. Please take as prescribed. Followup Instructions: ___
[ "G510", "N390", "E119", "I129", "N183", "E785", "N3941", "G4733", "L982", "J449", "Z23", "Z87891", "Z8542" ]
Allergies: Clindamycin Chief Complaint: Left facial droop Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] F w PMHx of DM, HTN, and HLD who presents to [MASKED] with almost 24hrs of left facial droop. Ms. [MASKED] reports that she noticed her deficits yesterday ([MASKED]) at around 3PM when they were pointed out by a relative. She is certain that her mouth and eye were working normally earlier in the day when she looked in the mirror to put on her make up. Her relative is a physician and while she told Ms. [MASKED] that she thought she had Bell's Palsy, she did recommend that she go to the ED. Ms. [MASKED] did not seek medical attention until this morning when she went to her primary care clinic. They recommended that she go to the ED to get a CT scan. Ms. [MASKED] does report a dull L sided headache that began yesterday, she does not usually suffer from headaches. She also complains of tenderness to palpation over the L mandibular angle, and a new L ear ache. Ms. [MASKED] denies any recent illnesses including URI or diarrhea. She denies any associated weakness or sensory changes. She denies new bowel and bladder difficulties. She denies any difficulties comprehending speech, though thinks she might be mildly dysarthric due to her facial droop. She denies confusion. She denies dizziness. She denies new auditory symptoms including hyperaccusis. She denies food tasting odd. No history suggestive of possible tick bite. Past Medical History: - DM - CKD, stage III - HTN - HLD (not taking prescribed Lipitor) - recurrent cystitis, urge incontinence - h/o endometrial cancer - s/p ex-lap, LAH, TAH, BSO - seen by OB-GYN [MASKED]: no e/o recurrence - OSA on home BiPAP - Sweet's syndrome - COPD, PRN supplemental O2 with ambulation - Pulmonary HTN - no prior history of MI, TIA, CVA Social History: [MASKED] Family History: Father - deceased of MI in his [MASKED] Mother - emphysema, deceased in her [MASKED] No children Physical Exam: ======================== ADMISSION PHYSICAL EXAM ======================== VS T98.1 HR72 BP112/67 RR16 Sat98%RA GEN - elderly W, talkative, pleasant HEENT - NC/AT, dry mouth, difficulty closing L eye; L TM clear, no vesicles or rash noted NECK - full ROM, does complain of some L sided pain on L rotation CV - RRR RESP - on supplemental O2, normal WOB ABD - obese, soft, NT, ND EXTR - healing sore on R heel, WWP NEUROLOGICAL EXAMINATION MS - Awake, alert, oriented x3. Attention to examiner easily attained and maintained. Concentration maintained when recalling months backwards, but misses [MASKED]. Recalls a coherent history. Speech is fluent with normal prosody and no paraphasias. Naming, repetition, comprehension, and reading are all intact. No apraxia. No evidence of hemineglect. No left-right agnosia. CN - [II] PERRL 3->2 brisk. VF full to number counting. [III, IV, VI] ?Incomplete abduction of R eye on R gaze and L eye on L gaze. Denies diplopia. Per patient, long-standing ?lateral gaze limitations. [V] V1-V3 without deficits to light touch or pin-prick bilaterally. [VII] L NLFF at rest with decreased activation of L lower face. Weak L eye closure. Frontalis muscle activation is symmetric. Lower face weakness persists with emotional smile. [VIII] Hearing intact to voice. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength [MASKED] bilaterally. [XII] Tongue midline with full ROM. MOTOR - Normal bulk and tone. No pronation, no drift. No orbiting with arm roll. No tremor or asterixis. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [[MASKED]] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5 4+ 5 5 5 5 5 R 5 5 5 5 5 4+ 5 5 5 5 5 SENSORY - No deficits to light touch or pin-prick throughout. Proprioception intact at B/L great toes. REFLEXES - =[Bic] [Tri] [[MASKED]] [Quad] [Gastroc] L 2 2 2 2 1 R 2 2 2 2 1 Plantar response flexor on the left, equivocal on the R. COORD - No dysmetria with finger to nose. Good speed and intact cadence with rapid alternating movements. GAIT - Normal initiation. Narrow base. Slightly antalgic and mildly unsteady, ?limping on the LLE. Patient does endorse being slightly unsteady, denies limp. . =========================== DISCHARGE PHYSICAL EXAM =========================== VS 98.1, 107-119/67-73, HR 73-88, RR 18, 96% on RA MS - Alert Cranial nerve - Incomplete L eyelid closure, left facial weakness, left facial droop with NLFF, Asymmetric blink on the left with + Bell's phenomenon. 3mm [MASKED], EOMI, VFF, sensation symmetric, tongue symmetric, palate symmetric, shoulder shrug symmetric strength. Motor - [MASKED] in Deltoid, biceps, triceps, IP, quad, TA No drift. Reflexes - 2+ bic, tric, [MASKED], Quad Pertinent Results: ================ ADMISSION LABS ================ [MASKED] 10:50AM BLOOD WBC-6.4 RBC-3.36* Hgb-10.0* Hct-31.4* MCV-94 MCH-29.8 MCHC-31.8* RDW-14.2 RDWSD-48.4* Plt [MASKED] [MASKED] 10:50AM BLOOD Neuts-64.8 [MASKED] Monos-8.6 Eos-2.5 Baso-1.2* Im [MASKED] AbsNeut-4.16 AbsLymp-1.45 AbsMono-0.55 AbsEos-0.16 AbsBaso-0.08 [MASKED] 10:50AM BLOOD Plt [MASKED] [MASKED] 12:45PM BLOOD [MASKED] PTT-31.0 [MASKED] [MASKED] 10:50AM BLOOD Glucose-153* UreaN-41* Creat-1.4* Na-137 K-4.5 Cl-100 HCO3-23 AnGap-19 [MASKED] 10:50AM BLOOD ALT-27 AST-24 AlkPhos-110* TotBili-0.5 [MASKED] 10:50AM BLOOD Lipase-67* [MASKED] 04:56AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1 Cholest-185 [MASKED] 10:50AM BLOOD Albumin-4.0 [MASKED] 12:45PM BLOOD %HbA1c-5.9 eAG-123 [MASKED] 04:56AM BLOOD Triglyc-90 HDL-55 CHOL/HD-3.4 LDLcalc-112 [MASKED] 12:45PM BLOOD TSH-1.1 [MASKED] 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 12:35PM URINE Color-Yellow Appear-Hazy Sp [MASKED] [MASKED] 12:35PM URINE Blood-NEG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [MASKED] 12:35PM URINE RBC-35* WBC->182* Bacteri-MANY Yeast-NONE Epi-6 TransE-2 [MASKED] 12:35PM URINE CastHy-6* [MASKED] 12:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG . URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. INTERPRET RESULTS WITH CAUTION. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL MORPHOLOGIES. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. . . ==================== STUDIES ==================== EKG [MASKED] Sinus rhythm with atrial premature beats. Otherwise, within normal limits. Compared to the previous tracing of [MASKED] wave abnormalities have resolved. . CXR [MASKED] No acute cardiopulmonary process. . CTA HEAD AND NECK [MASKED] 1. No acute intracranial abnormality. 2. No flow limiting stenosis within the vessels of the head and neck. . MRI BRAIN [MASKED] No acute infarct or mass effect. A few small scattered cerebral white matter changes, can relate to small vessel ischemic changes, etc. Mild to moderate diffuse parenchymal volume loss Brief Hospital Course: Ms. [MASKED] is a [MASKED] F w PMHx of DM, HTN, and HLD who presents to [MASKED] with new left facial droop. . By the morning after admission, she had developed significant left facial weakness, both upper and lower face involving eyelid closure which was consistent with peripheral [MASKED] nerve palsy. There were no other concerning findings on neurologic exam. . Her CTA head and neck did not show any significant vessel narrowing and her MRI Brain was negative for acute stroke. Her stroke risk factors were checked and HbA1C and thyroid studies were within normal limits. However, lipid panel was pending on discharge and will need follow up by primary care. . She was incidentally found to have a urinary tract infection on this admission and was treated with Nitrofurantoin for 7 days total. . She was treated for Bell's Palsy with a course of Prednisone 60mg daily and Valacyclovir 1000mg TID for 7 days total on discharge. . She should follow up with primary care - no neurology outpatient follow up is required. . No changes were made to her home medications. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Vesicare (solifenacin) 5 mg oral DAILY 4. Dapsone 100 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Lisinopril 2.5 mg PO DAILY 7. Sertraline 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Dapsone 100 mg PO DAILY 3. GlipiZIDE 5 mg PO DAILY 4. Lisinopril 2.5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Sertraline 100 mg PO DAILY 7. Vesicare (solifenacin) 5 mg oral DAILY 8. PredniSONE 60 mg PO DAILY Duration: 7 Days RX *prednisone 20 mg 3 tablet(s) by mouth DAILY Disp #*21 Tablet Refills:*0 9. ValACYclovir 1000 mg PO TID Duration: 7 Days RX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times a day Disp #*21 Tablet Refills:*0 10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7 Days RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth twice a day Disp #*12 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1.) Left Bell's Palsy/Left peripheral [MASKED] nerve palsy 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 for left facial droop which we feel is clinically consistent with Bell's Palsy. You had a CT of the vessels going to your brain that do not have any narrowing. You had a Brain MRI that was negative for stroke. You had no other abnormalities on your exam that are suspicious for any other process. We have started treatment for you Bell's Palsy with steroids and an antiviral medication that you should take for 7 days total. You were also found to have a urinary tract infection and will need antibiotics for 6 more days as prescribed. Please take as prescribed. Followup Instructions: [MASKED]
[]
[ "N390", "E119", "I129", "E785", "G4733", "J449", "Z87891" ]
[ "G510: Bell's palsy", "N390: Urinary tract infection, site not specified", "E119: Type 2 diabetes mellitus without complications", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "N3941: Urge incontinence", "G4733: Obstructive sleep apnea (adult) (pediatric)", "L982: Febrile neutrophilic dermatosis [Sweet]", "J449: Chronic obstructive pulmonary disease, unspecified", "Z23: Encounter for immunization", "Z87891: Personal history of nicotine dependence", "Z8542: Personal history of malignant neoplasm of other parts of uterus" ]
10,076,958
21,089,161
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Attending: ___. Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: ___, laparoscopic jejunostomy tube placement History of Present Illness: ___ is a ___ with a PMH pertinent for a laparoscopic pyloroplasty ___ and esophagectomy for stage T1b esophageal cancer in ___ now p/w intractable nausea and emesis since ___ last night after being discharged from the hospital 36 hours ago following an admission for similar symptoms as this presentation. She was also admitted for these symptoms on ___, making this the third admission in the last week, now three weeks removed from her pyloroplasty. Following each hospitalization, including the most recent, she has been tolerating a PO diet without nausea at the time of discharge. Unlike previous admissions, this episode was not triggered by any recognized attempt to advance her diet to more solid food. She had been tolerating soft solids and liquids in small amounts, and removed from any intake her nausea began. It was NBNB, and persistent enough that she could not attempt to take any of her anti-emetic medications, of which Ativan and Reglan have been helpful in the past. She appears pallid and cachectic, and is still having nausea only having received Ativan a few moments before this interview. Much of her history is obtained from her husband who is present and knows the course of her illness intimately. She denies fever, chills, dysphagia, diarrhea, constipation, or other changes in her bowel or bladder habits. She does endorse fatigue and ongoing nausea, increased with palpation of her abdomen. Her prior wounds are healing well, although she does have cellulitis in her L antecubital fossa from the site of a previous peripheral IV line. She has a mild leukocytosis to 12.4, hypochloremia to 94, and SBP >200, likely secondary to her ongoing discomfort and inability to take her antihypertensive medication earlier in the day. In the ED she received 1g IV ceftriaxone, 10 mg IV reglan, 1g IV Ativan, a 1L NS bolus and 5 mgIV Lopressor. Past Medical History: Benign Hypertension Hyperlipidemia laparoscopic pyloroplasty ___ esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis ___ esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy ___ with possible mild MI s/p hysterectomy Depression Social History: ___ Family History: - Sister died age ___ colon cancer after ___ yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged ___ and ___). Physical Exam: Admit PE: Temp: 97.6 HR: 72 BP: 229/115 RR: 16 O2 Sat: 100%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [ ] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [x] Abnormal findings: dry mucus membranes RESPIRATORY [x] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [x] Abnormal findings: healing wounds with surgical glue x3 CDI GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [ ] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: LYMPH NODES [x] Cervical nl [x] Supraclavicular nl [x] Axillary nl [x] Inguinal nl [ ] Abnormal findings: SKIN [ ] No rashes/lesions/ulcers [x] No induration/nodules/tightening [x] Abnormal findings: pallid, 3cm diameter erythematous spot in L antecubital fossa PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: Discharge PE: Temp: 98.4 HR: 55 BP: 154/79 RR: 18 O2 Sat: 92%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] Anicteric [x] Neck supple/NT/without mass [x] Trachea midline [ ] Abnormal findings RESPIRATORY [x] CTA/P, no increased work of breathing [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] No edema [x] Peripheral pulses nl [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [x] Abnormal findings: healing wounds CDI, J-tube site with dressing, mild dried drainage on dressing GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [ ] No clubbing [x] No cyanosis [x] No edema [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: SKIN [ ] No rashes/lesions/ulcers [x] No induration/nodules/tightening [x] Abnormal findings: pallid, 2x4cm area of erythema on right hand dorsum likely representing phlebitisr PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: ________________________________________________________________ ________________________________________________________________ Pertinent Results: ___ 12:02AM BLOOD WBC-12.4*# RBC-3.61* Hgb-11.5 Hct-33.4* MCV-93 MCH-31.9 MCHC-34.4 RDW-13.9 RDWSD-47.1* Plt ___ ___ 12:02AM BLOOD Glucose-195* UreaN-7 Creat-0.6 Na-134 K-3.8 Cl-94* HCO3-25 AnGap-19 ___ 12:02AM BLOOD ALT-15 AST-23 AlkPhos-103 TotBili-0.3 ___ 12:02AM BLOOD Albumin-3.8 Calcium-9.5 Phos-2.8 Mg-1.8 Iron-35 ___ 12:02AM BLOOD calTIBC-282 TRF-217 ___ 12:03AM BLOOD Lactate-1.8 Barium esophagram. Study Date of ___ IMPRESSION: Contrast readily passes through the pyloric sphincter without evidence of stricture or outlet obstruction. Brief Hospital Course: Ms. ___ is a ___ year old female s/p MIE in ___ and pyloroplasty ___ who presented on ___ with recurrent intractable emesis and moderate malnutrition and was re-admitted for PO intolerance. On HD 1 physical therapy and occupational therapy were consulted for evaluation and treatment of patient. She was given clear liquids which she tolerated well. Nutrition labs were normal with an albumin of 3.8. On HD 3 her jejunostomy was laparoscopically recannulated and a feeding tube was placed. There were no adverse events in the OR, see surgeons operative report for details. She was started on tube feeds the following day and these are advance to goal without complication. She was also given thiamine and folic acid supplements and her diet was advanced to full liquids which she tolerated well. On HD 5 the patient continued to tolerate tube feeds at goal and full liquids and thus her tube feeds were cycled that night. On HD 6 she continued to deny further pain, nausea, or vomiting and was deemed ready for discharge. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a full liquid 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. She was discharged with home services for assistance with tube feeds and monitoring of her J-tube site. She will advance her diet as tolerated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 50 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Omeprazole 40 mg PO BID 5. Vitamin D 1000 UNIT PO DAILY 6. Acetaminophen 650 mg PO Q8H:PRN pain/H/A 7. Dronabinol 2.5 mg PO BID 8. Metoclopramide 10 mg PO QIDACHS 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Simvastatin 40 mg PO QPM 11. Lorazepam 0.5 mg PO Q4H:PRN nausea Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain/H/A 2. Dronabinol 2.5 mg PO BID 3. Flecainide Acetate 50 mg PO Q12H 4. Fluoxetine 50 mg PO DAILY 5. Lorazepam 0.5 mg PO Q4H:PRN nausea 6. Metoprolol Succinate XL 25 mg PO QHS 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Omeprazole 40 mg PO BID 9. Simvastatin 40 mg PO QPM 10. Vitamin D 1000 UNIT PO DAILY 11. Docusate Sodium 100 mg PO BID do not take if you are having diarrhea RX *docusate sodium 50 mg/5 mL 10 ml by mouth twice a day Refills:*0 12. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain do not drive or drink alcohol while taking this medication RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 13. Senna 8.6 mg PO BID do not take if you are having diarrhea RX *sennosides [senna] 8.8 mg/5 mL 5 ml by mouth twice a day Refills:*0 14. Cephalexin 500 mg PO Q12H RX *cephalexin 500 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*10 Capsule Refills:*0 15. Metoclopramide 10 mg PO QIDACHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Intractable emesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital for treatment of intractable emesis and moderate malnutrition. You underwent laparoscopic replacement of a jejunostomy feeding tube and you've recovered well. You are now ready for discharge. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * You may continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol ___ mg every 6 hours in between your narcotic. If your doctor allows you may also take Ibuprofen to help relieve the pain. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk ___ times a day and gradually increase your activity as you can tolerate. Call Dr. ___ ___ if you experience: -Fevers > 101 or chills Followup Instructions: ___
