Split (1)

train · 122k rows

Search is not available for this dataset

subject_id int64 10M 20M	hadm_id int64 20M 30M	text stringlengths 598 58.6k	icd_code listlengths 1 39	cleaned_text stringlengths 382 57.3k	code_rare listlengths 0 5	code_commons listlengths 0 23	icd_descriptions listlengths 1 39
19,973,404	22,873,532	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with a history of type I diabetes c/b gastroparesis/nephropathy/retinopathy, bipolar, who presents with recurrent vomiting and nausea and abdominal pain. Pt was discharged 3 days ago for the same issues, recieved an EGD with botox injection. She was doing well, tolerating food until today at 9:30, when her symptoms suddenly returned. She had acute onset abdominal pain, diarrhea, and nausea/NBNB vomiting. She denies hematochezia or hematemesis. Denied fever, sick contacts or eating out. EKG: SR 98, RBBB QTc 491, no ST changes, similar to prior In the ED, initial vitals were: 97.4 109 126/69 16 100% RA - Labs were significant for WBC 18.7, H/H 14.8/43.8, BUN/Cr ___, blood glucose 338, negative u/a, normal lactate. - CT abd/pelvis showed small bowel inflammation c/w enteritis. - The patient was given 3L NS in ED, as well 1mg IV dilaudid x3, 4 mg Zofran IV x3, 6U insulin and 400 mg IV cipro and 500mg IV flagyl. Vitals prior to transfer were: 98.5 ___ 18 98% RA Upon arrival to the floor, VS were 97.8, 125/65, HR 106, RR 14, 97% RA. Patient reported her nausea/vomiting had resolved with the IV dilaudid and Zofran. Continued to endorse mild abdominal pain. Past Medical History: BIPOLAR DISORDER DIABETES MELLITUS - insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. GLAUCOMA RIGHT BUNDLE BRANCH BLOCK SEIZURE DISORDER - currently treated with Carbamazepine to which Pt attributes vertigo/dizziness, self-changed evening dose to 800mg from 1000mg yesterday (___) ALCOHOL ABUSE ASTHMA HEPATITIS B HEP C GASTROPARESIS - on domperidone, s/p Botox injection in ___ . Past Surgical History: CHOLECYSTECTOMY ___ FROZEN SHOULDER ___ UTERINE POLYPS PRIOR CESAREAN SECTION G3P1 BILATERAL TUBAL LIGATION Social History: ___ Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. ___ family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T97.8, 125/65, HR 106, RR 14, 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, mild mid-epigastric/RUQ ttp, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, moving all extremities, speech fluent, gait deferred. DISCHARGE PHYSICAL EXAM: Vital Signs: T: 98.1 BP: 108/59 HR: 83 RR: 18 Sp02: 98 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Normal S1,S2, regular rate, no m/r/g. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Without rashes or lesions Neuro: CN II-XII intact, no vertical nystagmus noted, distal sensation intact. Pertinent Results: ADMISSION LABS: ___ 03:15PM BLOOD WBC-18.7# RBC-4.61# Hgb-14.8# Hct-43.8# MCV-95 MCH-32.1 MCHC-33.8 RDW-12.1 RDWSD-42.1 Plt ___ ___ 03:15PM BLOOD Neuts-91.7* Lymphs-2.1* Monos-5.4 Eos-0.1* Baso-0.3 Im ___ AbsNeut-17.11* AbsLymp-0.40* AbsMono-1.00* AbsEos-0.01* AbsBaso-0.05 ___ 03:15PM BLOOD Plt ___ ___ 03:15PM BLOOD Glucose-338* UreaN-12 Creat-0.7 Na-135 K-4.5 Cl-95* HCO3-22 AnGap-23* ___ 03:15PM BLOOD ALT-34 AST-39 AlkPhos-68 TotBili-0.5 ___ 03:15PM BLOOD Lipase-25 ___ 03:15PM BLOOD Albumin-4.1 Calcium-10.2 Mg-1.6 ___ 03:15PM BLOOD Lactate-1.8 DISCHARGE LABS: ___ 06:55AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.1* Hct-30.7* MCV-95 MCH-31.2 MCHC-32.9 RDW-12.1 RDWSD-41.6 Plt ___ ___ 06:55AM BLOOD Plt ___ ___ 06:55AM BLOOD Glucose-81 UreaN-6 Creat-0.5 Na-140 K-3.4 Cl-103 HCO3-27 AnGap-13 ___ 06:55AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.5* PERTINENT IMAGING: ___ CT ABD/PELVIS W/ CONTRAST IMPRESSION: 1. Multiple focal regions of small bowel wall thickening with surrounding inflammatory changes, raise concern for enteritis. 2. Mild descending colonic wall thickening and edema. While these findings may be secondary to underdistention, the associated adjacent inflammatory changes and mesenteric fluid suggest colitis. Findings may be secondary to infectious, ischemic, or inflammatory causes. 3. Moderate axial hiatal hernia. 4. 2.2 cm left adnexal cyst may be physiologic if patient is premenopausal. If patient is postmenopausal, recommend follow-up pelvic ultrasound for further assessment. MICROBIOLOGY: Blood Culture- pending Stool Culture- pending Brief Hospital Course: ___ year old woman with a history of type I diabetes c/b gastroparesis recently admitted for nausea/vomiting in the setting of self-discontinuation of domperidone represents with acute onset sharp abdominal pain with diarrhea/nausea/vomiting. Clinical picture most concerning for gastroenteritis. She improved with hydration and was able to eat and drink normally on the day after admission. Stool cultures were sent but were pending at the time of discharge. ACTIVE ISSUES: ============== # Gastroenteritis: Nausea and diarrhea on day of admission. Was started on IV abx in Emergency Department. She was afebrile and hemodynamically stable. CT Abdomen/Pelvis showed enteritis/colitis. Most likely this is viral gastroenteritis, however bacterial could not be ruled out. C Diff was unlikely given no recent antibiotics. She improved with hydration and was able to eat without issue. Stool cultures were sent and are pending at discharge. #Gastroparesis: Gastroparesis was resolving as an outpatient and aside from some vomiting with her initial presentation, she was able to tolerate small meals on a low fiber, low fat diet. Controlled with Domperidone and Lorazepam 0.5 prior to meals for nausea. # DM Type 1: Recent high sugar to 480's as outpatient in the setting of eating canned fruit. Blood sugar was well controlled as an inpatient with home regimen of 18 ___ and sliding scale. CHRONIC ISSUES: =============== # Nephropathy: Lisinopril 10 mg PO/NG DAILY continued # Bipolar: stable. Not currently promoting any manic or depressed mood. Continued on Lithium Carbonate 900 mg PO QHS, QUEtiapine Fumarate 200 mg PO/NG BID, Lorazepam and CarBAMazepine 800 mg PO/NG BID # Hepatitis B: continue tenofovir. # Hyperlipidemia: hold Simvastatin 40 mg PO/NG DAILY Transitional Issues: ===================== [] consider alternative magnesium repletion as mg oxide is not well tolerated. [] f/u stool Yersinia, EHEC, Campylobacter, Shigella [] Recommendation from CT Abdomen/Pelvis: 2.2 cm left adnexal cyst may be physiologic if patient is premenopausal. If patient is postmenopausal, recommend follow-up pelvic ultrasound for further assessment. (From most recent d/c on ___ #) QTc: Patient on multiple QTc prolonging medications including domperidone and quetiapine. Please repeat EKG at next appointment and repeat as clinically warranted. #) Domiperidone: Patient tried to cut back due to cost. Planning to go back to QID dosing. Consider trialing taper to TID if clinically warranted to help with cost. At time of discharge, patient reported having insufficient amount of domperidone to make it until arrival of next shipment. Consequently was discharged on Zofran and advised to change back to domperidone once the next shipment arrived. #) Type 1 DM: Reports difficulty controlling BS due to gastroparesis and resultant difficulty in predicting required insulin dose. Reports hypoglycemia at home to ___ and hyperglycemia to 200s. Please follow up. # Diabetes: She should follow up in ___ as well. To schedule please contact (___) and/or ask for ___ or leave a voice message for her. #) Nystagmus: Worked up by neurology with no evidence of stroke. Follow up in neurology outpatient clinic if this persists and is symptomatic. CODE STATUS: Full Code CONTACT: ___ (husband) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carbamazepine 800 mg PO BID 2. Domperidone 10 mg PO QID 3. Fexofenadine 180 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. QUEtiapine Fumarate 200 mg PO BID 7. Simvastatin 40 mg PO DAILY 8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Aspirin 81 mg PO DAILY 11. Lithium Carbonate 900 mg PO QHS 12. Psyllium Powder 1 PKT PO TID:PRN constipation 13. Meclizine 12.5 mg PO Q6H:PRN vertigo 14. Lorazepam 0.5 mg PO QAC 15. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Carbamazepine 800 mg PO BID 3. Domperidone 10 mg PO QID 4. Fexofenadine 180 mg PO DAILY 5. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Lisinopril 10 mg PO DAILY 7. Lithium Carbonate 900 mg PO QHS 8. Lorazepam 0.5 mg PO QAC 9. Meclizine 12.5 mg PO Q6H:PRN vertigo 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. QUEtiapine Fumarate 200 mg PO BID 12. Simvastatin 40 mg PO DAILY 13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Psyllium Powder 1 PKT PO TID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Gastroenteritis Secondary Diagnoses: Gastroparesis Diabetes Type I Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You came in after you had severe abdominal pain with diarrhea and vomiting. In the Emergency Department, you were found to have a high white blood cell count concerning for possible infection. Your symptoms are likely due to gastroenteritis. This is likely viral and will get better on its own without antibiotics. You should follow-up with your PCP. It was as pleasure taking care of you. -Your ___ Team Followup Instructions: ___	[ "A084", "K3184", "E1021", "E1043", "B1910", "E10319", "F319", "G40909", "H409", "J45909", "E785", "H5500", "K219" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: abdominal pain, vomiting, diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old woman with a history of type I diabetes c/b gastroparesis/nephropathy/retinopathy, bipolar, who presents with recurrent vomiting and nausea and abdominal pain. Pt was discharged 3 days ago for the same issues, recieved an EGD with botox injection. She was doing well, tolerating food until today at 9:30, when her symptoms suddenly returned. She had acute onset abdominal pain, diarrhea, and nausea/NBNB vomiting. She denies hematochezia or hematemesis. Denied fever, sick contacts or eating out. EKG: SR 98, RBBB QTc 491, no ST changes, similar to prior In the ED, initial vitals were: 97.4 109 126/69 16 100% RA - Labs were significant for WBC 18.7, H/H 14.8/43.8, BUN/Cr [MASKED], blood glucose 338, negative u/a, normal lactate. - CT abd/pelvis showed small bowel inflammation c/w enteritis. - The patient was given 3L NS in ED, as well 1mg IV dilaudid x3, 4 mg Zofran IV x3, 6U insulin and 400 mg IV cipro and 500mg IV flagyl. Vitals prior to transfer were: 98.5 [MASKED] 18 98% RA Upon arrival to the floor, VS were 97.8, 125/65, HR 106, RR 14, 97% RA. Patient reported her nausea/vomiting had resolved with the IV dilaudid and Zofran. Continued to endorse mild abdominal pain. Past Medical History: BIPOLAR DISORDER DIABETES MELLITUS - insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. GLAUCOMA RIGHT BUNDLE BRANCH BLOCK SEIZURE DISORDER - currently treated with Carbamazepine to which Pt attributes vertigo/dizziness, self-changed evening dose to 800mg from 1000mg yesterday ([MASKED]) ALCOHOL ABUSE ASTHMA HEPATITIS B HEP C GASTROPARESIS - on domperidone, s/p Botox injection in [MASKED] . Past Surgical History: CHOLECYSTECTOMY [MASKED] FROZEN SHOULDER [MASKED] UTERINE POLYPS PRIOR CESAREAN SECTION G3P1 BILATERAL TUBAL LIGATION Social History: [MASKED] Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. [MASKED] family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T97.8, 125/65, HR 106, RR 14, 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, mild mid-epigastric/RUQ ttp, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, moving all extremities, speech fluent, gait deferred. DISCHARGE PHYSICAL EXAM: Vital Signs: T: 98.1 BP: 108/59 HR: 83 RR: 18 Sp02: 98 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Normal S1,S2, regular rate, no m/r/g. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Without rashes or lesions Neuro: CN II-XII intact, no vertical nystagmus noted, distal sensation intact. Pertinent Results: ADMISSION LABS: [MASKED] 03:15PM BLOOD WBC-18.7# RBC-4.61# Hgb-14.8# Hct-43.8# MCV-95 MCH-32.1 MCHC-33.8 RDW-12.1 RDWSD-42.1 Plt [MASKED] [MASKED] 03:15PM BLOOD Neuts-91.7* Lymphs-2.1* Monos-5.4 Eos-0.1* Baso-0.3 Im [MASKED] AbsNeut-17.11* AbsLymp-0.40* AbsMono-1.00* AbsEos-0.01* AbsBaso-0.05 [MASKED] 03:15PM BLOOD Plt [MASKED] [MASKED] 03:15PM BLOOD Glucose-338* UreaN-12 Creat-0.7 Na-135 K-4.5 Cl-95* HCO3-22 AnGap-23* [MASKED] 03:15PM BLOOD ALT-34 AST-39 AlkPhos-68 TotBili-0.5 [MASKED] 03:15PM BLOOD Lipase-25 [MASKED] 03:15PM BLOOD Albumin-4.1 Calcium-10.2 Mg-1.6 [MASKED] 03:15PM BLOOD Lactate-1.8 DISCHARGE LABS: [MASKED] 06:55AM BLOOD WBC-5.4 RBC-3.24* Hgb-10.1* Hct-30.7* MCV-95 MCH-31.2 MCHC-32.9 RDW-12.1 RDWSD-41.6 Plt [MASKED] [MASKED] 06:55AM BLOOD Plt [MASKED] [MASKED] 06:55AM BLOOD Glucose-81 UreaN-6 Creat-0.5 Na-140 K-3.4 Cl-103 HCO3-27 AnGap-13 [MASKED] 06:55AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.5* PERTINENT IMAGING: [MASKED] CT ABD/PELVIS W/ CONTRAST IMPRESSION: 1. Multiple focal regions of small bowel wall thickening with surrounding inflammatory changes, raise concern for enteritis. 2. Mild descending colonic wall thickening and edema. While these findings may be secondary to underdistention, the associated adjacent inflammatory changes and mesenteric fluid suggest colitis. Findings may be secondary to infectious, ischemic, or inflammatory causes. 3. Moderate axial hiatal hernia. 4. 2.2 cm left adnexal cyst may be physiologic if patient is premenopausal. If patient is postmenopausal, recommend follow-up pelvic ultrasound for further assessment. MICROBIOLOGY: Blood Culture- pending Stool Culture- pending Brief Hospital Course: [MASKED] year old woman with a history of type I diabetes c/b gastroparesis recently admitted for nausea/vomiting in the setting of self-discontinuation of domperidone represents with acute onset sharp abdominal pain with diarrhea/nausea/vomiting. Clinical picture most concerning for gastroenteritis. She improved with hydration and was able to eat and drink normally on the day after admission. Stool cultures were sent but were pending at the time of discharge. ACTIVE ISSUES: ============== # Gastroenteritis: Nausea and diarrhea on day of admission. Was started on IV abx in Emergency Department. She was afebrile and hemodynamically stable. CT Abdomen/Pelvis showed enteritis/colitis. Most likely this is viral gastroenteritis, however bacterial could not be ruled out. C Diff was unlikely given no recent antibiotics. She improved with hydration and was able to eat without issue. Stool cultures were sent and are pending at discharge. #Gastroparesis: Gastroparesis was resolving as an outpatient and aside from some vomiting with her initial presentation, she was able to tolerate small meals on a low fiber, low fat diet. Controlled with Domperidone and Lorazepam 0.5 prior to meals for nausea. # DM Type 1: Recent high sugar to 480's as outpatient in the setting of eating canned fruit. Blood sugar was well controlled as an inpatient with home regimen of 18 [MASKED] and sliding scale. CHRONIC ISSUES: =============== # Nephropathy: Lisinopril 10 mg PO/NG DAILY continued # Bipolar: stable. Not currently promoting any manic or depressed mood. Continued on Lithium Carbonate 900 mg PO QHS, QUEtiapine Fumarate 200 mg PO/NG BID, Lorazepam and CarBAMazepine 800 mg PO/NG BID # Hepatitis B: continue tenofovir. # Hyperlipidemia: hold Simvastatin 40 mg PO/NG DAILY Transitional Issues: ===================== [] consider alternative magnesium repletion as mg oxide is not well tolerated. [] f/u stool Yersinia, EHEC, Campylobacter, Shigella [] Recommendation from CT Abdomen/Pelvis: 2.2 cm left adnexal cyst may be physiologic if patient is premenopausal. If patient is postmenopausal, recommend follow-up pelvic ultrasound for further assessment. (From most recent d/c on [MASKED] #) QTc: Patient on multiple QTc prolonging medications including domperidone and quetiapine. Please repeat EKG at next appointment and repeat as clinically warranted. #) Domiperidone: Patient tried to cut back due to cost. Planning to go back to QID dosing. Consider trialing taper to TID if clinically warranted to help with cost. At time of discharge, patient reported having insufficient amount of domperidone to make it until arrival of next shipment. Consequently was discharged on Zofran and advised to change back to domperidone once the next shipment arrived. #) Type 1 DM: Reports difficulty controlling BS due to gastroparesis and resultant difficulty in predicting required insulin dose. Reports hypoglycemia at home to [MASKED] and hyperglycemia to 200s. Please follow up. # Diabetes: She should follow up in [MASKED] as well. To schedule please contact ([MASKED]) and/or ask for [MASKED] or leave a voice message for her. #) Nystagmus: Worked up by neurology with no evidence of stroke. Follow up in neurology outpatient clinic if this persists and is symptomatic. CODE STATUS: Full Code CONTACT: [MASKED] (husband) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carbamazepine 800 mg PO BID 2. Domperidone 10 mg PO QID 3. Fexofenadine 180 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. QUEtiapine Fumarate 200 mg PO BID 7. Simvastatin 40 mg PO DAILY 8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Aspirin 81 mg PO DAILY 11. Lithium Carbonate 900 mg PO QHS 12. Psyllium Powder 1 PKT PO TID:PRN constipation 13. Meclizine 12.5 mg PO Q6H:PRN vertigo 14. Lorazepam 0.5 mg PO QAC 15. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Carbamazepine 800 mg PO BID 3. Domperidone 10 mg PO QID 4. Fexofenadine 180 mg PO DAILY 5. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Lisinopril 10 mg PO DAILY 7. Lithium Carbonate 900 mg PO QHS 8. Lorazepam 0.5 mg PO QAC 9. Meclizine 12.5 mg PO Q6H:PRN vertigo 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. QUEtiapine Fumarate 200 mg PO BID 12. Simvastatin 40 mg PO DAILY 13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Psyllium Powder 1 PKT PO TID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Gastroenteritis Secondary Diagnoses: Gastroparesis Diabetes Type I Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], You came in after you had severe abdominal pain with diarrhea and vomiting. In the Emergency Department, you were found to have a high white blood cell count concerning for possible infection. Your symptoms are likely due to gastroenteritis. This is likely viral and will get better on its own without antibiotics. You should follow-up with your PCP. It was as pleasure taking care of you. -Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "J45909", "E785", "K219" ]	[ "A084: Viral intestinal infection, unspecified", "K3184: Gastroparesis", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "B1910: Unspecified viral hepatitis B without hepatic coma", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "F319: Bipolar disorder, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "H409: Unspecified glaucoma", "J45909: Unspecified asthma, uncomplicated", "E785: Hyperlipidemia, unspecified", "H5500: Unspecified nystagmus", "K219: Gastro-esophageal reflux disease without esophagitis" ]
19,973,404	23,760,432	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: ___ EGD with pyloric botox injection History of Present Illness: ___ year old woman with diabetic gastroparesis (on domperidone and s/p botox injection) presenting with three weeks of nausea, vomiting and abdominal pain. For the last three weeks, Ms. ___ has had epigastric pain, and nausea all worsened by eating. This became intolerable yesterday prompting her to call Dr. ___ instructed her to come into the hospital for EGD with possible botox injection. She describes this as similar to her prior flares. Her GERD is stable. Her FSBG have been variable - sometimes high, sometimes low. She does not smoke or ingest cannabis. She has had no regurgitation of food, no h/o rumination syndrome or bullemia. She has only vomited upon presentation to the hospital, this has been non-bloody. She has no cough, no diarrhea, no fevers, no blood in stool. No association of pain with exertion. Past Medical History: - Diabetes Mellitus: insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. - Gastroparesis - on domperidone, s/p Botox injections - Bipolar Disorder - Seizure Disorder - currently treated with Carbamazepine - EtOH Use Disorder - Right Bundle Branch Block - Asthma - Hepatitis B - Hepatitis C - Glaucoma - G3P1 Past Surgical History: - Cholecystectomy ___ - Frozen shoulder ___ - Uterine Polyps - Cesarean Section - Bilateral tubal ligation Social History: ___ Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. ___ family history of cancer. Physical Exam: ADMISSION EXAM: VS: T: 97.7 PO 140 / 84 R Lying HR: 83 RR: 18 SO2: 96 RA GENERAL: NAD, slightly flat affect HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: RRR, S1 with preserved S2, ___ systolic murmur with radiation toward both carotids, mild carotid-apical delay, no gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, tender diffusely but greatest in epigastrum, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: bounding 2+ DP pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: GENERAL: Well appearing. HEENT: No icterus or injection. MMM. CV: RRR. RESP: CTAB. ABD: Soft, NDNT. EXTR: Warm, no c/c/e. NEURO: Alert, oriented, attentive. Pertinent Results: ADMISSION LABS: ___ 04:40PM BLOOD WBC-5.9 RBC-3.90 Hgb-12.4 Hct-36.7 MCV-94 MCH-31.8 MCHC-33.8 RDW-12.1 RDWSD-41.5 Plt ___ ___ 04:40PM BLOOD Neuts-61.1 ___ Monos-8.7 Eos-2.9 Baso-0.5 Im ___ AbsNeut-3.59 AbsLymp-1.56 AbsMono-0.51 AbsEos-0.17 AbsBaso-0.03 ___ 04:40PM BLOOD Glucose-100 UreaN-15 Creat-0.5 Na-144 K-3.8 Cl-104 HCO3-27 AnGap-13 ___ 04:40PM BLOOD ALT-16 AST-18 AlkPhos-83 TotBili-<0.2 ___ 04:40PM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.9 Mg-1.7 DISCHARGE LABS: ___ 05:50AM BLOOD WBC-5.9 RBC-3.68* Hgb-11.8 Hct-35.1 MCV-95 MCH-32.1* MCHC-33.6 RDW-12.0 RDWSD-42.0 Plt ___ ___ 05:50AM BLOOD Glucose-295* UreaN-13 Creat-0.5 Na-142 K-4.1 Cl-103 HCO3-24 AnGap-15 ___ 05:50AM BLOOD Carbamz-3.1* ___ EGD - Normal esophagus, stomach, and duodenum. - Botox was injected into the four quadrants of the pylorus. Brief Hospital Course: ___ y/o woman with h/o type 1 diabetes complicated by gastroparesis managed with domperidone and botox injections, admitted for her typical gastroparesis symptoms. Evaluation for alternative etiologies was negative. Erythromycin was trialled without benefit. She underwent repeat endoscopic botox injection with excellent relief of symptoms and was discharged tolerating a regular diet. ACUTE ISSUES =================== # Gastroparesis flare: ___ above # Type 1 diabetes mellitus with hypoglycemia and hyperglycemia: Patient was transiently hypoglycemic in ED, then hyperglycemic when insulin was held. Her prior Lantus/Humalog regimen was resumed and she was euglycemic for the remainder of admissoin. CHRONIC ISSUES: =================== # Slow transit constipation: Continued home Linzess at 72 mcg (has diarrhea at 145 mcg) and miralax. # Bipolar disorder: Continued home asenapine 5 mg QHS # ?Seizure vs. mood disorder: Continued home carbamazepine 800 mg BID. Level was checked due to interaction with erythromycin and was subtherapeutic. Consider recheck and dose adjustment as outpatient. # GERD: Continued home omeprazole 40mg daily # Chronic hepatitis B: Continued home suppressive tenofovir. LTFs wnl this admission. # HTN: BP at goal <140/90 per ACCORD, continued home lisinopril # Systolic murmur: Normal TTE ___, exam most consistent with mild to moderate AS, would monitor as outpatient, consider repeat TTE non-urgently. TRANSITIONAL ISSUES: ====================== - No medications were changed. - Carbamazepine level was subtherapeutic (3.1). Consider rechecking and adjusting dose. - Consider non-urgent repeat TTE To assess systolic murmur. #CODE: Full (presumed) #CONTACT: ___, husband (___) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ASENapine 5 mg SL QHS 2. Aspirin 81 mg PO DAILY 3. CarBAMazepine 800 mg PO BID 4. Lisinopril 15 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Simvastatin 40 mg PO QPM 8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 9. Cetirizine 10 mg PO DAILY 10. linaCLOtide 72 mcg oral DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Psyllium Powder 1 PKT PO QHS 13. Glargine 12 Units Breakfast Glargine 17 Units Dinner Insulin SC Sliding Scale using HUM Insulin 14. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID 15. domperidone maleate Study Med 10 mg PO QACHS Discharge Medications: 1. ASENapine 5 mg SL QHS 2. Aspirin 81 mg PO DAILY 3. CarBAMazepine 800 mg PO BID 4. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID 5. Cetirizine 10 mg PO DAILY 6. domperidone maleate Study Med 10 mg PO QACHS 7. Glargine 12 Units Breakfast Glargine 17 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. linaCLOtide 72 mcg oral DAILY 9. Lisinopril 15 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Psyllium Powder 1 PKT PO QHS 14. Simvastatin 40 mg PO QPM 15. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: # Diabetic gastroparesis # Type 1 diabetes mellitus with hyperglycemia and hypoglycemia SECONDARY DIAGNOSES: # Bipolar disorder # Slow transit constipation # Gastroesophageal reflux disease # Chronic hepatitis B infection # Hypertension # Systolic murmur Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you had pain and nausea from your gastroparesis. We gave you medicines and a botox injection and you got better. WHEN YOU LEAVE THE HOSPITAL: - Take all your medicines as prescribed. We did not make any changes. ___ below for a complete list. - Follow up with your doctors. ___ below for a list of appointments. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___	[ "E1043", "K3184", "K3189", "E1065", "E10649", "F319", "K5901", "K319", "K219", "B181", "I10", "Z87891", "Z794", "Z85828", "Z8673", "I4510", "Z7901", "E10319", "E1021" ]	Allergies: morphine Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: [MASKED] EGD with pyloric botox injection History of Present Illness: [MASKED] year old woman with diabetic gastroparesis (on domperidone and s/p botox injection) presenting with three weeks of nausea, vomiting and abdominal pain. For the last three weeks, Ms. [MASKED] has had epigastric pain, and nausea all worsened by eating. This became intolerable yesterday prompting her to call Dr. [MASKED] instructed her to come into the hospital for EGD with possible botox injection. She describes this as similar to her prior flares. Her GERD is stable. Her FSBG have been variable - sometimes high, sometimes low. She does not smoke or ingest cannabis. She has had no regurgitation of food, no h/o rumination syndrome or bullemia. She has only vomited upon presentation to the hospital, this has been non-bloody. She has no cough, no diarrhea, no fevers, no blood in stool. No association of pain with exertion. Past Medical History: - Diabetes Mellitus: insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. - Gastroparesis - on domperidone, s/p Botox injections - Bipolar Disorder - Seizure Disorder - currently treated with Carbamazepine - EtOH Use Disorder - Right Bundle Branch Block - Asthma - Hepatitis B - Hepatitis C - Glaucoma - G3P1 Past Surgical History: - Cholecystectomy [MASKED] - Frozen shoulder [MASKED] - Uterine Polyps - Cesarean Section - Bilateral tubal ligation Social History: [MASKED] Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. [MASKED] family history of cancer. Physical Exam: ADMISSION EXAM: VS: T: 97.7 PO 140 / 84 R Lying HR: 83 RR: 18 SO2: 96 RA GENERAL: NAD, slightly flat affect HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: RRR, S1 with preserved S2, [MASKED] systolic murmur with radiation toward both carotids, mild carotid-apical delay, no gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, tender diffusely but greatest in epigastrum, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: bounding 2+ DP pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM: GENERAL: Well appearing. HEENT: No icterus or injection. MMM. CV: RRR. RESP: CTAB. ABD: Soft, NDNT. EXTR: Warm, no c/c/e. NEURO: Alert, oriented, attentive. Pertinent Results: ADMISSION LABS: [MASKED] 04:40PM BLOOD WBC-5.9 RBC-3.90 Hgb-12.4 Hct-36.7 MCV-94 MCH-31.8 MCHC-33.8 RDW-12.1 RDWSD-41.5 Plt [MASKED] [MASKED] 04:40PM BLOOD Neuts-61.1 [MASKED] Monos-8.7 Eos-2.9 Baso-0.5 Im [MASKED] AbsNeut-3.59 AbsLymp-1.56 AbsMono-0.51 AbsEos-0.17 AbsBaso-0.03 [MASKED] 04:40PM BLOOD Glucose-100 UreaN-15 Creat-0.5 Na-144 K-3.8 Cl-104 HCO3-27 AnGap-13 [MASKED] 04:40PM BLOOD ALT-16 AST-18 AlkPhos-83 TotBili-<0.2 [MASKED] 04:40PM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.9 Mg-1.7 DISCHARGE LABS: [MASKED] 05:50AM BLOOD WBC-5.9 RBC-3.68* Hgb-11.8 Hct-35.1 MCV-95 MCH-32.1* MCHC-33.6 RDW-12.0 RDWSD-42.0 Plt [MASKED] [MASKED] 05:50AM BLOOD Glucose-295* UreaN-13 Creat-0.5 Na-142 K-4.1 Cl-103 HCO3-24 AnGap-15 [MASKED] 05:50AM BLOOD Carbamz-3.1* [MASKED] EGD - Normal esophagus, stomach, and duodenum. - Botox was injected into the four quadrants of the pylorus. Brief Hospital Course: [MASKED] y/o woman with h/o type 1 diabetes complicated by gastroparesis managed with domperidone and botox injections, admitted for her typical gastroparesis symptoms. Evaluation for alternative etiologies was negative. Erythromycin was trialled without benefit. She underwent repeat endoscopic botox injection with excellent relief of symptoms and was discharged tolerating a regular diet. ACUTE ISSUES =================== # Gastroparesis flare: [MASKED] above # Type 1 diabetes mellitus with hypoglycemia and hyperglycemia: Patient was transiently hypoglycemic in ED, then hyperglycemic when insulin was held. Her prior Lantus/Humalog regimen was resumed and she was euglycemic for the remainder of admissoin. CHRONIC ISSUES: =================== # Slow transit constipation: Continued home Linzess at 72 mcg (has diarrhea at 145 mcg) and miralax. # Bipolar disorder: Continued home asenapine 5 mg QHS # ?Seizure vs. mood disorder: Continued home carbamazepine 800 mg BID. Level was checked due to interaction with erythromycin and was subtherapeutic. Consider recheck and dose adjustment as outpatient. # GERD: Continued home omeprazole 40mg daily # Chronic hepatitis B: Continued home suppressive tenofovir. LTFs wnl this admission. # HTN: BP at goal <140/90 per ACCORD, continued home lisinopril # Systolic murmur: Normal TTE [MASKED], exam most consistent with mild to moderate AS, would monitor as outpatient, consider repeat TTE non-urgently. TRANSITIONAL ISSUES: ====================== - No medications were changed. - Carbamazepine level was subtherapeutic (3.1). Consider rechecking and adjusting dose. - Consider non-urgent repeat TTE To assess systolic murmur. #CODE: Full (presumed) #CONTACT: [MASKED], husband ([MASKED]) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ASENapine 5 mg SL QHS 2. Aspirin 81 mg PO DAILY 3. CarBAMazepine 800 mg PO BID 4. Lisinopril 15 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Simvastatin 40 mg PO QPM 8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 9. Cetirizine 10 mg PO DAILY 10. linaCLOtide 72 mcg oral DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Psyllium Powder 1 PKT PO QHS 13. Glargine 12 Units Breakfast Glargine 17 Units Dinner Insulin SC Sliding Scale using HUM Insulin 14. Carbamide Peroxide 6.5% [MASKED] DROP BOTH EARS BID 15. domperidone maleate Study Med 10 mg PO QACHS Discharge Medications: 1. ASENapine 5 mg SL QHS 2. Aspirin 81 mg PO DAILY 3. CarBAMazepine 800 mg PO BID 4. Carbamide Peroxide 6.5% [MASKED] DROP BOTH EARS BID 5. Cetirizine 10 mg PO DAILY 6. domperidone maleate Study Med 10 mg PO QACHS 7. Glargine 12 Units Breakfast Glargine 17 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. linaCLOtide 72 mcg oral DAILY 9. Lisinopril 15 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Psyllium Powder 1 PKT PO QHS 14. Simvastatin 40 mg PO QPM 15. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: # Diabetic gastroparesis # Type 1 diabetes mellitus with hyperglycemia and hypoglycemia SECONDARY DIAGNOSES: # Bipolar disorder # Slow transit constipation # Gastroesophageal reflux disease # Chronic hepatitis B infection # Hypertension # Systolic murmur Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to the hospital because you had pain and nausea from your gastroparesis. We gave you medicines and a botox injection and you got better. WHEN YOU LEAVE THE HOSPITAL: - Take all your medicines as prescribed. We did not make any changes. [MASKED] below for a complete list. - Follow up with your doctors. [MASKED] below for a list of appointments. We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "K219", "I10", "Z87891", "Z794", "Z8673", "Z7901" ]	[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "K3189: Other diseases of stomach and duodenum", "E1065: Type 1 diabetes mellitus with hyperglycemia", "E10649: Type 1 diabetes mellitus with hypoglycemia without coma", "F319: Bipolar disorder, unspecified", "K5901: Slow transit constipation", "K319: Disease of stomach and duodenum, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "B181: Chronic viral hepatitis B without delta-agent", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "Z85828: Personal history of other malignant neoplasm of skin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I4510: Unspecified right bundle-branch block", "Z7901: Long term (current) use of anticoagulants", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1021: Type 1 diabetes mellitus with diabetic nephropathy" ]
19,973,404	25,187,218	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ female with history of IDDM1 c/b gastroparesis, chronic HBV, and bipolar disorder who presents with abdominal pain at the request of her gastroenterologist, Dr. ___. Patient describes worsening left-sided abdominal pain of one-week duration. She explains pain is ___ -> ___ (after morphine) in severity and "sharp" in nature with occasional leftward radiation. She attributes pain to paucity of bowel movements, estimating 5-day period without BM prior to onset. She trialed Senna 17.2 mg BID with successful BM by ___ (last BM ___. She derived some relief thereafter, and thus discontinued use. Pain, however, recurred by next meal. Pain overall seemingly worse in post-prandial period. Endorses nausea and bloating, but otherwise denies fevers/chills, CP/SOB, vomiting, change in stool caliber, diarrhea, melena/hematochezia, or urinary symptoms. No sick contacts or recent travel. Of note, stable hiatal hernia and gastritis on repeat EGD + pylorus Botox injection on ___. In the ED, initial vitals: T 97.8, HR 77, BP 142/79, RR 18, O2 100% RA -Exam notable for: not recorded. -Labs notable for: WBC 4.9 ALT 21, AST 25, AP 91, TB <0.2 Lipase 18 -Imaging notable for: CT ABD & PELVIS W/ CONTRAST (___) IMPRESSION: -No acute process in the abdomen or pelvis. -Mild central intrahepatic biliary duct dilatation is slightly more prominent compared with prior, however likely secondary to prior cholecystectomy. -Patient given: Morphine 4 mg IV x3 Ondansetron 4 mg IV x2 -Gastroenterology recommended: linaclotide 72 mg and pain consult -Vitals prior to transfer: T 97.9, HR 67, BP 140/87, RR 18, O2 98% RA Past Medical History: BIPOLAR DISORDER DIABETES MELLITUS - insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. GLAUCOMA RIGHT BUNDLE BRANCH BLOCK SEIZURE DISORDER - currently treated with Carbamazepine to which Pt attributes vertigo/dizziness, self-changed evening dose to 800mg from 1000mg yesterday (___) ALCOHOL ABUSE ASTHMA HEPATITIS B HEP C GASTROPARESIS - on domperidone, s/p Botox injection in ___ . Past Surgical History: CHOLECYSTECTOMY ___ FROZEN SHOULDER ___ UTERINE POLYPS PRIOR CESAREAN SECTION G3P1 BILATERAL TUBAL LIGATION Social History: ___ Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. ___ family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 97.4, HR 63, BP 132/82, RR 18, O2 98% RA GENERAL: NAD, lying comfortably in bed HEENT: anicteric sclerae, no oropharyngeal lesions NECK: supple, no LAD CV: RRR, S1/S2, III/VI systolic murmur at RUSB, no r/g PULM: unlabored, rare expiratory wheeze GI: soft, hypoactive, non-distended, tender left quadrants (most in RUQ), no rigidity/guarding/rebound, no organomegaly EXT: warm, pulses symmetric and palpable, without edema NEURO: non-focal DISCHARGE PHYSICAL EXAM: ======================== PHYSICAL EXAM: VITALS: 97.8 104/66 60 18 95 RA GENERAL: NAD, seated upright in bed eating breakfast HEENT: anicteric sclerae, no oropharyngeal lesions NECK: supple, no LAD CV: RRR, S1/S2, III/VI systolic murmur at RUSB, no r/g PULM: unlabored, CTAB GI: soft, non-distended, no tenderness, no rigidity/guarding/rebound, no organomegaly EXT: warm, pulses symmetric and palpable, without edema NEURO: non-focal Pertinent Results: ___ 11:48AM URINE HOURS-RANDOM ___ 11:48AM URINE UHOLD-HOLD ___ 11:48AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:48AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG ___ 10:36AM GLUCOSE-115* UREA N-10 CREAT-0.5 SODIUM-139 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12 ___ 10:36AM estGFR-Using this ___ 10:36AM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-91 TOT BILI-<0.2 ___ 10:36AM LIPASE-18 ___ 10:36AM ALBUMIN-4.2 ___ 10:36AM WBC-4.9 RBC-4.00 HGB-12.7 HCT-37.4 MCV-94 MCH-31.8 MCHC-34.0 RDW-11.6 RDWSD-39.8 ___ 10:36AM NEUTS-56.2 ___ MONOS-8.8 EOS-4.5 BASOS-0.8 IM ___ AbsNeut-2.74 AbsLymp-1.44 AbsMono-0.43 AbsEos-0.22 AbsBaso-0.04 ___ 10:36AM PLT COUNT-184 EXAMINATION: CT abdomen pelvis with contrast INDICATION: NO_PO contrast; History: ___ with LLQ painNO_PO contrast// ? acute process TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. FINDINGS: LOWER CHEST: A 4 mm subpleural nodule in the left lower lobe is not significantly changed since at least ___. There is minimal bibasilar atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A dense calcification the right hepatic lobe is not significantly changed. There is mild central intrahepatic biliary duct dilatation, slightly increased from prior, however likely related to prior cholecystectomy. The extrahepatic common bile duct is dilated up to 10.0 mm, not significantly changed and likely related to prior holecystectomy. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not well visualized, however there are no secondary signs of acute appendicitis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is unremarkable. Bilateral adnexal clips are consistent with history of bilateral tubal ligation. Again seen is a 1.8 cm cyst in the left adnexa, not significantly changed. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: -No acute process in the abdomen or pelvis. -Mild central intrahepatic biliary duct dilatation is slightly more prominent compared with prior, however likely secondary to prior cholecystectomy. Brief Hospital Course: ================ PATIENT SUMMARY: ================ ___ female with history of IDDM1 c/b gastroparesis and chronic HBV who presented with abdominal pain initially concerning for gastroparesis flare subsequently noted to have significant constipation with complete resolution of pain following BM. ============= ACUTE ISSUES: ============= # Abdominal pain Patient presented with severe abdominal pain in the left upper quadrant. However, the patient was afebrile, had no hemodynamic instability, no leukocytosis, and no radiographic evidence of abdominal pathology. The patient reported this episode was similar to her previous episodes of gastroparesis. However, she also reported significant constipation over the previous week before admission. Her abdominal pain was controlled with opioids. We were unable to continue the patient's home domperidone due to hospital policy. She was prescribed laxatives and an enema which resulted in a large BM and subsequent complete resolution of her abdominal pain. The patient was seen by the GI consult service during this hospitalization. They recommended starting the patient on linaclotide as an outpatient. ===================== CHONIC/STABLE ISSUES: ===================== # Insulin dependent diabetes: A1C 6.8% (___) The patient's home Lantus was continued. She also received mealtime NovoLog with carb counting. There were no episodes of hypoglycemia. # Chronic HBV: LFTs were stable. Continued home Viread 300 mg daily. # Seizure disorder, unspecified: Continued home carbamazepine 800 mg BID. # Bipolar disorder, unspecified: Continued home asenapine 5 mg QHS. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ASENapine 5 mg SL QHS 2. CarBAMazepine 800 mg PO BID 3. Glargine 20 Units Bedtime Novolog Unknown Dose 4. Lisinopril 15 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY 6. Simvastatin 40 mg PO QPM 7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Cetirizine 10 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Psyllium Powder 1 PKT PO QHS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation RX bisacodyl [Laxative (bisacodyl)] 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium [COLACE Clear] 50 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. linaclotide 72 mcg PO DAILY 4. ASENapine 5 mg SL QHS 5. Aspirin 81 mg PO DAILY 6. CarBAMazepine 800 mg PO BID 7. Cetirizine 10 mg PO DAILY 8. Glargine 20 Units Bedtime 9. Lisinopril 15 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Psyllium Powder 1 PKT PO QHS 13. Simvastatin 40 mg PO QPM 14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: constipation Secondary diagnoses: insulin-dependent diabetes, gastroparesis, chronic HBV 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 at ___ ___! WHY WERE YOU ADMITTED? -You admitted to the hospital because you had pain in your stomach and had not had a bowel movement WHAT HAPPENED IN THE HOSPITAL? -You had a CT scan of your abdomen which was normal -Your pain was controlled with pain medications -You were given medications to help you have a bowel movement -You were seen by the GI doctors who decided to prescribe you Linaclotide WHAT SHOULD YOU DO AT HOME? -You should take all of your medications as prescribed -You should take medications to help you have a bowel movement if you haven't gone in a couple days -You should follow up with Dr. ___ ___ you for allowing us be involved in your care, we wish you all the best! Your ___ Team ======================================= Followup Instructions: ___	[ "K5900", "E1143", "K3184", "E878", "Z23", "E11319", "B181", "Z794", "F319", "E1121", "B1920", "G40909", "H409", "Z87891", "F1010" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. [MASKED] is a [MASKED] female with history of IDDM1 c/b gastroparesis, chronic HBV, and bipolar disorder who presents with abdominal pain at the request of her gastroenterologist, Dr. [MASKED]. Patient describes worsening left-sided abdominal pain of one-week duration. She explains pain is [MASKED] -> [MASKED] (after morphine) in severity and "sharp" in nature with occasional leftward radiation. She attributes pain to paucity of bowel movements, estimating 5-day period without BM prior to onset. She trialed Senna 17.2 mg BID with successful BM by [MASKED] (last BM [MASKED]. She derived some relief thereafter, and thus discontinued use. Pain, however, recurred by next meal. Pain overall seemingly worse in post-prandial period. Endorses nausea and bloating, but otherwise denies fevers/chills, CP/SOB, vomiting, change in stool caliber, diarrhea, melena/hematochezia, or urinary symptoms. No sick contacts or recent travel. Of note, stable hiatal hernia and gastritis on repeat EGD + pylorus Botox injection on [MASKED]. In the ED, initial vitals: T 97.8, HR 77, BP 142/79, RR 18, O2 100% RA -Exam notable for: not recorded. -Labs notable for: WBC 4.9 ALT 21, AST 25, AP 91, TB <0.2 Lipase 18 -Imaging notable for: CT ABD & PELVIS W/ CONTRAST ([MASKED]) IMPRESSION: -No acute process in the abdomen or pelvis. -Mild central intrahepatic biliary duct dilatation is slightly more prominent compared with prior, however likely secondary to prior cholecystectomy. -Patient given: Morphine 4 mg IV x3 Ondansetron 4 mg IV x2 -Gastroenterology recommended: linaclotide 72 mg and pain consult -Vitals prior to transfer: T 97.9, HR 67, BP 140/87, RR 18, O2 98% RA Past Medical History: BIPOLAR DISORDER DIABETES MELLITUS - insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. GLAUCOMA RIGHT BUNDLE BRANCH BLOCK SEIZURE DISORDER - currently treated with Carbamazepine to which Pt attributes vertigo/dizziness, self-changed evening dose to 800mg from 1000mg yesterday ([MASKED]) ALCOHOL ABUSE ASTHMA HEPATITIS B HEP C GASTROPARESIS - on domperidone, s/p Botox injection in [MASKED] . Past Surgical History: CHOLECYSTECTOMY [MASKED] FROZEN SHOULDER [MASKED] UTERINE POLYPS PRIOR CESAREAN SECTION G3P1 BILATERAL TUBAL LIGATION Social History: [MASKED] Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. [MASKED] family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 97.4, HR 63, BP 132/82, RR 18, O2 98% RA GENERAL: NAD, lying comfortably in bed HEENT: anicteric sclerae, no oropharyngeal lesions NECK: supple, no LAD CV: RRR, S1/S2, III/VI systolic murmur at RUSB, no r/g PULM: unlabored, rare expiratory wheeze GI: soft, hypoactive, non-distended, tender left quadrants (most in RUQ), no rigidity/guarding/rebound, no organomegaly EXT: warm, pulses symmetric and palpable, without edema NEURO: non-focal DISCHARGE PHYSICAL EXAM: ======================== PHYSICAL EXAM: VITALS: 97.8 104/66 60 18 95 RA GENERAL: NAD, seated upright in bed eating breakfast HEENT: anicteric sclerae, no oropharyngeal lesions NECK: supple, no LAD CV: RRR, S1/S2, III/VI systolic murmur at RUSB, no r/g PULM: unlabored, CTAB GI: soft, non-distended, no tenderness, no rigidity/guarding/rebound, no organomegaly EXT: warm, pulses symmetric and palpable, without edema NEURO: non-focal Pertinent Results: [MASKED] 11:48AM URINE HOURS-RANDOM [MASKED] 11:48AM URINE UHOLD-HOLD [MASKED] 11:48AM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 11:48AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG [MASKED] 10:36AM GLUCOSE-115* UREA N-10 CREAT-0.5 SODIUM-139 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12 [MASKED] 10:36AM estGFR-Using this [MASKED] 10:36AM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-91 TOT BILI-<0.2 [MASKED] 10:36AM LIPASE-18 [MASKED] 10:36AM ALBUMIN-4.2 [MASKED] 10:36AM WBC-4.9 RBC-4.00 HGB-12.7 HCT-37.4 MCV-94 MCH-31.8 MCHC-34.0 RDW-11.6 RDWSD-39.8 [MASKED] 10:36AM NEUTS-56.2 [MASKED] MONOS-8.8 EOS-4.5 BASOS-0.8 IM [MASKED] AbsNeut-2.74 AbsLymp-1.44 AbsMono-0.43 AbsEos-0.22 AbsBaso-0.04 [MASKED] 10:36AM PLT COUNT-184 EXAMINATION: CT abdomen pelvis with contrast INDICATION: NO PO contrast; History: [MASKED] with LLQ painNO PO contrast// ? acute process TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. FINDINGS: LOWER CHEST: A 4 mm subpleural nodule in the left lower lobe is not significantly changed since at least [MASKED]. There is minimal bibasilar atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A dense calcification the right hepatic lobe is not significantly changed. There is mild central intrahepatic biliary duct dilatation, slightly increased from prior, however likely related to prior cholecystectomy. The extrahepatic common bile duct is dilated up to 10.0 mm, not significantly changed and likely related to prior holecystectomy. The gallbladder is surgically absent. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen shows normal size and attenuation throughout, without evidence of focal lesions. ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall thickness, and enhancement throughout. The colon and rectum are within normal limits. The appendix is not well visualized, however there are no secondary signs of acute appendicitis. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The uterus is unremarkable. Bilateral adnexal clips are consistent with history of bilateral tubal ligation. Again seen is a 1.8 cm cyst in the left adnexa, not significantly changed. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: There is no evidence of worrisome osseous lesions or acute fracture. SOFT TISSUES: The abdominal and pelvic wall is within normal limits. IMPRESSION: -No acute process in the abdomen or pelvis. -Mild central intrahepatic biliary duct dilatation is slightly more prominent compared with prior, however likely secondary to prior cholecystectomy. Brief Hospital Course: ================ PATIENT SUMMARY: ================ [MASKED] female with history of IDDM1 c/b gastroparesis and chronic HBV who presented with abdominal pain initially concerning for gastroparesis flare subsequently noted to have significant constipation with complete resolution of pain following BM. ============= ACUTE ISSUES: ============= # Abdominal pain Patient presented with severe abdominal pain in the left upper quadrant. However, the patient was afebrile, had no hemodynamic instability, no leukocytosis, and no radiographic evidence of abdominal pathology. The patient reported this episode was similar to her previous episodes of gastroparesis. However, she also reported significant constipation over the previous week before admission. Her abdominal pain was controlled with opioids. We were unable to continue the patient's home domperidone due to hospital policy. She was prescribed laxatives and an enema which resulted in a large BM and subsequent complete resolution of her abdominal pain. The patient was seen by the GI consult service during this hospitalization. They recommended starting the patient on linaclotide as an outpatient. ===================== CHONIC/STABLE ISSUES: ===================== # Insulin dependent diabetes: A1C 6.8% ([MASKED]) The patient's home Lantus was continued. She also received mealtime NovoLog with carb counting. There were no episodes of hypoglycemia. # Chronic HBV: LFTs were stable. Continued home Viread 300 mg daily. # Seizure disorder, unspecified: Continued home carbamazepine 800 mg BID. # Bipolar disorder, unspecified: Continued home asenapine 5 mg QHS. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ASENapine 5 mg SL QHS 2. CarBAMazepine 800 mg PO BID 3. Glargine 20 Units Bedtime Novolog Unknown Dose 4. Lisinopril 15 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY 6. Simvastatin 40 mg PO QPM 7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Cetirizine 10 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Psyllium Powder 1 PKT PO QHS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY:PRN Constipation RX bisacodyl [Laxative (bisacodyl)] 5 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium [COLACE Clear] 50 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. linaclotide 72 mcg PO DAILY 4. ASENapine 5 mg SL QHS 5. Aspirin 81 mg PO DAILY 6. CarBAMazepine 800 mg PO BID 7. Cetirizine 10 mg PO DAILY 8. Glargine 20 Units Bedtime 9. Lisinopril 15 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. Psyllium Powder 1 PKT PO QHS 13. Simvastatin 40 mg PO QPM 14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: constipation Secondary diagnoses: insulin-dependent diabetes, gastroparesis, chronic HBV 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 at [MASKED] [MASKED]! WHY WERE YOU ADMITTED? -You admitted to the hospital because you had pain in your stomach and had not had a bowel movement WHAT HAPPENED IN THE HOSPITAL? -You had a CT scan of your abdomen which was normal -Your pain was controlled with pain medications -You were given medications to help you have a bowel movement -You were seen by the GI doctors who decided to prescribe you Linaclotide WHAT SHOULD YOU DO AT HOME? -You should take all of your medications as prescribed -You should take medications to help you have a bowel movement if you haven't gone in a couple days -You should follow up with Dr. [MASKED] [MASKED] you for allowing us be involved in your care, we wish you all the best! Your [MASKED] Team ======================================= Followup Instructions: [MASKED]	[]	[ "K5900", "Z794", "Z87891" ]	[ "K5900: Constipation, unspecified", "E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "Z23: Encounter for immunization", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "B181: Chronic viral hepatitis B without delta-agent", "Z794: Long term (current) use of insulin", "F319: Bipolar disorder, unspecified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "B1920: Unspecified viral hepatitis C without hepatic coma", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "H409: Unspecified glaucoma", "Z87891: Personal history of nicotine dependence", "F1010: Alcohol abuse, uncomplicated" ]
19,973,404	25,531,595	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Pain, Nausea Major Surgical or Invasive Procedure: EGD ___ History of Present Illness: Mrs. ___ is a ___ woman with PMH DM type I complicated by gastroparesis, HTN, HBV, bipolar disorder, and seizure disorder. The patient reports that she was in her usual state of health until the day before presentation when she developed increasing abdominal pain and nausea without emesis. Of note, she describes that her blood sugar was in the 200s prior to her symptoms began and she also had eaten several greasy meals over the weekend. She describes her pain as epigastric without radiation, ___, sharp, worsening with eating, and improving with bowel movements. The patient has also experienced ___ episodes of watery diarrhea since developing the pain. Her pain steadily worsened throughout the day, so the patient presented to ___ ER for further evaluation. She denies fevers/chills, or other ROS symptoms. Of note she describes her current symptoms as very typical of her usual episodes of gastroparesis. She was last admitted for gastroparesis in ___ and was treated with opioids for pain control before being started on linaclotide after discharge. In the ED: - Initial vital signs were: T 98.1F\| HR 81\| BP 126/77\| RR 16\| 100% RA. - Exam notable for: abdominal tenderness in epigastrum and LUQ - Labs were notable for: glucose 162, otherwise CBC, chem-7, LFTs, lipase all normal - Patient was given: IV hydromorphone 1mg x2 and IV ondansetron 4mg with minimal improvement in symptoms Vitals on transfer: T 98.4F\| HR 76\| BP 127/77\| 97% RA Review of Systems: ================== Complete ROS obtained and is otherwise negative. Past Medical History: BIPOLAR DISORDER DIABETES MELLITUS - insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. GLAUCOMA RIGHT BUNDLE BRANCH BLOCK SEIZURE DISORDER - currently treated with Carbamazepine to which Pt attributes vertigo/dizziness, self-changed evening dose to 800mg from 1000mg yesterday (___) ALCOHOL ABUSE ASTHMA HEPATITIS B HEP C GASTROPARESIS - on domperidone, s/p Botox injection in ___ . Past Surgical History: CHOLECYSTECTOMY ___ FROZEN SHOULDER ___ UTERINE POLYPS PRIOR CESAREAN SECTION G3P1 BILATERAL TUBAL LIGATION Social History: ___ Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. ___ family history of cancer. Physical Exam: ADMISSION PHYSICAL ================== VITALS: T 98.4F\| HR 76\| BP 127/77\| 97% RA GENERAL: Alert and interactive. In no acute distress. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___ holosystolic murmur best auscultated at apex. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Tender to palpation, most notably in epigastrum. No rebound tenderness or guarding. Otherwise normal bowels sounds and non distended. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: Alert and responding to questions appropriately. Moving all four extremities. No facial asymmetry. DISCHARGE PHYSICAL ================== ___ 0803 Temp: 98.2 PO BP: 109/71 HR: 73 RR: 18 O2 sat: 95% O2 delivery: Ra FSBG: 82 GENERAL:NAD HEENT: NC/AT, MMM CARDIAC: RRR, ___ holosystolic murmur at LUSB LUNGS: CTAB, no wheezing/rales ABDOMEN: soft, non-tender, non-distended, +BS EXTREMITIES: no C/C/E SKIN: warm NEUROLOGIC: AAOx3, moving all extremities with purpose Pertinent Results: ADMISSION LABS ============== ___ 03:10PM BLOOD WBC-4.9 RBC-4.30 Hgb-13.7 Hct-39.3 MCV-91 MCH-31.9 MCHC-34.9 RDW-12.0 RDWSD-39.8 Plt ___ ___ 03:10PM BLOOD Neuts-63.1 ___ Monos-7.7 Eos-2.4 Baso-0.4 Im ___ AbsNeut-3.11 AbsLymp-1.29 AbsMono-0.38 AbsEos-0.12 AbsBaso-0.02 ___ 04:29PM BLOOD ___ PTT-27.8 ___ ___ 03:10PM BLOOD Glucose-162* UreaN-11 Creat-0.5 Na-140 K-4.2 Cl-100 HCO3-28 AnGap-12 ___ 03:10PM BLOOD ALT-20 AST-21 AlkPhos-98 TotBili-0.2 ___ 03:10PM BLOOD Lipase-17 ___ 03:10PM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.9 Mg-1.7 ___ 03:10PM BLOOD Lactate-0.9 MICRO ===== None STUDIES ======= EGD ___ Irregular z-line. Gastritis. 100units of Botox injected in all four quadrants of pylorus that appeared grossly patent. DISCHARGE LABS ============== ___ 05:30AM BLOOD WBC-3.9* RBC-3.91 Hgb-12.5 Hct-36.0 MCV-92 MCH-32.0 MCHC-34.7 RDW-12.0 RDWSD-40.3 Plt ___ ___ 05:30AM BLOOD Glucose-74 UreaN-14 Creat-0.5 Na-143 K-4.0 Cl-103 HCO3-30 AnGap-10 Brief Hospital Course: Mrs. ___ is a ___ woman with PMH DM type I complicated by gastroparesis, HTN, HBV, bipolar disorder, and seizure disorder presenting with abdominal pain, nausea, vomiting, and diarrhea mostly consistent with gastroparesis flare or viral gastroenteritis. # Epigastric Pain # Nausea/Vomiting # Diarrhea The patient's epigastric pain, nausea, vomiting were thought to be most likely to represent a gastroparesis flare in the setting of dietary indiscretion. However, patient's diarrhea is inconsistent with gastroparesis, so she was also evaluated for infectious gastroenteritis with stool studies. Discussed with outpatient ___ physician, and patient underwent EGD notable for irregular Z line and gastritis and also had Botox injection during the EGD to help alleviate some of her symptoms. Her home promotility agents were held in the setting her diarrhea initially. The patient's diarrhea self resolved within 1 day of hospitalization. Patient was initially given opiates and benzodiazepines to control her nausea and abdominal pain but was later transitioned to Tylenol and Zofran. # Type 1 Diabetes Patient has a known history of type 1 diabetes. Her last HbA1c 6.8% in ___. Home regimen included Tresiba 15U QHS and novolog dosage with meals based on carb counting. Given poor p.o. intake and n.p.o. status prior to EGD, the patient's home regimen was decreased and she was placed on an insulin sliding scale. # ___ Holosystolic Murmur at ___ Patient was noted to have a 3 out of 6 holosystolic murmur best heard at the left upper sternal border. Based on review of old records, this finding was consistent in the past. Patient was not having any cardiac symptoms. A TTE was deferred in the setting after discussion with the patient's primary care physician. CHRONIC ISSUES: =============== # HBV The patient's LFTs were baseline at presentation and she was continued on her home dose of tenofovir. # Seizure disorder, unspecified: Is continued on her home dose of carbamazepine 800 mg twice daily per # Bipolar disorder The patient was continued on home asenapine 5 mg SL QHS and carbamazepine as described above. TRANSITIONAL ISSUES: ==================== [] Diabetes: Recommend continuation of current outpatient insulin regimen and repeating A1c [] GI: Follow-up for continued management of gastroparesis and further evaluation of motility disorders [] Started on omeprazole 40mg daily given evidence of an irregular Z line and gastritis on EGD #CODE: Full Code #CONTACT: ___ (husband and HCP, cell: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tresiba 15 Units Bedtime + Novolog Carb Count 2. ASENapine 5 mg SL QHS 3. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Cetirizine 10 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Lisinopril 15 mg PO DAILY 9. Polyethylene Glycol 17 g PO DAILY 10. Psyllium Powder 1 PKT PO QHS 11. Simvastatin 40 mg PO QPM 12. Linzess (linaCLOtide) 72 mcg oral DAILY Discharge Medications: 1. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:*0 2. Tresiba 15 Units Bedtime + Novolog Carb COunt 3. ASENapine 5 mg SL QHS 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Cetirizine 10 mg PO DAILY 7. Linzess (linaCLOtide) 72 mcg oral DAILY 8. Lisinopril 15 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY 11. Psyllium Powder 1 PKT PO QHS 12. Simvastatin 40 mg PO QPM 13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses ================= Gastroparesis flare Diarrhea/Viral Gastroenteritis Secondary Diagnoses =================== Type 1 diabetes Bipolar disorder Seizure disorder Hepatitis B 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 in the hospital! Why was I admitted to the hospital? -You came to the hospital because you had abdominal pain, vomiting, and diarrhea What happened while I was admitted to the hospital? -You were tested for infections that may have been causing your symptoms You underwent an endoscopy with Botox injections to help with your symptoms -Your lab numbers were closely monitored and you were given medications What should I do after I leave the hospital? -Please continue taking all of your medications as prescribed, details below -Keep all of your appointments as scheduled We wish you the very best! Your ___ Care Team Followup Instructions: ___	[ "E1043", "K3184", "E1065", "B1910", "G40909", "I10", "E7800", "R011", "F319", "Z794", "Z833" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal Pain, Nausea Major Surgical or Invasive Procedure: EGD [MASKED] History of Present Illness: Mrs. [MASKED] is a [MASKED] woman with PMH DM type I complicated by gastroparesis, HTN, HBV, bipolar disorder, and seizure disorder. The patient reports that she was in her usual state of health until the day before presentation when she developed increasing abdominal pain and nausea without emesis. Of note, she describes that her blood sugar was in the 200s prior to her symptoms began and she also had eaten several greasy meals over the weekend. She describes her pain as epigastric without radiation, [MASKED], sharp, worsening with eating, and improving with bowel movements. The patient has also experienced [MASKED] episodes of watery diarrhea since developing the pain. Her pain steadily worsened throughout the day, so the patient presented to [MASKED] ER for further evaluation. She denies fevers/chills, or other ROS symptoms. Of note she describes her current symptoms as very typical of her usual episodes of gastroparesis. She was last admitted for gastroparesis in [MASKED] and was treated with opioids for pain control before being started on linaclotide after discharge. In the ED: - Initial vital signs were: T 98.1F\| HR 81\| BP 126/77\| RR 16\| 100% RA. - Exam notable for: abdominal tenderness in epigastrum and LUQ - Labs were notable for: glucose 162, otherwise CBC, chem-7, LFTs, lipase all normal - Patient was given: IV hydromorphone 1mg x2 and IV ondansetron 4mg with minimal improvement in symptoms Vitals on transfer: T 98.4F\| HR 76\| BP 127/77\| 97% RA Review of Systems: ================== Complete ROS obtained and is otherwise negative. Past Medical History: BIPOLAR DISORDER DIABETES MELLITUS - insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. GLAUCOMA RIGHT BUNDLE BRANCH BLOCK SEIZURE DISORDER - currently treated with Carbamazepine to which Pt attributes vertigo/dizziness, self-changed evening dose to 800mg from 1000mg yesterday ([MASKED]) ALCOHOL ABUSE ASTHMA HEPATITIS B HEP C GASTROPARESIS - on domperidone, s/p Botox injection in [MASKED] . Past Surgical History: CHOLECYSTECTOMY [MASKED] FROZEN SHOULDER [MASKED] UTERINE POLYPS PRIOR CESAREAN SECTION G3P1 BILATERAL TUBAL LIGATION Social History: [MASKED] Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. [MASKED] family history of cancer. Physical Exam: ADMISSION PHYSICAL ================== VITALS: T 98.4F\| HR 76\| BP 127/77\| 97% RA GENERAL: Alert and interactive. In no acute distress. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes, good dentition. Oropharynx is clear. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. [MASKED] holosystolic murmur best auscultated at apex. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Tender to palpation, most notably in epigastrum. No rebound tenderness or guarding. Otherwise normal bowels sounds and non distended. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: Alert and responding to questions appropriately. Moving all four extremities. No facial asymmetry. DISCHARGE PHYSICAL ================== [MASKED] 0803 Temp: 98.2 PO BP: 109/71 HR: 73 RR: 18 O2 sat: 95% O2 delivery: Ra FSBG: 82 GENERAL:NAD HEENT: NC/AT, MMM CARDIAC: RRR, [MASKED] holosystolic murmur at LUSB LUNGS: CTAB, no wheezing/rales ABDOMEN: soft, non-tender, non-distended, +BS EXTREMITIES: no C/C/E SKIN: warm NEUROLOGIC: AAOx3, moving all extremities with purpose Pertinent Results: ADMISSION LABS ============== [MASKED] 03:10PM BLOOD WBC-4.9 RBC-4.30 Hgb-13.7 Hct-39.3 MCV-91 MCH-31.9 MCHC-34.9 RDW-12.0 RDWSD-39.8 Plt [MASKED] [MASKED] 03:10PM BLOOD Neuts-63.1 [MASKED] Monos-7.7 Eos-2.4 Baso-0.4 Im [MASKED] AbsNeut-3.11 AbsLymp-1.29 AbsMono-0.38 AbsEos-0.12 AbsBaso-0.02 [MASKED] 04:29PM BLOOD [MASKED] PTT-27.8 [MASKED] [MASKED] 03:10PM BLOOD Glucose-162* UreaN-11 Creat-0.5 Na-140 K-4.2 Cl-100 HCO3-28 AnGap-12 [MASKED] 03:10PM BLOOD ALT-20 AST-21 AlkPhos-98 TotBili-0.2 [MASKED] 03:10PM BLOOD Lipase-17 [MASKED] 03:10PM BLOOD Albumin-4.3 Calcium-9.6 Phos-3.9 Mg-1.7 [MASKED] 03:10PM BLOOD Lactate-0.9 MICRO ===== None STUDIES ======= EGD [MASKED] Irregular z-line. Gastritis. 100units of Botox injected in all four quadrants of pylorus that appeared grossly patent. DISCHARGE LABS ============== [MASKED] 05:30AM BLOOD WBC-3.9* RBC-3.91 Hgb-12.5 Hct-36.0 MCV-92 MCH-32.0 MCHC-34.7 RDW-12.0 RDWSD-40.3 Plt [MASKED] [MASKED] 05:30AM BLOOD Glucose-74 UreaN-14 Creat-0.5 Na-143 K-4.0 Cl-103 HCO3-30 AnGap-10 Brief Hospital Course: Mrs. [MASKED] is a [MASKED] woman with PMH DM type I complicated by gastroparesis, HTN, HBV, bipolar disorder, and seizure disorder presenting with abdominal pain, nausea, vomiting, and diarrhea mostly consistent with gastroparesis flare or viral gastroenteritis. # Epigastric Pain # Nausea/Vomiting # Diarrhea The patient's epigastric pain, nausea, vomiting were thought to be most likely to represent a gastroparesis flare in the setting of dietary indiscretion. However, patient's diarrhea is inconsistent with gastroparesis, so she was also evaluated for infectious gastroenteritis with stool studies. Discussed with outpatient [MASKED] physician, and patient underwent EGD notable for irregular Z line and gastritis and also had Botox injection during the EGD to help alleviate some of her symptoms. Her home promotility agents were held in the setting her diarrhea initially. The patient's diarrhea self resolved within 1 day of hospitalization. Patient was initially given opiates and benzodiazepines to control her nausea and abdominal pain but was later transitioned to Tylenol and Zofran. # Type 1 Diabetes Patient has a known history of type 1 diabetes. Her last HbA1c 6.8% in [MASKED]. Home regimen included Tresiba 15U QHS and novolog dosage with meals based on carb counting. Given poor p.o. intake and n.p.o. status prior to EGD, the patient's home regimen was decreased and she was placed on an insulin sliding scale. # [MASKED] Holosystolic Murmur at [MASKED] Patient was noted to have a 3 out of 6 holosystolic murmur best heard at the left upper sternal border. Based on review of old records, this finding was consistent in the past. Patient was not having any cardiac symptoms. A TTE was deferred in the setting after discussion with the patient's primary care physician. CHRONIC ISSUES: =============== # HBV The patient's LFTs were baseline at presentation and she was continued on her home dose of tenofovir. # Seizure disorder, unspecified: Is continued on her home dose of carbamazepine 800 mg twice daily per # Bipolar disorder The patient was continued on home asenapine 5 mg SL QHS and carbamazepine as described above. TRANSITIONAL ISSUES: ==================== [] Diabetes: Recommend continuation of current outpatient insulin regimen and repeating A1c [] GI: Follow-up for continued management of gastroparesis and further evaluation of motility disorders [] Started on omeprazole 40mg daily given evidence of an irregular Z line and gastritis on EGD #CODE: Full Code #CONTACT: [MASKED] (husband and HCP, cell: [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tresiba 15 Units Bedtime + Novolog Carb Count 2. ASENapine 5 mg SL QHS 3. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Cetirizine 10 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Lisinopril 15 mg PO DAILY 9. Polyethylene Glycol 17 g PO DAILY 10. Psyllium Powder 1 PKT PO QHS 11. Simvastatin 40 mg PO QPM 12. Linzess (linaCLOtide) 72 mcg oral DAILY Discharge Medications: 1. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:*0 2. Tresiba 15 Units Bedtime + Novolog Carb COunt 3. ASENapine 5 mg SL QHS 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Cetirizine 10 mg PO DAILY 7. Linzess (linaCLOtide) 72 mcg oral DAILY 8. Lisinopril 15 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY 11. Psyllium Powder 1 PKT PO QHS 12. Simvastatin 40 mg PO QPM 13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses ================= Gastroparesis flare Diarrhea/Viral Gastroenteritis Secondary Diagnoses =================== Type 1 diabetes Bipolar disorder Seizure disorder Hepatitis B 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 in the hospital! Why was I admitted to the hospital? -You came to the hospital because you had abdominal pain, vomiting, and diarrhea What happened while I was admitted to the hospital? -You were tested for infections that may have been causing your symptoms You underwent an endoscopy with Botox injections to help with your symptoms -Your lab numbers were closely monitored and you were given medications What should I do after I leave the hospital? -Please continue taking all of your medications as prescribed, details below -Keep all of your appointments as scheduled We wish you the very best! Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I10", "Z794" ]	[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "E1065: Type 1 diabetes mellitus with hyperglycemia", "B1910: Unspecified viral hepatitis B without hepatic coma", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I10: Essential (primary) hypertension", "E7800: Pure hypercholesterolemia, unspecified", "R011: Cardiac murmur, unspecified", "F319: Bipolar disorder, unspecified", "Z794: Long term (current) use of insulin", "Z833: Family history of diabetes mellitus" ]
19,973,404	25,995,277	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___ Chief Complaint: abdominal pain, n/v Major Surgical or Invasive Procedure: n/a History of Present Illness: Ms. ___ is a ___ female with the past medical history of DM c/b gastroparesis, bipolar d/o, seizure d/o, Hep B who presents with abdominal pain, n/v, admitted for presumed gastroparesis flare. Patient recently seen by GI/gastroparesis specialist. Outpatient gastric emptying study ordered and patient instructed to hold domperidone for 5 days prior to exam. Test was scheduled for ___ however on ___ patient developed severe and acute abdominal pain. She was advised by her GI physician to present to ER for evaluation. Patient states the pain was ___, located in epigastric area, sharp and at times cramping, associated with NBNB emesis, currently down to ___ with dilaudid. Her last BM was yesterday, feels more constipated due to using Zofran. Denies f/c, states pain is consistent with her usual gastroparesis flares, has been unable to tolerate much food without pain or n/v. Denies CP, SOB, light-headedness and dizziness. Also notes glucose at home has been more labile since stopping domperidone which she attributes in part to inconsistent PO intake. Has had several hypoglycemic episodes at home as well as in ED. In the ED, patient's vitals were as follows: T 97.5, HR 86, BP 148/92, RR 16, SpO2 98% on RA. CMP wnl, CBC wnl. She had a RUQUS which did not show any acute abnormalities. She was given 0.5 mg IV dilaudid x 2, Zofran 4 mg x2, LR 1L x 2. Patient had an episode of hypoglycemia in ED to ___ requiring IV dextrose. She was admitted to medicine for further work up and monitoring. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Diabetes Mellitus: insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. - Gastroparesis - on domperidone, s/p Botox injections - Bipolar Disorder - Seizure Disorder - currently treated with Carbamazepine - EtOH Use Disorder - Right Bundle Branch Block - Asthma - Hepatitis B - Hepatitis C - Glaucoma - G3P1 Past Surgical History: - Cholecystectomy ___ - Frozen shoulder ___ - Uterine Polyps - Cesarean Section - Bilateral tubal ligation Social History: ___ Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. ___ family history of cancer. Physical Exam: GENERAL: Alert and in no apparent distress 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, slightly TTP in epigastric area. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation 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 Pertinent Results: ___ 02:03PM GLUCOSE-115* UREA N-10 CREAT-0.5 SODIUM-140 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10 ___ 02:03PM ALT(SGPT)-21 AST(SGOT)-21 ALK PHOS-82 TOT BILI-<0.2 ___ 02:03PM WBC-5.8 RBC-4.09 HGB-13.0 HCT-37.4 MCV-91 MCH-31.8 MCHC-34.8 RDW-11.9 RDWSD-39.4 RUQ US ___ FINDINGS: Limited views of the pancreas appear unremarkable. Distal CBD measures up to 1 cm, unchanged from prior. Gallbladder is surgically absent. Minimal prominence of the intrahepatic biliary tree is unchanged from prior. The liver is normal in appearance and echotexture. No ascites. Main portal vein is patent with hepatopetal flow. Right kidney measures 9.6 cm and appears normal without hydronephrosis or worrisome lesion. Left kidney measures 9.7 cm and is normal in grayscale appearance without worrisome lesion. The spleen is normal in size at 9.5 cm in length. IMPRESSION: Status post cholecystectomy. Stable prominence of the biliary tree. FINDINGS: Residual tracer activity in the stomach is as follows: At 45 mins 97% of the ingested activity remains in the stomach At 2 hours 83% of the ingested activity remains in the stomach At 3 hours 65% of the ingested activity remains in the stomach At 4 hours 33% of the ingested activity remains in the stomach The majority of the residual tracer activity remains in the gastric fundus throughout the study. The gastric emptying curve demonstrates a plateau over the first 45 minutes then gradually slopes more steeply downward. IMPRESSION: Markedly delayed gastric emptying. Brief Hospital Course: Ms. ___ is a ___ female with the past medical history of DM c/b gastroparesis, bipolar d/o, seizure d/o, Hep B who presents with abdominal pain, n/v, admitted for presumed gastroparesis flare. ACUTE/ACTIVE PROBLEMS: #Abdominal pain #Nausea/vomiting #Gastroparesis flare - occurred in setting of discontinuation of domperidone in preparation for gastric emptying study. Have instructed patient that narcotics should be used sparingly as this may also affect gastric emptying study. -NM gastric emptying study ___ showed Markedly delayed gastric emptying. I discussed with Dr. ___. The pt will likely need pyloroplasty. His office will call her to refer her to a surgeon for this procedure. -Pt can resume her domperidone at discharge. #DM1 c/b hypoglycemia and hyperglycemia - labile BS with one documented hypoglycemic episode in ED and several at home per patient. Likely in setting of inconsistent PO intake from gastroparesis -___ consult appreciated. -Per ___ recs, pt advised to take Lantus 10U in AM and 16U in ___ along with current sliding scale and carb counting (1U per every 18g carbohydrates) CHRONIC/STABLE PROBLEMS: #Hep B - continue viread #Bipolar d/o - continue asenapine #Seizure d/o - continue carbamazepine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ASENapine 5 mg SL QHS 2. Aspirin 81 mg PO DAILY 3. CarBAMazepine 800 mg PO BID 4. Lisinopril 15 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 8. domperidone maleate Study Med 10 mg PO QACHS 9. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID 10. linaCLOtide 72 mcg oral DAILY 11. Multivitamins 1 TAB PO DAILY 12. Simvastatin 40 mg PO QPM 13. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Glargine 10 Units Breakfast Glargine 16 Units Dinner Insulin SC Sliding Scale using HUM Insulin 2. ASENapine 5 mg SL QHS 3. Aspirin 81 mg PO DAILY 4. CarBAMazepine 800 mg PO BID 5. Carbamide Peroxide 6.5% ___ DROP BOTH EARS BID 6. Cetirizine 10 mg PO DAILY 7. domperidone maleate Study Med 10 mg PO QACHS 8. linaCLOtide 72 mcg oral DAILY 9. Lisinopril 15 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Simvastatin 40 mg PO QPM 14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Gastroparesis Type 1 diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented with a flare up of gastroparesis which caused nausea, vomiting and abdominal pain. You underwent a gastric emptying study which showed that you have marked delayed emptying. You will be contacted by the Gastrointestinal follow upw with regards to appropriate follow up. You were also seen by ___ specialists and your insulin was adjusted. Lantus 10U in the morning, 16U in the evening Sliding scale with meals as directed. Carbohydrate counting (1U for every 18g of carbs). Followup Instructions: ___	[ "E1043", "K3184", "Z794", "K30", "E1065", "E10649", "E10319", "E1040", "F319", "G40909", "B1910", "G8929", "Z87891" ]	Allergies: morphine Chief Complaint: abdominal pain, n/v Major Surgical or Invasive Procedure: n/a History of Present Illness: Ms. [MASKED] is a [MASKED] female with the past medical history of DM c/b gastroparesis, bipolar d/o, seizure d/o, Hep B who presents with abdominal pain, n/v, admitted for presumed gastroparesis flare. Patient recently seen by GI/gastroparesis specialist. Outpatient gastric emptying study ordered and patient instructed to hold domperidone for 5 days prior to exam. Test was scheduled for [MASKED] however on [MASKED] patient developed severe and acute abdominal pain. She was advised by her GI physician to present to ER for evaluation. Patient states the pain was [MASKED], located in epigastric area, sharp and at times cramping, associated with NBNB emesis, currently down to [MASKED] with dilaudid. Her last BM was yesterday, feels more constipated due to using Zofran. Denies f/c, states pain is consistent with her usual gastroparesis flares, has been unable to tolerate much food without pain or n/v. Denies CP, SOB, light-headedness and dizziness. Also notes glucose at home has been more labile since stopping domperidone which she attributes in part to inconsistent PO intake. Has had several hypoglycemic episodes at home as well as in ED. In the ED, patient's vitals were as follows: T 97.5, HR 86, BP 148/92, RR 16, SpO2 98% on RA. CMP wnl, CBC wnl. She had a RUQUS which did not show any acute abnormalities. She was given 0.5 mg IV dilaudid x 2, Zofran 4 mg x2, LR 1L x 2. Patient had an episode of hypoglycemia in ED to [MASKED] requiring IV dextrose. She was admitted to medicine for further work up and monitoring. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Diabetes Mellitus: insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. - Gastroparesis - on domperidone, s/p Botox injections - Bipolar Disorder - Seizure Disorder - currently treated with Carbamazepine - EtOH Use Disorder - Right Bundle Branch Block - Asthma - Hepatitis B - Hepatitis C - Glaucoma - G3P1 Past Surgical History: - Cholecystectomy [MASKED] - Frozen shoulder [MASKED] - Uterine Polyps - Cesarean Section - Bilateral tubal ligation Social History: [MASKED] Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. [MASKED] family history of cancer. Physical Exam: GENERAL: Alert and in no apparent distress 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, slightly TTP in epigastric area. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation 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 Pertinent Results: [MASKED] 02:03PM GLUCOSE-115* UREA N-10 CREAT-0.5 SODIUM-140 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10 [MASKED] 02:03PM ALT(SGPT)-21 AST(SGOT)-21 ALK PHOS-82 TOT BILI-<0.2 [MASKED] 02:03PM WBC-5.8 RBC-4.09 HGB-13.0 HCT-37.4 MCV-91 MCH-31.8 MCHC-34.8 RDW-11.9 RDWSD-39.4 RUQ US [MASKED] FINDINGS: Limited views of the pancreas appear unremarkable. Distal CBD measures up to 1 cm, unchanged from prior. Gallbladder is surgically absent. Minimal prominence of the intrahepatic biliary tree is unchanged from prior. The liver is normal in appearance and echotexture. No ascites. Main portal vein is patent with hepatopetal flow. Right kidney measures 9.6 cm and appears normal without hydronephrosis or worrisome lesion. Left kidney measures 9.7 cm and is normal in grayscale appearance without worrisome lesion. The spleen is normal in size at 9.5 cm in length. IMPRESSION: Status post cholecystectomy. Stable prominence of the biliary tree. FINDINGS: Residual tracer activity in the stomach is as follows: At 45 mins 97% of the ingested activity remains in the stomach At 2 hours 83% of the ingested activity remains in the stomach At 3 hours 65% of the ingested activity remains in the stomach At 4 hours 33% of the ingested activity remains in the stomach The majority of the residual tracer activity remains in the gastric fundus throughout the study. The gastric emptying curve demonstrates a plateau over the first 45 minutes then gradually slopes more steeply downward. IMPRESSION: Markedly delayed gastric emptying. Brief Hospital Course: Ms. [MASKED] is a [MASKED] female with the past medical history of DM c/b gastroparesis, bipolar d/o, seizure d/o, Hep B who presents with abdominal pain, n/v, admitted for presumed gastroparesis flare. ACUTE/ACTIVE PROBLEMS: #Abdominal pain #Nausea/vomiting #Gastroparesis flare - occurred in setting of discontinuation of domperidone in preparation for gastric emptying study. Have instructed patient that narcotics should be used sparingly as this may also affect gastric emptying study. -NM gastric emptying study [MASKED] showed Markedly delayed gastric emptying. I discussed with Dr. [MASKED]. The pt will likely need pyloroplasty. His office will call her to refer her to a surgeon for this procedure. -Pt can resume her domperidone at discharge. #DM1 c/b hypoglycemia and hyperglycemia - labile BS with one documented hypoglycemic episode in ED and several at home per patient. Likely in setting of inconsistent PO intake from gastroparesis -[MASKED] consult appreciated. -Per [MASKED] recs, pt advised to take Lantus 10U in AM and 16U in [MASKED] along with current sliding scale and carb counting (1U per every 18g carbohydrates) CHRONIC/STABLE PROBLEMS: #Hep B - continue viread #Bipolar d/o - continue asenapine #Seizure d/o - continue carbamazepine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ASENapine 5 mg SL QHS 2. Aspirin 81 mg PO DAILY 3. CarBAMazepine 800 mg PO BID 4. Lisinopril 15 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 8. domperidone maleate Study Med 10 mg PO QACHS 9. Carbamide Peroxide 6.5% [MASKED] DROP BOTH EARS BID 10. linaCLOtide 72 mcg oral DAILY 11. Multivitamins 1 TAB PO DAILY 12. Simvastatin 40 mg PO QPM 13. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Glargine 10 Units Breakfast Glargine 16 Units Dinner Insulin SC Sliding Scale using HUM Insulin 2. ASENapine 5 mg SL QHS 3. Aspirin 81 mg PO DAILY 4. CarBAMazepine 800 mg PO BID 5. Carbamide Peroxide 6.5% [MASKED] DROP BOTH EARS BID 6. Cetirizine 10 mg PO DAILY 7. domperidone maleate Study Med 10 mg PO QACHS 8. linaCLOtide 72 mcg oral DAILY 9. Lisinopril 15 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Omeprazole 40 mg PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Simvastatin 40 mg PO QPM 14. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Gastroparesis Type 1 diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented with a flare up of gastroparesis which caused nausea, vomiting and abdominal pain. You underwent a gastric emptying study which showed that you have marked delayed emptying. You will be contacted by the Gastrointestinal follow upw with regards to appropriate follow up. You were also seen by [MASKED] specialists and your insulin was adjusted. Lantus 10U in the morning, 16U in the evening Sliding scale with meals as directed. Carbohydrate counting (1U for every 18g of carbs). Followup Instructions: [MASKED]	[]	[ "Z794", "G8929", "Z87891" ]	[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "Z794: Long term (current) use of insulin", "K30: Functional dyspepsia", "E1065: Type 1 diabetes mellitus with hyperglycemia", "E10649: Type 1 diabetes mellitus with hypoglycemia without coma", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "F319: Bipolar disorder, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "B1910: Unspecified viral hepatitis B without hepatic coma", "G8929: Other chronic pain", "Z87891: Personal history of nicotine dependence" ]
19,973,404	27,142,177	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: morphine Attending: ___ Major Surgical or Invasive Procedure: None attach Pertinent Results: LAB RESULTS ON ADMISSION: ========================= ___ 03:55PM BLOOD WBC-5.8 RBC-3.92 Hgb-12.1 Hct-36.7 MCV-94 MCH-30.9 MCHC-33.0 RDW-12.1 RDWSD-41.7 Plt ___ ___ 03:55PM BLOOD Plt ___ ___ 09:22PM BLOOD D-Dimer-462 ___ 03:55PM BLOOD Glucose-75 UreaN-16 Creat-0.5 Na-139 K-4.2 Cl-103 HCO3-26 AnGap-10 ___ 03:55PM BLOOD ALT-10 AST-18 AlkPhos-91 TotBili-<0.2 ___ 03:55PM BLOOD Lipase-15 ___ 03:55PM BLOOD cTropnT-<0.01 ___ 04:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.6 ___ 03:55PM BLOOD Albumin-4.3 LAB RESULTS ON DISCHARGE: ========================= ___ 04:30AM BLOOD WBC-3.9* RBC-3.42* Hgb-10.6* Hct-31.7* MCV-93 MCH-31.0 MCHC-33.4 RDW-12.1 RDWSD-41.3 Plt ___ ___ 04:30AM BLOOD Glucose-186* UreaN-17 Creat-0.5 Na-139 K-4.3 Cl-102 HCO3-25 AnGap-12 ___ 04:30AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.6 IMAGING: ======== ___ CXR No acute cardiopulmonary abnormality. ___ PORTAL ABDOMEN Moderate to severe colonic fecal burden with a nonobstructive bowel gas pattern. Brief Hospital Course: ___ with hx of DM1, gastroparesis s/p laparoscopic converted to open pyloroplasty (___) c/b infected seroma, ___ disease, HLD, bipolar disorder, chronic abdominal pain presenting with recurrent abdominal pain likely ___ constipation and gastroparesis in combination, which resolved with increased bowel regimen. # RUQ/epigastric pain: # Nausea: Patient described progressive constipation in the setting of known gastroparesis with moderate to severe colonic fecal burden with a nonobstructive bowel gas pattern seen on CXR. Abdominal pain resolved with increasing bowel regimen, suspect primarily driven by constipation, potentially triggering gastroparesis symptoms. Throughout hospitalization, patient has been very upset, insisting that our gastroenterology colleagues see her while in the hospital, with vociferous vocalizations at nursing staff repeatedly. We increased her lactulose to daily dosing and also provided her with miralax upon discharge. # Type 1 DM: Home regimen is Levemir 12u qAM and 20u qHS, patient reports that in the hospital she uses glargine 20u qHS, without am dose. While she was here with us, we dose reduced basal insulin to 14u qHS with Humalog SS sliding scale 2+1 50>150. She preferred to carb count while with us. There was episode of hypoglycemia to ___ in setting of over correction. In discussion with ___, patient will be discharged on her home insulin regimen without change. # Bipolar disorder: - Continue home asenapine 5 mg PO daily # ___: - Continue carbidopa/levodopa ___ TID # Hepatitis B: - Continue home tenofovir 300 mg PO daily # Seizure disorder: - Continue home carbamazepine 800 mg PO BID # HLD: - Continue home simvastatin 40 mg PO daily # Hypertension: While in house, held patient's home lisinopril 15 mg as SBP 100s off this medication. Discussed holding it on discharge, but patient preferred to continue. In this case, discussed she should monitor blood pressures at home closely and call PCP should BP be low or should she have symptoms such as dizziness/weakness. TRANSITIONAL ISSUES: ==================== [] Increased bowel regimen to lactulose 15 mL daily + PRN miralax, patient instructed to titrate as needed - No changes made to home insulin regimen [] Discussed holding home lisinopril given SBP 100s in house off this medication, she strongly preferred to continue, please titrate as needed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LORazepam 1 mg PO DAILY:PRN nausea, anxiety 2. ASENapine 5 mg SL DAILY 3. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Simvastatin 40 mg PO QPM 7. Lisinopril 15 mg PO DAILY 8. Cetirizine 10 mg PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Carbidopa-Levodopa (___) 1 TAB PO TID 11. Lactulose 15 mL PO EVERY OTHER DAY 12. Levemir 12 Units Breakfast Levemir 20 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin Discharge Medications: 1. Lactulose 15 mL PO DAILY RX lactulose 10 gram/15 mL 15 ml by mouth once a day Refills:0 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line RX polyethylene glycol 3350 17 gram/dose 1 dose by mouth once a day Refills:0 3. ASENapine 5 mg SL DAILY 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Carbidopa-Levodopa (___) 1 TAB PO TID 7. Cetirizine 10 mg PO DAILY 8. Levemir 12 Units Breakfast Levemir 20 Units Bedtime 9. Lisinopril 15 mg PO DAILY Would prefer to hold as SBP 100s while off, please monitor BP carefully 10. LORazepam 1 mg PO DAILY:PRN nausea, anxiety 11. Omeprazole 40 mg PO DAILY 12. Simvastatin 40 mg PO QPM 13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Constipation History of gastroparesis Type 1 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 for abdominal pain, thought secondary to constipation and your gastroparesis. While you were here, you were given medications to help you have a bowel movement and you subsequently felt better. You were seen by our diabetes doctors and also our gastroenterologists per your request. No changes were made to your insulin. We have increased your bowel regimen and you can titrate it as needed to make sure you have bowel movements which will help prevent further episodes. Please take care and take all your medications as prescribed. We did temporarily hold your blood pressure medication because your systolic blood pressure was in the 100 range while here. You preferred to continue to take this on discharge, hence we discussed monitoring your blood pressure very carefully while at home and to call your primary care doctor if you feel dizzy. Sincerely, Your ___ Care Team Followup Instructions: ___	[ "K5909", "B181", "E1043", "K3184", "E1021", "E103299", "G20", "F319", "B182", "I10", "G40909", "E785", "J45909", "Z23", "Z794", "Z833" ]	Allergies: morphine Major Surgical or Invasive Procedure: None attach Pertinent Results: LAB RESULTS ON ADMISSION: ========================= [MASKED] 03:55PM BLOOD WBC-5.8 RBC-3.92 Hgb-12.1 Hct-36.7 MCV-94 MCH-30.9 MCHC-33.0 RDW-12.1 RDWSD-41.7 Plt [MASKED] [MASKED] 03:55PM BLOOD Plt [MASKED] [MASKED] 09:22PM BLOOD D-Dimer-462 [MASKED] 03:55PM BLOOD Glucose-75 UreaN-16 Creat-0.5 Na-139 K-4.2 Cl-103 HCO3-26 AnGap-10 [MASKED] 03:55PM BLOOD ALT-10 AST-18 AlkPhos-91 TotBili-<0.2 [MASKED] 03:55PM BLOOD Lipase-15 [MASKED] 03:55PM BLOOD cTropnT-<0.01 [MASKED] 04:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.6 [MASKED] 03:55PM BLOOD Albumin-4.3 LAB RESULTS ON DISCHARGE: ========================= [MASKED] 04:30AM BLOOD WBC-3.9* RBC-3.42* Hgb-10.6* Hct-31.7* MCV-93 MCH-31.0 MCHC-33.4 RDW-12.1 RDWSD-41.3 Plt [MASKED] [MASKED] 04:30AM BLOOD Glucose-186* UreaN-17 Creat-0.5 Na-139 K-4.3 Cl-102 HCO3-25 AnGap-12 [MASKED] 04:30AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.6 IMAGING: ======== [MASKED] CXR No acute cardiopulmonary abnormality. [MASKED] PORTAL ABDOMEN Moderate to severe colonic fecal burden with a nonobstructive bowel gas pattern. Brief Hospital Course: [MASKED] with hx of DM1, gastroparesis s/p laparoscopic converted to open pyloroplasty ([MASKED]) c/b infected seroma, [MASKED] disease, HLD, bipolar disorder, chronic abdominal pain presenting with recurrent abdominal pain likely [MASKED] constipation and gastroparesis in combination, which resolved with increased bowel regimen. # RUQ/epigastric pain: # Nausea: Patient described progressive constipation in the setting of known gastroparesis with moderate to severe colonic fecal burden with a nonobstructive bowel gas pattern seen on CXR. Abdominal pain resolved with increasing bowel regimen, suspect primarily driven by constipation, potentially triggering gastroparesis symptoms. Throughout hospitalization, patient has been very upset, insisting that our gastroenterology colleagues see her while in the hospital, with vociferous vocalizations at nursing staff repeatedly. We increased her lactulose to daily dosing and also provided her with miralax upon discharge. # Type 1 DM: Home regimen is Levemir 12u qAM and 20u qHS, patient reports that in the hospital she uses glargine 20u qHS, without am dose. While she was here with us, we dose reduced basal insulin to 14u qHS with Humalog SS sliding scale 2+1 50>150. She preferred to carb count while with us. There was episode of hypoglycemia to [MASKED] in setting of over correction. In discussion with [MASKED], patient will be discharged on her home insulin regimen without change. # Bipolar disorder: - Continue home asenapine 5 mg PO daily # [MASKED]: - Continue carbidopa/levodopa [MASKED] TID # Hepatitis B: - Continue home tenofovir 300 mg PO daily # Seizure disorder: - Continue home carbamazepine 800 mg PO BID # HLD: - Continue home simvastatin 40 mg PO daily # Hypertension: While in house, held patient's home lisinopril 15 mg as SBP 100s off this medication. Discussed holding it on discharge, but patient preferred to continue. In this case, discussed she should monitor blood pressures at home closely and call PCP should BP be low or should she have symptoms such as dizziness/weakness. TRANSITIONAL ISSUES: ==================== [] Increased bowel regimen to lactulose 15 mL daily + PRN miralax, patient instructed to titrate as needed - No changes made to home insulin regimen [] Discussed holding home lisinopril given SBP 100s in house off this medication, she strongly preferred to continue, please titrate as needed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LORazepam 1 mg PO DAILY:PRN nausea, anxiety 2. ASENapine 5 mg SL DAILY 3. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Simvastatin 40 mg PO QPM 7. Lisinopril 15 mg PO DAILY 8. Cetirizine 10 mg PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 11. Lactulose 15 mL PO EVERY OTHER DAY 12. Levemir 12 Units Breakfast Levemir 20 Units Bedtime Insulin SC Sliding Scale using Novolog Insulin Discharge Medications: 1. Lactulose 15 mL PO DAILY RX lactulose 10 gram/15 mL 15 ml by mouth once a day Refills:0 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line RX polyethylene glycol 3350 17 gram/dose 1 dose by mouth once a day Refills:0 3. ASENapine 5 mg SL DAILY 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 7. Cetirizine 10 mg PO DAILY 8. Levemir 12 Units Breakfast Levemir 20 Units Bedtime 9. Lisinopril 15 mg PO DAILY Would prefer to hold as SBP 100s while off, please monitor BP carefully 10. LORazepam 1 mg PO DAILY:PRN nausea, anxiety 11. Omeprazole 40 mg PO DAILY 12. Simvastatin 40 mg PO QPM 13. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Constipation History of gastroparesis Type 1 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 for abdominal pain, thought secondary to constipation and your gastroparesis. While you were here, you were given medications to help you have a bowel movement and you subsequently felt better. You were seen by our diabetes doctors and also our gastroenterologists per your request. No changes were made to your insulin. We have increased your bowel regimen and you can titrate it as needed to make sure you have bowel movements which will help prevent further episodes. Please take care and take all your medications as prescribed. We did temporarily hold your blood pressure medication because your systolic blood pressure was in the 100 range while here. You preferred to continue to take this on discharge, hence we discussed monitoring your blood pressure very carefully while at home and to call your primary care doctor if you feel dizzy. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I10", "E785", "J45909", "Z794" ]	[ "K5909: Other constipation", "B181: Chronic viral hepatitis B without delta-agent", "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "K3184: Gastroparesis", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E103299: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eye", "G20: Parkinson's disease", "F319: Bipolar disorder, unspecified", "B182: Chronic viral hepatitis C", "I10: Essential (primary) hypertension", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "Z23: Encounter for immunization", "Z794: Long term (current) use of insulin", "Z833: Family history of diabetes mellitus" ]
19,973,404	28,262,154	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: morphine Attending: ___. Chief Complaint: Persistent draining abdominal wound Major Surgical or Invasive Procedure: ___ WOUND EXPLORATION, RESECTION AND DEBRIDEMENT OF TRACT History of Present Illness: Ms. ___ is a ___ F who had a laparoscopic converted to open pyloromyotomy for gastroparesis. She developed a wound seroma, which partially drained. This eventually healed up, but then she developed a small open area, which would periodically open and drain some purulent material. Attempts at finding a suture responsible for this in the office were not successful. This has continued three times now and the patient wishes to have more definitive treatment Past Medical History: - Diabetes Mellitus: insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. - Gastroparesis - on domperidone, s/p Botox injections - Bipolar Disorder - Seizure Disorder - currently treated with Carbamazepine - EtOH Use Disorder - Right Bundle Branch Block - Asthma - Hepatitis B - Hepatitis C - Glaucoma - G3P1 Past Surgical History: - Cholecystectomy ___ - Frozen shoulder ___ - Uterine Polyps - Cesarean Section - Bilateral tubal ligation m Social History: ___ Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. ___ family history of cancer. Physical Exam: Per nursing progress note ___: NEUROLOGICAL [ x] WNL Alert and oriented to person, place, and time (age and disease appropriate). No neuropathy or sensory deficits. Speech clear. No tremors or weakness. No seizure activity. Exceptions (Specify and include Interventions and Response): ____________________________ CARDIOVASCULAR/HEMATOLOGICAL Cardiac Monitoring/Telemetry: [x ] No [ ] Yes: If Yes, describe rate, rhythm: [x ]WNL Pulse rate and rhythm within normal limits. No edema. Skin warm and dry. Denies chest pain or palpitations. Exceptions (Specify and include Interventions and Response): ____________________________ RESPIRATORY [ x] WNL Lung sounds clear/equal. Respiratory rate within normal limits. Denies SOB, DOE or cough. Exceptions (Specify and include Interventions and Response): ____________________________ GASTROINTESTINAL Last Bowel Movement: ___ per pt [x ] WNL Abdomen non-distended, soft and non-tender. Stools within own normal pattern and consistency. Normal/active bowel sounds. Tolerating diet as ordered. Denies nausea/vomiting. Exceptions (Specify and include Interventions and Response): good appetite at breakfast pt states discussed with MD this am that she carb counts and wants to dictate her insulin doses, MD aware, see orders via ___ ____________________________ GENITOURINARY [x ] WNL Voiding within own normal limits. Urine clear and yellow. Without complaints of urinary discomfort. Exceptions (Specify and include Interventions and Response): via hat ______________________________ ACTIVITY LEVEL/MUSCULOSKELETAL ADL: [ x] Independent [ ] Needs Assistance [ ] Dependent [x ] WNL Moves all extremities (age and disease appropriate). Tolerating activity level as ordered. Exceptions (Specify and include Interventions and Response): showered w supervision sl. shuffling gait due to Parkinsons., amb w supervision ______________________________ PSYCHOSOCIAL/COPING [ ] WNL Patient/family actively participates in care process. No acute signs or symptoms of depression, aggression or anxiety. Communicates needs and concerns effectively. Reacting to disease process appropriately. Exceptions (Specify and include Interventions and Response): pt appears anxious at times asks mult qu re insulin mgmnt and d/c process pt needs to call ride service and states they will not wait ____________________________ SKIN [ x]WNL Skin intact. Color within normal limits Exceptions (skin issues not documented in eFlowsheet) (Specify and include Interventions and Response): _________________________________ VTE PROPHYLAXIS MECHANICAL [x ]NA [ ]Pneumatic boots [ ]T.E.D.TM TEDs/Sequential compression sleeves removed and skin assessed: [ ]NA [ ] Yes Pertinent Results: None Brief Hospital Course: Ms. ___ was admitted on ___ under the general surgery service for management of her Persistent draining abdominal wound. She was taken to the operating room and underwent Wound exploration and resection and debridement of tract . Please see operative report for details of this procedure. She tolerated the procedure well and was extubated upon completion. She was subsequently taken to the PACU for recovery. She was transferred to the surgical floor hemodynamically stable. Her vital signs were routinely monitored and she remained afebrile and hemodynamically stable. She was initially given IV fluids postoperatively, which were discontinued when she was tolerating PO's. Her diet was advanced on the morning of ___ to regular, which she tolerated without abdominal pain, nausea, or vomiting. She was voiding adequate amounts of urine without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which she was able to do independently. Her pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On ___ she was discharged home with scheduled follow up in general surgery clinic on ___. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ASENapine 5 mg SL QHS 2. Aspirin 81 mg PO DAILY 3. CarBAMazepine 800 mg PO BID 4. Cetirizine 10 mg PO DAILY 5. Lactulose 15 mL PO TID 6. Lisinopril 15 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. domperidone maleate Study Med 10 mg PO QACHS 11. Librax (with clidinium) (chlordiazepoxide-clidinium) ___ mg oral TID W/MEALS 12. Acetaminophen 650 mg PO QID 13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 14. Carbidopa-Levodopa (___) 1 TAB PO TID Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp #4 Tablet Refills:0 2. Acetaminophen 650 mg PO QID 3. ASENapine 5 mg SL QHS 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Carbidopa-Levodopa (___) 1 TAB PO TID 7. Cetirizine 10 mg PO DAILY 8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 9. domperidone maleate Study Med 10 mg PO QACHS 10. Lactulose 15 mL PO TID 11. Librax (with clidinium) (chlordiazepoxide-clidinium) ___ mg oral TID W/MEALS 12. Lisinopril 15 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 40 mg PO DAILY 15. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: surgical site granuloma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to ___ and underwent wound exploration and resection of granuloma. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Followup Instructions: ___	[ "T8189XA", "E1040", "E1021", "E10319", "E1043", "G20", "F319", "Z794", "K3184", "F419", "Z87891", "Z8619", "Z833", "Z8249", "Z8673", "Z85828" ]	Allergies: morphine Chief Complaint: Persistent draining abdominal wound Major Surgical or Invasive Procedure: [MASKED] WOUND EXPLORATION, RESECTION AND DEBRIDEMENT OF TRACT History of Present Illness: Ms. [MASKED] is a [MASKED] F who had a laparoscopic converted to open pyloromyotomy for gastroparesis. She developed a wound seroma, which partially drained. This eventually healed up, but then she developed a small open area, which would periodically open and drain some purulent material. Attempts at finding a suture responsible for this in the office were not successful. This has continued three times now and the patient wishes to have more definitive treatment Past Medical History: - Diabetes Mellitus: insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. - Gastroparesis - on domperidone, s/p Botox injections - Bipolar Disorder - Seizure Disorder - currently treated with Carbamazepine - EtOH Use Disorder - Right Bundle Branch Block - Asthma - Hepatitis B - Hepatitis C - Glaucoma - G3P1 Past Surgical History: - Cholecystectomy [MASKED] - Frozen shoulder [MASKED] - Uterine Polyps - Cesarean Section - Bilateral tubal ligation m Social History: [MASKED] Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. [MASKED] family history of cancer. Physical Exam: Per nursing progress note [MASKED]: NEUROLOGICAL [ x] WNL Alert and oriented to person, place, and time (age and disease appropriate). No neuropathy or sensory deficits. Speech clear. No tremors or weakness. No seizure activity. Exceptions (Specify and include Interventions and Response): [MASKED] CARDIOVASCULAR/HEMATOLOGICAL Cardiac Monitoring/Telemetry: [x ] No [ ] Yes: If Yes, describe rate, rhythm: [x ]WNL Pulse rate and rhythm within normal limits. No edema. Skin warm and dry. Denies chest pain or palpitations. Exceptions (Specify and include Interventions and Response): [MASKED] RESPIRATORY [ x] WNL Lung sounds clear/equal. Respiratory rate within normal limits. Denies SOB, DOE or cough. Exceptions (Specify and include Interventions and Response): [MASKED] GASTROINTESTINAL Last Bowel Movement: [MASKED] per pt [x ] WNL Abdomen non-distended, soft and non-tender. Stools within own normal pattern and consistency. Normal/active bowel sounds. Tolerating diet as ordered. Denies nausea/vomiting. Exceptions (Specify and include Interventions and Response): good appetite at breakfast pt states discussed with MD this am that she carb counts and wants to dictate her insulin doses, MD aware, see orders via [MASKED] [MASKED] GENITOURINARY [x ] WNL Voiding within own normal limits. Urine clear and yellow. Without complaints of urinary discomfort. Exceptions (Specify and include Interventions and Response): via hat [MASKED] ACTIVITY LEVEL/MUSCULOSKELETAL ADL: [ x] Independent [ ] Needs Assistance [ ] Dependent [x ] WNL Moves all extremities (age and disease appropriate). Tolerating activity level as ordered. Exceptions (Specify and include Interventions and Response): showered w supervision sl. shuffling gait due to Parkinsons., amb w supervision [MASKED] PSYCHOSOCIAL/COPING [ ] WNL Patient/family actively participates in care process. No acute signs or symptoms of depression, aggression or anxiety. Communicates needs and concerns effectively. Reacting to disease process appropriately. Exceptions (Specify and include Interventions and Response): pt appears anxious at times asks mult qu re insulin mgmnt and d/c process pt needs to call ride service and states they will not wait [MASKED] SKIN [ x]WNL Skin intact. Color within normal limits Exceptions (skin issues not documented in eFlowsheet) (Specify and include Interventions and Response): [MASKED] VTE PROPHYLAXIS MECHANICAL [x ]NA [ ]Pneumatic boots [ ]T.E.D.TM TEDs/Sequential compression sleeves removed and skin assessed: [ ]NA [ ] Yes Pertinent Results: None Brief Hospital Course: Ms. [MASKED] was admitted on [MASKED] under the general surgery service for management of her Persistent draining abdominal wound. She was taken to the operating room and underwent Wound exploration and resection and debridement of tract . Please see operative report for details of this procedure. She tolerated the procedure well and was extubated upon completion. She was subsequently taken to the PACU for recovery. She was transferred to the surgical floor hemodynamically stable. Her vital signs were routinely monitored and she remained afebrile and hemodynamically stable. She was initially given IV fluids postoperatively, which were discontinued when she was tolerating PO's. Her diet was advanced on the morning of [MASKED] to regular, which she tolerated without abdominal pain, nausea, or vomiting. She was voiding adequate amounts of urine without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which she was able to do independently. Her pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. On [MASKED] she was discharged home with scheduled follow up in general surgery clinic on [MASKED]. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. ASENapine 5 mg SL QHS 2. Aspirin 81 mg PO DAILY 3. CarBAMazepine 800 mg PO BID 4. Cetirizine 10 mg PO DAILY 5. Lactulose 15 mL PO TID 6. Lisinopril 15 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. domperidone maleate Study Med 10 mg PO QACHS 11. Librax (with clidinium) (chlordiazepoxide-clidinium) [MASKED] mg oral TID W/MEALS 12. Acetaminophen 650 mg PO QID 13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 14. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID Discharge Medications: 1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp #4 Tablet Refills:0 2. Acetaminophen 650 mg PO QID 3. ASENapine 5 mg SL QHS 4. Aspirin 81 mg PO DAILY 5. CarBAMazepine 800 mg PO BID 6. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 7. Cetirizine 10 mg PO DAILY 8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 9. domperidone maleate Study Med 10 mg PO QACHS 10. Lactulose 15 mL PO TID 11. Librax (with clidinium) (chlordiazepoxide-clidinium) [MASKED] mg oral TID W/MEALS 12. Lisinopril 15 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 40 mg PO DAILY 15. Simvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: surgical site granuloma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [MASKED], You were admitted to [MASKED] and underwent wound exploration and resection of granuloma. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips [MASKED] days after surgery. Followup Instructions: [MASKED]	[]	[ "Z794", "F419", "Z87891", "Z8673" ]	[ "T8189XA: Other complications of procedures, not elsewhere classified, initial encounter", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "G20: Parkinson's disease", "F319: Bipolar disorder, unspecified", "Z794: Long term (current) use of insulin", "K3184: Gastroparesis", "F419: Anxiety disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z8619: Personal history of other infectious and parasitic diseases", "Z833: Family history of diabetes mellitus", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z85828: Personal history of other malignant neoplasm of skin" ]