[ "K910", "E440", "Z681", "I10", "E785", "Z8501", "Z87891", "Z800", "Y832", "Y929", "I252", "M19042", "M19041", "Z9049" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: [MASKED], laparoscopic jejunostomy tube placement History of Present Illness: [MASKED] is a [MASKED] with a PMH pertinent for a laparoscopic pyloroplasty [MASKED] and esophagectomy for stage T1b esophageal cancer in [MASKED] now p/w intractable nausea and emesis since [MASKED] last night after being discharged from the hospital 36 hours ago following an admission for similar symptoms as this presentation. She was also admitted for these symptoms on [MASKED], making this the third admission in the last week, now three weeks removed from her pyloroplasty. Following each hospitalization, including the most recent, she has been tolerating a PO diet without nausea at the time of discharge. Unlike previous admissions, this episode was not triggered by any recognized attempt to advance her diet to more solid food. She had been tolerating soft solids and liquids in small amounts, and removed from any intake her nausea began. It was NBNB, and persistent enough that she could not attempt to take any of her anti-emetic medications, of which Ativan and Reglan have been helpful in the past. She appears pallid and cachectic, and is still having nausea only having received Ativan a few moments before this interview. Much of her history is obtained from her husband who is present and knows the course of her illness intimately. She denies fever, chills, dysphagia, diarrhea, constipation, or other changes in her bowel or bladder habits. She does endorse fatigue and ongoing nausea, increased with palpation of her abdomen. Her prior wounds are healing well, although she does have cellulitis in her L antecubital fossa from the site of a previous peripheral IV line. She has a mild leukocytosis to 12.4, hypochloremia to 94, and SBP >200, likely secondary to her ongoing discomfort and inability to take her antihypertensive medication earlier in the day. In the ED she received 1g IV ceftriaxone, 10 mg IV reglan, 1g IV Ativan, a 1L NS bolus and 5 mgIV Lopressor. Past Medical History: Benign Hypertension Hyperlipidemia laparoscopic pyloroplasty [MASKED] esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis [MASKED] esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy [MASKED] with possible mild MI s/p hysterectomy Depression Social History: [MASKED] Family History: - Sister died age [MASKED] colon cancer after [MASKED] yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged [MASKED] and [MASKED]). Physical Exam: Admit PE: Temp: 97.6 HR: 72 BP: 229/115 RR: 16 O2 Sat: 100%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [ ] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [x] Abnormal findings: dry mucus membranes RESPIRATORY [x] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [x] Abnormal findings: healing wounds with surgical glue x3 CDI GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [ ] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: LYMPH NODES [x] Cervical nl [x] Supraclavicular nl [x] Axillary nl [x] Inguinal nl [ ] Abnormal findings: SKIN [ ] No rashes/lesions/ulcers [x] No induration/nodules/tightening [x] Abnormal findings: pallid, 3cm diameter erythematous spot in L antecubital fossa PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: Discharge PE: Temp: 98.4 HR: 55 BP: 154/79 RR: 18 O2 Sat: 92%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] Anicteric [x] Neck supple/NT/without mass [x] Trachea midline [ ] Abnormal findings RESPIRATORY [x] CTA/P, no increased work of breathing [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] No edema [x] Peripheral pulses nl [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [x] Abnormal findings: healing wounds CDI, J-tube site with dressing, mild dried drainage on dressing GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [ ] No clubbing [x] No cyanosis [x] No edema [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: SKIN [ ] No rashes/lesions/ulcers [x] No induration/nodules/tightening [x] Abnormal findings: pallid, 2x4cm area of erythema on right hand dorsum likely representing phlebitisr PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: [MASKED] [MASKED] Pertinent Results: [MASKED] 12:02AM BLOOD WBC-12.4*# RBC-3.61* Hgb-11.5 Hct-33.4* MCV-93 MCH-31.9 MCHC-34.4 RDW-13.9 RDWSD-47.1* Plt [MASKED] [MASKED] 12:02AM BLOOD Glucose-195* UreaN-7 Creat-0.6 Na-134 K-3.8 Cl-94* HCO3-25 AnGap-19 [MASKED] 12:02AM BLOOD ALT-15 AST-23 AlkPhos-103 TotBili-0.3 [MASKED] 12:02AM BLOOD Albumin-3.8 Calcium-9.5 Phos-2.8 Mg-1.8 Iron-35 [MASKED] 12:02AM BLOOD calTIBC-282 TRF-217 [MASKED] 12:03AM BLOOD Lactate-1.8 Barium esophagram. Study Date of [MASKED] IMPRESSION: Contrast readily passes through the pyloric sphincter without evidence of stricture or outlet obstruction. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old female s/p MIE in [MASKED] and pyloroplasty [MASKED] who presented on [MASKED] with recurrent intractable emesis and moderate malnutrition and was re-admitted for PO intolerance. On HD 1 physical therapy and occupational therapy were consulted for evaluation and treatment of patient. She was given clear liquids which she tolerated well. Nutrition labs were normal with an albumin of 3.8. On HD 3 her jejunostomy was laparoscopically recannulated and a feeding tube was placed. There were no adverse events in the OR, see surgeons operative report for details. She was started on tube feeds the following day and these are advance to goal without complication. She was also given thiamine and folic acid supplements and her diet was advanced to full liquids which she tolerated well. On HD 5 the patient continued to tolerate tube feeds at goal and full liquids and thus her tube feeds were cycled that night. On HD 6 she continued to deny further pain, nausea, or vomiting and was deemed ready for discharge. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a full liquid 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. She was discharged with home services for assistance with tube feeds and monitoring of her J-tube site. She will advance her diet as tolerated. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 50 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Omeprazole 40 mg PO BID 5. Vitamin D 1000 UNIT PO DAILY 6. Acetaminophen 650 mg PO Q8H:PRN pain/H/A 7. Dronabinol 2.5 mg PO BID 8. Metoclopramide 10 mg PO QIDACHS 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Simvastatin 40 mg PO QPM 11. Lorazepam 0.5 mg PO Q4H:PRN nausea Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain/H/A 2. Dronabinol 2.5 mg PO BID 3. Flecainide Acetate 50 mg PO Q12H 4. Fluoxetine 50 mg PO DAILY 5. Lorazepam 0.5 mg PO Q4H:PRN nausea 6. Metoprolol Succinate XL 25 mg PO QHS 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Omeprazole 40 mg PO BID 9. Simvastatin 40 mg PO QPM 10. Vitamin D 1000 UNIT PO DAILY 11. Docusate Sodium 100 mg PO BID do not take if you are having diarrhea RX *docusate sodium 50 mg/5 mL 10 ml by mouth twice a day Refills:*0 12. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain do not drive or drink alcohol while taking this medication RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 13. Senna 8.6 mg PO BID do not take if you are having diarrhea RX *sennosides [senna] 8.8 mg/5 mL 5 ml by mouth twice a day Refills:*0 14. Cephalexin 500 mg PO Q12H RX *cephalexin 500 mg 1 capsule(s) by mouth every twelve (12) hours Disp #*10 Capsule Refills:*0 15. Metoclopramide 10 mg PO QIDACHS Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Intractable emesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital for treatment of intractable emesis and moderate malnutrition. You underwent laparoscopic replacement of a jejunostomy feeding tube and you've recovered well. You are now ready for discharge. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * You may continue to need pain medication once you are home but you can wean it over a few weeks as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol [MASKED] mg every 6 hours in between your narcotic. If your doctor allows you may also take Ibuprofen to help relieve the pain. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk [MASKED] times a day and gradually increase your activity as you can tolerate. Call Dr. [MASKED] [MASKED] if you experience: -Fevers > 101 or chills Followup Instructions: [MASKED]
[]
[ "I10", "E785", "Z87891", "Y929", "I252" ]
[ "K910: Vomiting following gastrointestinal surgery", "E440: Moderate protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z8501: Personal history of malignant neoplasm of esophagus", "Z87891: Personal history of nicotine dependence", "Z800: Family history of malignant neoplasm of digestive organs", "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", "I252: Old myocardial infarction", "M19042: Primary osteoarthritis, left hand", "M19041: Primary osteoarthritis, right hand", "Z9049: Acquired absence of other specified parts of digestive tract" ]
10,076,958
24,463,507
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Attending: ___. Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: ___ 1. Esophagogastroduodenoscopy. 2. Laparoscopic pyloroplasty. History of Present Illness: Mrs. ___ is a ___ yo F with persistent nausea and vomiting, which have been a problem since her esophagectomy in ___ for T1b esophageal cancer. She has gone through a cycle of Botox injections and dilations of the pylorus, which have offered some temporary relief of symptoms, but after which symptoms typically have returned. She has had numerous hospitalizations for this and most recently on ___, during the hospitalization she had a barium upper GI series, which showed no contrast passage through the pylorus after four hours. She presents now for laparoscopic pyloroplasty. Past Medical History: Benign Hypertension Hyperlipidemia esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis ___ esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy ___ with possible mild MI s/p hysterectomy Depression Social History: ___ Family History: - Sister died age ___ colon cancer after ___ yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged ___ and ___). Physical Exam: Temp 98 HR 64 BP 134/62 RR 18 RA sat 96% Chest clear B/l COR Sl irreg Abd soft, NT Ext calves soft, no edema Pertinent Results: ___ Ba swallow : Status post esophagectomy, gastric pull-through and recent pyloroplasty. The pylorus remains narrowed with delayed transit of contrast. No leak was identified. ___ CXR : As compared to ___, areas of atelectatic lung in both the right and the left lung base have decreased in extent and severity. Overall, the lung parenchyma is better expanded than on the previous examination. Contrast material is seen in the basal portions of the neoesophagus. No pleural effusions. Normal appearance of the cardiac silhouette. WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 04:42 9.3 3.11* 9.9* 29.6* 95 31.8 33.4 14.0 48.7* 175 ___ 02:54 10.7* 3.27* 10.3* 30.8* 94 31.5 33.4 14.1 48.5* 172 ___ 05:21 13.4* 3.60* 11.5 34.3 95 31.9 33.5 14.0 48.8* 197 Brief Hospital Course: Mrs. ___ was admitted to the hospital and taken to the Operating Room where she underwent an esophagogastroduodenoscopy and laparoscopic pyloroplasty. She tolerated the procedure well and returned to the PACU in stable condition. She maintained stable hemodynamics and her pain was controlled with IV Dilaudid. Following transfer to the Surgical floor she continued to have problems with nausea and vomiting and had some relief with Reglan and Zofran. Her barium swallow was postponed one day due to her symptoms and she remained NPO and was hydrated with IV fluids. Her symptoms improved in 24 hours and she underwent a barium swallow on ___ which showed no leak and some delay of contrast. A liquid diet was started in modest amounts and she was able to tolerate it well. She had much less nausea. Her port sites were healing well and she was up and walking independently. From a cardiac standpoint she had some rapid atrial fibrillation on POD #2 and given her history of atrial fibrillation, she was evaluated by the Cardiology service. Her long acting betablocker was changed to short acting metoprolol and she continued on her pre op flecanide. She converted back to sinus bradycardia at a rate of 50-60 generally, sometimes higher with activity. Her pre op Metoprolol was resumed prior to discharge. Her room air saturations were 92-94% and she was using her incentive spirometer effectively. She was discharged home on ___ and will follow up in the Thoracic Clinic in 2 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO Q4H:PRN nausea 2. Metoprolol Succinate XL 25 mg PO QHS 3. Flecainide Acetate 50 mg PO Q12H 4. Simvastatin 40 mg PO QPM 5. Multivitamins 1 TAB PO DAILY 6. Metoclopramide 10 mg PO Q6H:PRN nausea 7. Omeprazole 40 mg PO BID 8. Fluoxetine 40 mg PO DAILY 9. Fluoxetine 10 mg PO DAILY 10. Vitamin D 1000 UNIT PO QHS Discharge Medications: 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 40 mg PO DAILY 3. Docusate Sodium 100 mg PO BID Take while requiring Oxycodone to prevent constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 4. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain Do not combine with other narcotics or alcohol. Do not drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 5. Lorazepam 0.5 mg PO Q4H:PRN nausea 6. Metoprolol Succinate XL 25 mg PO QHS 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO BID 9. Simvastatin 40 mg PO QPM 10. Vitamin D 1000 UNIT PO QHS 11. Fluoxetine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Gastric outlet obstruction Rapid atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr. ___ ___ if you experience: -Fevers > 101 or chills -Difficult or painful swallowing -Nausea, vomiting. -Increased shortness of breath Pain -Take stool softners while taking narcotics -No driving while taking narcotics Activity -Shower daily. Wash incision with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lotions or creams to incision -Walk ___ times a day for ___ minutes increase to a Goal of 30 minutes daily Diet: Full liquid diet for ___. Increase to soft solids as tolerates Eat small frequent meals. Sit in chair for all meals. Remain sitting up for ___ minutes after all meals NO CARBONATED DRINKS Followup Instructions: ___
[ "K311", "I480", "Z9049", "E785", "I252", "Z8501", "K219", "Z87891", "F329", "F419", "Z800", "I10" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: [MASKED] 1. Esophagogastroduodenoscopy. 2. Laparoscopic pyloroplasty. History of Present Illness: Mrs. [MASKED] is a [MASKED] yo F with persistent nausea and vomiting, which have been a problem since her esophagectomy in [MASKED] for T1b esophageal cancer. She has gone through a cycle of Botox injections and dilations of the pylorus, which have offered some temporary relief of symptoms, but after which symptoms typically have returned. She has had numerous hospitalizations for this and most recently on [MASKED], during the hospitalization she had a barium upper GI series, which showed no contrast passage through the pylorus after four hours. She presents now for laparoscopic pyloroplasty. Past Medical History: Benign Hypertension Hyperlipidemia esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis [MASKED] esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy [MASKED] with possible mild MI s/p hysterectomy Depression Social History: [MASKED] Family History: - Sister died age [MASKED] colon cancer after [MASKED] yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged [MASKED] and [MASKED]). Physical Exam: Temp 98 HR 64 BP 134/62 RR 18 RA sat 96% Chest clear B/l COR Sl irreg Abd soft, NT Ext calves soft, no edema Pertinent Results: [MASKED] Ba swallow : Status post esophagectomy, gastric pull-through and recent pyloroplasty. The pylorus remains narrowed with delayed transit of contrast. No leak was identified. [MASKED] CXR : As compared to [MASKED], areas of atelectatic lung in both the right and the left lung base have decreased in extent and severity. Overall, the lung parenchyma is better expanded than on the previous examination. Contrast material is seen in the basal portions of the neoesophagus. No pleural effusions. Normal appearance of the cardiac silhouette. WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct [MASKED] 04:42 9.3 3.11* 9.9* 29.6* 95 31.8 33.4 14.0 48.7* 175 [MASKED] 02:54 10.7* 3.27* 10.3* 30.8* 94 31.5 33.4 14.1 48.5* 172 [MASKED] 05:21 13.4* 3.60* 11.5 34.3 95 31.9 33.5 14.0 48.8* 197 Brief Hospital Course: Mrs. [MASKED] was admitted to the hospital and taken to the Operating Room where she underwent an esophagogastroduodenoscopy and laparoscopic pyloroplasty. She tolerated the procedure well and returned to the PACU in stable condition. She maintained stable hemodynamics and her pain was controlled with IV Dilaudid. Following transfer to the Surgical floor she continued to have problems with nausea and vomiting and had some relief with Reglan and Zofran. Her barium swallow was postponed one day due to her symptoms and she remained NPO and was hydrated with IV fluids. Her symptoms improved in 24 hours and she underwent a barium swallow on [MASKED] which showed no leak and some delay of contrast. A liquid diet was started in modest amounts and she was able to tolerate it well. She had much less nausea. Her port sites were healing well and she was up and walking independently. From a cardiac standpoint she had some rapid atrial fibrillation on POD #2 and given her history of atrial fibrillation, she was evaluated by the Cardiology service. Her long acting betablocker was changed to short acting metoprolol and she continued on her pre op flecanide. She converted back to sinus bradycardia at a rate of 50-60 generally, sometimes higher with activity. Her pre op Metoprolol was resumed prior to discharge. Her room air saturations were 92-94% and she was using her incentive spirometer effectively. She was discharged home on [MASKED] and will follow up in the Thoracic Clinic in 2 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO Q4H:PRN nausea 2. Metoprolol Succinate XL 25 mg PO QHS 3. Flecainide Acetate 50 mg PO Q12H 4. Simvastatin 40 mg PO QPM 5. Multivitamins 1 TAB PO DAILY 6. Metoclopramide 10 mg PO Q6H:PRN nausea 7. Omeprazole 40 mg PO BID 8. Fluoxetine 40 mg PO DAILY 9. Fluoxetine 10 mg PO DAILY 10. Vitamin D 1000 UNIT PO QHS Discharge Medications: 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 40 mg PO DAILY 3. Docusate Sodium 100 mg PO BID Take while requiring Oxycodone to prevent constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 4. OxycoDONE (Immediate Release) [MASKED] mg PO Q6H:PRN pain Do not combine with other narcotics or alcohol. Do not drive while taking RX *oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 5. Lorazepam 0.5 mg PO Q4H:PRN nausea 6. Metoprolol Succinate XL 25 mg PO QHS 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO BID 9. Simvastatin 40 mg PO QPM 10. Vitamin D 1000 UNIT PO QHS 11. Fluoxetine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Gastric outlet obstruction Rapid atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr. [MASKED] [MASKED] if you experience: -Fevers > 101 or chills -Difficult or painful swallowing -Nausea, vomiting. -Increased shortness of breath Pain -Take stool softners while taking narcotics -No driving while taking narcotics Activity -Shower daily. Wash incision with mild soap and water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lotions or creams to incision -Walk [MASKED] times a day for [MASKED] minutes increase to a Goal of 30 minutes daily Diet: Full liquid diet for [MASKED]. Increase to soft solids as tolerates Eat small frequent meals. Sit in chair for all meals. Remain sitting up for [MASKED] minutes after all meals NO CARBONATED DRINKS Followup Instructions: [MASKED]
[]
[ "I480", "E785", "I252", "K219", "Z87891", "F329", "F419", "I10" ]
[ "K311: Adult hypertrophic pyloric stenosis", "I480: Paroxysmal atrial fibrillation", "Z9049: Acquired absence of other specified parts of digestive tract", "E785: Hyperlipidemia, unspecified", "I252: Old myocardial infarction", "Z8501: Personal history of malignant neoplasm of esophagus", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z800: Family history of malignant neoplasm of digestive organs", "I10: Essential (primary) hypertension" ]
10,076,958
24,692,372
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Attending: ___. Chief Complaint: nausea/retching Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ with a PMH pertinent for a laparoscopic pyloroplasty ___ and esophagectomy for stage T1b esophageal cancer in ___ now p/w intractable nausea and retching since ___ last night after being discharged home earlier in the day from a hospitalization for the same. At the time of discharge she had been taking in good PO volume of clear liquids and had started a soft diet and had been tolerating it well. At home she had soup, crackers and tuna, and hot chocolate, and shortly after began retching NBNB. She was unable to take her PO Ativan at home which had previously been effective for treating her nausea, and when her symptoms had not abated by ___, she and her husband decided to come to the ED. There she received IV Ativan and IVF rehydration which has improved her nausea, although she is still pallid and uncomfortable. The rest of her exam is benign, and her abdomen is soft, non-tender and non-distended. On review of symptoms she denies fever, chills, sweats, chest or abdominal pain, change in bowel or bladder habits, SOB or dysphagia. She is hemodynamically appropriate and labs are unremarkable except for a leukocytosis to 16.4. Past Medical History: Benign Hypertension Hyperlipidemia laparoscopic pyloroplasty ___ esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis ___ esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy ___ with possible mild MI s/p hysterectomy Depression Social History: ___ Family History: - Sister died age ___ colon cancer after ___ yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged ___ and ___). Physical Exam: Temp: 97.6 HR: 88 BP: 204/125 RR: 18 O2 Sat: 99%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [ ] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [x] Abnormal findings: dry mucus membranes RESPIRATORY [x] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [x] Abnormal findings: healing wounds with surgical glue x3 CDI GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [ ] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: LYMPH NODES [x] Cervical nl [x] Supraclavicular nl [x] Axillary nl [x] Inguinal nl [ ] Abnormal findings: SKIN [x] No rashes/lesions/ulcers [x] No induration/nodules/tightening [x] Abnormal findings: pallid PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 06:29 6.2 3.20* 10.2* 30.5* 95 31.9 33.4 14.0 48.7* 344 ___ 05:00 16.4* 3.92 12.5 36.5 93 31.9 34.2 13.7 46.5* 534 Brief Hospital Course: Mrs. ___ was evaluated by the Thoracic Surgery service in the Emergency Room and admitted to the hospital for further management of her nausea. She was hydrated with IV fluids and placed on Erythromycin and Reglan along with Marinol. After rehydration she began a liquid diet and was able to tolerate it in modest amounts. She was having all meals up in a chair and walking a bit more with encouragement. She had an episode of diarrhea after 24 hours of erythromycin and it was stopped in case that was the culprit. Her diet was advanced to soft and again she was taking modest amounts of each meal. She was encouraged to take 5 small meals a day at home which she says she normally does and she will continue on Reglan and Marinol for the present time. She was discharged to home on ___ and will follow up in the Thoracic Clinic in 10 days with Dr. ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 50 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Omeprazole 40 mg PO BID 5. Simvastatin 40 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Lorazepam 0.5 mg PO Q4H:PRN nausea Discharge Medications: 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 50 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Omeprazole 40 mg PO BID 5. Vitamin D 1000 UNIT PO DAILY 6. Acetaminophen 650 mg PO Q8H:PRN pain/H/A 7. Dronabinol 2.5 mg PO BID RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 8. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tab by mouth four times a day Disp #*60 Tablet Refills:*1 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Simvastatin 40 mg PO QPM 11. Lorazepam 0.5 mg PO Q4H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: Nausea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were readmitted to the hospital with nausea and retching. You got some relief with Ativan but improved after starting some medications that improve gastric emptying which you will remain on until you see Dr. ___. * You should continue to eat soft foods in modest amounts, small frequent meals might help. * It's important that you eat all meals up in a chair and remain up for at least one hour after eating. * Your gastric motility will improve the more you get up and walk and exercise. If you're tired, rest for short periods then get back up. Lying in bed all day is detrimental to your well being and recovery. * If you can tolerate protein supplements or protein powder that will help. * If you have more nausea or vomiting, a feeding tube will have to be looked at again. Call Dr. ___ at ___ if you have any questions or concerns. Followup Instructions: ___
[ "R110", "E440", "Z681", "I5181", "I10", "E785", "F329", "Z8501", "Z87891" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Chief Complaint: nausea/retching Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] with a PMH pertinent for a laparoscopic pyloroplasty [MASKED] and esophagectomy for stage T1b esophageal cancer in [MASKED] now p/w intractable nausea and retching since [MASKED] last night after being discharged home earlier in the day from a hospitalization for the same. At the time of discharge she had been taking in good PO volume of clear liquids and had started a soft diet and had been tolerating it well. At home she had soup, crackers and tuna, and hot chocolate, and shortly after began retching NBNB. She was unable to take her PO Ativan at home which had previously been effective for treating her nausea, and when her symptoms had not abated by [MASKED], she and her husband decided to come to the ED. There she received IV Ativan and IVF rehydration which has improved her nausea, although she is still pallid and uncomfortable. The rest of her exam is benign, and her abdomen is soft, non-tender and non-distended. On review of symptoms she denies fever, chills, sweats, chest or abdominal pain, change in bowel or bladder habits, SOB or dysphagia. She is hemodynamically appropriate and labs are unremarkable except for a leukocytosis to 16.4. Past Medical History: Benign Hypertension Hyperlipidemia laparoscopic pyloroplasty [MASKED] esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis [MASKED] esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy [MASKED] with possible mild MI s/p hysterectomy Depression Social History: [MASKED] Family History: - Sister died age [MASKED] colon cancer after [MASKED] yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged [MASKED] and [MASKED]). Physical Exam: Temp: 97.6 HR: 88 BP: 204/125 RR: 18 O2 Sat: 99%RA GENERAL [x] WN/WD [x] NAD [x] AAO [ ] abnormal findings: HEENT [x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric [ ] OP/NP mucosa normal [x] Tongue midline [x] Palate symmetric [x] Neck supple/NT/without mass [x] Trachea midline [x] Thyroid nl size/contour [x] Abnormal findings: dry mucus membranes RESPIRATORY [x] CTA/P [x] Excursion normal [x] No fremitus [x] No egophony [x] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema [x] Peripheral pulses nl [x] No abd/carotid bruit [ ] Abnormal findings: GI [x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia [x] Abnormal findings: healing wounds with surgical glue x3 CDI GU [x] Deferred [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] Strength intact/symmetric [x] Sensation intact/ symmetric [x] Reflexes nl [x] No facial asymmetry [x] Cognition intact [x] Cranial nerves intact [ ] Abnormal findings: MS [ ] No clubbing [x] No cyanosis [x] No edema [x] Gait nl [x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl [x] Nails nl [ ] Abnormal findings: LYMPH NODES [x] Cervical nl [x] Supraclavicular nl [x] Axillary nl [x] Inguinal nl [ ] Abnormal findings: SKIN [x] No rashes/lesions/ulcers [x] No induration/nodules/tightening [x] Abnormal findings: pallid PSYCHIATRIC [x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect [ ] Abnormal findings: Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct [MASKED] 06:29 6.2 3.20* 10.2* 30.5* 95 31.9 33.4 14.0 48.7* 344 [MASKED] 05:00 16.4* 3.92 12.5 36.5 93 31.9 34.2 13.7 46.5* 534 Brief Hospital Course: Mrs. [MASKED] was evaluated by the Thoracic Surgery service in the Emergency Room and admitted to the hospital for further management of her nausea. She was hydrated with IV fluids and placed on Erythromycin and Reglan along with Marinol. After rehydration she began a liquid diet and was able to tolerate it in modest amounts. She was having all meals up in a chair and walking a bit more with encouragement. She had an episode of diarrhea after 24 hours of erythromycin and it was stopped in case that was the culprit. Her diet was advanced to soft and again she was taking modest amounts of each meal. She was encouraged to take 5 small meals a day at home which she says she normally does and she will continue on Reglan and Marinol for the present time. She was discharged to home on [MASKED] and will follow up in the Thoracic Clinic in 10 days with Dr. [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 50 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Omeprazole 40 mg PO BID 5. Simvastatin 40 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Lorazepam 0.5 mg PO Q4H:PRN nausea Discharge Medications: 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 50 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Omeprazole 40 mg PO BID 5. Vitamin D 1000 UNIT PO DAILY 6. Acetaminophen 650 mg PO Q8H:PRN pain/H/A 7. Dronabinol 2.5 mg PO BID RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 8. Metoclopramide 10 mg PO QIDACHS RX *metoclopramide HCl 10 mg 1 tab by mouth four times a day Disp #*60 Tablet Refills:*1 9. Multivitamins W/minerals 1 TAB PO DAILY 10. Simvastatin 40 mg PO QPM 11. Lorazepam 0.5 mg PO Q4H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: Nausea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were readmitted to the hospital with nausea and retching. You got some relief with Ativan but improved after starting some medications that improve gastric emptying which you will remain on until you see Dr. [MASKED]. * You should continue to eat soft foods in modest amounts, small frequent meals might help. * It's important that you eat all meals up in a chair and remain up for at least one hour after eating. * Your gastric motility will improve the more you get up and walk and exercise. If you're tired, rest for short periods then get back up. Lying in bed all day is detrimental to your well being and recovery. * If you can tolerate protein supplements or protein powder that will help. * If you have more nausea or vomiting, a feeding tube will have to be looked at again. Call Dr. [MASKED] at [MASKED] if you have any questions or concerns. Followup Instructions: [MASKED]
[]
[ "I10", "E785", "F329", "Z87891" ]
[ "R110: Nausea", "E440: Moderate protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "I5181: Takotsubo syndrome", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z8501: Personal history of malignant neoplasm of esophagus", "Z87891: Personal history of nicotine dependence" ]
10,076,958
24,892,669
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Attending: ___. Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: ___ is a ___ with a PMH pertinent for a laparoscopic pyloroplasty ___ and esophagectomy in ___ for stage T1b esophageal cancer now p/w intractable nausea and retching since ___ last night. She states that she has had bouts of nausea and retching such as this one since discharge on ___ following her surgery, but came to the ED this time because her symptoms did not resolve with medication. Previously she had been taking Ativan for her symptoms with a good response, but she has recently run out of that medication and only has Zofran, which does not work well for her. The current episode began without any obvious triggering stimulus. She describes her emesis as non-projectile, NBNB, mostly clear sputum. She is interviewed after administration of one dose each of Zofran and Ativan and for the moment is not having any nausea. She appears quite pallid but exam is otherwise quite benign - abdomen is soft, non-tender, non-distended, surgical incisions CDI, lungs CTAB, pulse 2+ and symmetric, skin dry. She is fatigued from being up all night retching, but for the moment is comfortable. On review of symptoms she denies fever, chills, night sweats, chest or abdominal pain, changes in bowel or bladder habits, SOB or dysphagia. Her serum electrolytes are WNL, but she does have a leukocytosis of 16.5. Vital signs are hemodynamically appropriate satting 99% on RA. Past Medical History: Benign Hypertension Hyperlipidemia laparoscopic pyloroplasty ___ esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis ___ esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy ___ with possible mild MI s/p hysterectomy Depression Social History: ___ Family History: - Sister died age ___ colon cancer after ___ yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged ___ and ___). Physical Exam: Vitals: 98.3 HR 53 BP 112/59 RR 66 SaO2 93%RA Gen: NAD A&Ox3 CV: RRR, no MRG PULM: CTAB, no resp. distress Abd: soft NTTP, non distended, no rebound/guarding Wound: CDI Ext: pulses 2+, WWP, no CCE Pertinent Results: ___ CXR 1. Stable postoperative appearance of the neo-esophagus with adjacent platelike atelectasis, improved since prior. 2. No convincing evidence of pneumomediastinum or pneumothorax, but lateral radiograph is technically suboptimal and at may be repeated at no additional charge to more fully exclude this possibility if warranted clinically ___ CXR No significant interval change. ___ ECG Artifact is present. Sinus rhythm. The Q-T interval is prolonged. Compared to the previous tracing of ___ the rate is slower and Q-T interval is longer. Intervals Axes RatePRQRSQTQTc (___) ___ ___ ___ 01:25AM BLOOD WBC-16.5*# RBC-3.96# Hgb-12.5# Hct-37.4# MCV-94 MCH-31.6 MCHC-33.4 RDW-13.9 RDWSD-47.8* Plt ___ ___ 01:25AM BLOOD Neuts-74.5* Lymphs-17.8* Monos-5.7 Eos-1.2 Baso-0.4 Im ___ AbsNeut-12.28*# AbsLymp-2.93 AbsMono-0.93* AbsEos-0.19 AbsBaso-0.06 ___ 01:25AM BLOOD Plt ___ ___ 01:25AM BLOOD Glucose-197* UreaN-11 Creat-0.6 Na-135 K-4.1 Cl-97 HCO3-23 AnGap-19 ___ 09:38AM BLOOD WBC-12.6* RBC-3.64* Hgb-11.5 Hct-34.2 MCV-94 MCH-31.6 MCHC-33.6 RDW-13.6 RDWSD-46.2 Plt ___ ___ 09:38AM BLOOD Neuts-85.4* Lymphs-10.5* Monos-3.5* Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.71* AbsLymp-1.32 AbsMono-0.44 AbsEos-0.00* AbsBaso-0.03 ___ 09:38AM BLOOD Plt ___ ___ 10:13AM BLOOD WBC-7.2 RBC-3.46* Hgb-11.0* Hct-33.0* MCV-95 MCH-31.8 MCHC-33.3 RDW-13.9 RDWSD-48.4* Plt ___ ___ 10:13AM BLOOD Plt ___ ___ 10:13AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-134 K-3.9 Cl-100 HCO3-23 AnGap-15 Brief Hospital Course: Mrs. ___ is a ___ who underwent esophagectomy in ___ for stage T1b esophageal cancer and laparoscopic pyloroplasty ___. She presented with 8 hours of nausea and intractable NBNB vomiting in the setting of having run out of her normally effective nausea medication. She was admitted for observation, IV hydration, nausea control, and nutritional advancement. She had CXR and labs in the ED which revealed only a mild leukocytosis. On HD 1 her WBC was downtrending, 12.6(16.5), but she continued to have PO intolerance. That evening she was advanced to a CLD which she tolerated well. On HD 2 she endorsed continued malaise and was refusing to get out of bed. Her WBC had normalized and her urine and blood cultures showed no growth. She was able to tolerate modest amounts of a soft diet. On HD 3 she was taking in a good volume PO of clear liquids and was also tolerating a soft diet well. She was started on nutritional supplements. She had experienced no further nausea or vomiting for greater than 48 hours and was able to ambulate independently. Thus, she was deemed ready for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO QHS 2. Flecainide Acetate 50 mg PO Q12H 3. Simvastatin 40 mg PO QPM 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO Frequency is Unknown 6. Fluoxetine 40 mg PO DAILY 7. Fluoxetine 10 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Lorazepam 0.5 mg PO Q4H:PRN nausea Discharge Medications: 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 50 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Omeprazole 40 mg PO BID 5. Simvastatin 40 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Lorazepam 0.5 mg PO Q4H:PRN nausea RX *lorazepam 0.5 mg 1 tablet by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: nausea and vomiting 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 nausea and vomiting. Your white blood cell count was initially elevated but came down quickly and is now normal. All of your cultures are negative thus far. * You should continue to eat soft foods in modest amounts, small frequent meals might help. * It's important that you eat all meals up in a chair and remain up for at least one hour after eating. * Your gastric motility will improve the more you get up and walk and exercise. If you're tired, rest for short periods then get back up. Lying in bed all day is detrimental to your well being and recovery. * If you can tolerate protein supplements or protein powder that will help. * If you have increased nausea or vomiting or any other problems that concern you call Dr. ___ at ___ Followup Instructions: ___