19,973,404	29,788,438	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: EGD with botox injections History of Present Illness: ======================================================= MEDICINE NIGHTFLOAT ADMISISON NOTE Date of admission: ___ ======================================================= ___. CC:nausea/vomiting and epigastric pain HISTORY OF PRESENT ILLNESS: ___ year old woman with a history of type I diabetes c/b gastroparesis/nephropathy/retinopathy, bipolar, who presents with vomiting and nausea and abdominal pain Ms ___ reports that this morning she awoke with ___ abdominal pain that was associated with non-bloody, mildly bilious vomiting. She reports that her symptoms were exactly the same as her previous gastroparesis episodes. Her last flare was one year ago and required hospitalization for IV pain meds and anti-emetics. In the ED, initial vs were: 18:45 10 97.6 101 151/84 20 99% RA Exam notable for: pt awake and alert, speaking in full clear sentences, pleasant and cooperative, abd was soft tender throughout, +bs. Labs were remarkable for: UA with 1000 glucose, Chem panel with glucose of 300 and white blood cell count of 12.4. Patient was given: 1000ml NS, reglan, Ativan, dilaudid with improvement of symptoms. She is admitted for further pain and nausea control. Vitals on transfer were: sleeping 98.2 101 127/64 18 97% RA On arrival to the floor, she is feeling much better and abdominal pain is now ___. Nausea is improving and she would like to try drinking gingerale. She has a history of gastroparesis and says this feels "exactly the same". Denies fever, chills, sweats, HA, rhinnorhea, cough, melena, BRBPR, CP, SOB. Endorses recent episode of hyperglycemia. She reports that she has obtained good control of her gastroparesis with Domperidone 10 mg PO QID, which she has to obtain in ___ and which is not FDA approved in the ___. She reports that she has difficulty with the expense and has recently cut back on how often she takes it over the past week. She is concerned that it was decreasing this med that lead to this flare. Review of sytems: (+) Per HPI PAST MEDICAL HISTORY: 1) Ventriculomegaly, not felt to have increased ICP 2) Bipolar Disorder 3) Diabetes Type I followed at ___ with retinopathy, nephropathy/proteinuria, and gastroparesis 4) Glaucoma 5) Hepatitis B per notes 6) S/p cholecystectomy ___ 7) S/p uterine polyp removal ___ and uterine laser MEDICATIONS AT HOME: The Preadmission Medication list is accurate and complete 1. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID 2. Carbamazepine 800 mg PO BID 3. Domperidone 10 mg PO QID 4. Lisinopril 10 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 7. Glargine 18 Units Bedtime 8. QUEtiapine Fumarate 200 mg PO BID 9. Fexofenadine 180 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Vitamin D 1000 UNIT PO DAILY ALLERGIES: NKDA SOCIAL HISTORY: ___ FAMILY HISTORY: She has a family history significant for asthma in her father. Her father is also a type-2 diabetic and has cardiac disease. She has a sister who is a type 2 diabetic and is schizophrenic and died of a heart attack in ___. PHYSICAL EXAM: Vitals: 97.9 121/54 107 18 97RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally CV: Regular rate, normal rhythm, normal S1S2. Has II/VI crescendo SEM at LUSB and holosytolic murmur at apex. Abdomen: soft, mild tenderness over epigastric region, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes appreciated Neuro: CN ___ grossly intact, ___ strength in all extremities, no peripheral sensory deficits. ACCESS: #20 ___ LABS: ========================= 137 97 11 ---------------< 305 AGap=24 4.2 20 0.6 Ca: 9.7 Mg: 1.7 P: 4.1 94 12.4 \ 12.7 / 223 / 36.9 \ N:92.8 L:4.1 M:2.3 E:0.1 Bas:0.3 ___: 0.4 MICRO:None pending STUDIES: ============================ + EGD (___): Normal mucosa in the whole esophagus Normal mucosa in the whole stomach (injection) Normal mucosa in the whole duodenum Otherwise normal EGD to third part of the duodenum ASSESSMENT AND PLAN: ___ year old woman with a history of type I diabetes c/b gastroparesis, nephropathy, retinopathy, bipolar, cholecystectomy, C-section who presents with vomiting and nausea and abdominal pain. #Gastroparesis: Current nausea and epigastic pain most likely secondary to gastroparesis given history of recurrent gastroparesis. Pt notes this feels exactly like similar episodes and she has been diagnosed in past by gastric emptying study. Pancreatitis or liver pathology less likely given negative in past but will check - check LFTs, lipase - Zofran, Ativan, Hydromorphone overnight - Sips with plan to ADAT a clear diet - Consider GI consult in AM - In AM, attending will need to write note in chart authorizing use of domperidone. # Mild Leukocytosis: Patient with WBC of 12.4. Suspect this is stress reaction for recurrent vomiting. She denies fevers, chills, dysuria or cough. - continue to monitor. CHRONIC ISSUES: ==================== # DM Type 1: Patient is very well educated regarding management and current dosing. Humalog sliding scale calorie based. - Continue with 18U qhs lantus and Humalog sliding scale # Nephropathy: Continue lisinopril # Bipolar: stable. Not currently promoting any manic or depressed mood. Continue with seroquel. # Hepatitis B: continue tenofovir. CORE MEASURES: ==================== # FEN: No IVF, replete electrolytes, regular diet # PPX: Subcutaneous heparin, senna/colace, pain meds # ACCESS: peripherals # CODE: Full # CONTACT: Husband ___ # DISPO: CC7, pending above Past Medical History: BIPOLAR DISORDER DIABETES MELLITUS - insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. GLAUCOMA RIGHT BUNDLE BRANCH BLOCK SEIZURE DISORDER - currently treated with Carbamazepine to which Pt attributes vertigo/dizziness, self-changed evening dose to 800mg from 1000mg yesterday (___) ALCOHOL ABUSE ASTHMA HEPATITIS B HEP C GASTROPARESIS - on domperidone, s/p Botox injection in ___ . Past Surgical History: CHOLECYSTECTOMY ___ FROZEN SHOULDER ___ UTERINE POLYPS PRIOR CESAREAN SECTION G3P1 BILATERAL TUBAL LIGATION Social History: ___ Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. ___ family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.9 121/54 107 18 97RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally CV: Regular rate, normal rhythm, normal S1S2. Has II/VI crescendo SEM at LUSB and holosytolic murmur at apex. Abdomen: soft, mild tenderness over epigastric region, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes appreciated Neuro: CN ___ grossly intact, ___ strength in all extremities, no peripheral sensory deficits. DISCHARGE PHYSICAL EXAM: Vitals: afebrile, BP baseline here in 130's/70's (currently 111/65)HR: , 100% RA General: Alert, oriented, in no acute distress HEENT: mmm, no vertical nystagmus noted. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rhythm, normal S1 + S2, no murmurs noted. Abdomen: soft, non-distended, tender in RLQ, no rebound Ext: Warm, well perfused Skin: No rash. Neuro: moving all extremities, distal sensation intact. Pertinent Results: ADMISSION LABS: ___ 08:51PM WBC-12.4# RBC-3.93 HGB-12.7 HCT-36.9 MCV-94 MCH-32.3 MCHC-34.4 RDW-11.9 RDWSD-41.1 ___ 08:51PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.3* EOS-0.1* BASOS-0.3 IM ___ AbsNeut-11.47# AbsLymp-0.51 AbsMono-0.29 AbsEos-0.01* AbsBaso-0.04 ___ 08:51PM GLUCOSE-305* UREA N-11 CREAT-0.6 SODIUM-137 POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-20* ANION GAP-24* ___ 08:51PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-75 TOT BILI-0.4 ___ 08:51PM LIPASE-18 ___ 08:51PM CALCIUM-9.7 PHOSPHATE-4.1 MAGNESIUM-1.7 ___ 08:56PM URINE MUCOUS-RARE ___ 08:56PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-1 ___ 08:56PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 08:56PM URINE COLOR-Straw APPEAR-Clear SP ___ DISCHARGE LABS: ___ 05:49AM BLOOD WBC-5.5 RBC-3.52* Hgb-11.2 Hct-34.8 MCV-99* MCH-31.8 MCHC-32.2 RDW-12.4 RDWSD-44.4 Plt ___ ___ 05:49AM BLOOD Plt ___ ___ 05:49AM BLOOD Glucose-142* UreaN-3* Creat-0.5 Na-135 K-4.0 Cl-98 HCO3-23 AnGap-18 ___ 05:49AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7 ___ 06:29AM BLOOD VitB12-1559* PERTINENT IMAGING: ___ ABDOMEN XR (SUPINE ONLY): Nonobstructive bowel gas pattern. ___ CTA HEAD W&W/O C & RECONS: final read pending, study sent for possible stroke and was unrevealing. ___ MR HEAD W/O CONTRAST: There is no acute infarct or intracranial hemorrhage. ___ TTE: The left atrium is normal in size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. 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. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. ___ CT HEAD W/O CONTRAST: No evidence of acute intracranial hemorrhage or large vascular territorial infarction. Brief Hospital Course: Ms. ___ is a ___ year old woman with a history of type I diabetes c/b gastroparesis, nephropathy, retinopathy, bipolar, cholecystectomy, C-section who presents with vomiting and nausea and abdominal pain. Vomiting, nausea and abdominal pain occured in the setting of trying to cut back on domiperidone dose from QID to BID due to cost of medication. Patient had no signs of infection and her lipase was normal. Domiperidone was restarted and patient was advanced to regular diabetic diet. Patient continued to have nausea and vomiting which was felt in part to be due to her elevated blood sugars. ___ was consulted who titrated her inpatient insulin regimen with subsequent improvement in her blood sugars. By the time of discharge, patient noted resolution of her nausea, vomiting, and abdominal pain and was tolerating po intake well. Since the patient reported having an insufficient amount of domperidone available before the arrival of her next shipment of domperidone from ___, she was prescribed Ativan to take in the meantime. She had an EGD with botox injection which she tolerated well with improvement of symptoms. Patient was noted to develop new vertical nystagmus during her hospital stay. A code stroke was called, however no evidence of stroke was noted on CT/CTA/MRI and TTE was performed demonstrating no defects including PFO. Neurology was consulted but ultimately etiology of nystagmus remained unclear and nystagmus improved by day of discharge. ACTIVE ISSUES ============= #Gastroparesis: Thought to be triggered by patient attempting to decrease domperidone dose frequency to save on cost. Domperidone restarted at old regimen. However, patient initially with persistent nausea and vomiting despite restarting domiperidone that was thought to be related to concomitant poor blood sugar control. S/p EGD with botox injections in pylorus. She was seen by nutrition with recommendations for a gastroparesis diet and she ultimately able to tolerate small meals and liquids. She discharged with Ativan for nausea and an anxiety component of her gastroparesis with instructions to take the Ativan 30 minutes prior to meals. #Vertical Nystagmus: Code stroke called ___ in absence of other symptoms with negative imaging for posterior stroke (CT/CTA/MRI), TTE also neg for PFO. Neurology re-consulted given acute change of nystagmus with vertigo and gait instability c/f central process. Per Neuro, vertical nystagmus similiar from prior assessment. Unlikely pontine stroke or seziure. Consider carbamazepime toxicity; nystagmus worsened by low magnesium. Repeat CTH negative. She was treated with Meclizine and magnesium repleted with improvement in her symptoms and was set-up with follow-up with Neurology. # DM Type 1: Managed per ___ recommendations, discharged on her home 18 units of Lantus. CHRONIC ISSUES: ==================== # Nephropathy: Lisinopril 10 mg PO/NG DAILY # Bipolar: stable. Not currently promoting any manic or depressed mood. Restarted on Lithium Carbonate 900 mg PO QHS per her home medications. Continued with QUEtiapine Fumarate 200 mg PO/NG BID, CarBAMazepine 800 mg PO/NG BID # Hepatitis B: continued tenofovir. # Hyperlipidemia: held Simvastatin 40 mg PO/NG DAILY while inpatient, restarted as outpatient. # GERD: Fexofenadine 180 mg PO DAILY Transitional Issues: ===================== #) Magnesium: Patient started on oral magnesium due to low Mg and because she is on multiple QTc prolonging medications. Please follow up and titrate as clinically warranted. #) QTc: Patient on multiple QTc prolonging medications including domperidone and quetiapine. Please repeat EKG at next appointment and repeat as clinically warranted. #) Domiperidone: Patient tried to cut back due to cost. Planning to go back to QID dosing. Consider trialing taper to TID if clinically warranted to help with cost. At time of discharge, patient reported having insufficient amount of domperidone to make it until arrival of next shipment. Consequently was discharged on Zofran and advised to change back to domperidone once the next shipment arrived. #) Type 1 DM: Reports difficulty controlling BS due to gastroparesis and resultant difficulty in predicing required insulin dose. Reports hypoglycemia at home to ___ and hyperglycemia to 200s. Please follow up. # Diabetes: She should follow up in ___ as well. To schedule please contact (___) and/or ask for ___ or leave a voice message for her. #) Nystagmus: Worked up by neurology with no evidence of stroke. Follow up in neurology outpatient clinic if this persists and is symptomatic. #) Code status: Full #) CONTACT: ___ (Husband) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID 2. Carbamazepine 800 mg PO BID 3. Domperidone 10 mg PO QID 4. Lisinopril 10 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 7. Glargine 18 Units Bedtime 8. QUEtiapine Fumarate 200 mg PO BID 9. Fexofenadine 180 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Vitamin D 1000 UNIT PO DAILY 12. Lithium Carbonate 900 mg PO QHS 13. Psyllium Powder 1 PKT PO TID:PRN constipation Discharge Medications: 1. Carbamazepine 800 mg PO BID 2. Domperidone 10 mg PO QID 3. Fexofenadine 180 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. QUEtiapine Fumarate 200 mg PO BID 7. Simvastatin 40 mg PO DAILY 8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Magnesium Oxide 400 mg PO DAILY RX magnesium oxide 400 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 11. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID 12. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 13. Lithium Carbonate 900 mg PO QHS 14. Psyllium Powder 1 PKT PO TID:PRN constipation 15. Glargine 18 Units Bedtime 16. Meclizine 12.5 mg PO Q6H:PRN vertigo RX meclizine 12.5 mg 1 tablet(s) by mouth every six (6) hours Disp #45 Tablet Refills:0 17. Lorazepam 0.5 mg PO QAC RX lorazepam 0.5 mg 1 tablet(s) by mouth before meals Disp #21 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: ================== 1. Gastroparesis 2. Type 1 Diabetes Mellitus 3. Nystagmus Secondary diagnoses: ===================== 1. Nephropathy 2. Bipolar disorder 3. Hepatitis B 4. Hyperlipidemia 5. Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was our pleasure caring for you during your admission to ___ ___. You were admitted due to nausea/vomiting and epigastric pain. This was felt to be due to your gastroparesis. We restarted your domiperidone at its prescribed dose of four times per a day. Unfortunately, you continued to have nausea and vomiting on this regimen. This was thought to be due to your high blood sugars. We changed your insulin regimen while you were in the hospital and your blood sugars then improved. You also saw your gastroenterologist and you had a procedure to inject botox into your stomach. You also had developed some eye movements while you were in the hospital that were concerning for a stroke. The neurology team evaluated you and performed a number of imaging tests that did not show any evidence of a stroke. It is unclear what caused these eye movements. Please follow up with neurology for continued management. You may take meclizine for your symptoms of vertigo. You should continue your domiperidone at your prescribed dose of four times a day. You stated that you did not have a sufficient quantity of domperidone to take until you received your next shipment. Thus, we have prescribed you some Ativan to take in the meantime. You should restart your dopmeridone at your usual dose once you get more domperidone. You should follow up with your GI doctor, a neurologist and your PCP. You should follow up with ___ clinic. You should follow up with Neurology if your eye symptoms continue. We wish you a speedy recovery! - Your ___ Care Team Followup Instructions: ___	[ "E1043", "E873", "E1021", "B1910", "E871", "E1065", "K3184", "E10319", "H5509", "F319", "Z87891", "T450X6A", "E860", "F419", "Z23", "Z91120", "Y92009", "R42", "G40909", "D72829", "K5900", "E8342", "K219" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: EGD with botox injections History of Present Illness: ======================================================= MEDICINE NIGHTFLOAT ADMISISON NOTE Date of admission: [MASKED] ======================================================= [MASKED]. CC:nausea/vomiting and epigastric pain HISTORY OF PRESENT ILLNESS: [MASKED] year old woman with a history of type I diabetes c/b gastroparesis/nephropathy/retinopathy, bipolar, who presents with vomiting and nausea and abdominal pain Ms [MASKED] reports that this morning she awoke with [MASKED] abdominal pain that was associated with non-bloody, mildly bilious vomiting. She reports that her symptoms were exactly the same as her previous gastroparesis episodes. Her last flare was one year ago and required hospitalization for IV pain meds and anti-emetics. In the ED, initial vs were: 18:45 10 97.6 101 151/84 20 99% RA Exam notable for: pt awake and alert, speaking in full clear sentences, pleasant and cooperative, abd was soft tender throughout, +bs. Labs were remarkable for: UA with 1000 glucose, Chem panel with glucose of 300 and white blood cell count of 12.4. Patient was given: 1000ml NS, reglan, Ativan, dilaudid with improvement of symptoms. She is admitted for further pain and nausea control. Vitals on transfer were: sleeping 98.2 101 127/64 18 97% RA On arrival to the floor, she is feeling much better and abdominal pain is now [MASKED]. Nausea is improving and she would like to try drinking gingerale. She has a history of gastroparesis and says this feels "exactly the same". Denies fever, chills, sweats, HA, rhinnorhea, cough, melena, BRBPR, CP, SOB. Endorses recent episode of hyperglycemia. She reports that she has obtained good control of her gastroparesis with Domperidone 10 mg PO QID, which she has to obtain in [MASKED] and which is not FDA approved in the [MASKED]. She reports that she has difficulty with the expense and has recently cut back on how often she takes it over the past week. She is concerned that it was decreasing this med that lead to this flare. Review of sytems: (+) Per HPI PAST MEDICAL HISTORY: 1) Ventriculomegaly, not felt to have increased ICP 2) Bipolar Disorder 3) Diabetes Type I followed at [MASKED] with retinopathy, nephropathy/proteinuria, and gastroparesis 4) Glaucoma 5) Hepatitis B per notes 6) S/p cholecystectomy [MASKED] 7) S/p uterine polyp removal [MASKED] and uterine laser MEDICATIONS AT HOME: The Preadmission Medication list is accurate and complete 1. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID 2. Carbamazepine 800 mg PO BID 3. Domperidone 10 mg PO QID 4. Lisinopril 10 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 7. Glargine 18 Units Bedtime 8. QUEtiapine Fumarate 200 mg PO BID 9. Fexofenadine 180 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Vitamin D 1000 UNIT PO DAILY ALLERGIES: NKDA SOCIAL HISTORY: [MASKED] FAMILY HISTORY: She has a family history significant for asthma in her father. Her father is also a type-2 diabetic and has cardiac disease. She has a sister who is a type 2 diabetic and is schizophrenic and died of a heart attack in [MASKED]. PHYSICAL EXAM: Vitals: 97.9 121/54 107 18 97RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally CV: Regular rate, normal rhythm, normal S1S2. Has II/VI crescendo SEM at LUSB and holosytolic murmur at apex. Abdomen: soft, mild tenderness over epigastric region, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes appreciated Neuro: CN [MASKED] grossly intact, [MASKED] strength in all extremities, no peripheral sensory deficits. ACCESS: #20 [MASKED] LABS: ========================= 137 97 11 ---------------< 305 AGap=24 4.2 20 0.6 Ca: 9.7 Mg: 1.7 P: 4.1 94 12.4 \ 12.7 / 223 / 36.9 \ N:92.8 L:4.1 M:2.3 E:0.1 Bas:0.3 [MASKED]: 0.4 MICRO:None pending STUDIES: ============================ + EGD ([MASKED]): Normal mucosa in the whole esophagus Normal mucosa in the whole stomach (injection) Normal mucosa in the whole duodenum Otherwise normal EGD to third part of the duodenum ASSESSMENT AND PLAN: [MASKED] year old woman with a history of type I diabetes c/b gastroparesis, nephropathy, retinopathy, bipolar, cholecystectomy, C-section who presents with vomiting and nausea and abdominal pain. #Gastroparesis: Current nausea and epigastic pain most likely secondary to gastroparesis given history of recurrent gastroparesis. Pt notes this feels exactly like similar episodes and she has been diagnosed in past by gastric emptying study. Pancreatitis or liver pathology less likely given negative in past but will check - check LFTs, lipase - Zofran, Ativan, Hydromorphone overnight - Sips with plan to ADAT a clear diet - Consider GI consult in AM - In AM, attending will need to write note in chart authorizing use of domperidone. # Mild Leukocytosis: Patient with WBC of 12.4. Suspect this is stress reaction for recurrent vomiting. She denies fevers, chills, dysuria or cough. - continue to monitor. CHRONIC ISSUES: ==================== # DM Type 1: Patient is very well educated regarding management and current dosing. Humalog sliding scale calorie based. - Continue with 18U qhs lantus and Humalog sliding scale # Nephropathy: Continue lisinopril # Bipolar: stable. Not currently promoting any manic or depressed mood. Continue with seroquel. # Hepatitis B: continue tenofovir. CORE MEASURES: ==================== # FEN: No IVF, replete electrolytes, regular diet # PPX: Subcutaneous heparin, senna/colace, pain meds # ACCESS: peripherals # CODE: Full # CONTACT: Husband [MASKED] # DISPO: CC7, pending above Past Medical History: BIPOLAR DISORDER DIABETES MELLITUS - insulin dependent. Pt reports proteinuria, nephropathy, and retinopathy in addition to gastroparesis. GLAUCOMA RIGHT BUNDLE BRANCH BLOCK SEIZURE DISORDER - currently treated with Carbamazepine to which Pt attributes vertigo/dizziness, self-changed evening dose to 800mg from 1000mg yesterday ([MASKED]) ALCOHOL ABUSE ASTHMA HEPATITIS B HEP C GASTROPARESIS - on domperidone, s/p Botox injection in [MASKED] . Past Surgical History: CHOLECYSTECTOMY [MASKED] FROZEN SHOULDER [MASKED] UTERINE POLYPS PRIOR CESAREAN SECTION G3P1 BILATERAL TUBAL LIGATION Social History: [MASKED] Family History: Extensive family history of Diabetes Mellitus with both parents still living. Heart disease in father. [MASKED] family history of cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.9 121/54 107 18 97RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally CV: Regular rate, normal rhythm, normal S1S2. Has II/VI crescendo SEM at LUSB and holosytolic murmur at apex. Abdomen: soft, mild tenderness over epigastric region, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes appreciated Neuro: CN [MASKED] grossly intact, [MASKED] strength in all extremities, no peripheral sensory deficits. DISCHARGE PHYSICAL EXAM: Vitals: afebrile, BP baseline here in 130's/70's (currently 111/65)HR: , 100% RA General: Alert, oriented, in no acute distress HEENT: mmm, no vertical nystagmus noted. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rhythm, normal S1 + S2, no murmurs noted. Abdomen: soft, non-distended, tender in RLQ, no rebound Ext: Warm, well perfused Skin: No rash. Neuro: moving all extremities, distal sensation intact. Pertinent Results: ADMISSION LABS: [MASKED] 08:51PM WBC-12.4# RBC-3.93 HGB-12.7 HCT-36.9 MCV-94 MCH-32.3 MCHC-34.4 RDW-11.9 RDWSD-41.1 [MASKED] 08:51PM NEUTS-92.8* LYMPHS-4.1* MONOS-2.3* EOS-0.1* BASOS-0.3 IM [MASKED] AbsNeut-11.47# AbsLymp-0.51 AbsMono-0.29 AbsEos-0.01* AbsBaso-0.04 [MASKED] 08:51PM GLUCOSE-305* UREA N-11 CREAT-0.6 SODIUM-137 POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-20* ANION GAP-24* [MASKED] 08:51PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-75 TOT BILI-0.4 [MASKED] 08:51PM LIPASE-18 [MASKED] 08:51PM CALCIUM-9.7 PHOSPHATE-4.1 MAGNESIUM-1.7 [MASKED] 08:56PM URINE MUCOUS-RARE [MASKED] 08:56PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-1 [MASKED] 08:56PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [MASKED] 08:56PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] DISCHARGE LABS: [MASKED] 05:49AM BLOOD WBC-5.5 RBC-3.52* Hgb-11.2 Hct-34.8 MCV-99* MCH-31.8 MCHC-32.2 RDW-12.4 RDWSD-44.4 Plt [MASKED] [MASKED] 05:49AM BLOOD Plt [MASKED] [MASKED] 05:49AM BLOOD Glucose-142* UreaN-3* Creat-0.5 Na-135 K-4.0 Cl-98 HCO3-23 AnGap-18 [MASKED] 05:49AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7 [MASKED] 06:29AM BLOOD VitB12-1559* PERTINENT IMAGING: [MASKED] ABDOMEN XR (SUPINE ONLY): Nonobstructive bowel gas pattern. [MASKED] CTA HEAD W&W/O C & RECONS: final read pending, study sent for possible stroke and was unrevealing. [MASKED] MR HEAD W/O CONTRAST: There is no acute infarct or intracranial hemorrhage. [MASKED] TTE: The left atrium is normal in size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is [MASKED] mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. 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. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. [MASKED] CT HEAD W/O CONTRAST: No evidence of acute intracranial hemorrhage or large vascular territorial infarction. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman with a history of type I diabetes c/b gastroparesis, nephropathy, retinopathy, bipolar, cholecystectomy, C-section who presents with vomiting and nausea and abdominal pain. Vomiting, nausea and abdominal pain occured in the setting of trying to cut back on domiperidone dose from QID to BID due to cost of medication. Patient had no signs of infection and her lipase was normal. Domiperidone was restarted and patient was advanced to regular diabetic diet. Patient continued to have nausea and vomiting which was felt in part to be due to her elevated blood sugars. [MASKED] was consulted who titrated her inpatient insulin regimen with subsequent improvement in her blood sugars. By the time of discharge, patient noted resolution of her nausea, vomiting, and abdominal pain and was tolerating po intake well. Since the patient reported having an insufficient amount of domperidone available before the arrival of her next shipment of domperidone from [MASKED], she was prescribed Ativan to take in the meantime. She had an EGD with botox injection which she tolerated well with improvement of symptoms. Patient was noted to develop new vertical nystagmus during her hospital stay. A code stroke was called, however no evidence of stroke was noted on CT/CTA/MRI and TTE was performed demonstrating no defects including PFO. Neurology was consulted but ultimately etiology of nystagmus remained unclear and nystagmus improved by day of discharge. ACTIVE ISSUES ============= #Gastroparesis: Thought to be triggered by patient attempting to decrease domperidone dose frequency to save on cost. Domperidone restarted at old regimen. However, patient initially with persistent nausea and vomiting despite restarting domiperidone that was thought to be related to concomitant poor blood sugar control. S/p EGD with botox injections in pylorus. She was seen by nutrition with recommendations for a gastroparesis diet and she ultimately able to tolerate small meals and liquids. She discharged with Ativan for nausea and an anxiety component of her gastroparesis with instructions to take the Ativan 30 minutes prior to meals. #Vertical Nystagmus: Code stroke called [MASKED] in absence of other symptoms with negative imaging for posterior stroke (CT/CTA/MRI), TTE also neg for PFO. Neurology re-consulted given acute change of nystagmus with vertigo and gait instability c/f central process. Per Neuro, vertical nystagmus similiar from prior assessment. Unlikely pontine stroke or seziure. Consider carbamazepime toxicity; nystagmus worsened by low magnesium. Repeat CTH negative. She was treated with Meclizine and magnesium repleted with improvement in her symptoms and was set-up with follow-up with Neurology. # DM Type 1: Managed per [MASKED] recommendations, discharged on her home 18 units of Lantus. CHRONIC ISSUES: ==================== # Nephropathy: Lisinopril 10 mg PO/NG DAILY # Bipolar: stable. Not currently promoting any manic or depressed mood. Restarted on Lithium Carbonate 900 mg PO QHS per her home medications. Continued with QUEtiapine Fumarate 200 mg PO/NG BID, CarBAMazepine 800 mg PO/NG BID # Hepatitis B: continued tenofovir. # Hyperlipidemia: held Simvastatin 40 mg PO/NG DAILY while inpatient, restarted as outpatient. # GERD: Fexofenadine 180 mg PO DAILY Transitional Issues: ===================== #) Magnesium: Patient started on oral magnesium due to low Mg and because she is on multiple QTc prolonging medications. Please follow up and titrate as clinically warranted. #) QTc: Patient on multiple QTc prolonging medications including domperidone and quetiapine. Please repeat EKG at next appointment and repeat as clinically warranted. #) Domiperidone: Patient tried to cut back due to cost. Planning to go back to QID dosing. Consider trialing taper to TID if clinically warranted to help with cost. At time of discharge, patient reported having insufficient amount of domperidone to make it until arrival of next shipment. Consequently was discharged on Zofran and advised to change back to domperidone once the next shipment arrived. #) Type 1 DM: Reports difficulty controlling BS due to gastroparesis and resultant difficulty in predicing required insulin dose. Reports hypoglycemia at home to [MASKED] and hyperglycemia to 200s. Please follow up. # Diabetes: She should follow up in [MASKED] as well. To schedule please contact ([MASKED]) and/or ask for [MASKED] or leave a voice message for her. #) Nystagmus: Worked up by neurology with no evidence of stroke. Follow up in neurology outpatient clinic if this persists and is symptomatic. #) Code status: Full #) CONTACT: [MASKED] (Husband) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID 2. Carbamazepine 800 mg PO BID 3. Domperidone 10 mg PO QID 4. Lisinopril 10 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 7. Glargine 18 Units Bedtime 8. QUEtiapine Fumarate 200 mg PO BID 9. Fexofenadine 180 mg PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Vitamin D 1000 UNIT PO DAILY 12. Lithium Carbonate 900 mg PO QHS 13. Psyllium Powder 1 PKT PO TID:PRN constipation Discharge Medications: 1. Carbamazepine 800 mg PO BID 2. Domperidone 10 mg PO QID 3. Fexofenadine 180 mg PO DAILY 4. Lisinopril 10 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. QUEtiapine Fumarate 200 mg PO BID 7. Simvastatin 40 mg PO DAILY 8. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Magnesium Oxide 400 mg PO DAILY RX magnesium oxide 400 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 11. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QID 12. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 13. Lithium Carbonate 900 mg PO QHS 14. Psyllium Powder 1 PKT PO TID:PRN constipation 15. Glargine 18 Units Bedtime 16. Meclizine 12.5 mg PO Q6H:PRN vertigo RX meclizine 12.5 mg 1 tablet(s) by mouth every six (6) hours Disp #45 Tablet Refills:0 17. Lorazepam 0.5 mg PO QAC RX lorazepam 0.5 mg 1 tablet(s) by mouth before meals Disp #21 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: ================== 1. Gastroparesis 2. Type 1 Diabetes Mellitus 3. Nystagmus Secondary diagnoses: ===================== 1. Nephropathy 2. Bipolar disorder 3. Hepatitis B 4. Hyperlipidemia 5. Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], It was our pleasure caring for you during your admission to [MASKED] [MASKED]. You were admitted due to nausea/vomiting and epigastric pain. This was felt to be due to your gastroparesis. We restarted your domiperidone at its prescribed dose of four times per a day. Unfortunately, you continued to have nausea and vomiting on this regimen. This was thought to be due to your high blood sugars. We changed your insulin regimen while you were in the hospital and your blood sugars then improved. You also saw your gastroenterologist and you had a procedure to inject botox into your stomach. You also had developed some eye movements while you were in the hospital that were concerning for a stroke. The neurology team evaluated you and performed a number of imaging tests that did not show any evidence of a stroke. It is unclear what caused these eye movements. Please follow up with neurology for continued management. You may take meclizine for your symptoms of vertigo. You should continue your domiperidone at your prescribed dose of four times a day. You stated that you did not have a sufficient quantity of domperidone to take until you received your next shipment. Thus, we have prescribed you some Ativan to take in the meantime. You should restart your dopmeridone at your usual dose once you get more domperidone. You should follow up with your GI doctor, a neurologist and your PCP. You should follow up with [MASKED] clinic. You should follow up with Neurology if your eye symptoms continue. We wish you a speedy recovery! - Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "E871", "Z87891", "F419", "K5900", "K219" ]	[ "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "E873: Alkalosis", "E1021: Type 1 diabetes mellitus with diabetic nephropathy", "B1910: Unspecified viral hepatitis B without hepatic coma", "E871: Hypo-osmolality and hyponatremia", "E1065: Type 1 diabetes mellitus with hyperglycemia", "K3184: Gastroparesis", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "H5509: Other forms of nystagmus", "F319: Bipolar disorder, unspecified", "Z87891: Personal history of nicotine dependence", "T450X6A: Underdosing of antiallergic and antiemetic drugs, initial encounter", "E860: Dehydration", "F419: Anxiety disorder, unspecified", "Z23: Encounter for immunization", "Z91120: Patient's intentional underdosing of medication regimen due to financial hardship", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R42: Dizziness and giddiness", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "D72829: Elevated white blood cell count, unspecified", "K5900: Constipation, unspecified", "E8342: Hypomagnesemia", "K219: Gastro-esophageal reflux disease without esophagitis" ]
19,973,580	25,153,072	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ / ___ Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female, recently admitted for multifocal pneumonia, who presents with cough and dyspnea. The patient was discharged 2 weeks ago with a diagnosis of pneumonia. Since then, she has had a persistent cough which became productive 2 days ago. She is also having increasing shortness of breath. She went to her PCP ___ ___ for evaluation, and there she required nasal oxygen. A family member, who is a pediatric ___, also noted increased wheezing. When attempting to get to her car from her doctor's office, she became lightheaded due to her shortness of breath. Otherwise, the patient denies any subjective fevers, hemoptysis, chest pain, abdominal pain, history of blood clots, or leg swelling. ___ the ED: - VITALS INITIAL: T 97.8 HR 88 BP 188/100 RR 20 SaO2 98% NC - EXAM: inspiratory and expiratory wheezes - LABS: - Chem10: Glu 124, otherwise WNL - CBC: WBC ___ (73.7% PMN) - Cardiac: Trop-T 0.11, CK 93, MB 4, proBNP 168 - Lactate: 2.7 - FluA/B PCR: Negative - BCx x1: PENDING - STUDIES: - CXR: no evidence of pneumonia, consistent with COPD - EKG: normal sinus rhythm with no ST changes - Peak flow: 150 - PATIENT GIVEN: - Albuterol/Ipratropium DuoNeb x2 - Prednisone PO 60mg x1 - ASA PO 324mg x1 - Azithromycin 500mg PO x1 - Heparin IV 4000 unit bolus + 800 units/hour started at 18:44 - VITALS ON TRANSFER: T 98.1 HR 84 BP 140/67 RR 17 SaO2 97% RA Upon arrival to the floor, patient reports wheezing and stable cough but no chest pain. Past Medical History: BREAST CANCER DEPRESSION BENIGN POSITIONAL VERTIGO KNEE PAIN OSTEOARTHRITIS TKR ___ Lumpectomy TAH/BSO Social History: ___ Family History: No family history of lung disease. Mother deceased at ___ (melanoma). Father deceased at ___ (___). Physical Exam: ADMISSION PHYSICAL EXAM ================= Vital Signs: T 97.7 HR 114 BP 162/90 RR 20 General: Alert, oriented, no acute distress. Coughing. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2 with soft systolic flow murmur. Lungs: Diffuse rhonchi, coarse inspiratory crackles especially at bases. Scattered expiratory wheezes. Abdomen: Obsese. Soft, non-tender. bowel sounds present. GU: No foley Ext: Warm, well perfused. 2+ DP pulses. Somewhat swollen-appearing with trace edema. Neuro: CNII-XII intact, ___ strength upper/lower extremities. Gait deferred. DISCHARGE PHYSICAL EXAM ================= VS: 98.6 166/70 75 21 94%RA General: Alert, oriented, no acute distress. Coughing occasionally HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2 with soft systolic flow murmur. Lungs: Bilateral expiratory wheezes, few ronchi. Abdomen: Obese. Soft, non-tender. bowel sounds present. Ext: Warm, well perfused. 2+ DP pulses. Mild trace edema, per patient baseline Neuro: CNII-XII intact, ___ strength upper/lower extremities. Gait deferred. Pertinent Results: ADMISSION LABS ========== ___ 02:20PM BLOOD WBC-13.4* RBC-4.62 Hgb-12.9 Hct-40.4 MCV-87 MCH-27.9# MCHC-31.9# RDW-15.1 RDWSD-47.2 Plt ___ ___ 02:20PM BLOOD Neuts-73.7* Lymphs-14.4* Monos-8.4 Eos-2.5 Baso-0.4 Im ___ AbsNeut-9.86# AbsLymp-1.93 AbsMono-1.13 AbsEos-0.33 AbsBaso-0.05 ___ 02:20PM BLOOD Glucose-124* UreaN-13 Creat-0.6 Na-141 K-3.7 Cl-100 HCO3-27 AnGap-18 ___ 02:20PM BLOOD CK(CPK)-93 ___ 02:20PM BLOOD CK-MB-4 proBNP-168 ___ 02:20PM BLOOD cTropnT-0.11* ___ 03:41PM BLOOD Lactate-2.7* NOTABLE LABS ========= ___ 06:45AM BLOOD %HbA1c-5.8 eAG-120 ___ 06:45AM BLOOD Triglyc-106 HDL-65 CHOL/HD-4.2 LDLcalc-186* ___ 06:37AM BLOOD Glucose-113* UreaN-22* Creat-0.7 Na-141 K-3.5 Cl-103 HCO3-25 AnGap-17 ___ 06:45AM BLOOD ALT-38 AST-25 CK(CPK)-104 AlkPhos-103 TotBili-0.5 ___ 02:20PM BLOOD cTropnT-0.11* ___ 01:15AM BLOOD CK-MB-6 cTropnT-0.06* ___ 06:45AM BLOOD CK-MB-7 ___ 01:55PM BLOOD CK-MB-6 cTropnT-0.02* IMAGING ====== ___ CXR Mild cardiomegaly, hilar congestion, no frank edema. Pectus excavatum likely simulates right middle lobe opacity. ___ LOWER EXTREMITY DOPPLER ULTRASOUND No evidence of deep venous thrombosis ___ the right or left lower extremity veins. ___ CTA CHEST 1. No evidence of pulmonary embolism or aortic abnormality. 2. Right base ___ opacification compatible with small airway inflammatory/infectious process. Also mild right basilar atelectasis. MICROBIOLOGY ========== ___ 04:00PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 6:44 am SPUTUM Source: Expectorated. GRAM STAIN (Final ___: <10 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. DISCHARGE LABS =========== ___ 06:37AM BLOOD WBC-10.3* RBC-4.11 Hgb-11.4 Hct-36.0 MCV-88 MCH-27.7 MCHC-31.7* RDW-15.5 RDWSD-48.0* Plt ___ ___ 06:37AM BLOOD Glucose-113* UreaN-22* Creat-0.7 Na-141 K-3.5 Cl-103 HCO3-25 AnGap-17 ___ 06:37AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.___ year old woman with recent hospitalization for multifocal pneumonia but no prior cardiopulmonary history, presenting with near-syncopal episode, cough and dyspnea found to have troponin leak with significant wheezing and CTA negative for PE. She was treated with duonebs, azithromycin, and prednisone for reactive airway disease. She was initially placed on heparin but this was stopped after troponin trended down with no evidence of EKG changes. ACTIVE ISSUES ========= #Hypoxia and wheezing likely secondary to reactive airway disease Patient with near-syncopal episode at ___ office due to significant shortness of breath, along with productive cough without fevers. Exam with wheezing. CXR without consolidations. Improved SaO2 with Duonebs ___ ED. COPD with bronchitis component is most likely given recent CAP, smoking history, productive cough without fever but she has not undergone PFT to establish COPD. She is a former smoker. She was given duonebs, albuterol nebs, and started on prednisone and azithromycin for a planned five day course from ___. CTA was performed that was negative for pulmonary embolism. Wheezing improved and hypoxia improved during her stay dramatically # Elevated troponin Patient with near-syncopal episode prior to admission. Labs with elevated troponin with normal CK-MB and EKG with normal sinus rhythm without ischemic ST-T chanes. Initial concern for atypical presentation of ACS ___ a female though likely demand ischemia ___ the setting of tachycardia. She was given atorvastatin, ASA, and heparin on admission. Troponin trended down on first day of admission and her symptoms likely better explained by COPD. Heparin and atorvastatin were stopped on first day of hospitalization. She was started on daily aspirin. Cardiac risk profile evaluated with HbA1C 5.8%. ASCVD ___ year risk calculated at 13% (non-smoker given that she quit over ___ years ago). CHRONIC ISSUES ========== #DEPRESSION: Continued home Fluoxetine 10mg daily #GERD: home Esomeprazole is NF and she was given omeprazole TRANSITIONAL ISSUES ============== #NEW MEDICATIONS - Azithromycin 250 mg daily till ___ - Prednisone 40 mg daily till ___ - Simvastatin 40 mg daily ___ the evening - Aspirin 81 mg daily #CHANGED MEDICATIONS - none #STOPPED MEDICATIONS - none [] Please ensure outpatient pulmonary follow up for pulmonary function tests to evaluate for obstructive lung disease [] Ensure cardiology follow up for consideration of exercise vs. dobutamine stress test # CODE: Full code, would not want prolonged intubation # CONTACT: ___, daughter Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 10 mg PO DAILY 2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing 3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 4. Esomeprazole Magnesium 40 mg oral DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:2 2. Azithromycin 250 mg PO Q24H Duration: 4 Doses RX azithromycin 250 mg 1 tablet(s) by mouth DAILY Disp #3 Tablet Refills:0 3. PredniSONE 40 mg PO DAILY Duration: 4 Doses RX prednisone 20 mg 2 tablet(s) by mouth daily Disp #6 Tablet Refills:0 4. Simvastatin 40 mg PO QPM RX simvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:1 5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 6. Esomeprazole Magnesium 40 mg oral DAILY 7. FLUoxetine 10 mg PO DAILY 8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing Discharge Disposition: Home Discharge Diagnosis: Primary: Obstructive pulmonary disease Secondary: Elevated troponin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ with shortness of breath. You had a lot of wheezing ___ your lungs. You were given nebulizers and steroids to help with your breathing. You were also given an antibiotic called azithromycin. You should keep taking azithromycin and prednisone until ___. Please use your combivent inhaler you have at home every 6 hours and use your albuterol inhaler as needed. A CT scan was done of your chest which did not show any blood clots ___ your lungs. We believe you have reactive airways ___ the lungs and you have lung disease. You should follow up with a pulmonary doctor to help with diagnosis and treatment for your lungs. You also had some damage to the heart. This may have been caused by your heart beating fast when you felt like you were going to pass out. Please see a cardiologist so that you can be evaluated for heart disease. You were started on a baby aspirin (for heart attack prevention) and a medication called Simvastatin (for high cholesterol). If you have any lightheadedness, difficulty breathing, wheezing, chest pain, fevers, chills, please call your doctor or return to the emergency department. It was a pleasure taking care of you. We wish you the best ___ your health. Sincerely, Your ___ Team Followup Instructions: ___	[ "J440", "I248", "K219", "F329", "J209", "J441", "Z87891", "J45909" ]	Allergies: [MASKED] / [MASKED] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] female, recently admitted for multifocal pneumonia, who presents with cough and dyspnea. The patient was discharged 2 weeks ago with a diagnosis of pneumonia. Since then, she has had a persistent cough which became productive 2 days ago. She is also having increasing shortness of breath. She went to her PCP [MASKED] [MASKED] for evaluation, and there she required nasal oxygen. A family member, who is a pediatric [MASKED], also noted increased wheezing. When attempting to get to her car from her doctor's office, she became lightheaded due to her shortness of breath. Otherwise, the patient denies any subjective fevers, hemoptysis, chest pain, abdominal pain, history of blood clots, or leg swelling. [MASKED] the ED: - VITALS INITIAL: T 97.8 HR 88 BP 188/100 RR 20 SaO2 98% NC - EXAM: inspiratory and expiratory wheezes - LABS: - Chem10: Glu 124, otherwise WNL - CBC: WBC [MASKED] (73.7% PMN) - Cardiac: Trop-T 0.11, CK 93, MB 4, proBNP 168 - Lactate: 2.7 - FluA/B PCR: Negative - BCx x1: PENDING - STUDIES: - CXR: no evidence of pneumonia, consistent with COPD - EKG: normal sinus rhythm with no ST changes - Peak flow: 150 - PATIENT GIVEN: - Albuterol/Ipratropium DuoNeb x2 - Prednisone PO 60mg x1 - ASA PO 324mg x1 - Azithromycin 500mg PO x1 - Heparin IV 4000 unit bolus + 800 units/hour started at 18:44 - VITALS ON TRANSFER: T 98.1 HR 84 BP 140/67 RR 17 SaO2 97% RA Upon arrival to the floor, patient reports wheezing and stable cough but no chest pain. Past Medical History: BREAST CANCER DEPRESSION BENIGN POSITIONAL VERTIGO KNEE PAIN OSTEOARTHRITIS TKR [MASKED] Lumpectomy TAH/BSO Social History: [MASKED] Family History: No family history of lung disease. Mother deceased at [MASKED] (melanoma). Father deceased at [MASKED] ([MASKED]). Physical Exam: ADMISSION PHYSICAL EXAM ================= Vital Signs: T 97.7 HR 114 BP 162/90 RR 20 General: Alert, oriented, no acute distress. Coughing. HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2 with soft systolic flow murmur. Lungs: Diffuse rhonchi, coarse inspiratory crackles especially at bases. Scattered expiratory wheezes. Abdomen: Obsese. Soft, non-tender. bowel sounds present. GU: No foley Ext: Warm, well perfused. 2+ DP pulses. Somewhat swollen-appearing with trace edema. Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities. Gait deferred. DISCHARGE PHYSICAL EXAM ================= VS: 98.6 166/70 75 21 94%RA General: Alert, oriented, no acute distress. Coughing occasionally HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. Neck: Supple. JVP not elevated. no LAD CV: Regular rate and rhythm. Normal S1+S2 with soft systolic flow murmur. Lungs: Bilateral expiratory wheezes, few ronchi. Abdomen: Obese. Soft, non-tender. bowel sounds present. Ext: Warm, well perfused. 2+ DP pulses. Mild trace edema, per patient baseline Neuro: CNII-XII intact, [MASKED] strength upper/lower extremities. Gait deferred. Pertinent Results: ADMISSION LABS ========== [MASKED] 02:20PM BLOOD WBC-13.4* RBC-4.62 Hgb-12.9 Hct-40.4 MCV-87 MCH-27.9# MCHC-31.9# RDW-15.1 RDWSD-47.2 Plt [MASKED] [MASKED] 02:20PM BLOOD Neuts-73.7* Lymphs-14.4* Monos-8.4 Eos-2.5 Baso-0.4 Im [MASKED] AbsNeut-9.86# AbsLymp-1.93 AbsMono-1.13 AbsEos-0.33 AbsBaso-0.05 [MASKED] 02:20PM BLOOD Glucose-124* UreaN-13 Creat-0.6 Na-141 K-3.7 Cl-100 HCO3-27 AnGap-18 [MASKED] 02:20PM BLOOD CK(CPK)-93 [MASKED] 02:20PM BLOOD CK-MB-4 proBNP-168 [MASKED] 02:20PM BLOOD cTropnT-0.11* [MASKED] 03:41PM BLOOD Lactate-2.7* NOTABLE LABS ========= [MASKED] 06:45AM BLOOD %HbA1c-5.8 eAG-120 [MASKED] 06:45AM BLOOD Triglyc-106 HDL-65 CHOL/HD-4.2 LDLcalc-186* [MASKED] 06:37AM BLOOD Glucose-113* UreaN-22* Creat-0.7 Na-141 K-3.5 Cl-103 HCO3-25 AnGap-17 [MASKED] 06:45AM BLOOD ALT-38 AST-25 CK(CPK)-104 AlkPhos-103 TotBili-0.5 [MASKED] 02:20PM BLOOD cTropnT-0.11* [MASKED] 01:15AM BLOOD CK-MB-6 cTropnT-0.06* [MASKED] 06:45AM BLOOD CK-MB-7 [MASKED] 01:55PM BLOOD CK-MB-6 cTropnT-0.02* IMAGING ====== [MASKED] CXR Mild cardiomegaly, hilar congestion, no frank edema. Pectus excavatum likely simulates right middle lobe opacity. [MASKED] LOWER EXTREMITY DOPPLER ULTRASOUND No evidence of deep venous thrombosis [MASKED] the right or left lower extremity veins. [MASKED] CTA CHEST 1. No evidence of pulmonary embolism or aortic abnormality. 2. Right base [MASKED] opacification compatible with small airway inflammatory/infectious process. Also mild right basilar atelectasis. MICROBIOLOGY ========== [MASKED] 04:00PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 6:44 am SPUTUM Source: Expectorated. GRAM STAIN (Final [MASKED]: <10 PMNs and <10 epithelial cells/100X field. 3+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): Further incubation required to determine the presence or absence of commensal respiratory flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH. DISCHARGE LABS =========== [MASKED] 06:37AM BLOOD WBC-10.3* RBC-4.11 Hgb-11.4 Hct-36.0 MCV-88 MCH-27.7 MCHC-31.7* RDW-15.5 RDWSD-48.0* Plt [MASKED] [MASKED] 06:37AM BLOOD Glucose-113* UreaN-22* Creat-0.7 Na-141 K-3.5 Cl-103 HCO3-25 AnGap-17 [MASKED] 06:37AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.[MASKED] year old woman with recent hospitalization for multifocal pneumonia but no prior cardiopulmonary history, presenting with near-syncopal episode, cough and dyspnea found to have troponin leak with significant wheezing and CTA negative for PE. She was treated with duonebs, azithromycin, and prednisone for reactive airway disease. She was initially placed on heparin but this was stopped after troponin trended down with no evidence of EKG changes. ACTIVE ISSUES ========= #Hypoxia and wheezing likely secondary to reactive airway disease Patient with near-syncopal episode at [MASKED] office due to significant shortness of breath, along with productive cough without fevers. Exam with wheezing. CXR without consolidations. Improved SaO2 with Duonebs [MASKED] ED. COPD with bronchitis component is most likely given recent CAP, smoking history, productive cough without fever but she has not undergone PFT to establish COPD. She is a former smoker. She was given duonebs, albuterol nebs, and started on prednisone and azithromycin for a planned five day course from [MASKED]. CTA was performed that was negative for pulmonary embolism. Wheezing improved and hypoxia improved during her stay dramatically # Elevated troponin Patient with near-syncopal episode prior to admission. Labs with elevated troponin with normal CK-MB and EKG with normal sinus rhythm without ischemic ST-T chanes. Initial concern for atypical presentation of ACS [MASKED] a female though likely demand ischemia [MASKED] the setting of tachycardia. She was given atorvastatin, ASA, and heparin on admission. Troponin trended down on first day of admission and her symptoms likely better explained by COPD. Heparin and atorvastatin were stopped on first day of hospitalization. She was started on daily aspirin. Cardiac risk profile evaluated with HbA1C 5.8%. ASCVD [MASKED] year risk calculated at 13% (non-smoker given that she quit over [MASKED] years ago). CHRONIC ISSUES ========== #DEPRESSION: Continued home Fluoxetine 10mg daily #GERD: home Esomeprazole is NF and she was given omeprazole TRANSITIONAL ISSUES ============== #NEW MEDICATIONS - Azithromycin 250 mg daily till [MASKED] - Prednisone 40 mg daily till [MASKED] - Simvastatin 40 mg daily [MASKED] the evening - Aspirin 81 mg daily #CHANGED MEDICATIONS - none #STOPPED MEDICATIONS - none [] Please ensure outpatient pulmonary follow up for pulmonary function tests to evaluate for obstructive lung disease [] Ensure cardiology follow up for consideration of exercise vs. dobutamine stress test # CODE: Full code, would not want prolonged intubation # CONTACT: [MASKED], daughter Phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 10 mg PO DAILY 2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing 3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 4. Esomeprazole Magnesium 40 mg oral DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:2 2. Azithromycin 250 mg PO Q24H Duration: 4 Doses RX azithromycin 250 mg 1 tablet(s) by mouth DAILY Disp #3 Tablet Refills:0 3. PredniSONE 40 mg PO DAILY Duration: 4 Doses RX prednisone 20 mg 2 tablet(s) by mouth daily Disp #6 Tablet Refills:0 4. Simvastatin 40 mg PO QPM RX simvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:1 5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 6. Esomeprazole Magnesium 40 mg oral DAILY 7. FLUoxetine 10 mg PO DAILY 8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing Discharge Disposition: Home Discharge Diagnosis: Primary: Obstructive pulmonary disease Secondary: Elevated troponin Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] with shortness of breath. You had a lot of wheezing [MASKED] your lungs. You were given nebulizers and steroids to help with your breathing. You were also given an antibiotic called azithromycin. You should keep taking azithromycin and prednisone until [MASKED]. Please use your combivent inhaler you have at home every 6 hours and use your albuterol inhaler as needed. A CT scan was done of your chest which did not show any blood clots [MASKED] your lungs. We believe you have reactive airways [MASKED] the lungs and you have lung disease. You should follow up with a pulmonary doctor to help with diagnosis and treatment for your lungs. You also had some damage to the heart. This may have been caused by your heart beating fast when you felt like you were going to pass out. Please see a cardiologist so that you can be evaluated for heart disease. You were started on a baby aspirin (for heart attack prevention) and a medication called Simvastatin (for high cholesterol). If you have any lightheadedness, difficulty breathing, wheezing, chest pain, fevers, chills, please call your doctor or return to the emergency department. It was a pleasure taking care of you. We wish you the best [MASKED] your health. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "K219", "F329", "Z87891", "J45909" ]	[ "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "I248: Other forms of acute ischemic heart disease", "K219: Gastro-esophageal reflux disease without esophagitis", "F329: Major depressive disorder, single episode, unspecified", "J209: Acute bronchitis, unspecified", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "Z87891: Personal history of nicotine dependence", "J45909: Unspecified asthma, uncomplicated" ]
19,973,580	27,373,602	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ / ___ Attending: ___ Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with PMH of GERD, depression, former tobacco use, and no known pulmonary history with recent admission for respiratory distress and wheezing, diagnosed with likely COPD. 2 weeks prior to that she had been admitted with community acquired pneumonia. She was discharged on ___ with inhalers, and a ___ outpatient note states that she was using them incorrectly, and felt immediate relief once instructed on correct usage. Of note, sputum culture from ___ shows sparse growth of GNRs. The patient received azithromycin only at this recent admission. In the evening yesterday the patient started feeling short of breath, but thought it would pass. She tried her inhalers without much effect. After continuing SOB by 3AM she decided to come to the ED. Since leaving the hospital on ___ her breathing has been ok, but she has been wheezy and has had a cough, mostly dry but sometimes productive of green sputum. She has also had runny nose. Otherwise she denies fevers/chills or muscle aches. In ED initial VS: 98.4 ___ 32 Placed on BiPAP Patient was given: Duonebs, IV methylprednisolone 125mg, azithromycin 500mg IV Imaging notable for: CXR showing pulmonary vascular congestion and mild pulmonary edema. VS prior to transfer: 98.6 108 118/67 20 100% bipap On arrival to the MICU, patient was on BiPAP and felt much improved in terms of SOB. REVIEW OF SYSTEMS: Positive per HPI. Otherwise ROS negative. Past Medical History: BREAST CANCER DEPRESSION BENIGN POSITIONAL VERTIGO KNEE PAIN OSTEOARTHRITIS TKR ___ Lumpectomy TAH/BSO Social History: ___ Family History: No family history of lung disease. Mother deceased at ___ (melanoma). Father deceased at ___ (___). Physical Exam: ADMISSION: GENERAL: Anxious and mildly distressed, but speaking in full sentences, alert, interactive HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: Diffuse wheezing, with good air movement throughout, fine crackles heard at the bases b/l 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: 1+ non-pitting edema b/l; Warm, well perfused, 2+ pulses NEURO: Moving all extremities with purpose DISCHARGE: VITALS: 98.1 158/88 80 20 94/RA GENERAL: Anxious and mildly distressed, but speaking in full sentences, alert, interactive HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: Faint wheezing improved from prior, with good air movement throughout, fine crackles heard at the bases b/l 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: 1+ non-pitting edema b/l; Warm, well perfused, 2+ pulses NEURO: Moving all extremities with purpose Pertinent Results: Admission labs: ___ 04:55AM BLOOD Neuts-59 Bands-0 ___ Monos-3* Eos-1 Baso-1 Atyps-2* ___ Myelos-0 AbsNeut-16.70* AbsLymp-10.19* AbsMono-0.85* AbsEos-0.28 AbsBaso-0.28* ___ 04:55AM BLOOD WBC-28.3# RBC-5.01 Hgb-13.3 Hct-43.9 MCV-88 MCH-26.5 MCHC-30.3 RDW-15.8* RDWSD-50.4* Plt ___ ___ 04:55AM BLOOD ___ PTT-32.7 ___ ___ 04:55AM BLOOD Glucose-170* UreaN-23* Creat-0.6 Na-139 K-5.3* Cl-100 HCO3-25 AnGap-19 ___ 04:55AM BLOOD ALT-23 AST-31 AlkPhos-110* TotBili-0.3 ___ 04:55AM BLOOD Albumin-4.3 Calcium-9.2 Phos-6.5* Mg-2.1 ___ 05:43AM BLOOD ___ pO2-49* pCO2-80* pH-7.18* calTCO2-31* Base XS-0 ___ 05:10AM BLOOD Lactate-1.6 ___ 08:02AM BLOOD Lactate-3.7* K-3.6 ___ 05:43AM BLOOD O2 Sat-74 PERTINENT/DISCHARGE LABS: ___ 06:20AM BLOOD WBC-15.0* RBC-4.27 Hgb-11.5 Hct-36.5 MCV-86 MCH-26.9 MCHC-31.5* RDW-15.9* RDWSD-49.1* Plt ___ ___ 06:40AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-139 K-4.1 Cl-99 HCO3-24 AnGap-20 ___ 06:15AM BLOOD LD(LDH)-269* CK(CPK)-41 ___ 06:15AM BLOOD proBNP-507* ___ 06:40AM BLOOD IgG-749 IgA-134 IgM-237* ___ 01:44PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE Micro: ___ 1:51 pm 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. Time Taken Not Noted Log-In Date/Time: ___ 1:45 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. ___ 11:14 am URINE Source: ___. FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ 5:20 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH x2 Imaging: CXR ___ Right basal consolidation has increased concerning for progression of infectious process. Cardiomegaly is mild, unchanged. Mediastinum is stable. Lungs overall clear. TTE ___: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal to mid inferior wall and inferoseptum. The remaining segments contract normally (LVEF = 50-55 %). Overall left ventricular systolic function is mildly depressed. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Regional left ventricular systolic dysfunction c/w possiblCAD. Normal right ventricular cavity size and systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. PFTs ___: FVC 1.77 (58%) FEV1 1.17 (50%) FEV1/FVC 65 (85%) no change with bronchodilators VC 2.08 (69%) TLC 4.34 (85%) Brief Hospital Course: ___ year old with significant remote smoking history and recent diagnosis of likely COPD (PFTs scheduled but not yet performed) presenting with hypercarbic respiratory failure likely ___ COPD exacerbation. ================= ACTIVE ISSUES ================= # Hypercarbic respiratory failure: She had been admitted ___ for PNA and found to have wheezing treated with steroids and nebs, which was thought to represent reactive airways in setting of new PNA and no known diagnosis of COPD. She was then readmitted ___ for dyspnea and hypoxemia, and treated with short steroid burst and azithromycin. Per patient, she was discharged home and felt well while on prednisone, but had worsening dyspnea once the burst completed. She presented to ED for dyspnea, VBG ___ suggesting acute CO2 retention. She was started on BiPAP and given IV solumedrol 125 x1 and nebs, with improvement in her breathing and normalization of her pH. Given prior, though remote smoking history and substantive wheezing on exam, it was thought this may represent underlying COPD. However, picture is not entirely clear, and last CT Chest on ___ showed tree in ___ lesions. She should have pulmonary follow up with PFTs and repeat CT scan prior to discharge. Long steroid taper as she has had rebound dyspnea after 2 prior shorter bursts. Of note, CXR did show a RLL opacity so she was started on CTX/azithro for a 5 day course of CAP treatment. PFTs demonstrated obstructive disease most consistent with COPD, no significant improvement with bronchodilators. NIF -45. Ambulatory sats >90 on RA. BNP slightly elevated to 507. Immunoglobins, aldolase pending on discharge. SLP consulted with no c/f aspiration. Patient significantly improved on discharge # Lactic acidosis: Patient had a mild lactic acidosis with max lactate of 4, without hypotension or evidence of poor organ perfusion. Etiology remained unclear but her lactate improved slowly. She was started on thiamine for possible deficiency. # Hypertension: Patient with no previous history of HTN. BP 140-170s/80-100s on the floor. Improved on amlodipine to 140s-150s. Discharged on Amlodipine 5 mg PO QDaily # CAD: Presumed diagnosis based on regional hypokinesis on recent TTE. She was unable to complete her recent stress test due to dyspnea. Should reschedule after discharge. She was continued on ASA81mg, simvastatin 40mg. Also consider starting B-blocker. #Depression: continued fluoxetine #GERD: continued esomeprazole TRANSITIONAL ISSUES -Prednisone taper over 10 days -Started on Advair/Spiriva -follow up CT likely in 6 months, but will defer to outpatient pulm -Should get repeat stress test as outpatient -Will defer decision to connect to cardiology to PCP -___ be started on b-blocker and ACEi as an outpatient given her cardiac disease -per discussion with pulm, cardio-selective BB should not have a significant effect on her airway disease -Pulm to follow pending laboratory studies -___ WBC count at PCP ___ - was 15.0 on discharge, downtrending. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing 2. Esomeprazole Magnesium 40 mg oral DAILY 3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 4. FLUoxetine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Simvastatin 40 mg PO QPM Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath / wheezing RX albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled every ___ hours as needed Disp #1 Inhaler Refills:0 2. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Atorvastatin 20 mg PO QPM RX atorvastatin 20 mg 1 tablet(s) by mouth every evening Disp #30 Tablet Refills:0 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID RX fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1 dose inhaled twice a day Disp #1 Disk Refills:0 5. PredniSONE 50 mg PO DAILY Duration: 2 Doses This is dose # 1 of 5 tapered doses RX prednisone 10 mg ___ tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. PredniSONE 40 mg PO DAILY Duration: 2 Doses Start: After 50 mg DAILY tapered dose This is dose # 2 of 5 tapered doses 7. PredniSONE 30 mg PO DAILY Duration: 2 Doses Start: After 40 mg DAILY tapered dose This is dose # 3 of 5 tapered doses 8. PredniSONE 20 mg PO DAILY Duration: 2 Doses This is dose # 4 of 5 tapered doses 9. PredniSONE 10 mg PO DAILY Duration: 2 Doses Start: After 20 mg DAILY tapered dose This is dose # 5 of 5 tapered doses 10. Tiotropium Bromide 1 CAP IH DAILY RX tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 capsule inhaled daily Disp #30 Capsule Refills:0 11. Aspirin 81 mg PO DAILY 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 13. Esomeprazole Magnesium 40 mg oral DAILY 14. FLUoxetine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY Hypercarbic respiratory failure SECONDARY Reactive airway disease Hypertension Leukocytosis Lactic acidosis Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, Thank you for choosing to receive your care at ___. You were admitted with respiratory failure, and briefly required intensive breathing treatments. You subsequently improved with medications that help open up your airways, and underwent testing which demonstrated that you have an obstructive airway disease, which is likely a combination of underlying COPD from previous smoking with inflammation from your respiratory infections you've experienced recently. You were started on steroids for treatment, which you should take for 10 more days through ___. You were also started on new inhaled medications to prevent further exacerbations. You have follow up appointments listed below for further management with lung disease specialists. Please see below for an updated list of your medications and upcoming appointments. We wish you the best with Followup Instructions: ___	[ "J9602", "E872", "J189", "J440", "J441", "F329", "K219", "I2510", "Z87891", "Z853" ]	Allergies: [MASKED] / [MASKED] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old woman with PMH of GERD, depression, former tobacco use, and no known pulmonary history with recent admission for respiratory distress and wheezing, diagnosed with likely COPD. 2 weeks prior to that she had been admitted with community acquired pneumonia. She was discharged on [MASKED] with inhalers, and a [MASKED] outpatient note states that she was using them incorrectly, and felt immediate relief once instructed on correct usage. Of note, sputum culture from [MASKED] shows sparse growth of GNRs. The patient received azithromycin only at this recent admission. In the evening yesterday the patient started feeling short of breath, but thought it would pass. She tried her inhalers without much effect. After continuing SOB by 3AM she decided to come to the ED. Since leaving the hospital on [MASKED] her breathing has been ok, but she has been wheezy and has had a cough, mostly dry but sometimes productive of green sputum. She has also had runny nose. Otherwise she denies fevers/chills or muscle aches. In ED initial VS: 98.4 [MASKED] 32 Placed on BiPAP Patient was given: Duonebs, IV methylprednisolone 125mg, azithromycin 500mg IV Imaging notable for: CXR showing pulmonary vascular congestion and mild pulmonary edema. VS prior to transfer: 98.6 108 118/67 20 100% bipap On arrival to the MICU, patient was on BiPAP and felt much improved in terms of SOB. REVIEW OF SYSTEMS: Positive per HPI. Otherwise ROS negative. Past Medical History: BREAST CANCER DEPRESSION BENIGN POSITIONAL VERTIGO KNEE PAIN OSTEOARTHRITIS TKR [MASKED] Lumpectomy TAH/BSO Social History: [MASKED] Family History: No family history of lung disease. Mother deceased at [MASKED] (melanoma). Father deceased at [MASKED] ([MASKED]). Physical Exam: ADMISSION: GENERAL: Anxious and mildly distressed, but speaking in full sentences, alert, interactive HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: Diffuse wheezing, with good air movement throughout, fine crackles heard at the bases b/l 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: 1+ non-pitting edema b/l; Warm, well perfused, 2+ pulses NEURO: Moving all extremities with purpose DISCHARGE: VITALS: 98.1 158/88 80 20 94/RA GENERAL: Anxious and mildly distressed, but speaking in full sentences, alert, interactive HEENT: Sclera anicteric, MMM, oropharynx clear LUNGS: Faint wheezing improved from prior, with good air movement throughout, fine crackles heard at the bases b/l 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: 1+ non-pitting edema b/l; Warm, well perfused, 2+ pulses NEURO: Moving all extremities with purpose Pertinent Results: Admission labs: [MASKED] 04:55AM BLOOD Neuts-59 Bands-0 [MASKED] Monos-3* Eos-1 Baso-1 Atyps-2* [MASKED] Myelos-0 AbsNeut-16.70* AbsLymp-10.19* AbsMono-0.85* AbsEos-0.28 AbsBaso-0.28* [MASKED] 04:55AM BLOOD WBC-28.3# RBC-5.01 Hgb-13.3 Hct-43.9 MCV-88 MCH-26.5 MCHC-30.3 RDW-15.8* RDWSD-50.4* Plt [MASKED] [MASKED] 04:55AM BLOOD [MASKED] PTT-32.7 [MASKED] [MASKED] 04:55AM BLOOD Glucose-170* UreaN-23* Creat-0.6 Na-139 K-5.3* Cl-100 HCO3-25 AnGap-19 [MASKED] 04:55AM BLOOD ALT-23 AST-31 AlkPhos-110* TotBili-0.3 [MASKED] 04:55AM BLOOD Albumin-4.3 Calcium-9.2 Phos-6.5* Mg-2.1 [MASKED] 05:43AM BLOOD [MASKED] pO2-49* pCO2-80* pH-7.18* calTCO2-31* Base XS-0 [MASKED] 05:10AM BLOOD Lactate-1.6 [MASKED] 08:02AM BLOOD Lactate-3.7* K-3.6 [MASKED] 05:43AM BLOOD O2 Sat-74 PERTINENT/DISCHARGE LABS: [MASKED] 06:20AM BLOOD WBC-15.0* RBC-4.27 Hgb-11.5 Hct-36.5 MCV-86 MCH-26.9 MCHC-31.5* RDW-15.9* RDWSD-49.1* Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-85 UreaN-16 Creat-0.6 Na-139 K-4.1 Cl-99 HCO3-24 AnGap-20 [MASKED] 06:15AM BLOOD LD(LDH)-269* CK(CPK)-41 [MASKED] 06:15AM BLOOD proBNP-507* [MASKED] 06:40AM BLOOD IgG-749 IgA-134 IgM-237* [MASKED] 01:44PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE Micro: [MASKED] 1:51 pm 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. Time Taken Not Noted Log-In Date/Time: [MASKED] 1:45 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. FINAL REPORT [MASKED] Respiratory Viral Culture (Final [MASKED]: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [MASKED] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information.. [MASKED] 11:14 am URINE Source: [MASKED]. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. [MASKED] 5:20 am BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH x2 Imaging: CXR [MASKED] Right basal consolidation has increased concerning for progression of infectious process. Cardiomegaly is mild, unchanged. Mediastinum is stable. Lungs overall clear. TTE [MASKED]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal to mid inferior wall and inferoseptum. The remaining segments contract normally (LVEF = 50-55 %). Overall left ventricular systolic function is mildly depressed. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Regional left ventricular systolic dysfunction c/w possiblCAD. Normal right ventricular cavity size and systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. PFTs [MASKED]: FVC 1.77 (58%) FEV1 1.17 (50%) FEV1/FVC 65 (85%) no change with bronchodilators VC 2.08 (69%) TLC 4.34 (85%) Brief Hospital Course: [MASKED] year old with significant remote smoking history and recent diagnosis of likely COPD (PFTs scheduled but not yet performed) presenting with hypercarbic respiratory failure likely [MASKED] COPD exacerbation. ================= ACTIVE ISSUES ================= # Hypercarbic respiratory failure: She had been admitted [MASKED] for PNA and found to have wheezing treated with steroids and nebs, which was thought to represent reactive airways in setting of new PNA and no known diagnosis of COPD. She was then readmitted [MASKED] for dyspnea and hypoxemia, and treated with short steroid burst and azithromycin. Per patient, she was discharged home and felt well while on prednisone, but had worsening dyspnea once the burst completed. She presented to ED for dyspnea, VBG [MASKED] suggesting acute CO2 retention. She was started on BiPAP and given IV solumedrol 125 x1 and nebs, with improvement in her breathing and normalization of her pH. Given prior, though remote smoking history and substantive wheezing on exam, it was thought this may represent underlying COPD. However, picture is not entirely clear, and last CT Chest on [MASKED] showed tree in [MASKED] lesions. She should have pulmonary follow up with PFTs and repeat CT scan prior to discharge. Long steroid taper as she has had rebound dyspnea after 2 prior shorter bursts. Of note, CXR did show a RLL opacity so she was started on CTX/azithro for a 5 day course of CAP treatment. PFTs demonstrated obstructive disease most consistent with COPD, no significant improvement with bronchodilators. NIF -45. Ambulatory sats >90 on RA. BNP slightly elevated to 507. Immunoglobins, aldolase pending on discharge. SLP consulted with no c/f aspiration. Patient significantly improved on discharge # Lactic acidosis: Patient had a mild lactic acidosis with max lactate of 4, without hypotension or evidence of poor organ perfusion. Etiology remained unclear but her lactate improved slowly. She was started on thiamine for possible deficiency. # Hypertension: Patient with no previous history of HTN. BP 140-170s/80-100s on the floor. Improved on amlodipine to 140s-150s. Discharged on Amlodipine 5 mg PO QDaily # CAD: Presumed diagnosis based on regional hypokinesis on recent TTE. She was unable to complete her recent stress test due to dyspnea. Should reschedule after discharge. She was continued on ASA81mg, simvastatin 40mg. Also consider starting B-blocker. #Depression: continued fluoxetine #GERD: continued esomeprazole TRANSITIONAL ISSUES -Prednisone taper over 10 days -Started on Advair/Spiriva -follow up CT likely in 6 months, but will defer to outpatient pulm -Should get repeat stress test as outpatient -Will defer decision to connect to cardiology to PCP -[MASKED] be started on b-blocker and ACEi as an outpatient given her cardiac disease -per discussion with pulm, cardio-selective BB should not have a significant effect on her airway disease -Pulm to follow pending laboratory studies -[MASKED] WBC count at PCP [MASKED] - was 15.0 on discharge, downtrending. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing 2. Esomeprazole Magnesium 40 mg oral DAILY 3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 4. FLUoxetine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Simvastatin 40 mg PO QPM Discharge Medications: 1. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN shortness of breath / wheezing RX albuterol sulfate [ProAir HFA] 90 mcg [MASKED] puffs inhaled every [MASKED] hours as needed Disp #1 Inhaler Refills:0 2. amLODIPine 5 mg PO DAILY RX amlodipine 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Atorvastatin 20 mg PO QPM RX atorvastatin 20 mg 1 tablet(s) by mouth every evening Disp #30 Tablet Refills:0 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID RX fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1 dose inhaled twice a day Disp #1 Disk Refills:0 5. PredniSONE 50 mg PO DAILY Duration: 2 Doses This is dose # 1 of 5 tapered doses RX prednisone 10 mg [MASKED] tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. PredniSONE 40 mg PO DAILY Duration: 2 Doses Start: After 50 mg DAILY tapered dose This is dose # 2 of 5 tapered doses 7. PredniSONE 30 mg PO DAILY Duration: 2 Doses Start: After 40 mg DAILY tapered dose This is dose # 3 of 5 tapered doses 8. PredniSONE 20 mg PO DAILY Duration: 2 Doses This is dose # 4 of 5 tapered doses 9. PredniSONE 10 mg PO DAILY Duration: 2 Doses Start: After 20 mg DAILY tapered dose This is dose # 5 of 5 tapered doses 10. Tiotropium Bromide 1 CAP IH DAILY RX tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 capsule inhaled daily Disp #30 Capsule Refills:0 11. Aspirin 81 mg PO DAILY 12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 13. Esomeprazole Magnesium 40 mg oral DAILY 14. FLUoxetine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY Hypercarbic respiratory failure SECONDARY Reactive airway disease Hypertension Leukocytosis Lactic acidosis 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], Thank you for choosing to receive your care at [MASKED]. You were admitted with respiratory failure, and briefly required intensive breathing treatments. You subsequently improved with medications that help open up your airways, and underwent testing which demonstrated that you have an obstructive airway disease, which is likely a combination of underlying COPD from previous smoking with inflammation from your respiratory infections you've experienced recently. You were started on steroids for treatment, which you should take for 10 more days through [MASKED]. You were also started on new inhaled medications to prevent further exacerbations. You have follow up appointments listed below for further management with lung disease specialists. Please see below for an updated list of your medications and upcoming appointments. We wish you the best with Followup Instructions: [MASKED]	[]	[ "E872", "F329", "K219", "I2510", "Z87891" ]	[ "J9602: Acute respiratory failure with hypercapnia", "E872: Acidosis", "J189: Pneumonia, unspecified organism", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "Z853: Personal history of malignant neoplasm of breast" ]
19,973,580	28,570,089	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ / Levaquin Attending: ___ Chief Complaint: Dyspnea, fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o F diagnosed with multifocal PNA on ___ presenting with persistent low-grade fevers, cough, and dyspnea on exertion. Patient had ___ weeks initially of URI-type symptoms, and then fevers/cough. She was seen at a clinic in ___ and told likely had a virus. More recently seen by PCP, and started on levoquin for abnormal lung exam and CXR showing bilateral LL PNA. Patient notes hives while on levoquin, and changed to doxy. Patient also reports some hives on doxy but ignored them as patient notes history of hives when nervous. Feels better than when she presented to PCP. Went back to ___ clinic today, and was noted to have O2 sat of 89% and referred to ___ ED for further evaluation. In the ED, initial vitals were: - Exam notable for: Lungs with rhonchi at bases, scattered wheezes RRR, no m/r/g - Labs notable for: normal BMP, CBC, and lactate. FluA&B negative. - Imaging was notable for: CXR (compared to ___ Continued bilateral parenchymal opacities, improved on the left more than the right. - Patient was given: Albuterol nebs, methylprednisolone 125mg IV, azithromycin 500mg, CTX 1g Patient became hypoxic to 89% and decision made to admit. Upon arrival to the floor, patient reports she feels comfortable at rest, but wheezes with movement. No current SOB. No CP, Abd pain. Notes recent diarrhea while on levoquin but this has improved. No dysuria or hematuria. Past Medical History: BREAST CANCER DEPRESSION BENIGN POSITIONAL VERTIGO KNEE PAIN OSTEOARTHRITIS TKR ___ Lumpectomy TAH/BSO Social History: ___ Family History: No family history of lung disease Physical Exam: ADMISSION PHYSICAL EXAM ================== VITAL SIGNS: 97.7 153/89 97 22 91% 3L GENERAL: NAD, appears comfortable in bed HEENT: MMM, no scleral icterus, PERRL NECK: no elevation in JVP, supple CARDIAC: RRR, normal s1 and s2, no m/g/r LUNGS: rhonchorous throughout lungs, frequent coughs. Wheezing. Decreased sounds in bases bilaterally ABDOMEN: Soft, nontender, nondistended, normal bowel sounds EXTREMITIES: WWP, 1+ edema around ankles symmetrically bilaterally. ___ bilaterally NEUROLOGIC: A&Ox3, CNII-XII intact, moving all extremities with purpose DISCHARGE PHYSICAL EXAM ================= Vitals: 98.1 157/92-170s/90s 80-109 20 90%RA GENERAL: NAD, appears comfortable in bed HEENT: MMM, no scleral icterus, PERRL NECK: no elevation in JVP, supple CARDIAC: RRR, normal s1 and s2, no m/g/r LUNGS: Lungs with decreased sounds in bases bilaterally. Mild wheezing throughout. ABDOMEN: Soft, nontender, nondistended, normal bowel sounds EXTREMITIES: WWP, 1+ edema around ankles symmetrically bilaterally. ___ bilaterally NEUROLOGIC: A&Ox3, CNII-XII intact, moving all extremities with purpose Pertinent Results: ADMISSION LABS =========== ___ 02:42PM BLOOD WBC-9.2 RBC-4.82 Hgb-13.5 Hct-41.0 MCV-85 MCH-28.0 MCHC-32.9 RDW-14.4 RDWSD-43.9 Plt ___ ___ 02:42PM BLOOD Neuts-59.4 ___ Monos-9.3 Eos-2.3 Baso-0.4 Im ___ AbsNeut-5.48 AbsLymp-2.60 AbsMono-0.86* AbsEos-0.21 AbsBaso-0.04 ___ 02:42PM BLOOD Glucose-107* UreaN-13 Creat-0.6 Na-140 K-3.8 Cl-99 HCO3-27 AnGap-18 ___ 03:09PM BLOOD Lactate-1.7 NOTABLE LABS ========= ___ 07:50AM BLOOD WBC-17.3# RBC-3.94 Hgb-12.4 Hct-34.8 MCV-88 MCH-31.5# MCHC-35.6# RDW-16.0 RDWSD-44.2 Plt ___ ___ 07:50AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.1 MICROBIOLOGY ========== Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. IMAGING ====== ___ CXR Since ___, the heterogeneous bibasilar opacities have slightly improved, more on the left than on the right. There is no associated pleural effusion or pneumothorax. Cardiomediastinal silhouette is normal. DISCHARGE LABS =========== ___ 07:50AM BLOOD WBC-17.3# RBC-3.94 Hgb-12.4 Hct-34.8 MCV-88 MCH-31.5# MCHC-35.6# RDW-16.0 RDWSD-44.2 Plt ___ ___ 07:50AM BLOOD Glucose-131* UreaN-15 Creat-0.6 Na-141 K-3.7 Cl-100 HCO3-24 AnGap-21* Brief Hospital Course: Ms. ___ is a ___ year old woman diagnosed with multifocal PNA on ___ presenting with persistent low-grade fevers, cough, and dyspnea on exertion. She had ___ weeks initially of URI-type symptoms, and then fevers/cough, found to have PNA which failed outpatient therapy. # Acute hypoxic respiratory failure secondary to community acquired pneumonia that failed outpatient therapy: Patient with PNA noted at ___ on ___ with cough, sputum, and exam/CXR findings. Patient feels as though she improved on levaquin but switched due to hives. Ongoing wheezing likely caused by reactive airway disease in setting of infection. Flu negative. She was given treatment for community acquired pneumonia with azithromycin and ceftriaxone. Because of significant wheezing on exam she was given steroids with IV methlprednisolone that transitioned to oral prednisone for a five day course. She was given duonebs and albuterol nebs for wheezing. Legionella urine antigen was negative. Blood cultures pending at the time of discharge. She remained on 3L NC for first two days of admission that was weaned to room air. Ambulatory saturation showed 86-94% on room air. Breathing ambient air she was at 92% at rest. She was transitioned to oral cefpoxodime to complete a seven day course. She was given combivent for reactive airways and continued on prednisone for total 7 day steroid course. #Hypertension: Blood pressures into systolic 160-170s during admission. Possibly related to acute illness, medication side effect from duonebs and IV steroids. No signs of hypertensive emergency. No history of hypertension. TRANSITIONAL ISSUES ============= #NEW MEDICATIONS - Azithromycin 250 mg PO Q24H (completes ___ - Cefpodoxime Proxetil 400 mg PO Q12H (completes ___ - PredniSONE 40 mg PO DAILY (completes ___ - Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing #CHANGED MEDICATIONS - None #STOPPED MEDICATIONS - None [] Follow up oxygen saturation and ambulatory saturation [] Continue antibiotics and steroids until ___ [] Consider follow up CXR in 6 weeks to ensure resolution [] Blood pressure check and consideration initiation of antihypertensive therapy if hypertension persists as outpatient # CODE: Full code, would not want prolonged intubation # CONTACT: ___, daughter Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 2. esomeprazole magnesium 40 mg oral DAILY 3. FLUoxetine 10 mg PO DAILY Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 2 Days RX azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #2 Tablet Refills:0 2. Cefpodoxime Proxetil 400 mg PO Q12H RX cefpodoxime 200 mg 2 tablet(s) by mouth Every 12 hours Disp #14 Tablet Refills:0 3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing RX ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 puff IH Every 6 hours Disp #1 Ampule Refills:1 4. PredniSONE 40 mg PO DAILY Duration: 4 Doses RX prednisone 20 mg 2 tablet(s) by mouth Daily Disp #6 Tablet Refills:0 5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 6. Esomeprazole Magnesium 40 mg oral DAILY 7. FLUoxetine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Community acquired pneumonia Reactive airway disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ with pneumonia after not improving with oral medications taken at home. You were given IV antibiotics, steroids, and breathing treatments to help with your pneumonia. Your oxygen level improved with treatment. You should take the following medications for your infectin: - Cefpodoxime: One pill every 12 hours. Last day ___ - Azithromycin: One pill daily. Last day ___. - Prednisone: One pill daily. Last day ___. You should use the inhaler to help with your breathing. Your blood pressure was elevated during you stay. We believe this was a medication side effect from the steroids. You should talk with your primary doctor about your blood pressure. If you experience difficulty breathing, fevers, chills, or worsening shortness of breath please call your doctor or return to the emergency department. It was a pleasure taking care of you. We wish you the best in your health. Sincerely, Your ___ Team Followup Instructions: ___	[ "J189", "J9601", "J45909", "F329", "K219", "I10", "D72829", "T380X5A", "Y929", "Z853" ]	Allergies: [MASKED] / Levaquin Chief Complaint: Dyspnea, fever Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o F diagnosed with multifocal PNA on [MASKED] presenting with persistent low-grade fevers, cough, and dyspnea on exertion. Patient had [MASKED] weeks initially of URI-type symptoms, and then fevers/cough. She was seen at a clinic in [MASKED] and told likely had a virus. More recently seen by PCP, and started on levoquin for abnormal lung exam and CXR showing bilateral LL PNA. Patient notes hives while on levoquin, and changed to doxy. Patient also reports some hives on doxy but ignored them as patient notes history of hives when nervous. Feels better than when she presented to PCP. Went back to [MASKED] clinic today, and was noted to have O2 sat of 89% and referred to [MASKED] ED for further evaluation. In the ED, initial vitals were: - Exam notable for: Lungs with rhonchi at bases, scattered wheezes RRR, no m/r/g - Labs notable for: normal BMP, CBC, and lactate. FluA&B negative. - Imaging was notable for: CXR (compared to [MASKED] Continued bilateral parenchymal opacities, improved on the left more than the right. - Patient was given: Albuterol nebs, methylprednisolone 125mg IV, azithromycin 500mg, CTX 1g Patient became hypoxic to 89% and decision made to admit. Upon arrival to the floor, patient reports she feels comfortable at rest, but wheezes with movement. No current SOB. No CP, Abd pain. Notes recent diarrhea while on levoquin but this has improved. No dysuria or hematuria. Past Medical History: BREAST CANCER DEPRESSION BENIGN POSITIONAL VERTIGO KNEE PAIN OSTEOARTHRITIS TKR [MASKED] Lumpectomy TAH/BSO Social History: [MASKED] Family History: No family history of lung disease Physical Exam: ADMISSION PHYSICAL EXAM ================== VITAL SIGNS: 97.7 153/89 97 22 91% 3L GENERAL: NAD, appears comfortable in bed HEENT: MMM, no scleral icterus, PERRL NECK: no elevation in JVP, supple CARDIAC: RRR, normal s1 and s2, no m/g/r LUNGS: rhonchorous throughout lungs, frequent coughs. Wheezing. Decreased sounds in bases bilaterally ABDOMEN: Soft, nontender, nondistended, normal bowel sounds EXTREMITIES: WWP, 1+ edema around ankles symmetrically bilaterally. [MASKED] bilaterally NEUROLOGIC: A&Ox3, CNII-XII intact, moving all extremities with purpose DISCHARGE PHYSICAL EXAM ================= Vitals: 98.1 157/92-170s/90s 80-109 20 90%RA GENERAL: NAD, appears comfortable in bed HEENT: MMM, no scleral icterus, PERRL NECK: no elevation in JVP, supple CARDIAC: RRR, normal s1 and s2, no m/g/r LUNGS: Lungs with decreased sounds in bases bilaterally. Mild wheezing throughout. ABDOMEN: Soft, nontender, nondistended, normal bowel sounds EXTREMITIES: WWP, 1+ edema around ankles symmetrically bilaterally. [MASKED] bilaterally NEUROLOGIC: A&Ox3, CNII-XII intact, moving all extremities with purpose Pertinent Results: ADMISSION LABS =========== [MASKED] 02:42PM BLOOD WBC-9.2 RBC-4.82 Hgb-13.5 Hct-41.0 MCV-85 MCH-28.0 MCHC-32.9 RDW-14.4 RDWSD-43.9 Plt [MASKED] [MASKED] 02:42PM BLOOD Neuts-59.4 [MASKED] Monos-9.3 Eos-2.3 Baso-0.4 Im [MASKED] AbsNeut-5.48 AbsLymp-2.60 AbsMono-0.86* AbsEos-0.21 AbsBaso-0.04 [MASKED] 02:42PM BLOOD Glucose-107* UreaN-13 Creat-0.6 Na-140 K-3.8 Cl-99 HCO3-27 AnGap-18 [MASKED] 03:09PM BLOOD Lactate-1.7 NOTABLE LABS ========= [MASKED] 07:50AM BLOOD WBC-17.3# RBC-3.94 Hgb-12.4 Hct-34.8 MCV-88 MCH-31.5# MCHC-35.6# RDW-16.0 RDWSD-44.2 Plt [MASKED] [MASKED] 07:50AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.1 MICROBIOLOGY ========== Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. IMAGING ====== [MASKED] CXR Since [MASKED], the heterogeneous bibasilar opacities have slightly improved, more on the left than on the right. There is no associated pleural effusion or pneumothorax. Cardiomediastinal silhouette is normal. DISCHARGE LABS =========== [MASKED] 07:50AM BLOOD WBC-17.3# RBC-3.94 Hgb-12.4 Hct-34.8 MCV-88 MCH-31.5# MCHC-35.6# RDW-16.0 RDWSD-44.2 Plt [MASKED] [MASKED] 07:50AM BLOOD Glucose-131* UreaN-15 Creat-0.6 Na-141 K-3.7 Cl-100 HCO3-24 AnGap-21* Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old woman diagnosed with multifocal PNA on [MASKED] presenting with persistent low-grade fevers, cough, and dyspnea on exertion. She had [MASKED] weeks initially of URI-type symptoms, and then fevers/cough, found to have PNA which failed outpatient therapy. # Acute hypoxic respiratory failure secondary to community acquired pneumonia that failed outpatient therapy: Patient with PNA noted at [MASKED] on [MASKED] with cough, sputum, and exam/CXR findings. Patient feels as though she improved on levaquin but switched due to hives. Ongoing wheezing likely caused by reactive airway disease in setting of infection. Flu negative. She was given treatment for community acquired pneumonia with azithromycin and ceftriaxone. Because of significant wheezing on exam she was given steroids with IV methlprednisolone that transitioned to oral prednisone for a five day course. She was given duonebs and albuterol nebs for wheezing. Legionella urine antigen was negative. Blood cultures pending at the time of discharge. She remained on 3L NC for first two days of admission that was weaned to room air. Ambulatory saturation showed 86-94% on room air. Breathing ambient air she was at 92% at rest. She was transitioned to oral cefpoxodime to complete a seven day course. She was given combivent for reactive airways and continued on prednisone for total 7 day steroid course. #Hypertension: Blood pressures into systolic 160-170s during admission. Possibly related to acute illness, medication side effect from duonebs and IV steroids. No signs of hypertensive emergency. No history of hypertension. TRANSITIONAL ISSUES ============= #NEW MEDICATIONS - Azithromycin 250 mg PO Q24H (completes [MASKED] - Cefpodoxime Proxetil 400 mg PO Q12H (completes [MASKED] - PredniSONE 40 mg PO DAILY (completes [MASKED] - Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing #CHANGED MEDICATIONS - None #STOPPED MEDICATIONS - None [] Follow up oxygen saturation and ambulatory saturation [] Continue antibiotics and steroids until [MASKED] [] Consider follow up CXR in 6 weeks to ensure resolution [] Blood pressure check and consideration initiation of antihypertensive therapy if hypertension persists as outpatient # CODE: Full code, would not want prolonged intubation # CONTACT: [MASKED], daughter Phone: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 2. esomeprazole magnesium 40 mg oral DAILY 3. FLUoxetine 10 mg PO DAILY Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 2 Days RX azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #2 Tablet Refills:0 2. Cefpodoxime Proxetil 400 mg PO Q12H RX cefpodoxime 200 mg 2 tablet(s) by mouth Every 12 hours Disp #14 Tablet Refills:0 3. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H Wheezing RX ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 puff IH Every 6 hours Disp #1 Ampule Refills:1 4. PredniSONE 40 mg PO DAILY Duration: 4 Doses RX prednisone 20 mg 2 tablet(s) by mouth Daily Disp #6 Tablet Refills:0 5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg calcium- 200 unit oral DAILY 6. Esomeprazole Magnesium 40 mg oral DAILY 7. FLUoxetine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Community acquired pneumonia Reactive airway disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] with pneumonia after not improving with oral medications taken at home. You were given IV antibiotics, steroids, and breathing treatments to help with your pneumonia. Your oxygen level improved with treatment. You should take the following medications for your infectin: - Cefpodoxime: One pill every 12 hours. Last day [MASKED] - Azithromycin: One pill daily. Last day [MASKED]. - Prednisone: One pill daily. Last day [MASKED]. You should use the inhaler to help with your breathing. Your blood pressure was elevated during you stay. We believe this was a medication side effect from the steroids. You should talk with your primary doctor about your blood pressure. If you experience difficulty breathing, fevers, chills, or worsening shortness of breath please call your doctor or return to the emergency department. It was a pleasure taking care of you. We wish you the best in your health. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "J9601", "J45909", "F329", "K219", "I10", "Y929" ]	[ "J189: Pneumonia, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "D72829: Elevated white blood cell count, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y929: Unspecified place or not applicable", "Z853: Personal history of malignant neoplasm of breast" ]
19,973,723	29,444,445	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Celebrex / Biaxin / Dilaudid / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Vioxx Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ w/ pancreatic CA s/p neoadjuvant FOLFIRNOX/radiation, now POD ___ s/p IVC filter for prior PE & POD ___ s/p radical pancreaticoduodenectomy with distal gastrectomy and en bloc resection of superior mesenteric vein/root of the colonic mesentery w/ SMV-PV confluence reconstruction (end-to-end primary) and GJ tube placement c/b post operative chyle leak and surgical wound infection. Patient discharged on ___ to rehabilitation facility and re-presented to ___ in ___ on ___ after complaining of abdominal discomfort after taking PO medications. Pain has been constant with intermittent exacerbations mostly epigastric in location. CTAP at OSH concerning for deep surgical site fluid collection/abscess. Upon review with ED, appears to be stable from ___ with decreased associated stranding. No abdominal wall collections or rim enhancement. On admission her lactate is 1.2, WBC 2.5, Hgb since discharge at 8 (from 8.7). She was started on IV Vancomycin and transferred to ___ for further evaluation. Past Medical History: PMH: - adenosquamous pancreatic carcinoma (borderline resectable w/ SMV involvement; s/p neoadjuvant FOLFIRINOX and radiation) - pulmonary embolism (on Lovenox since ___ - HTN/HLD - GERD - depression PSH: - s/p IVC filter placement w/ Dr. ___ ___ - s/p R port-a-cath placement - s/p hysterectomy Social History: ___ Family History: Father deceased from pancreatic cancer at age ___, living relative w/ pancreatic cancer (age ___ Physical Exam: Prior to Discharge: VS: 98.2, 95, 126/54, 16, 96 RA GEN: NAD pleasant HEENT: No scleral icterus CV: RRR, no m/r/g PULM: CTAB ABD: Subcostal incision open to air with steri strips. Mid and left lateral aspects are open and packed with moist to dry gauze dressing. No erythema or drainage. RLQ JP drain to bulb suction with minimal serous drainage, site with drain sponge and c/d/I. Midline G/J-tube capped, site c/d/I. EXTR: Warm, +1 bilateral pitted edema. Pertinent Results: RECENT LABS: ___ 04:00PM BLOOD WBC-3.7* RBC-2.69* Hgb-7.6* Hct-24.1* MCV-90 MCH-28.3 MCHC-31.5* RDW-14.7 RDWSD-47.8* Plt ___ ___ 01:54AM BLOOD Glucose-90 UreaN-16 Creat-0.4 Na-135 K-3.7 Cl-100 HCO3-25 AnGap-14 ___ 04:00PM BLOOD ALT-12 AST-12 AlkPhos-75 TotBili-<0.2 ___ 04:33PM BLOOD Lactate-1.4 MICRO: ___ 12:28 pm STOOL CONSISTENCY: FORMED Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 2:40 am URINE FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA OXYTOCA. >100,000 CFU/mL. CEFAZOLIN sensitivity testing confirmed by ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA \| AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: The patient s/p Whipple on ___ for pancreatic cancer was re-admitted to the HPB Surgical Service from rehabilitation for evaluation of increased abdominal pain. Patient's OSH CT scan was reviewed in ED and demonstrated normal post operative changes. Patient's oral Morphine was changed to IV and pain improved. Chronic pain and Geriatric serviced were called for consult. Patient was started on Sucralfate, Reglan and Erythromycin for motility, tubefeeds were restarted. Chronic pain service recommended to continue Fentanyl patch, stop IV Morphine, start Morphine elixir and add Gabapentin. Patient's pain was improved, she tolerated small amount of regular diet and tubefeeds at goal. Her stool was checked for C.diff infection secondary to frequent loose BMs. Stool was negative for C. diff and fiber was added to the TF, patient's diarrhea subsided prior to discharge. Geriatric service recommended Ritalin for stimulation, which was started. Patient's JP 1 was removed as output was low, JP 2 output continue to decrease. Patient was discharged in rehabilitation on HD 3. Prior to discharge patient was afebrile, pain was well controlled with Fentanyl patch and oxycodone elixir. The patient was tolerating a regular diet and TF at goal, ambulating with walker, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PARoxetine 20 mg PO DAILY 2. Senna 8.6 mg PO BID:PRN constipation 3. Acetaminophen 1000 mg PO Q8H 4. Aspirin 325 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Fentanyl Patch 12 mcg/h TD Q72H 7. Gabapentin 300 mg PO TID 8. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Moderate 9. Pantoprazole 40 mg PO Q12H 10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate 11. Enoxaparin Sodium 100 mg SC DAILY 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. Bisacodyl 5 mg PO DAILY:PRN constipation Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild 2. Calcium Carbonate 500 mg PO QID:PRN dyspepsia 3. Erythromycin 250 mg PO Q6H 4. Ferrous Sulfate 325 mg PO DAILY 5. MethylPHENIDATE (Ritalin) 2.5 mg PO BREAKFAST RX methylphenidate 2.5 mg 1 tablet(s) by mouth with breakfast and dinner Disp #60 Tablet Refills:0 6. MethylPHENIDATE (Ritalin) 2.5 mg PO LUNCH 7. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg/5 mL ___ mg by mouth every four (4) hours Refills:0 8. Sucralfate 1 gm PO QID 9. TraZODone 25 mg PO QHS:PRN insomnia 10. Ondansetron 4 mg PO Q8H:PRN nausea 11. Aspirin 325 mg PO DAILY 12. Docusate Sodium 100 mg PO BID hold if having diarrhea 13. Enoxaparin Sodium 100 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time 14. Fentanyl Patch 12 mcg/h TD Q72H RX fentanyl 12 mcg/hour 1 Q72H Disp #10 Patch Refills:0 15. Pantoprazole 40 mg PO Q12H 16. PARoxetine 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Pancreatic adenocarcinoma status post Whipple procedure 2. Acute on chromic pain 3. 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: You were re-admitted to the surgery service at ___ from rehabilitation to evaluate increased abdominal pain. You underwent CT scan, which was grossly normal. Chronic pain and Geriatric services were consulted, and you medications were adjusted for better pain control. You are now safe to return back in rehabilitation to complete your recovery with the following instructions: . Please call Dr. ___ office at ___ if you have any questions or concerns. . Wound care: Your wound dressing will be changed twice a day by the nurses in rehab or ___ if you at home. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Monitor for signs and symptoms of infection. . JP Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . G/J-tube care: Please continue G-tube capped. J-tube - continue with tubefeeds and free water flushes. Keep tube securely attached to your bode to prevent dislocation. Cleanse insertion site with ___ strength hydrogen peroxide and rinse with saline moistened q-tip or with mild soap and water. Apply a drain sponge if needed. Change dressing daily and as needed. Followup Instructions: ___	[ "R109", "C257", "K219", "I10", "F329", "G8918", "R197", "Z87891" ]	Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Celebrex / Biaxin / Dilaudid / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Vioxx Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [MASKED] w/ pancreatic CA s/p neoadjuvant FOLFIRNOX/radiation, now POD [MASKED] s/p IVC filter for prior PE & POD [MASKED] s/p radical pancreaticoduodenectomy with distal gastrectomy and en bloc resection of superior mesenteric vein/root of the colonic mesentery w/ SMV-PV confluence reconstruction (end-to-end primary) and GJ tube placement c/b post operative chyle leak and surgical wound infection. Patient discharged on [MASKED] to rehabilitation facility and re-presented to [MASKED] in [MASKED] on [MASKED] after complaining of abdominal discomfort after taking PO medications. Pain has been constant with intermittent exacerbations mostly epigastric in location. CTAP at OSH concerning for deep surgical site fluid collection/abscess. Upon review with ED, appears to be stable from [MASKED] with decreased associated stranding. No abdominal wall collections or rim enhancement. On admission her lactate is 1.2, WBC 2.5, Hgb since discharge at 8 (from 8.7). She was started on IV Vancomycin and transferred to [MASKED] for further evaluation. Past Medical History: PMH: - adenosquamous pancreatic carcinoma (borderline resectable w/ SMV involvement; s/p neoadjuvant FOLFIRINOX and radiation) - pulmonary embolism (on Lovenox since [MASKED] - HTN/HLD - GERD - depression PSH: - s/p IVC filter placement w/ Dr. [MASKED] [MASKED] - s/p R port-a-cath placement - s/p hysterectomy Social History: [MASKED] Family History: Father deceased from pancreatic cancer at age [MASKED], living relative w/ pancreatic cancer (age [MASKED] Physical Exam: Prior to Discharge: VS: 98.2, 95, 126/54, 16, 96 RA GEN: NAD pleasant HEENT: No scleral icterus CV: RRR, no m/r/g PULM: CTAB ABD: Subcostal incision open to air with steri strips. Mid and left lateral aspects are open and packed with moist to dry gauze dressing. No erythema or drainage. RLQ JP drain to bulb suction with minimal serous drainage, site with drain sponge and c/d/I. Midline G/J-tube capped, site c/d/I. EXTR: Warm, +1 bilateral pitted edema. Pertinent Results: RECENT LABS: [MASKED] 04:00PM BLOOD WBC-3.7* RBC-2.69* Hgb-7.6* Hct-24.1* MCV-90 MCH-28.3 MCHC-31.5* RDW-14.7 RDWSD-47.8* Plt [MASKED] [MASKED] 01:54AM BLOOD Glucose-90 UreaN-16 Creat-0.4 Na-135 K-3.7 Cl-100 HCO3-25 AnGap-14 [MASKED] 04:00PM BLOOD ALT-12 AST-12 AlkPhos-75 TotBili-<0.2 [MASKED] 04:33PM BLOOD Lactate-1.4 MICRO: [MASKED] 12:28 pm STOOL CONSISTENCY: FORMED Source: Stool. FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [MASKED] 2:40 am URINE FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: KLEBSIELLA OXYTOCA. >100,000 CFU/mL. CEFAZOLIN sensitivity testing confirmed by [MASKED]. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] KLEBSIELLA OXYTOCA \| AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: The patient s/p Whipple on [MASKED] for pancreatic cancer was re-admitted to the HPB Surgical Service from rehabilitation for evaluation of increased abdominal pain. Patient's OSH CT scan was reviewed in ED and demonstrated normal post operative changes. Patient's oral Morphine was changed to IV and pain improved. Chronic pain and Geriatric serviced were called for consult. Patient was started on Sucralfate, Reglan and Erythromycin for motility, tubefeeds were restarted. Chronic pain service recommended to continue Fentanyl patch, stop IV Morphine, start Morphine elixir and add Gabapentin. Patient's pain was improved, she tolerated small amount of regular diet and tubefeeds at goal. Her stool was checked for C.diff infection secondary to frequent loose BMs. Stool was negative for C. diff and fiber was added to the TF, patient's diarrhea subsided prior to discharge. Geriatric service recommended Ritalin for stimulation, which was started. Patient's JP 1 was removed as output was low, JP 2 output continue to decrease. Patient was discharged in rehabilitation on HD 3. Prior to discharge patient was afebrile, pain was well controlled with Fentanyl patch and oxycodone elixir. The patient was tolerating a regular diet and TF at goal, ambulating with walker, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PARoxetine 20 mg PO DAILY 2. Senna 8.6 mg PO BID:PRN constipation 3. Acetaminophen 1000 mg PO Q8H 4. Aspirin 325 mg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Fentanyl Patch 12 mcg/h TD Q72H 7. Gabapentin 300 mg PO TID 8. Morphine Sulfate [MASKED] [MASKED] mg PO Q4H:PRN Pain - Moderate 9. Pantoprazole 40 mg PO Q12H 10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate 11. Enoxaparin Sodium 100 mg SC DAILY 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. Bisacodyl 5 mg PO DAILY:PRN constipation Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q8H:PRN Pain - Mild 2. Calcium Carbonate 500 mg PO QID:PRN dyspepsia 3. Erythromycin 250 mg PO Q6H 4. Ferrous Sulfate 325 mg PO DAILY 5. MethylPHENIDATE (Ritalin) 2.5 mg PO BREAKFAST RX methylphenidate 2.5 mg 1 tablet(s) by mouth with breakfast and dinner Disp #60 Tablet Refills:0 6. MethylPHENIDATE (Ritalin) 2.5 mg PO LUNCH 7. OxycoDONE Liquid [MASKED] mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg/5 mL [MASKED] mg by mouth every four (4) hours Refills:0 8. Sucralfate 1 gm PO QID 9. TraZODone 25 mg PO QHS:PRN insomnia 10. Ondansetron 4 mg PO Q8H:PRN nausea 11. Aspirin 325 mg PO DAILY 12. Docusate Sodium 100 mg PO BID hold if having diarrhea 13. Enoxaparin Sodium 100 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time 14. Fentanyl Patch 12 mcg/h TD Q72H RX fentanyl 12 mcg/hour 1 Q72H Disp #10 Patch Refills:0 15. Pantoprazole 40 mg PO Q12H 16. PARoxetine 20 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: 1. Pancreatic adenocarcinoma status post Whipple procedure 2. Acute on chromic pain 3. 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: You were re-admitted to the surgery service at [MASKED] from rehabilitation to evaluate increased abdominal pain. You underwent CT scan, which was grossly normal. Chronic pain and Geriatric services were consulted, and you medications were adjusted for better pain control. You are now safe to return back in rehabilitation to complete your recovery with the following instructions: . Please call Dr. [MASKED] office at [MASKED] if you have any questions or concerns. . Wound care: Your wound dressing will be changed twice a day by the nurses in rehab or [MASKED] if you at home. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Monitor for signs and symptoms of infection. . JP Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, [MASKED], or [MASKED] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . G/J-tube care: Please continue G-tube capped. J-tube - continue with tubefeeds and free water flushes. Keep tube securely attached to your bode to prevent dislocation. Cleanse insertion site with [MASKED] strength hydrogen peroxide and rinse with saline moistened q-tip or with mild soap and water. Apply a drain sponge if needed. Change dressing daily and as needed. Followup Instructions: [MASKED]	[]	[ "K219", "I10", "F329", "Z87891" ]	[ "R109: Unspecified abdominal pain", "C257: Malignant neoplasm of other parts of pancreas", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "G8918: Other acute postprocedural pain", "R197: Diarrhea, unspecified", "Z87891: Personal history of nicotine dependence" ]
19,973,795	23,822,974	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Codeine / morphine Attending: ___. Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: amterior /posterior L3-S1 decompression and fusion History of Present Illness: Patient had progressive inability to ambulate secondary to neurogenic claudication Past Medical History: Hypertension/ scoliosis/ spinal stenosis Social History: ___ Family History: Non-contributory Physical Exam: Awake and alert/ vss Lungs clear to ausc. Abdomen soft, NT Extremities - moderate bilateral pedal swelling Calves soft, NT weakness diffusely ___ throughout both lower extremities Pertinent Results: ___ 12:42AM GLUCOSE-96 UREA N-17 CREAT-0.7 SODIUM-137 POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-27 ANION GAP-14 ___ 12:42AM estGFR-Using this ___ 12:42AM CRP-0.7 ___ 12:42AM WBC-6.0 RBC-4.05 HGB-13.3 HCT-39.9 MCV-99* MCH-32.8* MCHC-33.3 RDW-11.8 RDWSD-42.7 ___ 12:42AM NEUTS-58.5 ___ MONOS-11.4 EOS-4.0 BASOS-1.3* IM ___ AbsNeut-3.53 AbsLymp-1.48 AbsMono-0.69 AbsEos-0.24 AbsBaso-0.08 ___ 12:42AM ___ PTT-29.3 ___ ___ 12:42AM PLT COUNT-344 Brief Hospital Course: Patient was admitted and underwent an anterior and posterior lumbar decompression and fusion procedure in a staged fashion. She had post-operative atelectasis and was given an incentive spirometer. Her strength and sensation improved in both legs. at the time of discharge she was able to stand for short periods of time and had a bowel movement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 60 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Methadone 10 mg PO DAILY 5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain - Moderate 6. Potassium Chloride 40 mEq PO DAILY 7. TraZODone 200 mg PO QHS:PRN insomnia Discharge Medications: 1. Cyclobenzaprine 5 mg PO TID:PRN spasms RX cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID 3. Hydrochlorothiazide 50 mg PO DAILY diuretic RX hydrochlorothiazide 50 mg 1 tablet(s) by mouth once a day Disp #25 Tablet Refills:0 4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #14 Capsule Refills:0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #90 Tablet Refills:0 6. Senna 17.2 mg PO HS RX sennosides [senna] 8.6 mg 1 package by mouth once a day Disp #60 Tablet Refills:*0 7. Gabapentin 600 mg PO TID 8. Methadone 10 mg PO QHS 9. potassium chloride 40 meq oral BID 10. TraZODone 100 mg PO QHS:PRN insomnia 11. DULoxetine 60 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Scoliosis/ spinal stenosis Discharge Condition: Awake and alert/ vss/ Incision clean and dry/ moving both legs well Discharge Instructions: Keep incisions clean and dry/ ambulate as tolerated with brace Physical Therapy: Ambulate as tolerated / use corset for comfort Treatments Frequency: Keep incisions clean and dry/ Followup Instructions: ___	[ "M48062", "G9731", "M419", "G834", "J9811", "J9589", "M4316", "M5136", "M5126", "M810", "I10", "Y831", "Y92234", "Z8673", "Z87891", "Z96653" ]	Allergies: Codeine / morphine Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: amterior /posterior L3-S1 decompression and fusion History of Present Illness: Patient had progressive inability to ambulate secondary to neurogenic claudication Past Medical History: Hypertension/ scoliosis/ spinal stenosis Social History: [MASKED] Family History: Non-contributory Physical Exam: Awake and alert/ vss Lungs clear to ausc. Abdomen soft, NT Extremities - moderate bilateral pedal swelling Calves soft, NT weakness diffusely [MASKED] throughout both lower extremities Pertinent Results: [MASKED] 12:42AM GLUCOSE-96 UREA N-17 CREAT-0.7 SODIUM-137 POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-27 ANION GAP-14 [MASKED] 12:42AM estGFR-Using this [MASKED] 12:42AM CRP-0.7 [MASKED] 12:42AM WBC-6.0 RBC-4.05 HGB-13.3 HCT-39.9 MCV-99* MCH-32.8* MCHC-33.3 RDW-11.8 RDWSD-42.7 [MASKED] 12:42AM NEUTS-58.5 [MASKED] MONOS-11.4 EOS-4.0 BASOS-1.3* IM [MASKED] AbsNeut-3.53 AbsLymp-1.48 AbsMono-0.69 AbsEos-0.24 AbsBaso-0.08 [MASKED] 12:42AM [MASKED] PTT-29.3 [MASKED] [MASKED] 12:42AM PLT COUNT-344 Brief Hospital Course: Patient was admitted and underwent an anterior and posterior lumbar decompression and fusion procedure in a staged fashion. She had post-operative atelectasis and was given an incentive spirometer. Her strength and sensation improved in both legs. at the time of discharge she was able to stand for short periods of time and had a bowel movement. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 60 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Gabapentin 300 mg PO TID 4. Methadone 10 mg PO DAILY 5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain - Moderate 6. Potassium Chloride 40 mEq PO DAILY 7. TraZODone 200 mg PO QHS:PRN insomnia Discharge Medications: 1. Cyclobenzaprine 5 mg PO TID:PRN spasms RX cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID 3. Hydrochlorothiazide 50 mg PO DAILY diuretic RX hydrochlorothiazide 50 mg 1 tablet(s) by mouth once a day Disp #25 Tablet Refills:0 4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H RX nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 capsule(s) by mouth every twelve (12) hours Disp #14 Capsule Refills:0 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #90 Tablet Refills:0 6. Senna 17.2 mg PO HS RX sennosides [senna] 8.6 mg 1 package by mouth once a day Disp #60 Tablet Refills:*0 7. Gabapentin 600 mg PO TID 8. Methadone 10 mg PO QHS 9. potassium chloride 40 meq oral BID 10. TraZODone 100 mg PO QHS:PRN insomnia 11. DULoxetine 60 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Scoliosis/ spinal stenosis Discharge Condition: Awake and alert/ vss/ Incision clean and dry/ moving both legs well Discharge Instructions: Keep incisions clean and dry/ ambulate as tolerated with brace Physical Therapy: Ambulate as tolerated / use corset for comfort Treatments Frequency: Keep incisions clean and dry/ Followup Instructions: [MASKED]	[]	[ "I10", "Z8673", "Z87891" ]	[ "M48062: Spinal stenosis, lumbar region with neurogenic claudication", "G9731: Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure", "M419: Scoliosis, unspecified", "G834: Cauda equina syndrome", "J9811: Atelectasis", "J9589: Other postprocedural complications and disorders of respiratory system, not elsewhere classified", "M4316: Spondylolisthesis, lumbar region", "M5136: Other intervertebral disc degeneration, lumbar region", "M5126: Other intervertebral disc displacement, lumbar region", "M810: Age-related osteoporosis without current pathological fracture", "I10: Essential (primary) hypertension", "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", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "Z96653: Presence of artificial knee joint, bilateral" ]
19,973,987	22,442,118	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: S/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with T2DM and CKD who presented after falling backwards off ___ step going up to attic. He reports that he lost his footing and fell backwards onto his back and his head hit the floor. Had significant lower back pain immediately after the fall, had trouble getting up. Had to scoot downstairs to get to the phone. He denied numbness/tingling/weakness, No loss of continence or consciousness. No saddle anesthesia. Took 1g acetaminophen at home with no relief. Notably, the patient states that prior to falling he was feeling completely well. No dizziness or light-headedness at time of fall. And in recent days, no infectious symptoms. No cough, dyspnea, abdominal pain, diarrhea, urinary symptoms. A CT scan of the pelvis showed a non displaced fracture of the right iliac bone and a 1.8 cm diastasis of the pubic symphysis indicating unstable pelvic fracture. Additionally CT showed extensive stranding and hematoma of the retropubic area. Given CT also howing anterior bladder wall defect could represent bladder wall injury, CT cystogram was obtained. He was admitted to the ICU after being found to have hypotension, leukocytosis and hyperglycemia for further management. He had non-operative, conservative management of his fracture. His blood counts were noted to drift down slowly however he remained hemodynamically stable; a CT was repeated which did not show any worsening of his hematoma. He was transferred to the medical floor where his counts stabilized and he showed no further acute findings of blood loss. His leukocytosis and hypotension were initially thought to be infectious however his workup remained negative. Past Medical History: HTN DM CKD MGUS Social History: ___ Family History: None significant per patient Physical Exam: ADMISSION EXAM ============== VITALS: Reviewed in metavision GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM NECK: supple, JVP not elevated LUNGS: Clear to auscultation bilaterally CV: Tachycardic, regular rate, no murmurs, rubs, gallops ABD: Soft, non-tender, non-distended EXT: Warm, well perfused, 2+ pulses SKIN: Hematoma, tender, on right pelvis NEURO: AOx3, moving all extremities well DISCHARGE EXAM ============== VITALS: 98.2 97/59 89 20 98%RA GENERAL: Pleasant elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva pink. NECK: Supple with no LAD or JVD. CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. LUNGS: Resp unlabored, no accessory muscle use. Lungs CTA bilaterally. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: No c/c/e. Distal pulses palpable and symmetric. NEURO: ___ strength in bilateral upper extremities, proximally and distally. ___ strength L ___, 3+/5 strength in ___ (limited due to pain). ___ dorsiflexion/plantarflexion bilaterally. SKIN: Warm, dry, no rashes or obvious lesions. Pertinent Results: ADMISSION LABS ============== ___ 05:00AM BLOOD WBC-32.4* RBC-5.00 Hgb-14.7 Hct-46.6 MCV-93 MCH-29.4 MCHC-31.5* RDW-14.4 RDWSD-49.1* Plt ___ ___ 05:00AM BLOOD Neuts-89.9* Lymphs-3.2* Monos-5.4 Eos-0.0* Baso-0.2 Im ___ AbsNeut-29.11* AbsLymp-1.03* AbsMono-1.75* AbsEos-0.01* AbsBaso-0.05 ___ 05:00AM BLOOD Plt ___ ___ 06:41AM BLOOD ___ PTT-28.2 ___ ___ 05:00AM BLOOD ALT-41* AST-51* AlkPhos-59 TotBili-1.0 ___ 05:00AM BLOOD Lipase-60 ___ 05:00AM BLOOD cTropnT-0.03* ___ 05:00AM BLOOD Albumin-3.8 ___ 07:00AM BLOOD Calcium-8.5 Phos-7.3* Mg-2.1 ___ 05:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:27AM BLOOD ___ pO2-31* pCO2-39 pH-7.20* calTCO2-16* Base XS--12 ___ 06:24AM BLOOD Glucose-431* Na-130* K-7.8* Cl-101 calHCO3-15* NOTABLE LABS ============ ___ 07:27AM BLOOD Lactate-9.4* ___ 10:20AM BLOOD Glucose-316* Lactate-4.9* Na-132* K-5.9* Cl-107 calHCO3-18* ___ 01:53PM BLOOD Lactate-3.7* ___ 08:30PM BLOOD Lactate-2.7* ___ 04:19AM BLOOD Lactate-1.1 MICRO ===== ___ 7:00 am BLOOD CULTURE (1 out of 4 bottles) Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ ___ ___ - ___. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Two sets of blood cultures from ___ NGTD at time of discharge. Urine cultures from ___ negative. IMAGING ======= ___ CT C SPINE IMPRESSION: 1. No evidence for a fracture. 2. Minimal anterolisthesis of C3 on C4, of unknown chronicity in the absence of comparison exams, though most likely degenerative. 3. Multilevel degenerative disease. ___ NCHCT IMPRESSION: No evidence for acute intracranial abnormalities. ___ CT ABD/PELVIS IMPRESSION: 1. Comminuted, nondisplaced fracture of the right posterior ilium extending to the right sacroiliac joint resulting in right SI joint diastasis. 1.8 cm diastasis of the pubic symphysis. Findings are compatible with an unstable, AP compression type pelvic fracture. 2. Extensive stranding and hematoma within the anterior pelvis and space of Retzius. Questionable small focal defect in the anterior superior bladder wall which raises the concern for bladder wall injury, and further evaluation with CT cystogram is recommended. Additionally, please note that in the absence of intravenous contrast, this study does not assess for active extravasation. 3. Extensive subcutaneous fat stranding and hematoma anterior to the pubic symphysis and within the right anterior pelvic wall, extending to the right groin. 4. Cholelithiasis. ___ CXR IMPRESSION: No acute cardiopulmonary process. ___ CT PYELOGRAM IMPRESSION: 1. No evidence of traumatic bladder injury. 2. Lucency spanning the spinous processes of S1 and S2 is suggestive of fracture, however, clinical correlation is recommended to determine chronicity. Additional fractures and pubic symphysis diastasis as previously described. 3. Similar appearance of the known right pelvic fracture and hematoma involving the anterior abdominal wall, perivesicular soft tissue and right gluteal soft tissues. ___ CT ABD PELVIS IMPRESSION: 1. No evidence for new or increased retroperitoneal hematoma. Mild decrease in size of intrapelvic, anterior abdominal wall and perivesicular soft tissue stranding and likely hematoma. Slightly worsened bilateral gluteal soft tissue stranding. 2. No significant change in the comminuted, nondisplaced fracture of the right posterior ilium. Diastasis of the pubic symphysis measures 1.5 cm, slightly decreased from prior. 3. Minimally displaced fracture of the superior median sacral crest. DISCHARGE LABS ============== Brief Hospital Course: Mr. ___ is an ___ man with a history of T2DM and CKD who presented after a fall down stairs, found to have a pelvic fracture and lab abnormalities including leukocytosis, elevated lactate, new ___, and hyperglycemia, who was initially admitted to the MICU, then transferred to the floor for further management. He was found to have a non displaced pelvic fx which was treated conservatively and did not require operative intervention. His leukocytosis and borderline hypotension (which did not require a pressor) were initially attributed to infection; he had a set of positive blood cultures which later resulted as coagulase negative staph and was considered contaminant. His leukocytosis has been attributed to a stress response since he did not have any fevers and his WBC continued to trend down even off antibiotics. Anemia remained an issue where his H&H has drifted from the range of 17 (baseline) to ___, but he has had no signs to suggest worsening of bleeding in the pelvis. ACUTE ISSUES: ============ # Non-displaced pelvic fracture S/p mechanical fall. The patient was evaluated by orthopedics, and they recommended non-operative management. He was discharged to rehab, with arrangements for followup with ortho trauma clinic in 1 month. # Acute blood loss anemia # Pelvic hematoma Patient with Hgb 14.6 on admission, from baseline of ~17 (polycythemia, also uses testosterone supplements). Hgb further decreased to ___ after 5L IVF, then decreased further yet to ~10. Likely some component of hemodilution after significant volume resuscitation. However, given his pelvic hematoma identified on CT A/P, probably also a component of acute blood loss anemia. Fortunately, repeat CT scan on ___ showed hematoma stable in size. Hgb remained stable >10, and the patient remained hemodynamically stable after initial fluid repletion. Low suspicion for hemolysis. Blood pressure remained stable suggesting against new or worsening bleeding in the pelvis. # Hypovolemic shock, resolved # Leukocytosis The patient was hypotensive as low as 79/54 on admission, improved to normotension after IVF repletion. Differential for his shock includes hypovolemic and distributive (namely, sepsis). Given his leukocytosis and tachycardia, he did meet criteria for sepsis given feasible infectious source. ___ bottles blood cultures grew coagulase negative staph, likely contaminant. Sepsis is less likely the cause of his hypovolemia. His leukocytosis seems more likely to be a stress response to his hip fracture. He was started on empiric antibiotics with Vancomycin and Ceftriaxone (day ___, but given 2 days of negative cultures apart from that single bottle and lack of localizing infectious symptoms, antibiotics were discontinued (___). He had no fevers and his white blood cell count trended down while off antibiotics. Repeat blood cultures remained negative. # ___ on CKD III The patient's creatinine was 3.7 on admission, up from 1.5 at baseline. It returned to normal after ample fluid resuscitation. The etiology of the ___ was thought to be pre-renal in the setting of severe dehydration. # HTN The patient's home lisinopril was held on admission in the setting of shock, ___, and concern for acute bleed. It was resumed prior to discharge after his blood pressure returned to normal, his ___ resolved, and his Hgb stabilized. CHRONIC ISSUES: ============== # Hyperglycemia (resolved) # T2DM (last Hba1c 6.8 on ___ Initially with blood glucose > 500. No ketonuria. No hx DKA or HHS. Likely stress response as above. No altered mental status to suggest HHS. Was placed on insulin gtt on admission with improvement. Upon transfer to the floor, he was maintained on ISS. His home oral anti-hyperglycemics were held on admission and resumed at the time of discharge. Of note he remains on glipizide and was asked to discuss continuation of this with his nephrologist/PCP in case his creatinine worsens over time. # HLD - The patient's home simvastatin was initially held in the setting of elevated CPK. It was restarted prior to discharge after CPK normalized. - His home ASA was initially held given concern for active bleed. It was resumed prior to discharge after blood counts stabilized. # Testosterone therapy The patient has been on testosterone therapy for years, has continued it as he was never told to stop. His testosterone supplementation was held on admission, and was not resumed at time of discharge. He would benefit from outpatient endocrinology evaluation of his ongoing need for testosterone after discussion with PCP. #Code status: Full #Health care proxy/emergency contact: ___, daughter, ___ TRANSITIONAL ISSUES: ================== [ ] Please ensure that the patient follows up in ___ orthopedics trauma clinic with Dr. ___. An appointment has been scheduled. He should be getting a repeat x-ray on the day of his appointment. [ ] Please check a repeat CBC on ___. His hemoglobin remained stable >10 in the days leading up to discharge, and his pelvic hematoma appeared stable in size on last imaging (___). If significant drop in hemoglobin, would consider CT abdomen/pelvis to assess for ongoing bleeding. - DISCHARGE H/H: 9.8/30.0 [ ] The patient is on glipizide and sitagliptin for his diabetes. These were held on admission in the setting of ___. They were resumed at time of discharge, but given the patient's borderline renal function, could consider seeking alternative agents with fewer risks in chronic kidney disease. [ ] The patient has reportedly been on long-term testosterone therapy, although he states that he has continued it because he was never told to stop. The testosterone was held on this admission and not resumed at discharge. He would benefit from outpatient endocrinology evaluation of his ongoing need for testosterone. [ ] Please note that the patient's HR has been between ___ 100s while in the hospital and appears to have been in this range on review of his outpatient records from the past multiple years. He is asymptomatic and appears euvolemic. Time spent coordinating the discharge of this patient: 50 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 10 mg PO DAILY 2. Januvia (SITagliptin) 50 mg oral DAILY 3. Lisinopril 2.5 mg PO DAILY 4. Simvastatin 20 mg PO QPM 5. testosterone cypionate UNKNOWN injection ASDIR 6. Aspirin 81 mg PO DAILY 7. Vitamin E 400 UNIT PO DAILY 8. Ascorbic Acid ___ mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 3. Ascorbic Acid ___ mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. GlipiZIDE XL 10 mg PO DAILY 6. Januvia (SITagliptin) 50 mg oral DAILY 7. Lisinopril 2.5 mg PO DAILY 8. Simvastatin 20 mg PO QPM 9. Vitamin D 1000 UNIT PO DAILY 10. Vitamin E 400 UNIT PO DAILY 11. HELD- testosterone cypionate UNKNOWN injection ASDIR This medication was held. Do not restart testosterone cypionate until told by your doctor to restart it Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: non-displaced pelvic fracture status post mechanical fall hypovolemic shock acute kidney injury 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 to participate in your care. WHY WAS I ADMITTED TO THE HOSPITAL? You fell at home while walking upstairs to the attic. You were unable to get back up. WHAT HAPPENED WHILE I WAS HERE? - We found that you had broken your hip. The orthopedic surgery team came to see you, and they decided that you did not need surgery to fix this broken bone. - We gave you medicine to control your pain. - You were very dehydrated and your blood pressure was low, so we gave you fluid through the IV. This fixed your blood pressure. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? - We recommend that you spend some time at a rehab facility to work with physical therapy and regain your strength. - Please take all of your medications as instructed. - Please go to all of your follow up doctor's appointments, including your scheduled appointment with orthopedics (see below). We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___	[ "S32391A", "T794XXA", "N179", "E1122", "I959", "D62", "E872", "E1165", "D472", "E875", "W108XXA", "Y92018", "D751", "I129", "E785", "N183", "Z79890" ]	Allergies: Sulfa (Sulfonamide Antibiotics) Chief Complaint: S/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with T2DM and CKD who presented after falling backwards off [MASKED] step going up to attic. He reports that he lost his footing and fell backwards onto his back and his head hit the floor. Had significant lower back pain immediately after the fall, had trouble getting up. Had to scoot downstairs to get to the phone. He denied numbness/tingling/weakness, No loss of continence or consciousness. No saddle anesthesia. Took 1g acetaminophen at home with no relief. Notably, the patient states that prior to falling he was feeling completely well. No dizziness or light-headedness at time of fall. And in recent days, no infectious symptoms. No cough, dyspnea, abdominal pain, diarrhea, urinary symptoms. A CT scan of the pelvis showed a non displaced fracture of the right iliac bone and a 1.8 cm diastasis of the pubic symphysis indicating unstable pelvic fracture. Additionally CT showed extensive stranding and hematoma of the retropubic area. Given CT also howing anterior bladder wall defect could represent bladder wall injury, CT cystogram was obtained. He was admitted to the ICU after being found to have hypotension, leukocytosis and hyperglycemia for further management. He had non-operative, conservative management of his fracture. His blood counts were noted to drift down slowly however he remained hemodynamically stable; a CT was repeated which did not show any worsening of his hematoma. He was transferred to the medical floor where his counts stabilized and he showed no further acute findings of blood loss. His leukocytosis and hypotension were initially thought to be infectious however his workup remained negative. Past Medical History: HTN DM CKD MGUS Social History: [MASKED] Family History: None significant per patient Physical Exam: ADMISSION EXAM ============== VITALS: Reviewed in metavision GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM NECK: supple, JVP not elevated LUNGS: Clear to auscultation bilaterally CV: Tachycardic, regular rate, no murmurs, rubs, gallops ABD: Soft, non-tender, non-distended EXT: Warm, well perfused, 2+ pulses SKIN: Hematoma, tender, on right pelvis NEURO: AOx3, moving all extremities well DISCHARGE EXAM ============== VITALS: 98.2 97/59 89 20 98%RA GENERAL: Pleasant elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva pink. NECK: Supple with no LAD or JVD. CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. LUNGS: Resp unlabored, no accessory muscle use. Lungs CTA bilaterally. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: No c/c/e. Distal pulses palpable and symmetric. NEURO: [MASKED] strength in bilateral upper extremities, proximally and distally. [MASKED] strength L [MASKED], 3+/5 strength in [MASKED] (limited due to pain). [MASKED] dorsiflexion/plantarflexion bilaterally. SKIN: Warm, dry, no rashes or obvious lesions. Pertinent Results: ADMISSION LABS ============== [MASKED] 05:00AM BLOOD WBC-32.4* RBC-5.00 Hgb-14.7 Hct-46.6 MCV-93 MCH-29.4 MCHC-31.5* RDW-14.4 RDWSD-49.1* Plt [MASKED] [MASKED] 05:00AM BLOOD Neuts-89.9* Lymphs-3.2* Monos-5.4 Eos-0.0* Baso-0.2 Im [MASKED] AbsNeut-29.11* AbsLymp-1.03* AbsMono-1.75* AbsEos-0.01* AbsBaso-0.05 [MASKED] 05:00AM BLOOD Plt [MASKED] [MASKED] 06:41AM BLOOD [MASKED] PTT-28.2 [MASKED] [MASKED] 05:00AM BLOOD ALT-41* AST-51* AlkPhos-59 TotBili-1.0 [MASKED] 05:00AM BLOOD Lipase-60 [MASKED] 05:00AM BLOOD cTropnT-0.03* [MASKED] 05:00AM BLOOD Albumin-3.8 [MASKED] 07:00AM BLOOD Calcium-8.5 Phos-7.3* Mg-2.1 [MASKED] 05:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 07:27AM BLOOD [MASKED] pO2-31* pCO2-39 pH-7.20* calTCO2-16* Base XS--12 [MASKED] 06:24AM BLOOD Glucose-431* Na-130* K-7.8* Cl-101 calHCO3-15* NOTABLE LABS ============ [MASKED] 07:27AM BLOOD Lactate-9.4* [MASKED] 10:20AM BLOOD Glucose-316* Lactate-4.9* Na-132* K-5.9* Cl-107 calHCO3-18* [MASKED] 01:53PM BLOOD Lactate-3.7* [MASKED] 08:30PM BLOOD Lactate-2.7* [MASKED] 04:19AM BLOOD Lactate-1.1 MICRO ===== [MASKED] 7:00 am BLOOD CULTURE (1 out of 4 bottles) Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [MASKED]: Reported to and read back by [MASKED] @ [MASKED] [MASKED] - [MASKED]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Two sets of blood cultures from [MASKED] NGTD at time of discharge. Urine cultures from [MASKED] negative. IMAGING ======= [MASKED] CT C SPINE IMPRESSION: 1. No evidence for a fracture. 2. Minimal anterolisthesis of C3 on C4, of unknown chronicity in the absence of comparison exams, though most likely degenerative. 3. Multilevel degenerative disease. [MASKED] NCHCT IMPRESSION: No evidence for acute intracranial abnormalities. [MASKED] CT ABD/PELVIS IMPRESSION: 1. Comminuted, nondisplaced fracture of the right posterior ilium extending to the right sacroiliac joint resulting in right SI joint diastasis. 1.8 cm diastasis of the pubic symphysis. Findings are compatible with an unstable, AP compression type pelvic fracture. 2. Extensive stranding and hematoma within the anterior pelvis and space of Retzius. Questionable small focal defect in the anterior superior bladder wall which raises the concern for bladder wall injury, and further evaluation with CT cystogram is recommended. Additionally, please note that in the absence of intravenous contrast, this study does not assess for active extravasation. 3. Extensive subcutaneous fat stranding and hematoma anterior to the pubic symphysis and within the right anterior pelvic wall, extending to the right groin. 4. Cholelithiasis. [MASKED] CXR IMPRESSION: No acute cardiopulmonary process. [MASKED] CT PYELOGRAM IMPRESSION: 1. No evidence of traumatic bladder injury. 2. Lucency spanning the spinous processes of S1 and S2 is suggestive of fracture, however, clinical correlation is recommended to determine chronicity. Additional fractures and pubic symphysis diastasis as previously described. 3. Similar appearance of the known right pelvic fracture and hematoma involving the anterior abdominal wall, perivesicular soft tissue and right gluteal soft tissues. [MASKED] CT ABD PELVIS IMPRESSION: 1. No evidence for new or increased retroperitoneal hematoma. Mild decrease in size of intrapelvic, anterior abdominal wall and perivesicular soft tissue stranding and likely hematoma. Slightly worsened bilateral gluteal soft tissue stranding. 2. No significant change in the comminuted, nondisplaced fracture of the right posterior ilium. Diastasis of the pubic symphysis measures 1.5 cm, slightly decreased from prior. 3. Minimally displaced fracture of the superior median sacral crest. DISCHARGE LABS ============== Brief Hospital Course: Mr. [MASKED] is an [MASKED] man with a history of T2DM and CKD who presented after a fall down stairs, found to have a pelvic fracture and lab abnormalities including leukocytosis, elevated lactate, new [MASKED], and hyperglycemia, who was initially admitted to the MICU, then transferred to the floor for further management. He was found to have a non displaced pelvic fx which was treated conservatively and did not require operative intervention. His leukocytosis and borderline hypotension (which did not require a pressor) were initially attributed to infection; he had a set of positive blood cultures which later resulted as coagulase negative staph and was considered contaminant. His leukocytosis has been attributed to a stress response since he did not have any fevers and his WBC continued to trend down even off antibiotics. Anemia remained an issue where his H&H has drifted from the range of 17 (baseline) to [MASKED], but he has had no signs to suggest worsening of bleeding in the pelvis. ACUTE ISSUES: ============ # Non-displaced pelvic fracture S/p mechanical fall. The patient was evaluated by orthopedics, and they recommended non-operative management. He was discharged to rehab, with arrangements for followup with ortho trauma clinic in 1 month. # Acute blood loss anemia # Pelvic hematoma Patient with Hgb 14.6 on admission, from baseline of ~17 (polycythemia, also uses testosterone supplements). Hgb further decreased to [MASKED] after 5L IVF, then decreased further yet to ~10. Likely some component of hemodilution after significant volume resuscitation. However, given his pelvic hematoma identified on CT A/P, probably also a component of acute blood loss anemia. Fortunately, repeat CT scan on [MASKED] showed hematoma stable in size. Hgb remained stable >10, and the patient remained hemodynamically stable after initial fluid repletion. Low suspicion for hemolysis. Blood pressure remained stable suggesting against new or worsening bleeding in the pelvis. # Hypovolemic shock, resolved # Leukocytosis The patient was hypotensive as low as 79/54 on admission, improved to normotension after IVF repletion. Differential for his shock includes hypovolemic and distributive (namely, sepsis). Given his leukocytosis and tachycardia, he did meet criteria for sepsis given feasible infectious source. [MASKED] bottles blood cultures grew coagulase negative staph, likely contaminant. Sepsis is less likely the cause of his hypovolemia. His leukocytosis seems more likely to be a stress response to his hip fracture. He was started on empiric antibiotics with Vancomycin and Ceftriaxone (day [MASKED], but given 2 days of negative cultures apart from that single bottle and lack of localizing infectious symptoms, antibiotics were discontinued ([MASKED]). He had no fevers and his white blood cell count trended down while off antibiotics. Repeat blood cultures remained negative. # [MASKED] on CKD III The patient's creatinine was 3.7 on admission, up from 1.5 at baseline. It returned to normal after ample fluid resuscitation. The etiology of the [MASKED] was thought to be pre-renal in the setting of severe dehydration. # HTN The patient's home lisinopril was held on admission in the setting of shock, [MASKED], and concern for acute bleed. It was resumed prior to discharge after his blood pressure returned to normal, his [MASKED] resolved, and his Hgb stabilized. CHRONIC ISSUES: ============== # Hyperglycemia (resolved) # T2DM (last Hba1c 6.8 on [MASKED] Initially with blood glucose > 500. No ketonuria. No hx DKA or HHS. Likely stress response as above. No altered mental status to suggest HHS. Was placed on insulin gtt on admission with improvement. Upon transfer to the floor, he was maintained on ISS. His home oral anti-hyperglycemics were held on admission and resumed at the time of discharge. Of note he remains on glipizide and was asked to discuss continuation of this with his nephrologist/PCP in case his creatinine worsens over time. # HLD - The patient's home simvastatin was initially held in the setting of elevated CPK. It was restarted prior to discharge after CPK normalized. - His home ASA was initially held given concern for active bleed. It was resumed prior to discharge after blood counts stabilized. # Testosterone therapy The patient has been on testosterone therapy for years, has continued it as he was never told to stop. His testosterone supplementation was held on admission, and was not resumed at time of discharge. He would benefit from outpatient endocrinology evaluation of his ongoing need for testosterone after discussion with PCP. #Code status: Full #Health care proxy/emergency contact: [MASKED], daughter, [MASKED] TRANSITIONAL ISSUES: ================== [ ] Please ensure that the patient follows up in [MASKED] orthopedics trauma clinic with Dr. [MASKED]. An appointment has been scheduled. He should be getting a repeat x-ray on the day of his appointment. [ ] Please check a repeat CBC on [MASKED]. His hemoglobin remained stable >10 in the days leading up to discharge, and his pelvic hematoma appeared stable in size on last imaging ([MASKED]). If significant drop in hemoglobin, would consider CT abdomen/pelvis to assess for ongoing bleeding. - DISCHARGE H/H: 9.8/30.0 [ ] The patient is on glipizide and sitagliptin for his diabetes. These were held on admission in the setting of [MASKED]. They were resumed at time of discharge, but given the patient's borderline renal function, could consider seeking alternative agents with fewer risks in chronic kidney disease. [ ] The patient has reportedly been on long-term testosterone therapy, although he states that he has continued it because he was never told to stop. The testosterone was held on this admission and not resumed at discharge. He would benefit from outpatient endocrinology evaluation of his ongoing need for testosterone. [ ] Please note that the patient's HR has been between [MASKED] 100s while in the hospital and appears to have been in this range on review of his outpatient records from the past multiple years. He is asymptomatic and appears euvolemic. Time spent coordinating the discharge of this patient: 50 minutes Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE XL 10 mg PO DAILY 2. Januvia (SITagliptin) 50 mg oral DAILY 3. Lisinopril 2.5 mg PO DAILY 4. Simvastatin 20 mg PO QPM 5. testosterone cypionate UNKNOWN injection ASDIR 6. Aspirin 81 mg PO DAILY 7. Vitamin E 400 UNIT PO DAILY 8. Ascorbic Acid [MASKED] mg PO DAILY 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 3. Ascorbic Acid [MASKED] mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. GlipiZIDE XL 10 mg PO DAILY 6. Januvia (SITagliptin) 50 mg oral DAILY 7. Lisinopril 2.5 mg PO DAILY 8. Simvastatin 20 mg PO QPM 9. Vitamin D 1000 UNIT PO DAILY 10. Vitamin E 400 UNIT PO DAILY 11. HELD- testosterone cypionate UNKNOWN injection ASDIR This medication was held. Do not restart testosterone cypionate until told by your doctor to restart it Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: non-displaced pelvic fracture status post mechanical fall hypovolemic shock acute kidney injury 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 to participate in your care. WHY WAS I ADMITTED TO THE HOSPITAL? You fell at home while walking upstairs to the attic. You were unable to get back up. WHAT HAPPENED WHILE I WAS HERE? - We found that you had broken your hip. The orthopedic surgery team came to see you, and they decided that you did not need surgery to fix this broken bone. - We gave you medicine to control your pain. - You were very dehydrated and your blood pressure was low, so we gave you fluid through the IV. This fixed your blood pressure. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? - We recommend that you spend some time at a rehab facility to work with physical therapy and regain your strength. - Please take all of your medications as instructed. - Please go to all of your follow up doctor's appointments, including your scheduled appointment with orthopedics (see below). We wish you the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "N179", "E1122", "D62", "E872", "E1165", "I129", "E785" ]	[ "S32391A: Other fracture of right ilium, initial encounter for closed fracture", "T794XXA: Traumatic shock, initial encounter", "N179: Acute kidney failure, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I959: Hypotension, unspecified", "D62: Acute posthemorrhagic anemia", "E872: Acidosis", "E1165: Type 2 diabetes mellitus with hyperglycemia", "D472: Monoclonal gammopathy", "E875: Hyperkalemia", "W108XXA: Fall (on) (from) other stairs and steps, initial encounter", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "D751: Secondary polycythemia", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E785: Hyperlipidemia, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "Z79890: Hormone replacement therapy" ]
19,974,520	23,580,334	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Novocain / Asparagus Attending: ___. Chief Complaint: COUGH and FEVER Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx bronchiectasis presenting with ongoing purulent cough, fevers and weakness for one month failing a 10-day course of Augment. She has had a productive cough since the beginning of ___ which is continuing to worsen. She reports greenish/yellow sputum with no blood ___ sputum. Notes that her ribs on the right hurt "from coughing". Has been taking guaifenesin (Mucinex) and Tylenol and not feeling better. Has had reduced PO because she feels globally weak. Queasy feeling but no bowel movement changes and no vomiting. Notes her ankles are more swollen than usual. She also endorses fatigue and night sweats. She reports her symptoms of fever (as high as 102), sputum, cough, and SOB began ___ ___. She began a course of Augmentin on ___ after visiting her PCP but the script was changed to levofloxacin when a CXR showed multifocal pneumonia. However, she reports not taking the levofloxacin and choosing to finish the Augment course instead. Her symptoms improved slightly on antibiotics, but resumed when her course finished. She presented to her pulmonologist Dr. ___ on ___ with worsening purulent sputum, fever to 102, chest pain and fatigue. On exam she was tachycardic, sat 96%RA, afebrile, coughing thick green sputum, decreased breath sounds ___ lower left lobe and rhonchi diffusely, and edema ___ legs bilaterally to mid shins. CXR obtained at the visit (___) showed LLL and lingular infiltrates with effusion concerning. Also of note is that bronchoalveolar lavage ___ ___ grew aspergillus. She was sent to ED by her pulmonologist for further evaluation. Past Medical History: 1. Osteoporosis. 2. Basal cell carcinoma of the right forehead, surgically removed 3. Gastroesophageal reflux. 4. Weight loss. 5. Tinnitus. 6. Vertigo 7. Bronchiectasis chest CT scan. 8. Heart murmur (MVP) 9. Panic disorder Social History: ___ Family History: Father died of brain tumor ___ his ___. Mother died ___ ___ of heart disease. She does not have any siblings. Physical Exam: ADMISSION PHYSCIAL EXAM: ========================= VS - 98.5 114/58 90 18 100% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: Decreased BS on L base, soft rales at the right base ABDOMEN: nondistended, +BS, nontender ___ all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: 1+ pitting edema to mid-shin PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ========================= VS - Tc 97.6 Tm 98.3 BP 115/61 HR 95 RR 18 O297%RA GENERAL: woman lying ___ bed ___ NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition, mild fissuring ___ tongue along central sulcus, OP clear CARDIAC: RRR, S1/S2, ___ systolic murmur radiating to left apex, gallops, or rubs LUNG: basilar crackles on left side, high-pitched end-inspiratory sound heard inconsistently bilaterally ___ along upper and lower lung fields ABDOMEN: nondistended, +BS EXTREMITIES: trace edema to mid-shin NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ================= ___ 10:55AM BLOOD WBC-10.2# RBC-3.42 Hgb-9.6* Hct-30.6* MCV-90 MCH-28.1 MCHC-31.4* RDW-14.6 RDWSD-46.7* Plt ___ ___ 10:55AM BLOOD Neuts-79.1* Lymphs-10.1* Monos-9.4 Eos-0.5* Baso-0.3 Im ___ AbsNeut-8.11* AbsLymp-1.03* AbsMono-0.96* AbsEos-0.05 AbsBaso-0.03 ___ 02:48PM BLOOD Glucose-91 UreaN-11 Creat-0.4 Na-132* K-6.1* Cl-90* HCO3-30 AnGap-18 ___ 02:48PM BLOOD Albumin-3.2* ___ 02:54PM BLOOD Lactate-1.6 Na-133 K-4.6 DISCHARGE LABS: ================= ___ 06:15AM BLOOD WBC-7.0 RBC-3.29* Hgb-9.2* Hct-29.1* MCV-88 MCH-28.0 MCHC-31.6* RDW-14.6 RDWSD-46.9* Plt ___ ___ 06:15AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-135 K-4.6 Cl-94* HCO3-35* AnGap-11 ___ 06:15AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0 PERTINENT FINDINGS: ==================== Labs: ------ ___ 06:40AM BLOOD calTIBC-293 VitB12-735 Folate-15.7 Ferritn-67 TRF-225 ___ 02:48PM BLOOD Albumin-3.2* Micro: ------ ___ 05:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 05:00PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG ___ 05:00PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-2 ___ 05:00PM URINE Mucous-RARE ___ 05:00PM URINE Hours-RANDOM UreaN-280 Creat-26 Na-154 ___ 2:42 pm BLOOD CULTUREx2 Blood Culture, Routine (Pending): ___ 11:39 am SPUTUM Source: Expectorated. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested ___ cases of treatment failure ___ life-threatening infections.. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. ___ 5:15 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information. Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, ___ infected patients the excretion of antigen ___ urine may vary. ___ 2:38 am MRSA SCREEN Source: Nasal swab. *FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated Imaging: ---------- ___ Sinus tachycardia. Low limb lead voltage. Biatrial abnormality. Delayed R wave transition. Compared to the previous tracing of ___ the rate has increased. Otherwise, no diagnostic interim change. Read by: ___ ___ Axes Rate PR QRS QT QTc (___) P QRS T 107 171 80 ___ 70 -10 35 CXR ___ Compared to chest radiographs since ___, most recently ___. Large scale pneumonia ___ the left lower lobe and lingula is new, a smaller region of consolidation ___ the right lung base has a different distribution than before. Previous right upper lobe pneumonia left a region of bronchiectatic scarring. Moderate left pleural effusion is new. Multifocal pneumonia could be due to bronchiectasis, chronic aspiration, or even cryptogenic organizing pneumonia. Volume of left pleural effusion must be followed for any indication that the patient may be developing empyema. Heart size normal. No pneumothorax. CTA Chest ___: 1. Irregular inferior lingular, right upper lobe and bilateral lower lobe consolidations with areas of peribronchial nodularity compatible with multifocal pneumonia. 2. Small left-sided pleural effusion. 3. Worsening widespread bronchiectasis with bilateral lower lobe predominance with multiple areas of mucous impaction. 4. Mild hilar and mediastinal adenopathy, increased since ___, potentially reactive. 5. No evidence of pulmonary embolism or aortic abnormality. TTE ___: The left atrium is normal ___ size. The estimated right atrial pressure is ___ mmHg. Normal left ventricular wall thickness, cavity size, and global systolic function (3D LVEF = 63 %). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is mild bileaflet leaflet mitral valve prolapse. Trivial mitral regurgitation is seen. A late systolic jet of The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild mitral valve prolapse with trivial mitral regurgitation. Compared with the report of the prior study (images unavailable for review) of ___, the estimated LV filling pressure is elevated; other findings are similar. Brief Hospital Course: ___ hx bronchiectasis presenting with ongoing purulent cough, fevers, and weakness for one month failing a 10-day course of Augmentin. She visited her pulmonologist Dr. ___ collected a sputum sample and a CXR. The CXR showed bronchiectasis and left lower and lingular lobe infiltrates concerning for a multifocal pneumonia as well as a left pleural effusion. She was referred to the ED, where a CTA was performed. There was no evidence of PE and the left-sided pleural effusion was revealed to be minimal. Influenza and respiratory viral antigen screens were also performed and were negative. Legionella urinary antigen was performed and was negative. Blood cultures were also drawn and the results are still pending, though no growth has been noted after 3 days. Because the patient presented with an apparent multifocal pneumonia that had lasted several weeks and failed a course of Augmentin, she was started on broad-spectrum antibiotics of Cefepime/Levofloxacin/vancomycin to cover typical causes of community-acquired pneumonia as well as Pseudomonas, MRSA, and atypical causes of pneumonia. Furthermore, she received acapella and incentive spirometry to promote pulmonary hygiene. She received three days of IV vancomycin, cefepime, and levofloxacin. Her finalized sputum cultures grew beta-lactamase negative Haemophilus influenzae and normal respiratory flora, so she is being discharged on a 7-day course of levofloxacin 750MG PO, which should have sufficient coverage against H. influenzae and other typical causes of community-acquired pneumonia. Laboratory tests also revealed an albumin of less than 3 and hemoglobin ___ the ___ range. The patient reported a history of poor PO intake during the past few months and reports a primarily vegetarian diet. This finding was concerning for poor nutrition. She was seen by a nutritionist and was recommended meal supplementation, for example, with Ensure. The patient also reported some uncertainty ___ going home to live independently and met with one of our social workers to explore options that may lend her some help at home. Finally, she was also evaluated by ___ and was deemed fit and able to go home without the need for physical therapy. She was discharged with regular diet. TRANSITIONAL ISSUES: ====================== [ ] Complete 7 day course of PO Levofloxacin 750mg Qdaily (Last ___. [ ] Follow up with PCP office, esp. regarding anemia and fatigue. Consider Iron supplementation and dietary modification ___ the future. [ ] Follow up with pulmonologist Dr. ___ antibiotic course finishes for PFTs and repeat CXR [ ] Osteoporosis, not currently on Calcium supplementation, may want to consider. #Full code ___ (Friend) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 2. estradiol 0.01 % (0.1 mg/gram) vaginal unknown 3. Omeprazole 40 mg PO BID 4. Vitamin B Complex 1 CAP PO DAILY 5. Vitamin D ___ UNIT PO DAILY 6. Magnesium Citrate 300 mL PO ONCE Discharge Medications: 1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 2. Omeprazole 40 mg PO BID 3. Vitamin B Complex 1 CAP PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. estradiol 0.01 % (0.1 mg/gram) vaginal unknown 6. Magnesium Citrate 300 mL PO ONCE 7. Levofloxacin 750 mg PO Q24H Pneumonia Duration: 4 Days RX levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #5 Tablet Refills:0 8. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose Apply to areas of chest pain, 12 hours on, 12 hours off. RX lidocaine 5 % Apply thin layer over affected area once a day Refills:0 9. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough RX dextromethorphan-guaifenesin [Guaifenesin-DM] 100 mg-10 mg/5 mL 10 mg by mouth every six (6) hours Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY --------- -Pneumonia -Anemia SECONDARY ------------ -Bronchiectasis -Hyponatremia -Osteoporosis -GERD -Panic 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 ___ for shortness of breath and concern for pneumonia. WHAT WAS DONE DURING YOUR HOSPITAL STAY? ========================================== - An x-ray and CAT scan of your chest showed signs of pneumonia ___ addition to your known diagnosis of bronchiectasis. - You were started on IV antibiotics. - Sputum cultures as well as blood and urine cultures were sent off. - Sputum cultures grew a likely source of infection, a bacteria called Haemophilus influenzae. - A blood count test revealed you have moderate anemia. - You were transitioned to oral antibiotics, called Levofloxacin. - You were deemed to be stable for discharge. WHAT SHOULD YOU DO FOLLOWING DISCHARGE? ========================================= - Please take your medications as regularly prescribed. -- Finish your 7 day course of Levaquin antibiotics (LAST DAY = ___ - Follow up with your ___ at your PCP's office on ___ at 10:45 AM - Follow up with your pulmonologist, Dr. ___ on ___ at 9:10. You may call to make a new appointment if you prefer later time. It was a pleasure taking care of you during your hospital stay. If you have any questions about the care you received, please do not hesitate to ask. We wish you the best ___ health ___ the future. Sincerely, Your Inpatient ___ Care Team Followup Instructions: ___	[ "J14", "J918", "E46", "R64", "D649", "E8809", "Z681", "J479", "M810", "Z85828", "K219", "Z87891", "E781", "F410", "R600", "Z9181" ]	Allergies: Novocain / Asparagus Chief Complaint: COUGH and FEVER Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with hx bronchiectasis presenting with ongoing purulent cough, fevers and weakness for one month failing a 10-day course of Augment. She has had a productive cough since the beginning of [MASKED] which is continuing to worsen. She reports greenish/yellow sputum with no blood [MASKED] sputum. Notes that her ribs on the right hurt "from coughing". Has been taking guaifenesin (Mucinex) and Tylenol and not feeling better. Has had reduced PO because she feels globally weak. Queasy feeling but no bowel movement changes and no vomiting. Notes her ankles are more swollen than usual. She also endorses fatigue and night sweats. She reports her symptoms of fever (as high as 102), sputum, cough, and SOB began [MASKED] [MASKED]. She began a course of Augmentin on [MASKED] after visiting her PCP but the script was changed to levofloxacin when a CXR showed multifocal pneumonia. However, she reports not taking the levofloxacin and choosing to finish the Augment course instead. Her symptoms improved slightly on antibiotics, but resumed when her course finished. She presented to her pulmonologist Dr. [MASKED] on [MASKED] with worsening purulent sputum, fever to 102, chest pain and fatigue. On exam she was tachycardic, sat 96%RA, afebrile, coughing thick green sputum, decreased breath sounds [MASKED] lower left lobe and rhonchi diffusely, and edema [MASKED] legs bilaterally to mid shins. CXR obtained at the visit ([MASKED]) showed LLL and lingular infiltrates with effusion concerning. Also of note is that bronchoalveolar lavage [MASKED] [MASKED] grew aspergillus. She was sent to ED by her pulmonologist for further evaluation. Past Medical History: 1. Osteoporosis. 2. Basal cell carcinoma of the right forehead, surgically removed 3. Gastroesophageal reflux. 4. Weight loss. 5. Tinnitus. 6. Vertigo 7. Bronchiectasis chest CT scan. 8. Heart murmur (MVP) 9. Panic disorder Social History: [MASKED] Family History: Father died of brain tumor [MASKED] his [MASKED]. Mother died [MASKED] [MASKED] of heart disease. She does not have any siblings. Physical Exam: ADMISSION PHYSCIAL EXAM: ========================= VS - 98.5 114/58 90 18 100% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: Decreased BS on L base, soft rales at the right base ABDOMEN: nondistended, +BS, nontender [MASKED] all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: 1+ pitting edema to mid-shin PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: ========================= VS - Tc 97.6 Tm 98.3 BP 115/61 HR 95 RR 18 O297%RA GENERAL: woman lying [MASKED] bed [MASKED] NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition, mild fissuring [MASKED] tongue along central sulcus, OP clear CARDIAC: RRR, S1/S2, [MASKED] systolic murmur radiating to left apex, gallops, or rubs LUNG: basilar crackles on left side, high-pitched end-inspiratory sound heard inconsistently bilaterally [MASKED] along upper and lower lung fields ABDOMEN: nondistended, +BS EXTREMITIES: trace edema to mid-shin NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ================= [MASKED] 10:55AM BLOOD WBC-10.2# RBC-3.42 Hgb-9.6* Hct-30.6* MCV-90 MCH-28.1 MCHC-31.4* RDW-14.6 RDWSD-46.7* Plt [MASKED] [MASKED] 10:55AM BLOOD Neuts-79.1* Lymphs-10.1* Monos-9.4 Eos-0.5* Baso-0.3 Im [MASKED] AbsNeut-8.11* AbsLymp-1.03* AbsMono-0.96* AbsEos-0.05 AbsBaso-0.03 [MASKED] 02:48PM BLOOD Glucose-91 UreaN-11 Creat-0.4 Na-132* K-6.1* Cl-90* HCO3-30 AnGap-18 [MASKED] 02:48PM BLOOD Albumin-3.2* [MASKED] 02:54PM BLOOD Lactate-1.6 Na-133 K-4.6 DISCHARGE LABS: ================= [MASKED] 06:15AM BLOOD WBC-7.0 RBC-3.29* Hgb-9.2* Hct-29.1* MCV-88 MCH-28.0 MCHC-31.6* RDW-14.6 RDWSD-46.9* Plt [MASKED] [MASKED] 06:15AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-135 K-4.6 Cl-94* HCO3-35* AnGap-11 [MASKED] 06:15AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0 PERTINENT FINDINGS: ==================== Labs: ------ [MASKED] 06:40AM BLOOD calTIBC-293 VitB12-735 Folate-15.7 Ferritn-67 TRF-225 [MASKED] 02:48PM BLOOD Albumin-3.2* Micro: ------ [MASKED] 05:00PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 05:00PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [MASKED] 05:00PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-2 [MASKED] 05:00PM URINE Mucous-RARE [MASKED] 05:00PM URINE Hours-RANDOM UreaN-280 Creat-26 Na-154 [MASKED] 2:42 pm BLOOD CULTUREx2 Blood Culture, Routine (Pending): [MASKED] 11:39 am SPUTUM Source: Expectorated. GRAM STAIN (Final [MASKED]: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND CHAINS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [MASKED]: MODERATE GROWTH Commensal Respiratory Flora. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested [MASKED] cases of treatment failure [MASKED] life-threatening infections.. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. [MASKED] 5:15 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final [MASKED]: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information. Legionella Urinary Antigen (Final [MASKED]: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, [MASKED] infected patients the excretion of antigen [MASKED] urine may vary. [MASKED] 2:38 am MRSA SCREEN Source: Nasal swab. *FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated Imaging: ---------- [MASKED] Sinus tachycardia. Low limb lead voltage. Biatrial abnormality. Delayed R wave transition. Compared to the previous tracing of [MASKED] the rate has increased. Otherwise, no diagnostic interim change. Read by: [MASKED] [MASKED] Axes Rate PR QRS QT QTc ([MASKED]) P QRS T 107 171 80 [MASKED] 70 -10 35 CXR [MASKED] Compared to chest radiographs since [MASKED], most recently [MASKED]. Large scale pneumonia [MASKED] the left lower lobe and lingula is new, a smaller region of consolidation [MASKED] the right lung base has a different distribution than before. Previous right upper lobe pneumonia left a region of bronchiectatic scarring. Moderate left pleural effusion is new. Multifocal pneumonia could be due to bronchiectasis, chronic aspiration, or even cryptogenic organizing pneumonia. Volume of left pleural effusion must be followed for any indication that the patient may be developing empyema. Heart size normal. No pneumothorax. CTA Chest [MASKED]: 1. Irregular inferior lingular, right upper lobe and bilateral lower lobe consolidations with areas of peribronchial nodularity compatible with multifocal pneumonia. 2. Small left-sided pleural effusion. 3. Worsening widespread bronchiectasis with bilateral lower lobe predominance with multiple areas of mucous impaction. 4. Mild hilar and mediastinal adenopathy, increased since [MASKED], potentially reactive. 5. No evidence of pulmonary embolism or aortic abnormality. TTE [MASKED]: The left atrium is normal [MASKED] size. The estimated right atrial pressure is [MASKED] mmHg. Normal left ventricular wall thickness, cavity size, and global systolic function (3D LVEF = 63 %). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is mild bileaflet leaflet mitral valve prolapse. Trivial mitral regurgitation is seen. A late systolic jet of The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild mitral valve prolapse with trivial mitral regurgitation. Compared with the report of the prior study (images unavailable for review) of [MASKED], the estimated LV filling pressure is elevated; other findings are similar. Brief Hospital Course: [MASKED] hx bronchiectasis presenting with ongoing purulent cough, fevers, and weakness for one month failing a 10-day course of Augmentin. She visited her pulmonologist Dr. [MASKED] collected a sputum sample and a CXR. The CXR showed bronchiectasis and left lower and lingular lobe infiltrates concerning for a multifocal pneumonia as well as a left pleural effusion. She was referred to the ED, where a CTA was performed. There was no evidence of PE and the left-sided pleural effusion was revealed to be minimal. Influenza and respiratory viral antigen screens were also performed and were negative. Legionella urinary antigen was performed and was negative. Blood cultures were also drawn and the results are still pending, though no growth has been noted after 3 days. Because the patient presented with an apparent multifocal pneumonia that had lasted several weeks and failed a course of Augmentin, she was started on broad-spectrum antibiotics of Cefepime/Levofloxacin/vancomycin to cover typical causes of community-acquired pneumonia as well as Pseudomonas, MRSA, and atypical causes of pneumonia. Furthermore, she received acapella and incentive spirometry to promote pulmonary hygiene. She received three days of IV vancomycin, cefepime, and levofloxacin. Her finalized sputum cultures grew beta-lactamase negative Haemophilus influenzae and normal respiratory flora, so she is being discharged on a 7-day course of levofloxacin 750MG PO, which should have sufficient coverage against H. influenzae and other typical causes of community-acquired pneumonia. Laboratory tests also revealed an albumin of less than 3 and hemoglobin [MASKED] the [MASKED] range. The patient reported a history of poor PO intake during the past few months and reports a primarily vegetarian diet. This finding was concerning for poor nutrition. She was seen by a nutritionist and was recommended meal supplementation, for example, with Ensure. The patient also reported some uncertainty [MASKED] going home to live independently and met with one of our social workers to explore options that may lend her some help at home. Finally, she was also evaluated by [MASKED] and was deemed fit and able to go home without the need for physical therapy. She was discharged with regular diet. TRANSITIONAL ISSUES: ====================== [ ] Complete 7 day course of PO Levofloxacin 750mg Qdaily (Last [MASKED]. [ ] Follow up with PCP office, esp. regarding anemia and fatigue. Consider Iron supplementation and dietary modification [MASKED] the future. [ ] Follow up with pulmonologist Dr. [MASKED] antibiotic course finishes for PFTs and repeat CXR [ ] Osteoporosis, not currently on Calcium supplementation, may want to consider. #Full code [MASKED] (Friend) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 2. estradiol 0.01 % (0.1 mg/gram) vaginal unknown 3. Omeprazole 40 mg PO BID 4. Vitamin B Complex 1 CAP PO DAILY 5. Vitamin D [MASKED] UNIT PO DAILY 6. Magnesium Citrate 300 mL PO ONCE Discharge Medications: 1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 2. Omeprazole 40 mg PO BID 3. Vitamin B Complex 1 CAP PO DAILY 4. Vitamin D [MASKED] UNIT PO DAILY 5. estradiol 0.01 % (0.1 mg/gram) vaginal unknown 6. Magnesium Citrate 300 mL PO ONCE 7. Levofloxacin 750 mg PO Q24H Pneumonia Duration: 4 Days RX levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #5 Tablet Refills:0 8. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose Apply to areas of chest pain, 12 hours on, 12 hours off. RX lidocaine 5 % Apply thin layer over affected area once a day Refills:0 9. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough RX dextromethorphan-guaifenesin [Guaifenesin-DM] 100 mg-10 mg/5 mL 10 mg by mouth every six (6) hours Refills:0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY --------- -Pneumonia -Anemia SECONDARY ------------ -Bronchiectasis -Hyponatremia -Osteoporosis -GERD -Panic 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] for shortness of breath and concern for pneumonia. WHAT WAS DONE DURING YOUR HOSPITAL STAY? ========================================== - An x-ray and CAT scan of your chest showed signs of pneumonia [MASKED] addition to your known diagnosis of bronchiectasis. - You were started on IV antibiotics. - Sputum cultures as well as blood and urine cultures were sent off. - Sputum cultures grew a likely source of infection, a bacteria called Haemophilus influenzae. - A blood count test revealed you have moderate anemia. - You were transitioned to oral antibiotics, called Levofloxacin. - You were deemed to be stable for discharge. WHAT SHOULD YOU DO FOLLOWING DISCHARGE? ========================================= - Please take your medications as regularly prescribed. -- Finish your 7 day course of Levaquin antibiotics (LAST DAY = [MASKED] - Follow up with your [MASKED] at your PCP's office on [MASKED] at 10:45 AM - Follow up with your pulmonologist, Dr. [MASKED] on [MASKED] at 9:10. You may call to make a new appointment if you prefer later time. It was a pleasure taking care of you during your hospital stay. If you have any questions about the care you received, please do not hesitate to ask. We wish you the best [MASKED] health [MASKED] the future. Sincerely, Your Inpatient [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "D649", "K219", "Z87891" ]	[ "J14: Pneumonia due to Hemophilus influenzae", "J918: Pleural effusion in other conditions classified elsewhere", "E46: Unspecified protein-calorie malnutrition", "R64: Cachexia", "D649: Anemia, unspecified", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "Z681: Body mass index [BMI] 19.9 or less, adult", "J479: Bronchiectasis, uncomplicated", "M810: Age-related osteoporosis without current pathological fracture", "Z85828: Personal history of other malignant neoplasm of skin", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "E781: Pure hyperglyceridemia", "F410: Panic disorder [episodic paroxysmal anxiety]", "R600: Localized edema", "Z9181: History of falling" ]
19,974,576	20,930,639	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: vomiting, diarrhea, fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ with metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary s/p 3 cycles of carbotaxol targeting presumed gynecologic primary tumor without significant response, then with exlap (___) concerning for appendiceal primary presenting now with acute onset nausea/vomiting/diarrhea/fever. Interview conducted in ___ w/ family at bedside. She was in USOH until yesterday AM when she rather suddently developed watery diarrhea (nonbloody) and nonbloody nonbilious emesis and has been unable to keep down fluids for 24 hrs. She had chills at home and diffuse abdominal pain and was unable to keep down fluids so came to the ED. No sick contacts. No headache. No body aches. No dysuria, no CP/SOB. Regarding onc history: she saw her oncologist ___ and per notes it seems that they discussed that treatment would be palliative; with that in mind and evidence of disease progression despite therapy at the time, she had previously expressed to them that she would not want more chemo if the intent is palliative. They planned to see her in 4 weeks for follow up. ED course: T 100.0 HR 102 BP 97/50 RR 18 98%RA. 3L IVF given along with 5mg IV morphine and 4mg IV Zofran. CT a/p with contrast showing significant worsening of metastatic disease burden in the abd and pelvis with large predominattly cystic masses in pelvis and widespread omental caking and peritoneal mets. parenchymal cystic lesions in the liver spleen of also enlarged since prior study. No e/o SBO or intraperitoneal free air. Labs with WBC 16 up from 10 in ___, Hct stable at 33 Plts 343. 80% pmns. Chem with na of 132 and bun/cr ___. LFTs normal lipase 15. uA not consistent with infectious process. lactate 2.2. HR down to 77 prior to transfer. Past Medical History: PMH: - Asthma - Osteoporosis - Denies hypertension, diabetes, thromboembolic disease PSH: - Abdominal surgery to remove her placenta post-partum (pt unclear re details, occurred after vaginal delivery, via small infraumbilical 4cm vertical incision) - Ex lap, drainage of ascites, omental bx, peritoneal bx, ovarian bx, ___, ___ ___: - ___ (4 deceased in neonatal period) - SVD x 11 - One pregnancy c/b ? retained placenta, requiring abdominal surgery via vertical 4cm infraumbilical incision PGYN: - Menopausal, late ___ - Denies postmenopausal bleeding - Not currently sexually active - Denies hormonal replacement therapy or history of OCPs - Never had a Pap smear (pt denies and nothing in CHA records since ___ - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts Social History: ___ Family History: - Sister died of liver cancer - No known family history of breast, uterine, ovarian, cervical or colon cancer - No known history of bleeding or clotting disorder Physical Exam: PHYSICAL EXAM: VITAL SIGNS: T afeb 110/60 64 18 94-96% RA General: NAD HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, no masses or hepatosplenomegaly, nontender. Large midline well healed scar LIMBS: 1+ edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Oriented x3. Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed Pertinent Results: ___ 06:30AM BLOOD Glucose-107* UreaN-9 Creat-0.6 Na-133 K-4.0 Cl-102 HCO3-25 AnGap-10 ___ 06:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.6 CT abdomen IMPRESSION: 1. Significant worsening of metastatic disease burden in the abdomen and pelvis, with large predominantly cystic masses in the pelvis and widespread omental caking and peritoneal metastases. 2. Parenchymal cystic lesions in the liver spleen of also enlarged since the prior study. 3. No evidence of bowel obstruction or intraperitoneal free air. Brief Hospital Course: ___ with metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary s/p 3 cycles of carbotaxol targeting presumed gynecologic primary tumor without significant response, then with exlap (___) concerning for appendiceal primary presenting admitted with acute onset nausea/vomiting/diarrhea/fever. # nausea/vomiting/diarrhea/chills - concerning for infectious process given acute onset the day of ED presentation and absence of concerning acute pathology on abdominal exam. WBC elevated at 16 c/w infectious process also. Viral gastroenteritis seemed most likely explanation. CT with significant worsening of metastatic disease burden in the abd and pelvis likely contributor, but worsening disease alone should not cause this constellation of sx (vomiting/diarrhea) unless some obstructive process which is not suggested by imaging. LFTS/lipase reassuring. fevers up to 102.4 during hospitalization. Over course of her hospitalization diarrhea improved, appetite returned (though still weak), and had no vomiting. WBC improved also. C diff/norovirus negative. # Hypotension - resolved after hydration # Hypoxia - developed hypoxia on HD#2 in context of a fever 102.6. CXR normal. Exam unrevealing and so a CTA was obtained. BNP elevated. With stopping of IVF and one dose of Lasix, hypoxia improved. Did not obtain an echocardiogram in light of overall prognosis and this was in setting of very aggressive hydration #Metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary. Discussed with patient and her daughters several times. It was clear that they understood that the patient did not want any more chemotherapy and that her prognosis was grim. We had difficulty with conversations regarding code status as discussed in palliative care note and my notes. The only thing that patient discussed was the desire to die at home.We did try and facilitate home hospice enrollment with ___, but this was not set up before discharge due to holiday. Did not set up home health nurse given insurance issues. TRANSITIONAL ISSUES: - continue to engage family regarding hospice and code status - potentially pursue echocardiogram if pulm edema becomes an issue again Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H pain 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 3. Docusate Sodium 100 mg PO BID 4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 5. Lorazepam 0.5 mg PO QHS:PRN insomnia/agitation/anxiety/nausea 6. Fentanyl Patch 12 mcg/h TD Q72H 7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 8. Venlafaxine XR 75 mg PO DAILY 9. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain 2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 3. Fentanyl Patch 12 mcg/h TD Q72H 4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 5. Lorazepam 0.5 mg PO QHS:PRN insomnia/agitation/anxiety/nausea 6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 7. Prochlorperazine 10 mg PO Q6H:PRN nausea 8. Venlafaxine XR 75 mg PO DAILY ONLY MEDICATION STOPPED WAS COLACE Discharge Disposition: Home Discharge Diagnosis: Gastroenteritis Metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary Pulmonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___, it was a pleasure to care for you during this hospitalization. We believe you picked up a viral illness and you have improved with fluids. We expect that your diarrhea will slowly improve for the next few days Followup Instructions: ___	[ "A084", "C786", "J811", "R509", "I959", "R0902", "R079" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: vomiting, diarrhea, fever Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary s/p 3 cycles of carbotaxol targeting presumed gynecologic primary tumor without significant response, then with exlap ([MASKED]) concerning for appendiceal primary presenting now with acute onset nausea/vomiting/diarrhea/fever. Interview conducted in [MASKED] w/ family at bedside. She was in USOH until yesterday AM when she rather suddently developed watery diarrhea (nonbloody) and nonbloody nonbilious emesis and has been unable to keep down fluids for 24 hrs. She had chills at home and diffuse abdominal pain and was unable to keep down fluids so came to the ED. No sick contacts. No headache. No body aches. No dysuria, no CP/SOB. Regarding onc history: she saw her oncologist [MASKED] and per notes it seems that they discussed that treatment would be palliative; with that in mind and evidence of disease progression despite therapy at the time, she had previously expressed to them that she would not want more chemo if the intent is palliative. They planned to see her in 4 weeks for follow up. ED course: T 100.0 HR 102 BP 97/50 RR 18 98%RA. 3L IVF given along with 5mg IV morphine and 4mg IV Zofran. CT a/p with contrast showing significant worsening of metastatic disease burden in the abd and pelvis with large predominattly cystic masses in pelvis and widespread omental caking and peritoneal mets. parenchymal cystic lesions in the liver spleen of also enlarged since prior study. No e/o SBO or intraperitoneal free air. Labs with WBC 16 up from 10 in [MASKED], Hct stable at 33 Plts 343. 80% pmns. Chem with na of 132 and bun/cr [MASKED]. LFTs normal lipase 15. uA not consistent with infectious process. lactate 2.2. HR down to 77 prior to transfer. Past Medical History: PMH: - Asthma - Osteoporosis - Denies hypertension, diabetes, thromboembolic disease PSH: - Abdominal surgery to remove her placenta post-partum (pt unclear re details, occurred after vaginal delivery, via small infraumbilical 4cm vertical incision) - Ex lap, drainage of ascites, omental bx, peritoneal bx, ovarian bx, [MASKED], [MASKED] [MASKED]: - [MASKED] (4 deceased in neonatal period) - SVD x 11 - One pregnancy c/b ? retained placenta, requiring abdominal surgery via vertical 4cm infraumbilical incision PGYN: - Menopausal, late [MASKED] - Denies postmenopausal bleeding - Not currently sexually active - Denies hormonal replacement therapy or history of OCPs - Never had a Pap smear (pt denies and nothing in CHA records since [MASKED] - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts Social History: [MASKED] Family History: - Sister died of liver cancer - No known family history of breast, uterine, ovarian, cervical or colon cancer - No known history of bleeding or clotting disorder Physical Exam: PHYSICAL EXAM: VITAL SIGNS: T afeb 110/60 64 18 94-96% RA General: NAD HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, no masses or hepatosplenomegaly, nontender. Large midline well healed scar LIMBS: 1+ edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Oriented x3. Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed Pertinent Results: [MASKED] 06:30AM BLOOD Glucose-107* UreaN-9 Creat-0.6 Na-133 K-4.0 Cl-102 HCO3-25 AnGap-10 [MASKED] 06:30AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.6 CT abdomen IMPRESSION: 1. Significant worsening of metastatic disease burden in the abdomen and pelvis, with large predominantly cystic masses in the pelvis and widespread omental caking and peritoneal metastases. 2. Parenchymal cystic lesions in the liver spleen of also enlarged since the prior study. 3. No evidence of bowel obstruction or intraperitoneal free air. Brief Hospital Course: [MASKED] with metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary s/p 3 cycles of carbotaxol targeting presumed gynecologic primary tumor without significant response, then with exlap ([MASKED]) concerning for appendiceal primary presenting admitted with acute onset nausea/vomiting/diarrhea/fever. # nausea/vomiting/diarrhea/chills - concerning for infectious process given acute onset the day of ED presentation and absence of concerning acute pathology on abdominal exam. WBC elevated at 16 c/w infectious process also. Viral gastroenteritis seemed most likely explanation. CT with significant worsening of metastatic disease burden in the abd and pelvis likely contributor, but worsening disease alone should not cause this constellation of sx (vomiting/diarrhea) unless some obstructive process which is not suggested by imaging. LFTS/lipase reassuring. fevers up to 102.4 during hospitalization. Over course of her hospitalization diarrhea improved, appetite returned (though still weak), and had no vomiting. WBC improved also. C diff/norovirus negative. # Hypotension - resolved after hydration # Hypoxia - developed hypoxia on HD#2 in context of a fever 102.6. CXR normal. Exam unrevealing and so a CTA was obtained. BNP elevated. With stopping of IVF and one dose of Lasix, hypoxia improved. Did not obtain an echocardiogram in light of overall prognosis and this was in setting of very aggressive hydration #Metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary. Discussed with patient and her daughters several times. It was clear that they understood that the patient did not want any more chemotherapy and that her prognosis was grim. We had difficulty with conversations regarding code status as discussed in palliative care note and my notes. The only thing that patient discussed was the desire to die at home.We did try and facilitate home hospice enrollment with [MASKED], but this was not set up before discharge due to holiday. Did not set up home health nurse given insurance issues. TRANSITIONAL ISSUES: - continue to engage family regarding hospice and code status - potentially pursue echocardiogram if pulm edema becomes an issue again Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H pain 2. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN SOB 3. Docusate Sodium 100 mg PO BID 4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 5. Lorazepam 0.5 mg PO QHS:PRN insomnia/agitation/anxiety/nausea 6. Fentanyl Patch 12 mcg/h TD Q72H 7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 8. Venlafaxine XR 75 mg PO DAILY 9. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. Acetaminophen 650 mg PO Q6H pain 2. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN SOB 3. Fentanyl Patch 12 mcg/h TD Q72H 4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 5. Lorazepam 0.5 mg PO QHS:PRN insomnia/agitation/anxiety/nausea 6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain 7. Prochlorperazine 10 mg PO Q6H:PRN nausea 8. Venlafaxine XR 75 mg PO DAILY ONLY MEDICATION STOPPED WAS COLACE Discharge Disposition: Home Discharge Diagnosis: Gastroenteritis Metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary Pulmonary edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [MASKED], it was a pleasure to care for you during this hospitalization. We believe you picked up a viral illness and you have improved with fluids. We expect that your diarrhea will slowly improve for the next few days Followup Instructions: [MASKED]	[]	[]	[ "A084: Viral intestinal infection, unspecified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "J811: Chronic pulmonary edema", "R509: Fever, unspecified", "I959: Hypotension, unspecified", "R0902: Hypoxemia", "R079: Chest pain, unspecified" ]
19,974,576	22,382,774	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: metastatic mucinous adenocarcinoma Major Surgical or Invasive Procedure: s/p exploratory laparotomy History of Present Illness: Ms. ___ is a ___ woman seen today in consultation for metastatic mucinous adenocarcinoma of unknown primary though likely gyn in origin, recently started on neoadjuvant chemotherapy. She initially presented for care in ___ in ___. She reports that she was having abdominal pain, diarrhea, bloatedness, decreased appetite, early satiety, weight loss ___ pounds over few months), bright red rectal bleeding, nausea, and heartburn. She denies vaginal bleeding. She had an evaluation in ___. CT scan ___ showed R adnexal hypodense lesion with lobular, well-defined borders, showing multiple septations and linear calcifications measuring 8x4cm and L adnexa measuring 4x3cm with small cystic lesions. Pelvic US ___ showed 7.5 x 6.5 x 7.1cm complex, multiseptated cystic lesion without vascularization. On ___, she had an ex lap, drainage of 20ml of ascites that showed malignancy on pathology, a biopsy of the R ovarian mass, which showed inflammation but no evidence of malignancy, and a biopsy of the omental mass and parietal peritoneal biopsy, that was positive for metastatic adenocarcinoma. She also had an elevated CEA and CA-125. She was recommended to undergo chemotherapy. She subsequently moved to ___, where several of her children live, for care. Here, after presenting for care, she underwent a CT scan ___ that showed large amount of omental caking as a anterior mid abdominal mass measuring 5.3 x 22.6cm, with bilateral cystic adnexal masses, and scattered prominent retroperitoneal and mesenteric lymph nodes. Omental biopsy on ___ showed metastatic mucinous adenocarcinoma. By immunohistochemistry, ___ mor cells are positive for CK20; tumor cells do not stain for CK7, PAX-8, or CDX-2. The overall morphology and immunophenotype were not specific as to the site of origin; the differential diagnosis includes spread from a gastrointestinal/appendix, pancreaticobiliary, ovarian, or uterine cervical primary mucinous adenocarcinoma. EGD/colonoscopy ___ was limited due to tortuous sigmoid (could not extend beyond 20cm, felt likely due to adhesions from prior abdominal surgeries), however overall normal. Specifically, the esophagus and duodenum appeared normal, a 4mm white patch in the atrum was biopsied and normal, there were multiple diverticuli but otherwise normal limited view to the sigmoid. She was seen by Dr. ___ initial consultation ___. Given the diagnosis of metastatic mucinous adenocarcinoma of unknown primary with suspected gyn origin, and likelihood of incomplete debulking given extensive tumor burden, she was recommended to undergo neoadjuvant chemotherapy. She started carboplatin/paclitaxel chemotherapy on ___. Past Medical History: PMH: - Asthma - Osteoporosis - Denies hypertension, diabetes, thromboembolic disease PSH: - Abdominal surgery to remove her placenta post-partum (pt unclear re details, occurred after vaginal delivery, via small infraumbilical 4cm vertical incision) - Ex lap, drainage of ascites, omental bx, peritoneal bx, ovarian bx, ___, ___ ___: - ___ (4 deceased in neonatal period) - SVD x 11 - One pregnancy c/b ? retained placenta, requiring abdominal surgery via vertical 4cm infraumbilical incision PGYN: - Menopausal, late ___ - Denies postmenopausal bleeding - Not currently sexually active - Denies hormonal replacement therapy or history of OCPs - Never had a Pap smear (pt denies and nothing in CHA records since ___ - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts Social History: ___ Family History: - Sister died of liver cancer - No known family history of breast, uterine, ovarian, cervical or colon cancer - No known history of bleeding or clotting disorder Physical Exam: On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding ___: nontender, nonedematous Pertinent Results: ___ 11:00PM WBC-10.0 RBC-4.07 HGB-11.2 HCT-34.7 MCV-85 MCH-27.5 MCHC-32.3 RDW-14.8 RDWSD-45.9 ___ 11:00PM PLT COUNT-372 Brief Hospital Course: Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparotomy for metastatic mucinous adenocarcinoma of unknown origin. Based on the intraoperative findings, it is likely of appendiceal origin. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural. Overnight POD0-POD1 she suffered from hypotension, likely related to the epidural. The rate was titrated to an appropriate dose and her blood pressures improved, with concurrent adequate pain control. Her urine output, exam and vital signs remained stable for the remainder of her admission. She was transitioned off of the epidural on POD2. With removal of the epidural, she was transitioned to lovenox for prophylaxis. Her diet was advanced from sips to clears on POD2 and she tolerated this well, without nausea or vomiting. Her diet was advanced to a regular diet without difficulty and she was transitioned to PO tylenol and motrin for pain control. On post-operative day #2, her urine output was adequate and her epidural was removed so her Foley catheter was removed and she voided spontaneously. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Albuterol INH Zofran prn Tylenol prn Colace QD Senna QD Flonase prn Discharge Medications: 1. Enoxaparin Sodium 40 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #28 Syringe Refills:0 2. Acetaminophen 650 mg PO Q6H pain Do not take more than 4000mg in 24 hours. RX acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours Disp #50 Tablet Refills:1 3. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #50 Tablet Refills:2 5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 6. Ibuprofen 400 mg PO Q8H:PRN pain Take with food. RX ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp #50 Tablet Refills:1 7. RX lorazepam 0.5 mg ___ tablet(s) by mouth once at nighttime Disp #40 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p exploratory laparotomy for metastatic mucinous adenocarcinoma, likely appendiceal in origin 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 gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. If they are still on after ___ days from surgery, you may remove them. * 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: ___	[ "C181", "C786", "R180", "C778", "C7989", "I952", "T50995A", "Y92234", "J45909", "M810", "Z808", "Z23" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: metastatic mucinous adenocarcinoma Major Surgical or Invasive Procedure: s/p exploratory laparotomy History of Present Illness: Ms. [MASKED] is a [MASKED] woman seen today in consultation for metastatic mucinous adenocarcinoma of unknown primary though likely gyn in origin, recently started on neoadjuvant chemotherapy. She initially presented for care in [MASKED] in [MASKED]. She reports that she was having abdominal pain, diarrhea, bloatedness, decreased appetite, early satiety, weight loss [MASKED] pounds over few months), bright red rectal bleeding, nausea, and heartburn. She denies vaginal bleeding. She had an evaluation in [MASKED]. CT scan [MASKED] showed R adnexal hypodense lesion with lobular, well-defined borders, showing multiple septations and linear calcifications measuring 8x4cm and L adnexa measuring 4x3cm with small cystic lesions. Pelvic US [MASKED] showed 7.5 x 6.5 x 7.1cm complex, multiseptated cystic lesion without vascularization. On [MASKED], she had an ex lap, drainage of 20ml of ascites that showed malignancy on pathology, a biopsy of the R ovarian mass, which showed inflammation but no evidence of malignancy, and a biopsy of the omental mass and parietal peritoneal biopsy, that was positive for metastatic adenocarcinoma. She also had an elevated CEA and CA-125. She was recommended to undergo chemotherapy. She subsequently moved to [MASKED], where several of her children live, for care. Here, after presenting for care, she underwent a CT scan [MASKED] that showed large amount of omental caking as a anterior mid abdominal mass measuring 5.3 x 22.6cm, with bilateral cystic adnexal masses, and scattered prominent retroperitoneal and mesenteric lymph nodes. Omental biopsy on [MASKED] showed metastatic mucinous adenocarcinoma. By immunohistochemistry, [MASKED] mor cells are positive for CK20; tumor cells do not stain for CK7, PAX-8, or CDX-2. The overall morphology and immunophenotype were not specific as to the site of origin; the differential diagnosis includes spread from a gastrointestinal/appendix, pancreaticobiliary, ovarian, or uterine cervical primary mucinous adenocarcinoma. EGD/colonoscopy [MASKED] was limited due to tortuous sigmoid (could not extend beyond 20cm, felt likely due to adhesions from prior abdominal surgeries), however overall normal. Specifically, the esophagus and duodenum appeared normal, a 4mm white patch in the atrum was biopsied and normal, there were multiple diverticuli but otherwise normal limited view to the sigmoid. She was seen by Dr. [MASKED] initial consultation [MASKED]. Given the diagnosis of metastatic mucinous adenocarcinoma of unknown primary with suspected gyn origin, and likelihood of incomplete debulking given extensive tumor burden, she was recommended to undergo neoadjuvant chemotherapy. She started carboplatin/paclitaxel chemotherapy on [MASKED]. Past Medical History: PMH: - Asthma - Osteoporosis - Denies hypertension, diabetes, thromboembolic disease PSH: - Abdominal surgery to remove her placenta post-partum (pt unclear re details, occurred after vaginal delivery, via small infraumbilical 4cm vertical incision) - Ex lap, drainage of ascites, omental bx, peritoneal bx, ovarian bx, [MASKED], [MASKED] [MASKED]: - [MASKED] (4 deceased in neonatal period) - SVD x 11 - One pregnancy c/b ? retained placenta, requiring abdominal surgery via vertical 4cm infraumbilical incision PGYN: - Menopausal, late [MASKED] - Denies postmenopausal bleeding - Not currently sexually active - Denies hormonal replacement therapy or history of OCPs - Never had a Pap smear (pt denies and nothing in CHA records since [MASKED] - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts Social History: [MASKED] Family History: - Sister died of liver cancer - No known family history of breast, uterine, ovarian, cervical or colon cancer - No known history of bleeding or clotting disorder Physical Exam: On day of discharge: Afebrile, vitals stable No acute distress CV: regular rate and rhythm Pulm: clear to auscultation bilaterally Abd: soft, appropriately tender, nondistended, incision clean/dry/intact, no rebound/guarding [MASKED]: nontender, nonedematous Pertinent Results: [MASKED] 11:00PM WBC-10.0 RBC-4.07 HGB-11.2 HCT-34.7 MCV-85 MCH-27.5 MCHC-32.3 RDW-14.8 RDWSD-45.9 [MASKED] 11:00PM PLT COUNT-372 Brief Hospital Course: Ms. [MASKED] was admitted to the gynecologic oncology service after undergoing exploratory laparotomy for metastatic mucinous adenocarcinoma of unknown origin. Based on the intraoperative findings, it is likely of appendiceal origin. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with an epidural. Overnight POD0-POD1 she suffered from hypotension, likely related to the epidural. The rate was titrated to an appropriate dose and her blood pressures improved, with concurrent adequate pain control. Her urine output, exam and vital signs remained stable for the remainder of her admission. She was transitioned off of the epidural on POD2. With removal of the epidural, she was transitioned to lovenox for prophylaxis. Her diet was advanced from sips to clears on POD2 and she tolerated this well, without nausea or vomiting. Her diet was advanced to a regular diet without difficulty and she was transitioned to PO tylenol and motrin for pain control. On post-operative day #2, her urine output was adequate and her epidural was removed so her Foley catheter was removed and she voided spontaneously. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Albuterol INH Zofran prn Tylenol prn Colace QD Senna QD Flonase prn Discharge Medications: 1. Enoxaparin Sodium 40 mg SC Q24H Start: [MASKED], First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #28 Syringe Refills:0 2. Acetaminophen 650 mg PO Q6H pain Do not take more than 4000mg in 24 hours. RX acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours Disp #50 Tablet Refills:1 3. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN SOB 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #50 Tablet Refills:2 5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 6. Ibuprofen 400 mg PO Q8H:PRN pain Take with food. RX ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp #50 Tablet Refills:1 7. RX lorazepam 0.5 mg [MASKED] tablet(s) by mouth once at nighttime Disp #40 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p exploratory laparotomy for metastatic mucinous adenocarcinoma, likely appendiceal in origin 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 gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. . Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. If they are still on after [MASKED] days from surgery, you may remove them. * 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]	[]	[ "J45909" ]	[ "C181: Malignant neoplasm of appendix", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "R180: Malignant ascites", "C778: Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions", "C7989: Secondary malignant neoplasm of other specified sites", "I952: Hypotension due to drugs", "T50995A: Adverse effect of other drugs, medicaments and biological substances, initial encounter", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "J45909: Unspecified asthma, uncomplicated", "M810: Age-related osteoporosis without current pathological fracture", "Z808: Family history of malignant neoplasm of other organs or systems", "Z23: Encounter for immunization" ]
19,974,576	24,449,283	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Dilaudid Attending: ___. Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: NGT History of Present Illness: ___ M with advanced metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary presents with worsening of abdominal pain, nausea, vomiting. Per review of records, initially presented for care in ___ in ___. At that point, she was having abdominal pain, diarrhea, bloating, decreased appetite, early satiety, and a 25-pound weight loss over the preceding few months. She underwent a CT scan, which showed a right adnexal hypodense lesion. A pelvic ultrasound showed a multiseptated cystic lesion without vascularization. On ___, she underwent an exploratory laparotomy and drainage of 20 mL of ascites that showed malignancy on pathology. There was a biopsy of a right ovarian mass, which showed inflammation but no evidence of malignancy. A biopsy of an omental mass was positive for metastatic adenocarcinoma. She had elevated CEA and CA-125. She subsequently moved to the ___ area where she presented for care. An omental biopsy on ___, showed metastatic mucinous adenocarcinoma. The differential diagnosis included a GI or appendiceal primary, pancreaticobiliary, ovarian, or uterine/cervical primary. She underwent a thorough GI evaluation, which was negative. She was started on neoadjuvant chemotherapy with carboplatin and paclitaxel with the assumption that this represented a gynecologic malignancy. The patient was last seen at ___ ___ for similar symptoms, s/p chemo most recently last year with carbotaxol but did not elect to pursue further chemotherapy if intent was purely palliative. Underwent ex-lap in ___ for planned surgical debulking, extensive tumor burden at that time resulted in failure of debulking procedure, pt was advised to pursue HIPEC at ___, unclear if she established care. She did elect to return to ___ to spend time with family; developed worsening abdominal distension approximately 3 weeks ago with some serous leakage of fluid around her umbilicus. This was managed with an ostomy appliance, has not noted any drainage for past 4 days. Now having worsening abd pain, nausea, vomiting, and inability to tolerate PO. Last BM 4 days ago, underwent CT scan in ED that showed concern for mass effect from tumor on small bowel. In the ED, initial vitals were: 97.6 82 106/67 16 100% RA. Exam notable for cachectic woman, with distended abdomen, hypoactive bowel sounds, with ostomy in place without output in the bag, severe tenderness to light palpation, with diffuse guarding. Labs showed WBV of 11.8, H/H of 11.7/37.3, Plt 645. BMP notable for Na of 131, K 3.9, Cl 95, HCO3 23, BUN 11, Cr of 0.6. LFTS unremarkable with an alk phos of 150. Lactate 1.2. Imaging showed marked progression of primary and metastatic tumor burden. Received 2 mg IV morphine and was started on LR. ACS was consulted and recommended NG tube decompression. Decision was made to admit to medicine for further management. On the floor, patient reports the history above and c/o abdominal pain. Review of systems: 10-point ROS was performed and is negative except as noted in the HPI. Past Medical History: PMH: - Asthma - Osteoporosis - Denies hypertension, diabetes, thromboembolic disease PSH: - Abdominal surgery to remove her placenta post-partum (pt unclear re details, occurred after vaginal delivery, via small infraumbilical 4cm vertical incision) - Ex lap, drainage of ascites, omental bx, peritoneal bx, ovarian bx, ___, ___ ___: - ___ (4 deceased in neonatal period) - SVD x 11 - One pregnancy c/b ? retained placenta, requiring abdominal surgery via vertical 4cm infraumbilical incision PGYN: - Menopausal, late ___ - Denies postmenopausal bleeding - Not currently sexually active - Denies hormonal replacement therapy or history of OCPs - Never had a Pap smear (pt denies and nothing in CHA records since ___ - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts Social History: ___ Family History: - Sister died of liver cancer - No known family history of breast, uterine, ovarian, cervical or colon cancer - No known history of bleeding or clotting disorder Physical Exam: UPON ADMISSION: Vital Signs: 98.7 PO 94 / 60 79 16 95 RA General: ___ woman crying, in moderate distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, decreased breath sounds at the bases bilaterally Abdomen: moderately distended, TTP, focal guarding in the LUQ, +rebound tenderness 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. UPON DISCHARGE: VS: 98.2 100 / 56 80 16 95% ra General: ___ female, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, decreased breath sounds at the bases bilaterally Abdomen: moderately distended, TTP, focal guarding in the LLQ, +rebound tenderness, area of localized hyperpigmented skin overlying umbilicus with no drainage GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS UPON ADMISSION: ___ 10:05PM BLOOD WBC-11.8* RBC-4.63 Hgb-11.7 Hct-37.3 MCV-81* MCH-25.3* MCHC-31.4* RDW-15.1 RDWSD-43.9 Plt ___ ___ 10:05PM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-131* K-3.9 Cl-95* HCO3-23 AnGap-17 ___ 10:05PM BLOOD ALT-11 AST-20 AlkPhos-150* TotBili-0.4 ___ 10:05PM BLOOD Albumin-2.9* LABS UPON DISCHARGE ___ 08:00AM BLOOD WBC-9.6 RBC-3.74* Hgb-9.4* Hct-30.4* MCV-81* MCH-25.1* MCHC-30.9* RDW-15.3 RDWSD-44.8 Plt ___ ___ 08:00AM BLOOD Glucose-78 UreaN-4* Creat-0.4 Na-136 K-3.8 Cl-101 HCO3-26 AnGap-13 ___ 07:50AM BLOOD ALT-6 AST-12 AlkPhos-103 TotBili-0.3 ___ 08:00AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.5* EKG on admission: Sinus rhythm. There is an early transition that is non-specific. Low voltage in the precordial leads. Non-specific ST-T wave changes. The Q-T interval is prolonged. Compared to the previous tracing of ___ these findings are new. CT abdomen and pelvis w/contrast: IMPRESSION: 1. Markedly increased primary and metastatic tumor burden. Metastatic deposits extend through the anterior wall defect into the "ostomy". 2. Distention of proximal loops of small bowel with relative decompression but node discrete transition point in the distal ileum, compatible with partial obstruction likely due to mass effect by the large intra-abdominal cystic mass. Abdominal KUB: IMPRESSION: No intraperitoneal free air. Normal bowel gas pattern. CXR: IMPRESSION: In comparison with the study of ___, there are lower lung volumes. No evidence of vascular congestion or acute focal pneumonia. There has been placement of a nasogastric tube that extends to the lower body of the stomach. Residual contrast material is seen in the colon. Brief Hospital Course: ___ with metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary not currently receiving treatment who presented with abdominal pain, abdominal distension, emesis found to have partial small bowel obstruction. Patient had CT scan upon admission that showed increased primary and metastatic tumor burden as well as a partial bowel obstruction. Surgery was consulted and recommended no surgical intervention. NGT was placed to intermittent suction with minimal output. NGT placed to gravity and pt had nausea and abdominal pain. NGT was then placed back on to suction with relief of symptoms. NGT was to gravity prior to discharge and patient's pain was stable. Imaging noteable for worsening of patient's malignancy. Pt has been out of the country (___) for nearly a year and has received some medical treatment there (antibiotics per her family). Patient reported that she would not want chemotherapy or surgery. Palliative care was consulted and met with the patient. After an extensive goals of care discussion, pt was made DNR/DNI and is going home with hospice services. TRANSITIONAL ISSUES -Patient was discharged with "Hospice comfort kit contents"- acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol 5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution, senna-s -Also wrote script for fentanyl patch if needed -Please maintain patient's comfort -MOLST form was signed on ___. DNR/DNI, do not hospitalize Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Fentanyl Patch 12 mcg/h TD Q72H RX fentanyl 12 mcg/hour Place on skin every three days Disp #3 Patch Refills:0 2. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Disp #170 Gram Refills:0 ALSO DISCHARGED WITH PRESCRIPTIONS FOR: "Hospice comfort kit contents"- acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol 5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution, senna-s Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: Metastatic intraperitoneal mucinous adenocarcinoma Partial small bowel obstruction Hypotension Thrombocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, WHY DID YOU COME TO THE HOSPITAL? -You came to the hospital with belly pain WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? -We took a picture of your belly (CT scan) and it showed that you have a small blockage in your bowels and growing size of your cancer -We placed a tube through your nose in your belly to help with your bloating, nausea and pain WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? -You will be going home with hospice care. You and your family will receive help from nurses. -___ have an appointment with your oncologist at ___ on ___ (see below for more details). It was a pleasure taking care of you. Your ___ Team Followup Instructions: ___	[ "C181", "C786", "R180", "K5669", "I959", "K632", "Z66", "Z515", "M810", "D473" ]	Allergies: Penicillins / Dilaudid Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: NGT History of Present Illness: [MASKED] M with advanced metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary presents with worsening of abdominal pain, nausea, vomiting. Per review of records, initially presented for care in [MASKED] in [MASKED]. At that point, she was having abdominal pain, diarrhea, bloating, decreased appetite, early satiety, and a 25-pound weight loss over the preceding few months. She underwent a CT scan, which showed a right adnexal hypodense lesion. A pelvic ultrasound showed a multiseptated cystic lesion without vascularization. On [MASKED], she underwent an exploratory laparotomy and drainage of 20 mL of ascites that showed malignancy on pathology. There was a biopsy of a right ovarian mass, which showed inflammation but no evidence of malignancy. A biopsy of an omental mass was positive for metastatic adenocarcinoma. She had elevated CEA and CA-125. She subsequently moved to the [MASKED] area where she presented for care. An omental biopsy on [MASKED], showed metastatic mucinous adenocarcinoma. The differential diagnosis included a GI or appendiceal primary, pancreaticobiliary, ovarian, or uterine/cervical primary. She underwent a thorough GI evaluation, which was negative. She was started on neoadjuvant chemotherapy with carboplatin and paclitaxel with the assumption that this represented a gynecologic malignancy. The patient was last seen at [MASKED] [MASKED] for similar symptoms, s/p chemo most recently last year with carbotaxol but did not elect to pursue further chemotherapy if intent was purely palliative. Underwent ex-lap in [MASKED] for planned surgical debulking, extensive tumor burden at that time resulted in failure of debulking procedure, pt was advised to pursue HIPEC at [MASKED], unclear if she established care. She did elect to return to [MASKED] to spend time with family; developed worsening abdominal distension approximately 3 weeks ago with some serous leakage of fluid around her umbilicus. This was managed with an ostomy appliance, has not noted any drainage for past 4 days. Now having worsening abd pain, nausea, vomiting, and inability to tolerate PO. Last BM 4 days ago, underwent CT scan in ED that showed concern for mass effect from tumor on small bowel. In the ED, initial vitals were: 97.6 82 106/67 16 100% RA. Exam notable for cachectic woman, with distended abdomen, hypoactive bowel sounds, with ostomy in place without output in the bag, severe tenderness to light palpation, with diffuse guarding. Labs showed WBV of 11.8, H/H of 11.7/37.3, Plt 645. BMP notable for Na of 131, K 3.9, Cl 95, HCO3 23, BUN 11, Cr of 0.6. LFTS unremarkable with an alk phos of 150. Lactate 1.2. Imaging showed marked progression of primary and metastatic tumor burden. Received 2 mg IV morphine and was started on LR. ACS was consulted and recommended NG tube decompression. Decision was made to admit to medicine for further management. On the floor, patient reports the history above and c/o abdominal pain. Review of systems: 10-point ROS was performed and is negative except as noted in the HPI. Past Medical History: PMH: - Asthma - Osteoporosis - Denies hypertension, diabetes, thromboembolic disease PSH: - Abdominal surgery to remove her placenta post-partum (pt unclear re details, occurred after vaginal delivery, via small infraumbilical 4cm vertical incision) - Ex lap, drainage of ascites, omental bx, peritoneal bx, ovarian bx, [MASKED], [MASKED] [MASKED]: - [MASKED] (4 deceased in neonatal period) - SVD x 11 - One pregnancy c/b ? retained placenta, requiring abdominal surgery via vertical 4cm infraumbilical incision PGYN: - Menopausal, late [MASKED] - Denies postmenopausal bleeding - Not currently sexually active - Denies hormonal replacement therapy or history of OCPs - Never had a Pap smear (pt denies and nothing in CHA records since [MASKED] - Denies history of pelvic infections or sexually transmitted infections - Denies history of fibroids or cysts Social History: [MASKED] Family History: - Sister died of liver cancer - No known family history of breast, uterine, ovarian, cervical or colon cancer - No known history of bleeding or clotting disorder Physical Exam: UPON ADMISSION: Vital Signs: 98.7 PO 94 / 60 79 16 95 RA General: [MASKED] woman crying, in moderate distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, decreased breath sounds at the bases bilaterally Abdomen: moderately distended, TTP, focal guarding in the LUQ, +rebound tenderness 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. UPON DISCHARGE: VS: 98.2 100 / 56 80 16 95% ra General: [MASKED] female, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, decreased breath sounds at the bases bilaterally Abdomen: moderately distended, TTP, focal guarding in the LLQ, +rebound tenderness, area of localized hyperpigmented skin overlying umbilicus with no drainage GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS UPON ADMISSION: [MASKED] 10:05PM BLOOD WBC-11.8* RBC-4.63 Hgb-11.7 Hct-37.3 MCV-81* MCH-25.3* MCHC-31.4* RDW-15.1 RDWSD-43.9 Plt [MASKED] [MASKED] 10:05PM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-131* K-3.9 Cl-95* HCO3-23 AnGap-17 [MASKED] 10:05PM BLOOD ALT-11 AST-20 AlkPhos-150* TotBili-0.4 [MASKED] 10:05PM BLOOD Albumin-2.9* LABS UPON DISCHARGE [MASKED] 08:00AM BLOOD WBC-9.6 RBC-3.74* Hgb-9.4* Hct-30.4* MCV-81* MCH-25.1* MCHC-30.9* RDW-15.3 RDWSD-44.8 Plt [MASKED] [MASKED] 08:00AM BLOOD Glucose-78 UreaN-4* Creat-0.4 Na-136 K-3.8 Cl-101 HCO3-26 AnGap-13 [MASKED] 07:50AM BLOOD ALT-6 AST-12 AlkPhos-103 TotBili-0.3 [MASKED] 08:00AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.5* EKG on admission: Sinus rhythm. There is an early transition that is non-specific. Low voltage in the precordial leads. Non-specific ST-T wave changes. The Q-T interval is prolonged. Compared to the previous tracing of [MASKED] these findings are new. CT abdomen and pelvis w/contrast: IMPRESSION: 1. Markedly increased primary and metastatic tumor burden. Metastatic deposits extend through the anterior wall defect into the "ostomy". 2. Distention of proximal loops of small bowel with relative decompression but node discrete transition point in the distal ileum, compatible with partial obstruction likely due to mass effect by the large intra-abdominal cystic mass. Abdominal KUB: IMPRESSION: No intraperitoneal free air. Normal bowel gas pattern. CXR: IMPRESSION: In comparison with the study of [MASKED], there are lower lung volumes. No evidence of vascular congestion or acute focal pneumonia. There has been placement of a nasogastric tube that extends to the lower body of the stomach. Residual contrast material is seen in the colon. Brief Hospital Course: [MASKED] with metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary not currently receiving treatment who presented with abdominal pain, abdominal distension, emesis found to have partial small bowel obstruction. Patient had CT scan upon admission that showed increased primary and metastatic tumor burden as well as a partial bowel obstruction. Surgery was consulted and recommended no surgical intervention. NGT was placed to intermittent suction with minimal output. NGT placed to gravity and pt had nausea and abdominal pain. NGT was then placed back on to suction with relief of symptoms. NGT was to gravity prior to discharge and patient's pain was stable. Imaging noteable for worsening of patient's malignancy. Pt has been out of the country ([MASKED]) for nearly a year and has received some medical treatment there (antibiotics per her family). Patient reported that she would not want chemotherapy or surgery. Palliative care was consulted and met with the patient. After an extensive goals of care discussion, pt was made DNR/DNI and is going home with hospice services. TRANSITIONAL ISSUES -Patient was discharged with "Hospice comfort kit contents"- acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol 5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution, senna-s -Also wrote script for fentanyl patch if needed -Please maintain patient's comfort -MOLST form was signed on [MASKED]. DNR/DNI, do not hospitalize Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Fentanyl Patch 12 mcg/h TD Q72H RX fentanyl 12 mcg/hour Place on skin every three days Disp #3 Patch Refills:0 2. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth daily Disp #170 Gram Refills:0 ALSO DISCHARGED WITH PRESCRIPTIONS FOR: "Hospice comfort kit contents"- acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol 5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution, senna-s Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: Metastatic intraperitoneal mucinous adenocarcinoma Partial small bowel obstruction Hypotension Thrombocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [MASKED], WHY DID YOU COME TO THE HOSPITAL? -You came to the hospital with belly pain WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? -We took a picture of your belly (CT scan) and it showed that you have a small blockage in your bowels and growing size of your cancer -We placed a tube through your nose in your belly to help with your bloating, nausea and pain WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? -You will be going home with hospice care. You and your family will receive help from nurses. -[MASKED] have an appointment with your oncologist at [MASKED] on [MASKED] (see below for more details). It was a pleasure taking care of you. Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "Z66", "Z515" ]	[ "C181: Malignant neoplasm of appendix", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "R180: Malignant ascites", "K5669: Other intestinal obstruction", "I959: Hypotension, unspecified", "K632: Fistula of intestine", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "M810: Age-related osteoporosis without current pathological fracture", "D473: Essential (hemorrhagic) thrombocythemia" ]
19,974,706	21,789,738	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Atenolol / Vicodin / metformin Attending: ___. Chief Complaint: cough, dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMHx of asthma, smoking, HLD, DM2 who presents with dyspnea x 1 week. Patient states that on ___ she developed generalized malaise, chills, chest tightness, and shortness of breath with exertion. She also notes worsening of her cough which initially started around 2 months ago, occasionally productive of white sputum. She was seen in primary care clinic ___ ___ thought this was likely influenza and prescribed oseltamivir as well as Tylenol, Tessalon perles, albuterol/Symbicort inhaler for symptomatic improvement. The patient notes that her symptoms were initially getting better until ___ when she began to feel as though the cough and shortness of breath were getting worse. However, she no longer feels myalgias, headache, chest pain. No recent abdominal pain, n/v/d, dysuria, blood in the stool. She does believe that she has worse SOB when lying flat, however no reports ___ and ___ diagnosed with heart failure. Patient denies prior history of cath, stress test, echo. Notably never documented with hx of COPD but PFTs ___ with FEV1/FVC < 0.7, unchanged with bronchodilators, diagnostic of COPD. Patient additionally notes that she has had poor PO intake and unintentional weight loss of ~ 20 lbs over the past 6 mo. Past Medical History: CARPAL TUNNEL SYNDROME OCCIPITAL NEURALGIA tuberculum sella meningioma S/P resection ___ pituitary microadenoma s/p transphenoidal pituitary resection by ___, M.D. at the ___ in ___ COLONIC POLYPS GASTRITIS H pylori dx via EGD ___ treated GRANULAR CELL TUMOR HYPERLIPIDEMIA SMOKER WRIST PAIN BREAST DIABETES MELLITUS RECTAL FISSURE H/O HYPERPROLACTINEMIA H/O MENINGIOMA H/O PULMONARY NODULE Social History: ___ Family History: grandmother and mother with diabetes Mother with heart failure and unknown type of cancer Physical Exam: Admission Physical Exam ========================= VITALS: ___ 1744 Temp: 98.2 PO BP: 131/88 HR: 90 RR: 18 O2 sat: 94% GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. JVP not visibile when upright CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally but with mildly decreased breath sounds diffusely. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3.moving all 4 limbs spontaneously Discharge Physical Exam ============================= 98.3 PO 100 / 62 L Lying 74 18 98 ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. JVP not visible when upright CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. Reduced air movement throughout. No wheezes, rhonchi or rales. No increased work of breathing. Ambulatory O2 saturation in mid to high-90s. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously Pertinent Results: Admission Labs ===================== ___ 01:31PM BLOOD WBC-6.1 RBC-4.22 Hgb-13.7 Hct-40.5 MCV-96 MCH-32.5* MCHC-33.8 RDW-11.6 RDWSD-40.6 Plt ___ ___ 01:31PM BLOOD Neuts-45.2 ___ Monos-12.3 Eos-1.1 Baso-0.5 AbsNeut-2.75 AbsLymp-2.49 AbsMono-0.75 AbsEos-0.07 AbsBaso-0.03 ___ 01:31PM BLOOD Glucose-268* UreaN-7 Creat-0.6 Na-142 K-4.4 Cl-99 HCO3-29 AnGap-14 ___ 07:15AM BLOOD ALT-17 AST-12 AlkPhos-61 TotBili-0.3 ___ 07:15AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.8 Mg-1.8 ___ 02:23PM BLOOD %HbA1c-11.7* eAG-289* ___ 01:54PM BLOOD Lactate-1.6 ___ 02:55PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE ___ 8:25 am URINE Source: ___. 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. ___ 8:29 pm SPUTUM Source: Induced. FINAL REPORT ___ GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. Pertinent Findings ====================== ___ Imaging CHEST (PA & LAT) FINDINGS: No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Discharge Labs ==================== ___ 07:15AM BLOOD WBC-7.7 RBC-3.81* Hgb-12.4 Hct-36.2 MCV-95 MCH-32.5* MCHC-34.3 RDW-11.6 RDWSD-39.9 Plt ___ ___ 07:15AM BLOOD Glucose-327* UreaN-9 Creat-0.6 Na-139 K-4.0 Cl-100 HCO3-26 AnGap-13 ___ 07:15AM BLOOD ALT-17 AST-12 AlkPhos-61 TotBili-0.3 ___ 07:15AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.8 Mg-1.8 Brief Hospital Course: Ms. ___ is a ___ PMHx of asthma, smoking, HLD, DM2 who presents with dyspnea x 1 week in the setting of subacute cough which was likely chronic bronchitis and COPD exacerbation. ACUTE ISSUES: ============= #Dyspnea #COPD: Patient presented with dyspnea/chest tightness which initially improved with inhalers she was prescribed as outpatient. CXR without e/o consolidation. Presentation likely chronic bronchitis with concomitant COPD exacerbation. Last PFTs ___ with FEV1/FVC < 0.7, unchanged with bronchodilators, diagnostic of COPD. She was treated with 1x CTX/azithro for empiric CAP treatment in ED as well as nebs/prednisone. Duonebulizer, home inahled corticosteroids, and PO prednisone was maintained for total 5-day course of PO steroids. No hx of heart failure, but ECG with possible biatrial enlargement and has never had an echo or stress and normal BNP. The patient was advised to follow-up with pulmonary as outpatient, encouraged to maintain smoking cessation as she is doing, and given a work letter re: her animal dander allergy as possible trigger in her environment. #Cough #Chronic bronchitis: The patient presented with coughing spells x ~2 months. Her chronic cough is likely chronic bronchitis in addition to history of COPD and allergies to environmental triggers. No infectious symptoms at present. Flu negative. Urine legionella negative. Urine strep pending at discharge. She was treated with tessalon perles, cetirizine, guafenesin. #DM: poorly controlled On Tresiba 34 units qd at home. A1c 11.7 on admission. She was placed on sliding scale with short-acting with meals given her hyperglycemia, which will be further exacerbated by PO steroids per above. She was seen by ___ consultant while in house and given education on administration for sliding scale. She was recommended to follow-up at ___ next week re: diabetes management. #Weight loss: Patient describes poor PO intake and unintentional weight loss of ~ 20 lbs over the past 6 mo. Although checking her outpatient record and weight trend does not reflect this same history. Would recommend uptodate cancer screening. #Goals of care: the patient expressed that she wanted to be full code with limited life sustaining measures citing traumatic experience watching her mother at her end of life. I encouraged the patient to continue clarify her goals as outpatient with her PCP. CHRONIC ISSUES: =============== #HLD Continued on home atorvastatin 80mg QHS. TRANSITIONAL ISSUES: ============= [] Chronic bronchitis and COPD: follow-up with pulmonary as scheduled [] Patient given work note to avoid environment with animal dander per her allergy testing and likely trigger of her cough and symptoms [] Monitor for symptom resolution after discharge with interventions as listed above. [] Smoking cessation: continue to encourage smoking cessation. Patient may be interested in medication help to maintain cessation PRN. [] Poorly controlled diabetes: patient to follow-up with ___ ___ for diabetes control with elevated A1c of 11.4 on admission, high blood glucose during admission, and expected hyperglycemia with PO steroids. Patient was started on sliding scale during admission to cover during PO steroid use. #CODE: Full #CONTACT: Daughters: ___ (___), ___ (___) Greater than ___ hour spent on care on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Benzonatate 100 mg PO QPM:PRN cough 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID 4. Atorvastatin 80 mg PO QPM 5. Tresiba FlexTouch U-200 (insulin degludec) 34 units subcutaneous DAILY 6. linaCLOtide 145 mcg oral QAM:PRN Discharge Medications: 1. Cetirizine 10 mg PO DAILY RX cetirizine 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. GuaiFENesin ___ mL PO Q6H:PRN cough RX guaifenesin 100 mg/5 mL 10 mL by mouth every six (6) hours Refills:0 3. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin RX insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR Up to 16 Units QID per sliding scale Disp #4 Syringe Refills:0 4. PredniSONE 40 mg PO DAILY Duration: 4 Days RX prednisone 20 mg 2 tablet(s) by mouth once a day Disp #6 Tablet Refills:0 5. Benzonatate 100 mg PO TID:PRN cough RX benzonatate 200 mg 1 capsule(s) by mouth three times a day Disp #42 Capsule Refills:0 6. Atorvastatin 80 mg PO QPM 7. linaCLOtide 145 mcg oral QAM:PRN 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID 9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 10. Tresiba FlexTouch U-200 (insulin degludec) 34 units subcutaneous DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================== COPD exacerbation Chronic bronchitis SECONDARY DIAGNOSES ================== Diabetes mellitus 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 at ___ ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because of shortness of breathing and cough. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your cough and shortness of breath was diagnosed as chronic bronchitis and COPD exacerbation. - Your cough was treated cough medications. - Your COPD was treated with inhalers and oral prednisone. 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: ___	[ "J441", "R05", "R634", "Z6826", "E1165", "F17210", "E785", "Z794" ]	Allergies: Atenolol / Vicodin / metformin Chief Complaint: cough, dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMHx of asthma, smoking, HLD, DM2 who presents with dyspnea x 1 week. Patient states that on [MASKED] she developed generalized malaise, chills, chest tightness, and shortness of breath with exertion. She also notes worsening of her cough which initially started around 2 months ago, occasionally productive of white sputum. She was seen in primary care clinic [MASKED] [MASKED] thought this was likely influenza and prescribed oseltamivir as well as Tylenol, Tessalon perles, albuterol/Symbicort inhaler for symptomatic improvement. The patient notes that her symptoms were initially getting better until [MASKED] when she began to feel as though the cough and shortness of breath were getting worse. However, she no longer feels myalgias, headache, chest pain. No recent abdominal pain, n/v/d, dysuria, blood in the stool. She does believe that she has worse SOB when lying flat, however no reports [MASKED] and [MASKED] diagnosed with heart failure. Patient denies prior history of cath, stress test, echo. Notably never documented with hx of COPD but PFTs [MASKED] with FEV1/FVC < 0.7, unchanged with bronchodilators, diagnostic of COPD. Patient additionally notes that she has had poor PO intake and unintentional weight loss of ~ 20 lbs over the past 6 mo. Past Medical History: CARPAL TUNNEL SYNDROME OCCIPITAL NEURALGIA tuberculum sella meningioma S/P resection [MASKED] pituitary microadenoma s/p transphenoidal pituitary resection by [MASKED], M.D. at the [MASKED] in [MASKED] COLONIC POLYPS GASTRITIS H pylori dx via EGD [MASKED] treated GRANULAR CELL TUMOR HYPERLIPIDEMIA SMOKER WRIST PAIN BREAST DIABETES MELLITUS RECTAL FISSURE H/O HYPERPROLACTINEMIA H/O MENINGIOMA H/O PULMONARY NODULE Social History: [MASKED] Family History: grandmother and mother with diabetes Mother with heart failure and unknown type of cancer Physical Exam: Admission Physical Exam ========================= VITALS: [MASKED] 1744 Temp: 98.2 PO BP: 131/88 HR: 90 RR: 18 O2 sat: 94% GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. JVP not visibile when upright CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally but with mildly decreased breath sounds diffusely. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3.moving all 4 limbs spontaneously Discharge Physical Exam ============================= 98.3 PO 100 / 62 L Lying 74 18 98 ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. JVP not visible when upright CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. Reduced air movement throughout. No wheezes, rhonchi or rales. No increased work of breathing. Ambulatory O2 saturation in mid to high-90s. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously Pertinent Results: Admission Labs ===================== [MASKED] 01:31PM BLOOD WBC-6.1 RBC-4.22 Hgb-13.7 Hct-40.5 MCV-96 MCH-32.5* MCHC-33.8 RDW-11.6 RDWSD-40.6 Plt [MASKED] [MASKED] 01:31PM BLOOD Neuts-45.2 [MASKED] Monos-12.3 Eos-1.1 Baso-0.5 AbsNeut-2.75 AbsLymp-2.49 AbsMono-0.75 AbsEos-0.07 AbsBaso-0.03 [MASKED] 01:31PM BLOOD Glucose-268* UreaN-7 Creat-0.6 Na-142 K-4.4 Cl-99 HCO3-29 AnGap-14 [MASKED] 07:15AM BLOOD ALT-17 AST-12 AlkPhos-61 TotBili-0.3 [MASKED] 07:15AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.8 Mg-1.8 [MASKED] 02:23PM BLOOD %HbA1c-11.7* eAG-289* [MASKED] 01:54PM BLOOD Lactate-1.6 [MASKED] 02:55PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE [MASKED] 8:25 am URINE Source: [MASKED]. 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] 8:29 pm SPUTUM Source: Induced. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [MASKED]: TEST CANCELLED, PATIENT CREDITED. Pertinent Findings ====================== [MASKED] Imaging CHEST (PA & LAT) FINDINGS: No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. Discharge Labs ==================== [MASKED] 07:15AM BLOOD WBC-7.7 RBC-3.81* Hgb-12.4 Hct-36.2 MCV-95 MCH-32.5* MCHC-34.3 RDW-11.6 RDWSD-39.9 Plt [MASKED] [MASKED] 07:15AM BLOOD Glucose-327* UreaN-9 Creat-0.6 Na-139 K-4.0 Cl-100 HCO3-26 AnGap-13 [MASKED] 07:15AM BLOOD ALT-17 AST-12 AlkPhos-61 TotBili-0.3 [MASKED] 07:15AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.8 Mg-1.8 Brief Hospital Course: Ms. [MASKED] is a [MASKED] PMHx of asthma, smoking, HLD, DM2 who presents with dyspnea x 1 week in the setting of subacute cough which was likely chronic bronchitis and COPD exacerbation. ACUTE ISSUES: ============= #Dyspnea #COPD: Patient presented with dyspnea/chest tightness which initially improved with inhalers she was prescribed as outpatient. CXR without e/o consolidation. Presentation likely chronic bronchitis with concomitant COPD exacerbation. Last PFTs [MASKED] with FEV1/FVC < 0.7, unchanged with bronchodilators, diagnostic of COPD. She was treated with 1x CTX/azithro for empiric CAP treatment in ED as well as nebs/prednisone. Duonebulizer, home inahled corticosteroids, and PO prednisone was maintained for total 5-day course of PO steroids. No hx of heart failure, but ECG with possible biatrial enlargement and has never had an echo or stress and normal BNP. The patient was advised to follow-up with pulmonary as outpatient, encouraged to maintain smoking cessation as she is doing, and given a work letter re: her animal dander allergy as possible trigger in her environment. #Cough #Chronic bronchitis: The patient presented with coughing spells x ~2 months. Her chronic cough is likely chronic bronchitis in addition to history of COPD and allergies to environmental triggers. No infectious symptoms at present. Flu negative. Urine legionella negative. Urine strep pending at discharge. She was treated with tessalon perles, cetirizine, guafenesin. #DM: poorly controlled On Tresiba 34 units qd at home. A1c 11.7 on admission. She was placed on sliding scale with short-acting with meals given her hyperglycemia, which will be further exacerbated by PO steroids per above. She was seen by [MASKED] consultant while in house and given education on administration for sliding scale. She was recommended to follow-up at [MASKED] next week re: diabetes management. #Weight loss: Patient describes poor PO intake and unintentional weight loss of ~ 20 lbs over the past 6 mo. Although checking her outpatient record and weight trend does not reflect this same history. Would recommend uptodate cancer screening. #Goals of care: the patient expressed that she wanted to be full code with limited life sustaining measures citing traumatic experience watching her mother at her end of life. I encouraged the patient to continue clarify her goals as outpatient with her PCP. CHRONIC ISSUES: =============== #HLD Continued on home atorvastatin 80mg QHS. TRANSITIONAL ISSUES: ============= [] Chronic bronchitis and COPD: follow-up with pulmonary as scheduled [] Patient given work note to avoid environment with animal dander per her allergy testing and likely trigger of her cough and symptoms [] Monitor for symptom resolution after discharge with interventions as listed above. [] Smoking cessation: continue to encourage smoking cessation. Patient may be interested in medication help to maintain cessation PRN. [] Poorly controlled diabetes: patient to follow-up with [MASKED] [MASKED] for diabetes control with elevated A1c of 11.4 on admission, high blood glucose during admission, and expected hyperglycemia with PO steroids. Patient was started on sliding scale during admission to cover during PO steroid use. #CODE: Full #CONTACT: Daughters: [MASKED] ([MASKED]), [MASKED] ([MASKED]) Greater than [MASKED] hour spent on care on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Benzonatate 100 mg PO QPM:PRN cough 2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID 4. Atorvastatin 80 mg PO QPM 5. Tresiba FlexTouch U-200 (insulin degludec) 34 units subcutaneous DAILY 6. linaCLOtide 145 mcg oral QAM:PRN Discharge Medications: 1. Cetirizine 10 mg PO DAILY RX cetirizine 10 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. GuaiFENesin [MASKED] mL PO Q6H:PRN cough RX guaifenesin 100 mg/5 mL 10 mL by mouth every six (6) hours Refills:0 3. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin RX insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR Up to 16 Units QID per sliding scale Disp #4 Syringe Refills:0 4. PredniSONE 40 mg PO DAILY Duration: 4 Days RX prednisone 20 mg 2 tablet(s) by mouth once a day Disp #6 Tablet Refills:0 5. Benzonatate 100 mg PO TID:PRN cough RX benzonatate 200 mg 1 capsule(s) by mouth three times a day Disp #42 Capsule Refills:0 6. Atorvastatin 80 mg PO QPM 7. linaCLOtide 145 mcg oral QAM:PRN 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation QID 9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 10. Tresiba FlexTouch U-200 (insulin degludec) 34 units subcutaneous DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================== COPD exacerbation Chronic bronchitis SECONDARY DIAGNOSES ================== Diabetes mellitus 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 at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital because of shortness of breathing and cough. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your cough and shortness of breath was diagnosed as chronic bronchitis and COPD exacerbation. - Your cough was treated cough medications. - Your COPD was treated with inhalers and oral prednisone. 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]	[]	[ "E1165", "F17210", "E785", "Z794" ]	[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "R05: Cough", "R634: Abnormal weight loss", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "E1165: Type 2 diabetes mellitus with hyperglycemia", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin" ]