[ "R112", "I4891", "I5181", "I2510", "F329", "I10", "E785", "D72829", "I252", "Z90710", "Z8501" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Chief Complaint: nausea and vomiting Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] is a [MASKED] with a PMH pertinent for a laparoscopic pyloroplasty [MASKED] and esophagectomy in [MASKED] for stage T1b esophageal cancer now p/w intractable nausea and retching since [MASKED] last night. She states that she has had bouts of nausea and retching such as this one since discharge on [MASKED] following her surgery, but came to the ED this time because her symptoms did not resolve with medication. Previously she had been taking Ativan for her symptoms with a good response, but she has recently run out of that medication and only has Zofran, which does not work well for her. The current episode began without any obvious triggering stimulus. She describes her emesis as non-projectile, NBNB, mostly clear sputum. She is interviewed after administration of one dose each of Zofran and Ativan and for the moment is not having any nausea. She appears quite pallid but exam is otherwise quite benign - abdomen is soft, non-tender, non-distended, surgical incisions CDI, lungs CTAB, pulse 2+ and symmetric, skin dry. She is fatigued from being up all night retching, but for the moment is comfortable. On review of symptoms she denies fever, chills, night sweats, chest or abdominal pain, changes in bowel or bladder habits, SOB or dysphagia. Her serum electrolytes are WNL, but she does have a leukocytosis of 16.5. Vital signs are hemodynamically appropriate satting 99% on RA. Past Medical History: Benign Hypertension Hyperlipidemia laparoscopic pyloroplasty [MASKED] esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis [MASKED] esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy [MASKED] with possible mild MI s/p hysterectomy Depression Social History: [MASKED] Family History: - Sister died age [MASKED] colon cancer after [MASKED] yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged [MASKED] and [MASKED]). Physical Exam: Vitals: 98.3 HR 53 BP 112/59 RR 66 SaO2 93%RA Gen: NAD A&Ox3 CV: RRR, no MRG PULM: CTAB, no resp. distress Abd: soft NTTP, non distended, no rebound/guarding Wound: CDI Ext: pulses 2+, WWP, no CCE Pertinent Results: [MASKED] CXR 1. Stable postoperative appearance of the neo-esophagus with adjacent platelike atelectasis, improved since prior. 2. No convincing evidence of pneumomediastinum or pneumothorax, but lateral radiograph is technically suboptimal and at may be repeated at no additional charge to more fully exclude this possibility if warranted clinically [MASKED] CXR No significant interval change. [MASKED] ECG Artifact is present. Sinus rhythm. The Q-T interval is prolonged. Compared to the previous tracing of [MASKED] the rate is slower and Q-T interval is longer. Intervals Axes RatePRQRSQTQTc ([MASKED]) [MASKED] [MASKED] [MASKED] 01:25AM BLOOD WBC-16.5*# RBC-3.96# Hgb-12.5# Hct-37.4# MCV-94 MCH-31.6 MCHC-33.4 RDW-13.9 RDWSD-47.8* Plt [MASKED] [MASKED] 01:25AM BLOOD Neuts-74.5* Lymphs-17.8* Monos-5.7 Eos-1.2 Baso-0.4 Im [MASKED] AbsNeut-12.28*# AbsLymp-2.93 AbsMono-0.93* AbsEos-0.19 AbsBaso-0.06 [MASKED] 01:25AM BLOOD Plt [MASKED] [MASKED] 01:25AM BLOOD Glucose-197* UreaN-11 Creat-0.6 Na-135 K-4.1 Cl-97 HCO3-23 AnGap-19 [MASKED] 09:38AM BLOOD WBC-12.6* RBC-3.64* Hgb-11.5 Hct-34.2 MCV-94 MCH-31.6 MCHC-33.6 RDW-13.6 RDWSD-46.2 Plt [MASKED] [MASKED] 09:38AM BLOOD Neuts-85.4* Lymphs-10.5* Monos-3.5* Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-10.71* AbsLymp-1.32 AbsMono-0.44 AbsEos-0.00* AbsBaso-0.03 [MASKED] 09:38AM BLOOD Plt [MASKED] [MASKED] 10:13AM BLOOD WBC-7.2 RBC-3.46* Hgb-11.0* Hct-33.0* MCV-95 MCH-31.8 MCHC-33.3 RDW-13.9 RDWSD-48.4* Plt [MASKED] [MASKED] 10:13AM BLOOD Plt [MASKED] [MASKED] 10:13AM BLOOD Glucose-109* UreaN-7 Creat-0.6 Na-134 K-3.9 Cl-100 HCO3-23 AnGap-15 Brief Hospital Course: Mrs. [MASKED] is a [MASKED] who underwent esophagectomy in [MASKED] for stage T1b esophageal cancer and laparoscopic pyloroplasty [MASKED]. She presented with 8 hours of nausea and intractable NBNB vomiting in the setting of having run out of her normally effective nausea medication. She was admitted for observation, IV hydration, nausea control, and nutritional advancement. She had CXR and labs in the ED which revealed only a mild leukocytosis. On HD 1 her WBC was downtrending, 12.6(16.5), but she continued to have PO intolerance. That evening she was advanced to a CLD which she tolerated well. On HD 2 she endorsed continued malaise and was refusing to get out of bed. Her WBC had normalized and her urine and blood cultures showed no growth. She was able to tolerate modest amounts of a soft diet. On HD 3 she was taking in a good volume PO of clear liquids and was also tolerating a soft diet well. She was started on nutritional supplements. She had experienced no further nausea or vomiting for greater than 48 hours and was able to ambulate independently. Thus, she was deemed ready for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO QHS 2. Flecainide Acetate 50 mg PO Q12H 3. Simvastatin 40 mg PO QPM 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 40 mg PO Frequency is Unknown 6. Fluoxetine 40 mg PO DAILY 7. Fluoxetine 10 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Lorazepam 0.5 mg PO Q4H:PRN nausea Discharge Medications: 1. Flecainide Acetate 50 mg PO Q12H 2. Fluoxetine 50 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO QHS 4. Omeprazole 40 mg PO BID 5. Simvastatin 40 mg PO QPM 6. Vitamin D 1000 UNIT PO DAILY 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Lorazepam 0.5 mg PO Q4H:PRN nausea RX *lorazepam 0.5 mg 1 tablet by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: nausea and vomiting 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 nausea and vomiting. Your white blood cell count was initially elevated but came down quickly and is now normal. All of your cultures are negative thus far. * You should continue to eat soft foods in modest amounts, small frequent meals might help. * It's important that you eat all meals up in a chair and remain up for at least one hour after eating. * Your gastric motility will improve the more you get up and walk and exercise. If you're tired, rest for short periods then get back up. Lying in bed all day is detrimental to your well being and recovery. * If you can tolerate protein supplements or protein powder that will help. * If you have increased nausea or vomiting or any other problems that concern you call Dr. [MASKED] at [MASKED] Followup Instructions: [MASKED]
[]
[ "I4891", "I2510", "F329", "I10", "E785", "I252" ]
[ "R112: Nausea with vomiting, unspecified", "I4891: Unspecified atrial fibrillation", "I5181: Takotsubo syndrome", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "D72829: Elevated white blood cell count, unspecified", "I252: Old myocardial infarction", "Z90710: Acquired absence of both cervix and uterus", "Z8501: Personal history of malignant neoplasm of esophagus" ]
10,076,958
28,621,351
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Attending: ___. Chief Complaint: nausea and dry heaving Major Surgical or Invasive Procedure: Exploratory laparotomy, ___ History of Present Illness: Ms. ___ is a ___ year old female s/p MIE in ___ for stage T1b esophageal adenocarcinoma and subsequent pyloroplasty ___ for persistent gastric outlet obstruction who has been admitted on multiple occasions over the antecedent month month (___) for recurrent intractable emesis and moderate malnutrition. During her stay, on ___, her jejunostomy was laparoscopically recannulated and a feeding tube was placed. By the time of discharge on ___, she was tolerating cycled tube feeds at 70cc/hr and a full liquid diet, sent home with instructions to advance her diet as tolerated and to work with ___ for management/monitoring of her j tube. Unfortunately, the tube feeds she was supposed to get on discharge on ___ did not arrive to her home until ___ afternoon, and so she was unable to initiate her tube feeds until last night (___). Initially upon arriving home, she was feeling relatively well, however weak, but was able to walk around the house, was tolerating water and juices without nausea or vomiting. She tried taking canned peaches on ___, but this did not go well and she vomited them back up. She started the tube feeds overnight last night, which ran from ~10pm to ~8am this morning, and was able to get 3 cans in, but has had nausea and dry heaving all morning as a result. She reports normal urination and normal daily bowel movements that are non melanotic and non bloody, last was this morning. Given her nausea/vomiting, malnutrition, and failure to thrive she was admitted from clinic to the thoracic surgery service ___ for observation and management. Past Medical History: Benign Hypertension Hyperlipidemia esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy ___ with possible mild MI Depression PSH laparoscopic pyloroplasty ___ esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis ___ s/p hysterectomy Social History: ___ Family History: Sister died age ___ colon cancer after ___ yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged ___ and ___). Physical Exam: Admission PE: VS: BP: 217/110. Heart Rate: 58. Weight: Patient declined. Temperature: 98.6. Resp. Rate: 16. Pain Score: 0. O2 Saturation%: 98. Gen: NAD, cachectic, appears unwell Neck: soft, supple Chest: lungs ctab, no wheezes; normal wob Cor: rrr Abd: soft, non-tender and non-distended; incisions from ___ operation appear c/d/I, without any surrounding erythema, edema or drainage. J tube is in place, with minimal drainage around wound. Extrem: 1+ distal pulses Pertinent Results: ABDOMEN (SUPINE & ERECT)Study Date of ___ 1:41 ___ IMPRESSION: A nonobstructive bowel gas pattern is demonstrated. High density foci within the right lower quadrant likely reflects retained barium. No pneumatosis, free intraperitoneal air, or dilated loops of bowel are clearly visualized. Degenerative changes are noted within the lower lumbar spine without acute osseous abnormality. Tubal ligation clips are also noted within the pelvis as well as a clip within the left upper quadrant of the abdomen. CT ABD & PELVIS W/O CONTRASTStudy Date of ___ 6:33 AM IMPRESSION: 1. Extensive pneumatosis involving the nearly the entire small bowel, cecum, ascending colon, and transverse colon to the level of the hepatic flexure. Extensive gas within mesenteric venous structures and small amount of portal venous gas. 2. Status post esophagectomy, gastric pull-through, and pyloroplasty. Large amount of fluid distending the neo-esophagus in the right hemithorax resulting in worsening right lower lobe atelectasis. 3. Small ascites. 4. A Foley catheter is present. There is a small amount of high-density debris versus blood within the bladder. 5. Multiple foci of ground-glass attenuation within the lungs, including a new area in the left lower lobe. Stable 6 mm nodule in the right upper lobe. 6. 3 mm infrarenal abdominal aortic aneurysm. ___: WBC-12.8 Na-133 K-4.4 ___: WBC-8.9 ___: Na-126 K-3.7 Cl-90* HCO3-24 AnGap-16 ___: Na-127 K-3.7 Cl-91* HCO3-21* AnGap-19 ___: WBC-15.4 Na-122 K-4.1 Cl-86* HCO3-14* AnGap-26* ___ 06:05AM: Lactate-7.6 pO2-88 pCO2-17 pH-7.41 calTCO2-11 Base XS--10 ___ 08:14AM: Lactate-9.6 O2-116* pCO2-20 pH-7.20 calTCO2-8 Base XS--18 ___ 09:35AM: Lactate-11.5 pO2-198 pCO2-42 pH-7.09 calTCO2-13 Base XS--16 Brief Hospital Course: Ms. ___ was a ___ female who underwent a minimally invasive ___ esophagectomy in ___ for esophageal adenocarcinoma. Her post-operative course was complicated by persistent gastric outlet obstruction and she subsequently underwent pyloroplasty ___. Thereafter, she was readmitted on multiple occasions with intractable nausea, retching/vomiting, PO intolerance, and malnutrition. A jejunostomy feeding tube was placed on ___ during her most recent admission. She presented for follow-up in clinic on ___ at which time she intolerance to her tube feeding regimen at home. She was nauseous, retching and hypertensive to 220s/110s. She was taken by ambulance to the ED for evaluation and management of her blood pressure, IV hydration, and IV antiemetics. However, her nausea did not resolve throughout the day and her blood pressure remained labile. Thus, she was admitted to the thoracic surgery service for ongoing management that evening. Upon admission, she was continued on her home medications, unchanged from her prior discharge. She was written for a clear liquid diet and her tube feeds (osmolite 1.5) were resumed at 30ml/hr, to advance to her goal rate of 70 ml/hr. She initially tolerated her feeds well and her nausea was controlled with metoclopramide and IV lorazepam. However, by the morning of HD 1, shortly after her feeds had been advanced to goal, her nausea and retching returned. Her tube feeds were stopped at this time with a plan to continue cycling at a lower rate that evening. She became hypertensive again and was given IV hydralazine 10mg PRN for SBP>170. She received two doses during her admission, one on ___ at 2pm and another ___ at 1am. Nutrition was consulted for adjustment of her tube feeds. Per their recommendations, her feeds were restarted that evening at a continuous rate of 40 and she was given IV Thiamine. However, she once again became nauseous overnight and her feeds were held. Her feeds were restarted in the morning of HD 2 on an elemental formula, Vital 1.4, @10ml/hr, to be advanced to a goal of continuous 40ml/hr. She was also noted to be hyponatremic. Fluid restriction and salt tabs were initiated and nephrology was consulted. Her urine/serum sodium and osmalality suggested SIADH and her fluoxetine was held due to its association. Upon further discussion with pharmacy, the cephalixin which had been initiated at her prior admission for mild phlebitis of the hand was also discontinued given its association with nausea. Finally, her tube feeds were held for suspicion that they could be underlying her electrolyte abnormalities. On HD 3 she fell while moving to the bathroom. A CT head was obtained but revealed no acute intracranial process or mass. On HD 4 she continued to display electrolyte abnormalities which were repleted appropriately. Her hyponatremia had not improved and her situation was further discussed with nephrology who recommended additional fluid restriction and resumption of tube feeds for solute. Her tube feeds were restarted at 20ml/hr and her IV fluids (normal saline) were also discontinued. Around 2am on HD 4, ___, she was noted to be hypotensive with systolic blood pressures in the ___, shortness of breath, and new abdominal distension. A chest x-ray and ECG were ordered and demonstrated only normal sinus rhythm and new bilateral interstitial opacities in the mid and lower lungs. She was given a 500cc fluid bolus but did not respond well. Transfer to the ICU was initiated at 4:30am and upon arrival around 5:50am broad spectrum antibiotics were initiated, an arterial line was placed, and the patient was placed on multiple pressors. ABG demonstrated lactate of 7.6 but with good respiratory compensation (pH 7.41, pCO2 17). A CT abdomen done at 6:30am showed extensive pneumatosis. Acute care surgery was consulted. Her pressor requirement continued to increase despite receiving 2L IVF bolus. She continued to decompensate rapidly with increasing acidemia (Lactate 9.6, pCO2 20, pH 7.20 at 8:14am) and appeared to be in impending respiratory failure. The decision was made to intubate the patient prior emergent transport to the OR. Around the time of intubation she developed ventricular tachycardia. A code was called, and after approximately 15 minutes of resuscitation including multiple rounds of epinephrine and bicarbonate, the patient re-entered a perfusing rhythm. The patient was taken emergently to the OR and an exploratory laparotomy performed. Her entire small intestine was noted to be ischemic and her right, transverse, and left colon were also dead, with the sigmoid being spared. The clinical suspicion was that there was either an acute embolic phenomenon to her superior mesenteric artery or an acute on chronic event. The abdomen was closed and the patient was transported back to the SICU. Upon discussion with her family, the patient was made comfort measures only, and terminally extubated around 12:30pm. She was pronounced 12:44pm. An autopsy was consented for examination of the abdomen only. At autopsy, initial findings included that the a dusky/ischemic small intestine from the distal jejunum/ileum to cecum, right, transverse, and left colon. The sigmoid colon and rectum were only relatively mildly dusky. The superior mesenteric artery and vessels within the omentum were suspicious for embolism and sections were sent for microscopic evaluation. A 3.0 cm infrarenal abdominal aortic aneurism with areas of mild clot formation and areas atherosclerosis/ulceration at the level of the renal arteries were also noted. An area of plaque proximal to the SMA was also sent for microscopy. The celiac artery was grossly unremarkable. Gross autopsy findings suggest diffuse ischemic bowel but final report is pending microscopic studies. Medications on Admission: 1. Acetaminophen 650 mg PO Q8H:PRN pain/H/A 2. Dronabinol 2.5 mg PO BID 3. Flecainide Acetate 50 mg PO Q12H 4. Fluoxetine 50 mg PO DAILY 5. Lorazepam 0.5 mg PO Q4H:PRN nausea 6. Metoprolol Succinate XL 25 mg PO QHS 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Omeprazole 40 mg PO BID 9. Simvastatin 40 mg PO QPM 10. Vitamin D 1000 UNIT PO DAILY 11. Docusate Sodium 100 mg PO BID (not taking) 12. Oxycodone 2.5 mg PO Q4H:PRN pain (not taking) 13. Senna 8.6 mg PO BID(not taking) 14. Cephalexin 500 mg PO Q12H 15. Metoclopramide 10 mg PO QIDACHS Discharge Disposition: Expired Discharge Diagnosis: diffuse ischemic bowel Discharge Condition: deceased ___ MD ___ Completed by: ___
[ "R112", "K550", "A419", "E440", "E222", "E872", "R64", "I480", "S0990XA", "I10", "Z681", "E785", "I252", "K219", "Z87891", "F329", "F419", "Z8501", "Z934", "Z9049", "R339", "Z515", "Z66", "K6389", "R627", "Z800", "I714", "W1830XA", "Y92230" ]