19,974,907	24,289,459	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: artificial sweetner Attending: ___. Chief Complaint: cecal polyp/carcinoma Major Surgical or Invasive Procedure: Laparoscopic right colectomy. History of Present Illness: a Past Medical History: Past Medical History: AFib, on atenolol and bilateral laparoscopic inguinal hernia repairs ___. Also significant for high cholesterol and erectile dysfunction. 1. T1c prostate cancer, ___ cores on the right, ___ 3+3 and 3+4. 2. ___, ___ MRI, 33 mL, suspicion for extension into right SV and possible left base involvement. 3. ___ urinary score ___, sexual score ___, not sexually active (0 best). Social History: ___ Family History: Negative for prostate, kidney and bladder cancer. Physical Exam: General: Doing well, tolerating a regular diet, pain controlled Neuro: A&OX3 Cardio/Pulm: RRR, no shortness of breath, no chest pain Abd: no abdominal distension, lap sites intact without signs of infection ___: no lower extremity edema Pertinent Results: ___ 01:15PM BLOOD WBC-11.0# RBC-3.64 Hgb-12.5* Hct-37.4* MCV-103* MCH-34.3* MCHC-33.4 RDW-12.7 RDWSD-47.4* Plt ___ ___ 10:10AM BLOOD Hct-40.0 ___ 01:15PM BLOOD Plt ___ ___ 01:15PM BLOOD ___ PTT-22.3* ___ ___ 01:15PM BLOOD Glucose-214* UreaN-18 Creat-0.9 Na-130* K-4.8 Cl-97 HCO3-25 AnGap-13 ___ 10:10AM BLOOD K-4.7 ___ 01:15PM BLOOD ALT-25 AST-28 LD(LDH)-333* AlkPhos-51 TotBili-0.5 DirBili-<0.2 IndBili-0.5 ___ 01:15PM BLOOD TotProt-6.3* Albumin-3.6 Globuln-2.7 Calcium-8.5 Phos-2.6* UricAcd-6.7 Cholest-153 ___ 10:10AM BLOOD Mg-2.1 ___ 01:15PM BLOOD Free T4-1.5 ___ 01:15PM BLOOD RedHold-HOLD ___ 01:15PM BLOOD GreenHd-HOLD Brief Hospital Course: Mr. ___ was admitted after colectomy for cecal polyp. He did quite well post-operatively. He tolerated clear liquids on post-operative day one without issues and postoperative lab values were stable. He passed flatus into post-operative day two and was advanced to a regular diet. All laparoscopic sites were stable. He was meeting all discharge criteria. He was discharged home in the care of his family. Medications on Admission: atenolol (TENORMIN) 50 mg tablet Take 1 tablet by mouth daily folic acid 1 mg tablet Take 3 tablets by mouth daily aspirin 325 mg tablet Take 325 mg by mouth daily atorvastatin 40 mg tablet oxybutynin chloride ER 5 mg tablet,extended release 24 hr 1 tablet(s) by mouth daily flecainide 100'' Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain do not take more than 3000mg of Tylenol in 24 hours or drink alcohol while taking RX acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #50 Tablet Refills:0 2. Atenolol 50 mg PO DAILY 3. Flecainide Acetate 100 mg PO Q12H 4. Oxybutynin 2.5 mg PO BID 5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:0 6. FoLIC Acid 1 mg PO DAILY 7. Aspirin 325 mg PO DAILY 8. Atorvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Cecal cancer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a Laparoscopic Right Colectomy for surgical management of your Cecal Cancer. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next ___ days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have ___ laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if you develop any of these symptoms or a fever. You may go to the emergency room if your symptoms are severe. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. You will be prescribed narcotic pain medication Oxycodone. This medication should be taken when you have pain and as needed as written on the bottle. This is not a standing medication. You should continue to take Tylenol for pain around the clock and you can also take Advil. Please do not take more than 3000mg of Tylenol in 24 hours. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. ___ Dr. ___. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: ___	[ "C180", "I4891", "E780", "Z8546", "Z87891" ]	Allergies: artificial sweetner Chief Complaint: cecal polyp/carcinoma Major Surgical or Invasive Procedure: Laparoscopic right colectomy. History of Present Illness: a Past Medical History: Past Medical History: AFib, on atenolol and bilateral laparoscopic inguinal hernia repairs [MASKED]. Also significant for high cholesterol and erectile dysfunction. 1. T1c prostate cancer, [MASKED] cores on the right, [MASKED] 3+3 and 3+4. 2. [MASKED], [MASKED] MRI, 33 mL, suspicion for extension into right SV and possible left base involvement. 3. [MASKED] urinary score [MASKED], sexual score [MASKED], not sexually active (0 best). Social History: [MASKED] Family History: Negative for prostate, kidney and bladder cancer. Physical Exam: General: Doing well, tolerating a regular diet, pain controlled Neuro: A&OX3 Cardio/Pulm: RRR, no shortness of breath, no chest pain Abd: no abdominal distension, lap sites intact without signs of infection [MASKED]: no lower extremity edema Pertinent Results: [MASKED] 01:15PM BLOOD WBC-11.0# RBC-3.64 Hgb-12.5* Hct-37.4* MCV-103* MCH-34.3* MCHC-33.4 RDW-12.7 RDWSD-47.4* Plt [MASKED] [MASKED] 10:10AM BLOOD Hct-40.0 [MASKED] 01:15PM BLOOD Plt [MASKED] [MASKED] 01:15PM BLOOD [MASKED] PTT-22.3* [MASKED] [MASKED] 01:15PM BLOOD Glucose-214* UreaN-18 Creat-0.9 Na-130* K-4.8 Cl-97 HCO3-25 AnGap-13 [MASKED] 10:10AM BLOOD K-4.7 [MASKED] 01:15PM BLOOD ALT-25 AST-28 LD(LDH)-333* AlkPhos-51 TotBili-0.5 DirBili-<0.2 IndBili-0.5 [MASKED] 01:15PM BLOOD TotProt-6.3* Albumin-3.6 Globuln-2.7 Calcium-8.5 Phos-2.6* UricAcd-6.7 Cholest-153 [MASKED] 10:10AM BLOOD Mg-2.1 [MASKED] 01:15PM BLOOD Free T4-1.5 [MASKED] 01:15PM BLOOD RedHold-HOLD [MASKED] 01:15PM BLOOD GreenHd-HOLD Brief Hospital Course: Mr. [MASKED] was admitted after colectomy for cecal polyp. He did quite well post-operatively. He tolerated clear liquids on post-operative day one without issues and postoperative lab values were stable. He passed flatus into post-operative day two and was advanced to a regular diet. All laparoscopic sites were stable. He was meeting all discharge criteria. He was discharged home in the care of his family. Medications on Admission: atenolol (TENORMIN) 50 mg tablet Take 1 tablet by mouth daily folic acid 1 mg tablet Take 3 tablets by mouth daily aspirin 325 mg tablet Take 325 mg by mouth daily atorvastatin 40 mg tablet oxybutynin chloride ER 5 mg tablet,extended release 24 hr 1 tablet(s) by mouth daily flecainide 100'' Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain do not take more than 3000mg of Tylenol in 24 hours or drink alcohol while taking RX acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #50 Tablet Refills:0 2. Atenolol 50 mg PO DAILY 3. Flecainide Acetate 100 mg PO Q12H 4. Oxybutynin 2.5 mg PO BID 5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain do not drink alcohol or drive a car while taking this medication RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:0 6. FoLIC Acid 1 mg PO DAILY 7. Aspirin 325 mg PO DAILY 8. Atorvastatin 40 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Cecal cancer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a Laparoscopic Right Colectomy for surgical management of your Cecal Cancer. You have recovered from this procedure well and you are now ready to return home. Samples from your colon were taken and this tissue has been sent to the pathology department for analysis. You will receive these pathology results at your follow-up appointment. If there is an urgent need for the surgeon to contact you regarding these results they will contact you before this time. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. Please monitor your bowel function closely. You may or may not have had a bowel movement prior to your discharge which is acceptable, however it is important that you have a bowel movement in the next [MASKED] days. After anesthesia it is not uncommon for patients to have some decrease in bowel function but you should not have prolonged constipation. Some loose stool and passing of small amounts of dark, old appearing blood are expected. However, if you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. If you are taking narcotic pain medications there is a risk that you will have some constipation. Please take an over the counter stool softener such as Colace, and if the symptoms do not improve call the office. If you have any of the following symptoms please call the office for advice or go to the emergency room if severe: increasing abdominal distension, increasing abdominal pain, nausea, vomiting, inability to tolerate food or liquids, prolonged loose stool, or extended constipation. You have [MASKED] laparoscopic surgical incisions on your abdomen which are closed with internal sutures and a skin glue called Dermabond. These are healing well however it is important that you monitor these areas for signs and symptoms of infection including: increasing redness of the incision lines, white/green/yellow/malodorous drainage, increased pain at the incision, increased warmth of the skin at the incision, or swelling of the area. Please call the office if you develop any of these symptoms or a fever. You may go to the emergency room if your symptoms are severe. You may shower; pat the incisions dry with a towel, do not rub. The small incisions may be left open to the air. If closed with steri-strips (little white adhesive strips) instead of Dermabond, these will fall off over time, please do not remove them. Please no baths or swimming for 6 weeks after surgery unless told otherwise by your surgical team. You will be prescribed narcotic pain medication Oxycodone. This medication should be taken when you have pain and as needed as written on the bottle. This is not a standing medication. You should continue to take Tylenol for pain around the clock and you can also take Advil. Please do not take more than 3000mg of Tylenol in 24 hours. Do not drink alcohol while taking narcotic pain medication or Tylenol. Please do not drive a car while taking narcotic pain medication. No heavy lifting greater than 6 lbs for until your first post-operative visit after surgery. Please no strenuous activity until this time unless instructed otherwise by Dr. [MASKED] Dr. [MASKED]. Thank you for allowing us to participate in your care! Our hope is that you will have a quick return to your life and usual activities. Good luck! Followup Instructions: [MASKED]	[]	[ "I4891", "Z87891" ]	[ "C180: Malignant neoplasm of cecum", "I4891: Unspecified atrial fibrillation", "E780: Pure hypercholesterolemia", "Z8546: Personal history of malignant neoplasm of prostate", "Z87891: Personal history of nicotine dependence" ]
19,974,907	26,570,170	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: artificial sweetner Attending: ___. Chief Complaint: hematuria Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ with a history of prostatectomy and recent history of colon cancer who presents with a week of intermittent hematuria. He went into retention and presented for evaluation. He had a 3 way foley placed, and when his hematuria did not resolve he had CBI overnight. Past Medical History: Past Medical History: AFib, on atenolol and bilateral laparoscopic inguinal hernia repairs ___. Also significant for high cholesterol and erectile dysfunction. 1. T1c prostate cancer, ___ cores on the right, ___ 3+3 and 3+4. 2. ___, ___ MRI, 33 mL, suspicion for extension into right SV and possible left base involvement. 3. ___ urinary score ___, sexual score ___, not sexually active (0 best). Social History: ___ Family History: Negative for prostate, kidney and bladder cancer. Physical Exam: Gen: comfortable, NAD Resp: conversing easily no wheezes Abd: soft nontender GU: foley in place with light pink urine draining easily, hand irrigated for minimal clot Brief Hospital Course: Mr. ___ was admitted from the ED for continued CBI. He was weaned overnight. He required hand irrigation once around 7pm, then was on mild-moderate flow overnight. In the morning his CBI was clamped, he was hand irrigated for a small amount of clot, and his urine remained light clear pink. He was deemed appropriate for discharge. He will follow up as an outpatient with Dr. ___ further evaluation and hematuria workup. Medications on Admission: 1. Atenolol 50 mg PO QHS 2. Flecainide Acetate 100 mg PO Q12H 3. Oxybutynin 5 mg PO DAILY 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Medications: 1. Atenolol 50 mg PO QHS 2. Flecainide Acetate 100 mg PO Q12H 3. Oxybutynin 5 mg PO DAILY 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: hematuria Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: please follow up with Dr ___ as scheduled Followup Instructions: ___	[ "R319", "Z8546", "Z85038", "Z87891", "I4891" ]	Allergies: artificial sweetner Chief Complaint: hematuria Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] with a history of prostatectomy and recent history of colon cancer who presents with a week of intermittent hematuria. He went into retention and presented for evaluation. He had a 3 way foley placed, and when his hematuria did not resolve he had CBI overnight. Past Medical History: Past Medical History: AFib, on atenolol and bilateral laparoscopic inguinal hernia repairs [MASKED]. Also significant for high cholesterol and erectile dysfunction. 1. T1c prostate cancer, [MASKED] cores on the right, [MASKED] 3+3 and 3+4. 2. [MASKED], [MASKED] MRI, 33 mL, suspicion for extension into right SV and possible left base involvement. 3. [MASKED] urinary score [MASKED], sexual score [MASKED], not sexually active (0 best). Social History: [MASKED] Family History: Negative for prostate, kidney and bladder cancer. Physical Exam: Gen: comfortable, NAD Resp: conversing easily no wheezes Abd: soft nontender GU: foley in place with light pink urine draining easily, hand irrigated for minimal clot Brief Hospital Course: Mr. [MASKED] was admitted from the ED for continued CBI. He was weaned overnight. He required hand irrigation once around 7pm, then was on mild-moderate flow overnight. In the morning his CBI was clamped, he was hand irrigated for a small amount of clot, and his urine remained light clear pink. He was deemed appropriate for discharge. He will follow up as an outpatient with Dr. [MASKED] further evaluation and hematuria workup. Medications on Admission: 1. Atenolol 50 mg PO QHS 2. Flecainide Acetate 100 mg PO Q12H 3. Oxybutynin 5 mg PO DAILY 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Medications: 1. Atenolol 50 mg PO QHS 2. Flecainide Acetate 100 mg PO Q12H 3. Oxybutynin 5 mg PO DAILY 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: hematuria Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: please follow up with Dr [MASKED] as scheduled Followup Instructions: [MASKED]	[]	[ "Z87891", "I4891" ]	[ "R319: Hematuria, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z87891: Personal history of nicotine dependence", "I4891: Unspecified atrial fibrillation" ]
19,975,602	28,809,966	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Head injury after fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old man with PMhx DM2, HTN, CKD, BPAD presents with SAH after a syncopal episode. Patient is amnestic to event. Patient's son witnessed him stumbling backwards and hitting his head with laceration but no loss of consciousness. He was brought to ___ where CT head shows 5mm parafalcine vessel hemorrhage, without edema or shift. Labs were notable for WBC 5.9, Hgb 13.2, Cr 1.0, TropT < 0.03, U/A unremarkable. He was given Keppra IV and transferred to ___. Patient currently has no symptoms whatsoever and denies pain. In the ED, initial VS were: 98.9 76 190/111 16 98% RA Exam notable for: depression in the posterior occiput with 3 cm horizontal laceration, wound is explored with no evidence of fracture underneath, ___ clear bilaterally no battle signs. No tenderness to palpation over the midline of the back but abrasions over the mid thoracic spine. Regular rate and rhythm, Clear to auscultation bilateral with normal chest rise bilaterally, abdomen soft, nontender nondistended, pelvis is stable, moving all extremities with no tenderness to palpation Labs showed: - WBC 10.4 PMN 84.9 - Hgb 13.2 - normal Plt, ___ - Cr 0.8 Imaging showed: - NCHCT: 5mm right parafalcine SAH, no skull or cervical fractures Patient received: no medications or fluids Neurosurgery was consulted: Likely syncopal fall. The patient is neurologically intact on exam. Reviewed imaging and consulted with Dr. ___. Bleed meets ED obs criteria and there are no acute neurosurgical needs. Recommending possible medicine admission for syncopal workup. Hold aspirin, may resume in 3 days if needed. Transfer VS were: 98.1 69 121/78 14 100% RA On arrival to the floor, patient reports that he felt queasy and dizzy immediately before the fall without chest pain, SOB, light headedness, blurred vision. He denies post fall loss of bowel / bladder control, headache, blurred vision, dysarthria, focal numbness, weakness. Last fall was "a few months ago," while shopping, preceeded by leg weakness, no trauma, no medical attention. Leg weakness lasted ___ minutes, he was able to get up under his own power. He denies other antecedent symptoms or post fall symptoms. He also has chronic stable occasional urinary incontinence described as dripping without sensation of need to void. This has been present for years and has not changed. Denies straining, dribbling, hesitancy, need for diapers. Denies fever, cough, sore throat, chills, chest pain, SOB, abd pain, N/V/D, bloody stools, dysuria, hematuria, swollen joints, rash, focal numbness, weakness, other recent falls. Past Medical History: DM2 HTN CKD HLD Bipolar Anemia Social History: ___ Family History: Does not know too much about his family history, father had a stroke, no known aneurysms. Physical Exam: =========================== ADMISSION PHYSICAL EXAM: =========================== VS: 98.6 161/83 57 18 98% RA Weight: 75.52 kg GENERAL: WNWD man in NAD HEENT: 3in curvilinear horizontal occipital laceration, s/p staples, c/d/i, flattened occiput, tender, anicteric sclera, PERRL, EOMI, MOM, OP clear NECK: supple, no elevated JVD HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nondistended, nontender in all quadrants, no rebound/guarding, +BS EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&O, CN II-XII intact, SILT, ___ strength BUE/BLE, no clonus, dysmetria, HKS normal SKIN: warm and well perfused ======================= DISCHARGE PHYSICAL EXAM: ======================= Vitals: 98.1 PO 131 / 81 96 16 98 RA GENERAL: Sitting in bed, NAD HEENT: 3in curvilinear horizontal occipital laceration, s/p staples, c/d/i, flattened occiput, tender, anicteric sclera, PERRL, EOMI, MOM, OP clear NECK: supple, no elevated JVD HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nondistended, nontender in all quadrants EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&O, CN II-XII intact, ___ strength BUE/BLE, no clonus, dysmetria. Reflexes present in biceps and knees bilaterally, slightly diminished left patellar reflex. Cerebellar function intact. SKIN: warm and well perfused Pertinent Results: ADMISSION LABS: ___ 03:53PM GLUCOSE-130* UREA N-10 CREAT-0.8 SODIUM-145 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14 ___ 03:53PM estGFR-Using this ___ 03:53PM CK(CPK)-125 ___ 03:53PM CK-MB-4 cTropnT-0.01 ___ 03:53PM WBC-10.4* RBC-4.35* HGB-13.2* HCT-39.1* MCV-90 MCH-30.3 MCHC-33.8 RDW-13.2 RDWSD-43.5 ___ 03:53PM NEUTS-84.9* LYMPHS-8.6* MONOS-5.6 EOS-0.2* BASOS-0.1 IM ___ AbsNeut-8.84* AbsLymp-0.90* AbsMono-0.58 AbsEos-0.02* AbsBaso-0.01 ___ 03:53PM PLT COUNT-222 ___ 03:53PM ___ PTT-24.7* ___ PERTINENT IMAGING: CT HEAD SECOND OPINION (___): 1. 5 mm hyperdense extra-axial focus along the right parafalcine region, compatible with provided history of small subarachnoid hemorrhage. 2. No evidence of calvarial fracture. Soft tissue swelling and a small subgaleal hematoma noted along the posterior occiput. 3. No evidence of cervical spinal fracture or traumatic malalignment. 4. Moderate cervical spinal degenerative changes, as above. TRANSTHORACIC ECHOCARDIOGRAM (___): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. 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. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. LVEF 45%. IMPRESSION: Mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory. DISCHARGE LABS: ___ 06:25AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-145 K-3.2* Cl-105 HCO___-27 AnGap-13 ___ 06:15AM BLOOD ASA-NEG Ethanol-NEG Carbamz-4.7 Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: ___ year old man with PMhx DM2, HTN, CKD, BPAD presents with SAH after a syncopal episode. Seen by neurosurgery (with no recommendations for surgery at this time), admitted to the floor for observation and further workup of syncope. Patient was stable and doing well during admission. ACUTE ISSUES: ============= # ___ # Fall with headstrike # Syncope and # New diagnosis of HFrEF: Patient presented with a right parafalcine SAH (diagnosed on a head CT at OSH) after a falling episode, where he landed and hit the back of his head. Preceded by a prodrome of lightheadedness; his fall most consistent with neurocardiogenic syncope of unclear trigger. Pt did not have any preceding chest pain or exertional symptoms to suggest ischemia, nor has he had any throughout his hospital course. Pt was neurologically intact on admission with no urgent surgical intervention recommended by a neurosurgical consult. Patient was evaluated with EKG, telemetry, orthostatic vitals, cardiac enzymes, and an echocardiogram that demonstrated the presence of a right bundle branch block (EKG). Transthoracic echocardiogram performed on ___ demonstrated evidence of a prior RCA MI, with inferior wall akinesis and a depressed EF at 45%. His cardiac biomarkers remained negative throughout admission. Patient was given routine neurological exams (q4) that showed no neurological changes. Per neurosurgery recommendations, interval imaging was not performed; nor was any further antiepileptic medication started. Pt recommended to follow up at the concussion clinic ___ weeks after his presentation. Angiography (to evaluate for the presence of aneurysms) was considered as well, however given the traumatic nature of the patient's presentation, neurosurgery did not believe this to be necessary. Patient will follow up with neurology, cardiology, and his PCP in the outpatient setting once leaving the hospital. - Recommended holding ASA until ___ in setting of recent ___ - Staple removal from occipital wound to be performed 10d after placement at ___ ___ (on ___. # Urinary incontinence Patient without bladder obstructive symptoms and history of carbamazepine, lithium and risperidone presents with chronic stable urinary incontinence. Patient is also taking a diuretic for BP control. Likely a medication effects as these medications are associated with urinary incontinence but given clinical scenario of ___, this urinary incontinence was monitored closely during his hospital stay. CHRONIC ISSUES: =============== # DM2 Last A1c 5.7 ___, not on any medications. Presented without overt hyperglycemia. A1c is 5.4 on ___, obtained for risk stratification purposes. # HTN: hypertensive I/s/o. Continued valsartan, amlodipine, and HCTZ. Was giving metoprolol to further control pressures. # CKD: presents below prior readings of 1.3-1.6 in ___. # HLD: stable. Continued pravastatin and held home potassium chloride. # Bipolar: mood stable. Continued home Carbamazepine 200 mg QAM / 400 mg QPM and risperidone 2 mg QD. Carbamazepine level at discharge was 4.7, within the therapeutic range. # Anemia: presents above prior baseline of ___ in ___. Stably at baseline at time of discharge. TRANSITIONAL ISSUES: ==================== #CODE: Full (presumed) #CONTACT: ___ (son/HCP) ___ [ ] MEDICATION CHANGES: - Added: Atorvastatin 40mg (if tolerates can increase to 80mg) - Held: Aspirin 81mg. Do not restart until at least ___ given recent subarachnoid hemorrhage. [ ] NEW DIAGNOSIS OF HEART FAILURE WITH REDUCED EJECTION FRACTION: - Pt euvolemic at time of discharge. - Discharge weight: 76.98kg - Discharge creatinine: 0.9 - Recommend Pt follow up with cardiology as scheduled for further consideration of outpatient stress test, possible cardiac catheterization. [ ] SUBARACHNOID HEMORRHAGE: - Pt to hold on aspirin until ___. - Maintain blood pressure control with sBP < 160. He was under this threshold without PRN hydralazine by discharge; consider uptitrating home medicines as needed to achieve this effect. - To follow up in Cognitive Neurology clinic by calling the follow-up number. Mr. ___ is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care was greater than 30 minutes. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. CarBAMazepine 200 mg PO QAM 4. Potassium Chloride 20 mEq PO BID 5. RisperiDONE 2 mg PO DAILY 6. Valsartan 160 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. amLODIPine 10 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO DAILY 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. CarBAMazepine 400 mg PO QPM Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth QPM Disp #30 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY 3. CarBAMazepine 200 mg PO QAM 4. CarBAMazepine 400 mg PO QPM 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Potassium Chloride 20 mEq PO BID Hold for K > 4.5 9. Pravastatin 40 mg PO QPM 10. RisperiDONE 2 mg PO DAILY 11. Valsartan 160 mg PO DAILY 12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until at least ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: - Subarachnoid hemorrhage - New diagnosis of heart failure with reduced ejection fraction (EF 45%) SECONDARY DIAGNOSIS: - Right bundle branch block 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 the ___ ___. WHY WAS I SEEN IN THE HOSPITAL? - You had a fall and a small brain bleed. WHAT WAS DONE WHILE I WAS IN THE HOSPITAL? - We looked at the electrical activity of your heart and the squeeze of your heart. This showed that your heart was not squeezing as well as it should. - Our neurosurgeons did not recommend any further evaluation for your brain bleed. WHAT SHOULD I DO WHEN I AM OUT OF THE HOSPITAL? - Please call the cognitive neurology clinic for ___ week follow up. - Please go to your appointments as scheduled. - Weigh yourself every day, and call your doctor if your weight goes up more than three pounds in a day. We wish you the best, Your ___ Care Team Followup Instructions: ___	[ "S066X0A", "I130", "E1122", "I5022", "D649", "R55", "S0101XA", "I161", "N189", "I4510", "F319", "E785", "R32", "Y92481", "W1830XA" ]	Allergies: [MASKED] Chief Complaint: Head injury after fall Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] year old man with PMhx DM2, HTN, CKD, BPAD presents with SAH after a syncopal episode. Patient is amnestic to event. Patient's son witnessed him stumbling backwards and hitting his head with laceration but no loss of consciousness. He was brought to [MASKED] where CT head shows 5mm parafalcine vessel hemorrhage, without edema or shift. Labs were notable for WBC 5.9, Hgb 13.2, Cr 1.0, TropT < 0.03, U/A unremarkable. He was given Keppra IV and transferred to [MASKED]. Patient currently has no symptoms whatsoever and denies pain. In the ED, initial VS were: 98.9 76 190/111 16 98% RA Exam notable for: depression in the posterior occiput with 3 cm horizontal laceration, wound is explored with no evidence of fracture underneath, [MASKED] clear bilaterally no battle signs. No tenderness to palpation over the midline of the back but abrasions over the mid thoracic spine. Regular rate and rhythm, Clear to auscultation bilateral with normal chest rise bilaterally, abdomen soft, nontender nondistended, pelvis is stable, moving all extremities with no tenderness to palpation Labs showed: - WBC 10.4 PMN 84.9 - Hgb 13.2 - normal Plt, [MASKED] - Cr 0.8 Imaging showed: - NCHCT: 5mm right parafalcine SAH, no skull or cervical fractures Patient received: no medications or fluids Neurosurgery was consulted: Likely syncopal fall. The patient is neurologically intact on exam. Reviewed imaging and consulted with Dr. [MASKED]. Bleed meets ED obs criteria and there are no acute neurosurgical needs. Recommending possible medicine admission for syncopal workup. Hold aspirin, may resume in 3 days if needed. Transfer VS were: 98.1 69 121/78 14 100% RA On arrival to the floor, patient reports that he felt queasy and dizzy immediately before the fall without chest pain, SOB, light headedness, blurred vision. He denies post fall loss of bowel / bladder control, headache, blurred vision, dysarthria, focal numbness, weakness. Last fall was "a few months ago," while shopping, preceeded by leg weakness, no trauma, no medical attention. Leg weakness lasted [MASKED] minutes, he was able to get up under his own power. He denies other antecedent symptoms or post fall symptoms. He also has chronic stable occasional urinary incontinence described as dripping without sensation of need to void. This has been present for years and has not changed. Denies straining, dribbling, hesitancy, need for diapers. Denies fever, cough, sore throat, chills, chest pain, SOB, abd pain, N/V/D, bloody stools, dysuria, hematuria, swollen joints, rash, focal numbness, weakness, other recent falls. Past Medical History: DM2 HTN CKD HLD Bipolar Anemia Social History: [MASKED] Family History: Does not know too much about his family history, father had a stroke, no known aneurysms. Physical Exam: =========================== ADMISSION PHYSICAL EXAM: =========================== VS: 98.6 161/83 57 18 98% RA Weight: 75.52 kg GENERAL: WNWD man in NAD HEENT: 3in curvilinear horizontal occipital laceration, s/p staples, c/d/i, flattened occiput, tender, anicteric sclera, PERRL, EOMI, MOM, OP clear NECK: supple, no elevated JVD HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nondistended, nontender in all quadrants, no rebound/guarding, +BS EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&O, CN II-XII intact, SILT, [MASKED] strength BUE/BLE, no clonus, dysmetria, HKS normal SKIN: warm and well perfused ======================= DISCHARGE PHYSICAL EXAM: ======================= Vitals: 98.1 PO 131 / 81 96 16 98 RA GENERAL: Sitting in bed, NAD HEENT: 3in curvilinear horizontal occipital laceration, s/p staples, c/d/i, flattened occiput, tender, anicteric sclera, PERRL, EOMI, MOM, OP clear NECK: supple, no elevated JVD HEART: RRR, normal S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: soft, nondistended, nontender in all quadrants EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&O, CN II-XII intact, [MASKED] strength BUE/BLE, no clonus, dysmetria. Reflexes present in biceps and knees bilaterally, slightly diminished left patellar reflex. Cerebellar function intact. SKIN: warm and well perfused Pertinent Results: ADMISSION LABS: [MASKED] 03:53PM GLUCOSE-130* UREA N-10 CREAT-0.8 SODIUM-145 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14 [MASKED] 03:53PM estGFR-Using this [MASKED] 03:53PM CK(CPK)-125 [MASKED] 03:53PM CK-MB-4 cTropnT-0.01 [MASKED] 03:53PM WBC-10.4* RBC-4.35* HGB-13.2* HCT-39.1* MCV-90 MCH-30.3 MCHC-33.8 RDW-13.2 RDWSD-43.5 [MASKED] 03:53PM NEUTS-84.9* LYMPHS-8.6* MONOS-5.6 EOS-0.2* BASOS-0.1 IM [MASKED] AbsNeut-8.84* AbsLymp-0.90* AbsMono-0.58 AbsEos-0.02* AbsBaso-0.01 [MASKED] 03:53PM PLT COUNT-222 [MASKED] 03:53PM [MASKED] PTT-24.7* [MASKED] PERTINENT IMAGING: CT HEAD SECOND OPINION ([MASKED]): 1. 5 mm hyperdense extra-axial focus along the right parafalcine region, compatible with provided history of small subarachnoid hemorrhage. 2. No evidence of calvarial fracture. Soft tissue swelling and a small subgaleal hematoma noted along the posterior occiput. 3. No evidence of cervical spinal fracture or traumatic malalignment. 4. Moderate cervical spinal degenerative changes, as above. TRANSTHORACIC ECHOCARDIOGRAM ([MASKED]): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is mild regional left ventricular systolic dysfunction with basal to mid inferior and inferolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. 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. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. LVEF 45%. IMPRESSION: Mild regional LV systolic dysfunction c/w prior myocardial infarction in the RCA territory. DISCHARGE LABS: [MASKED] 06:25AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-145 K-3.2* Cl-105 HCO -27 AnGap-13 [MASKED] 06:15AM BLOOD ASA-NEG Ethanol-NEG Carbamz-4.7 Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: [MASKED] year old man with PMhx DM2, HTN, CKD, BPAD presents with SAH after a syncopal episode. Seen by neurosurgery (with no recommendations for surgery at this time), admitted to the floor for observation and further workup of syncope. Patient was stable and doing well during admission. ACUTE ISSUES: ============= # [MASKED] # Fall with headstrike # Syncope and # New diagnosis of HFrEF: Patient presented with a right parafalcine SAH (diagnosed on a head CT at OSH) after a falling episode, where he landed and hit the back of his head. Preceded by a prodrome of lightheadedness; his fall most consistent with neurocardiogenic syncope of unclear trigger. Pt did not have any preceding chest pain or exertional symptoms to suggest ischemia, nor has he had any throughout his hospital course. Pt was neurologically intact on admission with no urgent surgical intervention recommended by a neurosurgical consult. Patient was evaluated with EKG, telemetry, orthostatic vitals, cardiac enzymes, and an echocardiogram that demonstrated the presence of a right bundle branch block (EKG). Transthoracic echocardiogram performed on [MASKED] demonstrated evidence of a prior RCA MI, with inferior wall akinesis and a depressed EF at 45%. His cardiac biomarkers remained negative throughout admission. Patient was given routine neurological exams (q4) that showed no neurological changes. Per neurosurgery recommendations, interval imaging was not performed; nor was any further antiepileptic medication started. Pt recommended to follow up at the concussion clinic [MASKED] weeks after his presentation. Angiography (to evaluate for the presence of aneurysms) was considered as well, however given the traumatic nature of the patient's presentation, neurosurgery did not believe this to be necessary. Patient will follow up with neurology, cardiology, and his PCP in the outpatient setting once leaving the hospital. - Recommended holding ASA until [MASKED] in setting of recent [MASKED] - Staple removal from occipital wound to be performed 10d after placement at [MASKED] [MASKED] (on [MASKED]. # Urinary incontinence Patient without bladder obstructive symptoms and history of carbamazepine, lithium and risperidone presents with chronic stable urinary incontinence. Patient is also taking a diuretic for BP control. Likely a medication effects as these medications are associated with urinary incontinence but given clinical scenario of [MASKED], this urinary incontinence was monitored closely during his hospital stay. CHRONIC ISSUES: =============== # DM2 Last A1c 5.7 [MASKED], not on any medications. Presented without overt hyperglycemia. A1c is 5.4 on [MASKED], obtained for risk stratification purposes. # HTN: hypertensive I/s/o. Continued valsartan, amlodipine, and HCTZ. Was giving metoprolol to further control pressures. # CKD: presents below prior readings of 1.3-1.6 in [MASKED]. # HLD: stable. Continued pravastatin and held home potassium chloride. # Bipolar: mood stable. Continued home Carbamazepine 200 mg QAM / 400 mg QPM and risperidone 2 mg QD. Carbamazepine level at discharge was 4.7, within the therapeutic range. # Anemia: presents above prior baseline of [MASKED] in [MASKED]. Stably at baseline at time of discharge. TRANSITIONAL ISSUES: ==================== #CODE: Full (presumed) #CONTACT: [MASKED] (son/HCP) [MASKED] [ ] MEDICATION CHANGES: - Added: Atorvastatin 40mg (if tolerates can increase to 80mg) - Held: Aspirin 81mg. Do not restart until at least [MASKED] given recent subarachnoid hemorrhage. [ ] NEW DIAGNOSIS OF HEART FAILURE WITH REDUCED EJECTION FRACTION: - Pt euvolemic at time of discharge. - Discharge weight: 76.98kg - Discharge creatinine: 0.9 - Recommend Pt follow up with cardiology as scheduled for further consideration of outpatient stress test, possible cardiac catheterization. [ ] SUBARACHNOID HEMORRHAGE: - Pt to hold on aspirin until [MASKED]. - Maintain blood pressure control with sBP < 160. He was under this threshold without PRN hydralazine by discharge; consider uptitrating home medicines as needed to achieve this effect. - To follow up in Cognitive Neurology clinic by calling the follow-up number. Mr. [MASKED] is clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care was greater than 30 minutes. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. CarBAMazepine 200 mg PO QAM 4. Potassium Chloride 20 mEq PO BID 5. RisperiDONE 2 mg PO DAILY 6. Valsartan 160 mg PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. amLODIPine 10 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO DAILY 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. CarBAMazepine 400 mg PO QPM Discharge Medications: 1. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth QPM Disp #30 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY 3. CarBAMazepine 200 mg PO QAM 4. CarBAMazepine 400 mg PO QPM 5. Hydrochlorothiazide 12.5 mg PO DAILY 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Potassium Chloride 20 mEq PO BID Hold for K > 4.5 9. Pravastatin 40 mg PO QPM 10. RisperiDONE 2 mg PO DAILY 11. Valsartan 160 mg PO DAILY 12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until at least [MASKED]. Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSES: - Subarachnoid hemorrhage - New diagnosis of heart failure with reduced ejection fraction (EF 45%) SECONDARY DIAGNOSIS: - Right bundle branch block 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 the [MASKED] [MASKED]. WHY WAS I SEEN IN THE HOSPITAL? - You had a fall and a small brain bleed. WHAT WAS DONE WHILE I WAS IN THE HOSPITAL? - We looked at the electrical activity of your heart and the squeeze of your heart. This showed that your heart was not squeezing as well as it should. - Our neurosurgeons did not recommend any further evaluation for your brain bleed. WHAT SHOULD I DO WHEN I AM OUT OF THE HOSPITAL? - Please call the cognitive neurology clinic for [MASKED] week follow up. - Please go to your appointments as scheduled. - Weigh yourself every day, and call your doctor if your weight goes up more than three pounds in a day. We wish you the best, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I130", "E1122", "D649", "N189", "E785" ]	[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "D649: Anemia, unspecified", "R55: Syncope and collapse", "S0101XA: Laceration without foreign body of scalp, initial encounter", "I161: Hypertensive emergency", "N189: Chronic kidney disease, unspecified", "I4510: Unspecified right bundle-branch block", "F319: Bipolar disorder, unspecified", "E785: Hyperlipidemia, unspecified", "R32: Unspecified urinary incontinence", "Y92481: Parking lot as the place of occurrence of the external cause", "W1830XA: Fall on same level, unspecified, initial encounter" ]
19,975,710	20,266,816	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubated ___ History of Present Illness: ___ year old female with a history of diabetes, hypertension, hyperlipidemia and obesity discharged from ___ ___ today following total right hip replacement for osteoarthritis three days ago presenting with shortness of breath and found to have sats of 60% requiring intubation. In ED initial VS: HR 63 BP 110/58 RR 18 SO2 100% while intubated Labs significant for: WBC 17.3 (86% neutrophils) Hbg 8.1 Hct 26.2 ___ 14103 (was 287 on ___ Trop-T 0.27 Lactate 1.1 -> 0.7 Arterial blood gas with pH 7.27, pCO2 51, pO2 198, HCO3 24 UA: Moderate leuks, negative nitrates, 23 ___ Patient was given: Heparin for concern of DVT and started on vancomycin, cefepime and azithromycin due to concern of pneumonia Imaging notable for: Bedside echo revealing RV with good function and no evidence of RH strain and no pericardial effusion. Good AS EKG showing normal sinus rhythm with TWI in V3, no ST changes or Q waves Consults: Orthopedics On arrival to the FICU, unable to obtain additional history as patient was intubated and sedated. REVIEW OF SYSTEMS: Unable to obtain as patient was intubated and sedated. Past Medical History: Essential Hypertension Hypothyroidism Aortic Valve Stenosis Body Mass Index ___ - Severely Obese Chronic Kidney Disease, Stage 3 Diabetes Mellitus Type 2 in Obese Endometrial Carcinoma Gastroesophageal Reflux Disease Hyperlipidemia Iron Deficiency Anemia Osteoarthritis Social History: ___ Family History: Mother passed away at the age of ___ due to cancer. Physical Exam: Admission Physical Exam ======================== GENERAL: intubated and sedated LUNGS: Course breath sounds bilaterally CV: Regular rate and rhythm with holosystoic murmur ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, with mild lower extremity edema SKIN: incision on right hip with mild erythema and scant drainage, inferior portion of incision with surrounding Discharge Physical Exam ======================== GENERAL: NAD, well appearing HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD, JVP not appreciated CV: RRR, S1/S2, loud III/VI systolic murmur over RUSB, no gallops or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: obese abdomen, soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, 1+ edema to knees bilaterally (reports baseline from amlodipine) PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, ___ strength in upper extremities, face symmetric, sensation grossly intact, PERRL Pertinent Results: Admission Labs =============== ___ 07:00PM BLOOD WBC-17.3* RBC-3.01* Hgb-8.1* Hct-26.2* MCV-87 MCH-26.9 MCHC-30.9* RDW-17.7* RDWSD-55.8* Plt ___ ___:00PM BLOOD Neuts-86.0* Lymphs-6.4* Monos-6.2 Eos-0.4* Baso-0.2 Im ___ AbsNeut-14.86* AbsLymp-1.10* AbsMono-1.07* AbsEos-0.07 AbsBaso-0.03 ___ 07:00PM BLOOD ___ PTT-26.0 ___ ___ 07:00PM BLOOD Glucose-143* UreaN-30* Creat-1.1 Na-136 K-5.3 Cl-102 HCO3-21* AnGap-13 ___ 07:00PM BLOOD ___ ___ 07:00PM BLOOD cTropnT-0.27* ___ 07:00PM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8 ___ 07:40PM BLOOD Type-ART pO2-198* pCO2-51* pH-7.27* calTCO2-24 Base XS--3 ___ 07:08PM BLOOD Lactate-1.1 Micro/Other Pertinent Labs =========================== ___ 11:06 am URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 10:10 am Mini-BAL GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml. ___ 8:11 am SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: ___ PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. ___ 9:08 am MRSA SCREEN Source: Nasal swab. *FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 02:14PM BLOOD Ret Aut-1.8 Abs Ret-0.05 ___ 07:00PM BLOOD ___ ___ 07:00PM BLOOD cTropnT-0.27 ___ 02:25AM BLOOD CK-MB-9 cTropnT-0.29* ___ 07:30AM BLOOD CK-MB-8 cTropnT-0.30* ___ 11:57AM BLOOD CK-MB-9 cTropnT-0.25* ___ 02:02PM BLOOD cTropnT-0.49* ___ 10:15PM BLOOD cTropnT-0.45* ___ 05:23AM BLOOD cTropnT-0.94* ___ 02:14PM BLOOD calTIBC-160* ___ Hapto-357* Ferritn-97 TRF-123* ___ 02:14PM BLOOD Iron-20* Imaging ======== CTA CHEST ___ 1. No evidence of pulmonary embolism or aortic abnormality. 2. Cardiomegaly and diffuse bilateral ground-glass opacities and paraseptal thickening, suggestive of pulmonary edema. 3. Moderate right pleural effusion and small left pleural effusion. TTE ___ The left atrial volume index is normal. The right atrial pressure could not be estimated. There is normal left ventricular wall thickness with a normal cavity size. There is mild-moderate left ventricular regional systolic dysfunction with severe hypokinesis of the distal half of the anterior and anterior septum, distal inferior and apical walls (see schematic) and preserved/normal contractility of the remaining segments. Quantitative biplane left ventricular ejection fraction is 37 %. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area less than 1.0 cm2). There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is mild to moderate [___] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Severe aortic valve stenosis. Normal left ventricular cavity size with regional systolic dysfunction most c/w CAD (mid-LAD distribution). Moderate pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. CXR ___ Increased pulmonary edema and right pleural fluid. CXR ___ 1. Interval improvement of bilateral airspace opacities consistent with improved aeration. 2. Mild to moderate bilateral pleural effusions right worse than left, that are unchanged from prior exam. 3. Support lines and tubes are unchanged CORONARY ANGIOGRAPHY ___ LM- The left main coronary artery has no angiographically apparent disease. LAD- The left anterior descending coronary artery. The vessel is diffusely calcified. There is a proximal 90% stenosis. The lesion is is a culprit stenosis. Circ- The circumflex coronary artery has no angiographically apparent disease. OM1- The first obtuse marginal coronary artery. The vessel is small in diameter. There is a 90% stenosis. RI- The ramus intermedius has no angiographically apparent disease. RCA- The right coronary artery. There is a proximal 40% steno *A 6 ___ EBU3.5 guide provided adequate support. Crossed with a Prowater wire into the distal LAD. Predilated with a 2.5 mm balloon and then deployed a 3.0 mm x 12 mm DES at 16 atm. Final angiography revealed normal flow, no dissection and 0% residual stenosis CXR ___ Support lines and tubes unchanged. Bilateral effusions right greater than left are stable. Pulmonary edema has slightly worsened. Cardiomediastinal silhouette is stable. No pneumothorax is seen. Discharge Labs =============== ___ 06:01AM BLOOD WBC-12.7 RBC-3.73* Hgb-10.8* Hct-34.1 MCV-91 MCH-29.0 MCHC-31.7* RDW-17.8* RDWSD-55.8* Plt ___ ___ 06:01AM BLOOD ___ PTT-22.2* ___ ___ 06:01AM BLOOD Glucose-167* UreaN-18 Creat-0.9 Na-141 K-4.3 Cl-102 HCO3-25 AnGap-14 ___ 06:01AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.4* Brief Hospital Course: ___ year-old female with a history of diabetes, HTN, HLD, recently discharged from ___ on ___ following total right hip replacement, who presented with shortness of breath found to be in acute hypoxic respiratory failure in setting of fluid overload likely due to NSTEMI and severe AS, now s/p DES to LAD, with course c/b possible HAP. #CORONARIES: s/p DES to LAD, 90% occlusion OM1, 40% RCA #PUMP: EF 37% #RHYTHM: NSR ACTIVE ISSUES: =============== #NSTEMI: Two vessel disease (LAD, OM1) now s/p DES to LAD with new apical akinesis. Continued patient on atorvastatin 80mg daily, ASA daily, and Plavix daily. Given apical akinesis, plan for treatment with triple therapy for the next three months with INR goal ___. Will need repeat TTE at that time with consideration of discontinuation of warfarin. #CHF EF 37%: #Severe AS New heart failure (TTE in Atrius system from earlier this year without contractile dysfunction) secondary to NSTEMI. Patient volume overloaded on arrival, now 7.2L negative and grossly euvolemic. Started torsemide 10mg daily. Will continue metoprolol succinate 12.5mg daily, amlodipine 10mg daily, and valsartan 160mg BID. #Severe AS: Follow up for TAVR v SAVR eval in the outpatient setting. #Respiratory failure: Now resolved, likely in setting of volume overload and possible pneumonia. Initially was treated with antibiotics for HAP, but discontinued given signs of infection. She was treated with vanc/cefepime from ___ and ceftriaxone to ___. ___ Baseline creatinine 0.9 on admission, then developed ___ to 1.6, likely in setting of contrast load from cardiac catheterization and diuresis. Resolved. #Iron-deficiency anemia: s/p pRBC ___ for hgb 7, ___ for hgb<10 study, ___ for hgb<10 study, ___ for hgb<10 study. Received course of IV iron. She was transfused to Hb 10 for study in which she was entered. #s/p hip replacement Orthopedics aware of patient but not actively following. No acute issues. She will follow up with orthopedics at ___ ___. #Fungal rash: Continued miconaozole powder. CHRONIC/STABLE ISSUES: ======================= # Insulin Dependent Diabetes: Placed on ISS. # Hypothyroidism: Continued levothyroxine 88mcg PO daily # HLD: Continued home dose of 20 mg simvastatin # GERD: Continued home omeprazole 20 mg BID # HTN: hypotensive while in ICU in setting of NSTEMI - Consider restarting home metoprolol tartrate 50 bid and valsartan-hydrochlorothiazide 320-25 as pressures tolerate TRANSITIONAL ISSUES: ==================== Discharge weight: 102.2kg Discharge Cr: 0.9 Medication changes [] Started warfarin for apical akinesis after MI. Will continue with warfarin with goal INR ___. [] Started aspirin 81mg daily and Plavix 75mg daily. Will need to continue on DAPT for 12 months. Can consider discontinuation of Plavix at that time. [] Started torsemide 10mg daily [] Started irbesartan 150mg BID for hypertension (given issues with valsartan purity). Adjust based on BP. [] Stopped simvastatin and replaced with atorvastatin Other issues: [] Please recheck Chem10 in ___ days to assess for stable Cr on torsemide 10mg daily. If loses or gains more than ___ lbs, readjust dosing or discontinue. [] Repeat INR on ___ and adjust warfarin dosing accordingly. Goal INR ___. [] Repeat TTE in 3 months to assess for improvement in apical akinesis and ability to stop anticoagulation as well as aortic stenosis [] Arrange for outpatient follow-up for evaluation for TAVR vs SAVR [] Discharged on DAPT for 12 months. Should not stop for any reason without consulting cardiologist. Can discontinue Plavix at that time. [] f/u anemia and iron studies. Patient received IV iron [] Consider switching to metoprolol and amlodipine to carvedilol given possible contribution to fluid retention. [] Consider adding spironolactone if tolerated for HFrEF. [] Arrange for orthopedic follow up with Dr. ___ at NEB ___ or ___ *** #CONTACT: ___, ___ ___, Daughter, ___ #CODE: Full code (discussed with next of kin by CCU team) Medications on Admission: 1. amLODIPine 10 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Cyanocobalamin 100 mcg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. FoLIC Acid 0.8 mg PO DAILY 6. Gabapentin 300 mg PO BID 7. GlipiZIDE 5 mg PO BID 8. aspart 15 Units Breakfast aspart 18 Units Bedtime 9. Levothyroxine Sodium 88 mcg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Omeprazole 20 mg PO BID 12. Simvastatin 20 mg PO QPM 13. LORazepam 1 mg PO PRN prior to flying 14. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 15. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line 16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 17. Polyethylene Glycol 17 g PO DAILY 18. Senna 8.6 mg PO BID:PRN Constipation - First Line 19. Enoxaparin Sodium 30 mg SC Q12H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 4. Docusate Sodium 100 mg PO BID 5. irbesartan 150 mg oral BID 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Torsemide 10 mg PO DAILY 8. Warfarin 2 mg PO DAILY16 Goal INR ___ 9. aspart 15 Units Breakfast aspart 18 Units Bedtime 10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 11. amLODIPine 10 mg PO DAILY 12. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line 13. Cyanocobalamin 100 mcg PO DAILY 14. Ferrous Sulfate 325 mg PO DAILY 15. FoLIC Acid 0.8 mg PO DAILY 16. Gabapentin 300 mg PO BID 17. GlipiZIDE 5 mg PO BID 18. Levothyroxine Sodium 88 mcg PO DAILY 19. LORazepam 1 mg PO PRN prior to flying 20. MetFORMIN (Glucophage) 500 mg PO BID 21. Omeprazole 20 mg PO BID 22. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #18 Tablet Refills:*0 23. Polyethylene Glycol 17 g PO DAILY 24. Senna 8.6 mg PO BID:PRN Constipation - First Line 25. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Acute systolic heart failure ___ to NSTEMI SECONDARY DIAGNOSIS: ==================== Aortic stenosis Hypertension Hypothyroidism DM2 CKD3 GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted to the hospital because you had been feeling short of breath and had swelling in your legs. This was felt to be due to a condition called heart failure, where your heart does not pump hard enough and fluid backs up into your lungs. - You were found to have had a heart attack and it was thought to be the cause of your new heart failure. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were found to have fluid in your lungs with low oxygen levels in your blood. You had a temporary breathing tube placed (intubation) to support your breathing while in the ICU. You were given a diuretic medication through the IV to help get the fluid out. - Your heart arteries were examined (cardiac catheterization) which showed a blockage of one of the arteries, the left anterior descending (LAD). This was opened by placing a tube called a stent in the artery. You were given medications to prevent future blockages. - You received an ultrasound of your heart (echocardiogram) which showed that parts of your heart were found to be moving less than normal. This increases your risk of forming clots within your heart that can spread throughout the body and also cause a stroke. , and you were started WHAT SHOULD I DO WHEN I GO HOME? ================================ - It is very important to take your aspirin and clopidogrel (also known as Plavix) every day. These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. If you stop these medications or miss ___ dose, you risk causing a blood clot forming in your heart stents and having another heart attack. Please do not stop taking either medication without taking to your heart doctor. - It is also very important to take your warfarin (also known as Coumadin) to reduce the risk of developing clots within your heart that can then cause strokes. - Please follow-up with your doctor to have your INR level checked to make sure your warfarin is at appropriate levels. - You are also on other new medications to help your heart, such as atorvastatin, metoprolol, valsartan, and torsemide (replaces your hydrochlorothiazide). - Your weight at discharge is 102.2kg. Please weigh yourself today at home and use this as your new baseline - Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___	[ "I9789", "I214", "I5021", "J9601", "J189", "I130", "E871", "N179", "Z6842", "I2510", "Z87891", "Y838", "Y929", "N183", "E1122", "Z794", "I255", "I952", "T41295A", "Y92230", "R410", "I350", "N141", "T508X5A", "E039", "K219", "E785", "E6601", "Z8542", "D509", "B369", "Z006" ]	Allergies: No Allergies/ADRs on File Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubated [MASKED] History of Present Illness: [MASKED] year old female with a history of diabetes, hypertension, hyperlipidemia and obesity discharged from [MASKED] [MASKED] today following total right hip replacement for osteoarthritis three days ago presenting with shortness of breath and found to have sats of 60% requiring intubation. In ED initial VS: HR 63 BP 110/58 RR 18 SO2 100% while intubated Labs significant for: WBC 17.3 (86% neutrophils) Hbg 8.1 Hct 26.2 [MASKED] 14103 (was 287 on [MASKED] Trop-T 0.27 Lactate 1.1 -> 0.7 Arterial blood gas with pH 7.27, pCO2 51, pO2 198, HCO3 24 UA: Moderate leuks, negative nitrates, 23 [MASKED] Patient was given: Heparin for concern of DVT and started on vancomycin, cefepime and azithromycin due to concern of pneumonia Imaging notable for: Bedside echo revealing RV with good function and no evidence of RH strain and no pericardial effusion. Good AS EKG showing normal sinus rhythm with TWI in V3, no ST changes or Q waves Consults: Orthopedics On arrival to the FICU, unable to obtain additional history as patient was intubated and sedated. REVIEW OF SYSTEMS: Unable to obtain as patient was intubated and sedated. Past Medical History: Essential Hypertension Hypothyroidism Aortic Valve Stenosis Body Mass Index [MASKED] - Severely Obese Chronic Kidney Disease, Stage 3 Diabetes Mellitus Type 2 in Obese Endometrial Carcinoma Gastroesophageal Reflux Disease Hyperlipidemia Iron Deficiency Anemia Osteoarthritis Social History: [MASKED] Family History: Mother passed away at the age of [MASKED] due to cancer. Physical Exam: Admission Physical Exam ======================== GENERAL: intubated and sedated LUNGS: Course breath sounds bilaterally CV: Regular rate and rhythm with holosystoic murmur ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, with mild lower extremity edema SKIN: incision on right hip with mild erythema and scant drainage, inferior portion of incision with surrounding Discharge Physical Exam ======================== GENERAL: NAD, well appearing HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD, JVP not appreciated CV: RRR, S1/S2, loud III/VI systolic murmur over RUSB, no gallops or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: obese abdomen, soft, nondistended, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, 1+ edema to knees bilaterally (reports baseline from amlodipine) PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, [MASKED] strength in upper extremities, face symmetric, sensation grossly intact, PERRL Pertinent Results: Admission Labs =============== [MASKED] 07:00PM BLOOD WBC-17.3* RBC-3.01* Hgb-8.1* Hct-26.2* MCV-87 MCH-26.9 MCHC-30.9* RDW-17.7* RDWSD-55.8* Plt [MASKED] [MASKED]:00PM BLOOD Neuts-86.0* Lymphs-6.4* Monos-6.2 Eos-0.4* Baso-0.2 Im [MASKED] AbsNeut-14.86* AbsLymp-1.10* AbsMono-1.07* AbsEos-0.07 AbsBaso-0.03 [MASKED] 07:00PM BLOOD [MASKED] PTT-26.0 [MASKED] [MASKED] 07:00PM BLOOD Glucose-143* UreaN-30* Creat-1.1 Na-136 K-5.3 Cl-102 HCO3-21* AnGap-13 [MASKED] 07:00PM BLOOD [MASKED] [MASKED] 07:00PM BLOOD cTropnT-0.27* [MASKED] 07:00PM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8 [MASKED] 07:40PM BLOOD Type-ART pO2-198* pCO2-51* pH-7.27* calTCO2-24 Base XS--3 [MASKED] 07:08PM BLOOD Lactate-1.1 Micro/Other Pertinent Labs =========================== [MASKED] 11:06 am URINE Source: Catheter. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 10:10 am Mini-BAL GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml. [MASKED] 8:11 am SPUTUM Source: Endotracheal. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: [MASKED] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [MASKED]: SPARSE GROWTH Commensal Respiratory Flora. [MASKED] 9:08 am MRSA SCREEN Source: Nasal swab. *FINAL REPORT [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. [MASKED] 02:14PM BLOOD Ret Aut-1.8 Abs Ret-0.05 [MASKED] 07:00PM BLOOD [MASKED] [MASKED] 07:00PM BLOOD cTropnT-0.27 [MASKED] 02:25AM BLOOD CK-MB-9 cTropnT-0.29* [MASKED] 07:30AM BLOOD CK-MB-8 cTropnT-0.30* [MASKED] 11:57AM BLOOD CK-MB-9 cTropnT-0.25* [MASKED] 02:02PM BLOOD cTropnT-0.49* [MASKED] 10:15PM BLOOD cTropnT-0.45* [MASKED] 05:23AM BLOOD cTropnT-0.94* [MASKED] 02:14PM BLOOD calTIBC-160* [MASKED] Hapto-357* Ferritn-97 TRF-123* [MASKED] 02:14PM BLOOD Iron-20* Imaging ======== CTA CHEST [MASKED] 1. No evidence of pulmonary embolism or aortic abnormality. 2. Cardiomegaly and diffuse bilateral ground-glass opacities and paraseptal thickening, suggestive of pulmonary edema. 3. Moderate right pleural effusion and small left pleural effusion. TTE [MASKED] The left atrial volume index is normal. The right atrial pressure could not be estimated. There is normal left ventricular wall thickness with a normal cavity size. There is mild-moderate left ventricular regional systolic dysfunction with severe hypokinesis of the distal half of the anterior and anterior septum, distal inferior and apical walls (see schematic) and preserved/normal contractility of the remaining segments. Quantitative biplane left ventricular ejection fraction is 37 %. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area less than 1.0 cm2). There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is mild to moderate [[MASKED]] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Severe aortic valve stenosis. Normal left ventricular cavity size with regional systolic dysfunction most c/w CAD (mid-LAD distribution). Moderate pulmonary artery systolic hypertension. Mild-moderate mitral regurgitation. CXR [MASKED] Increased pulmonary edema and right pleural fluid. CXR [MASKED] 1. Interval improvement of bilateral airspace opacities consistent with improved aeration. 2. Mild to moderate bilateral pleural effusions right worse than left, that are unchanged from prior exam. 3. Support lines and tubes are unchanged CORONARY ANGIOGRAPHY [MASKED] LM- The left main coronary artery has no angiographically apparent disease. LAD- The left anterior descending coronary artery. The vessel is diffusely calcified. There is a proximal 90% stenosis. The lesion is is a culprit stenosis. Circ- The circumflex coronary artery has no angiographically apparent disease. OM1- The first obtuse marginal coronary artery. The vessel is small in diameter. There is a 90% stenosis. RI- The ramus intermedius has no angiographically apparent disease. RCA- The right coronary artery. There is a proximal 40% steno *A 6 [MASKED] EBU3.5 guide provided adequate support. Crossed with a Prowater wire into the distal LAD. Predilated with a 2.5 mm balloon and then deployed a 3.0 mm x 12 mm DES at 16 atm. Final angiography revealed normal flow, no dissection and 0% residual stenosis CXR [MASKED] Support lines and tubes unchanged. Bilateral effusions right greater than left are stable. Pulmonary edema has slightly worsened. Cardiomediastinal silhouette is stable. No pneumothorax is seen. Discharge Labs =============== [MASKED] 06:01AM BLOOD WBC-12.7 RBC-3.73* Hgb-10.8* Hct-34.1 MCV-91 MCH-29.0 MCHC-31.7* RDW-17.8* RDWSD-55.8* Plt [MASKED] [MASKED] 06:01AM BLOOD [MASKED] PTT-22.2* [MASKED] [MASKED] 06:01AM BLOOD Glucose-167* UreaN-18 Creat-0.9 Na-141 K-4.3 Cl-102 HCO3-25 AnGap-14 [MASKED] 06:01AM BLOOD Calcium-8.2* Phos-2.1* Mg-1.4* Brief Hospital Course: [MASKED] year-old female with a history of diabetes, HTN, HLD, recently discharged from [MASKED] on [MASKED] following total right hip replacement, who presented with shortness of breath found to be in acute hypoxic respiratory failure in setting of fluid overload likely due to NSTEMI and severe AS, now s/p DES to LAD, with course c/b possible HAP. #CORONARIES: s/p DES to LAD, 90% occlusion OM1, 40% RCA #PUMP: EF 37% #RHYTHM: NSR ACTIVE ISSUES: =============== #NSTEMI: Two vessel disease (LAD, OM1) now s/p DES to LAD with new apical akinesis. Continued patient on atorvastatin 80mg daily, ASA daily, and Plavix daily. Given apical akinesis, plan for treatment with triple therapy for the next three months with INR goal [MASKED]. Will need repeat TTE at that time with consideration of discontinuation of warfarin. #CHF EF 37%: #Severe AS New heart failure (TTE in Atrius system from earlier this year without contractile dysfunction) secondary to NSTEMI. Patient volume overloaded on arrival, now 7.2L negative and grossly euvolemic. Started torsemide 10mg daily. Will continue metoprolol succinate 12.5mg daily, amlodipine 10mg daily, and valsartan 160mg BID. #Severe AS: Follow up for TAVR v SAVR eval in the outpatient setting. #Respiratory failure: Now resolved, likely in setting of volume overload and possible pneumonia. Initially was treated with antibiotics for HAP, but discontinued given signs of infection. She was treated with vanc/cefepime from [MASKED] and ceftriaxone to [MASKED]. [MASKED] Baseline creatinine 0.9 on admission, then developed [MASKED] to 1.6, likely in setting of contrast load from cardiac catheterization and diuresis. Resolved. #Iron-deficiency anemia: s/p pRBC [MASKED] for hgb 7, [MASKED] for hgb<10 study, [MASKED] for hgb<10 study, [MASKED] for hgb<10 study. Received course of IV iron. She was transfused to Hb 10 for study in which she was entered. #s/p hip replacement Orthopedics aware of patient but not actively following. No acute issues. She will follow up with orthopedics at [MASKED] [MASKED]. #Fungal rash: Continued miconaozole powder. CHRONIC/STABLE ISSUES: ======================= # Insulin Dependent Diabetes: Placed on ISS. # Hypothyroidism: Continued levothyroxine 88mcg PO daily # HLD: Continued home dose of 20 mg simvastatin # GERD: Continued home omeprazole 20 mg BID # HTN: hypotensive while in ICU in setting of NSTEMI - Consider restarting home metoprolol tartrate 50 bid and valsartan-hydrochlorothiazide 320-25 as pressures tolerate TRANSITIONAL ISSUES: ==================== Discharge weight: 102.2kg Discharge Cr: 0.9 Medication changes [] Started warfarin for apical akinesis after MI. Will continue with warfarin with goal INR [MASKED]. [] Started aspirin 81mg daily and Plavix 75mg daily. Will need to continue on DAPT for 12 months. Can consider discontinuation of Plavix at that time. [] Started torsemide 10mg daily [] Started irbesartan 150mg BID for hypertension (given issues with valsartan purity). Adjust based on BP. [] Stopped simvastatin and replaced with atorvastatin Other issues: [] Please recheck Chem10 in [MASKED] days to assess for stable Cr on torsemide 10mg daily. If loses or gains more than [MASKED] lbs, readjust dosing or discontinue. [] Repeat INR on [MASKED] and adjust warfarin dosing accordingly. Goal INR [MASKED]. [] Repeat TTE in 3 months to assess for improvement in apical akinesis and ability to stop anticoagulation as well as aortic stenosis [] Arrange for outpatient follow-up for evaluation for TAVR vs SAVR [] Discharged on DAPT for 12 months. Should not stop for any reason without consulting cardiologist. Can discontinue Plavix at that time. [] f/u anemia and iron studies. Patient received IV iron [] Consider switching to metoprolol and amlodipine to carvedilol given possible contribution to fluid retention. [] Consider adding spironolactone if tolerated for HFrEF. [] Arrange for orthopedic follow up with Dr. [MASKED] at NEB [MASKED] or [MASKED] *** #CONTACT: [MASKED], [MASKED] [MASKED], Daughter, [MASKED] #CODE: Full code (discussed with next of kin by CCU team) Medications on Admission: 1. amLODIPine 10 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. Cyanocobalamin 100 mcg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. FoLIC Acid 0.8 mg PO DAILY 6. Gabapentin 300 mg PO BID 7. GlipiZIDE 5 mg PO BID 8. aspart 15 Units Breakfast aspart 18 Units Bedtime 9. Levothyroxine Sodium 88 mcg PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Omeprazole 20 mg PO BID 12. Simvastatin 20 mg PO QPM 13. LORazepam 1 mg PO PRN prior to flying 14. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 15. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line 16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate 17. Polyethylene Glycol 17 g PO DAILY 18. Senna 8.6 mg PO BID:PRN Constipation - First Line 19. Enoxaparin Sodium 30 mg SC Q12H Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 4. Docusate Sodium 100 mg PO BID 5. irbesartan 150 mg oral BID 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Torsemide 10 mg PO DAILY 8. Warfarin 2 mg PO DAILY16 Goal INR [MASKED] 9. aspart 15 Units Breakfast aspart 18 Units Bedtime 10. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 11. amLODIPine 10 mg PO DAILY 12. Bisacodyl 5 mg PO DAILY:PRN Constipation - First Line 13. Cyanocobalamin 100 mcg PO DAILY 14. Ferrous Sulfate 325 mg PO DAILY 15. FoLIC Acid 0.8 mg PO DAILY 16. Gabapentin 300 mg PO BID 17. GlipiZIDE 5 mg PO BID 18. Levothyroxine Sodium 88 mcg PO DAILY 19. LORazepam 1 mg PO PRN prior to flying 20. MetFORMIN (Glucophage) 500 mg PO BID 21. Omeprazole 20 mg PO BID 22. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #18 Tablet Refills:*0 23. Polyethylene Glycol 17 g PO DAILY 24. Senna 8.6 mg PO BID:PRN Constipation - First Line 25. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Acute systolic heart failure [MASKED] to NSTEMI SECONDARY DIAGNOSIS: ==================== Aortic stenosis Hypertension Hypothyroidism DM2 CKD3 GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted to the hospital because you had been feeling short of breath and had swelling in your legs. This was felt to be due to a condition called heart failure, where your heart does not pump hard enough and fluid backs up into your lungs. - You were found to have had a heart attack and it was thought to be the cause of your new heart failure. WHAT HAPPENED IN THE HOSPITAL? ============================== - You were found to have fluid in your lungs with low oxygen levels in your blood. You had a temporary breathing tube placed (intubation) to support your breathing while in the ICU. You were given a diuretic medication through the IV to help get the fluid out. - Your heart arteries were examined (cardiac catheterization) which showed a blockage of one of the arteries, the left anterior descending (LAD). This was opened by placing a tube called a stent in the artery. You were given medications to prevent future blockages. - You received an ultrasound of your heart (echocardiogram) which showed that parts of your heart were found to be moving less than normal. This increases your risk of forming clots within your heart that can spread throughout the body and also cause a stroke. , and you were started WHAT SHOULD I DO WHEN I GO HOME? ================================ - It is very important to take your aspirin and clopidogrel (also known as Plavix) every day. These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. If you stop these medications or miss [MASKED] dose, you risk causing a blood clot forming in your heart stents and having another heart attack. Please do not stop taking either medication without taking to your heart doctor. - It is also very important to take your warfarin (also known as Coumadin) to reduce the risk of developing clots within your heart that can then cause strokes. - Please follow-up with your doctor to have your INR level checked to make sure your warfarin is at appropriate levels. - You are also on other new medications to help your heart, such as atorvastatin, metoprolol, valsartan, and torsemide (replaces your hydrochlorothiazide). - Your weight at discharge is 102.2kg. Please weigh yourself today at home and use this as your new baseline - Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs. Thank you for allowing us to be involved in your care, we wish you all the best! Your [MASKED] Healthcare Team Followup Instructions: [MASKED]	[]	[ "J9601", "I130", "E871", "N179", "I2510", "Z87891", "Y929", "E1122", "Z794", "Y92230", "E039", "K219", "E785", "D509" ]	[ "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5021: Acute systolic (congestive) heart failure", "J9601: Acute respiratory failure with hypoxia", "J189: Pneumonia, unspecified organism", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "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", "N183: Chronic kidney disease, stage 3 (moderate)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z794: Long term (current) use of insulin", "I255: Ischemic cardiomyopathy", "I952: Hypotension due to drugs", "T41295A: Adverse effect of other general anesthetics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R410: Disorientation, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "Z8542: Personal history of malignant neoplasm of other parts of uterus", "D509: Iron deficiency anemia, unspecified", "B369: Superficial mycosis, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
19,975,740	29,321,695	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: ___ Aortic Valve Replacement (23mm ___ valve) History of Present Illness: Mr. ___ is a pleasant ___ year old man with a history of aortic stenosis, bicuspid aortic valve, chronic kidney disease, diabetes mellitus, hyperlipidemia, hypertension, and prostate cancer. He has had a heart murmur for years. He has recently noted dyspnea on exertion. An echocardiogram in ___ revealed severe aortic stenosis with peak and mean gradients of 65 mmHg and 44 mmHg, respectively. The aortic valve area was 0.9 cm2 and the valve was possibly bicuspid. He was referred to Dr. ___ surgical consultation. He has noted dyspnea on exertion. He otherwise denied syncope, fatigue, dizziness, lightheadedness, shortness of breath at rest, chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. Past Medical History: Bicuspid aortic valve with Aortic stenosis Chronic Kidney Disease, baseline Creatinine 1.52 Diabetes Mellitus Type II Hyperlipidemia Hypertension Obesity Peripheral Neuropathy Prostate Cancer Squamous Cell Carcinoma Radical Prostatectomy, ___ Tonsillectomy, ___ Umbilical Hernia Repair, ___ Social History: ___ Family History: Denies premature coronary artery disease Father - history of diabetes mellitus, died of sepsis at age ___ Mother - died of ___ at age ___ Sisters (2) - apparently healthy Brother - history of diabetes mellitus Physical Exam: BP: 124/73. Heart Rate: 93. Weight: 230 (Patient Reported). Resp. Rate: 16. O2 Saturation%: 98. Height: 66 inches Weight: 104 kg General: Pleasant man, WDWN, NAD Skin: Warm, dry, intact. Fungal rash mostly under right breast and armpit. Scant rash under left breast. HEENT: NCAT, PERRLA, EOMI, OP benign Neck: Supple, full ROM, no JVD Chest: Lungs clear bilaterally Heart: Regular rate and rhythm, III/VI SEM at LUSB Abdomen: Normal BS, soft, non-tender, non-distended Extremities: Warm, well-perfused, no edema Varicosities: None Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ ___ Right: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Transmitted murmur vs. bruit Pertinent Results: Echo ___: RIGHT ATRIUM/INTERATRIAL SEPTUM: Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Overall normal LVEF (>55%). AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve leaflets. Severe AS (area <1.0cm2). Mild (1+) AR. MITRAL VALVE: Mild (1+) MR ___ 07:20AM BLOOD WBC-11.8* RBC-3.81* Hgb-11.0* Hct-33.4* MCV-88 MCH-28.9 MCHC-32.9 RDW-12.4 RDWSD-39.7 Plt ___ ___ 07:10AM BLOOD WBC-10.6* RBC-3.46* Hgb-10.1* Hct-30.7* MCV-89 MCH-29.2 MCHC-32.9 RDW-12.6 RDWSD-40.6 Plt ___ ___ 06:10AM BLOOD WBC-11.9* RBC-3.42* Hgb-9.9* Hct-29.9* MCV-87 MCH-28.9 MCHC-33.1 RDW-12.4 RDWSD-39.4 Plt ___ ___ 06:15AM BLOOD WBC-13.0* RBC-3.66* Hgb-10.6* Hct-32.4* MCV-89 MCH-29.0 MCHC-32.7 RDW-12.6 RDWSD-41.1 Plt ___ ___ 03:25AM BLOOD WBC-18.1* RBC-3.78* Hgb-11.0* Hct-32.2* MCV-85 MCH-29.1 MCHC-34.2 RDW-12.4 RDWSD-38.2 Plt ___ ___ 07:20AM BLOOD ___ PTT-55.9* ___ ___ 07:10AM BLOOD ___ PTT-36.5 ___ ___ 06:10AM BLOOD ___ PTT-31.8 ___ ___ 06:15AM BLOOD ___ PTT-30.5 ___ ___ 07:20AM BLOOD Glucose-132* UreaN-22* Creat-1.3* Na-139 K-4.0 Cl-99 HCO3-27 AnGap-17 ___ 07:10AM BLOOD Glucose-119* UreaN-23* Creat-1.3* Na-136 K-4.3 Cl-100 HCO3-27 AnGap-13 ___ 06:10AM BLOOD Glucose-123* UreaN-20 Creat-1.1 Na-136 K-4.0 Cl-100 HCO3-26 AnGap-14 ___ 06:15AM BLOOD Glucose-141* UreaN-17 Creat-1.2 Na-139 K-4.1 Cl-100 HCO3-28 AnGap-15 ___ 03:25AM BLOOD Glucose-128* UreaN-15 Creat-1.3* Na-138 K-4.1 Cl-104 HCO3-23 AnGap-15 Brief Hospital Course: Mr. ___ was a same day admit and on ___ was brought directly to the operating room where he underwent a mechanical aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. 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. Coumadin was started for mechanical valve and he was bridged with Heparin per protocol until therapeutic. The patient was transferred to the telemetry floor for further recovery. On ___ he had a brief episode of atrial fibrillation and converted to sinus rhythm with increase in Lopressor. He did have an increase in creatinine to 1.3 but baseline was 1.4. 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. He had a therapeutic INR. Coumadin follow up was arranged with PCP and referral was to be placed to ___ by PCP. The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: Aspirin 81 mg tablet once a day Atorvastatin 20 mg tablet once a day Bicalutamide 50 mg tablet once a day Fenofibrate 50 mg capsule, 4 capsules once a day Glipizide ER 5 mg tablet once a day Lisinopril 5 mg tablet once a day Metformin 500 mg tablet three times a day Ketoconazole cream to affected areas BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Fenofibrate 200 mg PO DAILY 4. GlipiZIDE XL 5 mg PO DAILY 5. Ketoconazole 2% 1 Appl TP BID 6. MetFORMIN (Glucophage) 500 mg PO TID 7. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 8. Bisacodyl ___AILY:PRN constipation 9. Docusate Sodium 100 mg PO BID 10. Metoprolol Tartrate 75 mg PO BID RX metoprolol tartrate 50 mg 1.5 tablet(s) by mouth twice a day Disp #90 Tablet Refills:0 11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe RX oxycodone 5 mg ___ capsule(s) by mouth Q 4 hours Disp #60 Capsule Refills:0 12. Furosemide 40 mg PO DAILY RX furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 13. Potassium Chloride 20 mEq PO DAILY RX potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 14. Ranitidine 150 mg PO BID RX ranitidine HCl [Zantac Maximum Strength] 150 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Bicuspid aortic valve with Aortic stenosis s/p Aortic valve replacement Past medical history: Chronic Kidney Disease, baseline Creatinine 1.52 Diabetes Mellitus Type II Hyperlipidemia Hypertension Obesity Peripheral Neuropathy Prostate Cancer Squamous Cell Carcinoma Radical Prostatectomy, ___ Tonsillectomy, ___ Umbilical Hernia Repair, ___ Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Oxycodone Incisions: Sternal - healing well, no erythema or drainage Trace Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___	[ "Q231", "G629", "I129", "E119", "I4891", "N189", "E785", "Z8546", "Z7902", "Z7982", "E669", "Z6836", "Z85828" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [MASKED] Aortic Valve Replacement (23mm [MASKED] valve) History of Present Illness: Mr. [MASKED] is a pleasant [MASKED] year old man with a history of aortic stenosis, bicuspid aortic valve, chronic kidney disease, diabetes mellitus, hyperlipidemia, hypertension, and prostate cancer. He has had a heart murmur for years. He has recently noted dyspnea on exertion. An echocardiogram in [MASKED] revealed severe aortic stenosis with peak and mean gradients of 65 mmHg and 44 mmHg, respectively. The aortic valve area was 0.9 cm2 and the valve was possibly bicuspid. He was referred to Dr. [MASKED] surgical consultation. He has noted dyspnea on exertion. He otherwise denied syncope, fatigue, dizziness, lightheadedness, shortness of breath at rest, chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. Past Medical History: Bicuspid aortic valve with Aortic stenosis Chronic Kidney Disease, baseline Creatinine 1.52 Diabetes Mellitus Type II Hyperlipidemia Hypertension Obesity Peripheral Neuropathy Prostate Cancer Squamous Cell Carcinoma Radical Prostatectomy, [MASKED] Tonsillectomy, [MASKED] Umbilical Hernia Repair, [MASKED] Social History: [MASKED] Family History: Denies premature coronary artery disease Father - history of diabetes mellitus, died of sepsis at age [MASKED] Mother - died of [MASKED] at age [MASKED] Sisters (2) - apparently healthy Brother - history of diabetes mellitus Physical Exam: BP: 124/73. Heart Rate: 93. Weight: 230 (Patient Reported). Resp. Rate: 16. O2 Saturation%: 98. Height: 66 inches Weight: 104 kg General: Pleasant man, WDWN, NAD Skin: Warm, dry, intact. Fungal rash mostly under right breast and armpit. Scant rash under left breast. HEENT: NCAT, PERRLA, EOMI, OP benign Neck: Supple, full ROM, no JVD Chest: Lungs clear bilaterally Heart: Regular rate and rhythm, III/VI SEM at LUSB Abdomen: Normal BS, soft, non-tender, non-distended Extremities: Warm, well-perfused, no edema Varicosities: None Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ [MASKED] Right: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Transmitted murmur vs. bruit Pertinent Results: Echo [MASKED]: RIGHT ATRIUM/INTERATRIAL SEPTUM: Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Overall normal LVEF (>55%). AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed aortic valve leaflets. Severe AS (area <1.0cm2). Mild (1+) AR. MITRAL VALVE: Mild (1+) MR [MASKED] 07:20AM BLOOD WBC-11.8* RBC-3.81* Hgb-11.0* Hct-33.4* MCV-88 MCH-28.9 MCHC-32.9 RDW-12.4 RDWSD-39.7 Plt [MASKED] [MASKED] 07:10AM BLOOD WBC-10.6* RBC-3.46* Hgb-10.1* Hct-30.7* MCV-89 MCH-29.2 MCHC-32.9 RDW-12.6 RDWSD-40.6 Plt [MASKED] [MASKED] 06:10AM BLOOD WBC-11.9* RBC-3.42* Hgb-9.9* Hct-29.9* MCV-87 MCH-28.9 MCHC-33.1 RDW-12.4 RDWSD-39.4 Plt [MASKED] [MASKED] 06:15AM BLOOD WBC-13.0* RBC-3.66* Hgb-10.6* Hct-32.4* MCV-89 MCH-29.0 MCHC-32.7 RDW-12.6 RDWSD-41.1 Plt [MASKED] [MASKED] 03:25AM BLOOD WBC-18.1* RBC-3.78* Hgb-11.0* Hct-32.2* MCV-85 MCH-29.1 MCHC-34.2 RDW-12.4 RDWSD-38.2 Plt [MASKED] [MASKED] 07:20AM BLOOD [MASKED] PTT-55.9* [MASKED] [MASKED] 07:10AM BLOOD [MASKED] PTT-36.5 [MASKED] [MASKED] 06:10AM BLOOD [MASKED] PTT-31.8 [MASKED] [MASKED] 06:15AM BLOOD [MASKED] PTT-30.5 [MASKED] [MASKED] 07:20AM BLOOD Glucose-132* UreaN-22* Creat-1.3* Na-139 K-4.0 Cl-99 HCO3-27 AnGap-17 [MASKED] 07:10AM BLOOD Glucose-119* UreaN-23* Creat-1.3* Na-136 K-4.3 Cl-100 HCO3-27 AnGap-13 [MASKED] 06:10AM BLOOD Glucose-123* UreaN-20 Creat-1.1 Na-136 K-4.0 Cl-100 HCO3-26 AnGap-14 [MASKED] 06:15AM BLOOD Glucose-141* UreaN-17 Creat-1.2 Na-139 K-4.1 Cl-100 HCO3-28 AnGap-15 [MASKED] 03:25AM BLOOD Glucose-128* UreaN-15 Creat-1.3* Na-138 K-4.1 Cl-104 HCO3-23 AnGap-15 Brief Hospital Course: Mr. [MASKED] was a same day admit and on [MASKED] was brought directly to the operating room where he underwent a mechanical aortic valve replacement. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. 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. Coumadin was started for mechanical valve and he was bridged with Heparin per protocol until therapeutic. The patient was transferred to the telemetry floor for further recovery. On [MASKED] he had a brief episode of atrial fibrillation and converted to sinus rhythm with increase in Lopressor. He did have an increase in creatinine to 1.3 but baseline was 1.4. 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. He had a therapeutic INR. Coumadin follow up was arranged with PCP and referral was to be placed to [MASKED] by PCP. The patient was discharged home with visiting nurse services in good condition with appropriate follow up instructions. Medications on Admission: Aspirin 81 mg tablet once a day Atorvastatin 20 mg tablet once a day Bicalutamide 50 mg tablet once a day Fenofibrate 50 mg capsule, 4 capsules once a day Glipizide ER 5 mg tablet once a day Lisinopril 5 mg tablet once a day Metformin 500 mg tablet three times a day Ketoconazole cream to affected areas BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 20 mg PO QPM 3. Fenofibrate 200 mg PO DAILY 4. GlipiZIDE XL 5 mg PO DAILY 5. Ketoconazole 2% 1 Appl TP BID 6. MetFORMIN (Glucophage) 500 mg PO TID 7. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0 8. Bisacodyl AILY:PRN constipation 9. Docusate Sodium 100 mg PO BID 10. Metoprolol Tartrate 75 mg PO BID RX metoprolol tartrate 50 mg 1.5 tablet(s) by mouth twice a day Disp #90 Tablet Refills:0 11. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX oxycodone 5 mg [MASKED] capsule(s) by mouth Q 4 hours Disp #60 Capsule Refills:0 12. Furosemide 40 mg PO DAILY RX furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 13. Potassium Chloride 20 mEq PO DAILY RX potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 14. Ranitidine 150 mg PO BID RX ranitidine HCl [Zantac Maximum Strength] 150 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [MASKED] [MASKED] Diagnosis: Bicuspid aortic valve with Aortic stenosis s/p Aortic valve replacement Past medical history: Chronic Kidney Disease, baseline Creatinine 1.52 Diabetes Mellitus Type II Hyperlipidemia Hypertension Obesity Peripheral Neuropathy Prostate Cancer Squamous Cell Carcinoma Radical Prostatectomy, [MASKED] Tonsillectomy, [MASKED] Umbilical Hernia Repair, [MASKED] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Oxycodone Incisions: Sternal - healing well, no erythema or drainage Trace Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours* Followup Instructions: [MASKED]	[]	[ "I129", "E119", "I4891", "N189", "E785", "Z7902", "E669" ]	[ "Q231: Congenital insufficiency of aortic valve", "G629: Polyneuropathy, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E119: Type 2 diabetes mellitus without complications", "I4891: Unspecified atrial fibrillation", "N189: Chronic kidney disease, unspecified", "E785: Hyperlipidemia, unspecified", "Z8546: Personal history of malignant neoplasm of prostate", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7982: Long term (current) use of aspirin", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "Z85828: Personal history of other malignant neoplasm of skin" ]
19,975,747	28,362,274	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ female presenting with epigastric and back pain. Patient notes that her pain started yesterday at 6:30 ___ after dinner. Specifically, she describes an epigastric pain that is burning in character. It radiates around the right upper and left upper quadrants around to the back. The pain is constant and severe. Pain is accompanied with nausea as well as vomiting. Patient has had multiple episodes of emesis. She describes no fever or chills. Patient does not have any urinary changes. Patient continues to have normal bowel movements. Patient does not have any red flags with regards to her back pain. She does not describe any stool incontinence. She has no urinary retention. She has no saddle anesthesia. Patient's past medical history significant for breast cancer status post mastectomy and C-section x2. She also has GERD. Patient drinks alcohol only occasionally. She is a family history significant for ulcerative colitis. Past Medical History: PMH breast cancer ___ years ago s/p mastectomy GERD PSH 2 c sections Social History: ___ Family History: family history significant for ulcerative colitis. Physical Exam: Physical Exam on Admission: 98 110 149/87 18 97% RA gen: NAD CV: regular, mildly tachycardic pulm: nonlabored breathing on room air abd: soft, mildly distended, mildly tender to palpation in epigastric region Physical Exam on Discharge: Vitals: 24 HR Data (last updated ___ @ 2347) Temp: 98.3 (Tm 98.8), BP: 154/93 (129-168/71-93), HR: 87 (80-98), RR: 18, O2 sat: 97% (97-99), O2 delivery: Ra Fluid Balance (last updated ___ @ 1456) Last 8 hours No data found Last 24 hours Total cumulative 2055ml IN: Total 2155ml, PO Amt 735ml, IV Amt Infused 1420ml OUT: Total 100ml, Urine Amt 0ml, NGT 100ml Physical exam: Gen: NAD, AxOx3, NGT with bilious output Card: RRR Pulm: no respiratory distress Abd: Soft, non-tender, non-distended Ext: No edema, warm well-perfused Pertinent Results: Labs on Admission: ___ 01:30PM BLOOD WBC-11.8* RBC-4.61 Hgb-14.2 Hct-43.3 MCV-94 MCH-30.8 MCHC-32.8 RDW-12.0 RDWSD-41.3 Plt ___ ___ 01:30PM BLOOD Glucose-142* UreaN-15 Creat-0.9 Na-142 K-4.6 Cl-96 HCO3-29 AnGap-17 ___ 01:30PM BLOOD ALT-15 AST-36 AlkPhos-61 TotBili-0.3 ___ 01:30PM BLOOD Lipase-25 Labs on Discharge: ___ 07:55AM BLOOD WBC-7.2 RBC-4.03 Hgb-12.4 Hct-38.4 MCV-95 MCH-30.8 MCHC-32.3 RDW-12.1 RDWSD-42.1 Plt ___ ___ 07:55AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-142 K-3.5 Cl-104 HCO3-25 AnGap-13 ___ 07:55AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 IMAGING: =============================== ___: CTA CHEST ; CT ABD & PELVIS WITH CONTRAST IMPRESSION: 1. High-grade small-bowel obstruction with transition point in the low mid abdomen. Small volume pelvic free fluid. No pneumoperitoneum or organized fluid collections. 2. Marked distension of the stomach for which enteric tube decompression is recommended. 3. Distal esophageal wall thickening likely reflective of esophagitis from recent vomiting. 4. No pulmonary embolism or acute aortic pathology. 5. 4 mm left upper lobe pulmonary nodule. See recommendations below. 6. Evidence of prior granulomatous disease in the chest. 7. Mild cylindrical bronchiectasis and mild airway wall thickening suggestive of chronic bronchitis. Brief Hospital Course: ___ in good health, PMHx breast cancer s/p mastectomy ___ y/a and 2 c sections, presented with abdominal pain, nausea, and vomiting. A CT abd/pelvis demonstrated a SBO with transition point. A nasogastric tube was placed for decompression on admission and she was started on IVF and made NPO. She continued to have regular bowel movements. On the morning of ___, her abdominal pain and nausea were significantly improved. She had an abdominal X-ray with PO contrast that showed contrast passing through the colon without any signs of a small bowel obstruction. Her NG tube was removed on the morning of ___. She was started on a clear liquid diet, which she tolerated well, and then was advanced to a regular diet without any issues. She continued to have regular bowel movements. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Omeprazole Dose is Unknown PO DAILY Discharge Medications: 1. Omeprazole 20 mg PO DAILY 2. Gabapentin 300 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure providing care for you during your stay at ___. WHY I CAME TO THE HOSPITAL? - You came to the hospital because you were vomiting, feeling nauseas, and having abdominal pain. WHAT HAPPENED WHEN I WAS IN THE HOSPITAL? - A CT scan showed that you had a small bowel obstruction, which was causing your symptoms. We placed a nasogastric tube to relieve the pressure in your stomach, which provided significant relief of your pain and nausea. We started you on IV fluids and kept you from eating until your symptoms improved. We got x-rays that showed improved in the small bowel obstruction and removed your nasogastric tube. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? - You should follow up with your primary care provider within one week of discharge from the hospital - You should take your usual medications as prescribed - You should continue to eat your regular diet We wish you the best of luck! Sincerely, Your ___ Care Team Followup Instructions: ___	[ "K56609", "Z853", "K219" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female presenting with epigastric and back pain. Patient notes that her pain started yesterday at 6:30 [MASKED] after dinner. Specifically, she describes an epigastric pain that is burning in character. It radiates around the right upper and left upper quadrants around to the back. The pain is constant and severe. Pain is accompanied with nausea as well as vomiting. Patient has had multiple episodes of emesis. She describes no fever or chills. Patient does not have any urinary changes. Patient continues to have normal bowel movements. Patient does not have any red flags with regards to her back pain. She does not describe any stool incontinence. She has no urinary retention. She has no saddle anesthesia. Patient's past medical history significant for breast cancer status post mastectomy and C-section x2. She also has GERD. Patient drinks alcohol only occasionally. She is a family history significant for ulcerative colitis. Past Medical History: PMH breast cancer [MASKED] years ago s/p mastectomy GERD PSH 2 c sections Social History: [MASKED] Family History: family history significant for ulcerative colitis. Physical Exam: Physical Exam on Admission: 98 110 149/87 18 97% RA gen: NAD CV: regular, mildly tachycardic pulm: nonlabored breathing on room air abd: soft, mildly distended, mildly tender to palpation in epigastric region Physical Exam on Discharge: Vitals: 24 HR Data (last updated [MASKED] @ 2347) Temp: 98.3 (Tm 98.8), BP: 154/93 (129-168/71-93), HR: 87 (80-98), RR: 18, O2 sat: 97% (97-99), O2 delivery: Ra Fluid Balance (last updated [MASKED] @ 1456) Last 8 hours No data found Last 24 hours Total cumulative 2055ml IN: Total 2155ml, PO Amt 735ml, IV Amt Infused 1420ml OUT: Total 100ml, Urine Amt 0ml, NGT 100ml Physical exam: Gen: NAD, AxOx3, NGT with bilious output Card: RRR Pulm: no respiratory distress Abd: Soft, non-tender, non-distended Ext: No edema, warm well-perfused Pertinent Results: Labs on Admission: [MASKED] 01:30PM BLOOD WBC-11.8* RBC-4.61 Hgb-14.2 Hct-43.3 MCV-94 MCH-30.8 MCHC-32.8 RDW-12.0 RDWSD-41.3 Plt [MASKED] [MASKED] 01:30PM BLOOD Glucose-142* UreaN-15 Creat-0.9 Na-142 K-4.6 Cl-96 HCO3-29 AnGap-17 [MASKED] 01:30PM BLOOD ALT-15 AST-36 AlkPhos-61 TotBili-0.3 [MASKED] 01:30PM BLOOD Lipase-25 Labs on Discharge: [MASKED] 07:55AM BLOOD WBC-7.2 RBC-4.03 Hgb-12.4 Hct-38.4 MCV-95 MCH-30.8 MCHC-32.3 RDW-12.1 RDWSD-42.1 Plt [MASKED] [MASKED] 07:55AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-142 K-3.5 Cl-104 HCO3-25 AnGap-13 [MASKED] 07:55AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 IMAGING: =============================== [MASKED]: CTA CHEST ; CT ABD & PELVIS WITH CONTRAST IMPRESSION: 1. High-grade small-bowel obstruction with transition point in the low mid abdomen. Small volume pelvic free fluid. No pneumoperitoneum or organized fluid collections. 2. Marked distension of the stomach for which enteric tube decompression is recommended. 3. Distal esophageal wall thickening likely reflective of esophagitis from recent vomiting. 4. No pulmonary embolism or acute aortic pathology. 5. 4 mm left upper lobe pulmonary nodule. See recommendations below. 6. Evidence of prior granulomatous disease in the chest. 7. Mild cylindrical bronchiectasis and mild airway wall thickening suggestive of chronic bronchitis. Brief Hospital Course: [MASKED] in good health, PMHx breast cancer s/p mastectomy [MASKED] y/a and 2 c sections, presented with abdominal pain, nausea, and vomiting. A CT abd/pelvis demonstrated a SBO with transition point. A nasogastric tube was placed for decompression on admission and she was started on IVF and made NPO. She continued to have regular bowel movements. On the morning of [MASKED], her abdominal pain and nausea were significantly improved. She had an abdominal X-ray with PO contrast that showed contrast passing through the colon without any signs of a small bowel obstruction. Her NG tube was removed on the morning of [MASKED]. She was started on a clear liquid diet, which she tolerated well, and then was advanced to a regular diet without any issues. She continued to have regular bowel movements. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 300 mg PO TID 2. Omeprazole Dose is Unknown PO DAILY Discharge Medications: 1. Omeprazole 20 mg PO DAILY 2. Gabapentin 300 mg PO TID Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction 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 providing care for you during your stay at [MASKED]. WHY I CAME TO THE HOSPITAL? - You came to the hospital because you were vomiting, feeling nauseas, and having abdominal pain. WHAT HAPPENED WHEN I WAS IN THE HOSPITAL? - A CT scan showed that you had a small bowel obstruction, which was causing your symptoms. We placed a nasogastric tube to relieve the pressure in your stomach, which provided significant relief of your pain and nausea. We started you on IV fluids and kept you from eating until your symptoms improved. We got x-rays that showed improved in the small bowel obstruction and removed your nasogastric tube. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? - You should follow up with your primary care provider within one week of discharge from the hospital - You should take your usual medications as prescribed - You should continue to eat your regular diet We wish you the best of luck! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "K219" ]	[ "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "Z853: Personal history of malignant neoplasm of breast", "K219: Gastro-esophageal reflux disease without esophagitis" ]
19,975,796	22,651,802	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: syncope Major Surgical or Invasive Procedure: intubation ___ History of Present Illness: ___ with prior h/o heavy tobacco use, and severe COPD seen today for followup of squamous cell carcinoma of the lung presenting with weakness, AMS and syncope. Of note, patient recently had to stop high dose cycles of chemo ___ early ___ worsening functional status, post-obstructive PNA, and hypoxia. She was put on a 7 day course of levofloxacin by her oncologist which she completed ___. Over the last 2 days she has had increased cough, increased weakness, and AMS. She has been using her albuterol inhaler more frequently. This morning, dues to ongoing weakness, family was going to ___ patient to ED. However, patient sat down and "slumped" for 60 sec. No shaking. Afterwards was awake and brought to ED. ___ the ED, initial vitals: 97.5 113 95/50 20 100% Nasal Cannula Patient received 2 L LR, 1 L NS, and started on vancomycin and cefepime, and 325 mg ASA. EKG showed HR 96 normal axis, SR, PVCS Labs were notable for + U/A, lactate 3.9, VBG 7.32/___, Mg 1.5, BNP 4923 CTA showed persistent obstructive pneumonia. On transfer, vitals were: 95 117/49 22 98% Nasal Cannula Of note, Patient was first diagnosed with SCC when she had SOB, cough ___ ___ that prompted imaging which showed RUL perihilar mass and airway obstruction, subsequent biopsy showed 100% endobronchial occlusion of the RUL bronchus and moderately differentiated squamous cell carcinoma with abundant necrosis. Patient started chemoradiation with Carboplatin (AUC 2) and Paclitaxel (50mg/m2) on ___, she later had Carboplatin (AUC 5) and Paclitaxel (200mg/m2) given IV every 3 weeks for 2 planned cycles was initiated ___. This treatment was discontinued following 1 cycle due to worsening functional status, post-obstructive PNA, and hypoxia. Upon arrival to MICU patient feels well with no complaints. Family reports patient has had been feeling weak and "squirrely" over past week, with increasd urination. Past Medical History: COPD Raynaud's phenomena Tobacco dependence Social History: ___ Family History: Daughter healthy, lives ___ area, no lung disease. Physical Exam: ON ADMISSION Vitals: T: 97.4 BP: 117/57 P: 87 R: 21 O2: 99 4 L GENERAL: Alert, oriented but slow to respond. Cachetic HEENT: Sclera anicteric, dry mucous membranes, oropharynx with thrush NECK: supple, JVP not elevated, no LAD LUNGS: no wheezes, rales ___ R 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 ON D/C Pertinent Results: ON ADMISSION ___ 11:58AM ___ PTT-UNABLE TO ___ ___ 11:58AM PLT COUNT-709* ___ 11:58AM NEUTS-94.3* LYMPHS-1.5* MONOS-3.1* EOS-0.0* BASOS-0.2 IM ___ AbsNeut-20.36* AbsLymp-0.32* AbsMono-0.67 AbsEos-0.00* AbsBaso-0.04 ___ 11:58AM WBC-21.6* RBC-3.00* HGB-7.9* HCT-27.9* MCV-93 MCH-26.3 MCHC-28.3* RDW-18.5* RDWSD-62.0* ___ 11:58AM CALCIUM-9.0 PHOSPHATE-5.0# MAGNESIUM-1.5 ___ 11:58AM proBNP-4923* ___ 11:58AM estGFR-Using this ___ 11:58AM GLUCOSE-180* UREA N-21* CREAT-0.7 SODIUM-142 POTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-31 ANION GAP-21* ___ 12:06PM O2 SAT-65 ___ 12:06PM LACTATE-3.9* ___ 12:06PM ___ PO2-42* PCO2-72* PH-7.32* TOTAL CO2-39* BASE XS-7 ___ 03:36PM LACTATE-2.5* ___ 04:53PM URINE RBC-73* WBC-75* BACTERIA-MOD YEAST-NONE EPI-12 ___ 04:53PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG ___ 04:53PM URINE COLOR-Yellow APPEAR-Cloudy SP ___ ___ 04:53PM URINE UHOLD-HOLD ___ 11:04PM ___ TO PTT-UNABLE TO ___ TO ___ 11:04PM PLT COUNT-659* ___ 11:04PM WBC-20.9* RBC-2.77* HGB-7.2* HCT-26.0* MCV-94 MCH-26.0 MCHC-27.7* RDW-18.5* RDWSD-63.5* ___ 11:04PM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-1.3* ___ 11:04PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-92 TOT BILI-0.2 ___ 11:04PM GLUCOSE-131* UREA N-17 CREAT-0.5 SODIUM-139 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-32 ANION GAP-13 ___ 11:42PM VoidSpec-CLOTTY SPE MICRO: __________________________________________________________ ___ 10:15 am SPUTUM Source: Endotracheal. FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. __________________________________________________________ ___ 10:10 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, ___ infected patients the excretion of antigen ___ urine may vary. __________________________________________________________ ___ 9:21 am URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 4:53 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 12:02 pm BLOOD CULTURE SET#2. Blood Culture, Routine (Pending): __________________________________________________________ ___ 11:58 am BLOOD CULTURE Blood Culture, Routine (Pending): Brief Hospital Course: ___ with prior h/o heavy tobacco use, and severe COPD seen today for followup of squamous cell carcinoma of the lung presenting with palpitations and syncope, found to be hypotensive ___ ED with CTA concerning for post obstructive PNA now ___ ICU for sepsis ___ pneumonia source, with worsening area of post obstructive pna/likely necrotic material ___ RUL compared to prior CTA last month. # Hypoxemia/hypercapnic respiratory failure: Patient uses 2L O2 at home. Likely multifactorial and secondary to both PNA above and obstruction caused by known SCC below. Shortly after MICU admission, patient went into hypercapnic respiratory failure with pH. 7.08 and was emergently intubated. Her respiratory acidosis subsequently resolved. On discussion with outpt oncologist, patient's prognosis was deemed very poor. Extensive discussions with family and palliative care about goals of care: she was made DNI, and then as her course worsened she was transitioned to comfort measures and terminally extubated on ___. # Septic shock ___ pulmonary source: Patient with WBC 21.6 on admission, lactate 3.___oncerning for post obstruction pneumonia (which patient also had ___ early ___. Patient was started on vancomycin and cefepime, but with little clinical improvement. Goals of care were transitioned to comfort measures, and she was terminally extubated on ___. # SCC of lung, complicated with history post obstructive PNA: Patient s/p 1 cycle of chemo ___ early ___ with new treatment regimen, stopped secondary to patient developing post obstructive PNA. Per outpatient oncologist patient had very poor prognosis. Extensive discussions with family and palliative care about goals of care: she was made DNI, and then as her course worsened she was transitioned to comfort measures and terminally extubated on ___. # GERD: continued on PPI # HTN: per family, took dilt for HTN at home vs for HR control ___ setting of using home albuterol too often. She was put on TID diltiazem for rate control. TRANSITIONAL ISSUES: ==================== Patient died on ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Tiotropium Bromide 1 CAP IH DAILY 4. ALPRAZolam 0.25 mg PO BID:PRN anxiety 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 17.2 mg PO QHS 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 11. Nystatin Oral Suspension 10 mL PO QID:PRN thrush 12. Omeprazole 40 mg PO DAILY 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q6H:PRN 14. Vitamin D ___ UNIT PO DAILY Discharge Medications: Patient died ___ Discharge Disposition: Expired Discharge Diagnosis: Patient died ___ Discharge Condition: Patient died ___ Discharge Instructions: Patient died ___ Followup Instructions: ___	[ "A419", "J9602", "R6521", "J439", "R64", "C3411", "E872", "J449", "D649", "Z681", "I4892", "Z9981", "I4891", "Z87891", "Z7901", "E119", "Z9221", "J988", "I10", "E785", "K219" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: syncope Major Surgical or Invasive Procedure: intubation [MASKED] History of Present Illness: [MASKED] with prior h/o heavy tobacco use, and severe COPD seen today for followup of squamous cell carcinoma of the lung presenting with weakness, AMS and syncope. Of note, patient recently had to stop high dose cycles of chemo [MASKED] early [MASKED] worsening functional status, post-obstructive PNA, and hypoxia. She was put on a 7 day course of levofloxacin by her oncologist which she completed [MASKED]. Over the last 2 days she has had increased cough, increased weakness, and AMS. She has been using her albuterol inhaler more frequently. This morning, dues to ongoing weakness, family was going to [MASKED] patient to ED. However, patient sat down and "slumped" for 60 sec. No shaking. Afterwards was awake and brought to ED. [MASKED] the ED, initial vitals: 97.5 113 95/50 20 100% Nasal Cannula Patient received 2 L LR, 1 L NS, and started on vancomycin and cefepime, and 325 mg ASA. EKG showed HR 96 normal axis, SR, PVCS Labs were notable for + U/A, lactate 3.9, VBG 7.32/[MASKED], Mg 1.5, BNP 4923 CTA showed persistent obstructive pneumonia. On transfer, vitals were: 95 117/49 22 98% Nasal Cannula Of note, Patient was first diagnosed with SCC when she had SOB, cough [MASKED] [MASKED] that prompted imaging which showed RUL perihilar mass and airway obstruction, subsequent biopsy showed 100% endobronchial occlusion of the RUL bronchus and moderately differentiated squamous cell carcinoma with abundant necrosis. Patient started chemoradiation with Carboplatin (AUC 2) and Paclitaxel (50mg/m2) on [MASKED], she later had Carboplatin (AUC 5) and Paclitaxel (200mg/m2) given IV every 3 weeks for 2 planned cycles was initiated [MASKED]. This treatment was discontinued following 1 cycle due to worsening functional status, post-obstructive PNA, and hypoxia. Upon arrival to MICU patient feels well with no complaints. Family reports patient has had been feeling weak and "squirrely" over past week, with increasd urination. Past Medical History: COPD Raynaud's phenomena Tobacco dependence Social History: [MASKED] Family History: Daughter healthy, lives [MASKED] area, no lung disease. Physical Exam: ON ADMISSION Vitals: T: 97.4 BP: 117/57 P: 87 R: 21 O2: 99 4 L GENERAL: Alert, oriented but slow to respond. Cachetic HEENT: Sclera anicteric, dry mucous membranes, oropharynx with thrush NECK: supple, JVP not elevated, no LAD LUNGS: no wheezes, rales [MASKED] R 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 ON D/C Pertinent Results: ON ADMISSION [MASKED] 11:58AM [MASKED] PTT-UNABLE TO [MASKED] [MASKED] 11:58AM PLT COUNT-709* [MASKED] 11:58AM NEUTS-94.3* LYMPHS-1.5* MONOS-3.1* EOS-0.0* BASOS-0.2 IM [MASKED] AbsNeut-20.36* AbsLymp-0.32* AbsMono-0.67 AbsEos-0.00* AbsBaso-0.04 [MASKED] 11:58AM WBC-21.6* RBC-3.00* HGB-7.9* HCT-27.9* MCV-93 MCH-26.3 MCHC-28.3* RDW-18.5* RDWSD-62.0* [MASKED] 11:58AM CALCIUM-9.0 PHOSPHATE-5.0# MAGNESIUM-1.5 [MASKED] 11:58AM proBNP-4923* [MASKED] 11:58AM estGFR-Using this [MASKED] 11:58AM GLUCOSE-180* UREA N-21* CREAT-0.7 SODIUM-142 POTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-31 ANION GAP-21* [MASKED] 12:06PM O2 SAT-65 [MASKED] 12:06PM LACTATE-3.9* [MASKED] 12:06PM [MASKED] PO2-42* PCO2-72* PH-7.32* TOTAL CO2-39* BASE XS-7 [MASKED] 03:36PM LACTATE-2.5* [MASKED] 04:53PM URINE RBC-73* WBC-75* BACTERIA-MOD YEAST-NONE EPI-12 [MASKED] 04:53PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG [MASKED] 04:53PM URINE COLOR-Yellow APPEAR-Cloudy SP [MASKED] [MASKED] 04:53PM URINE UHOLD-HOLD [MASKED] 11:04PM [MASKED] TO PTT-UNABLE TO [MASKED] TO [MASKED] 11:04PM PLT COUNT-659* [MASKED] 11:04PM WBC-20.9* RBC-2.77* HGB-7.2* HCT-26.0* MCV-94 MCH-26.0 MCHC-27.7* RDW-18.5* RDWSD-63.5* [MASKED] 11:04PM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-1.3* [MASKED] 11:04PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-92 TOT BILI-0.2 [MASKED] 11:04PM GLUCOSE-131* UREA N-17 CREAT-0.5 SODIUM-139 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-32 ANION GAP-13 [MASKED] 11:42PM VoidSpec-CLOTTY SPE MICRO: [MASKED] [MASKED] 10:15 am SPUTUM Source: Endotracheal. FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ [MASKED] per 1000X FIELD): GRAM POSITIVE COCCI. [MASKED] PAIRS AND CHAINS. 2+ [MASKED] per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [MASKED]: SPARSE GROWTH Commensal Respiratory Flora. [MASKED] [MASKED] 10:10 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, [MASKED] infected patients the excretion of antigen [MASKED] urine may vary. [MASKED] [MASKED] 9:21 am URINE Source: Catheter. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] [MASKED] 4:53 pm URINE FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] [MASKED] 12:02 pm BLOOD CULTURE SET#2. Blood Culture, Routine (Pending): [MASKED] [MASKED] 11:58 am BLOOD CULTURE Blood Culture, Routine (Pending): Brief Hospital Course: [MASKED] with prior h/o heavy tobacco use, and severe COPD seen today for followup of squamous cell carcinoma of the lung presenting with palpitations and syncope, found to be hypotensive [MASKED] ED with CTA concerning for post obstructive PNA now [MASKED] ICU for sepsis [MASKED] pneumonia source, with worsening area of post obstructive pna/likely necrotic material [MASKED] RUL compared to prior CTA last month. # Hypoxemia/hypercapnic respiratory failure: Patient uses 2L O2 at home. Likely multifactorial and secondary to both PNA above and obstruction caused by known SCC below. Shortly after MICU admission, patient went into hypercapnic respiratory failure with pH. 7.08 and was emergently intubated. Her respiratory acidosis subsequently resolved. On discussion with outpt oncologist, patient's prognosis was deemed very poor. Extensive discussions with family and palliative care about goals of care: she was made DNI, and then as her course worsened she was transitioned to comfort measures and terminally extubated on [MASKED]. # Septic shock [MASKED] pulmonary source: Patient with WBC 21.6 on admission, lactate 3. oncerning for post obstruction pneumonia (which patient also had [MASKED] early [MASKED]. Patient was started on vancomycin and cefepime, but with little clinical improvement. Goals of care were transitioned to comfort measures, and she was terminally extubated on [MASKED]. # SCC of lung, complicated with history post obstructive PNA: Patient s/p 1 cycle of chemo [MASKED] early [MASKED] with new treatment regimen, stopped secondary to patient developing post obstructive PNA. Per outpatient oncologist patient had very poor prognosis. Extensive discussions with family and palliative care about goals of care: she was made DNI, and then as her course worsened she was transitioned to comfort measures and terminally extubated on [MASKED]. # GERD: continued on PPI # HTN: per family, took dilt for HTN at home vs for HR control [MASKED] setting of using home albuterol too often. She was put on TID diltiazem for rate control. TRANSITIONAL ISSUES: ==================== Patient died on [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Tiotropium Bromide 1 CAP IH DAILY 4. ALPRAZolam 0.25 mg PO BID:PRN anxiety 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 17.2 mg PO QHS 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 11. Nystatin Oral Suspension 10 mL PO QID:PRN thrush 12. Omeprazole 40 mg PO DAILY 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q6H:PRN 14. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: Patient died [MASKED] Discharge Disposition: Expired Discharge Diagnosis: Patient died [MASKED] Discharge Condition: Patient died [MASKED] Discharge Instructions: Patient died [MASKED] Followup Instructions: [MASKED]	[]	[ "E872", "J449", "D649", "I4891", "Z87891", "Z7901", "E119", "I10", "E785", "K219" ]	[ "A419: Sepsis, unspecified organism", "J9602: Acute respiratory failure with hypercapnia", "R6521: Severe sepsis with septic shock", "J439: Emphysema, unspecified", "R64: Cachexia", "C3411: Malignant neoplasm of upper lobe, right bronchus or lung", "E872: Acidosis", "J449: Chronic obstructive pulmonary disease, unspecified", "D649: Anemia, unspecified", "Z681: Body mass index [BMI] 19.9 or less, adult", "I4892: Unspecified atrial flutter", "Z9981: Dependence on supplemental oxygen", "I4891: Unspecified atrial fibrillation", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "E119: Type 2 diabetes mellitus without complications", "Z9221: Personal history of antineoplastic chemotherapy", "J988: Other specified respiratory disorders", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]
19,975,898	25,531,568	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Dilaudid / Demerol / ribavirin / venlafaxine Attending: ___. Chief Complaint: SI Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx of liver transplant went to ___ with anxiety/AMS. Transferred to ___ for further w/u given h/o transplant and due to lack of psychiatry at ___. No f/c, CP, SOB, N/V/D, abdominal pain. Patient arrived from ___ on ___ and endorsed SI. Of note patient had inpatient psych admission in early ___ for SI. He was seen by psychiatry in the ED due to SI - ___ was placed, pt unable to leave AMA. Psych bed search was initiated. Patient was also started on olanzapine 15 mg daily and ativan 1 mg PO TID. Per psych recs, his home imipramine and remeron were held given concern that his anxiety / SI may have been med related mood disorder. In the ED: - Labs were significant for normal white count, BUN/Cr 34/1.1, INR 1.1, normal LFTs, negative utox, negative serum tox; tacroFK 6.6. - Imaging revealed patent hepatic vasculature. Unremarkable liver Doppler examination - The patient was started on his home medications as well as psych medications per psych recs. Vitals prior to transfer were: 97.2 64 107/67 18 98% RA Upon arrival to the floor, VS were 97.5, 134/94, HR 81, RR 10, SaO2 99% RA. Patient denied SI, but reported ongoing intermittent anxiety. Denied fever, sob, cough, abd pain, n/v, diarrhea. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: possible hospitalization ___ years ago for 'mental break' ___ drug use Current treaters and treatment: no mental health providers ___ and ECT trials: trialed multiple SSRIs, SNRIs and benzodiazepines; patient uncertain as to exact names; most recently started Venlafaxine XR; also on Mirtazapine for unclear indication since OLT Self-injury: denied; however, ideation with research for plan Harm to others: asked to be restrained Access to weapons: denied PMH: -HCV cirrhosis s/p OLT with HCV in donor liver s/p treatment with Harvoni and ribaviron -nephrolithiasis -Chronic lower back pain -HTN Social History: ___ Family History: FAMILY PSYCHIATRIC HISTORY: mother ___, EtOH dependence, Alzheimer's Dementia), father (EtOH ___, sister and son (___) Physical Exam: ADMISSION: Vitals: 97.5, 134/94, HR 81, RR 10, SaO2 99% RA General: Alert, oriented, no acute distress HEENT: Sclera 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: well healed surgical scars from prior transplant, soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, ___ strength upper/lower extremities, grossly normal sensation, gait deferred. PSYCH: denies SI DISCHARGE: VS:98.0 109/67 66 16 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, normal thyroid exam, no JVD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, large RUQ healed scar Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no jaundice Neuro: no asterixis, AAOx3, denies active SI/HI Pertinent Results: ADMISSION ___ 04:40AM ___ PTT-36.7* ___ ___ 04:40AM WBC-4.7# RBC-4.28# HGB-12.3# HCT-36.8* MCV-86 MCH-28.7 MCHC-33.4 RDW-12.7 RDWSD-39.5 ___ 04:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 04:40AM tacroFK-6.6 ___ 04:40AM ALBUMIN-5.1 CALCIUM-9.7 PHOSPHATE-3.0 MAGNESIUM-2.1 ___ 04:40AM LIPASE-12 ___ 04:40AM ALT(SGPT)-18 AST(SGOT)-18 ALK PHOS-115 TOT BILI-0.7 ___ 04:50AM LACTATE-1.0 ___ 04:40AM GLUCOSE-106* UREA N-34* CREAT-1.1 SODIUM-139 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 ___ 01:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG INTERIM ___ 06:45AM BLOOD tacroFK-7.4 DISCHARGE ___ 06:35AM BLOOD WBC-4.0 RBC-3.85* Hgb-11.2* Hct-32.7* MCV-85 MCH-29.1 MCHC-34.3 RDW-12.6 RDWSD-38.0 Plt ___ ___ 06:35AM BLOOD Plt ___ ___ 06:35AM BLOOD Glucose-91 UreaN-32* Creat-1.0 Na-141 K-4.0 Cl-107 HCO3-23 AnGap-15 ___ 06:45AM BLOOD ALT-19 AST-16 AlkPhos-101 TotBili-0.6 ___ 06:35AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0 ___ 06:35AM BLOOD tacroFK-7.8 IMAGING: RUQ U/S (___): -IMPRESSION: 1. Patent hepatic vasculature. Unremarkable liver Doppler examination. 2. Unchanged 9 mm right upper pole nonobstructing renal calculus. No hydronephrosis. 3. Stable mild splenomegaly. STUDIES: -Urine cx: negative -Blood cx: Brief Hospital Course: ___ hx of liver transplant and depression presented to ED with suicidal ideation, admitted to medicine for further monitoring while awaiting safe transfer. # Suicidal Ideation: patient presented to ___ with anxiety / SI. Transferred for further mgmt given receives care at ___. He was seen in the ED and wassectioned by psychiatry, may not leave AMA. He remained medically stable in the ED x3 days without placement in psychiatry. Although medically cleared, patient was transferred to medicine floor. Per psych notes, patients may have had some component of med-related mood disorder causing manic symptoms from imipramine and remeron. The imipramine and remeron were discontinued and patient was started on olanzapine 15mg qHS with Ativan 1mg TID for breakthrough anxiety and vistaril 25mg PRN for anxiety. On arrival to the floor patient reported no active suicidal ideation. His 1:1 and section were discontinued after being cleared by psychiatry. He was discharged on olanzapine 15mg qHS with olanzapine 5mg qHS PRN if unable to fall asleep within x1 hour and vistaril 25mg PRN for anxiety. He was provided with the contact information for social work at the ___ and the social worker for the Liver Transplant service was contacted to further assist the patient in establishing psychiatric care. An appointment was made for him with his PCP ___ 2 days from discharge. # Liver transplant: s/p OLTx ___omplicated by HCV recurrence s/p treatment with harvoni/RBV as well as mild ACR ___. RUQ in ED showed patent hepatic vasculature. Tacro level on ___ was 6.6. He was evaluated by hepatology in the ED who reported he was doing well. He was continued on tacrolimus 2mg q12hours, mycophenolate 500mg BID, asa 81mg/Plavix 75mg daily for common hepatic stent. He will follow-up with his Hepatologist as an outpatient. # Hypertension: he was continued on his home amlodipine, metoprolol # Chronic back pain: he was continued on his home gabapentin, cyclobenzaprine TI: [] f/u w/psychiatry - will need to call insurance company to find out which providers he is eligible for, will likely need referral from PCP [] f/u w/social work # CODE STATUS: Full Code # CONTACT: ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Cyclobenzaprine ___ mg PO HS 5. Metoprolol Tartrate 25 mg PO BID 6. Mirtazapine 30 mg PO QHS 7. Mycophenolate Mofetil 500 mg PO BID 8. Tacrolimus 2 mg PO Q12H 9. OLANZapine 5 mg PO BID 10. Imipramine 10 mg PO QHS 11. Gabapentin 600 mg PO QHS Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Cyclobenzaprine ___ mg PO HS 5. Gabapentin 600 mg PO QHS 6. Metoprolol Tartrate 25 mg PO BID 7. Mycophenolate Mofetil 500 mg PO BID 8. OLANZapine 15 mg PO QHS You may take an additional 5mg at night if difficulty falling asleep RX olanzapine 15 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 9. Tacrolimus 2 mg PO Q12H 10. OLANZapine 5 mg PO QHS:PRN insomnia ___ take in addition to nighttime dose if difficulty falling asleep after 1 hour RX olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 11. HydrOXYzine 25 mg PO QHS:PRN insomnia, anxiety Please take only as needed for anxiety or insomnia RX hydroxyzine HCl 25 mg 1 tablet by mouth at bedtime Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Medication-induced mood disorder Suicidal ideation SECONDARY DIAGNOSES: OLT HTN Chronic lower back pain Discharge Condition: Appearance: Clean and casual Behavior: Cooperative, engaged in interview, appropriate eye contact Mood: 'Fine' Affect: Euthymic, mood congruent Thought process: Linear, logical, goal directed. Thought Content: Devoid of any delusional thoughts or paranoia, denies AH/VH, SI, or HI. Judgment: Improving Insight: Improving Discharge Instructions: Dear Mr. ___, You were admitted to the hospital due to concern about hurting yourself and anxiety. You were evaluated by the Psychiatry team who stopped your imipramine and mirtazapine and started you on olanzapine 15mg which you should take every night. It is very important that you follow-up with your Psychiatrist. If you begin to feel suicidal or not in control of your feelings please immediately return to the ED. Thank you for letting us be a part of your care! Your ___ Team -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. Followup Instructions: ___	[ "R45851", "F1994", "F419", "F329", "I10", "Z944", "G8929", "M545", "Z818" ]	Allergies: Dilaudid / Demerol / ribavirin / venlafaxine Chief Complaint: SI Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] hx of liver transplant went to [MASKED] with anxiety/AMS. Transferred to [MASKED] for further w/u given h/o transplant and due to lack of psychiatry at [MASKED]. No f/c, CP, SOB, N/V/D, abdominal pain. Patient arrived from [MASKED] on [MASKED] and endorsed SI. Of note patient had inpatient psych admission in early [MASKED] for SI. He was seen by psychiatry in the ED due to SI - [MASKED] was placed, pt unable to leave AMA. Psych bed search was initiated. Patient was also started on olanzapine 15 mg daily and ativan 1 mg PO TID. Per psych recs, his home imipramine and remeron were held given concern that his anxiety / SI may have been med related mood disorder. In the ED: - Labs were significant for normal white count, BUN/Cr 34/1.1, INR 1.1, normal LFTs, negative utox, negative serum tox; tacroFK 6.6. - Imaging revealed patent hepatic vasculature. Unremarkable liver Doppler examination - The patient was started on his home medications as well as psych medications per psych recs. Vitals prior to transfer were: 97.2 64 107/67 18 98% RA Upon arrival to the floor, VS were 97.5, 134/94, HR 81, RR 10, SaO2 99% RA. Patient denied SI, but reported ongoing intermittent anxiety. Denied fever, sob, cough, abd pain, n/v, diarrhea. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: PAST PSYCHIATRIC HISTORY: Hospitalizations: possible hospitalization [MASKED] years ago for 'mental break' [MASKED] drug use Current treaters and treatment: no mental health providers [MASKED] and ECT trials: trialed multiple SSRIs, SNRIs and benzodiazepines; patient uncertain as to exact names; most recently started Venlafaxine XR; also on Mirtazapine for unclear indication since OLT Self-injury: denied; however, ideation with research for plan Harm to others: asked to be restrained Access to weapons: denied PMH: -HCV cirrhosis s/p OLT with HCV in donor liver s/p treatment with Harvoni and ribaviron -nephrolithiasis -Chronic lower back pain -HTN Social History: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: mother [MASKED], EtOH dependence, Alzheimer's Dementia), father (EtOH [MASKED], sister and son ([MASKED]) Physical Exam: ADMISSION: Vitals: 97.5, 134/94, HR 81, RR 10, SaO2 99% RA General: Alert, oriented, no acute distress HEENT: Sclera 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: well healed surgical scars from prior transplant, soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII grossly intact, [MASKED] strength upper/lower extremities, grossly normal sensation, gait deferred. PSYCH: denies SI DISCHARGE: VS:98.0 109/67 66 16 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, normal thyroid exam, no JVD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, large RUQ healed scar Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no jaundice Neuro: no asterixis, AAOx3, denies active SI/HI Pertinent Results: ADMISSION [MASKED] 04:40AM [MASKED] PTT-36.7* [MASKED] [MASKED] 04:40AM WBC-4.7# RBC-4.28# HGB-12.3# HCT-36.8* MCV-86 MCH-28.7 MCHC-33.4 RDW-12.7 RDWSD-39.5 [MASKED] 04:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [MASKED] 04:40AM tacroFK-6.6 [MASKED] 04:40AM ALBUMIN-5.1 CALCIUM-9.7 PHOSPHATE-3.0 MAGNESIUM-2.1 [MASKED] 04:40AM LIPASE-12 [MASKED] 04:40AM ALT(SGPT)-18 AST(SGOT)-18 ALK PHOS-115 TOT BILI-0.7 [MASKED] 04:50AM LACTATE-1.0 [MASKED] 04:40AM GLUCOSE-106* UREA N-34* CREAT-1.1 SODIUM-139 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 [MASKED] 01:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG INTERIM [MASKED] 06:45AM BLOOD tacroFK-7.4 DISCHARGE [MASKED] 06:35AM BLOOD WBC-4.0 RBC-3.85* Hgb-11.2* Hct-32.7* MCV-85 MCH-29.1 MCHC-34.3 RDW-12.6 RDWSD-38.0 Plt [MASKED] [MASKED] 06:35AM BLOOD Plt [MASKED] [MASKED] 06:35AM BLOOD Glucose-91 UreaN-32* Creat-1.0 Na-141 K-4.0 Cl-107 HCO3-23 AnGap-15 [MASKED] 06:45AM BLOOD ALT-19 AST-16 AlkPhos-101 TotBili-0.6 [MASKED] 06:35AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0 [MASKED] 06:35AM BLOOD tacroFK-7.8 IMAGING: RUQ U/S ([MASKED]): -IMPRESSION: 1. Patent hepatic vasculature. Unremarkable liver Doppler examination. 2. Unchanged 9 mm right upper pole nonobstructing renal calculus. No hydronephrosis. 3. Stable mild splenomegaly. STUDIES: -Urine cx: negative -Blood cx: Brief Hospital Course: [MASKED] hx of liver transplant and depression presented to ED with suicidal ideation, admitted to medicine for further monitoring while awaiting safe transfer. # Suicidal Ideation: patient presented to [MASKED] with anxiety / SI. Transferred for further mgmt given receives care at [MASKED]. He was seen in the ED and wassectioned by psychiatry, may not leave AMA. He remained medically stable in the ED x3 days without placement in psychiatry. Although medically cleared, patient was transferred to medicine floor. Per psych notes, patients may have had some component of med-related mood disorder causing manic symptoms from imipramine and remeron. The imipramine and remeron were discontinued and patient was started on olanzapine 15mg qHS with Ativan 1mg TID for breakthrough anxiety and vistaril 25mg PRN for anxiety. On arrival to the floor patient reported no active suicidal ideation. His 1:1 and section were discontinued after being cleared by psychiatry. He was discharged on olanzapine 15mg qHS with olanzapine 5mg qHS PRN if unable to fall asleep within x1 hour and vistaril 25mg PRN for anxiety. He was provided with the contact information for social work at the [MASKED] and the social worker for the Liver Transplant service was contacted to further assist the patient in establishing psychiatric care. An appointment was made for him with his PCP [MASKED] 2 days from discharge. # Liver transplant: s/p OLTx omplicated by HCV recurrence s/p treatment with harvoni/RBV as well as mild ACR [MASKED]. RUQ in ED showed patent hepatic vasculature. Tacro level on [MASKED] was 6.6. He was evaluated by hepatology in the ED who reported he was doing well. He was continued on tacrolimus 2mg q12hours, mycophenolate 500mg BID, asa 81mg/Plavix 75mg daily for common hepatic stent. He will follow-up with his Hepatologist as an outpatient. # Hypertension: he was continued on his home amlodipine, metoprolol # Chronic back pain: he was continued on his home gabapentin, cyclobenzaprine TI: [] f/u w/psychiatry - will need to call insurance company to find out which providers he is eligible for, will likely need referral from PCP [] f/u w/social work # CODE STATUS: Full Code # CONTACT: [MASKED] (son) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Cyclobenzaprine [MASKED] mg PO HS 5. Metoprolol Tartrate 25 mg PO BID 6. Mirtazapine 30 mg PO QHS 7. Mycophenolate Mofetil 500 mg PO BID 8. Tacrolimus 2 mg PO Q12H 9. OLANZapine 5 mg PO BID 10. Imipramine 10 mg PO QHS 11. Gabapentin 600 mg PO QHS Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Cyclobenzaprine [MASKED] mg PO HS 5. Gabapentin 600 mg PO QHS 6. Metoprolol Tartrate 25 mg PO BID 7. Mycophenolate Mofetil 500 mg PO BID 8. OLANZapine 15 mg PO QHS You may take an additional 5mg at night if difficulty falling asleep RX olanzapine 15 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 9. Tacrolimus 2 mg PO Q12H 10. OLANZapine 5 mg PO QHS:PRN insomnia [MASKED] take in addition to nighttime dose if difficulty falling asleep after 1 hour RX olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 11. HydrOXYzine 25 mg PO QHS:PRN insomnia, anxiety Please take only as needed for anxiety or insomnia RX hydroxyzine HCl 25 mg 1 tablet by mouth at bedtime Disp #30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: Medication-induced mood disorder Suicidal ideation SECONDARY DIAGNOSES: OLT HTN Chronic lower back pain Discharge Condition: Appearance: Clean and casual Behavior: Cooperative, engaged in interview, appropriate eye contact Mood: 'Fine' Affect: Euthymic, mood congruent Thought process: Linear, logical, goal directed. Thought Content: Devoid of any delusional thoughts or paranoia, denies AH/VH, SI, or HI. Judgment: Improving Insight: Improving Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital due to concern about hurting yourself and anxiety. You were evaluated by the Psychiatry team who stopped your imipramine and mirtazapine and started you on olanzapine 15mg which you should take every night. It is very important that you follow-up with your Psychiatrist. If you begin to feel suicidal or not in control of your feelings please immediately return to the ED. Thank you for letting us be a part of your care! Your [MASKED] Team -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. Followup Instructions: [MASKED]	[]	[ "F419", "F329", "I10", "G8929" ]	[ "R45851: Suicidal ideations", "F1994: Other psychoactive substance use, unspecified with psychoactive substance-induced mood disorder", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "Z944: Liver transplant status", "G8929: Other chronic pain", "M545: Low back pain", "Z818: Family history of other mental and behavioral disorders" ]
19,975,995	26,284,923	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: RLQ pain, fever, and vomiting Major Surgical or Invasive Procedure: Laparoscopic appendectomy ___ ___ placement of three drains into pelvic abscesses ___ History of Present Illness: Mr. ___ is a ___ previously health M presented with three-day -old migratory RLQ pain, fever, and vomiting. He reports after having Chipotle on ___ evening (three days prior to presentation), he woke up from an excruciating LLQ pain and had an episode of non-bloody, non-bilious emesis. He went to the ___ ED, and got an KUB, which was unremarkable according to patient. He was cleared and discharged after having some Zofran and Tylenol. While nausea and vomiting has subsided, the pain migrated to supraumbilicus. Patient reports that he woke up feeling feverish yesterday morning (temp unmeasured), which resolved with Tylenol. Appetite has been poor since symptom occurred and he only had a few crackers since pain onset. Early this AM, the pain migrated to RLQ and has worsen. Pain exacerbates with movement. He reports haven't had any bowel movement in 3 days, deviating from his normal BM habit of ___ times a day. Pain has become unbearable this morning and he came to the ___ ED. At the ___ ED, he was febrile ___. He was given NS bolus, Morphine 4mg IV, Acetaminophen 1000mg, and Zofran 4mg. Patient reports pain and nausea are alleviated after IV meds. Basic labs were ordered, and CT has yet to be performed. ACS is consulted for abdominal pain. Patient denies chills, diarrhea, hematochezia, lightheadedness, vertigo, cough, SOB, chest pain, and change in urination. Patient denies recent travels, sick contacts, or antibiotic use. Past Medical History: PMHx: None PSHx: None Social History: ___ Family History: Father - HTN No known inflammatory bowel disease Physical Exam: Admission Physical Exam: Discharge Physical Exam: GEN: NAD, resting comfortably reclined in bed. Soeaking in clear and fluent sentences CTAB, RRR Abd: obese, soft, slight tenderness to palpation around drain insertion sites and lateral abdomen bilaterally; nontender at lap appy sites with steristrips in place on midline low abdomena nd periumbilical, no staining n lower set, min shatining anguine on umbilical steris; 3 ir drains- LLQ, Rmid lateral, midline low abd-- all dry dressings, ir drains in place, serosang out of right lateral, clear serous in left lat and midline 2+ DP Pertinent Results: ___ 05:39AM BLOOD WBC-14.5* RBC-4.25* Hgb-12.6* Hct-38.9* MCV-92 MCH-29.6 MCHC-32.4 RDW-13.5 RDWSD-45.3 Plt ___ ___ 11:48AM BLOOD Neuts-88.6* Lymphs-2.9* Monos-7.0 Eos-0.3* Baso-0.4 Im ___ AbsNeut-25.27* AbsLymp-0.83* AbsMono-1.99* AbsEos-0.08 AbsBaso-0.10* ___ 05:39AM BLOOD Plt ___ ___ 05:39AM BLOOD Glucose-115* UreaN-7 Creat-0.6 Na-135 K-3.9 Cl-100 HCO3-25 AnGap-14 ___ 11:48AM BLOOD ALT-10 AST-15 AlkPhos-83 TotBili-0.9 ___ 05:39AM BLOOD Calcium-8.3* Phos-4.5 Mg-2.1 Brief Hospital Course: Following initial surgical evaluation in the ED, the patient was sent for a CT of his Abdomen and Pelvis which demonstrated acute appendicitis with two appendicoliths and extensive surrounding soft tissue stranding. The patient was started on Flagyl and Ancef and was not deemed to be a non-operative candidate. He was consented for a Laparoscopic Appendectomy brought back to the operating room. During the procedure, the appendix was noted to be liquefied in the midportion and disintegrated with manipulation releasing multiple large fecaliths into the peritoneum, which were retrieved and extracted. Otherwise, he tolerated the procedure well and was sent to the PACU post-operatively. For further details on the operation, please refer to the operative note on ___. Over the ensuing three days, Mr. ___ progressed well; he was tolerating a regular diet and given PO pain control. On POD 3 however, he began to develop nausea, vomiting and sustained leukocytosis concerning for a developing intra-abdominal infection. Subsequent CT demonstrated numerous rim enhancing collections that were drained by ___ on ___. Three drains were left in place and the patient progressed well over the next several days. His diet was progressed in a step-wise fashion. By the time of discharge, he was tolerating a regular diet, voiding and stooling normally, pain was controlled with PO medications and he was independently ambulating with no issues. He is to follow up with Dr. ___ in 10 days and will receive a CT scan at that point. He was discharged on the aforementioned antibiotic regimen and was discharged home with ___ services to help with his 3 JP drains that were left in place. ___ will help with drain care, recoding output total 14 days antibiotics, will dc with another 6 days ct scan ___- pt made aware call dr ___- will call him, discussed drain care and ___ Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl [Cipro] 500 mg 1 (One) tablet(s) by mouth every twelve (12) hours Disp #12 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 (One) capsule(s) by mouth twice a day Disp #30 Capsule Refills:1 4. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 (One) tablet(s) by mouth every eight (8) hours Disp #18 Tablet Refills:0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) to six (6) hours Disp #40 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Perforated gangrenous appendicitis postop ileus Intra-abdominal abscesses 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 ___ with ruptured appendicitis and underwent a laparoscopic (minimally invasive) removal of your appendix. Because your appendix was ruptured, you developed fluid collections in your abdomen that were drained by our interventional radiologist. Your infection has since improved and you are ready for discharge home to continue your recovery. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. Do not drive until your pain no longer limits your motion- make sure you can make quick moves without stopping because of pain. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: Your visiting nurses should help you with your drains and their care. The nurses ___ go over with you how to take care of your drains. Please record how much comes out of your drains and what it looks like, and record this on a paper log. **General Drain Care:* Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. o Your incisions may be slightly red. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. ___ Drain Care: -Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). -Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. -Be sure to empty the drain bag or bulb frequently. Record the output daily. You should have a nurse doing this for you. -You may shower; wash the area gently with warm, soapy water. -Keep the insertion site clean and dry otherwise. -Avoid swimming, baths, hot tubs; do not submerge yourself in water. - If you develop worsening abdominal pain, fevers or chills please call Interventional Radiology at ___ at ___ and page ___. -When the drainage total is LESS THAN 10cc/ml for 2 days in a row, please have the ___ call Interventional Radiology at ___ at ___ and page ___. This is the Radiology fellow on call who can assist you. Followup Instructions: ___	[ "K353", "K9189", "R7881", "K567", "Z6841", "F17210", "K381", "Y836", "Y92239", "B9689", "E669" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: RLQ pain, fever, and vomiting Major Surgical or Invasive Procedure: Laparoscopic appendectomy [MASKED] [MASKED] placement of three drains into pelvic abscesses [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] previously health M presented with three-day -old migratory RLQ pain, fever, and vomiting. He reports after having Chipotle on [MASKED] evening (three days prior to presentation), he woke up from an excruciating LLQ pain and had an episode of non-bloody, non-bilious emesis. He went to the [MASKED] ED, and got an KUB, which was unremarkable according to patient. He was cleared and discharged after having some Zofran and Tylenol. While nausea and vomiting has subsided, the pain migrated to supraumbilicus. Patient reports that he woke up feeling feverish yesterday morning (temp unmeasured), which resolved with Tylenol. Appetite has been poor since symptom occurred and he only had a few crackers since pain onset. Early this AM, the pain migrated to RLQ and has worsen. Pain exacerbates with movement. He reports haven't had any bowel movement in 3 days, deviating from his normal BM habit of [MASKED] times a day. Pain has become unbearable this morning and he came to the [MASKED] ED. At the [MASKED] ED, he was febrile [MASKED]. He was given NS bolus, Morphine 4mg IV, Acetaminophen 1000mg, and Zofran 4mg. Patient reports pain and nausea are alleviated after IV meds. Basic labs were ordered, and CT has yet to be performed. ACS is consulted for abdominal pain. Patient denies chills, diarrhea, hematochezia, lightheadedness, vertigo, cough, SOB, chest pain, and change in urination. Patient denies recent travels, sick contacts, or antibiotic use. Past Medical History: PMHx: None PSHx: None Social History: [MASKED] Family History: Father - HTN No known inflammatory bowel disease Physical Exam: Admission Physical Exam: Discharge Physical Exam: GEN: NAD, resting comfortably reclined in bed. Soeaking in clear and fluent sentences CTAB, RRR Abd: obese, soft, slight tenderness to palpation around drain insertion sites and lateral abdomen bilaterally; nontender at lap appy sites with steristrips in place on midline low abdomena nd periumbilical, no staining n lower set, min shatining anguine on umbilical steris; 3 ir drains- LLQ, Rmid lateral, midline low abd-- all dry dressings, ir drains in place, serosang out of right lateral, clear serous in left lat and midline 2+ DP Pertinent Results: [MASKED] 05:39AM BLOOD WBC-14.5* RBC-4.25* Hgb-12.6* Hct-38.9* MCV-92 MCH-29.6 MCHC-32.4 RDW-13.5 RDWSD-45.3 Plt [MASKED] [MASKED] 11:48AM BLOOD Neuts-88.6* Lymphs-2.9* Monos-7.0 Eos-0.3* Baso-0.4 Im [MASKED] AbsNeut-25.27* AbsLymp-0.83* AbsMono-1.99* AbsEos-0.08 AbsBaso-0.10* [MASKED] 05:39AM BLOOD Plt [MASKED] [MASKED] 05:39AM BLOOD Glucose-115* UreaN-7 Creat-0.6 Na-135 K-3.9 Cl-100 HCO3-25 AnGap-14 [MASKED] 11:48AM BLOOD ALT-10 AST-15 AlkPhos-83 TotBili-0.9 [MASKED] 05:39AM BLOOD Calcium-8.3* Phos-4.5 Mg-2.1 Brief Hospital Course: Following initial surgical evaluation in the ED, the patient was sent for a CT of his Abdomen and Pelvis which demonstrated acute appendicitis with two appendicoliths and extensive surrounding soft tissue stranding. The patient was started on Flagyl and Ancef and was not deemed to be a non-operative candidate. He was consented for a Laparoscopic Appendectomy brought back to the operating room. During the procedure, the appendix was noted to be liquefied in the midportion and disintegrated with manipulation releasing multiple large fecaliths into the peritoneum, which were retrieved and extracted. Otherwise, he tolerated the procedure well and was sent to the PACU post-operatively. For further details on the operation, please refer to the operative note on [MASKED]. Over the ensuing three days, Mr. [MASKED] progressed well; he was tolerating a regular diet and given PO pain control. On POD 3 however, he began to develop nausea, vomiting and sustained leukocytosis concerning for a developing intra-abdominal infection. Subsequent CT demonstrated numerous rim enhancing collections that were drained by [MASKED] on [MASKED]. Three drains were left in place and the patient progressed well over the next several days. His diet was progressed in a step-wise fashion. By the time of discharge, he was tolerating a regular diet, voiding and stooling normally, pain was controlled with PO medications and he was independently ambulating with no issues. He is to follow up with Dr. [MASKED] in 10 days and will receive a CT scan at that point. He was discharged on the aforementioned antibiotic regimen and was discharged home with [MASKED] services to help with his 3 JP drains that were left in place. [MASKED] will help with drain care, recoding output total 14 days antibiotics, will dc with another 6 days ct scan [MASKED]- pt made aware call dr [MASKED]- will call him, discussed drain care and [MASKED] Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl [Cipro] 500 mg 1 (One) tablet(s) by mouth every twelve (12) hours Disp #12 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 (One) capsule(s) by mouth twice a day Disp #30 Capsule Refills:1 4. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 (One) tablet(s) by mouth every eight (8) hours Disp #18 Tablet Refills:0 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) to six (6) hours Disp #40 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Perforated gangrenous appendicitis postop ileus Intra-abdominal abscesses 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] with ruptured appendicitis and underwent a laparoscopic (minimally invasive) removal of your appendix. Because your appendix was ruptured, you developed fluid collections in your abdomen that were drained by our interventional radiologist. Your infection has since improved and you are ready for discharge home to continue your recovery. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. Do not drive until your pain no longer limits your motion- make sure you can make quick moves without stopping because of pain. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than [MASKED] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: Your visiting nurses should help you with your drains and their care. The nurses [MASKED] go over with you how to take care of your drains. Please record how much comes out of your drains and what it looks like, and record this on a paper log. **General Drain Care:* Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, [MASKED], or [MASKED] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. o Your incisions may be slightly red. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. [MASKED] Drain Care: -Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). -Note color, consistency, and amount of fluid in the drain. Call the doctor, [MASKED], or [MASKED] nurse if the amount increases significantly or changes in character. -Be sure to empty the drain bag or bulb frequently. Record the output daily. You should have a nurse doing this for you. -You may shower; wash the area gently with warm, soapy water. -Keep the insertion site clean and dry otherwise. -Avoid swimming, baths, hot tubs; do not submerge yourself in water. - If you develop worsening abdominal pain, fevers or chills please call Interventional Radiology at [MASKED] at [MASKED] and page [MASKED]. -When the drainage total is LESS THAN 10cc/ml for 2 days in a row, please have the [MASKED] call Interventional Radiology at [MASKED] at [MASKED] and page [MASKED]. This is the Radiology fellow on call who can assist you. Followup Instructions: [MASKED]	[]	[ "F17210", "E669" ]	[ "K353: Acute appendicitis with localized peritonitis", "K9189: Other postprocedural complications and disorders of digestive system", "R7881: Bacteremia", "K567: Ileus, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K381: Appendicular concretions", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "E669: Obesity, unspecified" ]
19,975,995	29,336,309	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Change in ___ Drain output Major Surgical or Invasive Procedure: ___ drain placement History of Present Illness: Mr. ___ is a ___ M s/p lap appendectomy ___ for acute appendicitis c/b multiple intrabdominal abscesses s/p ___ drain placement ___. He was discharged home on ___ on course of oral cipro/flagyl which he completed ___. He presents today with complaint of increased purulent drain output. He reports that over the preceding 4 days, all 3 JP drains were putting out minimal serosanguinous fluid (<10cc total daily from all 3 drains). He reports that this morning, however, he noted the drainage from drains #2 and #3 was thick, cheese-like and foul-smelling. He reports approximately 20cc purulent output from drains #2 and #3 with minimal output from drain #1. He also reports that drain ___ have become dislodged as he felt it moved. He denies fevers/chills, worsening abdominal pain, diarrhea/constipation, nausea/vomiting, or any other abdominal symptoms. Past Medical History: Past Medical History: None Past Surgical History: ___ Laparoscopic appendectomy ___ ___ drain placement x3 Social History: ___ Family History: Father - HTN No known inflammatory bowel disease Physical Exam: GEN: NAD, well appearing HEENT: NCAT CV: RRR RESP: breathing comfortably on room air GI: multiple well healing incisions (in the mid abdomen, suprapubic region and LLQ) used for previous ___ drains and appropriately covered with bandages, RLQ ___ Drain appropriate and bandaged pulling white-yellow fluid to bulb suction, right buttock ___ drain pulling serosanguinous fluid to bulb suction, abdomen soft, appropriately TTP, no masses or hernia, no guarding distension or rebound tenderness EXT: well perfused Pertinent Results: ___ 06:03AM BLOOD WBC-9.8 RBC-4.23* Hgb-12.5* Hct-38.6* MCV-91 MCH-29.6 MCHC-32.4 RDW-12.6 RDWSD-41.6 Plt ___ ___ 04:15AM BLOOD Neuts-72.9* Lymphs-12.6* Monos-12.4 Eos-0.9* Baso-0.6 Im ___ AbsNeut-10.43* AbsLymp-1.81 AbsMono-1.78* AbsEos-0.13 AbsBaso-0.09* ___ 06:03AM BLOOD Plt ___ ___ 06:03AM BLOOD Glucose-93 UreaN-5* Creat-0.6 Na-136 K-4.0 Cl-97 HCO3-25 AnGap-18 ___ 06:03AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0 Brief Hospital Course: Mr. ___ returned to ___ several weeks ago following an episode of Acute Appendicitis s/p Laparoscopic Appendenctomy c/b gangrenous and perforated appendix. Upon return to hospital following his procedure, he was found to have 3 abdominal fluid collections and abscesses that were subsequently drained by ___. He was discharged with the drains and ___ services but noticed that the output changed substantially in one of the drains. As directed, he returned to the ED most recently on ___ for further workup and management. During this admission, repeat CT imaging demonstrated a large pelvic fluid collection that was subsequently drained by ___ via a posterior approach. He tolerated the procedure well. For the procedure report, please see the note in the OMR. In the several days following the procedure, the patient's diet was advanced and pain was appropriately controlled. By the time of discharge, the patient was independently ambulatory, tolerating a PO diet, voiding and passing flatus. He was discharged with the appropriate follow up and given a course of oral antibiotics. CT: 1. Interval increase in size of midline pelvic abscess, now measuring 8.3 x 7.3 cm which extends to the left anterior pelvis. 2. Three pigtail catheters in place with interval resolution of the left-sided fluid collection and marked decrease in size of the two remaining collections. No new fluid collections identified. 3. New mild right-sided hydroureteronephrosis, with transition point in the distal right ureter as it courses in the region of phlegmonous changes in the right lower quadrant. 4. Wedge-shaped area of hyperdensity surrounding a hypodense tubular structure in segment VIII, more pronounced compared to prior study, which could represent a potentially thrombosed branch of the middle hepatic vein with thrombophlebitis, or less likely, cholangitis surrounding a dilated duct. This could be further assessed with MRCP. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Ciprofloxacin HCl 750 mg PO Q12H RX ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day Disp #11 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #20 Capsule Refills:0 4. MetroNIDAZOLE 500 mg PO TID RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #17 Tablet Refills:0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pelvic Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to the hospital for management of your abdominal discomfort and a workup to determine the cause of your changing drain output. Upon evaluation with CT imaging, it was determined that you had a large pelvic fluid collection consistent with an abscess; a collection of infected material in your abdomen. You were re-started on IV antibiotics and you received a drain that was placed in the fluid collection via radiologic intervention. The drain entered your abdomen via your backside. Two of your previously placed abdominal drains were removed during this admission; thus, you will return home with 1 drain exiting in your abdomen, and 1 drain exiting from your backside. A visiting nurse service will be helping you maintain your drains as they did previously. You will return to clinic for a follow up appointment in one week. You will continue on an oral antibiotic regimen until ___. You recovered well from this process and you are ready to return home to finish your recovery. Please remain in ___ until at least ___ so you are nearby the hospital should any issues arise. If you notice any change in the color or consistency in the output of your drains, have increasing abdominal pain, experience nausea, vomiting, fever, chills or increasing redness around the drain sites, please call the number listed below or return to the ER. Followup Instructions: ___	[ "T814XXA", "K651", "Y838", "Y92009" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Change in [MASKED] Drain output Major Surgical or Invasive Procedure: [MASKED] drain placement History of Present Illness: Mr. [MASKED] is a [MASKED] M s/p lap appendectomy [MASKED] for acute appendicitis c/b multiple intrabdominal abscesses s/p [MASKED] drain placement [MASKED]. He was discharged home on [MASKED] on course of oral cipro/flagyl which he completed [MASKED]. He presents today with complaint of increased purulent drain output. He reports that over the preceding 4 days, all 3 JP drains were putting out minimal serosanguinous fluid (<10cc total daily from all 3 drains). He reports that this morning, however, he noted the drainage from drains #2 and #3 was thick, cheese-like and foul-smelling. He reports approximately 20cc purulent output from drains #2 and #3 with minimal output from drain #1. He also reports that drain [MASKED] have become dislodged as he felt it moved. He denies fevers/chills, worsening abdominal pain, diarrhea/constipation, nausea/vomiting, or any other abdominal symptoms. Past Medical History: Past Medical History: None Past Surgical History: [MASKED] Laparoscopic appendectomy [MASKED] [MASKED] drain placement x3 Social History: [MASKED] Family History: Father - HTN No known inflammatory bowel disease Physical Exam: GEN: NAD, well appearing HEENT: NCAT CV: RRR RESP: breathing comfortably on room air GI: multiple well healing incisions (in the mid abdomen, suprapubic region and LLQ) used for previous [MASKED] drains and appropriately covered with bandages, RLQ [MASKED] Drain appropriate and bandaged pulling white-yellow fluid to bulb suction, right buttock [MASKED] drain pulling serosanguinous fluid to bulb suction, abdomen soft, appropriately TTP, no masses or hernia, no guarding distension or rebound tenderness EXT: well perfused Pertinent Results: [MASKED] 06:03AM BLOOD WBC-9.8 RBC-4.23* Hgb-12.5* Hct-38.6* MCV-91 MCH-29.6 MCHC-32.4 RDW-12.6 RDWSD-41.6 Plt [MASKED] [MASKED] 04:15AM BLOOD Neuts-72.9* Lymphs-12.6* Monos-12.4 Eos-0.9* Baso-0.6 Im [MASKED] AbsNeut-10.43* AbsLymp-1.81 AbsMono-1.78* AbsEos-0.13 AbsBaso-0.09* [MASKED] 06:03AM BLOOD Plt [MASKED] [MASKED] 06:03AM BLOOD Glucose-93 UreaN-5* Creat-0.6 Na-136 K-4.0 Cl-97 HCO3-25 AnGap-18 [MASKED] 06:03AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0 Brief Hospital Course: Mr. [MASKED] returned to [MASKED] several weeks ago following an episode of Acute Appendicitis s/p Laparoscopic Appendenctomy c/b gangrenous and perforated appendix. Upon return to hospital following his procedure, he was found to have 3 abdominal fluid collections and abscesses that were subsequently drained by [MASKED]. He was discharged with the drains and [MASKED] services but noticed that the output changed substantially in one of the drains. As directed, he returned to the ED most recently on [MASKED] for further workup and management. During this admission, repeat CT imaging demonstrated a large pelvic fluid collection that was subsequently drained by [MASKED] via a posterior approach. He tolerated the procedure well. For the procedure report, please see the note in the OMR. In the several days following the procedure, the patient's diet was advanced and pain was appropriately controlled. By the time of discharge, the patient was independently ambulatory, tolerating a PO diet, voiding and passing flatus. He was discharged with the appropriate follow up and given a course of oral antibiotics. CT: 1. Interval increase in size of midline pelvic abscess, now measuring 8.3 x 7.3 cm which extends to the left anterior pelvis. 2. Three pigtail catheters in place with interval resolution of the left-sided fluid collection and marked decrease in size of the two remaining collections. No new fluid collections identified. 3. New mild right-sided hydroureteronephrosis, with transition point in the distal right ureter as it courses in the region of phlegmonous changes in the right lower quadrant. 4. Wedge-shaped area of hyperdensity surrounding a hypodense tubular structure in segment VIII, more pronounced compared to prior study, which could represent a potentially thrombosed branch of the middle hepatic vein with thrombophlebitis, or less likely, cholangitis surrounding a dilated duct. This could be further assessed with MRCP. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild RX acetaminophen 500 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Ciprofloxacin HCl 750 mg PO Q12H RX ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day Disp #11 Tablet Refills:0 3. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #20 Capsule Refills:0 4. MetroNIDAZOLE 500 mg PO TID RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three times a day Disp #17 Tablet Refills:0 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe RX oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours Disp #30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Pelvic Abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to the hospital for management of your abdominal discomfort and a workup to determine the cause of your changing drain output. Upon evaluation with CT imaging, it was determined that you had a large pelvic fluid collection consistent with an abscess; a collection of infected material in your abdomen. You were re-started on IV antibiotics and you received a drain that was placed in the fluid collection via radiologic intervention. The drain entered your abdomen via your backside. Two of your previously placed abdominal drains were removed during this admission; thus, you will return home with 1 drain exiting in your abdomen, and 1 drain exiting from your backside. A visiting nurse service will be helping you maintain your drains as they did previously. You will return to clinic for a follow up appointment in one week. You will continue on an oral antibiotic regimen until [MASKED]. You recovered well from this process and you are ready to return home to finish your recovery. Please remain in [MASKED] until at least [MASKED] so you are nearby the hospital should any issues arise. If you notice any change in the color or consistency in the output of your drains, have increasing abdominal pain, experience nausea, vomiting, fever, chills or increasing redness around the drain sites, please call the number listed below or return to the ER. Followup Instructions: [MASKED]	[]	[]	[ "T814XXA: Infection following a procedure", "K651: Peritoneal abscess", "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", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]
19,976,356	26,043,328	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins / atenolol Attending: ___. Chief Complaint: Left femoral neck fracture Major Surgical or Invasive Procedure: ___: Left hip hemiarthroplasty History of Present Illness: ___ male presents with the above fracture s/p mechanical fall. Patient was out walking and tripped over the curb. Denies antecedent hip pain. Denies headstrike or LOC. Denies other injuries. Denies new numbness or paresthesias. Denies chest pain or SOB. Denies abdominal pain. Past Medical History: S/P COLONOSCOPY ___. ___ S/P CORONARY ARTERY BYPASS, VEIN, QUINTUPLE, LIMA TO LAD S/P REMOVAL OF TONSILS, UNDER AGE ___ CORONARY ARTERY DISEASE CYST, SEBACEOUS-NECK ELEVATED PSA- NEG BX ___ HYPERCHOLESTEROLEMIA HYPERTENSION NEOP, BNG, LARGE INTESTINE SIADH H/O FIBRILLATION, VENTRICULAR Social History: ___ Family History: NC Physical Exam: General: Well-appearing, breathing comfortably MSK: LLE dressing changed Fires TA, Gsc, ___ SILT tn/s/s/sp/dp Foot wwp Pertinent Results: see omr Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopaedic surgery team. The patient was found to have a left femoral neck fracture and was admitted to the orthopaedic surgery service. The patient was taken to the operating room on ___ for a left 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. The patient worked with ___ who determined that discharge to home with home ___ and visiting nurses aide was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enalapril Maleate 20 mg PO DAILY 2. Pindolol 10 mg PO BID 3. amLODIPine 5 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Omeprazole 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Sodium Chloride 1 gm PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day Disp #28 Syringe Refills:0 5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity partial fill ok. no driving/machinery. wean per discharge instructions. RX hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4 hours for pain Disp #25 Tablet Refills:*0 6. Senna 17.2 mg PO HS 7. amLODIPine 5 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Enalapril Maleate 20 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Pindolol 10 mg PO BID 13. Sodium Chloride 1 gm PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left femoral neck fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated left lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add low dose dilaudid as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever greater than 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please call ___ to schedule a follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. Physical Therapy: Activity: Activity: Activity as tolerated Left lower extremity: Full weight bearing Gait/Balance training Encourage turn, cough and deep breathe q2h when awake Treatments Frequency: For ___ -Change dressing as needed with gauze and paper tape -If not draining then OK to leave staples open to air -Staples will be taken out at your 2-week postoperative visit Followup Instructions: ___	[ "S72092A", "D62", "E222", "I2510", "I10", "E785", "K219", "R112", "I252", "W101XXA", "Y92480", "Z8674", "Z951" ]	Allergies: Penicillins / atenolol Chief Complaint: Left femoral neck fracture Major Surgical or Invasive Procedure: [MASKED]: Left hip hemiarthroplasty History of Present Illness: [MASKED] male presents with the above fracture s/p mechanical fall. Patient was out walking and tripped over the curb. Denies antecedent hip pain. Denies headstrike or LOC. Denies other injuries. Denies new numbness or paresthesias. Denies chest pain or SOB. Denies abdominal pain. Past Medical History: S/P COLONOSCOPY [MASKED]. [MASKED] S/P CORONARY ARTERY BYPASS, VEIN, QUINTUPLE, LIMA TO LAD S/P REMOVAL OF TONSILS, UNDER AGE [MASKED] CORONARY ARTERY DISEASE CYST, SEBACEOUS-NECK ELEVATED PSA- NEG BX [MASKED] HYPERCHOLESTEROLEMIA HYPERTENSION NEOP, BNG, LARGE INTESTINE SIADH H/O FIBRILLATION, VENTRICULAR Social History: [MASKED] Family History: NC Physical Exam: General: Well-appearing, breathing comfortably MSK: LLE dressing changed Fires TA, Gsc, [MASKED] SILT tn/s/s/sp/dp Foot wwp Pertinent Results: see omr Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopaedic surgery team. The patient was found to have a left femoral neck fracture and was admitted to the orthopaedic surgery service. The patient was taken to the operating room on [MASKED] for a left 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. The patient worked with [MASKED] who determined that discharge to home with home [MASKED] and visiting nurses aide was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enalapril Maleate 20 mg PO DAILY 2. Pindolol 10 mg PO BID 3. amLODIPine 5 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Omeprazole 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Sodium Chloride 1 gm PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day Disp #28 Syringe Refills:0 5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity partial fill ok. no driving/machinery. wean per discharge instructions. RX hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 4 hours for pain Disp #25 Tablet Refills:*0 6. Senna 17.2 mg PO HS 7. amLODIPine 5 mg PO DAILY 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 20 mg PO QPM 10. Enalapril Maleate 20 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Pindolol 10 mg PO BID 13. Sodium Chloride 1 gm PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Left femoral neck fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated left lower extremity MEDICATIONS: 1) Take Tylenol [MASKED] every 6 hours around the clock. This is an over the counter medication. 2) Add low dose dilaudid as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever greater than 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please call [MASKED] to schedule a follow up with your Orthopaedic Surgeon, Dr. [MASKED]. You will have follow up with [MASKED], NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call [MASKED] to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within [MASKED] weeks and for any new medications/refills. Physical Therapy: Activity: Activity: Activity as tolerated Left lower extremity: Full weight bearing Gait/Balance training Encourage turn, cough and deep breathe q2h when awake Treatments Frequency: For [MASKED] -Change dressing as needed with gauze and paper tape -If not draining then OK to leave staples open to air -Staples will be taken out at your 2-week postoperative visit Followup Instructions: [MASKED]	[]	[ "D62", "I2510", "I10", "E785", "K219", "I252", "Z951" ]	[ "S72092A: Other fracture of head and neck of left femur, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R112: Nausea with vomiting, unspecified", "I252: Old myocardial infarction", "W101XXA: Fall (on)(from) sidewalk curb, initial encounter", "Y92480: Sidewalk as the place of occurrence of the external cause", "Z8674: Personal history of sudden cardiac arrest", "Z951: Presence of aortocoronary bypass graft" ]
19,977,062	24,864,628	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: FDG avid pre-vascular mediastinal lymph nodes Major Surgical or Invasive Procedure: ___: Left VATS Mediastinal lymph node dissection History of Present Illness: Ms. ___ is a ___, current 30+ py smoker (recently switched to ___. Lung Cancer Screening Program chest CT ___ showed mult small bil pulm nodules measuring 1-2 mm. CT chest obtained ___ revealed interval substantial increase in size in pre-vascular lymph nodes. There was also a 1.2 cm focus of increased FDG uptake within the T6 vertebral body with an SUV max of 5.1, suspicious for metastatic disease. Pt reports that she has transitioned from regular cigarettes to vaping (___). Has been prescribed nicotine patches, but has not used them yet. She says she has severe anxiety about leaving the house and will not leave the house if not accompanied by her daughter or her close friend. She is not very physically active and she says she spends a lot of her time eating. Denies significant dyspnea, but difficult to gauge given lack of physical activity. Denies cardiac history. Says she does have chest pain at times, but this is when she is having a panic attack. Her gait is abnormal d/t hx of hip replacement. Denies recent falls/physical trauma. Has history of IBS, so sometimes has GI upset. Denies history of coagulation disorder/bleeding problem. No other physical complaints at this time. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: HTN Anxiety/Depression Eclampsia s/p C-section Left hip fracture s/p hip replacement HPV Microinvasive vulvar squamous cell carcinoma ?CAD Hypercholesterolemia IBS Social History: ___ Family History: Mother: breast ca, renal ca deceased at age ___ Father: COPD ___ Other Physical Exam: Vital Signs: T___.0, BP121 / 74, HR 65, RR 18, O2 92 Ra Gen: NAD, AOx4, conversational, Chest: minimal crackles in bilateral lower lobes. Chest tube site dressing clean, dry, intact, remaining incisions well approximated, non-erythematous, no drainage. CV: RRR, no m/r/g Abd: obese, but soft, nondistended, nontender Ext: Calves soft, no edema Pertinent Results: ___ post pull CXR: Low lung volumes with worsening bibasilar atelectasis and mild pulmonary edema. Persistent small bilateral pleural effusions. Interval removal of left chest tube with small left apical pneumothorax. ___ PA/Lateral CXR: Stable small left apical pneumothorax. Interval decrease in left chest wall soft tissue emphysema. There is worsening bibasilar platelike atelectasis. Mild pulmonary edema not significantly changed. Stable small bilateral pleural effusions. IMPRESSION: Small left apical pneumothorax. Worsening bibasilar platelike atelectasis with stable mild pulmonary edema and bilateral pleural effusions. Brief Hospital Course: Ms. ___ was admitted to the hospital and taken to the Operating Room where she underwent a Left video assisted thoracoscopy with mediastinal lymph node biopsy. 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 and Tylenol. Her Chest Tube ___ drain put out a scant amount of thin, bloody fluid and had no air leak. Following transfer to the Surgical floor she progressed well. Her ___ drain was removed on post op day #1 and her post pull chest xray revealed a small apical pneumothorax and small bilateral fluid collections. Her oxygen was weaned off and her room air saturations were above 92%. Her port sites were healing well without erythema. She was unable to voide after removing her foley, requiring one straight catheterization before being able to void without issues. She was up and walking with encouragement. Her pain was controlled with Tylenol, Ibuprofen, and Oxycodone. for the first two days, her pain was poorly controlled on just Tylenol and occasional oxycodone, which prevented her from being able to take and sustain deep breaths, limiting her IS use and ability to wean off oxygen. On ___, her ambulatory saturation without oxygen was around 82-85%. She was given 10mg of Lasix given her small pleural effusions and crackles on pulmonary exam. Over the next day, her pain was better controlled and she was given mucomyst nebs in addition to saline nebs. She was able to take larger volumes on IS. Throughout her hospitalization, she was asymptomatic in regards to her measured hypoxia without dyspnea, headaches, dizziness, or extreme fatigue. After an uneventful recovery she was discharged to home on ___ and will follow up with Dr. ___ in 2 weeks. She understood this plan and all of her questions were answered Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. lisinopril-hydrochlorothiazide ___ mg oral DAILY 3. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety 4. CARVedilol 25 mg PO BID 5. amLODIPine 5 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 8. Venlafaxine XR 225 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #10 Capsule Refills:0 2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:0 3. Senna 8.6 mg PO BID:PRN Constipation - First Line RX sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 4. Acetaminophen 650 mg PO Q6H 5. Ibuprofen 600 mg PO Q6H 6. amLODIPine 5 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. CARVedilol 25 mg PO BID 9. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety 10. lisinopril-hydrochlorothiazide ___ mg oral DAILY 11. Venlafaxine XR 225 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Metastatic Adenocarcinoma 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 mediastinal lymph node biopsies and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed ___ AFTERNOON. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol and Ibuprofen on a standing basis for the next two days to avoid more opiod use. Then take Tylenol on a standing basis for another few days to continue avoiding oxycodone use * Continue to stay well hydrated and eat well to heal your incisions * No heavy lifting > 10 lbs for 4 weeks. * Shower daily starting tomorrow. 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 -Increased shortness of breath, chest pain or any other symptoms that concern you. If pathology specimens were sent at the time of surgery, the reports will be reviewed with you in detail at your follow up appointment. This will give both you and your doctor time to understand the pathology, its implications and discuss options going forward. Followup Instructions: ___	[ "C771", "Z8544", "J9589", "J90", "J9811", "N9989", "R338", "Y838", "F17210", "F418", "R2689", "Z96642", "I10", "F329", "E7800", "K589", "Z803", "Z8051" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: FDG avid pre-vascular mediastinal lymph nodes Major Surgical or Invasive Procedure: [MASKED]: Left VATS Mediastinal lymph node dissection History of Present Illness: Ms. [MASKED] is a [MASKED], current 30+ py smoker (recently switched to [MASKED]. Lung Cancer Screening Program chest CT [MASKED] showed mult small bil pulm nodules measuring 1-2 mm. CT chest obtained [MASKED] revealed interval substantial increase in size in pre-vascular lymph nodes. There was also a 1.2 cm focus of increased FDG uptake within the T6 vertebral body with an SUV max of 5.1, suspicious for metastatic disease. Pt reports that she has transitioned from regular cigarettes to vaping ([MASKED]). Has been prescribed nicotine patches, but has not used them yet. She says she has severe anxiety about leaving the house and will not leave the house if not accompanied by her daughter or her close friend. She is not very physically active and she says she spends a lot of her time eating. Denies significant dyspnea, but difficult to gauge given lack of physical activity. Denies cardiac history. Says she does have chest pain at times, but this is when she is having a panic attack. Her gait is abnormal d/t hx of hip replacement. Denies recent falls/physical trauma. Has history of IBS, so sometimes has GI upset. Denies history of coagulation disorder/bleeding problem. No other physical complaints at this time. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: HTN Anxiety/Depression Eclampsia s/p C-section Left hip fracture s/p hip replacement HPV Microinvasive vulvar squamous cell carcinoma ?CAD Hypercholesterolemia IBS Social History: [MASKED] Family History: Mother: breast ca, renal ca deceased at age [MASKED] Father: COPD [MASKED] Other Physical Exam: Vital Signs: T .0, BP121 / 74, HR 65, RR 18, O2 92 Ra Gen: NAD, AOx4, conversational, Chest: minimal crackles in bilateral lower lobes. Chest tube site dressing clean, dry, intact, remaining incisions well approximated, non-erythematous, no drainage. CV: RRR, no m/r/g Abd: obese, but soft, nondistended, nontender Ext: Calves soft, no edema Pertinent Results: [MASKED] post pull CXR: Low lung volumes with worsening bibasilar atelectasis and mild pulmonary edema. Persistent small bilateral pleural effusions. Interval removal of left chest tube with small left apical pneumothorax. [MASKED] PA/Lateral CXR: Stable small left apical pneumothorax. Interval decrease in left chest wall soft tissue emphysema. There is worsening bibasilar platelike atelectasis. Mild pulmonary edema not significantly changed. Stable small bilateral pleural effusions. IMPRESSION: Small left apical pneumothorax. Worsening bibasilar platelike atelectasis with stable mild pulmonary edema and bilateral pleural effusions. Brief Hospital Course: Ms. [MASKED] was admitted to the hospital and taken to the Operating Room where she underwent a Left video assisted thoracoscopy with mediastinal lymph node biopsy. 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 and Tylenol. Her Chest Tube [MASKED] drain put out a scant amount of thin, bloody fluid and had no air leak. Following transfer to the Surgical floor she progressed well. Her [MASKED] drain was removed on post op day #1 and her post pull chest xray revealed a small apical pneumothorax and small bilateral fluid collections. Her oxygen was weaned off and her room air saturations were above 92%. Her port sites were healing well without erythema. She was unable to voide after removing her foley, requiring one straight catheterization before being able to void without issues. She was up and walking with encouragement. Her pain was controlled with Tylenol, Ibuprofen, and Oxycodone. for the first two days, her pain was poorly controlled on just Tylenol and occasional oxycodone, which prevented her from being able to take and sustain deep breaths, limiting her IS use and ability to wean off oxygen. On [MASKED], her ambulatory saturation without oxygen was around 82-85%. She was given 10mg of Lasix given her small pleural effusions and crackles on pulmonary exam. Over the next day, her pain was better controlled and she was given mucomyst nebs in addition to saline nebs. She was able to take larger volumes on IS. Throughout her hospitalization, she was asymptomatic in regards to her measured hypoxia without dyspnea, headaches, dizziness, or extreme fatigue. After an uneventful recovery she was discharged to home on [MASKED] and will follow up with Dr. [MASKED] in 2 weeks. She understood this plan and all of her questions were answered Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen [MASKED] mg PO Q6H:PRN Pain - Mild/Fever 2. lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY 3. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety 4. CARVedilol 25 mg PO BID 5. amLODIPine 5 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 8. Venlafaxine XR 225 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #10 Capsule Refills:0 2. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Patient is NPO or unable to tolerate PO RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #10 Tablet Refills:0 3. Senna 8.6 mg PO BID:PRN Constipation - First Line RX sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 4. Acetaminophen 650 mg PO Q6H 5. Ibuprofen 600 mg PO Q6H 6. amLODIPine 5 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. CARVedilol 25 mg PO BID 9. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety 10. lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY 11. Venlafaxine XR 225 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Metastatic Adenocarcinoma 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 mediastinal lymph node biopsies and you've recovered well. You are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed [MASKED] AFTERNOON. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. * You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol and Ibuprofen on a standing basis for the next two days to avoid more opiod use. Then take Tylenol on a standing basis for another few days to continue avoiding oxycodone use * Continue to stay well hydrated and eat well to heal your incisions * No heavy lifting > 10 lbs for 4 weeks. * Shower daily starting tomorrow. 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 -Increased shortness of breath, chest pain or any other symptoms that concern you. If pathology specimens were sent at the time of surgery, the reports will be reviewed with you in detail at your follow up appointment. This will give both you and your doctor time to understand the pathology, its implications and discuss options going forward. Followup Instructions: [MASKED]	[]	[ "F17210", "I10", "F329" ]	[ "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "Z8544: Personal history of malignant neoplasm of other female genital organs", "J9589: Other postprocedural complications and disorders of respiratory system, not elsewhere classified", "J90: Pleural effusion, not elsewhere classified", "J9811: Atelectasis", "N9989: Other postprocedural complications and disorders of genitourinary system", "R338: Other retention of urine", "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", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F418: Other specified anxiety disorders", "R2689: Other abnormalities of gait and mobility", "Z96642: Presence of left artificial hip joint", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "E7800: Pure hypercholesterolemia, unspecified", "K589: Irritable bowel syndrome without diarrhea", "Z803: Family history of malignant neoplasm of breast", "Z8051: Family history of malignant neoplasm of kidney" ]
19,977,875	22,689,963	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: metformin Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old female with a history of aortic stenosis s/p TAVR in ___, HFpEF (EF 40% ___, CAD, HTN, and HLD, who presented with one day of shortness of breath. Prior to 1AM on the day of admission, the patient's daughter in law reported that she was in her usual state of health. The patient denied cough or shortness of breath at baseline; does not use home O2. At 1AM, the patient called her son into the room because she had acute onset of shortness of breath and cough productive of white sputum. This occurred while she was lying in bed. Her dyspnea was significant enough for her daughter in law, a physician, to want to bring her for emergency evaluation. Per her daughter in law's history, no chest pain, increasing ___ edema, fever, fatigue, altered mental status, or recently decreased exercise tolerance. The household tries to minimize salt, but the patient does not keep close track of salt or fluid intake. Does not record weights. Reported complete adherence to medication regimen. The patient was hospitalized for elective TAVR (Evolut R, pre-mean gradient of 39.17, post-mean gradient 2) in ___, which occurred without complication, and the patient had been recovering well. On discharge on ___ showed an EF of 40-45%, with trace AR noted. Home Lasix dose was increased to 20 mg daily on discharge, though the patient's daughter-in-law subsequently decreased to 10 mg daily. The patient initially presented to the ___ ED prior to transfer to ___ ED. There, she received 20mg IV Lasix with output 300mL prior to arrival, and was put on BiPAP. Bedside ECHO at ___ reportedly showed EF 25%. In the BI ED initial vitals were: 97.2 108 118/75 20 98% NC. EKG: Sinus tachycardia, LBBB, no concerning ischemic changes, unchanged from prior except for rate. Labs/studies notable for: BNP 6319, WBC 16.9, UA negative for infection. Patient was not given any additional meds. Symptoms had much improved by the time she reached the BI ED, however, she noticed right hand weakness at approximately 06:20. Was evaluated by neurology, who had concern for stroke vs. peripheral nerve compression. CXR with worsening airspace opacities in bilateral lungs in the setting of moderate cardiomegaly concerning for worsening pulmonary edema. Small bilateral pleural effusions may be present. CTA showed mild contour irregularity of the M1 segment of the left MCA with narrowing of the vessel caliber, without evidence of acute infarct. On the floor, patient was breathing comfortably on room air. Past Medical History: HTN hypercholesterolemia Severe aortic stenosis, NYHA Class II Carotid stenosis bilaterally Social History: ___ Family History: FAMILY HISTORY: Both mother and father deceased in ___. Mother had asthma, was in a coma for a month. Father died of ___. One brother with coronary stent. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: T 98.3 BP 123/70 HR 101 RR 19 O2 SAT 97%RA Admission weight: 41.2 kg GENERAL: Thin, elderly female lying in bed in no acute distress. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. Mucus membranes appear moist. NECK: Supple. JVP noted below the mandible at 45 degrees. CARDIAC: Tachycardic, normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Crackles bilaterally in lower fields, no wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. NEURO: AOX3. Motor strength ___ in bilateral lower and left upper extremity. Patient unable to extend the right wrist. Motor strength in flexion and extension at the elbow is intact. Sensation equal and intact in both upper extremities. CNII-XII grossly intact. Positive pronator drift. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM ========================== Vitals: 98.4, 115-123/56-62, 71-86, 18, 95-98% RA Discharge weight: 40.5 kg GENERAL: Thin, elderly female lying in bed in no acute distress. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. Mucus membranes appear moist. NECK: Supple. No elevated JVD. CARDIAC: RRR, normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: CTAB, no wheezing ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. NEURO: AOX3. Motor strength ___ in bilateral lower and left upper extremity above wrist. Patient unable to extend the right wrist. Patient unable to flex or extend right finger digits. Motor strength in flexion and extension at the elbow is intact. Sensation equal and intact in both upper extremities. CNII-XII grossly intact. Positive pronator drift. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS ======================= ___ 06:50AM BLOOD WBC-16.6# RBC-4.02 Hgb-9.4 Hct-30.7* MCV-76* MCH-23.4* MCHC-30.6* RDW-17.2* RDWSD-47.6* Plt ___ ___ 06:50AM BLOOD Neuts-90.0* Lymphs-6.5* Monos-2.7* Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.87# AbsLymp-1.08 AbsMono-0.45 AbsEos-0.02* AbsBaso-0.04 ___ 06:50AM BLOOD Glucose-182* UreaN-25* Creat-0.8 Na-135 K-4.6 Cl-97 HCO3-21* AnGap-22* ___ 06:50AM BLOOD CK(CPK)-170 ___ 06:50AM BLOOD CK-MB-16* MB Indx-9.4* cTropnT-0.24* proBNP-6319* ___ 08:00AM BLOOD CK-MB-6 cTropnT-0.50* ___ 12:40PM BLOOD CK-MB-6 cTropnT-0.46* ___ 03:30AM BLOOD cTropnT-0.43* ___ 06:50AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.0 DISCHARGE LABS ======================== ___ 08:19AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.2 ___ 08:19AM BLOOD Glucose-101* UreaN-17 Creat-0.7 Na-133 K-5.0 Cl-97 HCO3-22 AnGap-19 ___ 08:19AM BLOOD ___ PTT-39.1* ___ ___ 08:19AM BLOOD WBC-8.8 RBC-3.65* Hgb-8.2* Hct-27.4* MCV-75* MCH-22.5* MCHC-29.9* RDW-16.9* RDWSD-45.8 Plt ___ MICROBIOLOGY ======================== ___ 9:20 am URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 7:00 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7:00 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 1:00 pm BLOOD CULTURE #1. Blood Culture, Routine (Pending): 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-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 3:07 pm BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING ========================= CXR ___: IMPRESSION: 1. Worsening airspace opacities in bilateral lungs in the setting of moderate cardiomegaly concerning for worsening pulmonary edema. 2. Small bilateral pleural effusions may be present. CTA head/neck ___ IMPRESSION: 1. No evidence for acute intracranial abnormalities. 2. Aerosolized secretions in the right maxillary sinus. Please correlate clinically whether the patient may have symptoms of acute sinusitis. Approximately 60% stenosis of the proximal right internal carotid artery and approximately 30% stenosis of the proximal left internal carotid artery by NASCET criteria. 3. Mild stenosis of the left vertebral artery origin. 4. Short-segment moderate stenosis of the proximal M1 segment of the left MCA, mild narrowing of the proximal inferior division of the right MCA, irregularity of the basilar artery with mild short-segment stenosis in its midportion, and irregularity and mild narrowing of P1 and proximal P2 segments of the left posterior cerebral artery, which are most likely atherosclerotic. 5. Multiple thyroid nodules measuring up to 0.9 cm. The ___ College of Radiology guidelines suggest that in the absence of risk factors for thyroid cancer, no further evaluation is recommended. 6. Partially visualized bilateral pleural effusions with associated atelectasis. Concurrent chest radiograph is reported separately. MRI brain w/o contrast ___ IMPRESSION: Numerous acute to subacute infra- and supratentorial infarcts in all vascular distributions, as described, with configuration suggestive of embolic etiology. ECHO ___ IMPRESSION: EF 40-45%. Well seated, normal functioning aortic valve Evolut TAVR with possible linear echodensity in the LVOT c/w possible vegetation/thrombus but no regurgitation. Mild-moderate mitral regurgitation. Normal left ventricular cavity size with mild regional systolic dysfunction. Compared with the prior study (images reviewed) of ___, the mobile LVOT echodensity is NEW. Regional left ventricular systolic function is similar. The other findings are similar. Brief Hospital Course: Ms. ___ is a ___ year old female with a history of aortic stenosis s/p TAVR in ___, HFpEF (EF 40% ___, CAD, HTN, and HLD, who presented with one day of acute shortness of breath and right hand weakness. #Acute embolic stroke: Per neurology, MRI consistent with an acute stroke likely secondary to emboli, and imaging consistent with cortical hand syndrome causing isolated wrist drop. Numerous other emboli likely subacute and could be ongoing after TAVR. No other neurological deficits on exam. ECHO showing possible clot in LVOT, likely source of emboli. Per discussion with patient's family TEE not within goals of care. Blood cultures to evaluate for infectious vegetation were negative. She was started on warfarin with heparin gtt bridge until INR therapeutic (goal ___. Aspirin was stopped and plavix was resumed. Atorvastatin 80 mg was started. The patient was followed by occupational therapy during admission, who recommended home with outpatient OT. Will follow up with neurology after discharge. #CAD/NSTEMI: Patient with troponin trend 0.24 -> 0.50 -> 0.46 -> 0.43. No history of chest pain; dyspnea quickly resolved after diuresis. EKG without clear evidence of ischemia. Potential etiologies included demand ischemia in heart failure exacerbation/flash pulmonary edema or coronary embolism from aortic valve thrombus. Heparin gtt was started as above, and discontinued once INR was therapeutic. Metoprolol succinate 25 mg daily was initiated for ASCVD risk reduction. LHC in ___ (prior to TAVR) demonstrated a 95% stenosis in the ___ diagonal but otherwise non-obstructive coronary artery disease. #Acute on chronic HFpEF (40-45%): The patient presented with acute shortness of breath, with crackles and elevated JVP on exam, BNP 6319 (previously ___. She was diuresed with Lasix 20mg IV x2 with improvement in symptoms and became euvolemic on exam. She is s/p TAVR on ___, and there was concern for valve dysfunction. TTE on ___ showed similar LVEF of 40-45%, normal gradients across the aortic valve, and no significant aortic regurgitation. Acute onset of symptoms also concerning for flash pulmonary edema, potentially due to valve thrombosis (with subsequent embolization resulting in normal gradients at the time of TTE) or uncontrolled hypertension (patient's daughter-in-law reports that BP at time of acute dyspnea was 180/100). Metoprolol succinate 25 mg PO daily started for heart failure. Amlodipine was continued. Discharge weight was 40.5 kg and discharge creatinine was 0.7. Will follow up with structural heart team in 2 weeks after discharge. #Urinary tract infection: Asymptomatic, but in elderly female at high risk and very positive UA, opted to treat. UCx demonstrated E. Coli sensitive to Ceftriaxone. She completed a 3-day course of ceftriaxone (___) for uncomplicated UTI. #Type 2 DM: A1C 7.1 in ___. On glimiperide at home. Low dose insulin sliding scale during admission. Transitional issues: - Please have INR checked on ___ and fax to Dr. ___ at ___ - Metoprolol started for NSTEMI - Atorvatstatin started for stroke - Asprin discontinued given initiation of warfarin, plavix continued - Warfarin started with plan for ___ months pending clot resolution. Discharge warfarin dose 4 mg daily and discharge INR 2.4 - Will need repeat ECHO to document clot resolution - Patient may benefit from home health aid - Discharge weight: 40.5 kg - Discharge Cr: 0.7 - Discharge Hgb: 8.2 Contact/phone#: daughter in law can be contacted at ___ or by email: ___ Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Furosemide 20 mg PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Psyllium Wafer 1 WAF PO DAILY 5. Warfarin 4 mg PO DAILY16 6. amLODIPine 5 mg PO DAILY 7.Outpatient Occupational Therapy ICD 10: I63.40 Evaluate and Treat 8.Outpatient Physical Therapy ICD 10: I63.40 Evaluate and Treat 9.Outpatient Lab Work Date ___ ICD10: ___.9 Please Draw INR Fax results to ___ attn: Dr. ___ ___ Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute embolic stroke Urinary tract infection NSTEMI Acute on chronic heart failure with preserved ejection fraction Secondary diagnosis: Aortic stenosis s/p TAVR Hypertension Diabetes mellitus Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. ___, It was a pleasure treating you at ___! Why was I admitted to the hospital? -You were admitted because you had shortness of breath and we were concerned there was a problem with your valve replacement. What happened while I was admitted? -We gave you medicine to take fluid off of your lungs so that you could breathe more easily. -We did an MRI of your brain, which showed that you had had a stroke, maybe because of a clot caused by the valve replacement. -For the stroke, we started a medicine to make your blood thinner, which you will keep taking after you leave. What should I do when I go home? -Please keep taking the blood thinner medicine (warfarin), and get your blood tested as directed to measure how the medicine is working. -Please weigh yourself every day and call your doctor if your weight goes up by more than 3 lbs. We wish you the best! Your ___ care providers ___: ___	[ "T82867A", "I214", "I5033", "I6340", "N390", "B9620", "E119", "I2510", "E785", "I6523", "M21331", "I110", "I255", "Y831", "Y929" ]	Allergies: metformin Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old female with a history of aortic stenosis s/p TAVR in [MASKED], HFpEF (EF 40% [MASKED], CAD, HTN, and HLD, who presented with one day of shortness of breath. Prior to 1AM on the day of admission, the patient's daughter in law reported that she was in her usual state of health. The patient denied cough or shortness of breath at baseline; does not use home O2. At 1AM, the patient called her son into the room because she had acute onset of shortness of breath and cough productive of white sputum. This occurred while she was lying in bed. Her dyspnea was significant enough for her daughter in law, a physician, to want to bring her for emergency evaluation. Per her daughter in law's history, no chest pain, increasing [MASKED] edema, fever, fatigue, altered mental status, or recently decreased exercise tolerance. The household tries to minimize salt, but the patient does not keep close track of salt or fluid intake. Does not record weights. Reported complete adherence to medication regimen. The patient was hospitalized for elective TAVR (Evolut R, pre-mean gradient of 39.17, post-mean gradient 2) in [MASKED], which occurred without complication, and the patient had been recovering well. On discharge on [MASKED] showed an EF of 40-45%, with trace AR noted. Home Lasix dose was increased to 20 mg daily on discharge, though the patient's daughter-in-law subsequently decreased to 10 mg daily. The patient initially presented to the [MASKED] ED prior to transfer to [MASKED] ED. There, she received 20mg IV Lasix with output 300mL prior to arrival, and was put on BiPAP. Bedside ECHO at [MASKED] reportedly showed EF 25%. In the BI ED initial vitals were: 97.2 108 118/75 20 98% NC. EKG: Sinus tachycardia, LBBB, no concerning ischemic changes, unchanged from prior except for rate. Labs/studies notable for: BNP 6319, WBC 16.9, UA negative for infection. Patient was not given any additional meds. Symptoms had much improved by the time she reached the BI ED, however, she noticed right hand weakness at approximately 06:20. Was evaluated by neurology, who had concern for stroke vs. peripheral nerve compression. CXR with worsening airspace opacities in bilateral lungs in the setting of moderate cardiomegaly concerning for worsening pulmonary edema. Small bilateral pleural effusions may be present. CTA showed mild contour irregularity of the M1 segment of the left MCA with narrowing of the vessel caliber, without evidence of acute infarct. On the floor, patient was breathing comfortably on room air. Past Medical History: HTN hypercholesterolemia Severe aortic stenosis, NYHA Class II Carotid stenosis bilaterally Social History: [MASKED] Family History: FAMILY HISTORY: Both mother and father deceased in [MASKED]. Mother had asthma, was in a coma for a month. Father died of [MASKED]. One brother with coronary stent. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: T 98.3 BP 123/70 HR 101 RR 19 O2 SAT 97%RA Admission weight: 41.2 kg GENERAL: Thin, elderly female lying in bed in no acute distress. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. Mucus membranes appear moist. NECK: Supple. JVP noted below the mandible at 45 degrees. CARDIAC: Tachycardic, normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Crackles bilaterally in lower fields, no wheezes or rhonchi. ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. NEURO: AOX3. Motor strength [MASKED] in bilateral lower and left upper extremity. Patient unable to extend the right wrist. Motor strength in flexion and extension at the elbow is intact. Sensation equal and intact in both upper extremities. CNII-XII grossly intact. Positive pronator drift. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM ========================== Vitals: 98.4, 115-123/56-62, 71-86, 18, 95-98% RA Discharge weight: 40.5 kg GENERAL: Thin, elderly female lying in bed in no acute distress. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. Mucus membranes appear moist. NECK: Supple. No elevated JVD. CARDIAC: RRR, normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: CTAB, no wheezing ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. NEURO: AOX3. Motor strength [MASKED] in bilateral lower and left upper extremity above wrist. Patient unable to extend the right wrist. Patient unable to flex or extend right finger digits. Motor strength in flexion and extension at the elbow is intact. Sensation equal and intact in both upper extremities. CNII-XII grossly intact. Positive pronator drift. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS ======================= [MASKED] 06:50AM BLOOD WBC-16.6# RBC-4.02 Hgb-9.4 Hct-30.7* MCV-76* MCH-23.4* MCHC-30.6* RDW-17.2* RDWSD-47.6* Plt [MASKED] [MASKED] 06:50AM BLOOD Neuts-90.0* Lymphs-6.5* Monos-2.7* Eos-0.1* Baso-0.2 Im [MASKED] AbsNeut-14.87# AbsLymp-1.08 AbsMono-0.45 AbsEos-0.02* AbsBaso-0.04 [MASKED] 06:50AM BLOOD Glucose-182* UreaN-25* Creat-0.8 Na-135 K-4.6 Cl-97 HCO3-21* AnGap-22* [MASKED] 06:50AM BLOOD CK(CPK)-170 [MASKED] 06:50AM BLOOD CK-MB-16* MB Indx-9.4* cTropnT-0.24* proBNP-6319* [MASKED] 08:00AM BLOOD CK-MB-6 cTropnT-0.50* [MASKED] 12:40PM BLOOD CK-MB-6 cTropnT-0.46* [MASKED] 03:30AM BLOOD cTropnT-0.43* [MASKED] 06:50AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.0 DISCHARGE LABS ======================== [MASKED] 08:19AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.2 [MASKED] 08:19AM BLOOD Glucose-101* UreaN-17 Creat-0.7 Na-133 K-5.0 Cl-97 HCO3-22 AnGap-19 [MASKED] 08:19AM BLOOD [MASKED] PTT-39.1* [MASKED] [MASKED] 08:19AM BLOOD WBC-8.8 RBC-3.65* Hgb-8.2* Hct-27.4* MCV-75* MCH-22.5* MCHC-29.9* RDW-16.9* RDWSD-45.8 Plt [MASKED] MICROBIOLOGY ======================== [MASKED] 9:20 am URINE FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] 7:00 pm BLOOD CULTURE FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 7:00 pm BLOOD CULTURE **FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: NO GROWTH. [MASKED] 1:00 pm BLOOD CULTURE #1. Blood Culture, Routine (Pending): 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-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] 3:07 pm BLOOD CULTURE Blood Culture, Routine (Pending): IMAGING ========================= CXR [MASKED]: IMPRESSION: 1. Worsening airspace opacities in bilateral lungs in the setting of moderate cardiomegaly concerning for worsening pulmonary edema. 2. Small bilateral pleural effusions may be present. CTA head/neck [MASKED] IMPRESSION: 1. No evidence for acute intracranial abnormalities. 2. Aerosolized secretions in the right maxillary sinus. Please correlate clinically whether the patient may have symptoms of acute sinusitis. Approximately 60% stenosis of the proximal right internal carotid artery and approximately 30% stenosis of the proximal left internal carotid artery by NASCET criteria. 3. Mild stenosis of the left vertebral artery origin. 4. Short-segment moderate stenosis of the proximal M1 segment of the left MCA, mild narrowing of the proximal inferior division of the right MCA, irregularity of the basilar artery with mild short-segment stenosis in its midportion, and irregularity and mild narrowing of P1 and proximal P2 segments of the left posterior cerebral artery, which are most likely atherosclerotic. 5. Multiple thyroid nodules measuring up to 0.9 cm. The [MASKED] College of Radiology guidelines suggest that in the absence of risk factors for thyroid cancer, no further evaluation is recommended. 6. Partially visualized bilateral pleural effusions with associated atelectasis. Concurrent chest radiograph is reported separately. MRI brain w/o contrast [MASKED] IMPRESSION: Numerous acute to subacute infra- and supratentorial infarcts in all vascular distributions, as described, with configuration suggestive of embolic etiology. ECHO [MASKED] IMPRESSION: EF 40-45%. Well seated, normal functioning aortic valve Evolut TAVR with possible linear echodensity in the LVOT c/w possible vegetation/thrombus but no regurgitation. Mild-moderate mitral regurgitation. Normal left ventricular cavity size with mild regional systolic dysfunction. Compared with the prior study (images reviewed) of [MASKED], the mobile LVOT echodensity is NEW. Regional left ventricular systolic function is similar. The other findings are similar. Brief Hospital Course: Ms. [MASKED] is a [MASKED] year old female with a history of aortic stenosis s/p TAVR in [MASKED], HFpEF (EF 40% [MASKED], CAD, HTN, and HLD, who presented with one day of acute shortness of breath and right hand weakness. #Acute embolic stroke: Per neurology, MRI consistent with an acute stroke likely secondary to emboli, and imaging consistent with cortical hand syndrome causing isolated wrist drop. Numerous other emboli likely subacute and could be ongoing after TAVR. No other neurological deficits on exam. ECHO showing possible clot in LVOT, likely source of emboli. Per discussion with patient's family TEE not within goals of care. Blood cultures to evaluate for infectious vegetation were negative. She was started on warfarin with heparin gtt bridge until INR therapeutic (goal [MASKED]. Aspirin was stopped and plavix was resumed. Atorvastatin 80 mg was started. The patient was followed by occupational therapy during admission, who recommended home with outpatient OT. Will follow up with neurology after discharge. #CAD/NSTEMI: Patient with troponin trend 0.24 -> 0.50 -> 0.46 -> 0.43. No history of chest pain; dyspnea quickly resolved after diuresis. EKG without clear evidence of ischemia. Potential etiologies included demand ischemia in heart failure exacerbation/flash pulmonary edema or coronary embolism from aortic valve thrombus. Heparin gtt was started as above, and discontinued once INR was therapeutic. Metoprolol succinate 25 mg daily was initiated for ASCVD risk reduction. LHC in [MASKED] (prior to TAVR) demonstrated a 95% stenosis in the [MASKED] diagonal but otherwise non-obstructive coronary artery disease. #Acute on chronic HFpEF (40-45%): The patient presented with acute shortness of breath, with crackles and elevated JVP on exam, BNP 6319 (previously [MASKED]. She was diuresed with Lasix 20mg IV x2 with improvement in symptoms and became euvolemic on exam. She is s/p TAVR on [MASKED], and there was concern for valve dysfunction. TTE on [MASKED] showed similar LVEF of 40-45%, normal gradients across the aortic valve, and no significant aortic regurgitation. Acute onset of symptoms also concerning for flash pulmonary edema, potentially due to valve thrombosis (with subsequent embolization resulting in normal gradients at the time of TTE) or uncontrolled hypertension (patient's daughter-in-law reports that BP at time of acute dyspnea was 180/100). Metoprolol succinate 25 mg PO daily started for heart failure. Amlodipine was continued. Discharge weight was 40.5 kg and discharge creatinine was 0.7. Will follow up with structural heart team in 2 weeks after discharge. #Urinary tract infection: Asymptomatic, but in elderly female at high risk and very positive UA, opted to treat. UCx demonstrated E. Coli sensitive to Ceftriaxone. She completed a 3-day course of ceftriaxone ([MASKED]) for uncomplicated UTI. #Type 2 DM: A1C 7.1 in [MASKED]. On glimiperide at home. Low dose insulin sliding scale during admission. Transitional issues: - Please have INR checked on [MASKED] and fax to Dr. [MASKED] at [MASKED] - Metoprolol started for NSTEMI - Atorvatstatin started for stroke - Asprin discontinued given initiation of warfarin, plavix continued - Warfarin started with plan for [MASKED] months pending clot resolution. Discharge warfarin dose 4 mg daily and discharge INR 2.4 - Will need repeat ECHO to document clot resolution - Patient may benefit from home health aid - Discharge weight: 40.5 kg - Discharge Cr: 0.7 - Discharge Hgb: 8.2 Contact/phone#: daughter in law can be contacted at [MASKED] or by email: [MASKED] Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Furosemide 20 mg PO DAILY Discharge Medications: 1. Atorvastatin 80 mg PO QPM 2. Clopidogrel 75 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Psyllium Wafer 1 WAF PO DAILY 5. Warfarin 4 mg PO DAILY16 6. amLODIPine 5 mg PO DAILY 7.Outpatient Occupational Therapy ICD 10: I63.40 Evaluate and Treat 8.Outpatient Physical Therapy ICD 10: I63.40 Evaluate and Treat 9.Outpatient Lab Work Date [MASKED] ICD10: [MASKED].9 Please Draw INR Fax results to [MASKED] attn: Dr. [MASKED] [MASKED] Disposition: Home Discharge Diagnosis: Primary diagnosis: Acute embolic stroke Urinary tract infection NSTEMI Acute on chronic heart failure with preserved ejection fraction Secondary diagnosis: Aortic stenosis s/p TAVR Hypertension Diabetes mellitus Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. [MASKED], It was a pleasure treating you at [MASKED]! Why was I admitted to the hospital? -You were admitted because you had shortness of breath and we were concerned there was a problem with your valve replacement. What happened while I was admitted? -We gave you medicine to take fluid off of your lungs so that you could breathe more easily. -We did an MRI of your brain, which showed that you had had a stroke, maybe because of a clot caused by the valve replacement. -For the stroke, we started a medicine to make your blood thinner, which you will keep taking after you leave. What should I do when I go home? -Please keep taking the blood thinner medicine (warfarin), and get your blood tested as directed to measure how the medicine is working. -Please weigh yourself every day and call your doctor if your weight goes up by more than 3 lbs. We wish you the best! Your [MASKED] care providers [MASKED]: [MASKED]	[]	[ "N390", "E119", "I2510", "E785", "I110", "Y929" ]	[ "T82867A: Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5033: Acute on chronic diastolic (congestive) heart failure", "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "N390: Urinary tract infection, site not specified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E119: Type 2 diabetes mellitus without complications", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I6523: Occlusion and stenosis of bilateral carotid arteries", "M21331: Wrist drop, right wrist", "I110: Hypertensive heart disease with heart failure", "I255: Ischemic cardiomyopathy", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]