Allergies: Sulfa (Sulfonamide Antibiotics) / Imdur Chief Complaint: nausea and dry heaving Major Surgical or Invasive Procedure: Exploratory laparotomy, [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] year old female s/p MIE in [MASKED] for stage T1b esophageal adenocarcinoma and subsequent pyloroplasty [MASKED] for persistent gastric outlet obstruction who has been admitted on multiple occasions over the antecedent month month ([MASKED]) for recurrent intractable emesis and moderate malnutrition. During her stay, on [MASKED], her jejunostomy was laparoscopically recannulated and a feeding tube was placed. By the time of discharge on [MASKED], she was tolerating cycled tube feeds at 70cc/hr and a full liquid diet, sent home with instructions to advance her diet as tolerated and to work with [MASKED] for management/monitoring of her j tube. Unfortunately, the tube feeds she was supposed to get on discharge on [MASKED] did not arrive to her home until [MASKED] afternoon, and so she was unable to initiate her tube feeds until last night ([MASKED]). Initially upon arriving home, she was feeling relatively well, however weak, but was able to walk around the house, was tolerating water and juices without nausea or vomiting. She tried taking canned peaches on [MASKED], but this did not go well and she vomited them back up. She started the tube feeds overnight last night, which ran from ~10pm to ~8am this morning, and was able to get 3 cans in, but has had nausea and dry heaving all morning as a result. She reports normal urination and normal daily bowel movements that are non melanotic and non bloody, last was this morning. Given her nausea/vomiting, malnutrition, and failure to thrive she was admitted from clinic to the thoracic surgery service [MASKED] for observation and management. Past Medical History: Benign Hypertension Hyperlipidemia esophageal strictures s/p multiple dilatations Takotsubo cardiomyopathy [MASKED] with possible mild MI Depression PSH laparoscopic pyloroplasty [MASKED] esophageal adenocarcinoma s/p esophagectomy with esophago-gastric anastamosis [MASKED] s/p hysterectomy Social History: [MASKED] Family History: Sister died age [MASKED] colon cancer after [MASKED] yrs untreated. History of diabetes and heart disease on both sides. Both parents died of CHF (aged [MASKED] and [MASKED]). Physical Exam: Admission PE: VS: BP: 217/110. Heart Rate: 58. Weight: Patient declined. Temperature: 98.6. Resp. Rate: 16. Pain Score: 0. O2 Saturation%: 98. Gen: NAD, cachectic, appears unwell Neck: soft, supple Chest: lungs ctab, no wheezes; normal wob Cor: rrr Abd: soft, non-tender and non-distended; incisions from [MASKED] operation appear c/d/I, without any surrounding erythema, edema or drainage. J tube is in place, with minimal drainage around wound. Extrem: 1+ distal pulses Pertinent Results: ABDOMEN (SUPINE & ERECT)Study Date of [MASKED] 1:41 [MASKED] IMPRESSION: A nonobstructive bowel gas pattern is demonstrated. High density foci within the right lower quadrant likely reflects retained barium. No pneumatosis, free intraperitoneal air, or dilated loops of bowel are clearly visualized. Degenerative changes are noted within the lower lumbar spine without acute osseous abnormality. Tubal ligation clips are also noted within the pelvis as well as a clip within the left upper quadrant of the abdomen. CT ABD & PELVIS W/O CONTRASTStudy Date of [MASKED] 6:33 AM IMPRESSION: 1. Extensive pneumatosis involving the nearly the entire small bowel, cecum, ascending colon, and transverse colon to the level of the hepatic flexure. Extensive gas within mesenteric venous structures and small amount of portal venous gas. 2. Status post esophagectomy, gastric pull-through, and pyloroplasty. Large amount of fluid distending the neo-esophagus in the right hemithorax resulting in worsening right lower lobe atelectasis. 3. Small ascites. 4. A Foley catheter is present. There is a small amount of high-density debris versus blood within the bladder. 5. Multiple foci of ground-glass attenuation within the lungs, including a new area in the left lower lobe. Stable 6 mm nodule in the right upper lobe. 6. 3 mm infrarenal abdominal aortic aneurysm. [MASKED]: WBC-12.8 Na-133 K-4.4 [MASKED]: WBC-8.9 [MASKED]: Na-126 K-3.7 Cl-90* HCO3-24 AnGap-16 [MASKED]: Na-127 K-3.7 Cl-91* HCO3-21* AnGap-19 [MASKED]: WBC-15.4 Na-122 K-4.1 Cl-86* HCO3-14* AnGap-26* [MASKED] 06:05AM: Lactate-7.6 pO2-88 pCO2-17 pH-7.41 calTCO2-11 Base XS--10 [MASKED] 08:14AM: Lactate-9.6 O2-116* pCO2-20 pH-7.20 calTCO2-8 Base XS--18 [MASKED] 09:35AM: Lactate-11.5 pO2-198 pCO2-42 pH-7.09 calTCO2-13 Base XS--16 Brief Hospital Course: Ms. [MASKED] was a [MASKED] female who underwent a minimally invasive [MASKED] esophagectomy in [MASKED] for esophageal adenocarcinoma. Her post-operative course was complicated by persistent gastric outlet obstruction and she subsequently underwent pyloroplasty [MASKED]. Thereafter, she was readmitted on multiple occasions with intractable nausea, retching/vomiting, PO intolerance, and malnutrition. A jejunostomy feeding tube was placed on [MASKED] during her most recent admission. She presented for follow-up in clinic on [MASKED] at which time she intolerance to her tube feeding regimen at home. She was nauseous, retching and hypertensive to 220s/110s. She was taken by ambulance to the ED for evaluation and management of her blood pressure, IV hydration, and IV antiemetics. However, her nausea did not resolve throughout the day and her blood pressure remained labile. Thus, she was admitted to the thoracic surgery service for ongoing management that evening. Upon admission, she was continued on her home medications, unchanged from her prior discharge. She was written for a clear liquid diet and her tube feeds (osmolite 1.5) were resumed at 30ml/hr, to advance to her goal rate of 70 ml/hr. She initially tolerated her feeds well and her nausea was controlled with metoclopramide and IV lorazepam. However, by the morning of HD 1, shortly after her feeds had been advanced to goal, her nausea and retching returned. Her tube feeds were stopped at this time with a plan to continue cycling at a lower rate that evening. She became hypertensive again and was given IV hydralazine 10mg PRN for SBP>170. She received two doses during her admission, one on [MASKED] at 2pm and another [MASKED] at 1am. Nutrition was consulted for adjustment of her tube feeds. Per their recommendations, her feeds were restarted that evening at a continuous rate of 40 and she was given IV Thiamine. However, she once again became nauseous overnight and her feeds were held. Her feeds were restarted in the morning of HD 2 on an elemental formula, Vital 1.4, @10ml/hr, to be advanced to a goal of continuous 40ml/hr. She was also noted to be hyponatremic. Fluid restriction and salt tabs were initiated and nephrology was consulted. Her urine/serum sodium and osmalality suggested SIADH and her fluoxetine was held due to its association. Upon further discussion with pharmacy, the cephalixin which had been initiated at her prior admission for mild phlebitis of the hand was also discontinued given its association with nausea. Finally, her tube feeds were held for suspicion that they could be underlying her electrolyte abnormalities. On HD 3 she fell while moving to the bathroom. A CT head was obtained but revealed no acute intracranial process or mass. On HD 4 she continued to display electrolyte abnormalities which were repleted appropriately. Her hyponatremia had not improved and her situation was further discussed with nephrology who recommended additional fluid restriction and resumption of tube feeds for solute. Her tube feeds were restarted at 20ml/hr and her IV fluids (normal saline) were also discontinued. Around 2am on HD 4, [MASKED], she was noted to be hypotensive with systolic blood pressures in the [MASKED], shortness of breath, and new abdominal distension. A chest x-ray and ECG were ordered and demonstrated only normal sinus rhythm and new bilateral interstitial opacities in the mid and lower lungs. She was given a 500cc fluid bolus but did not respond well. Transfer to the ICU was initiated at 4:30am and upon arrival around 5:50am broad spectrum antibiotics were initiated, an arterial line was placed, and the patient was placed on multiple pressors. ABG demonstrated lactate of 7.6 but with good respiratory compensation (pH 7.41, pCO2 17). A CT abdomen done at 6:30am showed extensive pneumatosis. Acute care surgery was consulted. Her pressor requirement continued to increase despite receiving 2L IVF bolus. She continued to decompensate rapidly with increasing acidemia (Lactate 9.6, pCO2 20, pH 7.20 at 8:14am) and appeared to be in impending respiratory failure. The decision was made to intubate the patient prior emergent transport to the OR. Around the time of intubation she developed ventricular tachycardia. A code was called, and after approximately 15 minutes of resuscitation including multiple rounds of epinephrine and bicarbonate, the patient re-entered a perfusing rhythm. The patient was taken emergently to the OR and an exploratory laparotomy performed. Her entire small intestine was noted to be ischemic and her right, transverse, and left colon were also dead, with the sigmoid being spared. The clinical suspicion was that there was either an acute embolic phenomenon to her superior mesenteric artery or an acute on chronic event. The abdomen was closed and the patient was transported back to the SICU. Upon discussion with her family, the patient was made comfort measures only, and terminally extubated around 12:30pm. She was pronounced 12:44pm. An autopsy was consented for examination of the abdomen only. At autopsy, initial findings included that the a dusky/ischemic small intestine from the distal jejunum/ileum to cecum, right, transverse, and left colon. The sigmoid colon and rectum were only relatively mildly dusky. The superior mesenteric artery and vessels within the omentum were suspicious for embolism and sections were sent for microscopic evaluation. A 3.0 cm infrarenal abdominal aortic aneurism with areas of mild clot formation and areas atherosclerosis/ulceration at the level of the renal arteries were also noted. An area of plaque proximal to the SMA was also sent for microscopy. The celiac artery was grossly unremarkable. Gross autopsy findings suggest diffuse ischemic bowel but final report is pending microscopic studies. Medications on Admission: 1. Acetaminophen 650 mg PO Q8H:PRN pain/H/A 2. Dronabinol 2.5 mg PO BID 3. Flecainide Acetate 50 mg PO Q12H 4. Fluoxetine 50 mg PO DAILY 5. Lorazepam 0.5 mg PO Q4H:PRN nausea 6. Metoprolol Succinate XL 25 mg PO QHS 7. Multivitamins W/minerals 1 TAB PO DAILY 8. Omeprazole 40 mg PO BID 9. Simvastatin 40 mg PO QPM 10. Vitamin D 1000 UNIT PO DAILY 11. Docusate Sodium 100 mg PO BID (not taking) 12. Oxycodone 2.5 mg PO Q4H:PRN pain (not taking) 13. Senna 8.6 mg PO BID(not taking) 14. Cephalexin 500 mg PO Q12H 15. Metoclopramide 10 mg PO QIDACHS Discharge Disposition: Expired Discharge Diagnosis: diffuse ischemic bowel Discharge Condition: deceased [MASKED] MD [MASKED] Completed by: [MASKED]
[]
[ "E872", "I480", "I10", "E785", "I252", "K219", "Z87891", "F329", "F419", "Z515", "Z66", "Y92230" ]
[ "R112: Nausea with vomiting, unspecified", "K550: Acute vascular disorders of intestine", "A419: Sepsis, unspecified organism", "E440: Moderate protein-calorie malnutrition", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E872: Acidosis", "R64: Cachexia", "I480: Paroxysmal atrial fibrillation", "S0990XA: Unspecified injury of head, initial encounter", "I10: Essential (primary) hypertension", "Z681: Body mass index [BMI] 19.9 or less, adult", "E785: Hyperlipidemia, unspecified", "I252: Old myocardial infarction", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z8501: Personal history of malignant neoplasm of esophagus", "Z934: Other artificial openings of gastrointestinal tract status", "Z9049: Acquired absence of other specified parts of digestive tract", "R339: Retention of urine, unspecified", "Z515: Encounter for palliative care", "Z66: Do not resuscitate", "K6389: Other specified diseases of intestine", "R627: Adult failure to thrive", "Z800: Family history of malignant neoplasm of digestive organs", "I714: Abdominal aortic aneurysm, without rupture", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
10,077,365
20,742,447
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: EGD ___ Colonoscopy ___ History of Present Illness: Patient is a ___ year old man with history of ___ fistulas s/p perianal fistulotomy @ OSH 2 weeks pta who is presenting with two days of epigastric abdominal pain. He reports he initially presented to his PCP at ___ in ___ with rectal bleeding and was diagnosed with ___ fistula by a general surgeon. He underwent simple fistulotomies and has been slowly healing with diet modification and ___ baths. He was seen by ___ GI MD in the interim at ___ and was planned for colonoscopy. He reports that for the past few days, he has been having worsening non-radiating epigastric abdominal pain, relieved after eating, associated with some bloating. He has had two soft brown BM's today, no diarrhea or purulent bloody discharge from the fistula. Patient reports fever of 101.6 which prompted him to present to ED. In the ED, initial VS were: 96.6 126 147/87 18 100% RA ED physical exam was recorded as - Mild abdominal tenderness in the epigastric region, no flank tenderness, fistulotomy appears well healing ED labs were notable for nl CBC, BMP, lact 1.7, lipase 160 CT showed hyperemia and mild edema of the terminal ileum and approximately 10 cm of continuous distal ileum, likely representing acute Crohn's flare. No evidence of fistulization or abscess. Reactive mesenteric lymphadenopathy. Patient was given Tylenol and IVF Transfer VS were: 98 101 ___ 96% RA When seen on the floor, he reports above sxs but otherwise, a ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: Anxiety disorder ___ fistula Social History: ___ Family History: No family history of Crohn's disease Physical Exam: ADMISSION EXAM: Gen: NAD, A&O x3, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, mildly distended, non tender, normoactive breath sounds. Rectal exam on visual inspection with no pus/blood draining. No clear abscess/fistula visualized. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect DISCHARGE EXAM: VS: 97.5PO 94/57 53 18 100% on RA Gen: NAD, A&Ox3, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA ___. GI: soft, non-distended, non tender, normoactive breath sounds. Rectal exam on visual inspection with no pus/blood draining. No clear abscess/fistula visualized. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect Pertinent Results: ADMISSION LABS -------------- ___ 05:08PM LACTATE-1.7 ___ 05:00PM GLUCOSE-121* UREA N-7 CREAT-0.9 SODIUM-135 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-24 ANION GAP-17 ___ 05:00PM ALT(SGPT)-20 AST(SGOT)-14 ALK PHOS-98 TOT BILI-0.2 ___ 05:00PM LIPASE-168* ___ 05:00PM ALBUMIN-3.1___ 05:00PM WBC-7.8 RBC-5.26 HGB-13.5* HCT-40.9 MCV-78* MCH-25.7* MCHC-33.0 RDW-15.0 RDWSD-42.2 ___ 05:00PM PLT COUNT-296 IMAGING ------- CT abd: 1. Hyperemia and mild edema of the terminal ileum and approximately 10 cm of continuous distal ileum, likely representing acute Crohn's flare with small amount of adjacent free fluid. No evidence of fistulization, abscess, or bowel obstruction. Reactive mesenteric lymphadenopathy. 2. Markedly distended urinary bladder. EGD ___: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Colonoscopy ___: Erythema, congestion , friability an multiple deep ulcers in the 20 cm of TI examined (biopsy) IC valve appeared stenotic and was dilated post TI-intubation Ulceration in the colon (biopsy) Otherwise normal colonoscopy to cecum and 20 cm into TI MICROBIOLOGY ------------ Blood cultures x ___: NGTD Urine culture ___: negative C. diff PCR ___: negative Stool culture and O&P testing: negative DISCHARGE LABS -------------- ___ 07:03AM BLOOD WBC-16.4*# RBC-4.53* Hgb-11.4* Hct-35.1* MCV-78* MCH-25.2* MCHC-32.5 RDW-15.4 RDWSD-43.2 Plt ___ ___ 07:03AM BLOOD Glucose-130* UreaN-12 Creat-0.6 Na-142 K-4.8 Cl-106 HCO3-26 AnGap-15 ___ 07:03AM BLOOD ALT-22 AST-13 LD(LDH)-145 AlkPhos-86 TotBili-<0.2 ___ 07:03AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.3 ___ 06:35AM BLOOD CRP-210.1* Brief Hospital Course: ___ year old man with history of ___ fistulas s/p perianal fistulotomy at ___ 2 weeks prior to admission who is presenting with two days of epigastric abdominal pain, found to have active inflammation of ileum on CT, concerning for acute Crohn's disease. # Likely Crohn's disease # ___ fistula # Epigastric pain # Inflammation of ileum on CT Patient presents with several days of upper abdominal pain in setting of known healing perirectal fistula, associated with low grade temperature and microcytosis on labs. His imaging showed hyperemia and mild edema of the terminal ileum and approximately 10 cm of continuous distal ileum, likely representing acute Crohn's flare. Gastroenterology was consulted and recommended EGD and colonoscopy. Colonoscopy with multiple ulcers likely indicative of Crohn's disease. He was started on IV methylprednisolone, transtioned to PO prednisone 40 mg PO daily indefinitely. Stool studies were negative, as well as C. difficile PCR. Diet was advanced without problem. He was not requiring pain medications on discharge. He will follow up with Gastroenterology, who will titrate his steroid dosing, and call him to schedule a follow-up appointment. TPMT testing will need to be followed up on discharge. # Vitamin D deficiency: noted to be low at 7 on admission. He will require high dose vitamin D upon discharge. TRANSITIONS OF CARE ------------------- # Code status: Full # Follow-up: He will follow up with Gastroenterology, who will titrate his steroid dosing, and call him to schedule a follow-up appointment. TPMT testing will need to be followed up on discharge. He will require high dose vitamin D after discharge when he follows up with his primary care doctor. Of note, patient wishes to establish new primary at ___ and was given the phone number to facilitate this. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Likely Crohn's disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure caring for you during your hospitalization at ___. You came to us with fevers and abdominal pain, and had imaging tests and a colonoscopy that showed multiple ulcerations that was suggestive of Crohn's disease. You were started on IV steroids, with plans now to use oral steroids for an indefinite amount of time. It is important that you take all medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: ___
[ "K5080", "E559", "R1013" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: EGD [MASKED] Colonoscopy [MASKED] History of Present Illness: Patient is a [MASKED] year old man with history of [MASKED] fistulas s/p perianal fistulotomy @ OSH 2 weeks pta who is presenting with two days of epigastric abdominal pain. He reports he initially presented to his PCP at [MASKED] in [MASKED] with rectal bleeding and was diagnosed with [MASKED] fistula by a general surgeon. He underwent simple fistulotomies and has been slowly healing with diet modification and [MASKED] baths. He was seen by [MASKED] GI MD in the interim at [MASKED] and was planned for colonoscopy. He reports that for the past few days, he has been having worsening non-radiating epigastric abdominal pain, relieved after eating, associated with some bloating. He has had two soft brown BM's today, no diarrhea or purulent bloody discharge from the fistula. Patient reports fever of 101.6 which prompted him to present to ED. In the ED, initial VS were: 96.6 126 147/87 18 100% RA ED physical exam was recorded as - Mild abdominal tenderness in the epigastric region, no flank tenderness, fistulotomy appears well healing ED labs were notable for nl CBC, BMP, lact 1.7, lipase 160 CT showed hyperemia and mild edema of the terminal ileum and approximately 10 cm of continuous distal ileum, likely representing acute Crohn's flare. No evidence of fistulization or abscess. Reactive mesenteric lymphadenopathy. Patient was given Tylenol and IVF Transfer VS were: 98 101 [MASKED] 96% RA When seen on the floor, he reports above sxs but otherwise, a ten point ROS was conducted and was negative except as above in the HPI. Past Medical History: Anxiety disorder [MASKED] fistula Social History: [MASKED] Family History: No family history of Crohn's disease Physical Exam: ADMISSION EXAM: Gen: NAD, A&O x3, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA [MASKED]. GI: soft, mildly distended, non tender, normoactive breath sounds. Rectal exam on visual inspection with no pus/blood draining. No clear abscess/fistula visualized. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect DISCHARGE EXAM: VS: 97.5PO 94/57 53 18 100% on RA Gen: NAD, A&Ox3, lying in bed Eyes: EOMI, sclerae anicteric ENT: MMM, OP clear Cardiovasc: RRR, no MRG, full pulses, no edema Resp: normal effort, no accessory muscle use, lungs CTA [MASKED]. GI: soft, non-distended, non tender, normoactive breath sounds. Rectal exam on visual inspection with no pus/blood draining. No clear abscess/fistula visualized. MSK: No significant kyphosis. No palpable synovitis. Skin: No visible rash. No jaundice. Neuro: AAOx3. No facial droop. Psych: Full range of affect Pertinent Results: ADMISSION LABS -------------- [MASKED] 05:08PM LACTATE-1.7 [MASKED] 05:00PM GLUCOSE-121* UREA N-7 CREAT-0.9 SODIUM-135 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-24 ANION GAP-17 [MASKED] 05:00PM ALT(SGPT)-20 AST(SGOT)-14 ALK PHOS-98 TOT BILI-0.2 [MASKED] 05:00PM LIPASE-168* [MASKED] 05:00PM ALBUMIN-3.1 05:00PM WBC-7.8 RBC-5.26 HGB-13.5* HCT-40.9 MCV-78* MCH-25.7* MCHC-33.0 RDW-15.0 RDWSD-42.2 [MASKED] 05:00PM PLT COUNT-296 IMAGING ------- CT abd: 1. Hyperemia and mild edema of the terminal ileum and approximately 10 cm of continuous distal ileum, likely representing acute Crohn's flare with small amount of adjacent free fluid. No evidence of fistulization, abscess, or bowel obstruction. Reactive mesenteric lymphadenopathy. 2. Markedly distended urinary bladder. EGD [MASKED]: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Colonoscopy [MASKED]: Erythema, congestion , friability an multiple deep ulcers in the 20 cm of TI examined (biopsy) IC valve appeared stenotic and was dilated post TI-intubation Ulceration in the colon (biopsy) Otherwise normal colonoscopy to cecum and 20 cm into TI MICROBIOLOGY ------------ Blood cultures x [MASKED]: NGTD Urine culture [MASKED]: negative C. diff PCR [MASKED]: negative Stool culture and O&P testing: negative DISCHARGE LABS -------------- [MASKED] 07:03AM BLOOD WBC-16.4*# RBC-4.53* Hgb-11.4* Hct-35.1* MCV-78* MCH-25.2* MCHC-32.5 RDW-15.4 RDWSD-43.2 Plt [MASKED] [MASKED] 07:03AM BLOOD Glucose-130* UreaN-12 Creat-0.6 Na-142 K-4.8 Cl-106 HCO3-26 AnGap-15 [MASKED] 07:03AM BLOOD ALT-22 AST-13 LD(LDH)-145 AlkPhos-86 TotBili-<0.2 [MASKED] 07:03AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.3 [MASKED] 06:35AM BLOOD CRP-210.1* Brief Hospital Course: [MASKED] year old man with history of [MASKED] fistulas s/p perianal fistulotomy at [MASKED] 2 weeks prior to admission who is presenting with two days of epigastric abdominal pain, found to have active inflammation of ileum on CT, concerning for acute Crohn's disease. # Likely Crohn's disease # [MASKED] fistula # Epigastric pain # Inflammation of ileum on CT Patient presents with several days of upper abdominal pain in setting of known healing perirectal fistula, associated with low grade temperature and microcytosis on labs. His imaging showed hyperemia and mild edema of the terminal ileum and approximately 10 cm of continuous distal ileum, likely representing acute Crohn's flare. Gastroenterology was consulted and recommended EGD and colonoscopy. Colonoscopy with multiple ulcers likely indicative of Crohn's disease. He was started on IV methylprednisolone, transtioned to PO prednisone 40 mg PO daily indefinitely. Stool studies were negative, as well as C. difficile PCR. Diet was advanced without problem. He was not requiring pain medications on discharge. He will follow up with Gastroenterology, who will titrate his steroid dosing, and call him to schedule a follow-up appointment. TPMT testing will need to be followed up on discharge. # Vitamin D deficiency: noted to be low at 7 on admission. He will require high dose vitamin D upon discharge. TRANSITIONS OF CARE ------------------- # Code status: Full # Follow-up: He will follow up with Gastroenterology, who will titrate his steroid dosing, and call him to schedule a follow-up appointment. TPMT testing will need to be followed up on discharge. He will require high dose vitamin D after discharge when he follows up with his primary care doctor. Of note, patient wishes to establish new primary at [MASKED] and was given the phone number to facilitate this. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Likely Crohn's disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], It was a pleasure caring for you during your hospitalization at [MASKED]. You came to us with fevers and abdominal pain, and had imaging tests and a colonoscopy that showed multiple ulcerations that was suggestive of Crohn's disease. You were started on IV steroids, with plans now to use oral steroids for an indefinite amount of time. It is important that you take all medications as prescribed and follow up with the appointments listed below. Good luck! Followup Instructions: [MASKED]
[]
[]
[ "K5080: Crohn's disease of both small and large intestine without complications", "E559: Vitamin D deficiency, unspecified", "R1013: Epigastric pain" ]
10,077,370
21,019,625
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Mintezol / codeine Attending: ___. Chief Complaint: Dysphagia Major Surgical or Invasive Procedure: ___: ESOPHAGOGASTRODUODENOSCOPY ___: ENDOBRONCHIAL ULTRASOUND, BIOPSY OF HILAR LYMPH NODES History of Present Illness: Mrs. ___ is a ___ year old female with past medical history of pre-diabetes and dyslipidemia, who presents for evaluation of dysphagia. She reports that she started experiencing difficulty swallowing food approximately 3 days ago. The dysphagia was initially to solids, then also involved liquids. She tried to eat crushed food but was unable to finish her meals. On the day prior to admission, she woke up with a sensation of food stuck and choking her. She also reports that it is starting to become difficult to swallow secretions. She ___ "it feels my throat is smaller". She went to ___, where a CT scan showed abnormal thickening of the mid to distal esophagus question esophagitis or mass. She came to ___ for further evaluation. In the ED, initial vitals: 98.6 103 161/81 20 98% RA Exam: managing secretions, comfortable, breathing comfdortbaly, no acute distress Imaging at ___ (see report below) Patient was given pantoprazole IV GI was consulted and recommended NPO, protonix BID 40 mg IVadmit to medicine, scope ___. Vitals prior to transfer: 98.1 97 148/90 16 100% RA On arrival to the floor, patient was overall comfortable but tired looking. She confirmed history above. In addition, she reports numbness in the right forehead, left groin, left hip, and left axilla a few weeks ago after returning from ___. She also reports intermittent left scapular pain for a few weeks, relieved with Tylenol. ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: GERD Leiomyoma of uterus Glaucoma suspect with open angle OHT (ocular hypertension) Cataract, nuclear sclerotic senile Optic atrophy Benign neoplasm of eyelid Hypercholesteremia Prediabetes Social History: ___ Family History: - Father ___ at age ___ Alzheimer's; Diabetes; Hypertension; Stroke - Mother ___ at age ___ Alzheimer's; Diabetes; Hyperlipidemia; Hypertension; Inflammatory Bowel Disease; Glaucoma - Sister ___ at age ___ Alzheimer's; Anemia - Hereditary; Breast cancer; Diabetes - Sister with breast cancer - Brother Alive; ___ at age ___ Diabetes; Hyperlipidemia; Hypertension; Stroke - Daughter Alive - Son Alive Physical ___: ADMISSION PHYSICAL EXAM: ======================== VS: 98.1 PO 168 / 83 95 18 99 RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, motor function grossly normal, decreased sensation in right forehead, left groin, left hip, and left axilla. DISCHARGE PHYSICAL EXAM: ======================== VS: 99.6 148/88 97 97%RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple, no masses palpated in thyroid, no tenderness to palpation PULM: CTA b/l without wheeze or rhonchi COR: RRR nml S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: AAOx3 - PERRLA, EOM intact, facial sensation as below, facial muscles strong and equal bilaterally, decreased palatal elevation on L, SCM ___ b/l, tongue protrudes midline with equal L and R movement. - Decreased sensation to light touch in right forehead (V1 distribution), L mandible (V3 distribution), left groin to hip in dermatomal fashion (T11-L1), and left axilla. - ___ strength upper and lower extremities. Finger to nose with mostly smooth pursuit, increasingly fatigued as test goes on with slight tremble. No pronator drift. Gait deferred. Pertinent Results: ADMISSION LABS: ============== ___ 08:10PM BLOOD WBC-3.6* RBC-4.37 Hgb-11.9 Hct-37.4 MCV-86 MCH-27.2 MCHC-31.8* RDW-13.1 RDWSD-40.7 Plt ___ ___ 08:10PM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-139 K-3.7 Cl-101 HCO3-27 AnGap-15 ___ 08:10PM BLOOD ALT-22 AST-21 LD(LDH)-227 AlkPhos-85 TotBili-0.4 ___ 08:10PM BLOOD Albumin-3.8 Calcium-9.6 Phos-3.2 Mg-2.0 OTHER PERTINENT LABS: ==================== ___ 07:37AM BLOOD TotProt-6.8 Calcium-9.6 Phos-2.8 Mg-2.1 ___ 05:10AM BLOOD VitB12-577 ___ 05:15AM BLOOD TSH-1.6 ___ 07:37AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* ___ 07:37AM BLOOD RheuFac-<10 ___ CRP-83.0* ___ 07:37AM BLOOD PEP-NO SPECIFI ___ 07:37AM BLOOD HCV Ab-Negative DISCHARGE LABS: ============== ___ 06:18AM BLOOD HBV VL-NOT DETECT ___ 06:18AM BLOOD WBC-3.6* RBC-4.19 Hgb-11.3 Hct-35.8 MCV-85 MCH-27.0 MCHC-31.6* RDW-13.3 RDWSD-41.7 Plt ___ ___ 06:18AM BLOOD Glucose-97 UreaN-8 Creat-0.8 Na-141 K-3.9 Cl-102 HCO3-27 AnGap-16 ___ 06:18AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.0 URINE STUDIES: ============= ___ 05:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 05:40PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 05:40PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE Epi-2 MICROBIOLOGY: ============= ___ 5:40 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 5:10 am Blood (LYME) Lyme IgG (Preliminary): Sent to ___ for Lyme Western Blot testing. Lyme IgM (Preliminary): Sent to ___ for Lyme Western Blot testing. ___ 5:10 am SEROLOGY/BLOOD **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive. Time Taken Not Noted Log-In Date/Time: ___ 5:47 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: 10,000-100,000 CFU/mL Commensal Respiratory Flora. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). IMAGING/STUDIES: ============== ___ Neck (___): IMPRESSION: 1. No suspicious mass in the oral pharynx or hypopharynx. 2. Incidental thyroid complex nodule. 3. Incidental tiny polyp right maxillary sinus. ___ Second Read: No oro pharyngeal or retropharyngeal mass identified. There is no narrowing of the airways. 1.6 cm enhancing thyroid nodule with surrounding hypodensity. Further evaluation is recommended with ultrasound RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up recommended. ___ College of Radiology guidelines recommend further evaluation for incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5 cm in patients age ___ or ___, or with suspicious findings. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___ Chest w/ Contrast (___): 1. Abnormal thickening of the mid to distal esophagus question esophagitis or mass. No obstruction as the oral contrast passes beyond this into the stomach. 2. Extensive bilateral hilar adenopathy. 3. 1.2 cm soft tissue nodule right lung base posterior medially. ___ Second Read: -Confluent mediastinal and symmetric bilateral hilar lymphadenopathy with peribronchial nodules, suspicious for sarcoidosis. -Slightly spiculated solid pulmonary nodule in the right lower lobe measuring up to 12 mm. This is likely be part of the spectrum of sarcoidosis and less likely lymphoma or small cell lung cancer. However, transbronchial biopsy and tissue diagnosis would be helpful for definitive clinical management. -Multiple enlarged lymph nodes adjacent to the esophagus, which is mildly enlarged. Gastric Biopsy (___): Stomach, mucosal biopsy: - Chemical-type gastropathy. Barium Swallow (___): 1. Mild penetration of thin liquids. Residue in the piriform sinuses with holdup of barium tablet in the left piriform sinus for around 2 minutes. Recommend dedicated formal video oropharyngeal swallow study with the speech pathology team for more detailed evaluation of the oropharynx. 2. Normal esophageal motility. 3. Small hiatal hernia. MRI Brain; MRA Head and Neck (___): 1. Images are limited by motion, pulsation, and other artifacts. 2. No evidence for an acute infarction, intracranial mass, or other intracranial abnormalities. 3. Inadequate assessment of the proximal common carotid and vertebral arteries. No evidence for internal carotid stenosis by NASCET criteria. 4. No evidence for flow-limiting intracranial arterial stenosis. 5. Approximately 1.7 cm left thyroid nodule is better seen on the ___T Mandible (___): 1. No evidence of focal mandibular lesion. 2. Incidental note of a torus ___. 3. Small right maxillary mucosal retention cyst. Bronchus Biopsy (___): TBNA: Nonspecific T cell dominant lymphoid profile; diagnostic Immunophenoptyic features of involvement by leukemia/lymphoma are not seen in specimen. Correlation with clinical, morphologic (see separate pathology report ___-___) and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. Surgical Pathology: Part 1: Endobronchial biopsy, carina: - Bronchial mucosa with focal necrotizing granulomatous inflammation, see note. Part 2: Endobronchial ultrasound guided transbronchial needle aspiration, lymph node level 7: - Non-necrotizing granulomatous inflammation, see note. - There is no evidence of malignancy. Part 3: Endobronchial ultrasound guided forceps level 7: - Scant fragments of lymphoid tissue and smooth muscle. - There is no evidence of granulomatous inflammation, nor of malignancy; multiple levels are examined. Note: AFB and GMS stains, performed on Parts 1 & 2, are negative. Fine Needle Aspiration: Lymph node, level 11R, EBUS-TBNA: NEGATIVE FOR MALIGNANT CELLS. - Non-necrotizing granulomas (see note). - Lymphocytes consistent with lymph node sampling. Lymph node, Level 7, EBUS-TBNA: NEGATIVE FOR MALIGNANT CELLS. - Rare histiocytic aggregates suggestive of non-necrotizing granulomas. - Lymphocytes consistent with lymph node sampling. Lingula Lavage: NEGATIVE FOR MALIGNANT CELLS. - Pulmonary macrophages and bronchial epithelial cells. Chest XRay (___): No pneumothorax identified Brief Hospital Course: Ms. ___ is a ___ yo F with hx of HLD who presented with ___ weeks of acute onset dysphagia with patchy numbness over forehead, chin, left arm, and left abdomen. Initially she presented to ___ where she had a CT scan that demonstrated confluent mediastinal and symmetric bilateral hilar lymphadenopathy as well as thickening of her distal esophagus. She was transferred to ___ for further evaluation of her lower esophageal thickness. Underwent an EGD on ___, which was unremarkable. Biopsy obtained demonstrated chemical-type gastropathy. Her dysphagia was further worked up during her hospitalization. She underwent additional imaging which did not demonstrate any evidence of brain stem stroke. She was evaluated by neurology who felt her presentation was most consistent with a neuropathy from a local nerve injury. A CT of her mandible did not demonstrate any mass compressing a peripheral nerve. She was evaluated by speech and swallow, who made adjustments to her diet which assisted greatly with swallowing. For her mediastinal lymphadenopathy noted on ___ chest CT, she underwent further work-up with a bronchoscopy with biopsy performed by interventional pulmonology on ___. Tolerated the procedure well. Final biopsy report pending at discharge, although preliminary read consistent with sarcoidosis. Rheumatology was consulted due to concern for possible sarcoidosis with nerve involvement leading to dysphagia. The plan at discharge was to initiate steroids as an outpatient to determine if this would aid in her dysphagia. ACTIVE ISSUES: =============== #Dysphagia: Acute dysphagia to solids and liquids over the two weeks prior to admission. Differential was broad and included possible CVA, mechanical obstruction, nerve injury, or neuropathy. Initially Mrs. ___ presented to ___, where she underwent imaging of the chest and neck. Neck without evidence of any masses. CT torso with extensive bilateral hilar adenopathy and abnormal thickening of the mid to distal esophagus concerning for esophagitis vs mass without evidence of obstruction. She was transferred to ___ for further evaluation. Due to concern for esophageal mass, GI was consulted and performed an EGD on ___. She tolerated the procedure well and a biopsy was obtained. EGD overall unremarkable and biopsy returned with findings of chemical-type gastropathy. On repeat read of CT torso, felt that this thickening may have been due to extensive lymphadenopathy. For further work-up of her dysphagia, ENT was consulted for evaluation for vocal cord dyfunction given that she also had some change in quality to her voice. Nothing remarkable was seen on examination. To work-up possible lateral medullary syndrome, an MRI brain and MRA head/neck were obtained to evaluate for stroke. These were overall unremarkable. Neurology was consulted who noticed she had subtle palate deviation to the right with chin numbness that may suggest a peripheral nerve injury. Recommended malignancy work-up and CT of