19,977,875	26,039,718	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: metformin Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ___ on ___ TRANSCATHETER AORTIC VALVE REPLACEMENT - TRANSFEMORAL Commercial Use: High/Extreme Symptomatic Risk Aortic Stenosis Procedures: Transaortic transcatheter aortic valve replacement Transcatheter Aortic Valve Replacement Catheter Placement, ___ Fr Sheath Right Femoral Artery Catheter Placement, ___ Fr Left Femoral Vein Catheter Placement, ___ Fr Left Femoral Artery Aortography, Ascending Aorta Vascular Access: Co-Surgeon: ___, MD Co-Surgeon: ___, MD Co-Surgeon: ___, MD Percutaneous Aortic Valve Replacement Co-Surgeon: ___, MD Co-Surgeon: ___, MD Co-Surgeon: ___, MD Total Contrast (mls): 40 Total Fluoro Time: 12.7 mins Blood loss: 50 ml Anesthesia: General Devices Used: Evolut-R: ___ ___ Loading System: ___ Delivery System: ___ The case complexity required a multidisciplinary approach with Cardiac Surgery and Interventional Cardiology. Vascular access was obtained in the left femoral artery and vein using vascular ultrasound techniques. The left femoral artery was used to advance a ___ Fr Pigtail catheter to the non coronary sinus. Aortography was performed using 15 cc contrast injection. Vascular access was obtained in the left femoral vein using ultrasound guidance and a ___ Fr sheath. A ___ Fr temporary pacemaker was placed in the right ventricle. Vascular access was obtained in the right femoral artery using vascular ultrasound guidance. A ___ Fr Cook Sheath was advanced in the right femoral artery after dilating with ___ Fr Coons dilator. Unfractionated heparin was given to achieve an ACT > 250 seconds. The aortic valve was crossed and a Pigtail catheter was advanced into the left ventricle. Simultaneous left ventricular and aortic pressures were recorded and demonstrated severe aortic stenosis. Aortic pressures were recorded at 9:03:37 AM Ao Pressure: ___ LV Pressure: 152/25/42 Mean Gradient: 39.17 mmHg The 0.035" exchange "J" wire was exchanged for a 0.035" Confida wire and the Pigtail was removed. Due to difficulty advancing the Pigtail across the valve, an 18 mm balloon was used to predilate the aortic valve using rapid ventricular pacing. A 26 mm Evolut R was then advanced across iliofemoral and aortic arch to the aortic valve without difficulty. Using aortography and placement of a Pigtail catheter to demonstrate the position of the Evolut-R 4 mm in the non coronary sinus and 4 mm in the left coronary sinus. Aortic pressures were recorded at 9:17:49 AM Ao Pressure: ___ mmHg LV Pressure: 133/32/39 Mean Gradient: 2 mmHg There was no evidence of coronary compromise following the procedure and was no aortic regurgitation by aortography or TEE. Protamine was given. The sheath was removed in the right femoral artery with two Proglides in a Preclose manner. The left femoral artery was closed with an ___ Fr Angioseal. History of Present Illness: ___ yr old ___ female with history of HTN, DMII, hypercholesterolemia and severe aortic stenosis. She was first diagnosed with aortic stenosis incidentally by her PCP in ___ and within the past month has become markedly short of breath with exertion. Her daughter in law is a ___ and felt that she should return to the US to be evaluated for AVR. Her family reports she is unable to climb one flight of stairs or shower without dyspnea. The patient denies chest pain, lower extremity edema, orthopnea, palpitation or syncope. She is able to do 15 minutes of yoga daily without complaints. Of note the patient takes many herbal ___ remedies which she has not brought with her today. Her family will attempt to investigate these medications. Past Medical History: HTN hypercholesterolemia Severe aortic stenosis, NYHA Class II Carotid stenosis bilaterally Social History: ___ Family History: FAMILY HISTORY: Both mother and father deceased in ___. Mother had asthma, was in a coma for a month. Father died of ___. One brother with coronary stent. Physical Exam: Admission exam: General: Elderly, frail female, appears comfortable in NAD. Neuro: A+O X3. Affect appropriate. MAE. Neck: supple (-) carotid bruits Chest: lungs diminished, bibasilar crackles CV: AP RRR III/VI SEM at ___ Abd: soft, nontender (+) bowel sounds Ext: No edema noted Pulses: Right: Radial:(+) Femoral bruit:(-) DP:(+) ___ Left: Radial:(+) Femoral bruit:(-) DP:(+) ___ Access sites: Left PIV Skin: Warm and well perfused, no rashes or lesions Discharge Exam: VS: 99.2, 120/69-135/56, HR 88, RR 18, 02 sat 97% RA LABS: ___: WBC 9.5, Hgb 7.3, Hct 23.3, Plts 260, Glucose 138, BUN 25, Creat 0.9, Na 135, K+ 4.6, Cl 98, Ca 8.3, Phos 3.7, Mag 2.2, HA1C 7.1, Repeated CBC ___: WBC 9.8, Hgb 8.4, Hct 27.8, Plts 297 Weight: 40.5kg I/O: 170/500 Physical Exam: Gen: thin woman lying flat in bed in NAD Neuro: alert and oriented no focal deficit, OOB to chair, ambulating in halls independently. Speech clear and appropriate. Neck/JVP: supple, no JVD CV: RRR Chest: LS CTA bilat no crackles, wheezes or rhonchi; slightly winded with climbing stairs trial ABD: soft NT + BS, Last BM ___ Extr: no edema, 2 + DP bilat Skin: WD+I Access sites: bilat groin sites soft; No bleeding, hematoma or bruit noted. Pertinent Results: Labs on admission ___ 09:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 07:30PM GLUCOSE-155* UREA N-28* CREAT-0.9 SODIUM-135 POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-17 ___ 07:30PM estGFR-Using this ___ 07:30PM ALT(SGPT)-43* AST(SGOT)-49* CK(CPK)-81 ALK PHOS-74 TOT BILI-0.2 ___ 07:30PM ___ ___ 07:30PM ALBUMIN-4.0 ___ 07:30PM WBC-8.3 RBC-3.81* HGB-9.1* HCT-29.7* MCV-78* MCH-23.9* MCHC-30.6* RDW-15.4 RDWSD-43.0 ___ 07:30PM PLT COUNT-331 ___ 07:30PM ___ PTT-30.9 ___ ___ 07:30PM ___ PTT-30.9 ___ ___ 07:30PM PLT COUNT-331 ___ 07:30PM WBC-8.3 RBC-3.81* HGB-9.1* HCT-29.7* MCV-78* MCH-23.9* MCHC-30.6* RDW-15.4 RDWSD-43.0 ___ 07:30PM ALBUMIN-4.0 ___ 07:30PM ___ ___ 07:30PM ALT(SGPT)-43* AST(SGOT)-49* CK(CPK)-81 ALK PHOS-74 TOT BILI-0.2 ___ 07:30PM estGFR-Using this ___ 07:30PM GLUCOSE-155* UREA N-28* CREAT-0.9 SODIUM-135 POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-17 ___ 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 09:30PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 10:50AM BLOOD WBC-9.8 RBC-3.58* Hgb-8.4* Hct-27.8* MCV-78* MCH-23.5* MCHC-30.2* RDW-15.4 RDWSD-43.1 Plt ___ ___ 07:45AM BLOOD WBC-9.5 RBC-3.03* Hgb-7.3* Hct-23.3* MCV-77* MCH-24.1* MCHC-31.3* RDW-15.7* RDWSD-43.4 Plt ___ ___ 07:00AM BLOOD WBC-9.8 RBC-3.12* Hgb-7.6* Hct-23.9* MCV-77* MCH-24.4* MCHC-31.8* RDW-15.7* RDWSD-43.4 Plt ___ ___ 10:29AM BLOOD WBC-12.3* RBC-3.33* Hgb-7.9* Hct-25.6* MCV-77* MCH-23.7* MCHC-30.9* RDW-15.3 RDWSD-42.5 Plt ___ ___ 07:00AM BLOOD Ret Aut-1.6 Abs Ret-0.05 ___ 07:45AM BLOOD Glucose-138* UreaN-25* Creat-0.9 Na-135 K-4.6 Cl-98 HCO3-23 AnGap-19 ___ 07:00AM BLOOD Glucose-151* UreaN-28* Creat-1.0 Na-132* K-4.9 Cl-98 HCO3-24 AnGap-15 ___ 10:29AM BLOOD UreaN-28* Creat-0.9 Na-134 K-4.6 Cl-101 HCO3-23 AnGap-15 ___ 07:30PM BLOOD Glucose-155* UreaN-28* Creat-0.9 Na-135 K-5.2* Cl-99 HCO3-24 AnGap-17 ___ 07:00AM BLOOD calTIBC-300 VitB12-648 Folate-5.8 Ferritn-27 TRF-231 ___ 07:00AM BLOOD %HbA1c-7.1* eAG-157* Brief Hospital Course: Prag___ was admitted on ___ for an elective ___. She underwent a successful ___ on ___. She tolerated the procedure well and was transferred to the telemetry unit where she was ambulating independently. Her bilateral groin access sites remained soft, without bleeding, hematoma or bruit. She was given additional 10mg of Lasix for a total of 20mg on post-procedure day 1 and 2 for symptoms of mild fluid overload. Her home Lasix dose was increased at discharge to 20mg daily. Her post procedure echocardiogram on ___ showed an EF of 45%, a mean gradient of ___R noted. She is chronically known to be anemic and her hemoglobin and hematocrit initially on admission were 7.9 and 25.6. Post procedure she drifted down to 7.3 and 23.3. She had no evidence of bleeding and was hemodynamically stable, without requiring any blood products or transfusions. A repeat on day of discharge was 8.4 and 27.8. Additionally, during this admission her blood sugars were slightly elevated. She stopped taking Metformin four weeks ago due to a rash and has not started anything in it's place. Her HgbA1c was 7.1%. Given her allergy to metformin, ___ was consulted (Dr. ___ and she was started on Nateglinide TIDAC. This worked well and morning blood sugar was 131. The patient then expressed wishes to be on a once a day medication, so she was changed to Glimeperide 1 mg daily by Dr. ___ will start tomorrow as she already received the Nateglinide this morning. She will have follow-up at ___ in one week to review her home blood sugar trends and adjustment in dose will be made at that time if needed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Furosemide 10 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Furosemide 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Aortic stenosis s/p ___ on ___ Discharge Condition: Subjective: I'm OK Objective: Reviewed VS and pertinent labs. VS: 99.2, 120/69-135/56, HR 88, RR 18, 02 sat 97% RA LABS: ___: WBC 9.5, Hgb 7.3, Hct 23.3, Plts 260, Glucose 138, BUN 25, Creat 0.9, Na 135, K+ 4.6, Cl 98, Ca 8.3, Phos 3.7, Mag 2.2, HA1C 7.1, Repeated CBC ___: WBC 9.8, Hgb 8.4, Hct 27.8, Plts 297 Weight: 40.3kg (38.8 kg yesterday) I/O: 300/975 ECG: SR with LBBB @ 97 bpm (New LBBB post ___ Physical Exam: Gen: thin woman lying flat in bed in NAD Neuro: alert and oriented no focal deficit, OOB to chair, ambulating in halls independently. Speech clear and appropriate. Neck/JVP: supple, no JVD CV: RRR Chest: LS CTA bilat no crackles, wheezes or rhonchi; slightly winded with climbing stairs trial ABD: soft NT + BS, Last BM ___ Extr: no edema, 2 + DP bilat Skin: WD+I Access sites: bilat groin sites soft; No bleeding, hematoma or bruit noted. Assessment/Plan: ___ year old woman with severe AS now s/p ___ with a 26mm Evolute valve #Aortic Stenosis s/p ___ with pre mean gradient of 39.17mm HG post mean gradient 2mm Hg -ASA 81mg daily and Plavix 75mg daily -Lasix 10mg daily; additional 10mg given x1 today; consider increasing dose if needed -Follow-up per ___ team outpatient # HTN Well controlled on Amlodipine 5mg daily #Anemia H/H 29.7/9.1 on admit; 23.9/7.3 today, repeated and 27.8/8.4. Hemodynamically stable. Asymptomatic, NO evidence of bleeding. Patient is vegetarian. -Iron studies normal #DMII: HA1C 7.1 - ISS while in house - DM diet - ___ consult done by Dr. ___: trialed Nateglinide 60mg TIDAC which worked well, however patient prefers once a day medication. Changed to Glimeperide 1mg tablet daily before breakfast to start tomorrow. TO follow-up with ___ outpatient in one week with history of blood sugars/glucometer to visit; will consider up-titrating PRN. #Hyperlipidemia: FLP unknown, per daughter her lipids are normal and she has not been taking atorvastatin Discharge Instructions: You were admitted to ___ with aortic stenosis and underwent a ___ procedure on ___. You will be on Plavix 75mg daily and Aspirin 81mg daily. These will prevent clot from forming within the new valve. Stopping these prematurely can put you at risk for clotting off the valve which could be life threatening. Do not stop these unless your cardiologist instructs you to do so. Care of your groin sites will be included in your discharge instructions. You also had an endocrine consult by Dr. ___ to evaluate your blood sugars. You will go home on a new medication called Glimeperide 1mg daily in the morning. You should test your blood sugars three times a day before each meal and track them. You should call ___ for a follow-up appointment within 1 week so that they can evaluate how your blood sugars are responding as your new medication may need to be adjusted. Please bring your glucometer and your history of blood sugars with you to your ___ appointment. Your PCP needs to refer you before an appointment can be made. You will followup with your PCP and the ___ team here at ___ as scheduled. It has been a pleasure caring for you at ___! Followup Instructions: ___	[ "I350", "Z681", "E1165", "E8770", "R54", "I10", "D649", "E785", "Z006" ]	Allergies: metformin Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [MASKED] on [MASKED] TRANSCATHETER AORTIC VALVE REPLACEMENT - TRANSFEMORAL Commercial Use: High/Extreme Symptomatic Risk Aortic Stenosis Procedures: Transaortic transcatheter aortic valve replacement Transcatheter Aortic Valve Replacement Catheter Placement, [MASKED] Fr Sheath Right Femoral Artery Catheter Placement, [MASKED] Fr Left Femoral Vein Catheter Placement, [MASKED] Fr Left Femoral Artery Aortography, Ascending Aorta Vascular Access: Co-Surgeon: [MASKED], MD Co-Surgeon: [MASKED], MD Co-Surgeon: [MASKED], MD Percutaneous Aortic Valve Replacement Co-Surgeon: [MASKED], MD Co-Surgeon: [MASKED], MD Co-Surgeon: [MASKED], MD Total Contrast (mls): 40 Total Fluoro Time: 12.7 mins Blood loss: 50 ml Anesthesia: General Devices Used: Evolut-R: [MASKED] [MASKED] Loading System: [MASKED] Delivery System: [MASKED] The case complexity required a multidisciplinary approach with Cardiac Surgery and Interventional Cardiology. Vascular access was obtained in the left femoral artery and vein using vascular ultrasound techniques. The left femoral artery was used to advance a [MASKED] Fr Pigtail catheter to the non coronary sinus. Aortography was performed using 15 cc contrast injection. Vascular access was obtained in the left femoral vein using ultrasound guidance and a [MASKED] Fr sheath. A [MASKED] Fr temporary pacemaker was placed in the right ventricle. Vascular access was obtained in the right femoral artery using vascular ultrasound guidance. A [MASKED] Fr Cook Sheath was advanced in the right femoral artery after dilating with [MASKED] Fr Coons dilator. Unfractionated heparin was given to achieve an ACT > 250 seconds. The aortic valve was crossed and a Pigtail catheter was advanced into the left ventricle. Simultaneous left ventricular and aortic pressures were recorded and demonstrated severe aortic stenosis. Aortic pressures were recorded at 9:03:37 AM Ao Pressure: [MASKED] LV Pressure: 152/25/42 Mean Gradient: 39.17 mmHg The 0.035" exchange "J" wire was exchanged for a 0.035" Confida wire and the Pigtail was removed. Due to difficulty advancing the Pigtail across the valve, an 18 mm balloon was used to predilate the aortic valve using rapid ventricular pacing. A 26 mm Evolut R was then advanced across iliofemoral and aortic arch to the aortic valve without difficulty. Using aortography and placement of a Pigtail catheter to demonstrate the position of the Evolut-R 4 mm in the non coronary sinus and 4 mm in the left coronary sinus. Aortic pressures were recorded at 9:17:49 AM Ao Pressure: [MASKED] mmHg LV Pressure: 133/32/39 Mean Gradient: 2 mmHg There was no evidence of coronary compromise following the procedure and was no aortic regurgitation by aortography or TEE. Protamine was given. The sheath was removed in the right femoral artery with two Proglides in a Preclose manner. The left femoral artery was closed with an [MASKED] Fr Angioseal. History of Present Illness: [MASKED] yr old [MASKED] female with history of HTN, DMII, hypercholesterolemia and severe aortic stenosis. She was first diagnosed with aortic stenosis incidentally by her PCP in [MASKED] and within the past month has become markedly short of breath with exertion. Her daughter in law is a [MASKED] and felt that she should return to the US to be evaluated for AVR. Her family reports she is unable to climb one flight of stairs or shower without dyspnea. The patient denies chest pain, lower extremity edema, orthopnea, palpitation or syncope. She is able to do 15 minutes of yoga daily without complaints. Of note the patient takes many herbal [MASKED] remedies which she has not brought with her today. Her family will attempt to investigate these medications. Past Medical History: HTN hypercholesterolemia Severe aortic stenosis, NYHA Class II Carotid stenosis bilaterally Social History: [MASKED] Family History: FAMILY HISTORY: Both mother and father deceased in [MASKED]. Mother had asthma, was in a coma for a month. Father died of [MASKED]. One brother with coronary stent. Physical Exam: Admission exam: General: Elderly, frail female, appears comfortable in NAD. Neuro: A+O X3. Affect appropriate. MAE. Neck: supple (-) carotid bruits Chest: lungs diminished, bibasilar crackles CV: AP RRR III/VI SEM at [MASKED] Abd: soft, nontender (+) bowel sounds Ext: No edema noted Pulses: Right: Radial:(+) Femoral bruit:(-) DP:(+) [MASKED] Left: Radial:(+) Femoral bruit:(-) DP:(+) [MASKED] Access sites: Left PIV Skin: Warm and well perfused, no rashes or lesions Discharge Exam: VS: 99.2, 120/69-135/56, HR 88, RR 18, 02 sat 97% RA LABS: [MASKED]: WBC 9.5, Hgb 7.3, Hct 23.3, Plts 260, Glucose 138, BUN 25, Creat 0.9, Na 135, K+ 4.6, Cl 98, Ca 8.3, Phos 3.7, Mag 2.2, HA1C 7.1, Repeated CBC [MASKED]: WBC 9.8, Hgb 8.4, Hct 27.8, Plts 297 Weight: 40.5kg I/O: 170/500 Physical Exam: Gen: thin woman lying flat in bed in NAD Neuro: alert and oriented no focal deficit, OOB to chair, ambulating in halls independently. Speech clear and appropriate. Neck/JVP: supple, no JVD CV: RRR Chest: LS CTA bilat no crackles, wheezes or rhonchi; slightly winded with climbing stairs trial ABD: soft NT + BS, Last BM [MASKED] Extr: no edema, 2 + DP bilat Skin: WD+I Access sites: bilat groin sites soft; No bleeding, hematoma or bruit noted. Pertinent Results: Labs on admission [MASKED] 09:30PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [MASKED] 07:30PM GLUCOSE-155* UREA N-28* CREAT-0.9 SODIUM-135 POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-17 [MASKED] 07:30PM estGFR-Using this [MASKED] 07:30PM ALT(SGPT)-43* AST(SGOT)-49* CK(CPK)-81 ALK PHOS-74 TOT BILI-0.2 [MASKED] 07:30PM [MASKED] [MASKED] 07:30PM ALBUMIN-4.0 [MASKED] 07:30PM WBC-8.3 RBC-3.81* HGB-9.1* HCT-29.7* MCV-78* MCH-23.9* MCHC-30.6* RDW-15.4 RDWSD-43.0 [MASKED] 07:30PM PLT COUNT-331 [MASKED] 07:30PM [MASKED] PTT-30.9 [MASKED] [MASKED] 07:30PM [MASKED] PTT-30.9 [MASKED] [MASKED] 07:30PM PLT COUNT-331 [MASKED] 07:30PM WBC-8.3 RBC-3.81* HGB-9.1* HCT-29.7* MCV-78* MCH-23.9* MCHC-30.6* RDW-15.4 RDWSD-43.0 [MASKED] 07:30PM ALBUMIN-4.0 [MASKED] 07:30PM [MASKED] [MASKED] 07:30PM ALT(SGPT)-43* AST(SGOT)-49* CK(CPK)-81 ALK PHOS-74 TOT BILI-0.2 [MASKED] 07:30PM estGFR-Using this [MASKED] 07:30PM GLUCOSE-155* UREA N-28* CREAT-0.9 SODIUM-135 POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-17 [MASKED] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [MASKED] 09:30PM URINE COLOR-Straw APPEAR-Clear SP [MASKED] [MASKED] 10:50AM BLOOD WBC-9.8 RBC-3.58* Hgb-8.4* Hct-27.8* MCV-78* MCH-23.5* MCHC-30.2* RDW-15.4 RDWSD-43.1 Plt [MASKED] [MASKED] 07:45AM BLOOD WBC-9.5 RBC-3.03* Hgb-7.3* Hct-23.3* MCV-77* MCH-24.1* MCHC-31.3* RDW-15.7* RDWSD-43.4 Plt [MASKED] [MASKED] 07:00AM BLOOD WBC-9.8 RBC-3.12* Hgb-7.6* Hct-23.9* MCV-77* MCH-24.4* MCHC-31.8* RDW-15.7* RDWSD-43.4 Plt [MASKED] [MASKED] 10:29AM BLOOD WBC-12.3* RBC-3.33* Hgb-7.9* Hct-25.6* MCV-77* MCH-23.7* MCHC-30.9* RDW-15.3 RDWSD-42.5 Plt [MASKED] [MASKED] 07:00AM BLOOD Ret Aut-1.6 Abs Ret-0.05 [MASKED] 07:45AM BLOOD Glucose-138* UreaN-25* Creat-0.9 Na-135 K-4.6 Cl-98 HCO3-23 AnGap-19 [MASKED] 07:00AM BLOOD Glucose-151* UreaN-28* Creat-1.0 Na-132* K-4.9 Cl-98 HCO3-24 AnGap-15 [MASKED] 10:29AM BLOOD UreaN-28* Creat-0.9 Na-134 K-4.6 Cl-101 HCO3-23 AnGap-15 [MASKED] 07:30PM BLOOD Glucose-155* UreaN-28* Creat-0.9 Na-135 K-5.2* Cl-99 HCO3-24 AnGap-17 [MASKED] 07:00AM BLOOD calTIBC-300 VitB12-648 Folate-5.8 Ferritn-27 TRF-231 [MASKED] 07:00AM BLOOD %HbA1c-7.1* eAG-157* Brief Hospital Course: Prag was admitted on [MASKED] for an elective [MASKED]. She underwent a successful [MASKED] on [MASKED]. She tolerated the procedure well and was transferred to the telemetry unit where she was ambulating independently. Her bilateral groin access sites remained soft, without bleeding, hematoma or bruit. She was given additional 10mg of Lasix for a total of 20mg on post-procedure day 1 and 2 for symptoms of mild fluid overload. Her home Lasix dose was increased at discharge to 20mg daily. Her post procedure echocardiogram on [MASKED] showed an EF of 45%, a mean gradient of R noted. She is chronically known to be anemic and her hemoglobin and hematocrit initially on admission were 7.9 and 25.6. Post procedure she drifted down to 7.3 and 23.3. She had no evidence of bleeding and was hemodynamically stable, without requiring any blood products or transfusions. A repeat on day of discharge was 8.4 and 27.8. Additionally, during this admission her blood sugars were slightly elevated. She stopped taking Metformin four weeks ago due to a rash and has not started anything in it's place. Her HgbA1c was 7.1%. Given her allergy to metformin, [MASKED] was consulted (Dr. [MASKED] and she was started on Nateglinide TIDAC. This worked well and morning blood sugar was 131. The patient then expressed wishes to be on a once a day medication, so she was changed to Glimeperide 1 mg daily by Dr. [MASKED] will start tomorrow as she already received the Nateglinide this morning. She will have follow-up at [MASKED] in one week to review her home blood sugar trends and adjustment in dose will be made at that time if needed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Furosemide 10 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. amLODIPine 5 mg PO DAILY 4. Furosemide 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Aortic stenosis s/p [MASKED] on [MASKED] Discharge Condition: Subjective: I'm OK Objective: Reviewed VS and pertinent labs. VS: 99.2, 120/69-135/56, HR 88, RR 18, 02 sat 97% RA LABS: [MASKED]: WBC 9.5, Hgb 7.3, Hct 23.3, Plts 260, Glucose 138, BUN 25, Creat 0.9, Na 135, K+ 4.6, Cl 98, Ca 8.3, Phos 3.7, Mag 2.2, HA1C 7.1, Repeated CBC [MASKED]: WBC 9.8, Hgb 8.4, Hct 27.8, Plts 297 Weight: 40.3kg (38.8 kg yesterday) I/O: 300/975 ECG: SR with LBBB @ 97 bpm (New LBBB post [MASKED] Physical Exam: Gen: thin woman lying flat in bed in NAD Neuro: alert and oriented no focal deficit, OOB to chair, ambulating in halls independently. Speech clear and appropriate. Neck/JVP: supple, no JVD CV: RRR Chest: LS CTA bilat no crackles, wheezes or rhonchi; slightly winded with climbing stairs trial ABD: soft NT + BS, Last BM [MASKED] Extr: no edema, 2 + DP bilat Skin: WD+I Access sites: bilat groin sites soft; No bleeding, hematoma or bruit noted. Assessment/Plan: [MASKED] year old woman with severe AS now s/p [MASKED] with a 26mm Evolute valve #Aortic Stenosis s/p [MASKED] with pre mean gradient of 39.17mm HG post mean gradient 2mm Hg -ASA 81mg daily and Plavix 75mg daily -Lasix 10mg daily; additional 10mg given x1 today; consider increasing dose if needed -Follow-up per [MASKED] team outpatient # HTN Well controlled on Amlodipine 5mg daily #Anemia H/H 29.7/9.1 on admit; 23.9/7.3 today, repeated and 27.8/8.4. Hemodynamically stable. Asymptomatic, NO evidence of bleeding. Patient is vegetarian. -Iron studies normal #DMII: HA1C 7.1 - ISS while in house - DM diet - [MASKED] consult done by Dr. [MASKED]: trialed Nateglinide 60mg TIDAC which worked well, however patient prefers once a day medication. Changed to Glimeperide 1mg tablet daily before breakfast to start tomorrow. TO follow-up with [MASKED] outpatient in one week with history of blood sugars/glucometer to visit; will consider up-titrating PRN. #Hyperlipidemia: FLP unknown, per daughter her lipids are normal and she has not been taking atorvastatin Discharge Instructions: You were admitted to [MASKED] with aortic stenosis and underwent a [MASKED] procedure on [MASKED]. You will be on Plavix 75mg daily and Aspirin 81mg daily. These will prevent clot from forming within the new valve. Stopping these prematurely can put you at risk for clotting off the valve which could be life threatening. Do not stop these unless your cardiologist instructs you to do so. Care of your groin sites will be included in your discharge instructions. You also had an endocrine consult by Dr. [MASKED] to evaluate your blood sugars. You will go home on a new medication called Glimeperide 1mg daily in the morning. You should test your blood sugars three times a day before each meal and track them. You should call [MASKED] for a follow-up appointment within 1 week so that they can evaluate how your blood sugars are responding as your new medication may need to be adjusted. Please bring your glucometer and your history of blood sugars with you to your [MASKED] appointment. Your PCP needs to refer you before an appointment can be made. You will followup with your PCP and the [MASKED] team here at [MASKED] as scheduled. It has been a pleasure caring for you at [MASKED]! Followup Instructions: [MASKED]	[]	[ "E1165", "I10", "D649", "E785" ]	[ "I350: Nonrheumatic aortic (valve) stenosis", "Z681: Body mass index [BMI] 19.9 or less, adult", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E8770: Fluid overload, unspecified", "R54: Age-related physical debility", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
19,978,119	20,178,379	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: amiodarone / gemcitabine / Abraxane Attending: ___. Chief Complaint: lethargy Major Surgical or Invasive Procedure: none History of Present Illness: ___ with hx of CAD s/p PCI (___), metastatic pancreatic cancer s/p ___ on FOLFOX, Afib on enoxaparin, chronic urinary retention, and current C Diff colitis on fidaxomicin who p/w lethargy and hypotension c/f infection found to have elevated troponins and pancolitis. Of note, the patient was recently admitted from ___ for E.coli bacteremia s/p ceftriaxone and urinary Retention/bilateral hydronephrosis, for which he was discharged with a foley. He is currently receiving fidaxomicin for C.diff colitis. At rehab on ___, the patient had increasing lethargy. At the OSH he has soft pressures to the systolics ___. Labs showed leukocytosis to 22, Trop I 1.5, creatinine 2.2 (baseline 1.0), positive UA. CXR showed infiltrate vs. atelectasis. He received Flagyl, 3+ L crystalloid. He was then transferred to ___. In the ED, initial vitals: 97.9 72 108/68 16 97% RA. - Labs were significant for Lactate: 1.4, Trop-T: 0.76, CK: 63 MB: 2, Cr 1.8, Na 128, Wbc 22.2 (N:88.0 L:3.0 M:6.7 E:0.8 Bas:0.2), UA with rare bacteria. - EKG w/o ischemic changes - CXR showed patchy opacities in lung bases c/w atelectasis but cannot exclude infection. - CT abd/pelvis showed diffuse pancolitis most severely affecting the descending and rectosigmoid colon, most consistent with ischemia. It also showed new splenic hypodensity c/w infarct and stable metastases. - Pt received IVF 1000 mL, IV CefePIME 2 g, IV Vancomycin 1000 mg and was started on IV Norepinephrine - Cardiology consulted and thought his high troponin was a trop leak due to hypoperfusion/demand ischemia. Recommended to trend cardiac enzymes; no indication for heparin gtt. - Surgery consulted, and recommended nothing to do. On arrival to the MICU, patient is significantly lethargic but no acute distress. He was somewhat confused, but ultimately oriented x3. He initially reported some lower abdominal pain but then denied. He also denied shortness of breath or chest pain. Past Medical History: PAST ONCOLOGIC HISTORY: Reconciled in OMR. Pancreatic cancer stage IIB (T3N1M0) now with progressive metastatic disease - ___ Admitted to the ___ with 2-week history of gradual onset of generalized malaise, dark urine, acoholic stools, and eventual painless jaundice. Found to have obstructive LFTS (AST 211, ALT 215, AP 741, TB 26.7) and subsequent US/CT showed moderate intrahepatic and extrahepatic biliary ductal dilatation to the level of the pancreatic head without overt mass seen (lack of IV contrast). US showed, "Moderate intrahepatic and extrahepatic biliary ductal dilatation to the level of the pancreatic head. The CBD measures 17 mm at the hilum. Limited evaluation of the pancreas does not demonstrate any pancreatic head mass. Cholelithiasis without evidence of acute cholecystitis. Borderline splenomegaly." Follow up CT showed, "Dilated intrahepatic and extrahepatic bile ducts. No obvious mass but evaluation is limited without contrast. Markedly dilated urinary bladder with mild left hydroureteronephrosis and distal right ureter dilatation possibly from obstructive uropathy. No calculus. There is an enlarged prostate gland with a suspected TURP defect." - ___ ERCP for stent placement, brushings negative for malignancy. He was discharged on ___. - ___ Seen by his PCP who arranged for EUS at ___. TB down to 3.8 at that point with improved symptoms. - ___ EUS performed by Dr. ___ showed, "No celiac adenopathy was seen. Reactive gastrohepatic ligament adenopathy seen. Two SB-IPMNs noted; one in the body and the larger one in the head. A solid mass was seen surrounding the distal CBD, measuring 1.2 cm. The CBD was dilated proximal to the mass up to 1.2 cm in size. A small, suspicious-appearing lymph node was seen around the distal CBD. FNA performed, prelim results show neoplastic ___ final pathology positive for malignant cells, CONSISTENT WITH ADENOCARCINOMA. - ___ ___ resection revealed pancreatic adenocarcinoma pT3N1 with 1 of 14 nodes involved with carcinoma, LVI negative, extensive perineural invasion present, margins clear by 2 mm at the SMV. - ___ Signed consent for APACT Trial ___ ___ - ___ CT torso showed celiac adenopathy and a possible new liver met - ___ MR liver showed likely liver met and adenopathy - ___ Began discussion of HALO trial - ___ FNA of the liver lesion via EUS showed metastatic adenocarcinoma - ___ Signed consent for HALO, randomized to control arm - ___ C1D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ C2D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ CT torso showed response to therapy - ___ C3D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ C4D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ CT torso showed further reduction in liver mets, new pneumomitis - ___ Holding chemo for pneumonitis. Start steroids. Off study ___ ___ control arm of the HALO trial. - ___ Much improved on steroids. - ___ CT torso showed progression of liver mets and development of numerous new liver mets as well as progression of portal adenopathy. - ___ C1D1 FOLFOX6 - ___ C2D1 FOLFOX6 - ___ CT torso showed progression of known disease and some increased pulmonary nodules. Rising tumor markers. - ___ C3D1 FOLFOX6 - ___ C3D15 dose of FOLFOX held for admission to OSH for MI - ___ CT torso showed stable lung nodules and enlargement of multiple hepatic metastatic lesions and the local recurrence in the tumor bed. - PLANNED ___ Resume chemotherapy with C4D1 FOLFOX6 PAST MEDICAL HISTORY: - Metastatic Pancreatic Cancer - CAD s/p PCI (___) - pAFib ___, converted to sinus spontaneously) - HTN - HLD - Obstructive Uropathy with BPH - followed by Dr. ___ ___ - ___ (baseline Cr 1.5) - Agent Orange exposure during ___ - Biceps tendon rupture - Cataracts PSH: - Whipple (___) - TURP - Left inguinal hernia repair (___) - Cholecystectomy - Bicept tendon repair - b/l cataract surgery Social History: ___ Family History: 1. Mother died of a ruptured abdominal aortic aneurysm. 2. Father was healthy until his ___. 3. Son died young of coronary artery disease. 4. No family history of malignancies that he is aware of. Physical Exam: ADMISSION: Vitals: T:97.2 BP: 101/48 P: 101 R: 18 O2: GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, faint bibasilar crackles, but no significant wheezes, rales, rhonchi CV: irreg irreg, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, hypoactive bowel sounds, no rebound tenderness or guarding, no organomegaly. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rashes or other lesions. port in place. NEURO: no facial droop, moving extremities, but unable to participate in formal neurologic exam. DISCHARGE: Physical Exam Vitals- Resting comfortable not febrile to touch, no tachypnea General- NAD HEENT- Anicteric sclera, dry MM Pertinent Results: ADMISSION/IMPORTANT LABS: ========================= ___ 05:33AM BLOOD WBC-27.1* RBC-3.80* Hgb-11.2* Hct-33.9* MCV-89 MCH-29.5 MCHC-33.0 RDW-15.7* RDWSD-50.9* Plt ___ ___ 04:50AM BLOOD WBC-20.8* RBC-3.42* Hgb-10.0* Hct-29.9* MCV-87 MCH-29.2 MCHC-33.4 RDW-15.6* RDWSD-49.5* Plt ___ ___ 09:10PM BLOOD Neuts-88.0* Lymphs-3.0* Monos-6.7 Eos-0.8* Baso-0.2 Im ___ AbsNeut-19.57# AbsLymp-0.66 AbsMono-1.48* AbsEos-0.18 AbsBaso-0.04 ___ 09:10PM BLOOD Glucose-104* UreaN-58* Creat-1.8* Na-128* K-3.8 Cl-97 HCO3-17* AnGap-18 ___ 09:10PM BLOOD ALT-27 AST-44* CK(CPK)-63 AlkPhos-321* TotBili-0.4 ___ 09:10PM BLOOD cTropnT-0.76* ___ 05:33AM BLOOD cTropnT-0.81* ___ 02:58PM BLOOD cTropnT-0.71* ___ 08:13AM BLOOD Lactate-1.4 LABS AT DISCHARGE: ================= ___ 05:51AM BLOOD WBC-13.6* RBC-3.33* Hgb-9.7* Hct-30.8* MCV-93 MCH-29.1 MCHC-31.5* RDW-18.3* RDWSD-58.7* Plt ___ ___ 05:51AM BLOOD Glucose-87 UreaN-21* Creat-0.9 Na-144 K-3.1* Cl-120* HCO3-18* AnGap-9 ___ 05:51AM BLOOD ALT-30 AST-95* AlkPhos-526* TotBili-0.5 MICROBIOLOGY: ============= C. difficile DNA amplification assay (Final ___: Reported to and read back by ___ AT 10:49 AM ___. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). URINE CULTURE (Final ___: NO GROWTH. IMAGING: ======= CT Abdomen/Pelvis w/o contrast ___. Diffuse pancolitis, most severely affecting the descending and rectosigmoid colon. Given the degree of wall thickening and fat stranding surrounding the distal colon, although nonspecific and limited in the absence of IV contrast, there is high concern for ischemia given this appearance. No portal venous gas or pneumatosis identified. 2. Small amount of ascites is primarily perihepatic and perisplenic. 3. New apparent wedge-shaped hypodensity in the spleen is nonspecific, possibly infarction, less likely metastasis. 4. Stable severe thoracolumbar spine degenerative change. 5. Stable multifocal hepatic hypodensities consistent with known metastatic prostate cancer. 6. Trace pericardial and bilateral layering pleural effusions. CXR ___ Limited study as result of low lung volumes. Patchy opacities in the lung bases may reflect atelectasis but infection or aspiration cannot be excluded in the correct clinical setting. CT ABD/PELVIS ___ 1. Splenic infarcts. 2. Numerous hypodense masses in the liver are consistent with history of metastatic pancreatic cancer. 3. Thrombus within the main portal vein and left portal vein branches. 4. Colonic wall thickening consistent with colitis is persistent but improved compared to ___. 5. Small to moderate amount of nonhemorrhagic ascites is slightly increased KUB ___ Comparison to ___. Three views of the abdomen are provided. Clips are projecting over the middle abdomen. Mild colonic distension at the level of the transverse and the descending colon. Colonic air-fluid levels are visualized on the cross-table view. No evidence of free intra-abdominal air. Several phleboliths projecting over the pelvis. ECHO ___ The left atrial volume index is normal. No atrial septal defect is seen by 2D or color Doppler. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 58 %). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Mild aortic regurgitation. Mild mitral regurgitation. Compared with the prior study (images reviewed) of ___, the severity of aortic regurgitation and mitral regurgitation are slighlty increased. Left ventricular regional and global systolic function are similar. The ventricular rate is now higher with frequent extrasystoles. LEFT UE US ___ There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. Brief Hospital Course: PLEASE ADMIT TO INPATIENT HOSPICE BRIEF HOSPITAL COURSE ===================== Mr. ___ is a ___ with hx of CAD s/p PCI (___), metastatic pancreatic cancer s/p Whipple (___) on FOLFOX, Afib on enoxaparin, chronic urinary retention, who presented with severe C Diff colitis on fidaxomicin and troponemia. #GOC: Patient has poor prognosis and is extremely weak given c-diff and metastatic pancreatic cancer. One month ago patient was quite functional and had actually driven himself to his oncology appointments. He has declined quite rapidly and is now unable to move his limbs against gravity. Since patient's mental status did not allow for a goals of care discussion, an in depth discussion was held with HCP, and decision was made to change care to comfort based care. Receiving comfort focused medications only. Other medical issues before transition to comfort based care: # Shock: Patient with hypotension and evidence of end-organ dysfunction with lethargy and ___. Given leukocytosis, thought to be septic shock. Although patient had positive troponin, he was without chest pain or significant changes on ECG. Thus, troponinemia is likely a type II demand event. Initial suspected sources of infection included C.diff given pancolitis and reported history (although C.diff negative on last admission) as well as potential PNA based on CXR findings. However, he denied any respiratory symptoms. Initially, patient was treated with broad spectrum antibiotics to cover both colitis and pneumonia with IV vanc, cefepime, flagyl, and PO vanc. C.diff was sent and returned positive. IV vanc, cefepime was discontinued. He remained on PO vanc and IV flagyl for treatment of severe C.diff until transfer to the floor. He was weaned off pressors and his leukocytosis was downtrending at the time of discharge from the ICU. #Severe C-diff colitis: As above he was transferred to the floor on both IV flagyl and high dose vancomycin. He was evaluated by speech and swallow who recommended initially that he be made NPO due to aspiration. He progressed to pureed solids and nectar thick liquids but had not progressed to meet his nutritional needs sufficiently. During that time he was started on tube feeds and the rate was gradual increased without residuals or worsening of his colitis symptoms. Was initially evaluated by surgery but no intervention with improvement in symptoms. His leukocytosis remained somewhat stable. Patient did not improve but remained stable. On ___ antibiotics were discontinued and tubefeeds were stopped per above goals of care discussion. # NSTEMI: Per cardiology, likely type 2 NSTEMI given absence of symptoms and no EKG changes. Had not been on beta blocker at home, therefore after troponins trended down and blood pressures improved patient was started on metoprolol tartrate 12.5 BID. He had been on an aspirin 81 every other day at home. Aspirin was restarted daily. Patient already anticoagulated with enoxaparin, however, this was held in setting ___ and concern for possible need for surgical intervention. It was restarted shortly thereafter without issue. Continued atorvastatin. All cardiac medications were discontinued as per above goals of care. # Acute on chronic renal injury: Likely prerenal given hypotension/sepsis. Creatinine initially 2.1 but downtrended appropriately in response to fluid resuscitation and resolution of hypotension. Cr prior to discharge was 0.9 # Hyponatremia: RESOLVED Likely hypovolemic. Patient asymptomatic. Na improved after fluids. # Metabolic acidosis: Lactate WNL. Non anion gab acidosis Likely due to diarrhea, as patient is noted to have chronic diarrhea since ___. Urine electrolytes with a pH of 6 and no AG in conjunction with patient normal potassium make RTA unlikely. # Afib on enoxaparin: Rate controlled throughout, on lovenox for anti-coagulation as previously decided by cardiologist given hx of metastatic pancreatic cancer. # Metastatic pancreatic cancer: Chemotherapy with FOLFOX from oncologist, Dr. ___. No chemotherapy given on this admission. Dr. ___ met with patient and family and communicated extremely poor prognosis, and that patient was not candidate for any chemo given poor functional status. # Urinary retention: continued indwelling foley which patient had on transfer from rehab to ___. Attempted voiding trial with high post void residuals. foley placed back. No UTI. # Depression: continued citalopram # GERD: Discontinued omeprazole in light of increasing risk of C-diff recurrence, changed to famotidine. TRANSITIONAL ISSUES =================== -Consider completely liberalizing diet, patient likely aspirating even on nectar thick liquids. -#DNR/DNI -#CONTACT GRANDSON ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Citalopram 20 mg PO DAILY 3. Enoxaparin Sodium 120 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 4. Gabapentin 400 mg PO BID:PRN shingles 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. LOPERamide ___ mg PO QID:PRN diarreha 7. Omeprazole 40 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 10. lidocaine HCl 3 % topical TID:PRN pain 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. CeftriaXONE 2 gm IV Q 24H 13. Sarna Lotion 1 Appl TP TID:PRN pruritis 14. Tamsulosin 0.4 mg PO QHS 15. Creon 12 3 CAP PO TID W/MEALS 16. Acetaminophen 325 mg PO Q6H:PRN pain 17. Dificid (fidaxomicin) 200 mg oral Q12H 18. Oyster Shell Calcium (calcium carbonate) 500 mg calcium (1,250 mg) oral BID 19. Ibuprofen 400 mg PO BID:PRN pain 20. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. lidocaine HCl 3 % topical TID:PRN pain 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Sarna Lotion 1 Appl TP TID:PRN pruritis 7. Miconazole Powder 2% 1 Appl TP BID groin 8. Acetaminophen 325 mg PO Q6H:PRN pain 9. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions 10. LORazepam 0.5-2 mg IV Q2H:PRN anxiety/distress 11. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory distress 12. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting Discharge Disposition: Extended Care Facility: ___. Discharge Diagnosis: Primary: Septic Shock Severe C-diff Colitis Aspiration Secondary: chronic systolic heart failure HTN HLD ___ Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to ___ after being found to have low blood pressures because of a severe c-diff. We gave you special medication to support your blood pressures and treated your c-diff with antibiotics. As your c-diff improved we were able to wean off the blood pressure medications. You had a swallow assessment which showed that your swallowing muscles were weak and so we started you on tube feeds to support your nutrition. After discussion with you and your HCP it was decided not to continue to pursue treatment and your care became focused on comfort only. All of your non-comfort medications were discontinued and you were discharged to hospice. Sincerely, Your ___ Care Team Followup Instructions: ___	[ "A419", "R6521", "I214", "N179", "A047", "C259", "E872", "C787", "C779", "K219", "E871", "I5022", "Z515", "I2510", "I480", "Z7901", "E780", "N400", "I129", "N189", "F329", "N401", "R338", "H269", "Z87891", "Z66" ]	Allergies: amiodarone / gemcitabine / Abraxane Chief Complaint: lethargy Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] with hx of CAD s/p PCI ([MASKED]), metastatic pancreatic cancer s/p [MASKED] on FOLFOX, Afib on enoxaparin, chronic urinary retention, and current C Diff colitis on fidaxomicin who p/w lethargy and hypotension c/f infection found to have elevated troponins and pancolitis. Of note, the patient was recently admitted from [MASKED] for E.coli bacteremia s/p ceftriaxone and urinary Retention/bilateral hydronephrosis, for which he was discharged with a foley. He is currently receiving fidaxomicin for C.diff colitis. At rehab on [MASKED], the patient had increasing lethargy. At the OSH he has soft pressures to the systolics [MASKED]. Labs showed leukocytosis to 22, Trop I 1.5, creatinine 2.2 (baseline 1.0), positive UA. CXR showed infiltrate vs. atelectasis. He received Flagyl, 3+ L crystalloid. He was then transferred to [MASKED]. In the ED, initial vitals: 97.9 72 108/68 16 97% RA. - Labs were significant for Lactate: 1.4, Trop-T: 0.76, CK: 63 MB: 2, Cr 1.8, Na 128, Wbc 22.2 (N:88.0 L:3.0 M:6.7 E:0.8 Bas:0.2), UA with rare bacteria. - EKG w/o ischemic changes - CXR showed patchy opacities in lung bases c/w atelectasis but cannot exclude infection. - CT abd/pelvis showed diffuse pancolitis most severely affecting the descending and rectosigmoid colon, most consistent with ischemia. It also showed new splenic hypodensity c/w infarct and stable metastases. - Pt received IVF 1000 mL, IV CefePIME 2 g, IV Vancomycin 1000 mg and was started on IV Norepinephrine - Cardiology consulted and thought his high troponin was a trop leak due to hypoperfusion/demand ischemia. Recommended to trend cardiac enzymes; no indication for heparin gtt. - Surgery consulted, and recommended nothing to do. On arrival to the MICU, patient is significantly lethargic but no acute distress. He was somewhat confused, but ultimately oriented x3. He initially reported some lower abdominal pain but then denied. He also denied shortness of breath or chest pain. Past Medical History: PAST ONCOLOGIC HISTORY: Reconciled in OMR. Pancreatic cancer stage IIB (T3N1M0) now with progressive metastatic disease - [MASKED] Admitted to the [MASKED] with 2-week history of gradual onset of generalized malaise, dark urine, acoholic stools, and eventual painless jaundice. Found to have obstructive LFTS (AST 211, ALT 215, AP 741, TB 26.7) and subsequent US/CT showed moderate intrahepatic and extrahepatic biliary ductal dilatation to the level of the pancreatic head without overt mass seen (lack of IV contrast). US showed, "Moderate intrahepatic and extrahepatic biliary ductal dilatation to the level of the pancreatic head. The CBD measures 17 mm at the hilum. Limited evaluation of the pancreas does not demonstrate any pancreatic head mass. Cholelithiasis without evidence of acute cholecystitis. Borderline splenomegaly." Follow up CT showed, "Dilated intrahepatic and extrahepatic bile ducts. No obvious mass but evaluation is limited without contrast. Markedly dilated urinary bladder with mild left hydroureteronephrosis and distal right ureter dilatation possibly from obstructive uropathy. No calculus. There is an enlarged prostate gland with a suspected TURP defect." - [MASKED] ERCP for stent placement, brushings negative for malignancy. He was discharged on [MASKED]. - [MASKED] Seen by his PCP who arranged for EUS at [MASKED]. TB down to 3.8 at that point with improved symptoms. - [MASKED] EUS performed by Dr. [MASKED] showed, "No celiac adenopathy was seen. Reactive gastrohepatic ligament adenopathy seen. Two SB-IPMNs noted; one in the body and the larger one in the head. A solid mass was seen surrounding the distal CBD, measuring 1.2 cm. The CBD was dilated proximal to the mass up to 1.2 cm in size. A small, suspicious-appearing lymph node was seen around the distal CBD. FNA performed, prelim results show neoplastic [MASKED] final pathology positive for malignant cells, CONSISTENT WITH ADENOCARCINOMA. - [MASKED] [MASKED] resection revealed pancreatic adenocarcinoma pT3N1 with 1 of 14 nodes involved with carcinoma, LVI negative, extensive perineural invasion present, margins clear by 2 mm at the SMV. - [MASKED] Signed consent for APACT Trial [MASKED] [MASKED] - [MASKED] CT torso showed celiac adenopathy and a possible new liver met - [MASKED] MR liver showed likely liver met and adenopathy - [MASKED] Began discussion of HALO trial - [MASKED] FNA of the liver lesion via EUS showed metastatic adenocarcinoma - [MASKED] Signed consent for HALO, randomized to control arm - [MASKED] C1D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - [MASKED] C2D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - [MASKED] CT torso showed response to therapy - [MASKED] C3D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - [MASKED] C4D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - [MASKED] CT torso showed further reduction in liver mets, new pneumomitis - [MASKED] Holding chemo for pneumonitis. Start steroids. Off study [MASKED] [MASKED] control arm of the HALO trial. - [MASKED] Much improved on steroids. - [MASKED] CT torso showed progression of liver mets and development of numerous new liver mets as well as progression of portal adenopathy. - [MASKED] C1D1 FOLFOX6 - [MASKED] C2D1 FOLFOX6 - [MASKED] CT torso showed progression of known disease and some increased pulmonary nodules. Rising tumor markers. - [MASKED] C3D1 FOLFOX6 - [MASKED] C3D15 dose of FOLFOX held for admission to OSH for MI - [MASKED] CT torso showed stable lung nodules and enlargement of multiple hepatic metastatic lesions and the local recurrence in the tumor bed. - PLANNED [MASKED] Resume chemotherapy with C4D1 FOLFOX6 PAST MEDICAL HISTORY: - Metastatic Pancreatic Cancer - CAD s/p PCI ([MASKED]) - pAFib [MASKED], converted to sinus spontaneously) - HTN - HLD - Obstructive Uropathy with BPH - followed by Dr. [MASKED] [MASKED] - [MASKED] (baseline Cr 1.5) - Agent Orange exposure during [MASKED] - Biceps tendon rupture - Cataracts PSH: - Whipple ([MASKED]) - TURP - Left inguinal hernia repair ([MASKED]) - Cholecystectomy - Bicept tendon repair - b/l cataract surgery Social History: [MASKED] Family History: 1. Mother died of a ruptured abdominal aortic aneurysm. 2. Father was healthy until his [MASKED]. 3. Son died young of coronary artery disease. 4. No family history of malignancies that he is aware of. Physical Exam: ADMISSION: Vitals: T:97.2 BP: 101/48 P: 101 R: 18 O2: GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, faint bibasilar crackles, but no significant wheezes, rales, rhonchi CV: irreg irreg, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, hypoactive bowel sounds, no rebound tenderness or guarding, no organomegaly. EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: no rashes or other lesions. port in place. NEURO: no facial droop, moving extremities, but unable to participate in formal neurologic exam. DISCHARGE: Physical Exam Vitals- Resting comfortable not febrile to touch, no tachypnea General- NAD HEENT- Anicteric sclera, dry MM Pertinent Results: ADMISSION/IMPORTANT LABS: ========================= [MASKED] 05:33AM BLOOD WBC-27.1* RBC-3.80* Hgb-11.2* Hct-33.9* MCV-89 MCH-29.5 MCHC-33.0 RDW-15.7* RDWSD-50.9* Plt [MASKED] [MASKED] 04:50AM BLOOD WBC-20.8* RBC-3.42* Hgb-10.0* Hct-29.9* MCV-87 MCH-29.2 MCHC-33.4 RDW-15.6* RDWSD-49.5* Plt [MASKED] [MASKED] 09:10PM BLOOD Neuts-88.0* Lymphs-3.0* Monos-6.7 Eos-0.8* Baso-0.2 Im [MASKED] AbsNeut-19.57# AbsLymp-0.66 AbsMono-1.48* AbsEos-0.18 AbsBaso-0.04 [MASKED] 09:10PM BLOOD Glucose-104* UreaN-58* Creat-1.8* Na-128* K-3.8 Cl-97 HCO3-17* AnGap-18 [MASKED] 09:10PM BLOOD ALT-27 AST-44* CK(CPK)-63 AlkPhos-321* TotBili-0.4 [MASKED] 09:10PM BLOOD cTropnT-0.76* [MASKED] 05:33AM BLOOD cTropnT-0.81* [MASKED] 02:58PM BLOOD cTropnT-0.71* [MASKED] 08:13AM BLOOD Lactate-1.4 LABS AT DISCHARGE: ================= [MASKED] 05:51AM BLOOD WBC-13.6* RBC-3.33* Hgb-9.7* Hct-30.8* MCV-93 MCH-29.1 MCHC-31.5* RDW-18.3* RDWSD-58.7* Plt [MASKED] [MASKED] 05:51AM BLOOD Glucose-87 UreaN-21* Creat-0.9 Na-144 K-3.1* Cl-120* HCO3-18* AnGap-9 [MASKED] 05:51AM BLOOD ALT-30 AST-95* AlkPhos-526* TotBili-0.5 MICROBIOLOGY: ============= C. difficile DNA amplification assay (Final [MASKED]: Reported to and read back by [MASKED] AT 10:49 AM [MASKED]. CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). URINE CULTURE (Final [MASKED]: NO GROWTH. IMAGING: ======= CT Abdomen/Pelvis w/o contrast [MASKED]. Diffuse pancolitis, most severely affecting the descending and rectosigmoid colon. Given the degree of wall thickening and fat stranding surrounding the distal colon, although nonspecific and limited in the absence of IV contrast, there is high concern for ischemia given this appearance. No portal venous gas or pneumatosis identified. 2. Small amount of ascites is primarily perihepatic and perisplenic. 3. New apparent wedge-shaped hypodensity in the spleen is nonspecific, possibly infarction, less likely metastasis. 4. Stable severe thoracolumbar spine degenerative change. 5. Stable multifocal hepatic hypodensities consistent with known metastatic prostate cancer. 6. Trace pericardial and bilateral layering pleural effusions. CXR [MASKED] Limited study as result of low lung volumes. Patchy opacities in the lung bases may reflect atelectasis but infection or aspiration cannot be excluded in the correct clinical setting. CT ABD/PELVIS [MASKED] 1. Splenic infarcts. 2. Numerous hypodense masses in the liver are consistent with history of metastatic pancreatic cancer. 3. Thrombus within the main portal vein and left portal vein branches. 4. Colonic wall thickening consistent with colitis is persistent but improved compared to [MASKED]. 5. Small to moderate amount of nonhemorrhagic ascites is slightly increased KUB [MASKED] Comparison to [MASKED]. Three views of the abdomen are provided. Clips are projecting over the middle abdomen. Mild colonic distension at the level of the transverse and the descending colon. Colonic air-fluid levels are visualized on the cross-table view. No evidence of free intra-abdominal air. Several phleboliths projecting over the pelvis. ECHO [MASKED] The left atrial volume index is normal. No atrial septal defect is seen by 2D or color Doppler. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 58 %). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Mild aortic regurgitation. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [MASKED], the severity of aortic regurgitation and mitral regurgitation are slighlty increased. Left ventricular regional and global systolic function are similar. The ventricular rate is now higher with frequent extrasystoles. LEFT UE US [MASKED] There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, basilic, and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: No evidence of deep vein thrombosis in the left upper extremity. Brief Hospital Course: PLEASE ADMIT TO INPATIENT HOSPICE BRIEF HOSPITAL COURSE ===================== Mr. [MASKED] is a [MASKED] with hx of CAD s/p PCI ([MASKED]), metastatic pancreatic cancer s/p Whipple ([MASKED]) on FOLFOX, Afib on enoxaparin, chronic urinary retention, who presented with severe C Diff colitis on fidaxomicin and troponemia. #GOC: Patient has poor prognosis and is extremely weak given c-diff and metastatic pancreatic cancer. One month ago patient was quite functional and had actually driven himself to his oncology appointments. He has declined quite rapidly and is now unable to move his limbs against gravity. Since patient's mental status did not allow for a goals of care discussion, an in depth discussion was held with HCP, and decision was made to change care to comfort based care. Receiving comfort focused medications only. Other medical issues before transition to comfort based care: # Shock: Patient with hypotension and evidence of end-organ dysfunction with lethargy and [MASKED]. Given leukocytosis, thought to be septic shock. Although patient had positive troponin, he was without chest pain or significant changes on ECG. Thus, troponinemia is likely a type II demand event. Initial suspected sources of infection included C.diff given pancolitis and reported history (although C.diff negative on last admission) as well as potential PNA based on CXR findings. However, he denied any respiratory symptoms. Initially, patient was treated with broad spectrum antibiotics to cover both colitis and pneumonia with IV vanc, cefepime, flagyl, and PO vanc. C.diff was sent and returned positive. IV vanc, cefepime was discontinued. He remained on PO vanc and IV flagyl for treatment of severe C.diff until transfer to the floor. He was weaned off pressors and his leukocytosis was downtrending at the time of discharge from the ICU. #Severe C-diff colitis: As above he was transferred to the floor on both IV flagyl and high dose vancomycin. He was evaluated by speech and swallow who recommended initially that he be made NPO due to aspiration. He progressed to pureed solids and nectar thick liquids but had not progressed to meet his nutritional needs sufficiently. During that time he was started on tube feeds and the rate was gradual increased without residuals or worsening of his colitis symptoms. Was initially evaluated by surgery but no intervention with improvement in symptoms. His leukocytosis remained somewhat stable. Patient did not improve but remained stable. On [MASKED] antibiotics were discontinued and tubefeeds were stopped per above goals of care discussion. # NSTEMI: Per cardiology, likely type 2 NSTEMI given absence of symptoms and no EKG changes. Had not been on beta blocker at home, therefore after troponins trended down and blood pressures improved patient was started on metoprolol tartrate 12.5 BID. He had been on an aspirin 81 every other day at home. Aspirin was restarted daily. Patient already anticoagulated with enoxaparin, however, this was held in setting [MASKED] and concern for possible need for surgical intervention. It was restarted shortly thereafter without issue. Continued atorvastatin. All cardiac medications were discontinued as per above goals of care. # Acute on chronic renal injury: Likely prerenal given hypotension/sepsis. Creatinine initially 2.1 but downtrended appropriately in response to fluid resuscitation and resolution of hypotension. Cr prior to discharge was 0.9 # Hyponatremia: RESOLVED Likely hypovolemic. Patient asymptomatic. Na improved after fluids. # Metabolic acidosis: Lactate WNL. Non anion gab acidosis Likely due to diarrhea, as patient is noted to have chronic diarrhea since [MASKED]. Urine electrolytes with a pH of 6 and no AG in conjunction with patient normal potassium make RTA unlikely. # Afib on enoxaparin: Rate controlled throughout, on lovenox for anti-coagulation as previously decided by cardiologist given hx of metastatic pancreatic cancer. # Metastatic pancreatic cancer: Chemotherapy with FOLFOX from oncologist, Dr. [MASKED]. No chemotherapy given on this admission. Dr. [MASKED] met with patient and family and communicated extremely poor prognosis, and that patient was not candidate for any chemo given poor functional status. # Urinary retention: continued indwelling foley which patient had on transfer from rehab to [MASKED]. Attempted voiding trial with high post void residuals. foley placed back. No UTI. # Depression: continued citalopram # GERD: Discontinued omeprazole in light of increasing risk of C-diff recurrence, changed to famotidine. TRANSITIONAL ISSUES =================== -Consider completely liberalizing diet, patient likely aspirating even on nectar thick liquids. -#DNR/DNI -#CONTACT GRANDSON [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Citalopram 20 mg PO DAILY 3. Enoxaparin Sodium 120 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 4. Gabapentin 400 mg PO BID:PRN shingles 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. LOPERamide [MASKED] mg PO QID:PRN diarreha 7. Omeprazole 40 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 10. lidocaine HCl 3 % topical TID:PRN pain 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. CeftriaXONE 2 gm IV Q 24H 13. Sarna Lotion 1 Appl TP TID:PRN pruritis 14. Tamsulosin 0.4 mg PO QHS 15. Creon 12 3 CAP PO TID W/MEALS 16. Acetaminophen 325 mg PO Q6H:PRN pain 17. Dificid (fidaxomicin) 200 mg oral Q12H 18. Oyster Shell Calcium (calcium carbonate) 500 mg calcium (1,250 mg) oral BID 19. Ibuprofen 400 mg PO BID:PRN pain 20. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Lidocaine 5% Patch 1 PTCH TD QAM 3. lidocaine HCl 3 % topical TID:PRN pain 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Sarna Lotion 1 Appl TP TID:PRN pruritis 7. Miconazole Powder 2% 1 Appl TP BID groin 8. Acetaminophen 325 mg PO Q6H:PRN pain 9. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions 10. LORazepam 0.5-2 mg IV Q2H:PRN anxiety/distress 11. Morphine Sulfate [MASKED] mg IV Q15MIN:PRN Pain or respiratory distress 12. Ondansetron [MASKED] mg IV Q6H:PRN nausea/vomiting Discharge Disposition: Extended Care Facility: [MASKED]. Discharge Diagnosis: Primary: Septic Shock Severe C-diff Colitis Aspiration Secondary: chronic systolic heart failure HTN HLD [MASKED] Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [MASKED], You were admitted to [MASKED] after being found to have low blood pressures because of a severe c-diff. We gave you special medication to support your blood pressures and treated your c-diff with antibiotics. As your c-diff improved we were able to wean off the blood pressure medications. You had a swallow assessment which showed that your swallowing muscles were weak and so we started you on tube feeds to support your nutrition. After discussion with you and your HCP it was decided not to continue to pursue treatment and your care became focused on comfort only. All of your non-comfort medications were discontinued and you were discharged to hospice. Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "N179", "E872", "K219", "E871", "Z515", "I2510", "I480", "Z7901", "N400", "I129", "N189", "F329", "Z87891", "Z66" ]	[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "N179: Acute kidney failure, unspecified", "A047: Enterocolitis due to Clostridium difficile", "C259: Malignant neoplasm of pancreas, unspecified", "E872: Acidosis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C779: Secondary and unspecified malignant neoplasm of lymph node, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E871: Hypo-osmolality and hyponatremia", "I5022: Chronic systolic (congestive) heart failure", "Z515: Encounter for palliative care", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "E780: Pure hypercholesterolemia", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "F329: Major depressive disorder, single episode, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "H269: Unspecified cataract", "Z87891: Personal history of nicotine dependence", "Z66: Do not resuscitate" ]
19,978,119	24,540,502	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: amiodarone / gemcitabine / Abraxane Attending: ___. Chief Complaint: Bacteremia, diarrhea and fevers Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a PMHx notable for CAD s/p PCI (___) and metastatic pancreatic cancer s/p ___ (___) s/p treawment with gemcitabine (complicated by pneumonitis), now on second line therapy with FOLFOX (C4D24) who is being transferred from ___ (in ___ for management of diarrhea and bacteremia. The patient was admitted to ___ on ___ with 1 month of diarrhea as well two episodes of vomiting. Labs were notable for stable pancytopenia. CT scan in the ED did not show any acute changes or bowel thickening, but did now bilateral hydro and a distended bladder so a foley was placed and he drained 1200 ccs. He had a negative cdiff but was briefly on IV Flagyl. He spiked a temp to 101.5 on ___ and his blood cultures returned with GNRs so he was started on Vanc/Cefepime. He was never hypotensive and did not have an elevated lactate. Patient was last seen by his oncologist, Dr. ___ on ___. Note from that day indicates that chemotherapy had recently been held due to an NSTEMI in the setting of a UTI and long rehabilitation stay. At that visit, he was having 5 bowel movements per day. On arrival to the floor, patient reports feeling much better since being on antibiotics. He denies any nausea, vomiting, fevers, chills, abdominal pain, or severe diarrhea at the moment. He does endorse pruritis as well as pain on his right shoulder from a prior shingles flare. REVIEW OF SYSTEMS: Per HPI, otherwise negative Past Medical History: PAST ONCOLOGIC HISTORY: Reconciled in OMR. Pancreatic cancer stage IIB (T3N1M0) now with progressive metastatic disease - ___ Admitted to the ___ with 2-week history of gradual onset of generalized malaise, dark urine, acoholic stools, and eventual painless jaundice. Found to have obstructive LFTS (AST 211, ALT 215, AP 741, TB 26.7) and subsequent US/CT showed moderate intrahepatic and extrahepatic biliary ductal dilatation to the level of the pancreatic head without overt mass seen (lack of IV contrast). US showed, "Moderate intrahepatic and extrahepatic biliary ductal dilatation to the level of the pancreatic head. The CBD measures 17 mm at the hilum. Limited evaluation of the pancreas does not demonstrate any pancreatic head mass. Cholelithiasis without evidence of acute cholecystitis. Borderline splenomegaly." Follow up CT showed, "Dilated intrahepatic and extrahepatic bile ducts. No obvious mass but evaluation is limited without contrast. Markedly dilated urinary bladder with mild left hydroureteronephrosis and distal right ureter dilatation possibly from obstructive uropathy. No calculus. There is an enlarged prostate gland with a suspected TURP defect." - ___ ERCP for stent placement, brushings negative for malignancy. He was discharged on ___. - ___ Seen by his PCP who arranged for EUS at ___. TB down to 3.8 at that point with improved symptoms. - ___ EUS performed by Dr. ___ showed, "No celiac adenopathy was seen. Reactive gastrohepatic ligament adenopathy seen. Two SB-IPMNs noted; one in the body and the larger one in the head. A solid mass was seen surrounding the distal CBD, measuring 1.2 cm. The CBD was dilated proximal to the mass up to 1.2 cm in size. A small, suspicious-appearing lymph node was seen around the distal CBD. FNA performed, prelim results show neoplastic ___ final pathology positive for malignant cells, CONSISTENT WITH ADENOCARCINOMA. - ___ Whipple resection revealed pancreatic adenocarcinoma pT3N1 with 1 of 14 nodes involved with carcinoma, LVI negative, extensive perineural invasion present, margins clear by 2 mm at the SMV. - ___ Signed consent for APACT Trial ___ ___ - ___ CT torso showed celiac adenopathy and a possible new liver met - ___ MR liver showed likely liver met and adenopathy - ___ Began discussion of HALO trial - ___ FNA of the liver lesion via EUS showed metastatic adenocarcinoma - ___ Signed consent for HALO, randomized to control arm - ___ C1D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ C2D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ CT torso showed response to therapy - ___ C3D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ C4D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - ___ CT torso showed further reduction in liver mets, new pneumomitis - ___ Holding chemo for pneumonitis. Start steroids. Off study ___ ___ control arm of the HALO trial. - ___ Much improved on steroids. - ___ CT torso showed progression of liver mets and development of numerous new liver mets as well as progression of portal adenopathy. - ___ C1D1 FOLFOX6 - ___ C2D1 FOLFOX6 - ___ CT torso showed progression of known disease and some increased pulmonary nodules. Rising tumor markers. - ___ C3D1 FOLFOX6 - ___ C3D15 dose of FOLFOX held for admission to OSH for MI - ___ CT torso showed stable lung nodules and enlargement of multiple hepatic metastatic lesions and the local recurrence in the tumor bed. - PLANNED ___ Resume chemotherapy with C4D1 FOLFOX6 PAST MEDICAL HISTORY: - Metastatic Pancreatic Cancer - CAD s/p PCI (___) - pAFib ___, converted to sinus spontaneously) - HTN - HLD - Obstructive Uropathy with BPH - followed by Dr. ___ ___ - ___ (baseline Cr 1.5) - Agent Orange exposure during ___ - Biceps tendon rupture - Cataracts PSH: - Whipple (___) - TURP - Left inguinal hernia repair (___) - Cholecystectomy - Bicept tendon repair - b/l cataract surgery Social History: ___ Family History: 1. Mother died of a ruptured abdominal aortic aneurysm. 2. Father was healthy until his ___. 3. Son died young of coronary artery disease. 4. No family history of malignancies that he is aware of. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98 ___ 18 98% RA GENERAL: NAD HEENT: NCAT, PERRLA, MMM CARDIAC: RRR, nl s1/s2, no murmurs, rubs, gallops LUNG: CTAB, no wheezes ABD: Prior abdominal scar. +BS. Nontender, nondistended EXT: No edema, 2+ pulses, warm NEURO: CNII-XII intact, sensation and strength grossly intact SKIN: Right shoulder with petichiae and excoriation ACCESS: Left chest wall port c/d/i Pertinent Results: ADMISSION ___ 10:05PM BLOOD WBC-5.1 RBC-2.86* Hgb-8.9* Hct-27.6* MCV-97 MCH-31.1 MCHC-32.2 RDW-15.9* RDWSD-56.4* Plt Ct-86* ___ 10:05PM BLOOD ___ PTT-35.0 ___ ___ 10:05PM BLOOD Glucose-97 UreaN-10 Creat-1.1 Na-135 K-4.3 Cl-110* HCO3-19* AnGap-10 ___ 10:05PM BLOOD ALT-15 AST-25 LD(___)-272* AlkPhos-121 TotBili-0.3 ___ 10:05PM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.0* Mg-2.0 Renal Ultrasound Mild dilatation of the right renal collecting system. There is no left hydronephrosis. E. coli: pansensitive DC LABS: ___ 06:35AM BLOOD WBC-6.6 RBC-3.14* Hgb-9.5* Hct-29.7* MCV-95 MCH-30.3 MCHC-32.0 RDW-15.9* RDWSD-54.8* Plt ___ ___ 06:35AM BLOOD Glucose-84 UreaN-6 Creat-1.0 Na-139 K-3.6 Cl-109* HCO3-20* AnGap-14 ___ 07:34AM BLOOD ALT-16 AST-24 LD(LDH)-281* AlkPhos-130 TotBili-0.4 ___ 06:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2 ___ 10:39PM BLOOD Lactate-1.2 Brief Hospital Course: This is a ___ year old male with past medical history CAD, metastatic pancreatic cancer on FOLFOX (C4D25), admitted to ___ ___ ___ with reported diarrhea and emesis, course notable for GNR bacteremia and urinary retention s/p broadspectrum antibiotics and foley, transferred to ___ for further management # Ecoli blood stream infection/septicemia - patient presented to OSH with nausea and vomiting; admission blood cultures returned positive for Ecoli; Unclear source, as UA at OSH was negative for nitr and leuk esterase, and had not been sent for culture. Patient initially treated with vancomycin/cefepime, narrowed to IV CTX cultures returned with pan-sensitive Ecoli. Additional workup up notable for no clear abscess or source, but since he had severe urinary retention, a urinary source was favored. He improved clinically and is discharged to complete a 14 day course of Ceftriaxone 2g IV q24, through ___. # Urinary Retention/Bilateral Hydronephrosis - seen on CT scan at ___ prompting foley placement; patient reported prior history of bladder obstruction requiring prior foley; UA not convincing for infection. Repeat ultrasound showed resolving hydronephrosis. Patient started on Flomax. After discussion with the patient, ___ was kept in placed and he was discharged with Foley. Recommend consideration of voiding trial in ___ days, and he should follow up with a urologist in 2 weeks. Continue Flomax. # Pancreatic cancer: Per OSH CT scan, disease looks to be worsening. Primary oncologist ___ informed. Follow up for ___ is arranged to consider further options. # Diarrhea - while at OSH, there had been concern for acute diarrhea, on additional history with patient, he clarified that diarrhea had been chronic ongoing since initiation of FOLFOX several months ago; infectious workup at OSH was negative, and stooling remained constant ___ per day. C. diff negative # CAD - continued statin # Depression - continued citalopram # GERD - continued PPI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Gabapentin 400 mg PO BID:PRN shingles 3. LOPERamide ___ mg PO QID:PRN diarreha 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. lidocaine HCl 3 % topical TID:PRN pain 7. Enoxaparin Sodium 120 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 8. Atorvastatin 40 mg PO QPM 9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 10. Omeprazole 40 mg PO DAILY 11. Citalopram 20 mg PO DAILY 12. Pyridoxine Dose is Unknown PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Citalopram 20 mg PO DAILY 3. Enoxaparin Sodium 120 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time 4. Gabapentin 400 mg PO BID:PRN shingles 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. LOPERamide ___ mg PO QID:PRN diarreha 7. Omeprazole 40 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 10. lidocaine HCl 3 % topical TID:PRN pain 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. CeftriaXONE 2 gm IV Q 24H ___ay 1 = ___. complete through ___ 13. Sarna Lotion 1 Appl TP TID:PRN pruritis 14. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: E. coli blood stream infection Urinary retention Pancreatic cancer Native CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with infection in your blood. This was likely caused by a urinary source. You will need to complete a course of IV Ceftriaxone through ___. A Foley catheter was placed for severe urinary retention. This should stay in place and follow up with Urology in 2 weeks is recommended Followup Instructions: ___	[ "A4151", "E872", "C787", "C250", "N1330", "I480", "D6959", "E871", "N401", "I129", "N189", "Z9861", "R338", "K529", "I2510", "E785", "H269", "Z87891", "F329", "K219" ]	Allergies: amiodarone / gemcitabine / Abraxane Chief Complaint: Bacteremia, diarrhea and fevers Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] with a PMHx notable for CAD s/p PCI ([MASKED]) and metastatic pancreatic cancer s/p [MASKED] ([MASKED]) s/p treawment with gemcitabine (complicated by pneumonitis), now on second line therapy with FOLFOX (C4D24) who is being transferred from [MASKED] (in [MASKED] for management of diarrhea and bacteremia. The patient was admitted to [MASKED] on [MASKED] with 1 month of diarrhea as well two episodes of vomiting. Labs were notable for stable pancytopenia. CT scan in the ED did not show any acute changes or bowel thickening, but did now bilateral hydro and a distended bladder so a foley was placed and he drained 1200 ccs. He had a negative cdiff but was briefly on IV Flagyl. He spiked a temp to 101.5 on [MASKED] and his blood cultures returned with GNRs so he was started on Vanc/Cefepime. He was never hypotensive and did not have an elevated lactate. Patient was last seen by his oncologist, Dr. [MASKED] on [MASKED]. Note from that day indicates that chemotherapy had recently been held due to an NSTEMI in the setting of a UTI and long rehabilitation stay. At that visit, he was having 5 bowel movements per day. On arrival to the floor, patient reports feeling much better since being on antibiotics. He denies any nausea, vomiting, fevers, chills, abdominal pain, or severe diarrhea at the moment. He does endorse pruritis as well as pain on his right shoulder from a prior shingles flare. REVIEW OF SYSTEMS: Per HPI, otherwise negative Past Medical History: PAST ONCOLOGIC HISTORY: Reconciled in OMR. Pancreatic cancer stage IIB (T3N1M0) now with progressive metastatic disease - [MASKED] Admitted to the [MASKED] with 2-week history of gradual onset of generalized malaise, dark urine, acoholic stools, and eventual painless jaundice. Found to have obstructive LFTS (AST 211, ALT 215, AP 741, TB 26.7) and subsequent US/CT showed moderate intrahepatic and extrahepatic biliary ductal dilatation to the level of the pancreatic head without overt mass seen (lack of IV contrast). US showed, "Moderate intrahepatic and extrahepatic biliary ductal dilatation to the level of the pancreatic head. The CBD measures 17 mm at the hilum. Limited evaluation of the pancreas does not demonstrate any pancreatic head mass. Cholelithiasis without evidence of acute cholecystitis. Borderline splenomegaly." Follow up CT showed, "Dilated intrahepatic and extrahepatic bile ducts. No obvious mass but evaluation is limited without contrast. Markedly dilated urinary bladder with mild left hydroureteronephrosis and distal right ureter dilatation possibly from obstructive uropathy. No calculus. There is an enlarged prostate gland with a suspected TURP defect." - [MASKED] ERCP for stent placement, brushings negative for malignancy. He was discharged on [MASKED]. - [MASKED] Seen by his PCP who arranged for EUS at [MASKED]. TB down to 3.8 at that point with improved symptoms. - [MASKED] EUS performed by Dr. [MASKED] showed, "No celiac adenopathy was seen. Reactive gastrohepatic ligament adenopathy seen. Two SB-IPMNs noted; one in the body and the larger one in the head. A solid mass was seen surrounding the distal CBD, measuring 1.2 cm. The CBD was dilated proximal to the mass up to 1.2 cm in size. A small, suspicious-appearing lymph node was seen around the distal CBD. FNA performed, prelim results show neoplastic [MASKED] final pathology positive for malignant cells, CONSISTENT WITH ADENOCARCINOMA. - [MASKED] Whipple resection revealed pancreatic adenocarcinoma pT3N1 with 1 of 14 nodes involved with carcinoma, LVI negative, extensive perineural invasion present, margins clear by 2 mm at the SMV. - [MASKED] Signed consent for APACT Trial [MASKED] [MASKED] - [MASKED] CT torso showed celiac adenopathy and a possible new liver met - [MASKED] MR liver showed likely liver met and adenopathy - [MASKED] Began discussion of HALO trial - [MASKED] FNA of the liver lesion via EUS showed metastatic adenocarcinoma - [MASKED] Signed consent for HALO, randomized to control arm - [MASKED] C1D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - [MASKED] C2D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - [MASKED] CT torso showed response to therapy - [MASKED] C3D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - [MASKED] C4D1 gemcitabine 1000 mg/m2 Abraxane 125 mg/m2 D1,8,15 - [MASKED] CT torso showed further reduction in liver mets, new pneumomitis - [MASKED] Holding chemo for pneumonitis. Start steroids. Off study [MASKED] [MASKED] control arm of the HALO trial. - [MASKED] Much improved on steroids. - [MASKED] CT torso showed progression of liver mets and development of numerous new liver mets as well as progression of portal adenopathy. - [MASKED] C1D1 FOLFOX6 - [MASKED] C2D1 FOLFOX6 - [MASKED] CT torso showed progression of known disease and some increased pulmonary nodules. Rising tumor markers. - [MASKED] C3D1 FOLFOX6 - [MASKED] C3D15 dose of FOLFOX held for admission to OSH for MI - [MASKED] CT torso showed stable lung nodules and enlargement of multiple hepatic metastatic lesions and the local recurrence in the tumor bed. - PLANNED [MASKED] Resume chemotherapy with C4D1 FOLFOX6 PAST MEDICAL HISTORY: - Metastatic Pancreatic Cancer - CAD s/p PCI ([MASKED]) - pAFib [MASKED], converted to sinus spontaneously) - HTN - HLD - Obstructive Uropathy with BPH - followed by Dr. [MASKED] [MASKED] - [MASKED] (baseline Cr 1.5) - Agent Orange exposure during [MASKED] - Biceps tendon rupture - Cataracts PSH: - Whipple ([MASKED]) - TURP - Left inguinal hernia repair ([MASKED]) - Cholecystectomy - Bicept tendon repair - b/l cataract surgery Social History: [MASKED] Family History: 1. Mother died of a ruptured abdominal aortic aneurysm. 2. Father was healthy until his [MASKED]. 3. Son died young of coronary artery disease. 4. No family history of malignancies that he is aware of. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 98 [MASKED] 18 98% RA GENERAL: NAD HEENT: NCAT, PERRLA, MMM CARDIAC: RRR, nl s1/s2, no murmurs, rubs, gallops LUNG: CTAB, no wheezes ABD: Prior abdominal scar. +BS. Nontender, nondistended EXT: No edema, 2+ pulses, warm NEURO: CNII-XII intact, sensation and strength grossly intact SKIN: Right shoulder with petichiae and excoriation ACCESS: Left chest wall port c/d/i Pertinent Results: ADMISSION [MASKED] 10:05PM BLOOD WBC-5.1 RBC-2.86* Hgb-8.9* Hct-27.6* MCV-97 MCH-31.1 MCHC-32.2 RDW-15.9* RDWSD-56.4* Plt Ct-86* [MASKED] 10:05PM BLOOD [MASKED] PTT-35.0 [MASKED] [MASKED] 10:05PM BLOOD Glucose-97 UreaN-10 Creat-1.1 Na-135 K-4.3 Cl-110* HCO3-19* AnGap-10 [MASKED] 10:05PM BLOOD ALT-15 AST-25 LD([MASKED])-272* AlkPhos-121 TotBili-0.3 [MASKED] 10:05PM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.0* Mg-2.0 Renal Ultrasound Mild dilatation of the right renal collecting system. There is no left hydronephrosis. E. coli: pansensitive DC LABS: [MASKED] 06:35AM BLOOD WBC-6.6 RBC-3.14* Hgb-9.5* Hct-29.7* MCV-95 MCH-30.3 MCHC-32.0 RDW-15.9* RDWSD-54.8* Plt [MASKED] [MASKED] 06:35AM BLOOD Glucose-84 UreaN-6 Creat-1.0 Na-139 K-3.6 Cl-109* HCO3-20* AnGap-14 [MASKED] 07:34AM BLOOD ALT-16 AST-24 LD(LDH)-281* AlkPhos-130 TotBili-0.4 [MASKED] 06:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2 [MASKED] 10:39PM BLOOD Lactate-1.2 Brief Hospital Course: This is a [MASKED] year old male with past medical history CAD, metastatic pancreatic cancer on FOLFOX (C4D25), admitted to [MASKED] [MASKED] [MASKED] with reported diarrhea and emesis, course notable for GNR bacteremia and urinary retention s/p broadspectrum antibiotics and foley, transferred to [MASKED] for further management # Ecoli blood stream infection/septicemia - patient presented to OSH with nausea and vomiting; admission blood cultures returned positive for Ecoli; Unclear source, as UA at OSH was negative for nitr and leuk esterase, and had not been sent for culture. Patient initially treated with vancomycin/cefepime, narrowed to IV CTX cultures returned with pan-sensitive Ecoli. Additional workup up notable for no clear abscess or source, but since he had severe urinary retention, a urinary source was favored. He improved clinically and is discharged to complete a 14 day course of Ceftriaxone 2g IV q24, through [MASKED]. # Urinary Retention/Bilateral Hydronephrosis - seen on CT scan at [MASKED] prompting foley placement; patient reported prior history of bladder obstruction requiring prior foley; UA not convincing for infection. Repeat ultrasound showed resolving hydronephrosis. Patient started on Flomax. After discussion with the patient, [MASKED] was kept in placed and he was discharged with Foley. Recommend consideration of voiding trial in [MASKED] days, and he should follow up with a urologist in 2 weeks. Continue Flomax. # Pancreatic cancer: Per OSH CT scan, disease looks to be worsening. Primary oncologist [MASKED] informed. Follow up for [MASKED] is arranged to consider further options. # Diarrhea - while at OSH, there had been concern for acute diarrhea, on additional history with patient, he clarified that diarrhea had been chronic ongoing since initiation of FOLFOX several months ago; infectious workup at OSH was negative, and stooling remained constant [MASKED] per day. C. diff negative # CAD - continued statin # Depression - continued citalopram # GERD - continued PPI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Gabapentin 400 mg PO BID:PRN shingles 3. LOPERamide [MASKED] mg PO QID:PRN diarreha 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. lidocaine HCl 3 % topical TID:PRN pain 7. Enoxaparin Sodium 120 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 8. Atorvastatin 40 mg PO QPM 9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 10. Omeprazole 40 mg PO DAILY 11. Citalopram 20 mg PO DAILY 12. Pyridoxine Dose is Unknown PO DAILY Discharge Medications: 1. Atorvastatin 40 mg PO QPM 2. Citalopram 20 mg PO DAILY 3. Enoxaparin Sodium 120 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time 4. Gabapentin 400 mg PO BID:PRN shingles 5. Lidocaine 5% Patch 1 PTCH TD QAM 6. LOPERamide [MASKED] mg PO QID:PRN diarreha 7. Omeprazole 40 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 10. lidocaine HCl 3 % topical TID:PRN pain 11. Prochlorperazine 10 mg PO Q6H:PRN nausea 12. CeftriaXONE 2 gm IV Q 24H ay 1 = [MASKED]. complete through [MASKED] 13. Sarna Lotion 1 Appl TP TID:PRN pruritis 14. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: E. coli blood stream infection Urinary retention Pancreatic cancer Native CAD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with infection in your blood. This was likely caused by a urinary source. You will need to complete a course of IV Ceftriaxone through [MASKED]. A Foley catheter was placed for severe urinary retention. This should stay in place and follow up with Urology in 2 weeks is recommended Followup Instructions: [MASKED]	[]	[ "E872", "I480", "E871", "I129", "N189", "I2510", "E785", "Z87891", "F329", "K219" ]	[ "A4151: Sepsis due to Escherichia coli [E. coli]", "E872: Acidosis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C250: Malignant neoplasm of head of pancreas", "N1330: Unspecified hydronephrosis", "I480: Paroxysmal atrial fibrillation", "D6959: Other secondary thrombocytopenia", "E871: Hypo-osmolality and hyponatremia", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z9861: Coronary angioplasty status", "R338: Other retention of urine", "K529: Noninfective gastroenteritis and colitis, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "H269: Unspecified cataract", "Z87891: Personal history of nicotine dependence", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]
19,978,265	23,713,862	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: Open reduction internal fixation of left mandibular angle fracture and extraction of multiple teeth, 15, 16, 18, 5, 30, 29, and 31. History of Present Illness: ___ PMHx for alcoholism, heroin use who presents to the ED s/p fall with displaced left mandibular fracture. Of note, patient states that she has a hx of alcohol use and was planning to check into an alcohol detoxification center in the near future. However, she had 4 pints of Whiskey and stumbled off the train, and fell on the ground landing on her left mandible. She did not have LOC, denies nausea/vomiting. Patient was brought into the ED by her BF and was evaluated by OMFS. Past Medical History: Alcohol use Hepatitis C Social History: ___ Family History: non-contributory Physical Exam: Admission Physical Exam: Vitals: Stable General: AAOx3, appears stressed and threatened to leave AMA HEENT: pupils equal and reactive, EOMI intact, no midface deformities, pain with biting down, swelling of left mandible. Cardiac: WNL Respiratory: Breathing comfortably on room air, right sided chest wall tenderness Abdomen: Soft, non-tender, no rebound or guarding, prior midline laparotomy scar Skin: Scar over right lip from bar fight last week, bruise over right eye brow, prior burn. Discharge Physical Exam: Gen: Alert, sitting up in bed. HEENT: bruising around left mandible, slightly swollen. trachea midline. neck supple. Cardiac: RRR Resp: Breath sounds clear to auscultation bilaterally Abd: Soft, non-tender, non-distended Ext: Warm and dry. 2+ ___ pulses. Neuro: A&Ox3. PERRL. Follows commands, moves all extremities equal and strong. Pertinent Results: ___ 09:00AM BLOOD WBC-11.0* RBC-3.61* Hgb-11.2 Hct-36.5 MCV-101* MCH-31.0 MCHC-30.7* RDW-17.1* RDWSD-62.9* Plt ___ ___ 11:16AM BLOOD WBC-9.3 RBC-3.16* Hgb-9.7* Hct-32.2* MCV-102* MCH-30.7 MCHC-30.1* RDW-15.8* RDWSD-59.2* Plt ___ ___ 12:36PM BLOOD WBC-11.9* RBC-3.00* Hgb-9.4* Hct-30.3* MCV-101* MCH-31.3 MCHC-31.0* RDW-16.1* RDWSD-59.7* Plt ___ ___ 04:10AM BLOOD WBC-10.0 RBC-3.24* Hgb-10.1* Hct-32.6* MCV-101* MCH-31.2 MCHC-31.0* RDW-15.9* RDWSD-58.4* Plt ___ ___ 09:00AM BLOOD Glucose-113* UreaN-6 Creat-0.6 Na-135 K-4.4 Cl-100 HCO3-26 AnGap-13 ___ 04:20AM BLOOD Glucose-100 UreaN-4* Creat-0.5 Na-131* K-4.2 Cl-98 HCO3-27 AnGap-10 ___ 11:16AM BLOOD Glucose-131* UreaN-2* Creat-0.5 Na-134 K-4.0 Cl-100 HCO3-24 AnGap-14 ___ 12:36PM BLOOD Glucose-102* UreaN-4* Creat-0.4 Na-136 K-3.6 Cl-100 HCO3-26 AnGap-14 ___ 04:10AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-144 K-3.6 Cl-107 HCO3-26 AnGap-15 ___ 09:00AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.8 ___ 04:20AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8 ___ 11:16AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.8 ___ 12:36PM BLOOD Calcium-7.6* Phos-3.1 Mg-1.2* ___ CT Sinus/Mandible 1. Mildly displaced left mandibular fracture. 2. Mild irregularity of the right nasal bone may indicate a fracture. 3. Multiple dental caries. Periapical lucencies right mandibular third molar. ___ CT Head 1. No acute intracranial process. 2. Mild irregularity of the right nasal bones may indicate a fracture. ___ CT C-Spine 1. Moderately limited by motion artifact. No convincing evidence for acute fracture. 2. Left mandibular fracture. ___ Lumbar Sacral Spine No fracture. ___ Chest PA/Lat No acute cardiopulmonary process. ___ CT Chest/Abdomen/Pelvis 1. No evidence of acute injury in the torso. No fractures. 2. Small filling defect in the right external iliac vein concerning for a small thrombus. 3. Status post cholecystectomy and splenectomy. 4. Hepatic steatosis. ___ Unilat lower extremity veins 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. 4.0 cm fluid collection in the right popliteal fossa, which does not definitely connect to the joint space. ___ Mandible series Left mandibular angle fracture. ___ MRV Pelvis Small nonocclusive, nonenhancing thrombus in the right external iliac vein, as seen previously. ___ Mandible Series In comparison with the study of ___, there is a fixation device about the distracted fracture in the region of the angle of the mandible on the left. ___ Unilat lower extremity vein No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: Ms. ___ is a ___ yo female admitted to the acute care trauma surgery service on ___own 4 stairs. Her past medical history is significant for alcoholism and heroin use. CT imaging showed a left mandibular fracture, a mildly displaced nasal bone, and a filling defect in the right external iliac vein. OMFS was consulted and recommended surgical repair. On ___ informed consent was obtained and she was taken to the OR for an open reduction internal fixation of left mandibular angle fracture and extraction of multiple teeth, 15, 16, 18, 5, 30, 29, and 31. She was extubated and taken to the PACU until stable then transferred to the floor for further management. On POD 1 her diet was advanced to full liquids which she tolerated well and her pain was controlled with PO pain medications. An MRV confirmed a small nonocclusive, nonenhancing thrombus in the right external iliac vein. On POD 2 vascular surgery was consulted for the thrombus and recommended lower extremity non-invasive studies which were negative for DVT. On POD 3 a heparin drip was started. On POD 4 coumadin therapy was initiated. Case management and social work were involved in the patients care plan throughout the hospitalization. Her discharge plan was complicated by her need for anticoagulation and limited insurance coverage in ___. Several options were discussed with the patient such as returning to ___ to be followed by her primary care provider. She did not want to do that at this time. The decision was made with the patient to start Xarelto therapy since she would not have frequent blood draws. She was given a 2 week supply of medication from the care plus pharmacy. She plans to go back to ___ to see her primary care provider and further discuss treatment within the month. Her primary care was made aware of the plan and agreed to assist her in obtaining continued therapy. The risks associated with her diagnosis of deep vein thrombosis and anticoagulation treatment were discussed and the patient verbalized agreement and understanding with the plan. Please see case management note for further details. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a full liquid diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged and reports having a safe place to stay. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Follow up appointments were made. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain Not to exceed 4,000 mg in 24 hours RX acetaminophen 325 mg ___ tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX chlorhexidine gluconate 0.12 % swish and spit twice a day Refills:0 3. Docusate Sodium 100 mg PO BID hold for diarrhea RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 4. Nicotine Patch 14 mg TD DAILY DO NOT smoke while wearing this patch. Only wear 1 patch at a time. RX nicotine 14 mg/24 hour apply to skin once a day Disp #14 Patch Refills:0 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 6. Rivaroxaban 15 mg PO BID Duration: 21 Days RX rivaroxaban [___] 15 mg 15 tablet(s) by mouth twice a day Disp #21 Tablet Refills:0 7. Rivaroxaban 20 mg PO DAILY DVT Duration: 10 Weeks Please start this dose/frequency after initial 21 days therapy (on ___. RX rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day Disp #7 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Right external iliac DVT Mildly displaced nasal bone Left angle mandible fracture and multiple retained roots. 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 ___own stairs. Imagining revealed that you fractured several bones in your face and jaw. The oral, maxillofacial surgery team was consulted and repaired these fractures in the operating room and removed 7 teeth. You were found to have a deep vein thrombosis (blood clot) in a vein near your right hip that is partially blocking blood flow. You are being treated for this with a blood thinning medication called Coumadin. It is very important that you take this medication as prescribed and have blood levels drawn as ordered by your doctor. You are now ready to be discharged from the hospital to continue your recovery. Please note the following discharge instructions. Wound care: Do not disturb or probe the surgical area with any objects. The sutures placed in your mouth are usually the type that self dissolve. If you have any sutures on the skin of your face or neck, your surgeon will remove them on the day of your first follow up appointment. SMOKING is detrimental to healing and will cause complications. Bleeding: Intermittent bleeding or oozing overnight is normal. Placing fresh gauze over the area and biting on the gauze for ___ minutes at a time may control the bleeding. If you had nasal surgery, you may have occasional slow oozing from your nostril for the first ___ days. Bleeding should never be severe. If bleeding persists or is severe or uncontrollable, please call our office immediately. If it is after normal business hours, please come to the emergency room and request that the oral surgery resident on call be paged. ___: Normal healing after oral surgery should be as follows: the first ___ days after surgery, are generally the most uncomfortable and there is usually significant swelling. After the first week, you should be more comfortable. The remainder of your postoperative course should be gradual, steady improvement. If you do not see continued improvement, please call our office. Physical activity: It is recommended that you not perform any strenuous physical activity for a few weeks after surgery. Do not lift any heavy loads and avoid physical sports unless you obtain permission from your surgeon. Swelling & Ice applications: Swelling is often associated with surgery. Swelling can be minimized by using a cold pack, ice bag or a bag of frozen peas wrapped in a towel, with firm application to face and neck areas. This should be applied 20 minutes on and 20 minutes off during the first ___ days after surgery. If you have been given medicine to control the swelling, be sure to take it as directed. Hot applications: Starting on the ___ or ___ day after surgery, you may apply warm compresses to the skin over the areas of swelling (hot water bottle wrapped in a towel, etc), for 20 minutes on and 20 min off to help soothe tender areas and help to decrease swelling and stiffness. Please use caution when applying ice or heat to your face as certain areas may feel numb after surgery and extremes of temperature may cause serious damage. Tooth brushing: Begin your normal oral hygiene the day after surgery. Soreness and swelling may nor permit vigorous brushing, but please make every effort to clean your teeth with the bounds of comfort. Any toothpaste is acceptable. Please remember that your gums may be numb after surgery. To avoid injury to the gums during brushing, use a child size toothbrush and brush in front of a mirror staying only on teeth. Mouth rinses: Keeping your mouth clean after surgery is essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass of warm water and gently rinse with portions of the solution, taking 5 min to use the entire glassful. Repeat as often as you like, but you should do this at least 4 times each day. If your surgeon has prescribed a specific rinse, use as directed. Showering: You may shower ___ days after surgery, but please ask your surgeon about this. If you have any incisions on the skin of your face or body, you should cover them with a water resistant dressing while showering. DO NOT SOAK SURGICAL SITES. This will avoid getting the area excessively wet. As you may physically feel weak after surgery, initially avoid extreme hot or cold showers, as these may cause some patients to pass out. Also it is a good idea to make sure someone is available to assist you in case if you may need help. Sleeping: Please keep your head elevated while sleeping. This will minimize swelling and discomfort and reduce pain while allowing you to breathe more easily. One or two pillows may be placed beneath your mattress at the head of the bed to prop the bed into a more vertical position. Pain: Most facial and jaw reconstructive surgery is accompanied by some degree of discomfort. You will usually have a prescription for pain medication. Some patients find that stronger pain medications cause nausea, but if you precede each pain pill with a small amount of food, chances of nausea will be reduced. The effects of pain medications vary widely among individuals. If you do not achieve adequate pain relief at first you may supplement each pain pill with an analgesic such as Tylenol or Motrin. If you find that you are taking large amounts of pain medications at frequent intervals, please call our office. If your jaws are wired shut with elastics, you may have been prescribed liquid pain medications. Please remember to rinse your mouth after taking liquid pain medications as they can stick to the braces and can cause gum disease and damage teeth. Diet: Unless otherwise instructed, only a cool, clear liquid diet is allowed for the first 24 hours after surgery. After 48 hours, you can increase to a full liquid diet, but please check with your doctor before doing this. Avoid extreme hot and cold. If your jaws are not wired shut, then after one week, you may be able to gradually progress to a soft diet, but ONLY if your surgeon instructs you to do so. It is important not to skip any meals. If you take nourishment regularly you will feel better, gain strength, have less discomfort and heal faster. Over the counter meal supplements are helpful to support nutritional needs in the first few days after surgery. A nutrition guidebook will be given to you before you are discharged from the hospital. Remember to rinse your mouth after any food intake, failure to do this may cause infections and gum disease and possible loss of teeth. Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes pain medications are the cause. Precede each pill with a small amount of soft food. Taking pain pills with a large glass of water can also reduce nausea. Try taking clear fluids and minimizing taking pain medications, but call us if you do not feel better. If your jaws are wired shut with elastics and you experience nausea/vomiting, try tilting your head and neck to one side. This will allow the vomitus to drain out of your mouth. If you feel that you cannot safely expel the vomitus in this manner, you can cut elastics/wires and open your mouth. Inform our office immediately if you elect to do this. If it is after normal business hours, please come to the emergency room at once, and have the oral surgery on call resident paged. ___: Depending on the type of surgery, you may have elastics and/or wires placed on your braces. Before discharge from the hospital, the doctor ___ instruct you regarding these wires/elastics. If for any reason, the elastics or wires break, or if you feel your bite is shifting, please call our office. Medications: You will be given prescriptions, some of which may include antibiotics, oral rinses, decongestants, nasal sprays and pain medications. Use them as directed. A daily multivitamin pill for ___ weeks after surgery is recommended but not essential. If you have any questions about your progress, please call our office at ___. Followup Instructions: ___	[ "S0265XA", "I82421", "S022XXA", "V814XXA", "Y92522", "F1020", "B1920", "F1190", "F17210", "Z96642", "Z590", "S01511A", "K029" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fall Major Surgical or Invasive Procedure: Open reduction internal fixation of left mandibular angle fracture and extraction of multiple teeth, 15, 16, 18, 5, 30, 29, and 31. History of Present Illness: [MASKED] PMHx for alcoholism, heroin use who presents to the ED s/p fall with displaced left mandibular fracture. Of note, patient states that she has a hx of alcohol use and was planning to check into an alcohol detoxification center in the near future. However, she had 4 pints of Whiskey and stumbled off the train, and fell on the ground landing on her left mandible. She did not have LOC, denies nausea/vomiting. Patient was brought into the ED by her BF and was evaluated by OMFS. Past Medical History: Alcohol use Hepatitis C Social History: [MASKED] Family History: non-contributory Physical Exam: Admission Physical Exam: Vitals: Stable General: AAOx3, appears stressed and threatened to leave AMA HEENT: pupils equal and reactive, EOMI intact, no midface deformities, pain with biting down, swelling of left mandible. Cardiac: WNL Respiratory: Breathing comfortably on room air, right sided chest wall tenderness Abdomen: Soft, non-tender, no rebound or guarding, prior midline laparotomy scar Skin: Scar over right lip from bar fight last week, bruise over right eye brow, prior burn. Discharge Physical Exam: Gen: Alert, sitting up in bed. HEENT: bruising around left mandible, slightly swollen. trachea midline. neck supple. Cardiac: RRR Resp: Breath sounds clear to auscultation bilaterally Abd: Soft, non-tender, non-distended Ext: Warm and dry. 2+ [MASKED] pulses. Neuro: A&Ox3. PERRL. Follows commands, moves all extremities equal and strong. Pertinent Results: [MASKED] 09:00AM BLOOD WBC-11.0* RBC-3.61* Hgb-11.2 Hct-36.5 MCV-101* MCH-31.0 MCHC-30.7* RDW-17.1* RDWSD-62.9* Plt [MASKED] [MASKED] 11:16AM BLOOD WBC-9.3 RBC-3.16* Hgb-9.7* Hct-32.2* MCV-102* MCH-30.7 MCHC-30.1* RDW-15.8* RDWSD-59.2* Plt [MASKED] [MASKED] 12:36PM BLOOD WBC-11.9* RBC-3.00* Hgb-9.4* Hct-30.3* MCV-101* MCH-31.3 MCHC-31.0* RDW-16.1* RDWSD-59.7* Plt [MASKED] [MASKED] 04:10AM BLOOD WBC-10.0 RBC-3.24* Hgb-10.1* Hct-32.6* MCV-101* MCH-31.2 MCHC-31.0* RDW-15.9* RDWSD-58.4* Plt [MASKED] [MASKED] 09:00AM BLOOD Glucose-113* UreaN-6 Creat-0.6 Na-135 K-4.4 Cl-100 HCO3-26 AnGap-13 [MASKED] 04:20AM BLOOD Glucose-100 UreaN-4* Creat-0.5 Na-131* K-4.2 Cl-98 HCO3-27 AnGap-10 [MASKED] 11:16AM BLOOD Glucose-131* UreaN-2* Creat-0.5 Na-134 K-4.0 Cl-100 HCO3-24 AnGap-14 [MASKED] 12:36PM BLOOD Glucose-102* UreaN-4* Creat-0.4 Na-136 K-3.6 Cl-100 HCO3-26 AnGap-14 [MASKED] 04:10AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-144 K-3.6 Cl-107 HCO3-26 AnGap-15 [MASKED] 09:00AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.8 [MASKED] 04:20AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8 [MASKED] 11:16AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.8 [MASKED] 12:36PM BLOOD Calcium-7.6* Phos-3.1 Mg-1.2* [MASKED] CT Sinus/Mandible 1. Mildly displaced left mandibular fracture. 2. Mild irregularity of the right nasal bone may indicate a fracture. 3. Multiple dental caries. Periapical lucencies right mandibular third molar. [MASKED] CT Head 1. No acute intracranial process. 2. Mild irregularity of the right nasal bones may indicate a fracture. [MASKED] CT C-Spine 1. Moderately limited by motion artifact. No convincing evidence for acute fracture. 2. Left mandibular fracture. [MASKED] Lumbar Sacral Spine No fracture. [MASKED] Chest PA/Lat No acute cardiopulmonary process. [MASKED] CT Chest/Abdomen/Pelvis 1. No evidence of acute injury in the torso. No fractures. 2. Small filling defect in the right external iliac vein concerning for a small thrombus. 3. Status post cholecystectomy and splenectomy. 4. Hepatic steatosis. [MASKED] Unilat lower extremity veins 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. 4.0 cm fluid collection in the right popliteal fossa, which does not definitely connect to the joint space. [MASKED] Mandible series Left mandibular angle fracture. [MASKED] MRV Pelvis Small nonocclusive, nonenhancing thrombus in the right external iliac vein, as seen previously. [MASKED] Mandible Series In comparison with the study of [MASKED], there is a fixation device about the distracted fracture in the region of the angle of the mandible on the left. [MASKED] Unilat lower extremity vein No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: Ms. [MASKED] is a [MASKED] yo female admitted to the acute care trauma surgery service on own 4 stairs. Her past medical history is significant for alcoholism and heroin use. CT imaging showed a left mandibular fracture, a mildly displaced nasal bone, and a filling defect in the right external iliac vein. OMFS was consulted and recommended surgical repair. On [MASKED] informed consent was obtained and she was taken to the OR for an open reduction internal fixation of left mandibular angle fracture and extraction of multiple teeth, 15, 16, 18, 5, 30, 29, and 31. She was extubated and taken to the PACU until stable then transferred to the floor for further management. On POD 1 her diet was advanced to full liquids which she tolerated well and her pain was controlled with PO pain medications. An MRV confirmed a small nonocclusive, nonenhancing thrombus in the right external iliac vein. On POD 2 vascular surgery was consulted for the thrombus and recommended lower extremity non-invasive studies which were negative for DVT. On POD 3 a heparin drip was started. On POD 4 coumadin therapy was initiated. Case management and social work were involved in the patients care plan throughout the hospitalization. Her discharge plan was complicated by her need for anticoagulation and limited insurance coverage in [MASKED]. Several options were discussed with the patient such as returning to [MASKED] to be followed by her primary care provider. She did not want to do that at this time. The decision was made with the patient to start Xarelto therapy since she would not have frequent blood draws. She was given a 2 week supply of medication from the care plus pharmacy. She plans to go back to [MASKED] to see her primary care provider and further discuss treatment within the month. Her primary care was made aware of the plan and agreed to assist her in obtaining continued therapy. The risks associated with her diagnosis of deep vein thrombosis and anticoagulation treatment were discussed and the patient verbalized agreement and understanding with the plan. Please see case management note for further details. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a full liquid diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged and reports having a safe place to stay. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Follow up appointments were made. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain Not to exceed 4,000 mg in 24 hours RX acetaminophen 325 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID RX chlorhexidine gluconate 0.12 % swish and spit twice a day Refills:0 3. Docusate Sodium 100 mg PO BID hold for diarrhea RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 4. Nicotine Patch 14 mg TD DAILY DO NOT smoke while wearing this patch. Only wear 1 patch at a time. RX nicotine 14 mg/24 hour apply to skin once a day Disp #14 Patch Refills:0 5. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #40 Tablet Refills:0 6. Rivaroxaban 15 mg PO BID Duration: 21 Days RX rivaroxaban [[MASKED]] 15 mg 15 tablet(s) by mouth twice a day Disp #21 Tablet Refills:0 7. Rivaroxaban 20 mg PO DAILY DVT Duration: 10 Weeks Please start this dose/frequency after initial 21 days therapy (on [MASKED]. RX rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day Disp #7 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Right external iliac DVT Mildly displaced nasal bone Left angle mandible fracture and multiple retained roots. 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 own stairs. Imagining revealed that you fractured several bones in your face and jaw. The oral, maxillofacial surgery team was consulted and repaired these fractures in the operating room and removed 7 teeth. You were found to have a deep vein thrombosis (blood clot) in a vein near your right hip that is partially blocking blood flow. You are being treated for this with a blood thinning medication called Coumadin. It is very important that you take this medication as prescribed and have blood levels drawn as ordered by your doctor. You are now ready to be discharged from the hospital to continue your recovery. Please note the following discharge instructions. Wound care: Do not disturb or probe the surgical area with any objects. The sutures placed in your mouth are usually the type that self dissolve. If you have any sutures on the skin of your face or neck, your surgeon will remove them on the day of your first follow up appointment. SMOKING is detrimental to healing and will cause complications. Bleeding: Intermittent bleeding or oozing overnight is normal. Placing fresh gauze over the area and biting on the gauze for [MASKED] minutes at a time may control the bleeding. If you had nasal surgery, you may have occasional slow oozing from your nostril for the first [MASKED] days. Bleeding should never be severe. If bleeding persists or is severe or uncontrollable, please call our office immediately. If it is after normal business hours, please come to the emergency room and request that the oral surgery resident on call be paged. [MASKED]: Normal healing after oral surgery should be as follows: the first [MASKED] days after surgery, are generally the most uncomfortable and there is usually significant swelling. After the first week, you should be more comfortable. The remainder of your postoperative course should be gradual, steady improvement. If you do not see continued improvement, please call our office. Physical activity: It is recommended that you not perform any strenuous physical activity for a few weeks after surgery. Do not lift any heavy loads and avoid physical sports unless you obtain permission from your surgeon. Swelling & Ice applications: Swelling is often associated with surgery. Swelling can be minimized by using a cold pack, ice bag or a bag of frozen peas wrapped in a towel, with firm application to face and neck areas. This should be applied 20 minutes on and 20 minutes off during the first [MASKED] days after surgery. If you have been given medicine to control the swelling, be sure to take it as directed. Hot applications: Starting on the [MASKED] or [MASKED] day after surgery, you may apply warm compresses to the skin over the areas of swelling (hot water bottle wrapped in a towel, etc), for 20 minutes on and 20 min off to help soothe tender areas and help to decrease swelling and stiffness. Please use caution when applying ice or heat to your face as certain areas may feel numb after surgery and extremes of temperature may cause serious damage. Tooth brushing: Begin your normal oral hygiene the day after surgery. Soreness and swelling may nor permit vigorous brushing, but please make every effort to clean your teeth with the bounds of comfort. Any toothpaste is acceptable. Please remember that your gums may be numb after surgery. To avoid injury to the gums during brushing, use a child size toothbrush and brush in front of a mirror staying only on teeth. Mouth rinses: Keeping your mouth clean after surgery is essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass of warm water and gently rinse with portions of the solution, taking 5 min to use the entire glassful. Repeat as often as you like, but you should do this at least 4 times each day. If your surgeon has prescribed a specific rinse, use as directed. Showering: You may shower [MASKED] days after surgery, but please ask your surgeon about this. If you have any incisions on the skin of your face or body, you should cover them with a water resistant dressing while showering. DO NOT SOAK SURGICAL SITES. This will avoid getting the area excessively wet. As you may physically feel weak after surgery, initially avoid extreme hot or cold showers, as these may cause some patients to pass out. Also it is a good idea to make sure someone is available to assist you in case if you may need help. Sleeping: Please keep your head elevated while sleeping. This will minimize swelling and discomfort and reduce pain while allowing you to breathe more easily. One or two pillows may be placed beneath your mattress at the head of the bed to prop the bed into a more vertical position. Pain: Most facial and jaw reconstructive surgery is accompanied by some degree of discomfort. You will usually have a prescription for pain medication. Some patients find that stronger pain medications cause nausea, but if you precede each pain pill with a small amount of food, chances of nausea will be reduced. The effects of pain medications vary widely among individuals. If you do not achieve adequate pain relief at first you may supplement each pain pill with an analgesic such as Tylenol or Motrin. If you find that you are taking large amounts of pain medications at frequent intervals, please call our office. If your jaws are wired shut with elastics, you may have been prescribed liquid pain medications. Please remember to rinse your mouth after taking liquid pain medications as they can stick to the braces and can cause gum disease and damage teeth. Diet: Unless otherwise instructed, only a cool, clear liquid diet is allowed for the first 24 hours after surgery. After 48 hours, you can increase to a full liquid diet, but please check with your doctor before doing this. Avoid extreme hot and cold. If your jaws are not wired shut, then after one week, you may be able to gradually progress to a soft diet, but ONLY if your surgeon instructs you to do so. It is important not to skip any meals. If you take nourishment regularly you will feel better, gain strength, have less discomfort and heal faster. Over the counter meal supplements are helpful to support nutritional needs in the first few days after surgery. A nutrition guidebook will be given to you before you are discharged from the hospital. Remember to rinse your mouth after any food intake, failure to do this may cause infections and gum disease and possible loss of teeth. Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes pain medications are the cause. Precede each pill with a small amount of soft food. Taking pain pills with a large glass of water can also reduce nausea. Try taking clear fluids and minimizing taking pain medications, but call us if you do not feel better. If your jaws are wired shut with elastics and you experience nausea/vomiting, try tilting your head and neck to one side. This will allow the vomitus to drain out of your mouth. If you feel that you cannot safely expel the vomitus in this manner, you can cut elastics/wires and open your mouth. Inform our office immediately if you elect to do this. If it is after normal business hours, please come to the emergency room at once, and have the oral surgery on call resident paged. [MASKED]: Depending on the type of surgery, you may have elastics and/or wires placed on your braces. Before discharge from the hospital, the doctor [MASKED] instruct you regarding these wires/elastics. If for any reason, the elastics or wires break, or if you feel your bite is shifting, please call our office. Medications: You will be given prescriptions, some of which may include antibiotics, oral rinses, decongestants, nasal sprays and pain medications. Use them as directed. A daily multivitamin pill for [MASKED] weeks after surgery is recommended but not essential. If you have any questions about your progress, please call our office at [MASKED]. Followup Instructions: [MASKED]	[]	[ "F17210" ]	[ "S0265XA: Fracture of angle of mandible", "I82421: Acute embolism and thrombosis of right iliac vein", "S022XXA: Fracture of nasal bones, initial encounter for closed fracture", "V814XXA: Person injured while boarding or alighting from railway train or railway vehicle, initial encounter", "Y92522: Railway station as the place of occurrence of the external cause", "F1020: Alcohol dependence, uncomplicated", "B1920: Unspecified viral hepatitis C without hepatic coma", "F1190: Opioid use, unspecified, uncomplicated", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z96642: Presence of left artificial hip joint", "Z590: Homelessness", "S01511A: Laceration without foreign body of lip, initial encounter", "K029: Dental caries, unspecified" ]
19,978,454	22,070,393	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 TACE Major Surgical or Invasive Procedure: transcatheter arterial chemoembolization ___ History of Present Illness: Ms. ___ is a ___ year old woman with history of HCV cirrhosis, decompensated by esophageal varices and hepatic encephalopathy, who was recently found to have HCC and undergoing local ablative therapy admitted s/p TACE. She has hepatic lesions in segments VI (1.4cm), III (1.4cm), and VII (8mm) seen on MRI liver in ___. She underwent RFA of segment VI lesion on ___. During the procedure, an attempt to ablate a segment III lesion was aborted, as the lesion was too close to the stomach. The patient underwent scheduled TACE on ___ to abate segment III lesion. Procedure was successful. Access was obtained through R femoral approach; ablation was uncomplicated. Patient experienced nausea during the procedure, for which she received ondansetron to good effect. She also received 0.25 mg dilaudid iv for pain, also to good effect. On arrival to floor, patient is tired and reports soreness in groin site. She denies any lightheadedness, nausea, vomiting, fevers, chills, chest pain, palpitations, SOB, abdominal pain at rest. Past Medical History: - HCV cirrhosis, now with sustained HCV response following antiviral treatment. Cirrhosis complicated by ascites and hepatic encephalopathy - HCC (on biopsy ___ - Rheumatoid arthritis. Seropositive (RF and CCP) per ___ notes. On hydroxychloroquine for ___ years - Iron deficiency anemia - Anxiety - Diverticulitis Social History: ___ Family History: Father with some type of smoking related lung disease. Brother died of melanoma. No family history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VS: 98.1 PO 111 / 51 104 16 98 RA Gen: AAOx3, NAD, tired-appearing HEENT: NC/AT, MMM, PERRL, EOMI CV: RRR, ___ murmur, no gallops, rubs Pulm: CTAB, no wheezes/rales/rhonchi Abd: epig pain pain palpation, otherwise soft, nontympanitic, nonperitonitic, +BS GU: no foley Ext: pain over R femoral groin site but site c/d/I w/o bruit, hematoma. Skin: no rash Neuro: grossly intact. Very mild asterixis DISCHARGE PHYSICAL EXAM: ========================= VS: 99.1 PO 100/62 97 18 94 RA Gen: AAOx3, NAD, pleasant and appropriate HEENT: NC/AT, MMM CV: RRR, ___ systolic murmur, no gallops, rubs Pulm: CTAB, no wheezes/rales/rhonchi Abd: soft, nontender, nontympanitic, nonperitonitic, +BS GU: no foley Ext: pain over R femoral groin site but site c/d/I w/o bruit, hematoma. Distal pulses 2+, RLE w/o c/c/e Skin: no rash Neuro: grossly intact. Very mild asterixis Pertinent Results: ADMISSION LABS: =============== ___ 11:00AM WBC-3.5* RBC-3.96 HGB-10.3* HCT-34.7 MCV-88 MCH-26.0 MCHC-29.7* RDW-17.9* RDWSD-57.1* ___ 11:00AM AFP-5.5 ___ 11:00AM PLT COUNT-63* ___ 11:00AM calTIBC-413 FERRITIN-21 TRF-318 ___ 11:00AM IRON-38 ___ 07:40AM ___ ___ 07:40AM ALT(SGPT)-11 AST(SGOT)-27 ALK PHOS-104 TOT BILI-1.1 ___ 07:40AM AFP-6.1 STUDIES: ======== Chemoembolization ___: FINDINGS: 1. Conventional hepatic arterial anatomy. 2. Pre-embolization arteriogram of a third order branch arising from the left hepatic artery showing tumor blush in segment 3 of the left hepatic lobe. 3. Cone-beam CT showing known segment 3 left hepatic lesion supplied by branches arising from a third order branch of the left hepatic artery. 4. Post-embolization showing staining of tumor in segment 3, as expected based on cross-sectional imaging. IMPRESSION: Successful right common femoral artery approach trans-arterial chemoembolization of known segment 3 lesion. RECOMMENDATION(S): Non contrast CT to be obtained the next day. CT A/P ___: IMPRESSION: Expected high-density material in the left lobe of the liver, consistent with recent chemoembolization. No non targeted embolization identified. MICRO: ====== NONE DISCHARGE LABS: =============== ___ 05:30AM BLOOD WBC-4.9 RBC-3.29* Hgb-8.8* Hct-28.8* MCV-88 MCH-26.7 MCHC-30.6* RDW-17.2* RDWSD-55.1* Plt Ct-47* ___ 05:30AM BLOOD Glucose-76 UreaN-6 Creat-0.8 Na-144 K-4.0 Cl-110* HCO___-22 AnGap-___ with history of HCV cirrhosis decompensated by esophageal varices and encephalopathy, biopsy proven HCC, s/p TACE (___) admitted for monitoring. Patient tolerated the procedure well, without complications. CT abdomen ___ revealed expected high-density material in the left lobe of the liver, consistent with recent chemoembolization. No non targeted embolization identified. Patient had transient nausea during the procedure and some abdominal discomfort that resolved by the morning. She also reported soreness in the R groin at the access site which improved overnight. No bruit, bleeding or hematoma were noted. Patient was continued on her home medications for her other chronic conditions. TRANSITIONAL ISSUES: ===================== [ ] No medication changes. New medication: - oxycodone 5 mg to use only if Tylenol is not helping [ ] Follow up with Interventional radiology at 1 pm on ___. [ ] Pt to come to ___ building on the ___ on the ___ floor to have labs drawn on ___. # CODE: FULL (confirmed) # CONTACT: Husband ___, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion XL (Once Daily) 150 mg PO DAILY 2. TraZODone ___ mg PO QHS:PRN sleep 3. LORazepam 0.5 mg PO Q8H:PRN anxiety 4. Omeprazole 20 mg PO DAILY 5. Lactulose 15 mL PO BID 6. Rifaximin 550 mg PO BID 7. PredniSONE 10 mg PO PRN severe increased cough 8. Loratadine 10 mg PO DAILY:PRN allergy Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild DO NOT EXCEED 2 GRAMS/DAY RX acetaminophen 325 mg 2 tablet(s) by mouth every 8 hours as needed Disp #60 Tablet Refills:0 2. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Severe Duration: 6 Days take only as needed if Tylenol not sufficient RX oxycodone 5 mg 1 tablet(s) by mouth daily as needed Disp #6 Tablet Refills:0 3. BuPROPion XL (Once Daily) 150 mg PO DAILY 4. Lactulose 15 mL PO BID 5. Loratadine 10 mg PO DAILY:PRN allergy 6. LORazepam 0.5 mg PO Q8H:PRN anxiety 7. Omeprazole 20 mg PO DAILY 8. PredniSONE 10 mg PO PRN severe increased cough 9. Rifaximin 550 mg PO BID 10. TraZODone ___ mg PO QHS:PRN sleep Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Hepatocellular carcinoma status post transcatheter arterial chemoembolization (TACE) SECONDARY DIAGNOSES Hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, It was a pleasure taking care of you during your hospitalization at ___! Why were you hospitalized? -Because you had an elective procedure called 'transcatheter arterial chemoembolization' or 'TACE' performed by the interventional radiologists (___) and you needed monitoring after the procedure What was done for you this hospitalization? -You had successful ___ intervention, confirmed by a CT scan the next day -Your pain was controlled -We monitored you for bleeding and other side effects from the procedure, but did not see any. What should you do after you leave the hospital? -Continue to monitor for any new symptoms such as bleeding or swelling at the groin site, right upper quadrant pain. -Take Tylenol ___ mg up to three times a day as needed for pain. You will also have a small amount of oxycodone to help you with the pain when Tylenol is not enough. -You should come to the ___ building to get labs drawn on ___ so the results are ready for your follow up appointment. -You have a follow up appointment with ___ on ___. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "Z5111", "C228", "K7469", "B1920", "M069", "D509", "F419", "G4700", "Z87891", "Z808" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: s/p TACE Major Surgical or Invasive Procedure: transcatheter arterial chemoembolization [MASKED] History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with history of HCV cirrhosis, decompensated by esophageal varices and hepatic encephalopathy, who was recently found to have HCC and undergoing local ablative therapy admitted s/p TACE. She has hepatic lesions in segments VI (1.4cm), III (1.4cm), and VII (8mm) seen on MRI liver in [MASKED]. She underwent RFA of segment VI lesion on [MASKED]. During the procedure, an attempt to ablate a segment III lesion was aborted, as the lesion was too close to the stomach. The patient underwent scheduled TACE on [MASKED] to abate segment III lesion. Procedure was successful. Access was obtained through R femoral approach; ablation was uncomplicated. Patient experienced nausea during the procedure, for which she received ondansetron to good effect. She also received 0.25 mg dilaudid iv for pain, also to good effect. On arrival to floor, patient is tired and reports soreness in groin site. She denies any lightheadedness, nausea, vomiting, fevers, chills, chest pain, palpitations, SOB, abdominal pain at rest. Past Medical History: - HCV cirrhosis, now with sustained HCV response following antiviral treatment. Cirrhosis complicated by ascites and hepatic encephalopathy - HCC (on biopsy [MASKED] - Rheumatoid arthritis. Seropositive (RF and CCP) per [MASKED] notes. On hydroxychloroquine for [MASKED] years - Iron deficiency anemia - Anxiety - Diverticulitis Social History: [MASKED] Family History: Father with some type of smoking related lung disease. Brother died of melanoma. No family history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VS: 98.1 PO 111 / 51 104 16 98 RA Gen: AAOx3, NAD, tired-appearing HEENT: NC/AT, MMM, PERRL, EOMI CV: RRR, [MASKED] murmur, no gallops, rubs Pulm: CTAB, no wheezes/rales/rhonchi Abd: epig pain pain palpation, otherwise soft, nontympanitic, nonperitonitic, +BS GU: no foley Ext: pain over R femoral groin site but site c/d/I w/o bruit, hematoma. Skin: no rash Neuro: grossly intact. Very mild asterixis DISCHARGE PHYSICAL EXAM: ========================= VS: 99.1 PO 100/62 97 18 94 RA Gen: AAOx3, NAD, pleasant and appropriate HEENT: NC/AT, MMM CV: RRR, [MASKED] systolic murmur, no gallops, rubs Pulm: CTAB, no wheezes/rales/rhonchi Abd: soft, nontender, nontympanitic, nonperitonitic, +BS GU: no foley Ext: pain over R femoral groin site but site c/d/I w/o bruit, hematoma. Distal pulses 2+, RLE w/o c/c/e Skin: no rash Neuro: grossly intact. Very mild asterixis Pertinent Results: ADMISSION LABS: =============== [MASKED] 11:00AM WBC-3.5* RBC-3.96 HGB-10.3* HCT-34.7 MCV-88 MCH-26.0 MCHC-29.7* RDW-17.9* RDWSD-57.1* [MASKED] 11:00AM AFP-5.5 [MASKED] 11:00AM PLT COUNT-63* [MASKED] 11:00AM calTIBC-413 FERRITIN-21 TRF-318 [MASKED] 11:00AM IRON-38 [MASKED] 07:40AM [MASKED] [MASKED] 07:40AM ALT(SGPT)-11 AST(SGOT)-27 ALK PHOS-104 TOT BILI-1.1 [MASKED] 07:40AM AFP-6.1 STUDIES: ======== Chemoembolization [MASKED]: FINDINGS: 1. Conventional hepatic arterial anatomy. 2. Pre-embolization arteriogram of a third order branch arising from the left hepatic artery showing tumor blush in segment 3 of the left hepatic lobe. 3. Cone-beam CT showing known segment 3 left hepatic lesion supplied by branches arising from a third order branch of the left hepatic artery. 4. Post-embolization showing staining of tumor in segment 3, as expected based on cross-sectional imaging. IMPRESSION: Successful right common femoral artery approach trans-arterial chemoembolization of known segment 3 lesion. RECOMMENDATION(S): Non contrast CT to be obtained the next day. CT A/P [MASKED]: IMPRESSION: Expected high-density material in the left lobe of the liver, consistent with recent chemoembolization. No non targeted embolization identified. MICRO: ====== NONE DISCHARGE LABS: =============== [MASKED] 05:30AM BLOOD WBC-4.9 RBC-3.29* Hgb-8.8* Hct-28.8* MCV-88 MCH-26.7 MCHC-30.6* RDW-17.2* RDWSD-55.1* Plt Ct-47* [MASKED] 05:30AM BLOOD Glucose-76 UreaN-6 Creat-0.8 Na-144 K-4.0 Cl-110* HCO -22 AnGap-[MASKED] with history of HCV cirrhosis decompensated by esophageal varices and encephalopathy, biopsy proven HCC, s/p TACE ([MASKED]) admitted for monitoring. Patient tolerated the procedure well, without complications. CT abdomen [MASKED] revealed expected high-density material in the left lobe of the liver, consistent with recent chemoembolization. No non targeted embolization identified. Patient had transient nausea during the procedure and some abdominal discomfort that resolved by the morning. She also reported soreness in the R groin at the access site which improved overnight. No bruit, bleeding or hematoma were noted. Patient was continued on her home medications for her other chronic conditions. TRANSITIONAL ISSUES: ===================== [ ] No medication changes. New medication: - oxycodone 5 mg to use only if Tylenol is not helping [ ] Follow up with Interventional radiology at 1 pm on [MASKED]. [ ] Pt to come to [MASKED] building on the [MASKED] on the [MASKED] floor to have labs drawn on [MASKED]. # CODE: FULL (confirmed) # CONTACT: Husband [MASKED], [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion XL (Once Daily) 150 mg PO DAILY 2. TraZODone [MASKED] mg PO QHS:PRN sleep 3. LORazepam 0.5 mg PO Q8H:PRN anxiety 4. Omeprazole 20 mg PO DAILY 5. Lactulose 15 mL PO BID 6. Rifaximin 550 mg PO BID 7. PredniSONE 10 mg PO PRN severe increased cough 8. Loratadine 10 mg PO DAILY:PRN allergy Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild DO NOT EXCEED 2 GRAMS/DAY RX acetaminophen 325 mg 2 tablet(s) by mouth every 8 hours as needed Disp #60 Tablet Refills:0 2. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Severe Duration: 6 Days take only as needed if Tylenol not sufficient RX oxycodone 5 mg 1 tablet(s) by mouth daily as needed Disp #6 Tablet Refills:0 3. BuPROPion XL (Once Daily) 150 mg PO DAILY 4. Lactulose 15 mL PO BID 5. Loratadine 10 mg PO DAILY:PRN allergy 6. LORazepam 0.5 mg PO Q8H:PRN anxiety 7. Omeprazole 20 mg PO DAILY 8. PredniSONE 10 mg PO PRN severe increased cough 9. Rifaximin 550 mg PO BID 10. TraZODone [MASKED] mg PO QHS:PRN sleep Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Hepatocellular carcinoma status post transcatheter arterial chemoembolization (TACE) SECONDARY DIAGNOSES Hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [MASKED], It was a pleasure taking care of you during your hospitalization at [MASKED]! Why were you hospitalized? -Because you had an elective procedure called 'transcatheter arterial chemoembolization' or 'TACE' performed by the interventional radiologists ([MASKED]) and you needed monitoring after the procedure What was done for you this hospitalization? -You had successful [MASKED] intervention, confirmed by a CT scan the next day -Your pain was controlled -We monitored you for bleeding and other side effects from the procedure, but did not see any. What should you do after you leave the hospital? -Continue to monitor for any new symptoms such as bleeding or swelling at the groin site, right upper quadrant pain. -Take Tylenol [MASKED] mg up to three times a day as needed for pain. You will also have a small amount of oxycodone to help you with the pain when Tylenol is not enough. -You should come to the [MASKED] building to get labs drawn on [MASKED] so the results are ready for your follow up appointment. -You have a follow up appointment with [MASKED] on [MASKED]. We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "D509", "F419", "G4700", "Z87891" ]	[ "Z5111: Encounter for antineoplastic chemotherapy", "C228: Malignant neoplasm of liver, primary, unspecified as to type", "K7469: Other cirrhosis of liver", "B1920: Unspecified viral hepatitis C without hepatic coma", "M069: Rheumatoid arthritis, unspecified", "D509: Iron deficiency anemia, unspecified", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "Z87891: Personal history of nicotine dependence", "Z808: Family history of malignant neoplasm of other organs or systems" ]