her mandible to look for bony lesion. CT mandible was overall unremarkable, and the patient had recently had normal screening mammogram and colonoscopy within the past year without any concerning new symptoms. Due to concern that perhaps her sarcoid was contributing to her neurologic symptoms, she underwent a bronchoscopy to evaluate for her hilar lymphadenopathy. Underwent a bronchoscopy with biopsy on ___iopsy with preliminary findings suggestive of sarcoidosis. Other testing for infectious etiologies including Quantiferon gold, Aspergillus, and B-glucan were negative. Rheumatology was consulted and recommended initiating steroids, which the patient preferred to do as an outpatient. Noted to be hepatitis B core positive and surface antibody positive, indicating past, cleared infection. Hepatology was consulted and recommended that should she be initiated on high dose steroids, she should start entecavir 0.5mg po daily, to be continued until 6 months after completion of immunosuppresion. #Scattered numbness: On presentation described numbness in right forehead, left groin, left hip, and left axilla in dermatomal fashion (terminates midline). No other motor or sensation deficits. Unclear etiology, although had extensive work-up as above. Possibly secondary to sarcoidosis with neurologic involvement. #Leukopenia: White blood cell counts during hospitalization between 2.8K - 4.5K. Possibly due to underlying inflammatory condition. Stable throughout hospitalization without evidence of infection. # Elevated blood pressure: Noted during hospitalization intermittently up to SBP 170s. Should be followed up and treated as an outpatient if this persists. CHRONIC ISSUES: =============== #Dyslipidemia: Continued home pravastatin ***TRANSITIONAL ISSUES:*** ======================== - Please follow-up on final biopsy results; if sarcoid may benefit from trial of steroids - If steroids are started, the patient will need to be started on entecavir 0.5mg po daily. Will also need liver follow-up within one month if started on therapy. This therapy should continue until about 6 months after steroids are discontinued. - Dysphagia: Patient discharged on pureed liquids. Patient will benefit from continued speech and swallow therapy as an outpatient. Please continue to monitor her nutritional status as it is very difficult to take in anything PO. - Hypertension: Blood pressures inpatient ranged from 111-170/59-94. Consider starting blood pressure agents upon discharge. - Noted to have a 1.5 cm complex left thyroid nodule with calcification on CT chest at ___ Please follow-up as an outpatient - If started on steroids will need to take supplemental calcium and vitamin D if low; will also need DEXA screening - Started on pantoprazole to help with reflux and given that she will be started on steroids as an outpatient. - Contact: ___ (husband) ___ - Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 20 mg PO QPM 2. coenzyme Q10 10 mg oral DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Discharge Medications: 1. Entecavir 0.5 mg PO DAILY Only to be started if started on prednisone RX *entecavir 0.5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 (One) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. coenzyme Q10 10 mg oral DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Multivitamins 1 TAB PO DAILY 7. Pravastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary: Sarcoidosis, Oropharyngeal dysphagia Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ (___) due to difficulty with swallowing. While here, they did a CT scan which showed enlarged lymph nodes near the esophagus. An upper endoscopy with a stomach biopsy showed no evidence of cancer. Given that you were having continued difficulty with swallowing, an MRI was obtained of your brain which did not show any evidence of stroke. Neurology also evaluated you and agreed you did not have a stroke. We believe some of your swallowing difficulty could be from underlying sarcoidosis given the large lymph nodes we saw on your CT scan. An endobronchial ultrasound with biopsy of your lymph nodes was done that preliminarily showed sarcoidosis. We are awaiting the final results. You will have an appointment with Rheumatology this week to discuss further treatment options. During your admission, you were also found to have been exposed to Hepatitis B in the past and made a full recovery. However, because the treatment of sarcoidosis is steroids, there is a risk of reactivation of the Hepatitis B viral infection. Thus, if rheumatology initiates you on steroids, you will also need to take entecavir to prevent reactivation. If started on entecavir, you will also need to make an appointment with Dr. ___ (hepatology) for 1 month follow-up. Please follow up with your outpatient providers and all your scheduled appointments. Thank you for allowing us to be involved in your care. Sincerely, Your ___ Care Team Followup Instructions: ___
[ "D869", "R1312", "K449", "K319", "K219", "E785", "R000", "R591", "R911", "R200", "E041", "H2589", "H4010X0", "R7303", "Z8619" ]
Allergies: Mintezol / codeine Chief Complaint: Dysphagia Major Surgical or Invasive Procedure: [MASKED]: ESOPHAGOGASTRODUODENOSCOPY [MASKED]: ENDOBRONCHIAL ULTRASOUND, BIOPSY OF HILAR LYMPH NODES History of Present Illness: Mrs. [MASKED] is a [MASKED] year old female with past medical history of pre-diabetes and dyslipidemia, who presents for evaluation of dysphagia. She reports that she started experiencing difficulty swallowing food approximately 3 days ago. The dysphagia was initially to solids, then also involved liquids. She tried to eat crushed food but was unable to finish her meals. On the day prior to admission, she woke up with a sensation of food stuck and choking her. She also reports that it is starting to become difficult to swallow secretions. She [MASKED] "it feels my throat is smaller". She went to [MASKED], where a CT scan showed abnormal thickening of the mid to distal esophagus question esophagitis or mass. She came to [MASKED] for further evaluation. In the ED, initial vitals: 98.6 103 161/81 20 98% RA Exam: managing secretions, comfortable, breathing comfdortbaly, no acute distress Imaging at [MASKED] (see report below) Patient was given pantoprazole IV GI was consulted and recommended NPO, protonix BID 40 mg IVadmit to medicine, scope [MASKED]. Vitals prior to transfer: 98.1 97 148/90 16 100% RA On arrival to the floor, patient was overall comfortable but tired looking. She confirmed history above. In addition, she reports numbness in the right forehead, left groin, left hip, and left axilla a few weeks ago after returning from [MASKED]. She also reports intermittent left scapular pain for a few weeks, relieved with Tylenol. ROS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: GERD Leiomyoma of uterus Glaucoma suspect with open angle OHT (ocular hypertension) Cataract, nuclear sclerotic senile Optic atrophy Benign neoplasm of eyelid Hypercholesteremia Prediabetes Social History: [MASKED] Family History: - Father [MASKED] at age [MASKED] Alzheimer's; Diabetes; Hypertension; Stroke - Mother [MASKED] at age [MASKED] Alzheimer's; Diabetes; Hyperlipidemia; Hypertension; Inflammatory Bowel Disease; Glaucoma - Sister [MASKED] at age [MASKED] Alzheimer's; Anemia - Hereditary; Breast cancer; Diabetes - Sister with breast cancer - Brother Alive; [MASKED] at age [MASKED] Diabetes; Hyperlipidemia; Hypertension; Stroke - Daughter Alive - Son Alive Physical [MASKED]: ADMISSION PHYSICAL EXAM: ======================== VS: 98.1 PO 168 / 83 95 18 99 RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple without LAD PULM: Generally CTA b/l without wheeze or rhonchi COR: RRR (+)S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: CN II-XII grossly intact, motor function grossly normal, decreased sensation in right forehead, left groin, left hip, and left axilla. DISCHARGE PHYSICAL EXAM: ======================== VS: 99.6 148/88 97 97%RA GEN: Alert, lying in bed, no acute distress HEENT: Moist MM, anicteric sclerae, no conjunctival pallor NECK: Supple, no masses palpated in thyroid, no tenderness to palpation PULM: CTA b/l without wheeze or rhonchi COR: RRR nml S1/S2 no m/r/g ABD: Soft, non-tender, non-distended EXTREM: Warm, well-perfused, no edema NEURO: AAOx3 - PERRLA, EOM intact, facial sensation as below, facial muscles strong and equal bilaterally, decreased palatal elevation on L, SCM [MASKED] b/l, tongue protrudes midline with equal L and R movement. - Decreased sensation to light touch in right forehead (V1 distribution), L mandible (V3 distribution), left groin to hip in dermatomal fashion (T11-L1), and left axilla. - [MASKED] strength upper and lower extremities. Finger to nose with mostly smooth pursuit, increasingly fatigued as test goes on with slight tremble. No pronator drift. Gait deferred. Pertinent Results: ADMISSION LABS: ============== [MASKED] 08:10PM BLOOD WBC-3.6* RBC-4.37 Hgb-11.9 Hct-37.4 MCV-86 MCH-27.2 MCHC-31.8* RDW-13.1 RDWSD-40.7 Plt [MASKED] [MASKED] 08:10PM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-139 K-3.7 Cl-101 HCO3-27 AnGap-15 [MASKED] 08:10PM BLOOD ALT-22 AST-21 LD(LDH)-227 AlkPhos-85 TotBili-0.4 [MASKED] 08:10PM BLOOD Albumin-3.8 Calcium-9.6 Phos-3.2 Mg-2.0 OTHER PERTINENT LABS: ==================== [MASKED] 07:37AM BLOOD TotProt-6.8 Calcium-9.6 Phos-2.8 Mg-2.1 [MASKED] 05:10AM BLOOD VitB12-577 [MASKED] 05:15AM BLOOD TSH-1.6 [MASKED] 07:37AM BLOOD HBsAg-Negative HBsAb-Positive HBcAb-Positive* [MASKED] 07:37AM BLOOD RheuFac-<10 [MASKED] CRP-83.0* [MASKED] 07:37AM BLOOD PEP-NO SPECIFI [MASKED] 07:37AM BLOOD HCV Ab-Negative DISCHARGE LABS: ============== [MASKED] 06:18AM BLOOD HBV VL-NOT DETECT [MASKED] 06:18AM BLOOD WBC-3.6* RBC-4.19 Hgb-11.3 Hct-35.8 MCV-85 MCH-27.0 MCHC-31.6* RDW-13.3 RDWSD-41.7 Plt [MASKED] [MASKED] 06:18AM BLOOD Glucose-97 UreaN-8 Creat-0.8 Na-141 K-3.9 Cl-102 HCO3-27 AnGap-16 [MASKED] 06:18AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.0 URINE STUDIES: ============= [MASKED] 05:40PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 05:40PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [MASKED] 05:40PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE Epi-2 MICROBIOLOGY: ============= [MASKED] 5:40 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] 5:10 am Blood (LYME) Lyme IgG (Preliminary): Sent to [MASKED] for Lyme Western Blot testing. Lyme IgM (Preliminary): Sent to [MASKED] for Lyme Western Blot testing. [MASKED] 5:10 am SEROLOGY/BLOOD **FINAL REPORT [MASKED] RAPID PLASMA REAGIN TEST (Final [MASKED]: NONREACTIVE. Reference Range: Non-Reactive. Time Taken Not Noted Log-In Date/Time: [MASKED] 5:47 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: 10,000-100,000 CFU/mL Commensal Respiratory Flora. ACID FAST SMEAR (Final [MASKED]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [MASKED]: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory ([MASKED]). IMAGING/STUDIES: ============== [MASKED] Neck ([MASKED]): IMPRESSION: 1. No suspicious mass in the oral pharynx or hypopharynx. 2. Incidental thyroid complex nodule. 3. Incidental tiny polyp right maxillary sinus. [MASKED] Second Read: No oro pharyngeal or retropharyngeal mass identified. There is no narrowing of the airways. 1.6 cm enhancing thyroid nodule with surrounding hypodensity. Further evaluation is recommended with ultrasound RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up recommended. [MASKED] College of Radiology guidelines recommend further evaluation for incidental thyroid nodules of 1.0 cm or larger in patients under age [MASKED] or 1.5 cm in patients age [MASKED] or [MASKED], or with suspicious findings. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. [MASKED] Chest w/ Contrast ([MASKED]): 1. Abnormal thickening of the mid to distal esophagus question esophagitis or mass. No obstruction as the oral contrast passes beyond this into the stomach. 2. Extensive bilateral hilar adenopathy. 3. 1.2 cm soft tissue nodule right lung base posterior medially. [MASKED] Second Read: -Confluent mediastinal and symmetric bilateral hilar lymphadenopathy with peribronchial nodules, suspicious for sarcoidosis. -Slightly spiculated solid pulmonary nodule in the right lower lobe measuring up to 12 mm. This is likely be part of the spectrum of sarcoidosis and less likely lymphoma or small cell lung cancer. However, transbronchial biopsy and tissue diagnosis would be helpful for definitive clinical management. -Multiple enlarged lymph nodes adjacent to the esophagus, which is mildly enlarged. Gastric Biopsy ([MASKED]): Stomach, mucosal biopsy: - Chemical-type gastropathy. Barium Swallow ([MASKED]): 1. Mild penetration of thin liquids. Residue in the piriform sinuses with holdup of barium tablet in the left piriform sinus for around 2 minutes. Recommend dedicated formal video oropharyngeal swallow study with the speech pathology team for more detailed evaluation of the oropharynx. 2. Normal esophageal motility. 3. Small hiatal hernia. MRI Brain; MRA Head and Neck ([MASKED]): 1. Images are limited by motion, pulsation, and other artifacts. 2. No evidence for an acute infarction, intracranial mass, or other intracranial abnormalities. 3. Inadequate assessment of the proximal common carotid and vertebral arteries. No evidence for internal carotid stenosis by NASCET criteria. 4. No evidence for flow-limiting intracranial arterial stenosis. 5. Approximately 1.7 cm left thyroid nodule is better seen on the T Mandible ([MASKED]): 1. No evidence of focal mandibular lesion. 2. Incidental note of a torus [MASKED]. 3. Small right maxillary mucosal retention cyst. Bronchus Biopsy ([MASKED]): TBNA: Nonspecific T cell dominant lymphoid profile; diagnostic Immunophenoptyic features of involvement by leukemia/lymphoma are not seen in specimen. Correlation with clinical, morphologic (see separate pathology report [MASKED]-[MASKED]) and other ancillary findings is recommended. Flow cytometry immunophenotyping may not detect all abnormal populations due to topography, sampling or artifacts of sample preparation. Surgical Pathology: Part 1: Endobronchial biopsy, carina: - Bronchial mucosa with focal necrotizing granulomatous inflammation, see note. Part 2: Endobronchial ultrasound guided transbronchial needle aspiration, lymph node level 7: - Non-necrotizing granulomatous inflammation, see note. - There is no evidence of malignancy. Part 3: Endobronchial ultrasound guided forceps level 7: - Scant fragments of lymphoid tissue and smooth muscle. - There is no evidence of granulomatous inflammation, nor of malignancy; multiple levels are examined. Note: AFB and GMS stains, performed on Parts 1 & 2, are negative. Fine Needle Aspiration: Lymph node, level 11R, EBUS-TBNA: NEGATIVE FOR MALIGNANT CELLS. - Non-necrotizing granulomas (see note). - Lymphocytes consistent with lymph node sampling. Lymph node, Level 7, EBUS-TBNA: NEGATIVE FOR MALIGNANT CELLS. - Rare histiocytic aggregates suggestive of non-necrotizing granulomas. - Lymphocytes consistent with lymph node sampling. Lingula Lavage: NEGATIVE FOR MALIGNANT CELLS. - Pulmonary macrophages and bronchial epithelial cells. Chest XRay ([MASKED]): No pneumothorax identified Brief Hospital Course: Ms. [MASKED] is a [MASKED] yo F with hx of HLD who presented with [MASKED] weeks of acute onset dysphagia with patchy numbness over forehead, chin, left arm, and left abdomen. Initially she presented to [MASKED] where she had a CT scan that demonstrated confluent mediastinal and symmetric bilateral hilar lymphadenopathy as well as thickening of her distal esophagus. She was transferred to [MASKED] for further evaluation of her lower esophageal thickness. Underwent an EGD on [MASKED], which was unremarkable. Biopsy obtained demonstrated chemical-type gastropathy. Her dysphagia was further worked up during her hospitalization. She underwent additional imaging which did not demonstrate any evidence of brain stem stroke. She was evaluated by neurology who felt her presentation was most consistent with a neuropathy from a local nerve injury. A CT of her mandible did not demonstrate any mass compressing a peripheral nerve. She was evaluated by speech and swallow, who made adjustments to her diet which assisted greatly with swallowing. For her mediastinal lymphadenopathy noted on [MASKED] chest CT, she underwent further work-up with a bronchoscopy with biopsy performed by interventional pulmonology on [MASKED]. Tolerated the procedure well. Final biopsy report pending at discharge, although preliminary read consistent with sarcoidosis. Rheumatology was consulted due to concern for possible sarcoidosis with nerve involvement leading to dysphagia. The plan at discharge was to initiate steroids as an outpatient to determine if this would aid in her dysphagia. ACTIVE ISSUES: =============== #Dysphagia: Acute dysphagia to solids and liquids over the two weeks prior to admission. Differential was broad and included possible CVA, mechanical obstruction, nerve injury, or neuropathy. Initially Mrs. [MASKED] presented to [MASKED], where she underwent imaging of the chest and neck. Neck without evidence of any masses. CT torso with extensive bilateral hilar adenopathy and abnormal thickening of the mid to distal esophagus concerning for esophagitis vs mass without evidence of obstruction. She was transferred to [MASKED] for further evaluation. Due to concern for esophageal mass, GI was consulted and performed an EGD on [MASKED]. She tolerated the procedure well and a biopsy was obtained. EGD overall unremarkable and biopsy returned with findings of chemical-type gastropathy. On repeat read of CT torso, felt that this thickening may have been due to extensive lymphadenopathy. For further work-up of her dysphagia, ENT was consulted for evaluation for vocal cord dyfunction given that she also had some change in quality to her voice. Nothing remarkable was seen on examination. To work-up possible lateral medullary syndrome, an MRI brain and MRA head/neck were obtained to evaluate for stroke. These were overall unremarkable. Neurology was consulted who noticed she had subtle palate deviation to the right with chin numbness that may suggest a peripheral nerve injury. Recommended malignancy work-up and CT of her mandible to look for bony lesion. CT mandible was overall unremarkable, and the patient had recently had normal screening mammogram and colonoscopy within the past year without any concerning new symptoms. Due to concern that perhaps her sarcoid was contributing to her neurologic symptoms, she underwent a bronchoscopy to evaluate for her hilar lymphadenopathy. Underwent a bronchoscopy with biopsy on iopsy with preliminary findings suggestive of sarcoidosis. Other testing for infectious etiologies including Quantiferon gold, Aspergillus, and B-glucan were negative. Rheumatology was consulted and recommended initiating steroids, which the patient preferred to do as an outpatient. Noted to be hepatitis B core positive and surface antibody positive, indicating past, cleared infection. Hepatology was consulted and recommended that should she be initiated on high dose steroids, she should start entecavir 0.5mg po daily, to be continued until 6 months after completion of immunosuppresion. #Scattered numbness: On presentation described numbness in right forehead, left groin, left hip, and left axilla in dermatomal fashion (terminates midline). No other motor or sensation deficits. Unclear etiology, although had extensive work-up as above. Possibly secondary to sarcoidosis with neurologic involvement. #Leukopenia: White blood cell counts during hospitalization between 2.8K - 4.5K. Possibly due to underlying inflammatory condition. Stable throughout hospitalization without evidence of infection. # Elevated blood pressure: Noted during hospitalization intermittently up to SBP 170s. Should be followed up and treated as an outpatient if this persists. CHRONIC ISSUES: =============== #Dyslipidemia: Continued home pravastatin ***TRANSITIONAL ISSUES:*** ======================== - Please follow-up on final biopsy results; if sarcoid may benefit from trial of steroids - If steroids are started, the patient will need to be started on entecavir 0.5mg po daily. Will also need liver follow-up within one month if started on therapy. This therapy should continue until about 6 months after steroids are discontinued. - Dysphagia: Patient discharged on pureed liquids. Patient will benefit from continued speech and swallow therapy as an outpatient. Please continue to monitor her nutritional status as it is very difficult to take in anything PO. - Hypertension: Blood pressures inpatient ranged from 111-170/59-94. Consider starting blood pressure agents upon discharge. - Noted to have a 1.5 cm complex left thyroid nodule with calcification on CT chest at [MASKED] Please follow-up as an outpatient - If started on steroids will need to take supplemental calcium and vitamin D if low; will also need DEXA screening - Started on pantoprazole to help with reflux and given that she will be started on steroids as an outpatient. - Contact: [MASKED] (husband) [MASKED] - Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pravastatin 20 mg PO QPM 2. coenzyme Q10 10 mg oral DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Discharge Medications: 1. Entecavir 0.5 mg PO DAILY Only to be started if started on prednisone RX *entecavir 0.5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 (One) tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. coenzyme Q10 10 mg oral DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 6. Multivitamins 1 TAB PO DAILY 7. Pravastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary: Sarcoidosis, Oropharyngeal dysphagia Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] ([MASKED]) due to difficulty with swallowing. While here, they did a CT scan which showed enlarged lymph nodes near the esophagus. An upper endoscopy with a stomach biopsy showed no evidence of cancer. Given that you were having continued difficulty with swallowing, an MRI was obtained of your brain which did not show any evidence of stroke. Neurology also evaluated you and agreed you did not have a stroke. We believe some of your swallowing difficulty could be from underlying sarcoidosis given the large lymph nodes we saw on your CT scan. An endobronchial ultrasound with biopsy of your lymph nodes was done that preliminarily showed sarcoidosis. We are awaiting the final results. You will have an appointment with Rheumatology this week to discuss further treatment options. During your admission, you were also found to have been exposed to Hepatitis B in the past and made a full recovery. However, because the treatment of sarcoidosis is steroids, there is a risk of reactivation of the Hepatitis B viral infection. Thus, if rheumatology initiates you on steroids, you will also need to take entecavir to prevent reactivation. If started on entecavir, you will also need to make an appointment with Dr. [MASKED] (hepatology) for 1 month follow-up. Please follow up with your outpatient providers and all your scheduled appointments. Thank you for allowing us to be involved in your care. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]
[]
[ "K219", "E785" ]
[ "D869: Sarcoidosis, unspecified", "R1312: Dysphagia, oropharyngeal phase", "K449: Diaphragmatic hernia without obstruction or gangrene", "K319: Disease of stomach and duodenum, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "R000: Tachycardia, unspecified", "R591: Generalized enlarged lymph nodes", "R911: Solitary pulmonary nodule", "R200: Anesthesia of skin", "E041: Nontoxic single thyroid nodule", "H2589: Other age-related cataract", "H4010X0: Unspecified open-angle glaucoma, stage unspecified", "R7303: Prediabetes", "Z8619: Personal history of other infectious and parasitic diseases" ]
10,077,499
24,881,119
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Juxtarenal abdominal aortic aneurysm Major Surgical or Invasive Procedure: S/p Open juxtarenal aneurysm repair via retroperitoneal approach. History of Present Illness: This is a ___ gentleman with a strong family history of abdominal aortic aneurysm, who presented with a 5 cm aneurysm, which would require a fenestrated repair. Due to his multiple small renal arteries, this was suboptimal and the patient wished to proceed with open repair. Past Medical History: PMH: Coronary artery disease status post CABG x3 in ___ Hyperlipidemia Transient ischemic attack Melanoma status post neck radiation PSH: status post CABG x3 in ___ s/p tonsillectomy s/p cholecystectomy s/p appendectomy Social History: ___ Family History: Father died of aneurysm (type and location unknown) in his ___. Physical Exam: General: Well-appearing gentleman sitting comfortably in his recliner. Not in any acute distress. HEENT: Normocephalic, atraumatic. Moist mucous membranes. Voice clear, no hoarseness. Extraocular movements intact. Cardiovascular: Regular rate and rhythm. No murmurs or rubs on auscultation. Lungs: Clear to auscultation bilaterally. Dim bases. Abdomen: Active bowel sounds. Soft and nontender to palpation. Extremities: No peripheral edema. Pulses: R ___ and L AT dopplerable signals. Neuro: Alert and oriented x3. Facial expressions symmetrical. Able to move all his 4 extremities spontaneously. Pertinent Results: ___ 07:35AM BLOOD WBC-12.6* RBC-2.97* Hgb-10.3* Hct-31.4* MCV-106* MCH-34.7* MCHC-32.8 RDW-13.2 RDWSD-51.2* Plt ___ ___ 07:35AM BLOOD Glucose-95 UreaN-68* Creat-3.9* Na-142 K-4.8 Cl-101 HCO3-27 AnGap-14 Brief Hospital Course: Mr. ___ is a ___ former smoker with hx of CAD s/p CABGx3 (___), hyperlipidemia and TIA who is s/p elective open repair of juxtarenal AAA. He has been followed for several years with ultrasound and CT scans for a known asymptomatic AAA. It was found to have enlarged to about 5cm, and he was referred to Dr. ___ in ___. Since then, he has had repeat CT and US demonstrating growth in the aneurysm, with most recent CT showing a 5.2 x 4.5 cm juxtarenal AAA with heavily calcified iliacs and L CFA chronic dissection. Given his anatomy and his strong family history, the decision was made to offer open repair. He underwent cardiac stress testing in ___ which demonstrated no significant ischemia, with LVEF of 49% and a fixed low septal inferior defect. He underwent open AAA repair via retroperitoneal approach on ___ with tube graft. Intraoperatively, he had one transient episode of hypotension with systolic in the ___ and sporadically required phenylephrine. He had an estimated blood loss of 1400 cc, received 2.5 L IV fluids, 1 L albumin and 400 cc through Cell Saver. He also had a 30-minute intraoperative ischemic time. Postoperatively, he has received 10 L of IV fluids and has been running 125 cc/h for perfusion. His urine output has been low at 50-70 cc/h and since surgery his creatinine has gone up from 1.1 preoperatively to 4.0. Development of sudden acute kidney injury following a vascular surgery near the renal arteries with intraoperative ischemia goes in favor of acute tubular necrosis related to ischemia. Urine microscopy also with muddy brown casts. His creatinine rose rapidly from normal to 4.0, and has plateaued since ___. He continues to make urine but has received an extremely high amount of IV fluids intraoperatively, and postoperatively. There was concern for volume overload given that he is net +12 L since admission. Concomitant with this he has gained >6 kg as of ___. The nephrology team has been following throughout his hospitalization. He has been on Lasix for the last two days- ___ and his creatinine has been plateaued- 3.8 on ___ and 3.9 on ___. Per nephrology recommendations he should be on Lasix 40mg twice a day for 8 days. He should avoid nephrotoxic agents like NSAIDs, contrast and Fleet enemas and hydrate adequately. From surgical stand point- the patient is stable, surgical site is dry and clean. He had two BMs yesterday. He will follow up in ___ clinic in two weeks for staple removal. he is ambulating independently. The patient has been on regular diet and is stable for discharge with ___ at home. He will follow up with Dr. ___ on ___ and his nephrologist the same day. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Simvastatin 40 mg PO QPM 6. Cyanocobalamin 1000 mcg PO DAILY 7. Vitamin D ___ UNIT PO DAILY 8. Fish Oil (Omega 3) Dose is Unknown PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever 2. Calcium Carbonate 500 mg PO QID:PRN indigestion 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 4. Furosemide 40 mg PO BID ___ Duration: 8 Days 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 6. amLODIPine 5 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atenolol 25 mg PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. Simvastatin 40 mg PO QPM 11. Vitamin D ___ UNIT PO DAILY 12. HELD- Fish Oil (Omega 3) Dose is Unknown PO BID This medication was held. Do not restart Fish Oil (Omega 3) until two weeks from discharge 13. HELD- Losartan Potassium 100 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you see your kidney doctor Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: ABDOMINAL AORTIC ANEURYSM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was pleasure taking care of you at ___. WHAT TO EXPECT DURING YOUR RECOVERY: 1. It is normal to feel weak and 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! 2. It is normal to have incisional and leg swelling: •Wear loose fitting pants/clothing (this will be less irritating to incision) •Elevate your legs above the level of your heart with ___ pillows every ___ hours throughout the day and at night •Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time •You will probably lose your taste for food and lose some weight •Eat small frequent meals •It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing •To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication • •Take all the medications you were taking before surgery, unless otherwise directed •Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ACTIVITIES: •No driving until post-op visit and you are no longer taking pain medications •You should get up every day, get dressed and walk, gradually increasing 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 (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 Followup Instructions: ___
[ "I714", "I7777", "N170", "N390", "I10", "E785", "I2510", "Z951", "Z87891", "I959", "Z85820", "Z8673", "E861", "N990", "E8351", "Y92239" ]
Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Juxtarenal abdominal aortic aneurysm Major Surgical or Invasive Procedure: S/p Open juxtarenal aneurysm repair via retroperitoneal approach. History of Present Illness: This is a [MASKED] gentleman with a strong family history of abdominal aortic aneurysm, who presented with a 5 cm aneurysm, which would require a fenestrated repair. Due to his multiple small renal arteries, this was suboptimal and the patient wished to proceed with open repair. Past Medical History: PMH: Coronary artery disease status post CABG x3 in [MASKED] Hyperlipidemia Transient ischemic attack Melanoma status post neck radiation PSH: status post CABG x3 in [MASKED] s/p tonsillectomy s/p cholecystectomy s/p appendectomy Social History: [MASKED] Family History: Father died of aneurysm (type and location unknown) in his [MASKED]. Physical Exam: General: Well-appearing gentleman sitting comfortably in his recliner. Not in any acute distress. HEENT: Normocephalic, atraumatic. Moist mucous membranes. Voice clear, no hoarseness. Extraocular movements intact. Cardiovascular: Regular rate and rhythm. No murmurs or rubs on auscultation. Lungs: Clear to auscultation bilaterally. Dim bases. Abdomen: Active bowel sounds. Soft and nontender to palpation. Extremities: No peripheral edema. Pulses: R [MASKED] and L AT dopplerable signals. Neuro: Alert and oriented x3. Facial expressions symmetrical. Able to move all his 4 extremities spontaneously. Pertinent Results: [MASKED] 07:35AM BLOOD WBC-12.6* RBC-2.97* Hgb-10.3* Hct-31.4* MCV-106* MCH-34.7* MCHC-32.8 RDW-13.2 RDWSD-51.2* Plt [MASKED] [MASKED] 07:35AM BLOOD Glucose-95 UreaN-68* Creat-3.9* Na-142 K-4.8 Cl-101 HCO3-27 AnGap-14 Brief Hospital Course: Mr. [MASKED] is a [MASKED] former smoker with hx of CAD s/p CABGx3 ([MASKED]), hyperlipidemia and TIA who is s/p elective open repair of juxtarenal AAA. He has been followed for several years with ultrasound and CT scans for a known asymptomatic AAA. It was found to have enlarged to about 5cm, and he was referred to Dr. [MASKED] in [MASKED]. Since then, he has had repeat CT and US demonstrating growth in the aneurysm, with most recent CT showing a 5.2 x 4.5 cm juxtarenal AAA with heavily calcified iliacs and L CFA chronic dissection. Given his anatomy and his strong family history, the decision was made to offer open repair. He underwent cardiac stress testing in [MASKED] which demonstrated no significant ischemia, with LVEF of 49% and a fixed low septal inferior defect. He underwent open AAA repair via retroperitoneal approach on [MASKED] with tube graft. Intraoperatively, he had one transient episode of hypotension with systolic in the [MASKED] and sporadically required phenylephrine. He had an estimated blood loss of 1400 cc, received 2.5 L IV fluids, 1 L albumin and 400 cc through Cell Saver. He also had a 30-minute intraoperative ischemic time. Postoperatively, he has received 10 L of IV fluids and has been running 125 cc/h for perfusion. His urine output has been low at 50-70 cc/h and since surgery his creatinine has gone up from 1.1 preoperatively to 4.0. Development of sudden acute kidney injury following a vascular surgery near the renal arteries with intraoperative ischemia goes in favor of acute tubular necrosis related to ischemia. Urine microscopy also with muddy brown casts. His creatinine rose rapidly from normal to 4.0, and has plateaued since [MASKED]. He continues to make urine but has received an extremely high amount of IV fluids intraoperatively, and postoperatively. There was concern for volume overload given that he is net +12 L since admission. Concomitant with this he has gained >6 kg as of [MASKED]. The nephrology team has been following throughout his hospitalization. He has been on Lasix for the last two days- [MASKED] and his creatinine has been plateaued- 3.8 on [MASKED] and 3.9 on [MASKED]. Per nephrology recommendations he should be on Lasix 40mg twice a day for 8 days. He should avoid nephrotoxic agents like NSAIDs, contrast and Fleet enemas and hydrate adequately. From surgical stand point- the patient is stable, surgical site is dry and clean. He had two BMs yesterday. He will follow up in [MASKED] clinic in two weeks for staple removal. he is ambulating independently. The patient has been on regular diet and is stable for discharge with [MASKED] at home. He will follow up with Dr. [MASKED] on [MASKED] and his nephrologist the same day. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Simvastatin 40 mg PO QPM 6. Cyanocobalamin 1000 mcg PO DAILY 7. Vitamin D [MASKED] UNIT PO DAILY 8. Fish Oil (Omega 3) Dose is Unknown PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever 2. Calcium Carbonate 500 mg PO QID:PRN indigestion 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 4. Furosemide 40 mg PO BID [MASKED] Duration: 8 Days 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 6. amLODIPine 5 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atenolol 25 mg PO DAILY 9. Cyanocobalamin 1000 mcg PO DAILY 10. Simvastatin 40 mg PO QPM 11. Vitamin D [MASKED] UNIT PO DAILY 12. HELD- Fish Oil (Omega 3) Dose is Unknown PO BID This medication was held. Do not restart Fish Oil (Omega 3) until two weeks from discharge 13. HELD- Losartan Potassium 100 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you see your kidney doctor Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: ABDOMINAL AORTIC ANEURYSM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], It was pleasure taking care of you at [MASKED]. WHAT TO EXPECT DURING YOUR RECOVERY: 1. It is normal to feel weak and 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! 2. It is normal to have incisional and leg swelling: •Wear loose fitting pants/clothing (this will be less irritating to incision) •Elevate your legs above the level of your heart with [MASKED] pillows every [MASKED] hours throughout the day and at night •Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time •You will probably lose your taste for food and lose some weight •Eat small frequent meals •It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing •To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication • •Take all the medications you were taking before surgery, unless otherwise directed •Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ACTIVITIES: •No driving until post-op visit and you are no longer taking pain medications •You should get up every day, get dressed and walk, gradually increasing 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 (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 Followup Instructions: [MASKED]
[]
[ "N390", "I10", "E785", "I2510", "Z951", "Z87891", "Z8673" ]
[ "I714: Abdominal aortic aneurysm, without rupture", "I7777: Dissection of artery of lower extremity", "N170: Acute kidney failure with tubular necrosis", "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence", "I959: Hypotension, unspecified", "Z85820: Personal history of malignant melanoma of skin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E861: Hypovolemia", "N990: Postprocedural (acute) (chronic) kidney failure", "E8351: Hypocalcemia", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]