19,978,630	21,940,751	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left distal ___ femoral shaft fracture Major Surgical or Invasive Procedure: left retrograde femoral nail placement History of Present Illness: This is a ___ with hx of Alzheimers and who is non-ambulatory who presents s/p fall at home with a left mid-shaft femur fracture. She was being transferred from her wheelchair to her bed by her daughter and health care worker when they lost grip on her and she fell to the ground. She was crying in pain and taken to ___ where xrays showed the aforementioned fracture. She is very hard of hearing and confused. Past Medical History: Alzheimers Social History: ___ Family History: Non contributory Physical Exam: Exam on discharge: Vitals: AVSS General: Well-appearing, breathing comfortably on RA. Neuro: A&Ox1-2, at baseline CV: RRR by palp Pulm: nonlabored breathing, no audible wheezes or crackles MSK: -Appropriately tender to palpation -Dressings c/d/I -Left Thigh compartments soft -Sensorimotor exam intact -Left foot WWP Pertinent Results: see OMR for pertinent results Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on ___ for left retrograde femoral nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. In discussion of dispo planning, multiple conversations involving the family, medicine, palliative care, and case management teams were had. Ultimately given the family's goals of care regarding the patient, it was decided that comfort measures only would be in the patient's best interest. Given the frequent demands and needs for care of the patient, it was thought that nursing home with hospice would be the best setting for the patient. However, the family wanted the patient to be brought home with hospice services despite the demands including wound care, dressing changes, assistance with transfers and ambulation, and administration for subcutaneous heparin on a daily basis. 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 left lower extremity, and will be discharged on Subcutaneous Heparin twice daily for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID 4. Senna 8.6 mg PO BID 5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left distal ___ femoral shaft fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - weight-bearing as tolerated left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Subcutaneous heparin three times daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. Physical Therapy: -weight-bearing as tolerated left lower extremity Treatments Frequency: -staples to remain in place until follow up visit Followup Instructions: ___	[ "S72302A", "J9690", "G92", "E870", "E878", "D696", "D62", "G309", "E860", "I10", "R1310", "E875", "F0280", "Z66", "H9190", "W050XXA", "Y92003", "M4800" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left distal [MASKED] femoral shaft fracture Major Surgical or Invasive Procedure: left retrograde femoral nail placement History of Present Illness: This is a [MASKED] with hx of Alzheimers and who is non-ambulatory who presents s/p fall at home with a left mid-shaft femur fracture. She was being transferred from her wheelchair to her bed by her daughter and health care worker when they lost grip on her and she fell to the ground. She was crying in pain and taken to [MASKED] where xrays showed the aforementioned fracture. She is very hard of hearing and confused. Past Medical History: Alzheimers Social History: [MASKED] Family History: Non contributory Physical Exam: Exam on discharge: Vitals: AVSS General: Well-appearing, breathing comfortably on RA. Neuro: A&Ox1-2, at baseline CV: RRR by palp Pulm: nonlabored breathing, no audible wheezes or crackles MSK: -Appropriately tender to palpation -Dressings c/d/I -Left Thigh compartments soft -Sensorimotor exam intact -Left foot WWP Pertinent Results: see OMR for pertinent results 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 retrograde femoral nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. The [MASKED] hospital course was otherwise unremarkable. In discussion of dispo planning, multiple conversations involving the family, medicine, palliative care, and case management teams were had. Ultimately given the family's goals of care regarding the patient, it was decided that comfort measures only would be in the patient's best interest. Given the frequent demands and needs for care of the patient, it was thought that nursing home with hospice would be the best setting for the patient. However, the family wanted the patient to be brought home with hospice services despite the demands including wound care, dressing changes, assistance with transfers and ambulation, and administration for subcutaneous heparin on a daily basis. 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 left lower extremity, and will be discharged on Subcutaneous Heparin twice daily for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID 4. Senna 8.6 mg PO BID 5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: left distal [MASKED] femoral shaft fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - weight-bearing as tolerated left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Subcutaneous heparin three times daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. Physical Therapy: -weight-bearing as tolerated left lower extremity Treatments Frequency: -staples to remain in place until follow up visit Followup Instructions: [MASKED]	[]	[ "D696", "D62", "I10", "Z66" ]	[ "S72302A: Unspecified fracture of shaft of left femur, initial encounter for closed fracture", "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "G92: Toxic encephalopathy", "E870: Hyperosmolality and hypernatremia", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "D696: Thrombocytopenia, unspecified", "D62: Acute posthemorrhagic anemia", "G309: Alzheimer's disease, unspecified", "E860: Dehydration", "I10: Essential (primary) hypertension", "R1310: Dysphagia, unspecified", "E875: Hyperkalemia", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "Z66: Do not resuscitate", "H9190: Unspecified hearing loss, unspecified ear", "W050XXA: Fall from non-moving wheelchair, initial encounter", "Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "M4800: Spinal stenosis, site unspecified" ]
19,978,694	20,052,997	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: lisinopril / Citrus And Derivatives / cat dander Attending: ___. Chief Complaint: atypical cells seen on drainage of right hydrosalpinx Major Surgical or Invasive Procedure: laparoscopic converted to open exploratory laparotomy; bilateral salpingo-oophorectomy, oversew of bowel serosa, primary enterotomy repair, extensive lysis of adhesions History of Present Illness: Ms. ___ is a ___ YO P2 who is referred by Dr. ___ for recently diagnosed atypical cells seen on drainage of a right hydrosalpinx performed on ___. ___ states that she started having right lower quadrant discomfort and acute on chronic low back pain earlier in ___. She presented to her primary care to thought that she may have a kidney stone and a CT urogram was done on ___. A right hydrosalpinx was noted to be 11.3 cm and the left measuring 3.5 cm both have increased in size compared to ___ pelvic MRI. There were no solid enhancing nodules. On ___ she had 500 cc of fluid drained transvaginally and she states that the right lower discomfort improved after drainage as she was once again able to sleep on her stomach but she feels that the discomfort may be coming back. Past Medical History: PMH: -History of right DVT and what sounds like the popliteal vein behind her right knee in ___ that was unprovoked. She was treated with 6 months of Coumadin. To her knowledge she did not have further work-up. -Prediabetes -Arthritis -Hypertension -Chronic sinusitis PSH: Total abdominal hysterectomy for fibroids at ___ in ___ Myomectomy in ___ Lumpectomy for a right breast cyst LTCS OBGYN HX: Para 2 She is never taken hormone replacement She does have a history of abnormal Paps, most recent ___ was normal, HPV negative Social History: ___ Family History: She has an extensive family history of cancer -Breast: Maternal aunt diagnosed in her ___ and died in her ___ Maternal ___ cousin diagnosed in her late ___ or early ___ and is currently alive has not had any genetic testing as the cousin is in ___ Her mother who is ___ years old also has a breast mass but does not want it to be biopsied -Colon: Father diagnosed in his early ___ and died at age ___ -Prostate: Father diagnosed after diagnosis of colon cancer -Multiple myeloma: Sister diagnosed early ___ died at age ___ -Heart disease: Maternal aunt -___: Father, cousins, grandparents Hypertension: Father, maternal grandparents -___: Maternal aunt -No family history known of DVT Physical Exam: 'Vital Signs' sheet entries for ___: BP: 138/92 Weight: 300.9 BMI: 52.5 GENERAL: No acute distress, well developed, well nourished, appears stated age. HEENT: NC/AT EYES: sclera anicteric SKIN: Warm and dry. NEURO/PSYCH: Alert and oriented x 4. NECK: Supple no mass LYMPHATICS: No palpable supraclavicular, cervical, or inguinofemoral lymphadenopathy. RESPIRATORY: Lungs clear to auscultation bilaterally. CARDIOVASCULAR: Heart regular rate and rhythm. MUSCULOSKELETAL: No spinal or cva tenderness. GASTROINTESTINAL: Abdomen soft, nontender, nondistended, normoactive bowel sounds, without palpable masses or hepatosplenomegaly. EXTREMITIES: Nontender, no edema bilaterally. GENITOURINARY: External female genitalia: normal Vagina: no lesions Cervix: surgically absent Uterus: surgically absent Adnexa: no palpable masses RECTAL: Normal tone, smooth rectovaginal septum, no rectal impingement, and otherwise confirms the pelvic exam above. Exam Day of Discharge 24 HR Data (last updated ___ @ 535) Temp: 97.8 (Tm 98.6), BP: 109/66 (99-109/56-66), HR: 66 (66-80), RR: 17 (___), O2 sat: 94% (94-96), O2 delivery: ra I/Os: Fluid Balance (last updated ___ @ 533) Last 8 hours Total cumulative 40ml IN: Total 240ml, PO Amt 240ml OUT: Total 200ml, Urine Amt 200ml Last 24 hours Total cumulative -180ml IN: Total 1220ml, PO Amt 1220ml OUT: Total 1400ml, Urine Amt 1400ml General: NAD, sitting up in chair CV: RRR Lungs: nonlabored breathing, CTAB Abdomen: soft, ND, appropriately tender to palpation without rebound or guarding Incision: midline incision prevena vac in place and belly binder Extremities: no edema, no TTP, pneumoboots in place bilaterally Brief Hospital Course: Ms. ___ was admitted to the gynecologic oncology service after undergoing a laparoscopic converted to open exploratory laparotomy; bilateral salpingo-oophorectomy, oversew of bowel serosa, primary enterotomy repair, extensive lysis of adhesions. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with a TAP block, IV dilaudid/toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone/acetaminophen/ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, passing flatus, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Atenolol 100 mg PO DAILY Fluticasone Propionate 110mcg 2 PUFF IH BID Losartan Potassium 50 mg PO DAILY 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 #60 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Tablet Refills:0 3. Enoxaparin (Prophylaxis) 80 mg SC DAILY hx of unprovoked PE Duration: 2 Weeks RX enoxaparin 80 mg/0.8 mL 1 syringe subcutaneous once a day Disp #14 Syringe Refills:0 4. Ibuprofen 600 mg PO Q6H RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #60 Tablet Refills:0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 6. Atenolol 100 mg PO DAILY 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Losartan Potassium 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___: atypical cells of the fallopian tubes 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 gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. * Do not put anything in the rectum (suppository, enema, etc) for 6 months, unless advised otherwise by your doctor. Incision care: * You may shower and allow soapy water to run over your wound vacuum; no scrubbing of the wound/vacuum. No bath tubs for 6 weeks. * You will have nurse visits to help with your wound dressing and sponge changes 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 ___. ** Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery especially given your history of an unprovoked pulmonary embolus. This risk is highest in the first few weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse ___ assist you in administering these injections. * You will be taking 80mg subcutaneous injections of lovenox every day for 2 weeks Followup Instructions: ___	[ "N838", "K9172", "Z6843", "I10", "K660", "M1990", "Y836", "E669", "Y92234", "Z90710", "Z86718", "Z5331", "J329" ]	Allergies: lisinopril / Citrus And Derivatives / cat dander Chief Complaint: atypical cells seen on drainage of right hydrosalpinx Major Surgical or Invasive Procedure: laparoscopic converted to open exploratory laparotomy; bilateral salpingo-oophorectomy, oversew of bowel serosa, primary enterotomy repair, extensive lysis of adhesions History of Present Illness: Ms. [MASKED] is a [MASKED] YO P2 who is referred by Dr. [MASKED] for recently diagnosed atypical cells seen on drainage of a right hydrosalpinx performed on [MASKED]. [MASKED] states that she started having right lower quadrant discomfort and acute on chronic low back pain earlier in [MASKED]. She presented to her primary care to thought that she may have a kidney stone and a CT urogram was done on [MASKED]. A right hydrosalpinx was noted to be 11.3 cm and the left measuring 3.5 cm both have increased in size compared to [MASKED] pelvic MRI. There were no solid enhancing nodules. On [MASKED] she had 500 cc of fluid drained transvaginally and she states that the right lower discomfort improved after drainage as she was once again able to sleep on her stomach but she feels that the discomfort may be coming back. Past Medical History: PMH: -History of right DVT and what sounds like the popliteal vein behind her right knee in [MASKED] that was unprovoked. She was treated with 6 months of Coumadin. To her knowledge she did not have further work-up. -Prediabetes -Arthritis -Hypertension -Chronic sinusitis PSH: Total abdominal hysterectomy for fibroids at [MASKED] in [MASKED] Myomectomy in [MASKED] Lumpectomy for a right breast cyst LTCS OBGYN HX: Para 2 She is never taken hormone replacement She does have a history of abnormal Paps, most recent [MASKED] was normal, HPV negative Social History: [MASKED] Family History: She has an extensive family history of cancer -Breast: Maternal aunt diagnosed in her [MASKED] and died in her [MASKED] Maternal [MASKED] cousin diagnosed in her late [MASKED] or early [MASKED] and is currently alive has not had any genetic testing as the cousin is in [MASKED] Her mother who is [MASKED] years old also has a breast mass but does not want it to be biopsied -Colon: Father diagnosed in his early [MASKED] and died at age [MASKED] -Prostate: Father diagnosed after diagnosis of colon cancer -Multiple myeloma: Sister diagnosed early [MASKED] died at age [MASKED] -Heart disease: Maternal aunt -[MASKED]: Father, cousins, grandparents Hypertension: Father, maternal grandparents -[MASKED]: Maternal aunt -No family history known of DVT Physical Exam: 'Vital Signs' sheet entries for [MASKED]: BP: 138/92 Weight: 300.9 BMI: 52.5 GENERAL: No acute distress, well developed, well nourished, appears stated age. HEENT: NC/AT EYES: sclera anicteric SKIN: Warm and dry. NEURO/PSYCH: Alert and oriented x 4. NECK: Supple no mass LYMPHATICS: No palpable supraclavicular, cervical, or inguinofemoral lymphadenopathy. RESPIRATORY: Lungs clear to auscultation bilaterally. CARDIOVASCULAR: Heart regular rate and rhythm. MUSCULOSKELETAL: No spinal or cva tenderness. GASTROINTESTINAL: Abdomen soft, nontender, nondistended, normoactive bowel sounds, without palpable masses or hepatosplenomegaly. EXTREMITIES: Nontender, no edema bilaterally. GENITOURINARY: External female genitalia: normal Vagina: no lesions Cervix: surgically absent Uterus: surgically absent Adnexa: no palpable masses RECTAL: Normal tone, smooth rectovaginal septum, no rectal impingement, and otherwise confirms the pelvic exam above. Exam Day of Discharge 24 HR Data (last updated [MASKED] @ 535) Temp: 97.8 (Tm 98.6), BP: 109/66 (99-109/56-66), HR: 66 (66-80), RR: 17 ([MASKED]), O2 sat: 94% (94-96), O2 delivery: ra I/Os: Fluid Balance (last updated [MASKED] @ 533) Last 8 hours Total cumulative 40ml IN: Total 240ml, PO Amt 240ml OUT: Total 200ml, Urine Amt 200ml Last 24 hours Total cumulative -180ml IN: Total 1220ml, PO Amt 1220ml OUT: Total 1400ml, Urine Amt 1400ml General: NAD, sitting up in chair CV: RRR Lungs: nonlabored breathing, CTAB Abdomen: soft, ND, appropriately tender to palpation without rebound or guarding Incision: midline incision prevena vac in place and belly binder Extremities: no edema, no TTP, pneumoboots in place bilaterally Brief Hospital Course: Ms. [MASKED] was admitted to the gynecologic oncology service after undergoing a laparoscopic converted to open exploratory laparotomy; bilateral salpingo-oophorectomy, oversew of bowel serosa, primary enterotomy repair, extensive lysis of adhesions. Please see the operative report for full details. Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with a TAP block, IV dilaudid/toradol. Her diet was advanced without difficulty and she was transitioned to PO oxycodone/acetaminophen/ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day 3, she was tolerating a regular diet, voiding spontaneously, ambulating independently, passing flatus, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Atenolol 100 mg PO DAILY Fluticasone Propionate 110mcg 2 PUFF IH BID Losartan Potassium 50 mg PO DAILY 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 #60 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Tablet Refills:0 3. Enoxaparin (Prophylaxis) 80 mg SC DAILY hx of unprovoked PE Duration: 2 Weeks RX enoxaparin 80 mg/0.8 mL 1 syringe subcutaneous once a day Disp #14 Syringe Refills:0 4. Ibuprofen 600 mg PO Q6H RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #60 Tablet Refills:0 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 6. Atenolol 100 mg PO DAILY 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Losartan Potassium 50 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] [MASKED]: atypical cells of the fallopian tubes 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 gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: Take your medications as prescribed. We recommend you take non-narcotics (i.e. Tylenol, ibuprofen) regularly for the first few days post-operatively, and use the narcotic as needed. As you start to feel better and need less medication, you should decrease/stop the narcotic first. * Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (tylenol) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 12 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * It is safe to walk up stairs. * Do not put anything in the rectum (suppository, enema, etc) for 6 months, unless advised otherwise by your doctor. Incision care: * You may shower and allow soapy water to run over your wound vacuum; no scrubbing of the wound/vacuum. No bath tubs for 6 weeks. * You will have nurse visits to help with your wound dressing and sponge changes 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]. ** Lovenox injections: * Patients having surgery for cancer have risk of developing blood clots after surgery especially given your history of an unprovoked pulmonary embolus. This risk is highest in the first few weeks after surgery. You will be discharged with a daily Lovenox (blood thinning) medication. This is a preventive dose of medication to decrease your risk of a forming a blood clot. A visiting nurse [MASKED] assist you in administering these injections. * You will be taking 80mg subcutaneous injections of lovenox every day for 2 weeks Followup Instructions: [MASKED]	[]	[ "I10", "E669", "Z86718" ]	[ "N838: Other noninflammatory disorders of ovary, fallopian tube and broad ligament", "K9172: Accidental puncture and laceration of a digestive system organ or structure during other procedure", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "I10: Essential (primary) hypertension", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "M1990: Unspecified osteoarthritis, unspecified site", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "E669: Obesity, unspecified", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z90710: Acquired absence of both cervix and uterus", "Z86718: Personal history of other venous thrombosis and embolism", "Z5331: Laparoscopic surgical procedure converted to open procedure", "J329: Chronic sinusitis, unspecified" ]
19,978,860	26,604,403	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Dizziness Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: ___ w/ PMHx of CAD (s/p PCI ___, HTN, HLD, and tobacco use who presented for planned PCI to RCA CTO now s/p DES x3 to RCA, post-procedure course c/b hypotension and groin hematoma. Patient initially presented to outpatient cardiology in ___ with worsening dyspnea on exertion. A screening chest CT to evaluate known lung nodules was reported to show coronary calcifications. ECG showed new T wave inversions in II, III, avF, V3- V5. Stress testing was notable for septal and apical ischemia and possible inferobasal infarction. He underwent coronary angiogram on ___ which showed 80-90% stenosis of proximal LAD and chronic total occlusion of RCA. He underwent PCI to the LAD on ___, with plan to consider intervention for the RCA CTO if he remained symptomatic. He continued to report progressive fatigue since his PCI and presented today for planned PCI to RCA CTO. He underwent successful PCI to RCA CTO with 3 overlapping DES, with right radial and right groin access (groin was angiosealed). Catheter thrombus was noted, which was treated with aspiration thrombectomy and tirofiban bolus. He was re-loaded with Plavix 600mg. In the PACU, patient was not adherent to activity restrictions and kept sitting up. Soon after, groin hematoma was noted and patient became dizzy and hypotensive. Tirofiban was stopped. CTA showed no evidence of RP hematoma. C-clamp was applied, and dopamine gtt was started. Hct dropped from 36 pre-cath -> 24 post-cath. He was transferred to the CCU. On arrival to the CCU, patient feels fine. Denies lightheadedness, chest pain, dyspnea, abdominal pain, nausea. Past Medical History: 1. CVD Risk Factors - HTN - Dyslipidemia - Tobacco 2. Cardiac History - CAD s/p LAD DES ___, known TO RCA 3. Other PMH - Multinodular goiter per ___- patient feels this is incorrect information - Pulmonary nodules - Hiatal hernia - Elevated PSA - ? Prior remote TIA - Remote ganglion removed from wrist - Tonsillectomy as a child Social History: ___ Family History: Patient is adopted- family history unknown Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: HR 97, BP 97/70, RR 21, 95% on RA GENERAL: Well developed, well nourished in NAD. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP flat. CARDIAC: Normal rate, regular rhythm. No murmurs. LUNGS: CTAB anteriorly, no wheezes/crackles. Respiration is unlabored with no accessory muscle use. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No peripheral edema. Right groin/thigh with swelling and small ecchymosis, mildly tender to palpation. PULSES: DP pulse 2+ on right. NEURO: Alert, answering questions appropriately. =================== DISCHARGE PHYSICAL EXAMINATION: VS: T 97.1F, HR 75, BP 127/91, RR 16, 88% RA GENERAL: pacing the room, adamant about leaving hospital HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP flat. CARDIAC: Normal rate, regular rhythm. No murmurs. LUNGS: CTAB no wheezing, rales, rhonchi ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No peripheral edema. Right groin/thigh with mild swelling, stable ecchymosis, non-tender PULSES: DP pulse 2+ on right. NEURO: Alert, answering questions appropriately. Ambulating. Pertinent Results: ADMISSION LABS: ___ 03:25PM BLOOD WBC-7.9 RBC-3.62* Hgb-10.0* Hct-31.1* MCV-86 MCH-27.6 MCHC-32.2 RDW-13.3 RDWSD-41.8 Plt ___ ___ 03:25PM BLOOD ___ PTT-37.1* ___ ___ 03:25PM BLOOD Glucose-123* UreaN-26* Creat-0.8 Na-143 K-4.2 Cl-106 HCO3-26 AnGap-11 ___ 03:25PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2 IMAGING/STUDIES: Cardiac Catheterization ___: Coronary Anatomy Right dominant LM: No disease. LAD: Widely patent mid LAD stents. Septal collaterals to the RCA. LCx: Mild irregularities. RCA: Proximal CTO. Impressions: Successful CTO PCI of the RCA (3 overlapping DES). Catheter thrombus, treated with aspiration thrombectomy and Tirofiban bolus. ------------------- DISCHARGE LABS (pending prior to patient eloping) ___ 05:23AM BLOOD ___ PTT-PND ___ ___ 05:23AM BLOOD Plt ___ ___ 05:23AM BLOOD WBC-8.6 RBC-3.44* Hgb-9.5* Hct-28.8* MCV-84 MCH-27.6 MCHC-33.0 RDW-13.4 RDWSD-40.9 Plt ___ ___ 05:23AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND K-PND Cl-PND HCO3-PND ___ 05:23AM BLOOD Calcium-PND Phos-PND Mg-PND Brief Hospital Course: SUMMARY STATEMENT ================= ___ w/ PMHx of CAD (s/p PCI ___, HTN, HLD, and tobacco use who presented for planned PCI to RCA CTO now s/p DES x3 to RCA, post-procedure course c/b hemorrhagic shock requiring dopamine gtt secondary to groin hematoma and H/H drop. ACUTE ISSUES ============ # Hemorrhagic Shock vs vagal hypotension # Acute blood loss anemia # Rt groin hematoma Post-cath, patient was non-compliant with bedrest and was repeatedly sitting up in chair. He develop groin hematoma in setting of antiplatelet agents (ASA, Clopidogrel, and tirofiban during cath). Likely due to vagal response vs anemia, patient developed dizziness and hypotension to SBP ___, found to have new anemia initial (Hct 24 from 36) and Rt groin hematoma. CTA showed no evidence of RP bleed. C-clamp was applied and given 1U RBC transfusion. Patient was weaned off dopamine gtt and remained normotensive. The plan was for ongoing monitoring with CBC checks and BP monitoring. However, on ___, the night after admission, patient demanded to leave the hospital because he felt better. He denied chest pain, SOB, lightheadedness. He expressed understanding that leaving the hospital could lead to death due to further bleeding. He reported that he never wanted to be admitted and was unwilling to stay for only a few hours for follow up of his blood counts. We discussed with him that for a safe discharge, he should stay until we confirm his hemoglobin remained stable, but he still chose to leave AGAINST MEDICAL ADVICE. He was felt to have the capacity to do so given his expressed vocalization of understanding why he was admitted and risk of death, bleeding, incapacity injury, and re-hospitalization. Patient ELOPED at 6:00 AM on ___. His labs were still pending prior to his elopement. Patient's blood pressure on discharge was 127/91. His H/H remained stable at 9.5/28.8 from 9.8/29.8, and the results were communicated to the patient over the phone after discharge. It was recommended that he come back to the hospital if he develops any lightheadedness, chest pain, shortness of breath. It was recommended that he follow-up with his PCP and cardiologist within 1 week. He expressed his understanding. Initially metoprolol and HCTZ were held. Metoprolol was recommended to be restarted on discharge. His HCTZ was held on discharge. # CAD s/p PCI to LAD and RCA CTO Patient presented for planned PCI to RCA CTO, which was complicated by hypotension and groin hematoma as above. Patient should continue aspirin for life and Plavix 75 mg daily for ___ years minimum. # HFrEF: LVEF 28% on TTE dated ___ ischemic cardiomyopathy per OMR. Appeared euvolemic on exam. Repeat TTE was planned but patient left AMA. His HCTZ was held on discharge. Metoprolol restarted on discharge. CHRONIC ISSUES: =============== # Hypertension: - HCTZ was held on discharge. Metoprolol restarted on discharge. # Hyperlipidemia: FLP unknown. - Continued atorvastatin 40 mg TI: [ ] Patient should follow-up with cardiology for CAD s/p DES x3 to RCA [ ] Patient should continue aspirin for life and Plavix 75 mg daily for ___ years minimum [ ] Note that patient elected to leave AMA and ultimately eloped. Please follow up CBC as soon as able, within this week, and evaluate R groin for hematoma. [ ] Note that no follow up appointments were arranged given timing of elopement Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. sildenafil 20 mg oral ONCE:PRN 4. Clopidogrel 75 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 6. sildenafil 20 mg oral ONCE:PRN 7. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until you follow-up with your PCP ___: Home Discharge Diagnosis: Coronary artery disease Right groin hematoma Hemorrhagic shock Anemia Heart failure with reduced ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for coronary artery disease requiring stenting. You also developed a bleed after your procedure. You required blood pressure medication to keep your blood pressure up and you were admitted to the intensive care unit. What was done for me in the hospital? - You underwent the cardiac catheterization during which 3 stents were placed. - You received medications to keep your blood pressure normal. You received a blood transfusion for the bleed. You were monitored in the intensive care unit. What should I do when I leave the hospital? - You preferred to leave the hospital against medical advice. - Please take all of your medicines and attend all of your follow-up appointments. We wish you all the best! Sincerely, Your ___ Treatment Team Followup Instructions: ___	[ "I2510", "T8119XA", "D62", "I5022", "L7632", "T85868A", "I110", "I255", "F17210", "E785", "I2582", "Y840", "Y92239", "Z9119", "Z955", "Z7902" ]	Allergies: Penicillins Chief Complaint: Dizziness Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: [MASKED] w/ PMHx of CAD (s/p PCI [MASKED], HTN, HLD, and tobacco use who presented for planned PCI to RCA CTO now s/p DES x3 to RCA, post-procedure course c/b hypotension and groin hematoma. Patient initially presented to outpatient cardiology in [MASKED] with worsening dyspnea on exertion. A screening chest CT to evaluate known lung nodules was reported to show coronary calcifications. ECG showed new T wave inversions in II, III, avF, V3- V5. Stress testing was notable for septal and apical ischemia and possible inferobasal infarction. He underwent coronary angiogram on [MASKED] which showed 80-90% stenosis of proximal LAD and chronic total occlusion of RCA. He underwent PCI to the LAD on [MASKED], with plan to consider intervention for the RCA CTO if he remained symptomatic. He continued to report progressive fatigue since his PCI and presented today for planned PCI to RCA CTO. He underwent successful PCI to RCA CTO with 3 overlapping DES, with right radial and right groin access (groin was angiosealed). Catheter thrombus was noted, which was treated with aspiration thrombectomy and tirofiban bolus. He was re-loaded with Plavix 600mg. In the PACU, patient was not adherent to activity restrictions and kept sitting up. Soon after, groin hematoma was noted and patient became dizzy and hypotensive. Tirofiban was stopped. CTA showed no evidence of RP hematoma. C-clamp was applied, and dopamine gtt was started. Hct dropped from 36 pre-cath -> 24 post-cath. He was transferred to the CCU. On arrival to the CCU, patient feels fine. Denies lightheadedness, chest pain, dyspnea, abdominal pain, nausea. Past Medical History: 1. CVD Risk Factors - HTN - Dyslipidemia - Tobacco 2. Cardiac History - CAD s/p LAD DES [MASKED], known TO RCA 3. Other PMH - Multinodular goiter per [MASKED]- patient feels this is incorrect information - Pulmonary nodules - Hiatal hernia - Elevated PSA - ? Prior remote TIA - Remote ganglion removed from wrist - Tonsillectomy as a child Social History: [MASKED] Family History: Patient is adopted- family history unknown Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: HR 97, BP 97/70, RR 21, 95% on RA GENERAL: Well developed, well nourished in NAD. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP flat. CARDIAC: Normal rate, regular rhythm. No murmurs. LUNGS: CTAB anteriorly, no wheezes/crackles. Respiration is unlabored with no accessory muscle use. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No peripheral edema. Right groin/thigh with swelling and small ecchymosis, mildly tender to palpation. PULSES: DP pulse 2+ on right. NEURO: Alert, answering questions appropriately. =================== DISCHARGE PHYSICAL EXAMINATION: VS: T 97.1F, HR 75, BP 127/91, RR 16, 88% RA GENERAL: pacing the room, adamant about leaving hospital HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP flat. CARDIAC: Normal rate, regular rhythm. No murmurs. LUNGS: CTAB no wheezing, rales, rhonchi ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No peripheral edema. Right groin/thigh with mild swelling, stable ecchymosis, non-tender PULSES: DP pulse 2+ on right. NEURO: Alert, answering questions appropriately. Ambulating. Pertinent Results: ADMISSION LABS: [MASKED] 03:25PM BLOOD WBC-7.9 RBC-3.62* Hgb-10.0* Hct-31.1* MCV-86 MCH-27.6 MCHC-32.2 RDW-13.3 RDWSD-41.8 Plt [MASKED] [MASKED] 03:25PM BLOOD [MASKED] PTT-37.1* [MASKED] [MASKED] 03:25PM BLOOD Glucose-123* UreaN-26* Creat-0.8 Na-143 K-4.2 Cl-106 HCO3-26 AnGap-11 [MASKED] 03:25PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2 IMAGING/STUDIES: Cardiac Catheterization [MASKED]: Coronary Anatomy Right dominant LM: No disease. LAD: Widely patent mid LAD stents. Septal collaterals to the RCA. LCx: Mild irregularities. RCA: Proximal CTO. Impressions: Successful CTO PCI of the RCA (3 overlapping DES). Catheter thrombus, treated with aspiration thrombectomy and Tirofiban bolus. ------------------- DISCHARGE LABS (pending prior to patient eloping) [MASKED] 05:23AM BLOOD [MASKED] PTT-PND [MASKED] [MASKED] 05:23AM BLOOD Plt [MASKED] [MASKED] 05:23AM BLOOD WBC-8.6 RBC-3.44* Hgb-9.5* Hct-28.8* MCV-84 MCH-27.6 MCHC-33.0 RDW-13.4 RDWSD-40.9 Plt [MASKED] [MASKED] 05:23AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND K-PND Cl-PND HCO3-PND [MASKED] 05:23AM BLOOD Calcium-PND Phos-PND Mg-PND Brief Hospital Course: SUMMARY STATEMENT ================= [MASKED] w/ PMHx of CAD (s/p PCI [MASKED], HTN, HLD, and tobacco use who presented for planned PCI to RCA CTO now s/p DES x3 to RCA, post-procedure course c/b hemorrhagic shock requiring dopamine gtt secondary to groin hematoma and H/H drop. ACUTE ISSUES ============ # Hemorrhagic Shock vs vagal hypotension # Acute blood loss anemia # Rt groin hematoma Post-cath, patient was non-compliant with bedrest and was repeatedly sitting up in chair. He develop groin hematoma in setting of antiplatelet agents (ASA, Clopidogrel, and tirofiban during cath). Likely due to vagal response vs anemia, patient developed dizziness and hypotension to SBP [MASKED], found to have new anemia initial (Hct 24 from 36) and Rt groin hematoma. CTA showed no evidence of RP bleed. C-clamp was applied and given 1U RBC transfusion. Patient was weaned off dopamine gtt and remained normotensive. The plan was for ongoing monitoring with CBC checks and BP monitoring. However, on [MASKED], the night after admission, patient demanded to leave the hospital because he felt better. He denied chest pain, SOB, lightheadedness. He expressed understanding that leaving the hospital could lead to death due to further bleeding. He reported that he never wanted to be admitted and was unwilling to stay for only a few hours for follow up of his blood counts. We discussed with him that for a safe discharge, he should stay until we confirm his hemoglobin remained stable, but he still chose to leave AGAINST MEDICAL ADVICE. He was felt to have the capacity to do so given his expressed vocalization of understanding why he was admitted and risk of death, bleeding, incapacity injury, and re-hospitalization. Patient ELOPED at 6:00 AM on [MASKED]. His labs were still pending prior to his elopement. Patient's blood pressure on discharge was 127/91. His H/H remained stable at 9.5/28.8 from 9.8/29.8, and the results were communicated to the patient over the phone after discharge. It was recommended that he come back to the hospital if he develops any lightheadedness, chest pain, shortness of breath. It was recommended that he follow-up with his PCP and cardiologist within 1 week. He expressed his understanding. Initially metoprolol and HCTZ were held. Metoprolol was recommended to be restarted on discharge. His HCTZ was held on discharge. # CAD s/p PCI to LAD and RCA CTO Patient presented for planned PCI to RCA CTO, which was complicated by hypotension and groin hematoma as above. Patient should continue aspirin for life and Plavix 75 mg daily for [MASKED] years minimum. # HFrEF: LVEF 28% on TTE dated [MASKED] ischemic cardiomyopathy per OMR. Appeared euvolemic on exam. Repeat TTE was planned but patient left AMA. His HCTZ was held on discharge. Metoprolol restarted on discharge. CHRONIC ISSUES: =============== # Hypertension: - HCTZ was held on discharge. Metoprolol restarted on discharge. # Hyperlipidemia: FLP unknown. - Continued atorvastatin 40 mg TI: [ ] Patient should follow-up with cardiology for CAD s/p DES x3 to RCA [ ] Patient should continue aspirin for life and Plavix 75 mg daily for [MASKED] years minimum [ ] Note that patient elected to leave AMA and ultimately eloped. Please follow up CBC as soon as able, within this week, and evaluate R groin for hematoma. [ ] Note that no follow up appointments were arranged given timing of elopement Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. sildenafil 20 mg oral ONCE:PRN 4. Clopidogrel 75 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 6. sildenafil 20 mg oral ONCE:PRN 7. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until you follow-up with your PCP [MASKED]: Home Discharge Diagnosis: Coronary artery disease Right groin hematoma Hemorrhagic shock Anemia Heart failure with reduced ejection fraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking part in your care here at [MASKED]! Why was I admitted to the hospital? - You were admitted for coronary artery disease requiring stenting. You also developed a bleed after your procedure. You required blood pressure medication to keep your blood pressure up and you were admitted to the intensive care unit. What was done for me in the hospital? - You underwent the cardiac catheterization during which 3 stents were placed. - You received medications to keep your blood pressure normal. You received a blood transfusion for the bleed. You were monitored in the intensive care unit. What should I do when I leave the hospital? - You preferred to leave the hospital against medical advice. - Please take all of your medicines and attend all of your follow-up appointments. We wish you all the best! Sincerely, Your [MASKED] Treatment Team Followup Instructions: [MASKED]	[]	[ "I2510", "D62", "I110", "F17210", "E785", "Z955", "Z7902" ]	[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "T8119XA: Other postprocedural shock, initial encounter", "D62: Acute posthemorrhagic anemia", "I5022: Chronic systolic (congestive) heart failure", "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "T85868A: Thrombosis due to other internal prosthetic devices, implants and grafts, initial encounter", "I110: Hypertensive heart disease with heart failure", "I255: Ischemic cardiomyopathy", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E785: Hyperlipidemia, unspecified", "I2582: Chronic total occlusion of coronary artery", "Y840: Cardiac catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z9119: Patient's noncompliance with other medical treatment and regimen", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
19,978,886	25,887,347	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: lower back pain Major Surgical or Invasive Procedure: None History of Present Illness: Condensed history per ED HPI and further discussion with patient: ___ man with PMH herniated disc s/p L5 through S1 discectomy in ___, hyperlipidemia, HTN who presents ___ of mildly worsening LBP but ___ experienced excruciating left low back pain radiating into his L mid-calf when rising from his car. He was able to stand upright and "walk it off" but the symptoms repeated when rising from the dinner table and was debilitating. He says this is very similar to prior episode when he needed the discectomy. He presented to an ___ and was transferred to ___ due to multiple prior spinal surgeries performed here. In the ED, initial vitals were: T 97.2 BP 126/65 HR 96 RR 16 Sat96% RA Exam notable for: Neuro: A&Ox3, CN II-XII intact ___ strength in b/lUE RLE: ___ strength in hip flexion and extension; ___ knee flexion and extension; ___ dorsiflexion and plantarflexion with normal sensation throughout LLE: ___ strength in hip flexion and extension; ___ knee flexion and extension; ___ dorsiflexion and plantarflexion with decreased sensation on plantar aspect of the L foot with normal sensation over the legs and thighs Psych: Normal mentation Rectal tone: normal with normal perirectal sensation - Labs notable for: - Imaging was notable for: CT Lumbar W&W/O Contrast (myelogram) ****************** - Patient was given: IV Dilaudid (2.5g total), Ketorolac 15mg, started on Solmedrol 8mg Upon arrival to the floor, patient reports ongoing stabbing sharp backpain that starts in the middle of his back and radiates down his left leg, also on the side of the leg, and is associated with numbness on the top of the left foot. He also experiences left back and leg pain when he moves his right leg, but does not have any pain or numbness in right leg. He denies any incontinence of urine or stool. Past Medical History: L5-S1 Disectomy Cerebral aneurysm with subarachnoid hemorrhage and frontal contusions, s/p 2 aneurysm clips in brain - ___ HTN HLD past smoker chronic lower back pain depression (d/t subarachnoid hemorrhage and concussions) hx of testicular CA s/p orchiectomy Social History: ___ Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITAL SIGNS: T 97.2 BP 126/65 HR 96 RR 16 Sat96% RA GENERAL: well-nourished, pleasant man who appears uncomfortable HEENT: PERRLA, nystagmus noted with horizontal eye movement NECK: supple with no LAD CARDIAC: RRR, no m/r/g LUNGS: CTAB, no wheezes or ronchi ABDOMEN: soft, NT/ND, BS+ EXTREMITIES: Pulses 2+, ___, ___ strength in UE and ___ bilaterally NEUROLOGIC: CN2-12 intact, straight-leg positive on left leg; decreased sensation on dorsal aspect of left foot and mildly decreased on interior plantar aspect of left foot SKIN: no rashes, lesions DISCHARGE PHYSICAL EXAM: ========================= ___ 1227 Temp: 97.3 PO BP: 135/76 HR: 68 RR: 20 O2 sat: 97% O2 delivery: Ra General: Pleasant, alert, oriented and in no acute distress but significant amount of pain with movement HEENT: NCAT. PERRLA, no icterus or injection bilaterally. EOMI. No erythema or exudate in posterior pharynx; uvula midline; MMM. Neck: neck veins flat with full ROM Resp: Breathing comfortably on RA. No incr WOB, CTAB with no crackles or wheezes. CV: RRR. Normal S1/S2. NMRG. 2+ radial and DP pulses bilateral. Abd: Soft, Nontender, Nondistended with no organomegaly; no rebound tenderness or guarding. MSK: ___ without edema bilaterally; paraspinal tenderness to palpation Skin: No rash, Warm and dry, No petechiae Neuro: A&Ox3, CNII-XII intact. Decreased sensation to light touch and cold on dorsum of left foot, strength of toe dorsiflexion slightly limited by pain on left. Pertinent Results: ___ 02:00PM GLUCOSE-119* UREA N-15 CREAT-0.8 SODIUM-137 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16 ___ 02:00PM estGFR-Using this ___ 02:00PM WBC-7.8 RBC-4.04* HGB-12.8* HCT-39.0* MCV-97 MCH-31.7 MCHC-32.8 RDW-12.5 RDWSD-44.8 ___ 02:00PM NEUTS-79.0* LYMPHS-12.6* MONOS-4.5* EOS-2.4 BASOS-1.0 IM ___ AbsNeut-6.12* AbsLymp-0.98* AbsMono-0.35 AbsEos-0.19 AbsBaso-0.08 ___ 02:00PM PLT COUNT-261 ___ 02:00PM ___ PTT-30.9 ___ Brief Hospital Course: ==================== Summary ==================== ___ man with PMH herniated disc s/p L5 through S1 discectomy in ___, hyperlipidemia, HTN who presents ___ of mildly worsening LBP but ___ experienced excruciating left low back pain radiating into his L mid-calf when rising from his car. He presented to an ___ and was transferred to ___ due to multiple prior spinal surgeries performed here. CT and myelogram imaging revealed notable for stable disc bulge at L4-L5 level; Ortho Spine determined there was no need for surgical intervention. Pts pain was controlled and will be discharged on oral pain control regimen. =============== ACUTE ISSUES: =============== #Acute on chronic lower back pain with radiculopathy Has had multiple lower back procedures including herniated disc s/p L5 through S1 discectomy in ___, presents with acutely worsened LBP that radiates down l leg and associated L foot numbness that started the day prior to discharge while getting out of his car at work and became unbearable that evening as he stood up from seated position. CT non-contrast and myelogram notable only for: "At L4-L5, there is a diffuse disc bulge causing mild anterior thecal sac deformity and moderate bilateral neural foraminal narrowing, facet joint arthropathy and ligamentum flavum hypertrophy. Findings are relatively stable when compared with the prior examination in ___ There was no evidence of any hardware complications. Per ortho, no surgical intervention needed. Acute pain episode thought to be caused by bulging or irritated spinal disc causing radicular pain and muscle strain with spasms based on paraspinal muscle tenderness on exam. Initially pain controlled with IV Dilaudid and IV Ketorolac. Steroids were not given due to lack of sufficient evidence for their efficacy in this clinical context. Discharged on Ibuprofen 800mg Q8 hours for 3 days, capsaicin topical, cyclobenzaprine 10mg QHS PRN, and prescription for outpatient physical therapy. #Pain control Pt is followed by Dr. ___ in ___ for chronic LBP that is normally well controlled with home Gabapentin and Duloxetine, and PRN Advil. Continued home Gabapentin & Duloxetine. For acute episode of LBP, regimen is as stated above. ================== CHRONIC ISSUES: ================== #Depression Patient followed by neuropsychiatrist as outpatient and has recently been weaned off Eszopiclone (Lunesta) and transitioned to Mirtazepine QHS for help with sleeping. Subarachnoid hemorrhage and concussions have contributed to depression since ___. Continued home Duloxetine 90mg QDaily, Mirtazepine 7.5mg QHS, and Amantadine 200mg QAM and 100mg QPM. #Hypertension Well controlled on home regimen. Continued home atenolol 50mg Qdaily, Lisinopril 60mg QDaily, and Chlorthalidone 12.5mg QDaily. #Hyperlipidmia: Continued atorvastatin 40mg QDaily. ========================= TRANSITIONAL ISSUES: ========================= [ ] Of note, the patient's CNS clips are MRI compatible: per the ___ ___, the craniotomy and clipping was performed on ___, and he then had an MRI Brain on ___, which showed the residual aneurysm (1mm) below the clips along-- these are MRI compatible clips per the ___ Notes the bifurcation. Therefore, if further imaging is needed, MRI can be done. [ ] Discharged with prescription for physical therapy. Can follow up with outpatient PCP regarding need for ongoing ___. [ ] Patient previously on oxydocone in the past, he received ___ doses of this on this admission but our goal was to discharge off of opiates so he was sent with ibuprofen instead Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amantadine 200 mg PO QAM 2. Amantadine 100 mg PO LUNCH 3. Atenolol 50 mg PO DAILY 4. Chlorthalidone 12.5 mg PO DAILY 5. DULoxetine 90 mg PO DAILY 6. Gabapentin 300 mg PO BID 7. Lisinopril 60 mg PO DAILY 8. Mirtazapine 7.5 mg PO QHS Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Capsaicin 0.025% 1 Appl TP TID RX capsaicin [Capzasin-HP] 0.1 % apply cream to lower back up to three times daily, as needed Refills:0 3. Cyclobenzaprine 10 mg PO HS:PRN Back pain RX cyclobenzaprine 10 mg 1 tablet(s) by mouth evenings before bed, as needed Disp #10 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day as needed Disp #30 Capsule Refills:0 5. Ibuprofen 800 mg PO Q8H Duration: 3 Days RX ibuprofen [IBU] 800 mg 1 tablet(s) by mouth every 8 hours Disp #9 Tablet Refills:0 6. Lidocaine 5% Patch 1 PTCH TD QAM Alternate the lidocaine patch with the topical capsaicin ointment. RX lidocaine [Lidocaine Pain Relief] 4 % apply patch to affected area may remain up to 12 hrs in 24-hour period Disp #12 Patch Refills:0 7. Amantadine 200 mg PO QAM 8. Amantadine 100 mg PO LUNCH 9. Atenolol 50 mg PO DAILY 10. Chlorthalidone 12.5 mg PO DAILY 11. DULoxetine 90 mg PO DAILY 12. Gabapentin 300 mg PO BID 13. Lisinopril 60 mg PO DAILY 14. Mirtazapine 7.5 mg PO QHS 15.Outpatient Physical Therapy Physical therapy to reduce lower back pain, paraspinal muscle spasms, and treat radiculopathy. ICD10: M54.4 Duration: ongoing Discharge Disposition: Home Discharge Diagnosis: Primary: ----------- Acute left LBP w/ sciatica Paraspinal muscular spasm Secondary: ----------- Depression Chronic LBP Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You had severe lower back pain and there was concern for a herniated disk or more serious issue due to your prior spine surgeries. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had CT imaging of your spine, which showed no spinal cord impingement and no issues with your existing hardware. - Your back pain is thought to be due to an irritated spinal disc as well as surrounding muscular spasms. - Your pain was managed with anti-inflammatory and analgesic medications. 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: ___	[ "M5442", "M62830", "I69815", "F338", "I10", "E785", "Z8547", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: lower back pain Major Surgical or Invasive Procedure: None History of Present Illness: Condensed history per ED HPI and further discussion with patient: [MASKED] man with PMH herniated disc s/p L5 through S1 discectomy in [MASKED], hyperlipidemia, HTN who presents [MASKED] of mildly worsening LBP but [MASKED] experienced excruciating left low back pain radiating into his L mid-calf when rising from his car. He was able to stand upright and "walk it off" but the symptoms repeated when rising from the dinner table and was debilitating. He says this is very similar to prior episode when he needed the discectomy. He presented to an [MASKED] and was transferred to [MASKED] due to multiple prior spinal surgeries performed here. In the ED, initial vitals were: T 97.2 BP 126/65 HR 96 RR 16 Sat96% RA Exam notable for: Neuro: A&Ox3, CN II-XII intact [MASKED] strength in b/lUE RLE: [MASKED] strength in hip flexion and extension; [MASKED] knee flexion and extension; [MASKED] dorsiflexion and plantarflexion with normal sensation throughout LLE: [MASKED] strength in hip flexion and extension; [MASKED] knee flexion and extension; [MASKED] dorsiflexion and plantarflexion with decreased sensation on plantar aspect of the L foot with normal sensation over the legs and thighs Psych: Normal mentation Rectal tone: normal with normal perirectal sensation - Labs notable for: - Imaging was notable for: CT Lumbar W&W/O Contrast (myelogram) ****************** - Patient was given: IV Dilaudid (2.5g total), Ketorolac 15mg, started on Solmedrol 8mg Upon arrival to the floor, patient reports ongoing stabbing sharp backpain that starts in the middle of his back and radiates down his left leg, also on the side of the leg, and is associated with numbness on the top of the left foot. He also experiences left back and leg pain when he moves his right leg, but does not have any pain or numbness in right leg. He denies any incontinence of urine or stool. Past Medical History: L5-S1 Disectomy Cerebral aneurysm with subarachnoid hemorrhage and frontal contusions, s/p 2 aneurysm clips in brain - [MASKED] HTN HLD past smoker chronic lower back pain depression (d/t subarachnoid hemorrhage and concussions) hx of testicular CA s/p orchiectomy Social History: [MASKED] Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITAL SIGNS: T 97.2 BP 126/65 HR 96 RR 16 Sat96% RA GENERAL: well-nourished, pleasant man who appears uncomfortable HEENT: PERRLA, nystagmus noted with horizontal eye movement NECK: supple with no LAD CARDIAC: RRR, no m/r/g LUNGS: CTAB, no wheezes or ronchi ABDOMEN: soft, NT/ND, BS+ EXTREMITIES: Pulses 2+, [MASKED], [MASKED] strength in UE and [MASKED] bilaterally NEUROLOGIC: CN2-12 intact, straight-leg positive on left leg; decreased sensation on dorsal aspect of left foot and mildly decreased on interior plantar aspect of left foot SKIN: no rashes, lesions DISCHARGE PHYSICAL EXAM: ========================= [MASKED] 1227 Temp: 97.3 PO BP: 135/76 HR: 68 RR: 20 O2 sat: 97% O2 delivery: Ra General: Pleasant, alert, oriented and in no acute distress but significant amount of pain with movement HEENT: NCAT. PERRLA, no icterus or injection bilaterally. EOMI. No erythema or exudate in posterior pharynx; uvula midline; MMM. Neck: neck veins flat with full ROM Resp: Breathing comfortably on RA. No incr WOB, CTAB with no crackles or wheezes. CV: RRR. Normal S1/S2. NMRG. 2+ radial and DP pulses bilateral. Abd: Soft, Nontender, Nondistended with no organomegaly; no rebound tenderness or guarding. MSK: [MASKED] without edema bilaterally; paraspinal tenderness to palpation Skin: No rash, Warm and dry, No petechiae Neuro: A&Ox3, CNII-XII intact. Decreased sensation to light touch and cold on dorsum of left foot, strength of toe dorsiflexion slightly limited by pain on left. Pertinent Results: [MASKED] 02:00PM GLUCOSE-119* UREA N-15 CREAT-0.8 SODIUM-137 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16 [MASKED] 02:00PM estGFR-Using this [MASKED] 02:00PM WBC-7.8 RBC-4.04* HGB-12.8* HCT-39.0* MCV-97 MCH-31.7 MCHC-32.8 RDW-12.5 RDWSD-44.8 [MASKED] 02:00PM NEUTS-79.0* LYMPHS-12.6* MONOS-4.5* EOS-2.4 BASOS-1.0 IM [MASKED] AbsNeut-6.12* AbsLymp-0.98* AbsMono-0.35 AbsEos-0.19 AbsBaso-0.08 [MASKED] 02:00PM PLT COUNT-261 [MASKED] 02:00PM [MASKED] PTT-30.9 [MASKED] Brief Hospital Course: ==================== Summary ==================== [MASKED] man with PMH herniated disc s/p L5 through S1 discectomy in [MASKED], hyperlipidemia, HTN who presents [MASKED] of mildly worsening LBP but [MASKED] experienced excruciating left low back pain radiating into his L mid-calf when rising from his car. He presented to an [MASKED] and was transferred to [MASKED] due to multiple prior spinal surgeries performed here. CT and myelogram imaging revealed notable for stable disc bulge at L4-L5 level; Ortho Spine determined there was no need for surgical intervention. Pts pain was controlled and will be discharged on oral pain control regimen. =============== ACUTE ISSUES: =============== #Acute on chronic lower back pain with radiculopathy Has had multiple lower back procedures including herniated disc s/p L5 through S1 discectomy in [MASKED], presents with acutely worsened LBP that radiates down l leg and associated L foot numbness that started the day prior to discharge while getting out of his car at work and became unbearable that evening as he stood up from seated position. CT non-contrast and myelogram notable only for: "At L4-L5, there is a diffuse disc bulge causing mild anterior thecal sac deformity and moderate bilateral neural foraminal narrowing, facet joint arthropathy and ligamentum flavum hypertrophy. Findings are relatively stable when compared with the prior examination in [MASKED] There was no evidence of any hardware complications. Per ortho, no surgical intervention needed. Acute pain episode thought to be caused by bulging or irritated spinal disc causing radicular pain and muscle strain with spasms based on paraspinal muscle tenderness on exam. Initially pain controlled with IV Dilaudid and IV Ketorolac. Steroids were not given due to lack of sufficient evidence for their efficacy in this clinical context. Discharged on Ibuprofen 800mg Q8 hours for 3 days, capsaicin topical, cyclobenzaprine 10mg QHS PRN, and prescription for outpatient physical therapy. #Pain control Pt is followed by Dr. [MASKED] in [MASKED] for chronic LBP that is normally well controlled with home Gabapentin and Duloxetine, and PRN Advil. Continued home Gabapentin & Duloxetine. For acute episode of LBP, regimen is as stated above. ================== CHRONIC ISSUES: ================== #Depression Patient followed by neuropsychiatrist as outpatient and has recently been weaned off Eszopiclone (Lunesta) and transitioned to Mirtazepine QHS for help with sleeping. Subarachnoid hemorrhage and concussions have contributed to depression since [MASKED]. Continued home Duloxetine 90mg QDaily, Mirtazepine 7.5mg QHS, and Amantadine 200mg QAM and 100mg QPM. #Hypertension Well controlled on home regimen. Continued home atenolol 50mg Qdaily, Lisinopril 60mg QDaily, and Chlorthalidone 12.5mg QDaily. #Hyperlipidmia: Continued atorvastatin 40mg QDaily. ========================= TRANSITIONAL ISSUES: ========================= [ ] Of note, the patient's CNS clips are MRI compatible: per the [MASKED] [MASKED], the craniotomy and clipping was performed on [MASKED], and he then had an MRI Brain on [MASKED], which showed the residual aneurysm (1mm) below the clips along-- these are MRI compatible clips per the [MASKED] Notes the bifurcation. Therefore, if further imaging is needed, MRI can be done. [ ] Discharged with prescription for physical therapy. Can follow up with outpatient PCP regarding need for ongoing [MASKED]. [ ] Patient previously on oxydocone in the past, he received [MASKED] doses of this on this admission but our goal was to discharge off of opiates so he was sent with ibuprofen instead Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amantadine 200 mg PO QAM 2. Amantadine 100 mg PO LUNCH 3. Atenolol 50 mg PO DAILY 4. Chlorthalidone 12.5 mg PO DAILY 5. DULoxetine 90 mg PO DAILY 6. Gabapentin 300 mg PO BID 7. Lisinopril 60 mg PO DAILY 8. Mirtazapine 7.5 mg PO QHS Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. Capsaicin 0.025% 1 Appl TP TID RX capsaicin [Capzasin-HP] 0.1 % apply cream to lower back up to three times daily, as needed Refills:0 3. Cyclobenzaprine 10 mg PO HS:PRN Back pain RX cyclobenzaprine 10 mg 1 tablet(s) by mouth evenings before bed, as needed Disp #10 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day as needed Disp #30 Capsule Refills:0 5. Ibuprofen 800 mg PO Q8H Duration: 3 Days RX ibuprofen [IBU] 800 mg 1 tablet(s) by mouth every 8 hours Disp #9 Tablet Refills:0 6. Lidocaine 5% Patch 1 PTCH TD QAM Alternate the lidocaine patch with the topical capsaicin ointment. RX lidocaine [Lidocaine Pain Relief] 4 % apply patch to affected area may remain up to 12 hrs in 24-hour period Disp #12 Patch Refills:0 7. Amantadine 200 mg PO QAM 8. Amantadine 100 mg PO LUNCH 9. Atenolol 50 mg PO DAILY 10. Chlorthalidone 12.5 mg PO DAILY 11. DULoxetine 90 mg PO DAILY 12. Gabapentin 300 mg PO BID 13. Lisinopril 60 mg PO DAILY 14. Mirtazapine 7.5 mg PO QHS 15.Outpatient Physical Therapy Physical therapy to reduce lower back pain, paraspinal muscle spasms, and treat radiculopathy. ICD10: M54.4 Duration: ongoing Discharge Disposition: Home Discharge Diagnosis: Primary: ----------- Acute left LBP w/ sciatica Paraspinal muscular spasm Secondary: ----------- Depression Chronic LBP Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a privilege caring for you at [MASKED]. WHY WAS I IN THE HOSPITAL? - You had severe lower back pain and there was concern for a herniated disk or more serious issue due to your prior spine surgeries. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had CT imaging of your spine, which showed no spinal cord impingement and no issues with your existing hardware. - Your back pain is thought to be due to an irritated spinal disc as well as surrounding muscular spasms. - Your pain was managed with anti-inflammatory and analgesic medications. 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]	[]	[ "I10", "E785", "Z87891" ]	[ "M5442: Lumbago with sciatica, left side", "M62830: Muscle spasm of back", "I69815: Cognitive social or emotional deficit following other cerebrovascular disease", "F338: Other recurrent depressive disorders", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z8547: Personal history of malignant neoplasm of testis", "Z87891: Personal history of nicotine dependence" ]
19,979,222	29,022,078	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath, throat pain Major Surgical or Invasive Procedure: Bedside nasopharyngolaryngoscopy ___ (by ENT in ED) History of Present Illness: Ms. ___ is a very pleasant ___ yo breastfeeding female with no significant past medical history who presents with 2 days of shortness of breath, tachypnea, and stridor. She reports that she experienced onset of cough, sore throat and subjective fevers on ___ that progressed over the course of the next 1.5 days. She was unable to check her temperature at her shelter. On night of ___ patient woke up with acute shortness of breath and aching, painful sensation in her throat, at which point she presented to the ED. Endorses +SOB, intermittent non-productive cough and wheezing at the time. She denies a history of asthma or reactive airway disease. She received the flu shot this year and says that she received all of her childhood vaccines in ___ where she grew up. She has her baby ___ here with her and is currently breastfeeding. In the ED, vitals were notable for Temp 102.9 HR 137 BP 144/65 RR 16 SaO2 98% RA Exam notable for mild stertor and expiratory wheezing, no stridor. Significant clear nasal secretions noted w/ posterior pharyngeal and arytenoid erythema but widely patent airway and no supraglottic or glottic edema. Visualized portion of subglottis is patent. Labs notable for 7.45 \| 31 \| 26 , K 2.9, phos 1.9 Imaging notable for normal CXR Patient was given albuterol, ipratropium, 1 g Tylenol, racemic epinephrine . 5 mL inhaled x 2, Penicillin V Potassium PO 500 mg x 2, Ampicillin-Sulbactam 3 g, magnesium sulfate 4 g. Patient was seen by ENT who recommended discontinuation of steroids and albuterol, continuation of unasyn, admission and pulm consult if upper airway symptoms persist Decision was made to admit for ongoing treatment and dispo During ED visit patient triggered for tachycardia to 150s. She reported discomfort in her throat but denied chest pain or pleuritic pain. Exam notable for significant wheezing. No rash was noted on exam, and there was no concern for allergic reaction to Augmentin or penicillin. On the floor, patient reports that she is overall doing better. Her main complaint is a sore, uncomfortable feeling in her throat made worse when swallowing. She denies current shortness of breath, wheezing, chills. Still with dry cough. Review of systems: (+) Per HPI Past Medical History: Depression Denies History of Asthma Social History: ___ Family History: Great aunt- breast cancer, denies uterine, ovarian cancer Physical Exam: ADMISSION PHYSICAL ============= VS: Temp 98.4 BP 124/78 HR 100 RR 18 97%ra GENERAL: NAD, alert, interactive HEENT: NC/AT, sclerae anicteric, MMM. Punctate hemorrhage over hard palate, uvula midline. Erythema and cobblestoning over posterior pharynx, pathchy erethma over tonsils and anterior tonsillar fauces bilaterally, no tonsillar enlargement, no exudate. LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r. No stertor, wheezing noted currently. HEART: NRRR. No W/R/G ABDOMEN: NABS, soft/NT/ND. EXTREMITIES: WWP NEURO: awake, A&Ox3. ___ strength and tone UE and LEs. DISCHARGE PHYSICAL ============= VS: Temp 98.1 BP 110 / 65 HR 79 RR 16 98%RA GENERAL: NAD, alert, interactive HEENT: NC/AT, sclerae anicteric, MMM. Still with punctate hemorrhage over hard palate, uvula midline. Erythema and cobblestoning over posterior pharynx, pathchy erethma over tonsils and anterior tonsillar fauces bilaterally, no tonsillar enlargement, no exudate. LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r. HEART: NRRR. No W/R/G ABDOMEN: NABS, soft/NT/ND. EXTREMITIES: WWP NEURO: awake, A&Ox3. ___ strength and tone UE and LEs. STUDIES: Viral and bacterial throat cultures pending, HIV pending Pertinent Results: ADMISSION LABS =========== ___ 02:33AM BLOOD WBC-14.2# RBC-4.72 Hgb-14.3 Hct-42.6 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.6 RDWSD-41.4 Plt ___ ___ 02:33AM BLOOD Neuts-81.1 Lymphs-8.6* Monos-8.4 Eos-1.1 Baso-0.4 Im ___ AbsNeut-11.48# AbsLymp-1.22 AbsMono-1.19 AbsEos-0.16 AbsBaso-0.05 ___ 09:40AM BLOOD Glucose-144* UreaN-6 Creat-0.5 Na-141 K-2.9* Cl-102 HCO3-21* AnGap-21* ___ 08:04AM BLOOD ALT-61* AST-33 LD(LDH)-176 AlkPhos-100 TotBili-0.3 ___ 09:40AM BLOOD Calcium-9.2 Phos-1.9* Mg-2.2 ___ 10:23AM BLOOD HIV Ab-Negative ___ 09:46AM BLOOD ___ pO2-26* pCO2-31* pH-7.45 calTCO2-22 Base XS--1 ___ 09:25PM BLOOD ___ pO2-149* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 Comment-PERIPHERAL ___ 09:25PM BLOOD K-3.7 MICROBIOLOGY ========== ___ 3:40 pm THROAT CULTURE *FINAL REPORT ___ R/O Beta Strep Group A (Final ___: Reported to and read back by ___ ON ___ @ 2:50PM. BETA STREPTOCOCCUS GROUP A. RARE GROWTH. ___ 12:00 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Pending): IMAGING ====== CXR ___ Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal silhouette and well-aerated lungs without focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: No acute cardiopulmonary process. 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 ___, MD electronically signed on ___ ___ 8:36 AM Brief Hospital Course: Ms. ___ is a very pleasant ___ yo female with no significant past medical history who presented with 2 days of cough and acute shortness of breath. During the course of her hospital stay the following issues were addressed: # Pharyngitis. Ms. ___ presented with sore throat, fever of 102, leukocytosis of 14 and exam consistent with an acute pharyngitis. Likely bacterial vs viral. Lower concern for influenza (though clinical picture fits) given negative flu swab. HIV negative. Received both Pneicillin V and Unasyn in ED and was continued on Ampicillin-Sulbactam 3 g IV Q6H through night of ___. Discontinued on ___ due to low clinical suspicion for viral process. Symptom relief with viscous lidocaine, guafenasin ___ mL Q 6H. Viral and bacterial nasopharyngeal swab pending on discharge. Update: On ___, after discharge, group A strep throat culture result positive. Dr. ___ called patient to inform her of the results. Rx for Penicillin V 500mg TID for 10d, 0 refills called in to ___ # Shortness of breath. Not witnessed while patient on the floor. Thought to be ___ asthma exacerbation in ED though patient has no history of asthma and ENT exam in ED more consistent with stertor and oropharyngeal resonation rather than tracheobronchial narrowing and true wheeze. # Tachycardia. Likely a reaction to racemic epinephrine. Now rate wnl and patient is without palpitations, shortness of breath, or chest pain. Transitional Issues =================== - Patient's phone number for results: ___ - Viral culture, strep culture, and HIV test pending at time of discharge - Follow-up in ___ clinic in ___ weeks after discharge. Please call ___ (___) to schedule an appointment - Patient was on Ampicillin-Sulbactam 3 g IV Q6H while in the hospital, but this was discontinued due to Centor criteria of 1 and low suspicion for bacterial process. Please consider restarting amoxicillin if patient does not show signs of defervescence on follow up. - Patient triggered for tachycardia of 150 in ED in setting of racemic epinephrine administration (for presumed asthma exacerbation). By the time she presented to the medicine wards she was no longer experiencing shortness of breath or tachycardia. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Headache RX acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every six (6) hours Disp #120 Tablet Refills:0 2. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 3. GuaiFENesin ___ mL PO Q6H:PRN cough RX guaifenesin 100 mg/5 mL ___ ml by mouth every six (6) hours Refills:0 4. Multivitamins 1 TAB PO DAILY RX multivitamin 1 capsule(s) by mouth Daily Disp #30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary ======= Pharyngitis Shortness of Breath Tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure caring for you at ___ ___. You came to us with cough, shortness of breath and significant throat pain. You were treated with antibiotics in the emergency department and did well. Several tests were sent and are pending on discharge, but we feel comfortable letting you go with close follow up. Your pharyngitis is likely viral, please continue supportive care with cough syrup, lots of water and rest. If your symptoms do not improve in ___ days or if you experience any of the danger signs below, please call your primary care doctor or come to the emergency department immediately. Best Wishes, Your ___ Care Team Followup Instructions: ___	[ "J029", "R0602", "R000" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Shortness of breath, throat pain Major Surgical or Invasive Procedure: Bedside nasopharyngolaryngoscopy [MASKED] (by ENT in ED) History of Present Illness: Ms. [MASKED] is a very pleasant [MASKED] yo breastfeeding female with no significant past medical history who presents with 2 days of shortness of breath, tachypnea, and stridor. She reports that she experienced onset of cough, sore throat and subjective fevers on [MASKED] that progressed over the course of the next 1.5 days. She was unable to check her temperature at her shelter. On night of [MASKED] patient woke up with acute shortness of breath and aching, painful sensation in her throat, at which point she presented to the ED. Endorses +SOB, intermittent non-productive cough and wheezing at the time. She denies a history of asthma or reactive airway disease. She received the flu shot this year and says that she received all of her childhood vaccines in [MASKED] where she grew up. She has her baby [MASKED] here with her and is currently breastfeeding. In the ED, vitals were notable for Temp 102.9 HR 137 BP 144/65 RR 16 SaO2 98% RA Exam notable for mild stertor and expiratory wheezing, no stridor. Significant clear nasal secretions noted w/ posterior pharyngeal and arytenoid erythema but widely patent airway and no supraglottic or glottic edema. Visualized portion of subglottis is patent. Labs notable for 7.45 \| 31 \| 26 , K 2.9, phos 1.9 Imaging notable for normal CXR Patient was given albuterol, ipratropium, 1 g Tylenol, racemic epinephrine . 5 mL inhaled x 2, Penicillin V Potassium PO 500 mg x 2, Ampicillin-Sulbactam 3 g, magnesium sulfate 4 g. Patient was seen by ENT who recommended discontinuation of steroids and albuterol, continuation of unasyn, admission and pulm consult if upper airway symptoms persist Decision was made to admit for ongoing treatment and dispo During ED visit patient triggered for tachycardia to 150s. She reported discomfort in her throat but denied chest pain or pleuritic pain. Exam notable for significant wheezing. No rash was noted on exam, and there was no concern for allergic reaction to Augmentin or penicillin. On the floor, patient reports that she is overall doing better. Her main complaint is a sore, uncomfortable feeling in her throat made worse when swallowing. She denies current shortness of breath, wheezing, chills. Still with dry cough. Review of systems: (+) Per HPI Past Medical History: Depression Denies History of Asthma Social History: [MASKED] Family History: Great aunt- breast cancer, denies uterine, ovarian cancer Physical Exam: ADMISSION PHYSICAL ============= VS: Temp 98.4 BP 124/78 HR 100 RR 18 97%ra GENERAL: NAD, alert, interactive HEENT: NC/AT, sclerae anicteric, MMM. Punctate hemorrhage over hard palate, uvula midline. Erythema and cobblestoning over posterior pharynx, pathchy erethma over tonsils and anterior tonsillar fauces bilaterally, no tonsillar enlargement, no exudate. LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r. No stertor, wheezing noted currently. HEART: NRRR. No W/R/G ABDOMEN: NABS, soft/NT/ND. EXTREMITIES: WWP NEURO: awake, A&Ox3. [MASKED] strength and tone UE and LEs. DISCHARGE PHYSICAL ============= VS: Temp 98.1 BP 110 / 65 HR 79 RR 16 98%RA GENERAL: NAD, alert, interactive HEENT: NC/AT, sclerae anicteric, MMM. Still with punctate hemorrhage over hard palate, uvula midline. Erythema and cobblestoning over posterior pharynx, pathchy erethma over tonsils and anterior tonsillar fauces bilaterally, no tonsillar enlargement, no exudate. LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r. HEART: NRRR. No W/R/G ABDOMEN: NABS, soft/NT/ND. EXTREMITIES: WWP NEURO: awake, A&Ox3. [MASKED] strength and tone UE and LEs. STUDIES: Viral and bacterial throat cultures pending, HIV pending Pertinent Results: ADMISSION LABS =========== [MASKED] 02:33AM BLOOD WBC-14.2# RBC-4.72 Hgb-14.3 Hct-42.6 MCV-90 MCH-30.3 MCHC-33.6 RDW-12.6 RDWSD-41.4 Plt [MASKED] [MASKED] 02:33AM BLOOD Neuts-81.1 Lymphs-8.6* Monos-8.4 Eos-1.1 Baso-0.4 Im [MASKED] AbsNeut-11.48# AbsLymp-1.22 AbsMono-1.19 AbsEos-0.16 AbsBaso-0.05 [MASKED] 09:40AM BLOOD Glucose-144* UreaN-6 Creat-0.5 Na-141 K-2.9* Cl-102 HCO3-21* AnGap-21* [MASKED] 08:04AM BLOOD ALT-61* AST-33 LD(LDH)-176 AlkPhos-100 TotBili-0.3 [MASKED] 09:40AM BLOOD Calcium-9.2 Phos-1.9* Mg-2.2 [MASKED] 10:23AM BLOOD HIV Ab-Negative [MASKED] 09:46AM BLOOD [MASKED] pO2-26* pCO2-31* pH-7.45 calTCO2-22 Base XS--1 [MASKED] 09:25PM BLOOD [MASKED] pO2-149* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 Comment-PERIPHERAL [MASKED] 09:25PM BLOOD K-3.7 MICROBIOLOGY ========== [MASKED] 3:40 pm THROAT CULTURE *FINAL REPORT [MASKED] R/O Beta Strep Group A (Final [MASKED]: Reported to and read back by [MASKED] ON [MASKED] @ 2:50PM. BETA STREPTOCOCCUS GROUP A. RARE GROWTH. [MASKED] 12:00 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Pending): IMAGING ====== CXR [MASKED] Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal silhouette and well-aerated lungs without focal consolidation, pleural effusion, or pneumothorax. IMPRESSION: No acute cardiopulmonary process. 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], MD [MASKED], MD electronically signed on [MASKED] [MASKED] 8:36 AM Brief Hospital Course: Ms. [MASKED] is a very pleasant [MASKED] yo female with no significant past medical history who presented with 2 days of cough and acute shortness of breath. During the course of her hospital stay the following issues were addressed: # Pharyngitis. Ms. [MASKED] presented with sore throat, fever of 102, leukocytosis of 14 and exam consistent with an acute pharyngitis. Likely bacterial vs viral. Lower concern for influenza (though clinical picture fits) given negative flu swab. HIV negative. Received both Pneicillin V and Unasyn in ED and was continued on Ampicillin-Sulbactam 3 g IV Q6H through night of [MASKED]. Discontinued on [MASKED] due to low clinical suspicion for viral process. Symptom relief with viscous lidocaine, guafenasin [MASKED] mL Q 6H. Viral and bacterial nasopharyngeal swab pending on discharge. Update: On [MASKED], after discharge, group A strep throat culture result positive. Dr. [MASKED] called patient to inform her of the results. Rx for Penicillin V 500mg TID for 10d, 0 refills called in to [MASKED] # Shortness of breath. Not witnessed while patient on the floor. Thought to be [MASKED] asthma exacerbation in ED though patient has no history of asthma and ENT exam in ED more consistent with stertor and oropharyngeal resonation rather than tracheobronchial narrowing and true wheeze. # Tachycardia. Likely a reaction to racemic epinephrine. Now rate wnl and patient is without palpitations, shortness of breath, or chest pain. Transitional Issues =================== - Patient's phone number for results: [MASKED] - Viral culture, strep culture, and HIV test pending at time of discharge - Follow-up in [MASKED] clinic in [MASKED] weeks after discharge. Please call [MASKED] ([MASKED]) to schedule an appointment - Patient was on Ampicillin-Sulbactam 3 g IV Q6H while in the hospital, but this was discontinued due to Centor criteria of 1 and low suspicion for bacterial process. Please consider restarting amoxicillin if patient does not show signs of defervescence on follow up. - Patient triggered for tachycardia of 150 in ED in setting of racemic epinephrine administration (for presumed asthma exacerbation). By the time she presented to the medicine wards she was no longer experiencing shortness of breath or tachycardia. Medications on Admission: None Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Headache RX acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every six (6) hours Disp #120 Tablet Refills:0 2. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:0 3. GuaiFENesin [MASKED] mL PO Q6H:PRN cough RX guaifenesin 100 mg/5 mL [MASKED] ml by mouth every six (6) hours Refills:0 4. Multivitamins 1 TAB PO DAILY RX multivitamin 1 capsule(s) by mouth Daily Disp #30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary ======= Pharyngitis Shortness of Breath Tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. You came to us with cough, shortness of breath and significant throat pain. You were treated with antibiotics in the emergency department and did well. Several tests were sent and are pending on discharge, but we feel comfortable letting you go with close follow up. Your pharyngitis is likely viral, please continue supportive care with cough syrup, lots of water and rest. If your symptoms do not improve in [MASKED] days or if you experience any of the danger signs below, please call your primary care doctor or come to the emergency department immediately. Best Wishes, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[]	[ "J029: Acute pharyngitis, unspecified", "R0602: Shortness of breath", "R000: Tachycardia, unspecified" ]
19,979,239	26,031,061	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ year old female with L4-L5 left disc herniation and LLE radicular pain. Major Surgical or Invasive Procedure: Revision left L4-L5 microdiscectomy by Dr. ___ on ___ History of Present Illness: ___ year old female with Left L4-L5 disc herniation and LLE radiculopathy who has failed conservative therapies. Patient had h/o previous L4-L5 microdiscectomy by Dr. ___ in ___. Past Medical History: depression Social History: ___ Family History: nc Physical Exam: NAD, A&Ox4 nl resp effort RRR Sensory: ___ L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: ___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___ R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Pertinent Results: ___ 09:17PM WBC-6.4 RBC-4.53 HGB-13.5 HCT-40.0 MCV-88 MCH-29.8 MCHC-33.8 RDW-13.0 RDWSD-42.2 ___ 09:17PM GLUCOSE-82 UREA N-16 CREAT-0.9 SODIUM-142 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 Brief Hospital Course: Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a IV and PO pain medications. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed postoperatively without issue. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Sertraline 100 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Please obtain over the counter. 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #14 Capsule Refills:1 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #36 Tablet Refills:0 4. Gabapentin 600 mg PO TID 5. Sertraline 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left L4-L5 disc herniation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have undergone the following operation: Revision Microdiscectomy Immediately after the operation: Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without moving around. Rehabilitation/ Physical Therapy: ___ times a day you should go for a walk for ___ minutes as part of your recovery. You can walk as much as you can tolerate. Limit any kind of lifting. Diet: Eat a normal healthy diet. You may have some constipation after surgery. Brace: You do not need a brace. Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on ___. We are not allowed to call in narcotic prescriptions (oxycontin, oxycodone, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound Physical Therapy: No heavy lifting, twisting or bending for 6 weeks. Treatments Frequency: Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually ___ days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. Followup Instructions: ___	[ "M5116", "M48061", "F329" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: [MASKED] year old female with L4-L5 left disc herniation and LLE radicular pain. Major Surgical or Invasive Procedure: Revision left L4-L5 microdiscectomy by Dr. [MASKED] on [MASKED] History of Present Illness: [MASKED] year old female with Left L4-L5 disc herniation and LLE radiculopathy who has failed conservative therapies. Patient had h/o previous L4-L5 microdiscectomy by Dr. [MASKED] in [MASKED]. Past Medical History: depression Social History: [MASKED] Family History: nc Physical Exam: NAD, A&Ox4 nl resp effort RRR Sensory: [MASKED] L2 L3 L4 L5 S1 S2 (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh) R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor: [MASKED] Flex(L1) Add(L2) Quad(L3) TA(L4) [MASKED] [MASKED] R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Pertinent Results: [MASKED] 09:17PM WBC-6.4 RBC-4.53 HGB-13.5 HCT-40.0 MCV-88 MCH-29.8 MCHC-33.8 RDW-13.0 RDWSD-42.2 [MASKED] 09:17PM GLUCOSE-82 UREA N-16 CREAT-0.9 SODIUM-142 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 Brief Hospital Course: Patient was admitted to the [MASKED] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a IV and PO pain medications. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed postoperatively without issue. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Sertraline 100 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H Please obtain over the counter. 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #14 Capsule Refills:1 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #36 Tablet Refills:0 4. Gabapentin 600 mg PO TID 5. Sertraline 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left L4-L5 disc herniation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have undergone the following operation: Revision Microdiscectomy Immediately after the operation: Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without moving around. Rehabilitation/ Physical Therapy: [MASKED] times a day you should go for a walk for [MASKED] minutes as part of your recovery. You can walk as much as you can tolerate. Limit any kind of lifting. Diet: Eat a normal healthy diet. You may have some constipation after surgery. Brace: You do not need a brace. Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually [MASKED] days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [MASKED]. We are not allowed to call in narcotic prescriptions (oxycontin, oxycodone, percocet) to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up: Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound Physical Therapy: No heavy lifting, twisting or bending for 6 weeks. Treatments Frequency: Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually [MASKED] days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. Followup Instructions: [MASKED]	[]	[ "F329" ]	[ "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "F329: Major depressive disorder, single episode, unspecified" ]
19,979,275	20,033,240	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Depakote / gabapentin / morphine / naproxen Attending: ___. Chief Complaint: Seizure-Like Episodes Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: Mr. ___ is a ___ with a history of right occipital gliosarcoma s/p resection with residual left field defect, non-small cell carcinoma, and chronic dizziness who presented with seizure like episodes. He (with help from his family - wife, son, daughter at bedside) describes the episodes as left arm shaking, which evolves into to full-body tremulousness. He never loses consciousness and remembers the events, but he feels poorly for a few minutes prior. He notices that the events spontaneously happen when he lifts his left arm, just about every time he lifts it today, corroborated by his family. He feels like he has no control over it and that moving the arm exacerbates it. Per report, he had multiple episodes over the week prior to admission (1 on ___ and ___, at which time Dr. ___ his lamictal to 125mg twice daily, in addition to Vimpat 100mg twice daily. This initially resolved the issue for about 1 week. On ___, he was noted by his wife to have hand clenching and arching of his back; the episode lasted a minute or so. Based on this, Dr. ___ increased ___ to 150mg twice daily and started dexamethasone 2mg daily for concern for progression of his gliosarcoma. His MRI was moved up. However, he was then brought into the ED because of ongoing shaking and family concern for seizures. He is chronically dizzy with vertigo for which he has been going to vestibular ___ and getting Epley maneuvers, which he feels makes things worse. He has nausea with the vertigo but no vomiting. He reports double vision today but his family was very surprised by this. His left leg has been colder than the right for 4 days, but per family this is a baseline and people have compared pulses before. He has had chronic neck pain on the right side which is ongoing, perhaps worse over the past few days. He did have some chest pain on the drive in to the hospital, left and right sided, difficult to describe which resolved when he had settled down in the ED. Notably, his prior seizure episodes were staring episodes, on EEG found to arise from the right central parasagital region. In the ED, initial vitals were: 73 \| 111/76 \| 19 \| 97% RA . His neuro exam was noted to be nonfocal, notable for "some difficulties with memory and recounting event, tangential speech, left inferior quadrantanopia, decreased pinprick in the hands," and his family reportedly felt him to be at his baseline. Labs were notable for: 142 \| 102 \| 24 9.8 ---------------< 102 1.9 4.8 \| 24 \| 1.5 3.7 6.7 > 13.1/41.3 <229 N 75.2 AST 13, ALT 8, AP 89, Tbili 0.2, Alb4.4, Lipase 21 Neg serum tox Trio 0.01 ___ 11.6, PTT 36.4, INR 1.1 UA: Neg Imaging notable for an MR head with no acute findings. The patient was given IV lorazepam. Vitals prior to transfer: 98.8 \| 68 \| 128/79 24 \| 96% RA. Past Medical History: PAST ONCOLOGIC HISTORY, per primary oncologist note: (1) blurry vision and headache on ___, (2) ___ ___ head CT showed intracranial hemorrhage in the right occipital brain, (3) started on ___ levetiracetam 500 mg twice daily and dexamethasone 4 mg TID, (4) reportedly gross total resection on ___ ___. ___ by Dr. ___ (4) began ___ IMRT + temozolomide by Dr. ___, (5) dexamethasone reduced to 2 mg TID for insomnia in ___, (6) developed strange behavior on ___ with difficulty buttoning his shirt and word-finding difficulty, (7) developed right upper extremity tremor on ___, (8) ___ ED on ___ seizures, (9) admission to ___ ___ general neurology for seizures (10) EEG ___ to ___ showed 8 electrographic seizures in the right central parasagittal region lasting ___ minutes, (11) lacosamide 100 mg IV BID, fosphenytoin 100 mg IV Q8H added, (12) EEG ___ to ___ showed bursts of focal slowing at the right hemisphere, (13) resumed IMRT + TMZ on ___ at ___ to ___, (14) monthly TMZ x 11 cycles ended in ___, (15) both dexamethasone and Bactrim stopped in ___, 916) Pt noted to struggle with low mood in ___, which seemed to improve. PAST MEDICAL HISTORY: - NSCLC: a long standing smoker; developed a chronic cough. PCP sent him for a chest X-ray which revealed a LUL mass on ___. Staging scans were negative except for the lung. CT guided biopsy on ___ revealed non-small cell lung cancer consistent with squamous cell carcinoma. Power port was inserted ___. He was treated with chemo-irradiation at ___ Cancer radiation. Chest irradiation was applied to 6300 cGy and it ended ___. - CAD - HTN - HLD - Asthma - Anxiety - Degenerative disk disease PAST SURGICAL HISTORY - ___ CABG x3 vessel - ___ AAA repair Social History: ___ Family History: Father with alcohol use disorder and lung cancer. Mother with pancreatitis. Physical Exam: ======================== Admission Physical Exam: ======================== VS: 98.3 \| 131/79 \| 58 \| 19 \| 97%Ra GENERAL: Appears cachectic and fatigued. Laying in bed, looks uncomfortable, partially covering face with sheet, intermittently deferring to his wife ___ mucous membranes. Pupils 4mm and equally reactive to light (to 2mm). NECK: No concerning lymphadenopathy. Can turn neck complete to left, somewhat limited by pain (only about 45* on right) CV: RRR, no murmurs. PULM: CTAB without adventitious sounds. ABD: Scaphoid, soft, nontender, nondistended. EXT: WWP without edema. SKIN: No visible rashes. NEURO: Oriented to year, month; date "___ but knows his birthday is coming up. Somewhat confused on details of recent history (per family) and perseverating a bit on older history (eg, used to be strong enough to lift water buckets for work; now weaker than that). Face is grossly symmetric though beard may obscure a slight left lip droop. Strength and sensation on face are intact and symmetric. Tongue is midline with some jerking movmements intermittently. No dysarthria. Can follow two-step commands: use your left pointer finger to point at your son. Can name high and low frequency objects (though does steth-es-cope by syllables). He has large-amplitude jerking movement when he moves either his left shoulder or his left elbow, which can evolve into a whole body jerking movement during which he is still conscious; however, this can be suppressed by distraction, or by helping him get into position (eg, left arm outstretched) and then removing supporting hand. He has no cogwheel rigditiy. He has no asterixis or jerking on prolonged finger grip. His strength is grossly ___ in large muscle groups Sensation to light touch is grossly symmetric in upper extremities; lower extremities "left feels a little different." No pronator drift. Gait not assessed. Pertinent Results: =============== Admission Labs: =============== ___ 09:37PM BLOOD WBC-6.8 RBC-4.36* Hgb-13.1* Hct-41.3 MCV-95 MCH-30.0 MCHC-31.7* RDW-14.1 RDWSD-48.7* Plt ___ ___ 09:37PM BLOOD Neuts-75.2* Lymphs-15.7* Monos-7.3 Eos-0.6* Baso-0.9 Im ___ AbsNeut-5.12 AbsLymp-1.07* AbsMono-0.50 AbsEos-0.04 AbsBaso-0.06 ___ 09:39PM BLOOD ___ PTT-36.4 ___ ___ 09:37PM BLOOD Glucose-102* UreaN-24* Creat-1.5* Na-142 K-4.8 Cl-102 HCO3-24 AnGap-16 ___ 09:37PM BLOOD ALT-8 AST-13 AlkPhos-89 TotBili-0.2 ___ 09:37PM BLOOD Lipase-21 ___ 09:37PM BLOOD cTropnT-<0.01 ___ 09:37PM BLOOD Albumin-4.4 Calcium-9.8 Phos-3.7 Mg-1.9 ___ 09:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 09:39PM BLOOD Lactate-1.5 ======================== Discharge Physical Exam: ======================== ___ 06:19AM BLOOD WBC-6.4 RBC-4.38* Hgb-13.2* Hct-41.1 MCV-94 MCH-30.1 MCHC-32.1 RDW-14.0 RDWSD-49.1* Plt ___ ___ 06:19AM BLOOD Glucose-91 UreaN-19 Creat-1.2 Na-141 K-4.1 Cl-99 HCO3-31 AnGap-11 ___ 06:19AM BLOOD Calcium-9.8 Phos-4.2 Mg-2.1 ============= Microbiology: ============= ___ Urine Culture < 10,000 CFU/mL ======== Imaging: ======== 1. Redemonstrated postsurgical changes related to resection of previously noted right temporoparietal mass. 2. Thin linear enhancement along the inferolateral margin of the resection cavity appears unchanged. 3. The extent of FLAIR hyperintense signal surrounding the resection cavity and involving the splenium of the corpus callosum and white matter along the left occipital horn appears unchanged. 4. Interval decrease in size of a rounded nonenhancing focus within the dependent resection cavity, mild measuring 9 mm, previously measuring 17 mm on ___. Findings likely reflect clotted blood products with interval partial resorption. 5. No new region of FLAIR signal abnormality or enhancement is seen. Brief Hospital Course: ___ with a history of right occipital gliosarcoma s/p resection with residual left field defect, non-small cell carcinoma, and chronic dizziness who presented with seizure like episodes of left arm myoclonus and whole-body jerking, not associated with an aura or post-ictal state, which is suppressible on exam, but nonetheless potentially concerning for seizure activity. # Non-Epileptic Convulsions/Seizures: # Gliosarcoma: MRI brain was unchanged. Monitored on EEG without true seizures. He was continued on lamictal (recently increased as outpatient) and lacosamide. Continued dexamethasone. His symptoms were improved at discharge. He will follow-up with Dr. ___. # Acute Kidney Injury: Resolved with fluids. # Depression: His sertraline was increased to 100mg daily. He was continued on his other home medications. # Chronic Back Pain: Continued home oxycodone and oxycontin. # Hypertension: Continued home metoprolol. # Hyperlipidemia: Continued home pravastatin. # BILLING: 35 minutes were spent in preparation of discharge summary, coordination with outpatient providers, and counseling with patient/family. ==================== Transitional Issues: ==================== - Sertraline increased to 100mg daily. - Continued Lamictal 150mg BID and dexamethasone 2mg daily. - Please follow-up final EEG report from ___ and ___. - Please ensure follow-up with Dr. ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dexamethasone 2 mg PO DAILY 2. LACOSamide 100 mg PO BID 3. LamoTRIgine 150 mg PO BID 4. ALPRAZolam 0.5-1 mg PO BID:PRN anxiety 5. Metoprolol Succinate XL 25 mg PO BID 6. Pravastatin 20 mg PO QPM 7. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 8. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H 9. Omeprazole 20 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath/wheezing 13. Ipratropium Bromide MDI 2 PUFF IH BID:PRN shortness of breath/wheezing 14. ALPRAZolam 2 mg PO DAILY Discharge Medications: 1. Sertraline 100 mg PO DAILY RX sertraline 100 mg Take 1 tablet by mouth daily. Disp #30 Tablet Refills:2 2. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath/wheezing RX albuterol sulfate 90 mcg Take ___ puffs IH every six (6) hours Disp #1 Inhaler Refills:2 3. ALPRAZolam 0.5-1 mg PO BID:PRN anxiety 4. ALPRAZolam 2 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Dexamethasone 2 mg PO DAILY RX dexamethasone 2 mg Take 1 tablet by mouth daily. Disp #30 Tablet Refills:0 7. Ipratropium Bromide MDI 2 PUFF IH BID:PRN shortness of breath/wheezing 8. LACOSamide 100 mg PO BID 9. LamoTRIgine 150 mg PO BID RX lamotrigine 150 mg Take 1 tablet by mouth twice daily. Disp #60 Tablet Refills:2 10. Metoprolol Succinate XL 25 mg PO BID 11. Omeprazole 20 mg PO DAILY 12. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 13. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H 14. Pravastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Non-Epileptic Convulsions/Seizures - Acute Kidney Injury - Gliosarcoma - 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 Mr. ___, It was a pleasure taking care of you at the ___ ___. You were admitted with concern for seizure. You had a brain MRI that did not show any changes. You had an EEG that did show any true seizure activity. Your symptoms improved. Your lamictal and sertraline dose was increased. You will follow-up with Dr. ___. All the best, Your ___ Team Followup Instructions: ___	[ "G40909", "E43", "C712", "N179", "R64", "Z85118", "Z9221", "Z923", "I10", "J45909", "E785", "F419", "I2510", "Z951", "F17210", "Z6824", "H8120" ]	Allergies: Depakote / gabapentin / morphine / naproxen Chief Complaint: Seizure-Like Episodes Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: Mr. [MASKED] is a [MASKED] with a history of right occipital gliosarcoma s/p resection with residual left field defect, non-small cell carcinoma, and chronic dizziness who presented with seizure like episodes. He (with help from his family - wife, son, daughter at bedside) describes the episodes as left arm shaking, which evolves into to full-body tremulousness. He never loses consciousness and remembers the events, but he feels poorly for a few minutes prior. He notices that the events spontaneously happen when he lifts his left arm, just about every time he lifts it today, corroborated by his family. He feels like he has no control over it and that moving the arm exacerbates it. Per report, he had multiple episodes over the week prior to admission (1 on [MASKED] and [MASKED], at which time Dr. [MASKED] his lamictal to 125mg twice daily, in addition to Vimpat 100mg twice daily. This initially resolved the issue for about 1 week. On [MASKED], he was noted by his wife to have hand clenching and arching of his back; the episode lasted a minute or so. Based on this, Dr. [MASKED] increased [MASKED] to 150mg twice daily and started dexamethasone 2mg daily for concern for progression of his gliosarcoma. His MRI was moved up. However, he was then brought into the ED because of ongoing shaking and family concern for seizures. He is chronically dizzy with vertigo for which he has been going to vestibular [MASKED] and getting Epley maneuvers, which he feels makes things worse. He has nausea with the vertigo but no vomiting. He reports double vision today but his family was very surprised by this. His left leg has been colder than the right for 4 days, but per family this is a baseline and people have compared pulses before. He has had chronic neck pain on the right side which is ongoing, perhaps worse over the past few days. He did have some chest pain on the drive in to the hospital, left and right sided, difficult to describe which resolved when he had settled down in the ED. Notably, his prior seizure episodes were staring episodes, on EEG found to arise from the right central parasagital region. In the ED, initial vitals were: 73 \| 111/76 \| 19 \| 97% RA . His neuro exam was noted to be nonfocal, notable for "some difficulties with memory and recounting event, tangential speech, left inferior quadrantanopia, decreased pinprick in the hands," and his family reportedly felt him to be at his baseline. Labs were notable for: 142 \| 102 \| 24 9.8 ---------------< 102 1.9 4.8 \| 24 \| 1.5 3.7 6.7 > 13.1/41.3 <229 N 75.2 AST 13, ALT 8, AP 89, Tbili 0.2, Alb4.4, Lipase 21 Neg serum tox Trio 0.01 [MASKED] 11.6, PTT 36.4, INR 1.1 UA: Neg Imaging notable for an MR head with no acute findings. The patient was given IV lorazepam. Vitals prior to transfer: 98.8 \| 68 \| 128/79 24 \| 96% RA. Past Medical History: PAST ONCOLOGIC HISTORY, per primary oncologist note: (1) blurry vision and headache on [MASKED], (2) [MASKED] [MASKED] head CT showed intracranial hemorrhage in the right occipital brain, (3) started on [MASKED] levetiracetam 500 mg twice daily and dexamethasone 4 mg TID, (4) reportedly gross total resection on [MASKED] [MASKED]. [MASKED] by Dr. [MASKED] (4) began [MASKED] IMRT + temozolomide by Dr. [MASKED], (5) dexamethasone reduced to 2 mg TID for insomnia in [MASKED], (6) developed strange behavior on [MASKED] with difficulty buttoning his shirt and word-finding difficulty, (7) developed right upper extremity tremor on [MASKED], (8) [MASKED] ED on [MASKED] seizures, (9) admission to [MASKED] [MASKED] general neurology for seizures (10) EEG [MASKED] to [MASKED] showed 8 electrographic seizures in the right central parasagittal region lasting [MASKED] minutes, (11) lacosamide 100 mg IV BID, fosphenytoin 100 mg IV Q8H added, (12) EEG [MASKED] to [MASKED] showed bursts of focal slowing at the right hemisphere, (13) resumed IMRT + TMZ on [MASKED] at [MASKED] to [MASKED], (14) monthly TMZ x 11 cycles ended in [MASKED], (15) both dexamethasone and Bactrim stopped in [MASKED], 916) Pt noted to struggle with low mood in [MASKED], which seemed to improve. PAST MEDICAL HISTORY: - NSCLC: a long standing smoker; developed a chronic cough. PCP sent him for a chest X-ray which revealed a LUL mass on [MASKED]. Staging scans were negative except for the lung. CT guided biopsy on [MASKED] revealed non-small cell lung cancer consistent with squamous cell carcinoma. Power port was inserted [MASKED]. He was treated with chemo-irradiation at [MASKED] Cancer radiation. Chest irradiation was applied to 6300 cGy and it ended [MASKED]. - CAD - HTN - HLD - Asthma - Anxiety - Degenerative disk disease PAST SURGICAL HISTORY - [MASKED] CABG x3 vessel - [MASKED] AAA repair Social History: [MASKED] Family History: Father with alcohol use disorder and lung cancer. Mother with pancreatitis. Physical Exam: ======================== Admission Physical Exam: ======================== VS: 98.3 \| 131/79 \| 58 \| 19 \| 97%Ra GENERAL: Appears cachectic and fatigued. Laying in bed, looks uncomfortable, partially covering face with sheet, intermittently deferring to his wife [MASKED] mucous membranes. Pupils 4mm and equally reactive to light (to 2mm). NECK: No concerning lymphadenopathy. Can turn neck complete to left, somewhat limited by pain (only about 45* on right) CV: RRR, no murmurs. PULM: CTAB without adventitious sounds. ABD: Scaphoid, soft, nontender, nondistended. EXT: WWP without edema. SKIN: No visible rashes. NEURO: Oriented to year, month; date "[MASKED] but knows his birthday is coming up. Somewhat confused on details of recent history (per family) and perseverating a bit on older history (eg, used to be strong enough to lift water buckets for work; now weaker than that). Face is grossly symmetric though beard may obscure a slight left lip droop. Strength and sensation on face are intact and symmetric. Tongue is midline with some jerking movmements intermittently. No dysarthria. Can follow two-step commands: use your left pointer finger to point at your son. Can name high and low frequency objects (though does steth-es-cope by syllables). He has large-amplitude jerking movement when he moves either his left shoulder or his left elbow, which can evolve into a whole body jerking movement during which he is still conscious; however, this can be suppressed by distraction, or by helping him get into position (eg, left arm outstretched) and then removing supporting hand. He has no cogwheel rigditiy. He has no asterixis or jerking on prolonged finger grip. His strength is grossly [MASKED] in large muscle groups Sensation to light touch is grossly symmetric in upper extremities; lower extremities "left feels a little different." No pronator drift. Gait not assessed. Pertinent Results: =============== Admission Labs: =============== [MASKED] 09:37PM BLOOD WBC-6.8 RBC-4.36* Hgb-13.1* Hct-41.3 MCV-95 MCH-30.0 MCHC-31.7* RDW-14.1 RDWSD-48.7* Plt [MASKED] [MASKED] 09:37PM BLOOD Neuts-75.2* Lymphs-15.7* Monos-7.3 Eos-0.6* Baso-0.9 Im [MASKED] AbsNeut-5.12 AbsLymp-1.07* AbsMono-0.50 AbsEos-0.04 AbsBaso-0.06 [MASKED] 09:39PM BLOOD [MASKED] PTT-36.4 [MASKED] [MASKED] 09:37PM BLOOD Glucose-102* UreaN-24* Creat-1.5* Na-142 K-4.8 Cl-102 HCO3-24 AnGap-16 [MASKED] 09:37PM BLOOD ALT-8 AST-13 AlkPhos-89 TotBili-0.2 [MASKED] 09:37PM BLOOD Lipase-21 [MASKED] 09:37PM BLOOD cTropnT-<0.01 [MASKED] 09:37PM BLOOD Albumin-4.4 Calcium-9.8 Phos-3.7 Mg-1.9 [MASKED] 09:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 09:39PM BLOOD Lactate-1.5 ======================== Discharge Physical Exam: ======================== [MASKED] 06:19AM BLOOD WBC-6.4 RBC-4.38* Hgb-13.2* Hct-41.1 MCV-94 MCH-30.1 MCHC-32.1 RDW-14.0 RDWSD-49.1* Plt [MASKED] [MASKED] 06:19AM BLOOD Glucose-91 UreaN-19 Creat-1.2 Na-141 K-4.1 Cl-99 HCO3-31 AnGap-11 [MASKED] 06:19AM BLOOD Calcium-9.8 Phos-4.2 Mg-2.1 ============= Microbiology: ============= [MASKED] Urine Culture < 10,000 CFU/mL ======== Imaging: ======== 1. Redemonstrated postsurgical changes related to resection of previously noted right temporoparietal mass. 2. Thin linear enhancement along the inferolateral margin of the resection cavity appears unchanged. 3. The extent of FLAIR hyperintense signal surrounding the resection cavity and involving the splenium of the corpus callosum and white matter along the left occipital horn appears unchanged. 4. Interval decrease in size of a rounded nonenhancing focus within the dependent resection cavity, mild measuring 9 mm, previously measuring 17 mm on [MASKED]. Findings likely reflect clotted blood products with interval partial resorption. 5. No new region of FLAIR signal abnormality or enhancement is seen. Brief Hospital Course: [MASKED] with a history of right occipital gliosarcoma s/p resection with residual left field defect, non-small cell carcinoma, and chronic dizziness who presented with seizure like episodes of left arm myoclonus and whole-body jerking, not associated with an aura or post-ictal state, which is suppressible on exam, but nonetheless potentially concerning for seizure activity. # Non-Epileptic Convulsions/Seizures: # Gliosarcoma: MRI brain was unchanged. Monitored on EEG without true seizures. He was continued on lamictal (recently increased as outpatient) and lacosamide. Continued dexamethasone. His symptoms were improved at discharge. He will follow-up with Dr. [MASKED]. # Acute Kidney Injury: Resolved with fluids. # Depression: His sertraline was increased to 100mg daily. He was continued on his other home medications. # Chronic Back Pain: Continued home oxycodone and oxycontin. # Hypertension: Continued home metoprolol. # Hyperlipidemia: Continued home pravastatin. # BILLING: 35 minutes were spent in preparation of discharge summary, coordination with outpatient providers, and counseling with patient/family. ==================== Transitional Issues: ==================== - Sertraline increased to 100mg daily. - Continued Lamictal 150mg BID and dexamethasone 2mg daily. - Please follow-up final EEG report from [MASKED] and [MASKED]. - Please ensure follow-up with Dr. [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dexamethasone 2 mg PO DAILY 2. LACOSamide 100 mg PO BID 3. LamoTRIgine 150 mg PO BID 4. ALPRAZolam 0.5-1 mg PO BID:PRN anxiety 5. Metoprolol Succinate XL 25 mg PO BID 6. Pravastatin 20 mg PO QPM 7. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 8. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H 9. Omeprazole 20 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN shortness of breath/wheezing 13. Ipratropium Bromide MDI 2 PUFF IH BID:PRN shortness of breath/wheezing 14. ALPRAZolam 2 mg PO DAILY Discharge Medications: 1. Sertraline 100 mg PO DAILY RX sertraline 100 mg Take 1 tablet by mouth daily. Disp #30 Tablet Refills:2 2. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN shortness of breath/wheezing RX albuterol sulfate 90 mcg Take [MASKED] puffs IH every six (6) hours Disp #1 Inhaler Refills:2 3. ALPRAZolam 0.5-1 mg PO BID:PRN anxiety 4. ALPRAZolam 2 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Dexamethasone 2 mg PO DAILY RX dexamethasone 2 mg Take 1 tablet by mouth daily. Disp #30 Tablet Refills:0 7. Ipratropium Bromide MDI 2 PUFF IH BID:PRN shortness of breath/wheezing 8. LACOSamide 100 mg PO BID 9. LamoTRIgine 150 mg PO BID RX lamotrigine 150 mg Take 1 tablet by mouth twice daily. Disp #60 Tablet Refills:2 10. Metoprolol Succinate XL 25 mg PO BID 11. Omeprazole 20 mg PO DAILY 12. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 13. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H 14. Pravastatin 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Non-Epileptic Convulsions/Seizures - Acute Kidney Injury - Gliosarcoma - 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 Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]. You were admitted with concern for seizure. You had a brain MRI that did not show any changes. You had an EEG that did show any true seizure activity. Your symptoms improved. Your lamictal and sertraline dose was increased. You will follow-up with Dr. [MASKED]. All the best, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "N179", "I10", "J45909", "E785", "F419", "I2510", "Z951", "F17210" ]	[ "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "E43: Unspecified severe protein-calorie malnutrition", "C712: Malignant neoplasm of temporal lobe", "N179: Acute kidney failure, unspecified", "R64: Cachexia", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "H8120: Vestibular neuronitis, unspecified ear" ]
19,979,275	25,621,728	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: Depakote / gabapentin / morphine / naproxen Attending: ___. Chief Complaint: Seizure Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ right-handed man with a history of glial sarcoma who presents with seizures. He presented to ___ on ___ with blurry vision and headache, and CT scan showed intracranial hemorrhage. Subsequent workup revealed a tumor which was quickly resected by neurosurgery on ___. He has residual partial left visual field deficit which has since improved. One month later he began chemotherapy with temozolomide 140mg daily, and radiation 5 days per week. He was also started on Keppra 500 mg twice daily, as well as Decadron 4 mg TID. Two weeks ago the Decadron was reduced to 2mg TID due to insomnia. Earlier this week on ___, he was noted to be "not himself" was having difficulty buttoning his shirt and finding words. The next day during his radiation treatment his Decadron was increased back to 4 mg. On ___ he seems to be back to his baseline. However on ___ morning he was again having difficulty buttoning his shirt and seems to be "off" according to his son and wife. He underwent radiation, then when he was back home was noted to be acting strangely. His son observed him standing in the bathroom holding a towel between his hands, trembling, and appearing confused. He was moving very slowly as they went to the kitchen. He had trouble using a straw. He was able to speak but was very slow, and his hands are trembling. Then, while standing in the kitchen he had a five-minute staring spell looking at his son the entire time. He was unresponsive to commands and did not appear to track some. He then recovered somewhat, but remained tremulous and confused. His son gave him a drink of water, and he again froze, this time holding the water in his mouth for over 2 minutes. His son called ___ and sat down in the chair. He then vomited, and immediately returned to his "100%" baseline, better than he had been all week. He was taken to ___ ___ morning. In the ED he had another episode. He remembers saying "I am not taking any more steroids", then his family reports he became unresponsive for ~2 minutes, staring straight ahead. He had eyelid fluttering for another ___ minutes, then shaking of his lower legs (possibly synchronously, according to son), and both hands (which were under the covers). He then became heaving, then vomited, after which he again returned to his completely normal baseline. He was admitted to the hospital and appeared well during the overnight admission. His Keppra was increased from 500mg BID to ___ BID. He was discharged ___ morning, and on the way home they stopped at a store. He had another episode while lifting up his wife's purse, he became unresponsive and would not follow commands to let go. His wife again called ___. This episode was shorter lasting only 5 minutes and was not followed by emesis. Repeat CT at ___ showed unchanged edema, and the physician did not think his seizures were associated with the edema, so he was transferred to ___ for further management. He had another brief episode in the ambulance which was reportedly aborted by Ativan. In the ED here ~6:30pm, he had another episode with both hands shaking and unreponsiveness, though he appeared to regard. He does not have clear memory during the middle of these episodes, though says he did remember saying "I'm not taking more steroids" before one episode, and typically remembers vomiting afterwards. He says that the chemotherapy makes him feel "drunk" every time he takes it. ROS: As per HPI. Past Medical History: AAA s/p repair (___) 3-vessel bypass (___) Left-upper lobe lung ___ (___) s/p chemo x2, rads x7 weeks. HTN HLD Anxiety Degenerative disc disease Social History: ___ Family History: Retired ___. Smokes ___ cigarettes per day for the last ___ years. Does not drink alcohol. Physical Exam: ADMISSION PHYSICAL ======================= Vitals: T: 98.2 BP: 153/87 HR: 85 RR: 18 SaO2: 95% -General: Awake, cooperative, NAD. -HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. -Neck: Supple. No nuchal rigidity. -Cardiac: 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. NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Wife and son presented majority of history, while he only occasionally chimed in. Unable to name ___ backwards ("I won't be able to do that" before trying), though able to give ___ backwards albeit slowly. Language is fluent with intact repetition and comprehension. Normal prosody. There are no paraphasic errors. Able to name both high and low frequency objects (cuticle). Speech is not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 5 minutes (answered others correctly only with multiple choice). There is no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation and no extinction. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 1 2 2 1 R 2 1 2 2 1 Plantar response was flexor bilaterally. -Coordination: Bilateral postural tremor (L>R). No dysmetria on FNF. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. DISCHARGE EXAM: ======================= 24 HR Data (last updated ___ @ 451) Temp: 97.5 (Tm 98.6), BP: 162/93 (131-162/72-93), HR: 80 (80-101), RR: 18 (___), O2 sat: 97% (94-97%), O2 delivery: ra GENERAL: Pleasant man laying in bed in no acute distress. HEENT: Linear surgical scar noted over right occipital skull. Pupils equal round reactive to light, extraocular movements intact, left upper peripheral visual field defect. Moist mucous membranes, good dentition. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi, rales HEART: Normal rate and regular rhythm. Normal S1, S2, no murmurs auscultated. ABD: Normal bowel sounds. Nondistended, nontender, normal bowel sounds. EXT: Warm with 2+ dorsal pedis and tibialis posterior pulses SKIN: Warm no rashes. NEURO: Cranial nerves grossly intact, moving all extremities, no focal deficit. ACCESS: Peripheral IV Pertinent Results: ADMISSION LABS: ==================== ___ 04:30PM BLOOD WBC-8.7 RBC-4.53* Hgb-14.4 Hct-41.7 MCV-92 MCH-31.8 MCHC-34.5 RDW-16.2* RDWSD-54.4* Plt ___ ___ 05:34PM BLOOD ___ PTT-24.6* ___ ___ 04:30PM BLOOD Glucose-132* UreaN-25* Creat-1.1 Na-136 K-4.3 Cl-95* HCO3-25 AnGap-16 ___ 04:30PM BLOOD ALT-35 AST-25 AlkPhos-56 TotBili-0.5 ___ 04:30PM BLOOD cTropnT-<0.01 ___ 04:30PM BLOOD Lipase-20 ___ 04:30PM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.9 Mg-2.2 ___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DIAGNOSTIC STUDIES: ===================== MR ___ ___: 1. Large late subacute intraparenchymal hemorrhage within the right occipital and posterior temporal lobes, with partial effacement of the occipital horn of the right lateral ventricle, but no shift of midline structures or mass effect on basal cisterns. 2. Encephalomalacia in the posterior right occipital lobe likely represents the surgical cavity. Surrounding T2 hyperintensity extending to the atrium of the right lateral ventricle, without prior MRI for comparison. No nodular enhancement is identified. 3. Please note that the inferior portions of the cerebellar hemispheres are not adequately imaged. EEG ___: This is an abnormal continuous EEG monitoring study because of eight electrographic seizures originating in the right central/parasagittal region lasting ___ minutes. Clinically, the patient is able to converse at the beginning of these events however he becomes progressively more tremulous with difficulty communicating as the event progresses. After the sharply contoured rhythmic activity ceases, there is relatively rapid return of baseline and he is able to converse and perform routine activities such as eating. The background is mildly disorganized suggesting a mild encephalopathy. This is a nonspecific finding with regards to etiology but can be seen in the setting of toxic/metabolic derangements, anoxia, medication affect. There is diffuse overriding fast activity which is typically seen in the setting of medication affect, i.e. benzodiazepines and barbiturates. There are multiple pushbutton activation for patient tremulousness or difficulty moving his upper extremities which are associated with electrographic seizures. After the patient receives IV lorazepam, there is improvement in the background and no further discrete electrographic seizures. However there continue to be periods of rhythmic slowing lasting seconds at a time while the patient appears to be sleeping. EEG ___: This is an abnormal continuous EEG monitoring study because of focal slowing most prominent over the right parasagittal region consistent with the area of cerebral dysfunction in this region. There are also bursts of focal slowing over the right hemisphere consistent with subcortical or deep midline dysfunction. There is a mildly disorganized background consistent with a mild encephalopathy. This is a nonspecific finding with regards to etiology but can be seen in the setting of toxic/metabolic derangements, anoxia, and medication effect. There is diffuse overriding fast activity which is typically seen in the setting of medications, i.e. benzodiazepines and barbiturates. There are multiple pushbutton activations for decreased responsiveness or patient tremulousness, which are at times associated with delta slowing most prominent over the right posterior quadrant. When compared to the previous day's study, there are no further electrographic seizures, which is an overall improvement. EEG ___: This is an abnormal continuous EEG monitoring study because of focal slowing most prominent over the right parasagittal region consistent with the area of cerebral dysfunction in this region. There are also bursts of focal slowing over the right hemisphere consistent with subcortical or deep midline dysfunction. There is a disorganized background consistent with a mild-moderate encephalopathy. This is a nonspecific finding with regards to etiology but can be seen in the setting of toxic/metabolic derangements, anoxia, and medication effect. There is diffuse overriding fast activity which is typically seen in the setting of medications, i.e. benzodiazepines and barbiturates. There are multiple pushbutton activations for decreased responsiveness or patient tremulousness, which are at times associated with delta slowing most prominent over the right posterior quadrant, however this slowing is also present at other times when the button is not pressed. Compared to the previous day's study, there are prolonged periods with prominent delta slowing which is an overall worsening. CHEST X-RAY ___ There are low lung volumes. This causes crowding the bronchovascular markings and exaggeration of heart size. The study is compromised secondary to patient positioning. The heart is not enlarged. With there may be pulmonary vascular congestion versus supine positioning. There is a grossly stable left upper lobe mass. There are no large pleural effusions. Degenerative changes are seen in the spine. Sternal wires appear intact. CT ___ ___: Stable subacute parenchymal hematoma, surrounding posttreatment changes. Mass effect on the atrium right lateral ventricle, mild prominence of the right temporal horn, similar. No new hemorrhage. INTERVAL LABS ================== ___ 06:55AM BLOOD Glucose-93 UreaN-20 Creat-1.3* Na-143 K-4.0 Cl-103 HCO3-27 AnGap-13 ___ 08:03PM BLOOD Phenyto-19.8 ___ 05:40AM BLOOD Phenyto-17.8 ___ 06:18AM BLOOD Phenyto-13.3 MICRO ================== URINE CULTURE (Final ___: < 10,000 CFU/mL. DISCHARGE LABS =================== ___ 07:05AM BLOOD WBC-7.4 RBC-4.01* Hgb-13.0* Hct-37.9* MCV-95 MCH-32.4* MCHC-34.3 RDW-15.8* RDWSD-54.6* Plt ___ ___ 07:05AM BLOOD Glucose-129* UreaN-15 Creat-1.1 Na-145 K-4.5 Cl-105 HCO3-27 AnGap-13 ___ 07:35AM BLOOD Calcium-8.2* Phos-2.1* Mg-2.0 Brief Hospital Course: Mr. ___ is a ___ year old male with history of lung ___ ___ year ago, in remission), R temporal gliosarcoma s/p resection 1 month ago, with a hemorrhage at the resection site since 1 week prior to admission who presents with frequent seizures characterized by staring, decreased responsiveness, nonspecific arm raise and tremor. He was initially on the neurology service until his seizures were controlled then transferred to the oncology service where the decision was made to resume outpatient radiation. ACUTE ISSUES ======================= #Seizures Keppra had been recently increased to 1000 mg BID prior to admission. It was further increased to 1500mg BID upon admission. During the first day of admission, the patient had 8 electro clinical seizures arising from deep midline with generalization bilaterally. He has given lacosamide 200 mg IV load, and continued on 200mg BID. The second day of admission, the patient continued to have clinical events, but no longer had EEG correlate. As the semiology was very similar, it was felt that these were epileptic seizures with a deep seizure focus that is difficult to capture on EEG. The seizures are characterized by suddenly decreased responsiveness with arm tremor with nonspecific reaching or picking movements in either arm. He is intermittently responsive to simple yes/no questions and intermittently follows simple commands with delay during the seizures. The event ends with slowly improving mental status, and it is difficult to tell when the seizure ends vs postictal state. The patient was loaded with phenytoin on ___, and had decreased episodes of paroxysmal poor responsiveness. However, he became more encephalopathic, and phenytoin was discontinued on ___. He continued on keppra and lacosamide without further clinical seizures between ___ - ___. Patient pulled off his EEG leads but clinically improved therefore was kept of EEG monitoring. #Encephalopathy: By ___, he became more encephalopathic and agitated. He had been conversant and appropriate on ___. CT ___ was obtained which was stable. Evaluation for infectious etiology was negative with blood and urine cultures. Patient had a mild leukocytosis on ___ that downtrended thereafter and was not febrile. His mental status change was attributed to multiple AEDs, mild benzodiazepine withdrawal (patient refusing home PO doses), and hospital acquired delirium. Given urgency of radiation planning, patient was given 5mg zyprexa IM BID to help him stay calm during procedures. Home Ativan was converted to IV Ativan (1.5mg q6hours) to avoid benzodiazepine withdrawal, as patient otherwise often refused PO medications. His mental status improved throughout the admission and was able to tolerate PO medications. #Tachycardia: On the day of discharge patient was working with occupational therapy he became tachycardic to 139 with standing and walking. EKG showed sinus tachycardia. He received 500cc bolus with resolution of his orthostatic tachycardia and his heart rates were in the ___ with ambulation. # Gliosarcoma MRI showed significant edema in R posterior temporal lobe that was stable. A small area of bleeding was stable, and per family had been present postoperatively. Neuro-oncology was consulted during admission. Radiation oncology was involved to consider transfer radiation plan to ___ but plan was made to resume his outpatient radiation at ___ since it was closer to home. Patient underwent CT mapping with radiation oncology on ___ and was transferred to the oncology service for further management. He was continued on dexamethasone 4mg q8 hours and temazolamide was resumed when he was taking PO at 140mg qdaily. CHRONIC ISSUES ===================== # Hypertension Patient was continued on home antihypertensives. Losartan was added for anti-inflammatory benefit. He had elevated blood pressures to 140-150s systolic while agitated. # Hyperlipidemia # CAD s/p CABG Patient was on rosuvastatin at home. Statin was switched to pravastatin which has some anti-inflammatory benefit. Patient has been off aspirin since initial presentation for gliosarcoma due to concern for worsening hemorrhage. ================== MEDICATION CHANGES ================== Keppra dose increased from 1000 mg twice a day to 1500 mg twice a day due to recurrent seizures on lower dose. -Started on lacosamide 200 mg twice a day for control of recurrent seizures. -Losartan 25 mg daily was started in the neuro ICU for blood pressure control and anti-inflammatory benefits. -Home rosuvastatin was changed to pravastatin 20 mg nightly as pravastatin is thought to have added anti-inflammatory benefits. -Patient discharged on home Bactrim as prophylaxis for steroids. Additionally, omeprazole 20 mg daily was started for GI ppx. -Patient given script for nicotine patch at discharge. =================== TRANSITIONAL ISSUES =================== [] Gliosarcoma: Plan to resume radiation at ___ ___ on ___. [] Mild anemia at the time of discharge (___), likely due to phlebotomy. Please follow-up at next appointment. [] Patient discharged with home ___, OT, and ___ for rehabilitation and medication management. [] Patient should not be alone walking outside as he is a high fall risk. [] Due to seizures, patient should not drive for 6 months or until cleared by MD. #HCP/CONTACT: Name of health care proxy: ___ Relationship: Wife Phone: ___ #CODE STATUS: Full confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LevETIRAcetam 1000 mg PO BID 2. Dexamethasone 4 mg PO Q8H 3. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 4. ALPRAZolam 0.5-1 mg PO TID 5. Xanax XR (ALPRAZolam) 3 mg oral QAM 6. amLODIPine 5 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO BID 8. OxyCODONE SR (OxyconTIN) 15 mg PO Q12H 9. Rosuvastatin Calcium 20 mg PO QPM 10. Sertraline 33 mg PO DAILY 11. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) 12. Temodar (temozolomide) 140 mg oral DAILY Discharge Medications: 1. LACOSamide 200 mg PO BID RX lacosamide [Vimpat] 200 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 2. Losartan Potassium 25 mg PO DAILY RX losartan 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Nicotine Patch 21 mg TD DAILY RX nicotine 21 mg/24 hour apply patch to arm once daily Disp #30 Patch Refills:0 4. Omeprazole 20 mg PO DAILY RX omeprazole 20 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 5. Pravastatin 20 mg PO QPM RX pravastatin 20 mg 1 tablet(s) by mouth once daily at bedtime Disp #30 Tablet Refills:0 6. LevETIRAcetam 1500 mg PO Q12H RX levetiracetam [Keppra] 750 mg 2 tablet(s) by mouth twice a day Disp #120 Tablet Refills:0 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 8. ALPRAZolam 0.5-1 mg PO TID 9. amLODIPine 5 mg PO DAILY 10. Dexamethasone 4 mg PO Q8H 11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 12. Metoprolol Succinate XL 25 mg PO BID 13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 14. OxyCODONE SR (OxyconTIN) 15 mg PO Q12H 15. Sertraline 100 mg PO DAILY 16. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___) 17. Temodar (temozolomide) 140 mg oral DAILY 18. Xanax XR (ALPRAZolam) 3 mg oral QAM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis ===================== Focal seizure with altered awareness Secondary diagnoses ======================== Gliosarcoma Hypovolemia Encephalopathy Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? -You were admitted to the Neurology service due to frequent seizures. WHAT HAPPENED WHILE YOU WERE HERE? -We were initially on the Neurology service. The neurologists felt your seizures were related to your tumor resection and a small area of bleeding that is irritating the brain. -After your seizures were under control, he was transferred to the oncology service for evaluation for radiation therapy for your brain ___. -Your mental status got much better while you were in the hospital. -You were seen by the physical therapist and occupational therapists who felt it was safe for you to go home. You will have occupational and physical therapy while you are at home. -We decided it would be better for you to get your radiation closer to home so we set up outpatient follow-up with Dr. ___. You will start radiation again on ___. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - Continue taking all of your home medications. - Please follow up with neuro-oncology and radiation oncology. Your appointments are listed below. - Please make sure to stay well hydrated and drink plenty of water. - Because you had seizures, you are legally not allowed to drive a car. Please do not start driving for at least 6 months or until your doctor says its safe for you to drive. Sincerely, Your ___ Neurology Team. Followup Instructions: ___	[ "G40909", "I611", "G9340", "F05", "C7931", "N179", "I10", "E785", "I2510", "M545", "G8929", "F419", "D72829", "D696", "E876", "E861", "R000", "D649", "F329", "R413", "F17210", "Z781", "Z951", "Z85118" ]	Allergies: Depakote / gabapentin / morphine / naproxen Chief Complaint: Seizure Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] is a [MASKED] right-handed man with a history of glial sarcoma who presents with seizures. He presented to [MASKED] on [MASKED] with blurry vision and headache, and CT scan showed intracranial hemorrhage. Subsequent workup revealed a tumor which was quickly resected by neurosurgery on [MASKED]. He has residual partial left visual field deficit which has since improved. One month later he began chemotherapy with temozolomide 140mg daily, and radiation 5 days per week. He was also started on Keppra 500 mg twice daily, as well as Decadron 4 mg TID. Two weeks ago the Decadron was reduced to 2mg TID due to insomnia. Earlier this week on [MASKED], he was noted to be "not himself" was having difficulty buttoning his shirt and finding words. The next day during his radiation treatment his Decadron was increased back to 4 mg. On [MASKED] he seems to be back to his baseline. However on [MASKED] morning he was again having difficulty buttoning his shirt and seems to be "off" according to his son and wife. He underwent radiation, then when he was back home was noted to be acting strangely. His son observed him standing in the bathroom holding a towel between his hands, trembling, and appearing confused. He was moving very slowly as they went to the kitchen. He had trouble using a straw. He was able to speak but was very slow, and his hands are trembling. Then, while standing in the kitchen he had a five-minute staring spell looking at his son the entire time. He was unresponsive to commands and did not appear to track some. He then recovered somewhat, but remained tremulous and confused. His son gave him a drink of water, and he again froze, this time holding the water in his mouth for over 2 minutes. His son called [MASKED] and sat down in the chair. He then vomited, and immediately returned to his "100%" baseline, better than he had been all week. He was taken to [MASKED] [MASKED] morning. In the ED he had another episode. He remembers saying "I am not taking any more steroids", then his family reports he became unresponsive for ~2 minutes, staring straight ahead. He had eyelid fluttering for another [MASKED] minutes, then shaking of his lower legs (possibly synchronously, according to son), and both hands (which were under the covers). He then became heaving, then vomited, after which he again returned to his completely normal baseline. He was admitted to the hospital and appeared well during the overnight admission. His Keppra was increased from 500mg BID to [MASKED] BID. He was discharged [MASKED] morning, and on the way home they stopped at a store. He had another episode while lifting up his wife's purse, he became unresponsive and would not follow commands to let go. His wife again called [MASKED]. This episode was shorter lasting only 5 minutes and was not followed by emesis. Repeat CT at [MASKED] showed unchanged edema, and the physician did not think his seizures were associated with the edema, so he was transferred to [MASKED] for further management. He had another brief episode in the ambulance which was reportedly aborted by Ativan. In the ED here ~6:30pm, he had another episode with both hands shaking and unreponsiveness, though he appeared to regard. He does not have clear memory during the middle of these episodes, though says he did remember saying "I'm not taking more steroids" before one episode, and typically remembers vomiting afterwards. He says that the chemotherapy makes him feel "drunk" every time he takes it. ROS: As per HPI. Past Medical History: AAA s/p repair ([MASKED]) 3-vessel bypass ([MASKED]) Left-upper lobe lung [MASKED] ([MASKED]) s/p chemo x2, rads x7 weeks. HTN HLD Anxiety Degenerative disc disease Social History: [MASKED] Family History: Retired [MASKED]. Smokes [MASKED] cigarettes per day for the last [MASKED] years. Does not drink alcohol. Physical Exam: ADMISSION PHYSICAL ======================= Vitals: T: 98.2 BP: 153/87 HR: 85 RR: 18 SaO2: 95% -General: Awake, cooperative, NAD. -HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. -Neck: Supple. No nuchal rigidity. -Cardiac: 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. NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Wife and son presented majority of history, while he only occasionally chimed in. Unable to name [MASKED] backwards ("I won't be able to do that" before trying), though able to give [MASKED] backwards albeit slowly. Language is fluent with intact repetition and comprehension. Normal prosody. There are no paraphasic errors. Able to name both high and low frequency objects (cuticle). Speech is not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall [MASKED] at 5 minutes (answered others correctly only with multiple choice). There is no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation and no extinction. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [MASKED] L 5 [MASKED] [MASKED] 5 5 5 5 5 R 5 [MASKED] [MASKED] 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. -DTRs: Bi Tri [MASKED] Pat Ach L 2 1 2 2 1 R 2 1 2 2 1 Plantar response was flexor bilaterally. -Coordination: Bilateral postural tremor (L>R). No dysmetria on FNF. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Romberg absent. DISCHARGE EXAM: ======================= 24 HR Data (last updated [MASKED] @ 451) Temp: 97.5 (Tm 98.6), BP: 162/93 (131-162/72-93), HR: 80 (80-101), RR: 18 ([MASKED]), O2 sat: 97% (94-97%), O2 delivery: ra GENERAL: Pleasant man laying in bed in no acute distress. HEENT: Linear surgical scar noted over right occipital skull. Pupils equal round reactive to light, extraocular movements intact, left upper peripheral visual field defect. Moist mucous membranes, good dentition. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi, rales HEART: Normal rate and regular rhythm. Normal S1, S2, no murmurs auscultated. ABD: Normal bowel sounds. Nondistended, nontender, normal bowel sounds. EXT: Warm with 2+ dorsal pedis and tibialis posterior pulses SKIN: Warm no rashes. NEURO: Cranial nerves grossly intact, moving all extremities, no focal deficit. ACCESS: Peripheral IV Pertinent Results: ADMISSION LABS: ==================== [MASKED] 04:30PM BLOOD WBC-8.7 RBC-4.53* Hgb-14.4 Hct-41.7 MCV-92 MCH-31.8 MCHC-34.5 RDW-16.2* RDWSD-54.4* Plt [MASKED] [MASKED] 05:34PM BLOOD [MASKED] PTT-24.6* [MASKED] [MASKED] 04:30PM BLOOD Glucose-132* UreaN-25* Creat-1.1 Na-136 K-4.3 Cl-95* HCO3-25 AnGap-16 [MASKED] 04:30PM BLOOD ALT-35 AST-25 AlkPhos-56 TotBili-0.5 [MASKED] 04:30PM BLOOD cTropnT-<0.01 [MASKED] 04:30PM BLOOD Lipase-20 [MASKED] 04:30PM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.9 Mg-2.2 [MASKED] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG DIAGNOSTIC STUDIES: ===================== MR [MASKED] [MASKED]: 1. Large late subacute intraparenchymal hemorrhage within the right occipital and posterior temporal lobes, with partial effacement of the occipital horn of the right lateral ventricle, but no shift of midline structures or mass effect on basal cisterns. 2. Encephalomalacia in the posterior right occipital lobe likely represents the surgical cavity. Surrounding T2 hyperintensity extending to the atrium of the right lateral ventricle, without prior MRI for comparison. No nodular enhancement is identified. 3. Please note that the inferior portions of the cerebellar hemispheres are not adequately imaged. EEG [MASKED]: This is an abnormal continuous EEG monitoring study because of eight electrographic seizures originating in the right central/parasagittal region lasting [MASKED] minutes. Clinically, the patient is able to converse at the beginning of these events however he becomes progressively more tremulous with difficulty communicating as the event progresses. After the sharply contoured rhythmic activity ceases, there is relatively rapid return of baseline and he is able to converse and perform routine activities such as eating. The background is mildly disorganized suggesting a mild encephalopathy. This is a nonspecific finding with regards to etiology but can be seen in the setting of toxic/metabolic derangements, anoxia, medication affect. There is diffuse overriding fast activity which is typically seen in the setting of medication affect, i.e. benzodiazepines and barbiturates. There are multiple pushbutton activation for patient tremulousness or difficulty moving his upper extremities which are associated with electrographic seizures. After the patient receives IV lorazepam, there is improvement in the background and no further discrete electrographic seizures. However there continue to be periods of rhythmic slowing lasting seconds at a time while the patient appears to be sleeping. EEG [MASKED]: This is an abnormal continuous EEG monitoring study because of focal slowing most prominent over the right parasagittal region consistent with the area of cerebral dysfunction in this region. There are also bursts of focal slowing over the right hemisphere consistent with subcortical or deep midline dysfunction. There is a mildly disorganized background consistent with a mild encephalopathy. This is a nonspecific finding with regards to etiology but can be seen in the setting of toxic/metabolic derangements, anoxia, and medication effect. There is diffuse overriding fast activity which is typically seen in the setting of medications, i.e. benzodiazepines and barbiturates. There are multiple pushbutton activations for decreased responsiveness or patient tremulousness, which are at times associated with delta slowing most prominent over the right posterior quadrant. When compared to the previous day's study, there are no further electrographic seizures, which is an overall improvement. EEG [MASKED]: This is an abnormal continuous EEG monitoring study because of focal slowing most prominent over the right parasagittal region consistent with the area of cerebral dysfunction in this region. There are also bursts of focal slowing over the right hemisphere consistent with subcortical or deep midline dysfunction. There is a disorganized background consistent with a mild-moderate encephalopathy. This is a nonspecific finding with regards to etiology but can be seen in the setting of toxic/metabolic derangements, anoxia, and medication effect. There is diffuse overriding fast activity which is typically seen in the setting of medications, i.e. benzodiazepines and barbiturates. There are multiple pushbutton activations for decreased responsiveness or patient tremulousness, which are at times associated with delta slowing most prominent over the right posterior quadrant, however this slowing is also present at other times when the button is not pressed. Compared to the previous day's study, there are prolonged periods with prominent delta slowing which is an overall worsening. CHEST X-RAY [MASKED] There are low lung volumes. This causes crowding the bronchovascular markings and exaggeration of heart size. The study is compromised secondary to patient positioning. The heart is not enlarged. With there may be pulmonary vascular congestion versus supine positioning. There is a grossly stable left upper lobe mass. There are no large pleural effusions. Degenerative changes are seen in the spine. Sternal wires appear intact. CT [MASKED] [MASKED]: Stable subacute parenchymal hematoma, surrounding posttreatment changes. Mass effect on the atrium right lateral ventricle, mild prominence of the right temporal horn, similar. No new hemorrhage. INTERVAL LABS ================== [MASKED] 06:55AM BLOOD Glucose-93 UreaN-20 Creat-1.3* Na-143 K-4.0 Cl-103 HCO3-27 AnGap-13 [MASKED] 08:03PM BLOOD Phenyto-19.8 [MASKED] 05:40AM BLOOD Phenyto-17.8 [MASKED] 06:18AM BLOOD Phenyto-13.3 MICRO ================== URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. DISCHARGE LABS =================== [MASKED] 07:05AM BLOOD WBC-7.4 RBC-4.01* Hgb-13.0* Hct-37.9* MCV-95 MCH-32.4* MCHC-34.3 RDW-15.8* RDWSD-54.6* Plt [MASKED] [MASKED] 07:05AM BLOOD Glucose-129* UreaN-15 Creat-1.1 Na-145 K-4.5 Cl-105 HCO3-27 AnGap-13 [MASKED] 07:35AM BLOOD Calcium-8.2* Phos-2.1* Mg-2.0 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with history of lung [MASKED] [MASKED] year ago, in remission), R temporal gliosarcoma s/p resection 1 month ago, with a hemorrhage at the resection site since 1 week prior to admission who presents with frequent seizures characterized by staring, decreased responsiveness, nonspecific arm raise and tremor. He was initially on the neurology service until his seizures were controlled then transferred to the oncology service where the decision was made to resume outpatient radiation. ACUTE ISSUES ======================= #Seizures Keppra had been recently increased to 1000 mg BID prior to admission. It was further increased to 1500mg BID upon admission. During the first day of admission, the patient had 8 electro clinical seizures arising from deep midline with generalization bilaterally. He has given lacosamide 200 mg IV load, and continued on 200mg BID. The second day of admission, the patient continued to have clinical events, but no longer had EEG correlate. As the semiology was very similar, it was felt that these were epileptic seizures with a deep seizure focus that is difficult to capture on EEG. The seizures are characterized by suddenly decreased responsiveness with arm tremor with nonspecific reaching or picking movements in either arm. He is intermittently responsive to simple yes/no questions and intermittently follows simple commands with delay during the seizures. The event ends with slowly improving mental status, and it is difficult to tell when the seizure ends vs postictal state. The patient was loaded with phenytoin on [MASKED], and had decreased episodes of paroxysmal poor responsiveness. However, he became more encephalopathic, and phenytoin was discontinued on [MASKED]. He continued on keppra and lacosamide without further clinical seizures between [MASKED] - [MASKED]. Patient pulled off his EEG leads but clinically improved therefore was kept of EEG monitoring. #Encephalopathy: By [MASKED], he became more encephalopathic and agitated. He had been conversant and appropriate on [MASKED]. CT [MASKED] was obtained which was stable. Evaluation for infectious etiology was negative with blood and urine cultures. Patient had a mild leukocytosis on [MASKED] that downtrended thereafter and was not febrile. His mental status change was attributed to multiple AEDs, mild benzodiazepine withdrawal (patient refusing home PO doses), and hospital acquired delirium. Given urgency of radiation planning, patient was given 5mg zyprexa IM BID to help him stay calm during procedures. Home Ativan was converted to IV Ativan (1.5mg q6hours) to avoid benzodiazepine withdrawal, as patient otherwise often refused PO medications. His mental status improved throughout the admission and was able to tolerate PO medications. #Tachycardia: On the day of discharge patient was working with occupational therapy he became tachycardic to 139 with standing and walking. EKG showed sinus tachycardia. He received 500cc bolus with resolution of his orthostatic tachycardia and his heart rates were in the [MASKED] with ambulation. # Gliosarcoma MRI showed significant edema in R posterior temporal lobe that was stable. A small area of bleeding was stable, and per family had been present postoperatively. Neuro-oncology was consulted during admission. Radiation oncology was involved to consider transfer radiation plan to [MASKED] but plan was made to resume his outpatient radiation at [MASKED] since it was closer to home. Patient underwent CT mapping with radiation oncology on [MASKED] and was transferred to the oncology service for further management. He was continued on dexamethasone 4mg q8 hours and temazolamide was resumed when he was taking PO at 140mg qdaily. CHRONIC ISSUES ===================== # Hypertension Patient was continued on home antihypertensives. Losartan was added for anti-inflammatory benefit. He had elevated blood pressures to 140-150s systolic while agitated. # Hyperlipidemia # CAD s/p CABG Patient was on rosuvastatin at home. Statin was switched to pravastatin which has some anti-inflammatory benefit. Patient has been off aspirin since initial presentation for gliosarcoma due to concern for worsening hemorrhage. ================== MEDICATION CHANGES ================== Keppra dose increased from 1000 mg twice a day to 1500 mg twice a day due to recurrent seizures on lower dose. -Started on lacosamide 200 mg twice a day for control of recurrent seizures. -Losartan 25 mg daily was started in the neuro ICU for blood pressure control and anti-inflammatory benefits. -Home rosuvastatin was changed to pravastatin 20 mg nightly as pravastatin is thought to have added anti-inflammatory benefits. -Patient discharged on home Bactrim as prophylaxis for steroids. Additionally, omeprazole 20 mg daily was started for GI ppx. -Patient given script for nicotine patch at discharge. =================== TRANSITIONAL ISSUES =================== [] Gliosarcoma: Plan to resume radiation at [MASKED] [MASKED] on [MASKED]. [] Mild anemia at the time of discharge ([MASKED]), likely due to phlebotomy. Please follow-up at next appointment. [] Patient discharged with home [MASKED], OT, and [MASKED] for rehabilitation and medication management. [] Patient should not be alone walking outside as he is a high fall risk. [] Due to seizures, patient should not drive for 6 months or until cleared by MD. #HCP/CONTACT: Name of health care proxy: [MASKED] Relationship: Wife Phone: [MASKED] #CODE STATUS: Full confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LevETIRAcetam 1000 mg PO BID 2. Dexamethasone 4 mg PO Q8H 3. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 4. ALPRAZolam 0.5-1 mg PO TID 5. Xanax XR (ALPRAZolam) 3 mg oral QAM 6. amLODIPine 5 mg PO DAILY 7. Metoprolol Succinate XL 25 mg PO BID 8. OxyCODONE SR (OxyconTIN) 15 mg PO Q12H 9. Rosuvastatin Calcium 20 mg PO QPM 10. Sertraline 33 mg PO DAILY 11. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK ([MASKED]) 12. Temodar (temozolomide) 140 mg oral DAILY Discharge Medications: 1. LACOSamide 200 mg PO BID RX lacosamide [Vimpat] 200 mg 1 tablet(s) by mouth twice daily Disp #60 Tablet Refills:0 2. Losartan Potassium 25 mg PO DAILY RX losartan 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Nicotine Patch 21 mg TD DAILY RX nicotine 21 mg/24 hour apply patch to arm once daily Disp #30 Patch Refills:0 4. Omeprazole 20 mg PO DAILY RX omeprazole 20 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 5. Pravastatin 20 mg PO QPM RX pravastatin 20 mg 1 tablet(s) by mouth once daily at bedtime Disp #30 Tablet Refills:0 6. LevETIRAcetam 1500 mg PO Q12H RX levetiracetam [Keppra] 750 mg 2 tablet(s) by mouth twice a day Disp #120 Tablet Refills:0 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 8. ALPRAZolam 0.5-1 mg PO TID 9. amLODIPine 5 mg PO DAILY 10. Dexamethasone 4 mg PO Q8H 11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 12. Metoprolol Succinate XL 25 mg PO BID 13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 14. OxyCODONE SR (OxyconTIN) 15 mg PO Q12H 15. Sertraline 100 mg PO DAILY 16. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK ([MASKED]) 17. Temodar (temozolomide) 140 mg oral DAILY 18. Xanax XR (ALPRAZolam) 3 mg oral QAM Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Primary diagnosis ===================== Focal seizure with altered awareness Secondary diagnoses ======================== Gliosarcoma Hypovolemia Encephalopathy Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], WHY WERE YOU ADMITTED TO THE HOSPITAL? -You were admitted to the Neurology service due to frequent seizures. WHAT HAPPENED WHILE YOU WERE HERE? -We were initially on the Neurology service. The neurologists felt your seizures were related to your tumor resection and a small area of bleeding that is irritating the brain. -After your seizures were under control, he was transferred to the oncology service for evaluation for radiation therapy for your brain [MASKED]. -Your mental status got much better while you were in the hospital. -You were seen by the physical therapist and occupational therapists who felt it was safe for you to go home. You will have occupational and physical therapy while you are at home. -We decided it would be better for you to get your radiation closer to home so we set up outpatient follow-up with Dr. [MASKED]. You will start radiation again on [MASKED]. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - Continue taking all of your home medications. - Please follow up with neuro-oncology and radiation oncology. Your appointments are listed below. - Please make sure to stay well hydrated and drink plenty of water. - Because you had seizures, you are legally not allowed to drive a car. Please do not start driving for at least 6 months or until your doctor says its safe for you to drive. Sincerely, Your [MASKED] Neurology Team. Followup Instructions: [MASKED]	[]	[ "N179", "I10", "E785", "I2510", "G8929", "F419", "D696", "D649", "F329", "F17210", "Z951" ]	[ "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I611: Nontraumatic intracerebral hemorrhage in hemisphere, cortical", "G9340: Encephalopathy, unspecified", "F05: Delirium due to known physiological condition", "C7931: Secondary malignant neoplasm of brain", "N179: Acute kidney failure, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M545: Low back pain", "G8929: Other chronic pain", "F419: Anxiety disorder, unspecified", "D72829: Elevated white blood cell count, unspecified", "D696: Thrombocytopenia, unspecified", "E876: Hypokalemia", "E861: Hypovolemia", "R000: Tachycardia, unspecified", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "R413: Other amnesia", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z781: Physical restraint status", "Z951: Presence of aortocoronary bypass graft", "Z85118: Personal history of other malignant neoplasm of bronchus and lung" ]
19,979,360	22,648,194	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weight gain and dyspnea Major Surgical or Invasive Procedure: Right heart cath ___ Tricuspid valve mitraclip ___ History of Present Illness: ___ with PMHx of HFrEF ___ iCMP (LVEF ___, CAD s/p anterior MI (___), HTN, HLD, DM, s/p BIVICD w/ RA lead replacement, severe tricuspid regurgitation, moderate mitral regurgitation s/p mitral clip x2 (___), who presented to the ___ with worsening dyspnea and ___ weight gain now being admitted for CHF exacerbation He was hospitalized in ___ for an acute heart failure exacerbation was diuresed with Lasix drip of 30 mg/hr and ultimately discharged with a dry weight dry weight of 125.7 lbs. At the end of that admission the patient opted to trial ___ medical therapy and was started on lisinopril 2.5mg QD, metoprolol 12.5 XL, spironolactone 25mg daily. After that admission he had ongoing symptoms and in ___ and had an elective MitraClip for his severe regurgitation and refractory heart failure. He was diuresed another 15lbs with 10L removed with a Lasix drip and transitioned to PO torsemide 80 BID with the plan to continue the metoprolol and spironolactone, but hold the lisinopril to give room for disuresis. At some point following discharge, he and his wife were told to hold the metoprolol and spironolactone due to low blood pressures, although they are unclear which one. Since his last discharge, started to slowly and progressively gain weight with ___ edema. He was evaluated in the ___ where his wt was 159 lbs and he was found to be volume overloaded on exam. He was started on a Lasix gtt of 10mg with a bolus of 160mg IV X1. He was admitted for IV diuresis and when euvolemic, evaluation for possible tricuspid valve repair. On the floor, pt endorses the history above. He endorses ___ edema, orthopnea at baseline. Denies fatigue, CP, palpitations, PND. REVIEW OF SYSTEMS: Positive per HPI. All of the other review of systems were negative. Past Medical History: 1. Heart failure with reduced ejection fraction * ___ CRT-D 2. Severe mitral regurgitation 3. Severe tricuspid regurgitation 4. Hypertension 5. Dyslipidemia 6. Status post pacemaker 7. Chronic kidney disease 8. Thrombocytopenia * Per hematology consult, felt to be due to congestive hepatopathy/cardiac cirrhosis Social History: ___ Family History: 1 brother with a stroke 1 brother with a heart attack in his ___ Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: ___ Temp: 97.9 PO BP: 102/62 HR: 77 RR: 18 O2 sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ GENERAL: Appears comfortable. Somewhat confused. No carotid bruits. HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP to the angle of the jaw accentuated by HJR. CARDIAC: Regular rate and rhythm, systolic murmur that radiates to the axilla, S3 present. LUNGS: Diminished breath sounds tat bases No wheezes or rhonchi. ABDOMEN: Soft, NT ND No hepatomegaly. No splenomegaly. EXTREMITIES: WWP, 2+ edema through the thigh. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM ======================== Pertinent Results: ADMISSION LABS =============== ___ 03:30PM BLOOD WBC-5.0 RBC-2.88* Hgb-8.9* Hct-28.6* MCV-99* MCH-30.9 MCHC-31.1* RDW-14.6 RDWSD-53.0* Plt Ct-90* ___ 03:30PM BLOOD ___ PTT-32.0 ___ ___ 03:30PM BLOOD Glucose-39* UreaN-21* Creat-1.1 Na-142 K-3.3* Cl-101 HCO3-26 AnGap-15 ___ 03:30PM BLOOD ALT-23 AST-38 LD(LDH)-336* AlkPhos-240* Amylase-82 TotBili-0.9 ___ 03:30PM BLOOD Lipase-40 ___ 03:30PM BLOOD proBNP-62___* ___ 11:20PM BLOOD Calcium-8.3* Phos-4.0 Mg-2.2 DISCHARGE LABS =============== MICROBIOLOGY ============= None IMAGING ======== TTE (___) -------------- CONCLUSION: The left atrial volume index is SEVERELY increased. The right atrium is markedly enlarged. The estimated right atrial pressure is >15mmHg. There is normal left ventricular wall thickness with a SEVERELY increased/ dilated cavity. There is SEVERE global left ventricular hypokinesis. No thrombus or mass is seen in the left ventricle. Quantitative 3D volumetric left ventricular ejection fraction is 14 %. Due to severity of mitral regurgitation, intrinsic left ventricular systolic function likely be lower. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). SEVERELY dilated right ventricular cavity with SEVERE global free wall hypokinesis. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.5-1.9 cm2). There is no aortic regurgitation. A MitraClip prosthesis is present. The prosthesis is well-seated with thickened leaflets but normal motion. There is a central jet of moderate [2+] mitral regurgitation. The pulmonic valve leaflets are mildly thickened. There is mild pulmonic regurgitation. The tricuspid valve leaflets are mildly thickened. There is SEVERE [4+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Severely dilated left and right ventricles with severe global biventricular hypokinesis. Mitraclips in place with moderate mitral regurgitation. Severe tricuspid regurgitation. At least moderate pulmonary hypertension. TTE (___) --------------- CONCLUSION: The left atrial volume index is SEVERELY increased. The right atrium is markedly enlarged. There is normal left ventricular wall thickness with a SEVERELY increased/dialted cavity. There is SEVERE global left ventricular hypokinesis with near akinesis of the apical ___ of the ventricle which is also aneurysmal. No thrombus or mass is seen in the left ventricle. The visually estimated left ventricular ejection fraction is <=20%. Due to severity of mitral regurgitation, intrinsic left ventricular systolic function likely be lower. Moderately dilated right ventricular cavity with SEVERE global free wall hypokinesis. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic valve leaflets (?#) are mildly thickened. There is no aortic regurgitation. A MitraClip prosthesis is present. The MitraClip is attached to both leaflets, with thin/mobile leaflets and normal mean gradient. There is moderate [2+] mitral regurgitation. There is moderate to severe [3+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Biventricular cavity dilation with severe global hypokinesis most c/w multivessel CAD or other diffuse process. Moderate to severe tricuspid regurgitation. Moderate mitral regurgitation. Compared with the prior TTE (images reviewed) of ___, the findings are similar. CLINICAL IMPLICATIONS: Based on the echocardiographic findings and ___ ACC/AHA recommendations, antibiotic prophylaxis IS recommended prior to dental cleanings and other non-sterile procedures. The patient's LVEF is less than 40%; a threshold for which they may benefit from a beta blocker and an ACE inhibitor or ___. RIGHT HEART CATH (___) Elevated right heart filling pressure.- unable to obtain access to PA or PCWP but RA and RV pressures measured = mean RA pressure 11 mmHg with V wave to 20 mmHg. CXR (___) --------------- FINDINGS: A left chest Wall AICD with 4 leads is again present. A mitral clip is unchanged. There is no focal consolidation, pleural effusion or pneumothorax. Size of the cardiac silhouette remains massively enlarged. IMPRESSION: No acute cardiopulmonary abnormality TRANS-ESOPHAGEAL ECHO ___ The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (LVEF= 10 %). Right ventricular chamber size and free wall motion are mildly reduced. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. Mild (1+) mitral regurgitation is seen. Prior mitraclip in mitral position seen in good position. The tricuspid valve leaflets are moderately thickened. There is a minimal increased gradient consistent with trivial tricuspid stenosis. Severe [4+] tricuspid regurgitation is seen. There is no pericardial effusion. Patient is status post mitraclip placement in the tricuspid position. Intraoperative echocardiography performed for guidance of mitraclip placement in tricuspid position for severe TR. No pericardial effusion. Mitraclip in tricuspid position appears in good position with right ventricular pacing lead unchanged. Tricuspid valve mean gradient 2.2 mm Hg, peak gradient 6 mmHg with residual moderate TR. TRANSTHORACIC ECHO ___ The left atrial volume index is SEVERELY increased. There is normal left ventricular wall thickness with a SEVERELY increased/dilated cavity. There is SEVERE global left ventricular hypokinesis. No thrombus or mass is seen in the left ventricle. The visually estimated left ventricular ejection fraction is 15%. There is no resting left ventricular outflow tract gradient. Moderately dilated right ventricular cavity with moderate global free wall hypokinesis. The aortic sinus is mildly dilated with normal ascending aorta diameter for gender. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. A MitraClip prosthesis is present. The MitraClip is attached to both leaflets and normal mean gradient. There is moderate mitral chordal thickening. There is moderate [2+] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. MitraClip prosthesis is present. The MitraClip(s) appear to be well attached. There is moderate to severe [3+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is moderate pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Dilated left ventricle with severe global LV systolic dysfunction. Moderate right ventricular systolic dysfunction. Well-seated mitral clip (x2) with moderate residual mitral regurgitation. Well-seated tricuspid clip with moderate to severe residual tricuspid regurgitation. At least moderate pulmonary hypertension. Compared with the prior TTE ___, tricuspid regurgitation has perhaps slightly decreased in severity, although the change isn't by any means dramatic. Brief Hospital Course: SUMMARY: --------- ___ with PMHx of HFrEF ___ iCMP (LVEF ___, CAD s/p anterior MI (___), HTN, HLD, DM, s/p BIVICD w/ RA lead replacement, severe tricuspid regurgitation, moderate mitral regurgitation s/p mitral clip x2 (___), who presented to the ___ with worsening dyspnea and ___ weight gain admitted for CHF exacerbation diuresed on a Lasix gtt and then right heart cathed on ___. He was recommended for inpatient tricuspid valve clip, which was done on ___. ACTIVE ISSUES: ============== #Acute Decompensated Heart Failure: #Ischemic Cardiomyopathy HFrEF EF15%: Patient initially presented to the ___ after recent hospitalizations with worsening heart failure symptoms, 30lb weight gain, and volume overload on exam. He was diuresed in the CDAC prior to admission with a Lasix gtt and Lasix 160 mg IV prior to being transferred to the floor for further diuresis. His exacerbation was likely due in part to his severe ischemic cardiomyopathy complicated by valvular disease and discontinuation of beta blockade, afterload reduction and neurohormonal blockade. He reportedly had his home goal directed therapy discontinued for low blood pressure incidentally noticed by his home ___. On the floor he was diuresed with IV Lasix gtt up to 30 mg/hr and Diuril 250 mg IV boluses. He was eventually transitioned to Torsemide 100 mg BID. He also had a right heart cath on ___ and appeared to be euvolemic with a RA pressure of 11; his RV pressure was ___ with a mean of 11 with an inability to obtain PA pressures or a wedge pressure. His dry weight on the day of discharge was 59.9 kg. His final heart failure regimen is listed below. Also of note after discussion about etiology and whether his heart failure was truly ischemic we attempted to obtain records from ___. Patient has no recorded left heart cath after discussion with Dr. ___ (his outpatient cardiologist). The low heart rate on his pacemaker was increased from 50 bpm to 70 bpm so that patient could be restarted on metoprolol succinate XL for optimal HFrEF therapy. DIURESIS: Torsemide 100 mg BID AFTERLOAD: Lisinopril 2.5 mg QD Spironolactone 25 mg QD NHBK: Metoprolol succinate XL 12.5 mg QD Spironolactone 25mg QD #Mitral regurgitation s/p Mitral Clip #Tricuspid regurgitation s/p tricuspid clip The patient was evaluated by structural cardiac team and was recommended for inpatient tricuspid clip, which was done on ___. PACU course was complicated by hypotension to the 60-80 systolic/40 diastolic. He was given 1.5 L of fluid and started on phenylephrine. He was transferred to the CCU. He received additional volume repletion and was weaned off pressors. His post-procedure TTE showed slight improvement in tricuspid regurgitation. His preload and afterload reducing medications were held while he was recovering from hypotension, but were successfully reintroduced within several days. #DMII: Patient had very poorly controlled sugars during his hospital stay. Upon further discussion with the patient, it appears that the patient has an inconsistent and poorly developed plan for managing his insulin regimen and his sugars. The team spoke to his wife who said that the patient manages his diabetes on his own and that she is not involved. The ___ Diabetes service was consulted to help manage his insulin regimen and to recommend the best discharge plan for him, especially given his suspected dementia (most recent MOCA of 14). Chronic Issues: ================= #HTN: Started on lisinopril 2.5mg Continued home spironolactone 25mg once daily #CAD: Continued home atorvastatin, clopidogrel, and aspirin #Cognitive impairment Patient without history of cognitive impairment noted but concern during prior admissions. OT was consulted and say needs help with 100% of IADLs. MOCA ___ was 14. TRANSITIONAL ISSUES: ===================== [] HFrEF - Patient had his pacer limit increased to 70 from 50. [] HFrEF - He was discharged on 100mg BID of his torsemide which was an increase from his prior home dose of 80mg BID. [] HFrEF - He was re-started on afterload reduction with lisinopril 2.5mg daily and spironolactone 25mg once daily. Recommend repeat Chem-10 in 1 week of discharge. [] HFrEF - Patient started on metoprolol, lisinopril, and spironolactone at low doses, please monitor for hypotension as patient was hypotensive on higher doses previously and had these medications discontinued. Of note, patients BPs were stable on this regimen prior to discharge. [] Diabetes - Patient should be assessed further on ability to correctly administer and calculate insulin dosing. Patient's wife should partake in diabetes education and insulin management with patient. Wife was unable to come to the hospital to receive insulin training during the holidays. Recommend further simplification of insulin regimen and follow-up with ___ ___ as scheduled. Outpatient providers to consider initiation of Empagliflozin. [] Dementia - Consider neurocognitive testing and geriatrics referral for the patient for formal diagnosis. #CODE STATUS: Full #CONTACT: ___ (wife/primary contact) ___ ___ (son) ___ Discharge Weight: 59.5kg/131.17lbs Discharge Cr: 1.1 Discharge Hgb: 9.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Torsemide 80 mg PO BID 4. Vitamin D ___ UNIT PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Calcium Carbonate 600 mg PO DAILY 7. Glargine 22 Units Bedtime 8. Potassium Chloride 10 mEq PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Glargine 22 Units Breakfast Insulin SC Sliding Scale using Novolog Insulin 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Calcium Carbonate 600 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Ferrous Sulfate 325 mg PO DAILY 7. Torsemide 80 mg PO BID RX torsemide 20 mg 4 tablet(s) by mouth twice daily Disp #200 Tablet Refills:*0 8. Vitamin D ___ UNIT PO DAILY 9. HELD- Potassium Chloride 10 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until repeat labs are done and you talk to your PCP ___: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Acute on chronic HFrEF exacerbation Hypertension Coronary Artery Disease SECONDARY DIAGNOSES =================== Mitral regurgitation s/p mitral clip Tricuspid regurgitation Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Confused - sometimes. 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 ADMITTED TO THE HOSPITAL? - You were admitted because you had worsening of your heart failure symptoms, including shortness of breath and weight gain. WHAT WAS DONE WHILE I WAS HERE? - You were given medications to get the fluid out of your lungs and out of your legs. - You were given medications to treat your heart failure. - You had an echocardiogram done, which is an ultrasound of your heart that takes pictures of your heart. - You had a right heart catheterization done, which is a procedure in which we placed a tube in your neck vein to look at your heart internally to see how it was functioning. WHAT DO I NEED TO DO ONCE I LEAVE? - Please continue taking all of your medications as prescribed. - Please keep all of your follow-up appointments. - Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. - We recommend that you do not drive until you discuss your ability to safely do so with your primary doctor ___ well, Your ___ Care Team Followup Instructions: ___	[ "I130", "I5023", "E871", "N189", "I255", "I2510", "I252", "E785", "E1022", "E1065", "I081", "I9581", "D696", "G3184", "Z7902", "Z794", "Z45018" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weight gain and dyspnea Major Surgical or Invasive Procedure: Right heart cath [MASKED] Tricuspid valve mitraclip [MASKED] History of Present Illness: [MASKED] with PMHx of HFrEF [MASKED] iCMP (LVEF [MASKED], CAD s/p anterior MI ([MASKED]), HTN, HLD, DM, s/p BIVICD w/ RA lead replacement, severe tricuspid regurgitation, moderate mitral regurgitation s/p mitral clip x2 ([MASKED]), who presented to the [MASKED] with worsening dyspnea and [MASKED] weight gain now being admitted for CHF exacerbation He was hospitalized in [MASKED] for an acute heart failure exacerbation was diuresed with Lasix drip of 30 mg/hr and ultimately discharged with a dry weight dry weight of 125.7 lbs. At the end of that admission the patient opted to trial [MASKED] medical therapy and was started on lisinopril 2.5mg QD, metoprolol 12.5 XL, spironolactone 25mg daily. After that admission he had ongoing symptoms and in [MASKED] and had an elective MitraClip for his severe regurgitation and refractory heart failure. He was diuresed another 15lbs with 10L removed with a Lasix drip and transitioned to PO torsemide 80 BID with the plan to continue the metoprolol and spironolactone, but hold the lisinopril to give room for disuresis. At some point following discharge, he and his wife were told to hold the metoprolol and spironolactone due to low blood pressures, although they are unclear which one. Since his last discharge, started to slowly and progressively gain weight with [MASKED] edema. He was evaluated in the [MASKED] where his wt was 159 lbs and he was found to be volume overloaded on exam. He was started on a Lasix gtt of 10mg with a bolus of 160mg IV X1. He was admitted for IV diuresis and when euvolemic, evaluation for possible tricuspid valve repair. On the floor, pt endorses the history above. He endorses [MASKED] edema, orthopnea at baseline. Denies fatigue, CP, palpitations, PND. REVIEW OF SYSTEMS: Positive per HPI. All of the other review of systems were negative. Past Medical History: 1. Heart failure with reduced ejection fraction * [MASKED] CRT-D 2. Severe mitral regurgitation 3. Severe tricuspid regurgitation 4. Hypertension 5. Dyslipidemia 6. Status post pacemaker 7. Chronic kidney disease 8. Thrombocytopenia * Per hematology consult, felt to be due to congestive hepatopathy/cardiac cirrhosis Social History: [MASKED] Family History: 1 brother with a stroke 1 brother with a heart attack in his [MASKED] Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: [MASKED] Temp: 97.9 PO BP: 102/62 HR: 77 RR: 18 O2 sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: [MASKED] GENERAL: Appears comfortable. Somewhat confused. No carotid bruits. HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple. JVP to the angle of the jaw accentuated by HJR. CARDIAC: Regular rate and rhythm, systolic murmur that radiates to the axilla, S3 present. LUNGS: Diminished breath sounds tat bases No wheezes or rhonchi. ABDOMEN: Soft, NT ND No hepatomegaly. No splenomegaly. EXTREMITIES: WWP, 2+ edema through the thigh. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM ======================== Pertinent Results: ADMISSION LABS =============== [MASKED] 03:30PM BLOOD WBC-5.0 RBC-2.88* Hgb-8.9* Hct-28.6* MCV-99* MCH-30.9 MCHC-31.1* RDW-14.6 RDWSD-53.0* Plt Ct-90* [MASKED] 03:30PM BLOOD [MASKED] PTT-32.0 [MASKED] [MASKED] 03:30PM BLOOD Glucose-39* UreaN-21* Creat-1.1 Na-142 K-3.3* Cl-101 HCO3-26 AnGap-15 [MASKED] 03:30PM BLOOD ALT-23 AST-38 LD(LDH)-336* AlkPhos-240* Amylase-82 TotBili-0.9 [MASKED] 03:30PM BLOOD Lipase-40 [MASKED] 03:30PM BLOOD proBNP-62 * [MASKED] 11:20PM BLOOD Calcium-8.3* Phos-4.0 Mg-2.2 DISCHARGE LABS =============== MICROBIOLOGY ============= None IMAGING ======== TTE ([MASKED]) -------------- CONCLUSION: The left atrial volume index is SEVERELY increased. The right atrium is markedly enlarged. The estimated right atrial pressure is >15mmHg. There is normal left ventricular wall thickness with a SEVERELY increased/ dilated cavity. There is SEVERE global left ventricular hypokinesis. No thrombus or mass is seen in the left ventricle. Quantitative 3D volumetric left ventricular ejection fraction is 14 %. Due to severity of mitral regurgitation, intrinsic left ventricular systolic function likely be lower. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). SEVERELY dilated right ventricular cavity with SEVERE global free wall hypokinesis. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.5-1.9 cm2). There is no aortic regurgitation. A MitraClip prosthesis is present. The prosthesis is well-seated with thickened leaflets but normal motion. There is a central jet of moderate [2+] mitral regurgitation. The pulmonic valve leaflets are mildly thickened. There is mild pulmonic regurgitation. The tricuspid valve leaflets are mildly thickened. There is SEVERE [4+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Severely dilated left and right ventricles with severe global biventricular hypokinesis. Mitraclips in place with moderate mitral regurgitation. Severe tricuspid regurgitation. At least moderate pulmonary hypertension. TTE ([MASKED]) --------------- CONCLUSION: The left atrial volume index is SEVERELY increased. The right atrium is markedly enlarged. There is normal left ventricular wall thickness with a SEVERELY increased/dialted cavity. There is SEVERE global left ventricular hypokinesis with near akinesis of the apical [MASKED] of the ventricle which is also aneurysmal. No thrombus or mass is seen in the left ventricle. The visually estimated left ventricular ejection fraction is <=20%. Due to severity of mitral regurgitation, intrinsic left ventricular systolic function likely be lower. Moderately dilated right ventricular cavity with SEVERE global free wall hypokinesis. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic valve leaflets (?#) are mildly thickened. There is no aortic regurgitation. A MitraClip prosthesis is present. The MitraClip is attached to both leaflets, with thin/mobile leaflets and normal mean gradient. There is moderate [2+] mitral regurgitation. There is moderate to severe [3+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Biventricular cavity dilation with severe global hypokinesis most c/w multivessel CAD or other diffuse process. Moderate to severe tricuspid regurgitation. Moderate mitral regurgitation. Compared with the prior TTE (images reviewed) of [MASKED], the findings are similar. CLINICAL IMPLICATIONS: Based on the echocardiographic findings and [MASKED] ACC/AHA recommendations, antibiotic prophylaxis IS recommended prior to dental cleanings and other non-sterile procedures. The patient's LVEF is less than 40%; a threshold for which they may benefit from a beta blocker and an ACE inhibitor or [MASKED]. RIGHT HEART CATH ([MASKED]) Elevated right heart filling pressure.- unable to obtain access to PA or PCWP but RA and RV pressures measured = mean RA pressure 11 mmHg with V wave to 20 mmHg. CXR ([MASKED]) --------------- FINDINGS: A left chest Wall AICD with 4 leads is again present. A mitral clip is unchanged. There is no focal consolidation, pleural effusion or pneumothorax. Size of the cardiac silhouette remains massively enlarged. IMPRESSION: No acute cardiopulmonary abnormality TRANS-ESOPHAGEAL ECHO [MASKED] The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (LVEF= 10 %). Right ventricular chamber size and free wall motion are mildly reduced. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. Mild (1+) mitral regurgitation is seen. Prior mitraclip in mitral position seen in good position. The tricuspid valve leaflets are moderately thickened. There is a minimal increased gradient consistent with trivial tricuspid stenosis. Severe [4+] tricuspid regurgitation is seen. There is no pericardial effusion. Patient is status post mitraclip placement in the tricuspid position. Intraoperative echocardiography performed for guidance of mitraclip placement in tricuspid position for severe TR. No pericardial effusion. Mitraclip in tricuspid position appears in good position with right ventricular pacing lead unchanged. Tricuspid valve mean gradient 2.2 mm Hg, peak gradient 6 mmHg with residual moderate TR. TRANSTHORACIC ECHO [MASKED] The left atrial volume index is SEVERELY increased. There is normal left ventricular wall thickness with a SEVERELY increased/dilated cavity. There is SEVERE global left ventricular hypokinesis. No thrombus or mass is seen in the left ventricle. The visually estimated left ventricular ejection fraction is 15%. There is no resting left ventricular outflow tract gradient. Moderately dilated right ventricular cavity with moderate global free wall hypokinesis. The aortic sinus is mildly dilated with normal ascending aorta diameter for gender. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. A MitraClip prosthesis is present. The MitraClip is attached to both leaflets and normal mean gradient. There is moderate mitral chordal thickening. There is moderate [2+] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. MitraClip prosthesis is present. The MitraClip(s) appear to be well attached. There is moderate to severe [3+] tricuspid regurgitation. Due to acoustic shadowing, the severity of tricuspid regurgitation may be UNDERestimated. There is moderate pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Dilated left ventricle with severe global LV systolic dysfunction. Moderate right ventricular systolic dysfunction. Well-seated mitral clip (x2) with moderate residual mitral regurgitation. Well-seated tricuspid clip with moderate to severe residual tricuspid regurgitation. At least moderate pulmonary hypertension. Compared with the prior TTE [MASKED], tricuspid regurgitation has perhaps slightly decreased in severity, although the change isn't by any means dramatic. Brief Hospital Course: SUMMARY: --------- [MASKED] with PMHx of HFrEF [MASKED] iCMP (LVEF [MASKED], CAD s/p anterior MI ([MASKED]), HTN, HLD, DM, s/p BIVICD w/ RA lead replacement, severe tricuspid regurgitation, moderate mitral regurgitation s/p mitral clip x2 ([MASKED]), who presented to the [MASKED] with worsening dyspnea and [MASKED] weight gain admitted for CHF exacerbation diuresed on a Lasix gtt and then right heart cathed on [MASKED]. He was recommended for inpatient tricuspid valve clip, which was done on [MASKED]. ACTIVE ISSUES: ============== #Acute Decompensated Heart Failure: #Ischemic Cardiomyopathy HFrEF EF15%: Patient initially presented to the [MASKED] after recent hospitalizations with worsening heart failure symptoms, 30lb weight gain, and volume overload on exam. He was diuresed in the CDAC prior to admission with a Lasix gtt and Lasix 160 mg IV prior to being transferred to the floor for further diuresis. His exacerbation was likely due in part to his severe ischemic cardiomyopathy complicated by valvular disease and discontinuation of beta blockade, afterload reduction and neurohormonal blockade. He reportedly had his home goal directed therapy discontinued for low blood pressure incidentally noticed by his home [MASKED]. On the floor he was diuresed with IV Lasix gtt up to 30 mg/hr and Diuril 250 mg IV boluses. He was eventually transitioned to Torsemide 100 mg BID. He also had a right heart cath on [MASKED] and appeared to be euvolemic with a RA pressure of 11; his RV pressure was [MASKED] with a mean of 11 with an inability to obtain PA pressures or a wedge pressure. His dry weight on the day of discharge was 59.9 kg. His final heart failure regimen is listed below. Also of note after discussion about etiology and whether his heart failure was truly ischemic we attempted to obtain records from [MASKED]. Patient has no recorded left heart cath after discussion with Dr. [MASKED] (his outpatient cardiologist). The low heart rate on his pacemaker was increased from 50 bpm to 70 bpm so that patient could be restarted on metoprolol succinate XL for optimal HFrEF therapy. DIURESIS: Torsemide 100 mg BID AFTERLOAD: Lisinopril 2.5 mg QD Spironolactone 25 mg QD NHBK: Metoprolol succinate XL 12.5 mg QD Spironolactone 25mg QD #Mitral regurgitation s/p Mitral Clip #Tricuspid regurgitation s/p tricuspid clip The patient was evaluated by structural cardiac team and was recommended for inpatient tricuspid clip, which was done on [MASKED]. PACU course was complicated by hypotension to the 60-80 systolic/40 diastolic. He was given 1.5 L of fluid and started on phenylephrine. He was transferred to the CCU. He received additional volume repletion and was weaned off pressors. His post-procedure TTE showed slight improvement in tricuspid regurgitation. His preload and afterload reducing medications were held while he was recovering from hypotension, but were successfully reintroduced within several days. #DMII: Patient had very poorly controlled sugars during his hospital stay. Upon further discussion with the patient, it appears that the patient has an inconsistent and poorly developed plan for managing his insulin regimen and his sugars. The team spoke to his wife who said that the patient manages his diabetes on his own and that she is not involved. The [MASKED] Diabetes service was consulted to help manage his insulin regimen and to recommend the best discharge plan for him, especially given his suspected dementia (most recent MOCA of 14). Chronic Issues: ================= #HTN: Started on lisinopril 2.5mg Continued home spironolactone 25mg once daily #CAD: Continued home atorvastatin, clopidogrel, and aspirin #Cognitive impairment Patient without history of cognitive impairment noted but concern during prior admissions. OT was consulted and say needs help with 100% of IADLs. MOCA [MASKED] was 14. TRANSITIONAL ISSUES: ===================== [] HFrEF - Patient had his pacer limit increased to 70 from 50. [] HFrEF - He was discharged on 100mg BID of his torsemide which was an increase from his prior home dose of 80mg BID. [] HFrEF - He was re-started on afterload reduction with lisinopril 2.5mg daily and spironolactone 25mg once daily. Recommend repeat Chem-10 in 1 week of discharge. [] HFrEF - Patient started on metoprolol, lisinopril, and spironolactone at low doses, please monitor for hypotension as patient was hypotensive on higher doses previously and had these medications discontinued. Of note, patients BPs were stable on this regimen prior to discharge. [] Diabetes - Patient should be assessed further on ability to correctly administer and calculate insulin dosing. Patient's wife should partake in diabetes education and insulin management with patient. Wife was unable to come to the hospital to receive insulin training during the holidays. Recommend further simplification of insulin regimen and follow-up with [MASKED] [MASKED] as scheduled. Outpatient providers to consider initiation of Empagliflozin. [] Dementia - Consider neurocognitive testing and geriatrics referral for the patient for formal diagnosis. #CODE STATUS: Full #CONTACT: [MASKED] (wife/primary contact) [MASKED] [MASKED] (son) [MASKED] Discharge Weight: 59.5kg/131.17lbs Discharge Cr: 1.1 Discharge Hgb: 9.2 Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Torsemide 80 mg PO BID 4. Vitamin D [MASKED] UNIT PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Calcium Carbonate 600 mg PO DAILY 7. Glargine 22 Units Bedtime 8. Potassium Chloride 10 mEq PO DAILY 9. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Glargine 22 Units Breakfast Insulin SC Sliding Scale using Novolog Insulin 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Calcium Carbonate 600 mg PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Ferrous Sulfate 325 mg PO DAILY 7. Torsemide 80 mg PO BID RX torsemide 20 mg 4 tablet(s) by mouth twice daily Disp #200 Tablet Refills:*0 8. Vitamin D [MASKED] UNIT PO DAILY 9. HELD- Potassium Chloride 10 mEq PO DAILY This medication was held. Do not restart Potassium Chloride until repeat labs are done and you talk to your PCP [MASKED]: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Acute on chronic HFrEF exacerbation Hypertension Coronary Artery Disease SECONDARY DIAGNOSES =================== Mitral regurgitation s/p mitral clip Tricuspid regurgitation Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? - You were admitted because you had worsening of your heart failure symptoms, including shortness of breath and weight gain. WHAT WAS DONE WHILE I WAS HERE? - You were given medications to get the fluid out of your lungs and out of your legs. - You were given medications to treat your heart failure. - You had an echocardiogram done, which is an ultrasound of your heart that takes pictures of your heart. - You had a right heart catheterization done, which is a procedure in which we placed a tube in your neck vein to look at your heart internally to see how it was functioning. WHAT DO I NEED TO DO ONCE I LEAVE? - Please continue taking all of your medications as prescribed. - Please keep all of your follow-up appointments. - Please weigh yourself every morning, call MD if weight goes up more than 3 lbs. - We recommend that you do not drive until you discuss your ability to safely do so with your primary doctor [MASKED] well, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I130", "E871", "N189", "I2510", "I252", "E785", "D696", "Z7902", "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", "I5023: Acute on chronic systolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "N189: Chronic kidney disease, unspecified", "I255: Ischemic cardiomyopathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "E785: Hyperlipidemia, unspecified", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "E1065: Type 1 diabetes mellitus with hyperglycemia", "I081: Rheumatic disorders of both mitral and tricuspid valves", "I9581: Postprocedural hypotension", "D696: Thrombocytopenia, unspecified", "G3184: Mild cognitive impairment, so stated", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z794: Long term (current) use of insulin", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker" ]
19,979,360	26,177,492	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: None History of Present Illness: Mr. ___ is a ___ with PMHx of HFrEF ___ iCMP (LVEF ___, CAD ___ anterior MI (___), HTN, HLD, DM, ___ BIVICD w/ RA lead replacement, severe tricuspid regurgitation, moderate mitral regurgitation ___ mitral clip x2 (___) who presents with syncope, fall w headstrike, and observed NSVT at the other hospital. The patient was in his usual health until yesterday evening, when he was going from seated to sitting position. He developed dizziness and palpitations, lost consciousness, and fell to the floor, striking his head. EMS was called, and he was transferred to ___ for further evaluation. He underwent noncontrast head CT which showed no acute process. He was going to have noncontrast CT scans of the cervical, thoracic, and lumbar spines, but he was too agitated and the scans could not be obtained. On 2 occasions, he had episodes of nonsustained VT lasting about 20 seconds, with during which time the patient reported feeling woozy and had altered mental status; his ICD did not fire, and after the episodes resolved, his mental status returned to baseline. Given his recent mitral clipping here, he was transferred to our hospital for further evaluation. In the ED, initial vitals were T 97.1, HR 70, BP 101/60, RR 20, O2 99% on RA, however the was transiently hypotensive to 84/56 and he developed an O2 requirement sating 95% on 3L. Per report, physical exam was notable for bibasilar crackles, 1+ ___, and warm extremities. Labs were notable for stable Hgb at 7.6, Cr 1.4 from baseline 0.9, K 4.7, Mg 2.3, Ca 8.9, trops 0.03 --> 0.07, BNP 7535 (6268 at presentation for last hospitalization), lactate 1.3, alk phos 256, UA small blood/1 RBC. EKG showed NSR with AV pacing. CT C spine w/o evidence of acute fracture or subluxation. Patient was given IV Tylenol, morphine, 81 mg aspirin, 75 mg Clopidogrel, and 25 mg spironolactone. EP was consulted who interrogated his pacer and noted VT at 22:00 on ___ terminated by antitachycardia pacing (ATP) and multiple other NSVT episodes were noted. They recommended starting an amiodarone load, which was started. Vitals on transfer were 70 91/63 12 98% 3L NC. On the floor, patient reaffirms story as above. He is a poor historian, but states he was in his normal state of health prior to the incidence last night. His wife states the last few days he has been feeling "off", but did not further clarify. She also states he has gained about ___ since discharge. He was on the ground about 5 minutes prior to re-gaining consciousness. She did not note any seizure-like activity, nor bladder incontinence. Otherwise, she states he appeared to be doing well, and had been taking his Torsemide and other medications as prescribed. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, or ankle edema. He does endorse palpitations and light-headedness with episodes of palpitations. Past Medical History: - Diabetes, insulin-dependent, poorly controlled - Hypertension - Dyslipidemia - CKD - CAD: no LHC in our system - PACING/ICD: AV paced with CRT-D - EF: Dilated LV w/ severe global LV dysfunction (EF 15%), moderate RV systolic dysfunction - Severe MR ___ mitraclip on ___ - Severe TR ___ mitraclip on ___ - Thrombocytopenia - Per hematology consult, felt to be due to congestive hepatopathy/cardiac cirrhosis - Cognitive impairment, OT recommending help with 100% of ADLs Social History: ___ Family History: 1 brother with a stroke 1 brother with a heart attack in his ___ Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VITALS: ___ 1547 Temp: 97.8 BP: 106/60 HR: 78 RR: 20 O2 sat: 95% O2 delivery: 3L FSBG: 271 Fluid Balance (last updated ___ @ 1613) Last 8 hours Total cumulative 420ml IN: Total 420ml, PO Amt 420ml OUT: Total 0ml Last 24 hours Total cumulative 420ml IN: Total 420ml, PO Amt 420ml OUT: Total 0ml GENERAL: Chronically ill appearing male in no acute distress. HEENT: Small abrasions along left scalp, no apparent open wounds or lesions. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 9-10 cm. CARDIAC: Regular rate and rhythm, S1, S2. S3, no murmurs. No thrills, lifts. LUNGS: Difficult to position patient forward, but has bibasilar crackles. No accessory muscle use. ABDOMEN: Soft, non-tender, but markedly distended EXTREMITIES: Diffuse ecchymosis throughout extremities. Excoriations on right extremity. Trace edema in lower extremities, warm throughout. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: ========================= On exam the patient was unresponsive, no spontaneous movement was observed, pt did not respond to verbal or noxious stimuli. Absent heart and breath sounds for more than 1 minute. Patient pronounced dead at 1401. Pertinent Results: ADMISSION LABS: =============== ___ 03:45AM BLOOD WBC-6.8 RBC-2.50* Hgb-7.6* Hct-23.5* MCV-94 MCH-30.4 MCHC-32.3 RDW-16.4* RDWSD-57.1* Plt ___ ___ 03:45AM BLOOD Neuts-79.8* Lymphs-7.0* Monos-12.3 Eos-0.1* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-5.43 AbsLymp-0.48* AbsMono-0.84* AbsEos-0.01* AbsBaso-0.01 ___ 03:45AM BLOOD Glucose-98 UreaN-38* Creat-1.4* Na-136 K-4.7 Cl-98 HCO3-23 AnGap-15 ___ 03:45AM BLOOD ALT-25 AST-38 AlkPhos-256* TotBili-0.9 ___ 03:45AM BLOOD CK-MB-3 proBNP-7535* ___ 03:45AM BLOOD cTropnT-0.03* ___ 11:35AM BLOOD cTropnT-0.07* ___ 06:00PM BLOOD cTropnT-0.08* ___ 11:49PM BLOOD CK-MB-4 cTropnT-0.08* ___ 03:45AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.7* Mg-2.3 ___ 03:56AM BLOOD Lactate-1.3 INTERIM LABS: =============== ___ 09:13AM BLOOD Glucose-328* UreaN-82* Creat-3.0* Na-132* K-4.8 Cl-90* HCO3-17* AnGap-25* ___ 09:30PM BLOOD ALT-116* AST-164* LD(LDH)-498* AlkPhos-232* TotBili-1.9* DirBili-1.1* IndBili-0.8 ___ 09:27AM BLOOD CK-MB-3 cTropnT-0.13* ___ 09:43AM BLOOD Lactate-6.9* DISCHARGE LABS: ================ N/A IMAGING: ========= ___ CT-NECK: 1. No evidence of acute fracture or subluxation of the cervical spine. ___ CXR: Trace pleural effusions. ___ PORTABLE ABDOMEN: Mildly dilated segment of small bowel may be consistent with early partial small bowel obstruction or focal ileus. ___ TTE Severe global biventricular systolic dysfunction. Well-seated MitralClip with moderate to severe residual mitral regurgitation. Severe tricuspid regurgitation. At least mild pulmonary hypertension. Compared with the prior TTE (images reviewed) of ___, RV systolic function has further deteriorated and RV cavity appears larger. ___ CXR: Moderate to severe cardiomegaly has increased as have the caliber of the hila and pulmonary vasculature. Patient is on the edge of pulmonary edema. Pleural effusions small if any. No pneumothorax. Multiple transvenous pacer and defibrillator leads are unchanged in their respective positions. Brief Hospital Course: Mr. ___ is a ___ year old gentleman with PMHx of HFrEF ___ iCMP (LVEF ___, CAD ___ anterior MI (___), HTN, HLD, DM, ___ BIVICD w/ RA lead replacement, severe tricuspid regurgitation ___ clip, moderate mitral regurgitation ___ mitral clip x2 (___) who presents with syncope, fall w/ headstrike, found to have episodes of NSVT, and cardiogenic shock requiring increasing doses dopamine and eventually transferred to the CCU for additional inotrope/pressor management. #CORONARIES: unknown, no coronary studies in our system #PUMP: EF ___ #RHYTHM: BiV paced ACUTE PROBLEMS: =============== #GOC #Death Patient had end-stage HFrEF and was not a candidate for any additional advanced therapy. Discussed patient's declining clinical status with son ___ and daughter ___ at the bedside, explained that dopamine and Lasix were both palliative and there were no additional procedures that he could get. They seemed focused on getting him home and ___ in particular was concerned about mobilizing him. I relayed concerns that he is too sick to go home with hospice now but that we can readdress every day. Had previous discussions with wife ___ regarding code status and confirmed DNR/DNI but she was not sure about turning the ICD off. After further deterioration and with transfer to CCU, decided that ICD should be turned off. ___ is the principal decision maker though no HCP form in our system. The family seemed to understand that care plans should focus more on comfort. Palliative care was following. On ___ at 1000, the primary team spoke to Mr. ___ wife and informed her of his worsening cardiogenic shock despite treatment with max dopamine doxing and high dose of diuretics. Discussed transferring him to the CCU for additional pressor and inotrope support, but that with those interventions, he still may not survive. She understood and confirmed that she would like to try these interventions, but he was DNR/DNI. We discussed that if his defibrillator fired, it would not reverse his underlying cardiogenic shock and would likely cause harm without benefit. She agreed and would like his defibrillator turned off. Later that day in the CCU, it was decided to make him CMO. He died at ___ on ___. Autopsy was declined. # Acute on chronic HFrEF # Cardiogenic shock # Ischemic Cardiomyopathy EF ___, thought to be ischemic although no L heart cath in our system. Patient was not taking lisinopril, spironolactone, or metoprolol. Admission CXR showing cardiogenic edema and patient is grossly fluid overloaded despite Lasix drip and intermittent chlorothiazide boluses and dopamine for inotropy. His lactate and creatinine continued to rise despite escalating dopamine dose suggesting ongoing shock. Initiating transfer to the CCU for increasing inotrope/pressor requirements. He was continued on home spironolactone 25mg QD. # Leukocytosis Most likely source is abdominal given distension and tenderness. No pulmonary or GU symptoms. Other possible source includes leg with considerable discoloration and scaling; possibility of cellulitis. Shock is most likely cardiogenic (see above), but sepsis also on ddx. Patient started on vancomycin, Cefepime, and mtdz (___). # Ileus KUB showing distended loops of bowel c/w ileus vs partial SBO. No previous surgeries or other risk factors for SBO. Most likely ileus iso poorly controlled diabetes. Allowing to eat for comfort after discussion with family. Surgery consulted, but canceled consult given not a surgical candidate. He was placed on an aggressive bowel regimen and given a soap suds enema, but with ongoing constipation. # Fall # Syncope # NSVT CT scan was unremarkable; mild signs of trauma on exam. Signs and symptoms concerning for cardiac insufficiency in the setting of NSVT/VT with baseline severely reduced EF of ___. However, patient found to be dizzy on tele while paced (not in VT). Other etiologies for consideration appear less likely including hypovolemia given normal PO intake and increase weight. Orthostatics negative. Electrolytes/glucose normal. Signs and symptoms not consistent with seizure. Recent TTE with normal aortic valve. Potentially may have reduced cerebral perfusion pressure in the setting of carotid stenosis, but no carotid imaging in our system. EP was consulted and recommended Amiodarone load with 400mg po TID for 10d (___), followed by 200mg/day. This was converted to IV due to concern for ileus # ___ (baseline cr ~1.0) Rising Cr, likely cardiorenal in the setting of volume overload vs. pre-renal etiology in the setting of hypotension. # Troponinemia Likely secondary to demand in setting of volume overload. EKG without changes although A-V paced, so difficult to stay. Patient is chest-pain free. CHRONIC PROBLEMS: ================= # Mitral regurgitation ___ Mitral Clip # Tricuspid regurgitation ___ tricuspid clip # DM II Difficult to control at last hospitalization. On PAML, patient's wife notes he is using both Humalog and Novalog for sliding scale. ___ was consulted for ongoing inuslin management. # CAD No record of prior coronary cath. Continued home atorvastatin 80 mg PO daily and aspirin 81 mg PO daily. Continued Plavix 75 mg PO daily (unclear why on DAPT). #Cognitive impairment Patient without history of cognitive impairment noted but concern during prior admissions. OT was consulted on last admission and say needs help with 100% of IADLs. MOCA ___ was 14. # CODE: DNR/DNI # CONTACT: HCP: Wife, Mrs. ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amoxicillin ___ mg PO PREOP 1 hr prior to dental procedures 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 100 unit/mL subcutaneous QIDACHS 5. Lantus U-100 Insulin (insulin glargine) 22 u subcutaneous BREAKFAST 6. Torsemide 80 mg PO BID 7. Aspirin 81 mg PO DAILY 8. Calcium Carbonate 1500 mg PO DAILY 9. Vitamin D ___ UNIT PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Lantus U-100 Insulin (insulin glargine) 2 u subcutaneous QHS Discharge Medications: Patient died at 1401 on ___. Discharge Disposition: Expired Discharge Diagnosis: Patient died at 1401 on ___. Discharge Condition: Patient died at 1401 on ___. Discharge Instructions: Patient died at 1401 on ___. Followup Instructions: ___	[ "I130", "J9601", "I5023", "N179", "K567", "I471", "R570", "D696", "E1122", "E11649", "E1140", "E1159", "I081", "I255", "Z66", "Z515", "D72829", "R778", "R410", "I2510", "N189", "K5900", "E785", "W1800XA", "Y929", "Z794", "Z4502", "Z95810", "I252" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] with PMHx of HFrEF [MASKED] iCMP (LVEF [MASKED], CAD [MASKED] anterior MI ([MASKED]), HTN, HLD, DM, [MASKED] BIVICD w/ RA lead replacement, severe tricuspid regurgitation, moderate mitral regurgitation [MASKED] mitral clip x2 ([MASKED]) who presents with syncope, fall w headstrike, and observed NSVT at the other hospital. The patient was in his usual health until yesterday evening, when he was going from seated to sitting position. He developed dizziness and palpitations, lost consciousness, and fell to the floor, striking his head. EMS was called, and he was transferred to [MASKED] for further evaluation. He underwent noncontrast head CT which showed no acute process. He was going to have noncontrast CT scans of the cervical, thoracic, and lumbar spines, but he was too agitated and the scans could not be obtained. On 2 occasions, he had episodes of nonsustained VT lasting about 20 seconds, with during which time the patient reported feeling woozy and had altered mental status; his ICD did not fire, and after the episodes resolved, his mental status returned to baseline. Given his recent mitral clipping here, he was transferred to our hospital for further evaluation. In the ED, initial vitals were T 97.1, HR 70, BP 101/60, RR 20, O2 99% on RA, however the was transiently hypotensive to 84/56 and he developed an O2 requirement sating 95% on 3L. Per report, physical exam was notable for bibasilar crackles, 1+ [MASKED], and warm extremities. Labs were notable for stable Hgb at 7.6, Cr 1.4 from baseline 0.9, K 4.7, Mg 2.3, Ca 8.9, trops 0.03 --> 0.07, BNP 7535 (6268 at presentation for last hospitalization), lactate 1.3, alk phos 256, UA small blood/1 RBC. EKG showed NSR with AV pacing. CT C spine w/o evidence of acute fracture or subluxation. Patient was given IV Tylenol, morphine, 81 mg aspirin, 75 mg Clopidogrel, and 25 mg spironolactone. EP was consulted who interrogated his pacer and noted VT at 22:00 on [MASKED] terminated by antitachycardia pacing (ATP) and multiple other NSVT episodes were noted. They recommended starting an amiodarone load, which was started. Vitals on transfer were 70 91/63 12 98% 3L NC. On the floor, patient reaffirms story as above. He is a poor historian, but states he was in his normal state of health prior to the incidence last night. His wife states the last few days he has been feeling "off", but did not further clarify. She also states he has gained about [MASKED] since discharge. He was on the ground about 5 minutes prior to re-gaining consciousness. She did not note any seizure-like activity, nor bladder incontinence. Otherwise, she states he appeared to be doing well, and had been taking his Torsemide and other medications as prescribed. REVIEW OF SYSTEMS: Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, or ankle edema. He does endorse palpitations and light-headedness with episodes of palpitations. Past Medical History: - Diabetes, insulin-dependent, poorly controlled - Hypertension - Dyslipidemia - CKD - CAD: no LHC in our system - PACING/ICD: AV paced with CRT-D - EF: Dilated LV w/ severe global LV dysfunction (EF 15%), moderate RV systolic dysfunction - Severe MR [MASKED] mitraclip on [MASKED] - Severe TR [MASKED] mitraclip on [MASKED] - Thrombocytopenia - Per hematology consult, felt to be due to congestive hepatopathy/cardiac cirrhosis - Cognitive impairment, OT recommending help with 100% of ADLs Social History: [MASKED] Family History: 1 brother with a stroke 1 brother with a heart attack in his [MASKED] Physical Exam: ADMISSION PHYSICAL EXAMINATION: =============================== VITALS: [MASKED] 1547 Temp: 97.8 BP: 106/60 HR: 78 RR: 20 O2 sat: 95% O2 delivery: 3L FSBG: 271 Fluid Balance (last updated [MASKED] @ 1613) Last 8 hours Total cumulative 420ml IN: Total 420ml, PO Amt 420ml OUT: Total 0ml Last 24 hours Total cumulative 420ml IN: Total 420ml, PO Amt 420ml OUT: Total 0ml GENERAL: Chronically ill appearing male in no acute distress. HEENT: Small abrasions along left scalp, no apparent open wounds or lesions. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 9-10 cm. CARDIAC: Regular rate and rhythm, S1, S2. S3, no murmurs. No thrills, lifts. LUNGS: Difficult to position patient forward, but has bibasilar crackles. No accessory muscle use. ABDOMEN: Soft, non-tender, but markedly distended EXTREMITIES: Diffuse ecchymosis throughout extremities. Excoriations on right extremity. Trace edema in lower extremities, warm throughout. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: ========================= On exam the patient was unresponsive, no spontaneous movement was observed, pt did not respond to verbal or noxious stimuli. Absent heart and breath sounds for more than 1 minute. Patient pronounced dead at 1401. Pertinent Results: ADMISSION LABS: =============== [MASKED] 03:45AM BLOOD WBC-6.8 RBC-2.50* Hgb-7.6* Hct-23.5* MCV-94 MCH-30.4 MCHC-32.3 RDW-16.4* RDWSD-57.1* Plt [MASKED] [MASKED] 03:45AM BLOOD Neuts-79.8* Lymphs-7.0* Monos-12.3 Eos-0.1* Baso-0.1 NRBC-0.3* Im [MASKED] AbsNeut-5.43 AbsLymp-0.48* AbsMono-0.84* AbsEos-0.01* AbsBaso-0.01 [MASKED] 03:45AM BLOOD Glucose-98 UreaN-38* Creat-1.4* Na-136 K-4.7 Cl-98 HCO3-23 AnGap-15 [MASKED] 03:45AM BLOOD ALT-25 AST-38 AlkPhos-256* TotBili-0.9 [MASKED] 03:45AM BLOOD CK-MB-3 proBNP-7535* [MASKED] 03:45AM BLOOD cTropnT-0.03* [MASKED] 11:35AM BLOOD cTropnT-0.07* [MASKED] 06:00PM BLOOD cTropnT-0.08* [MASKED] 11:49PM BLOOD CK-MB-4 cTropnT-0.08* [MASKED] 03:45AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.7* Mg-2.3 [MASKED] 03:56AM BLOOD Lactate-1.3 INTERIM LABS: =============== [MASKED] 09:13AM BLOOD Glucose-328* UreaN-82* Creat-3.0* Na-132* K-4.8 Cl-90* HCO3-17* AnGap-25* [MASKED] 09:30PM BLOOD ALT-116* AST-164* LD(LDH)-498* AlkPhos-232* TotBili-1.9* DirBili-1.1* IndBili-0.8 [MASKED] 09:27AM BLOOD CK-MB-3 cTropnT-0.13* [MASKED] 09:43AM BLOOD Lactate-6.9* DISCHARGE LABS: ================ N/A IMAGING: ========= [MASKED] CT-NECK: 1. No evidence of acute fracture or subluxation of the cervical spine. [MASKED] CXR: Trace pleural effusions. [MASKED] PORTABLE ABDOMEN: Mildly dilated segment of small bowel may be consistent with early partial small bowel obstruction or focal ileus. [MASKED] TTE Severe global biventricular systolic dysfunction. Well-seated MitralClip with moderate to severe residual mitral regurgitation. Severe tricuspid regurgitation. At least mild pulmonary hypertension. Compared with the prior TTE (images reviewed) of [MASKED], RV systolic function has further deteriorated and RV cavity appears larger. [MASKED] CXR: Moderate to severe cardiomegaly has increased as have the caliber of the hila and pulmonary vasculature. Patient is on the edge of pulmonary edema. Pleural effusions small if any. No pneumothorax. Multiple transvenous pacer and defibrillator leads are unchanged in their respective positions. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old gentleman with PMHx of HFrEF [MASKED] iCMP (LVEF [MASKED], CAD [MASKED] anterior MI ([MASKED]), HTN, HLD, DM, [MASKED] BIVICD w/ RA lead replacement, severe tricuspid regurgitation [MASKED] clip, moderate mitral regurgitation [MASKED] mitral clip x2 ([MASKED]) who presents with syncope, fall w/ headstrike, found to have episodes of NSVT, and cardiogenic shock requiring increasing doses dopamine and eventually transferred to the CCU for additional inotrope/pressor management. #CORONARIES: unknown, no coronary studies in our system #PUMP: EF [MASKED] #RHYTHM: BiV paced ACUTE PROBLEMS: =============== #GOC #Death Patient had end-stage HFrEF and was not a candidate for any additional advanced therapy. Discussed patient's declining clinical status with son [MASKED] and daughter [MASKED] at the bedside, explained that dopamine and Lasix were both palliative and there were no additional procedures that he could get. They seemed focused on getting him home and [MASKED] in particular was concerned about mobilizing him. I relayed concerns that he is too sick to go home with hospice now but that we can readdress every day. Had previous discussions with wife [MASKED] regarding code status and confirmed DNR/DNI but she was not sure about turning the ICD off. After further deterioration and with transfer to CCU, decided that ICD should be turned off. [MASKED] is the principal decision maker though no HCP form in our system. The family seemed to understand that care plans should focus more on comfort. Palliative care was following. On [MASKED] at 1000, the primary team spoke to Mr. [MASKED] wife and informed her of his worsening cardiogenic shock despite treatment with max dopamine doxing and high dose of diuretics. Discussed transferring him to the CCU for additional pressor and inotrope support, but that with those interventions, he still may not survive. She understood and confirmed that she would like to try these interventions, but he was DNR/DNI. We discussed that if his defibrillator fired, it would not reverse his underlying cardiogenic shock and would likely cause harm without benefit. She agreed and would like his defibrillator turned off. Later that day in the CCU, it was decided to make him CMO. He died at [MASKED] on [MASKED]. Autopsy was declined. # Acute on chronic HFrEF # Cardiogenic shock # Ischemic Cardiomyopathy EF [MASKED], thought to be ischemic although no L heart cath in our system. Patient was not taking lisinopril, spironolactone, or metoprolol. Admission CXR showing cardiogenic edema and patient is grossly fluid overloaded despite Lasix drip and intermittent chlorothiazide boluses and dopamine for inotropy. His lactate and creatinine continued to rise despite escalating dopamine dose suggesting ongoing shock. Initiating transfer to the CCU for increasing inotrope/pressor requirements. He was continued on home spironolactone 25mg QD. # Leukocytosis Most likely source is abdominal given distension and tenderness. No pulmonary or GU symptoms. Other possible source includes leg with considerable discoloration and scaling; possibility of cellulitis. Shock is most likely cardiogenic (see above), but sepsis also on ddx. Patient started on vancomycin, Cefepime, and mtdz ([MASKED]). # Ileus KUB showing distended loops of bowel c/w ileus vs partial SBO. No previous surgeries or other risk factors for SBO. Most likely ileus iso poorly controlled diabetes. Allowing to eat for comfort after discussion with family. Surgery consulted, but canceled consult given not a surgical candidate. He was placed on an aggressive bowel regimen and given a soap suds enema, but with ongoing constipation. # Fall # Syncope # NSVT CT scan was unremarkable; mild signs of trauma on exam. Signs and symptoms concerning for cardiac insufficiency in the setting of NSVT/VT with baseline severely reduced EF of [MASKED]. However, patient found to be dizzy on tele while paced (not in VT). Other etiologies for consideration appear less likely including hypovolemia given normal PO intake and increase weight. Orthostatics negative. Electrolytes/glucose normal. Signs and symptoms not consistent with seizure. Recent TTE with normal aortic valve. Potentially may have reduced cerebral perfusion pressure in the setting of carotid stenosis, but no carotid imaging in our system. EP was consulted and recommended Amiodarone load with 400mg po TID for 10d ([MASKED]), followed by 200mg/day. This was converted to IV due to concern for ileus # [MASKED] (baseline cr ~1.0) Rising Cr, likely cardiorenal in the setting of volume overload vs. pre-renal etiology in the setting of hypotension. # Troponinemia Likely secondary to demand in setting of volume overload. EKG without changes although A-V paced, so difficult to stay. Patient is chest-pain free. CHRONIC PROBLEMS: ================= # Mitral regurgitation [MASKED] Mitral Clip # Tricuspid regurgitation [MASKED] tricuspid clip # DM II Difficult to control at last hospitalization. On PAML, patient's wife notes he is using both Humalog and Novalog for sliding scale. [MASKED] was consulted for ongoing inuslin management. # CAD No record of prior coronary cath. Continued home atorvastatin 80 mg PO daily and aspirin 81 mg PO daily. Continued Plavix 75 mg PO daily (unclear why on DAPT). #Cognitive impairment Patient without history of cognitive impairment noted but concern during prior admissions. OT was consulted on last admission and say needs help with 100% of IADLs. MOCA [MASKED] was 14. # CODE: DNR/DNI # CONTACT: HCP: Wife, Mrs. [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amoxicillin [MASKED] mg PO PREOP 1 hr prior to dental procedures 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. NovoLOG U-100 Insulin aspart (insulin aspart U-100) 100 unit/mL subcutaneous QIDACHS 5. Lantus U-100 Insulin (insulin glargine) 22 u subcutaneous BREAKFAST 6. Torsemide 80 mg PO BID 7. Aspirin 81 mg PO DAILY 8. Calcium Carbonate 1500 mg PO DAILY 9. Vitamin D [MASKED] UNIT PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Lantus U-100 Insulin (insulin glargine) 2 u subcutaneous QHS Discharge Medications: Patient died at 1401 on [MASKED]. Discharge Disposition: Expired Discharge Diagnosis: Patient died at 1401 on [MASKED]. Discharge Condition: Patient died at 1401 on [MASKED]. Discharge Instructions: Patient died at 1401 on [MASKED]. Followup Instructions: [MASKED]	[]	[ "I130", "J9601", "N179", "D696", "E1122", "Z66", "Z515", "I2510", "N189", "K5900", "E785", "Y929", "Z794", "I252" ]	[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "J9601: Acute respiratory failure with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "K567: Ileus, unspecified", "I471: Supraventricular tachycardia", "R570: Cardiogenic shock", "D696: Thrombocytopenia, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E1159: Type 2 diabetes mellitus with other circulatory complications", "I081: Rheumatic disorders of both mitral and tricuspid valves", "I255: Ischemic cardiomyopathy", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "D72829: Elevated white blood cell count, unspecified", "R778: Other specified abnormalities of plasma proteins", "R410: Disorientation, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N189: Chronic kidney disease, unspecified", "K5900: Constipation, unspecified", "E785: Hyperlipidemia, unspecified", "W1800XA: Striking against unspecified object with subsequent fall, initial encounter", "Y929: Unspecified place or not applicable", "Z794: Long term (current) use of insulin", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "I252: Old myocardial infarction" ]
19,979,360	29,543,376	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weight Gain Major Surgical or Invasive Procedure: ___ Transesophageal ECHO History of Present Illness: Mr. ___ is a ___ yo M w/ PMH with ___ MI (anterolateral wall), ischemic cardiomyopathy with resulting HFrEF (EF 20% w/ severe MR and TR), HTN, HLD, DM, who is being directly admitted after TEE because of volume overload. The patient was at the BI to have a TEE. He was referred by his outpatient cardiologist. While here he was found to be in a heart failure exacerbation and was admitted to the hospital. According to outpatient records the patient was last seen by Dr. ___ on ___. At that time he was also overloaded, but they were increasing his dose of torsemide in the outpatient setting. There was concern over his hypotension decreasing his ability to tolerate medications. It was felt he should be admitted if he became refractory to PO diuretics. His last dose of torsemide as an outpatient was 30 mg TID torsemide. The patient states he has not been feeling well since he was admitted with a broken pacemaker to ___ ___ years ago. He says he feels similar to how he felt then, now. He says that he switched to ___ and is concerned they are not checking his pacemaker as well as they were before and that is what is wrong with him. He says that most recently he has leg issues. They are swollen and painful. He mostly sleeps in a chair with his legs up. He is able to lay flat without difficulty and does not wake at night with shortness of breath. He notes that his abdomen has felt more distended as well. He is able to do less leg raises and crunches than before ___ years ago). He is unsure if he has gained weight. He says his last weight was 134 lbs at ___ ___ years ago. According to his son, the patient has been getting progressively worsen. He has felt awful, can't walk. He has been having memory issues. Things have not been as good since at ___. On ROS the patient reports that he does occasionally have constipation. Otherwise he does not have any other problems including fever, chills, headaches, shortness of breath, nausea, vomiting, diarrhea, bloody stools, urinary straining or frequency (except when taking torsemide). Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - type II - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Coronaries? CAD? - Pump 20% w/ dilated RV and depressed free wall motion. severe MR ___ hx of decompensated heart failure - Pacemaker Social History: ___ Family History: 1 brother with a stroke 1 brother with a heart attack in his ___ Physical Exam: Admission Physical Exam ======================== GENERAL: Well developed, well nourished in NAD. Oriented x3. Tangential in conversation HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. NECK: Supple. JVD to the mandible CARDIAC: regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: normal respiratory effort, rales at bases bilaterally ABDOMEN: Soft, non-tender, distended, soft. No hepatomegaly. No splenomegaly. EXTREMITIES: cool with 2+ peripheral edema up his legs bilaterally. Molted appearance of feet bilaterally very cold to touch. He has dopplerable pulses in the DP and ___ SKIN: No significant skin lesions or rashes. Discharge Physical Exam ========================= 24 HR Data (last updated ___ @ 409) Temp: 97.7 (Tm 98.8), BP: 101/57 (79-101/35-65), HR: 54 (54-69), RR: 20 (___), O2 sat: 96% (92-100), Wt: 125.7 lb/57.02 kg Fluid Balance (last updated ___ @ 626) Last 8 hours Total cumulative -10ml IN: Total 840ml, PO Amt 840ml OUT: Total 850ml, Urine Amt 850ml Last 24 hours Total cumulative -210ml IN: Total 840ml, PO Amt 840ml OUT: Total 1050ml, Urine Amt 1050ml General: Well appearing, in no acute distress. HEENT: PERRL, MMM Neck: JVP <10 when upright. Lungs: Improved, clear to auscultation bilaterally CV: RRR, nls1/s2, ___ systolic murmur, best heard at apex and left sternal border. Abdomen: Moderate distension, soft, nontender. No masses or HSM noted. Extremities: No ___. WWP. Skin: No rash, stasis dermatitis, or ulcers noted. PULSES: Distal pulses palpable and symmetric Neuro: AOx3 Pertinent Results: Admission Labs ___ 06:33PM GLUCOSE-283* UREA N-27* CREAT-1.2 SODIUM-135 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-14 ___ 06:33PM estGFR-Using this ___ 06:33PM ALT(SGPT)-27 AST(SGOT)-43* LD(LDH)-281* ALK PHOS-293* TOT BILI-1.4 ___ 06:33PM proBNP-4683* ___ 06:33PM proBNP-4683* ___ 06:33PM calTIBC-389 VIT B12-1427* HAPTOGLOB-63 FERRITIN-62 TRF-299 ___ 06:33PM HCV Ab-NEG ___ 06:33PM WBC-4.8 RBC-3.02* HGB-9.7* HCT-29.8* MCV-99* MCH-32.1* MCHC-32.6 RDW-15.9* RDWSD-57.8* ___ 06:33PM NEUTS-67.0 ___ MONOS-10.7 EOS-2.7 BASOS-0.2 IM ___ AbsNeut-3.20 AbsLymp-0.92* AbsMono-0.51 AbsEos-0.13 AbsBaso-0.01 ___ 06:33PM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* MICROCYT-NORMAL POLYCHROM-1+* OVALOCYT-1+* TEARDROP-OCCASIONAL BITE-1+* ACANTHOCY-2+* FRAGMENT-2+* ELLIPTOCY-1+* ___ 06:33PM PLT SMR-VERY LOW* PLT COUNT-32* ___ 06:33PM ___ PTT-33.1 ___ ___ 06:33PM RET AUT-2.2* ABS RET-0.07 ___ 06:32PM LACTATE-1.8 Discharge Labs ___ 07:37AM BLOOD WBC-5.1 RBC-3.72* Hgb-12.1* Hct-34.8* MCV-94 MCH-32.5* MCHC-34.8 RDW-15.1 RDWSD-51.3* Plt Ct-95* ___ 08:08AM BLOOD Glucose-214* UreaN-50* Creat-1.4* Na-128* K-4.2 Cl-85* HCO3-31 AnGap-12 ___ 08:08AM BLOOD ALT-41* AST-61* AlkPhos-271* TotBili-1.6* ___ 08:08AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.6 Studies ___ ECHO There is no spontaneous echo contrast in the body of the left atrium or left atrial appendage. There is no evidence for an atrial septal defect by 2D/color Doppler. The left ventricle has an increased/dilated cavity. Overall left ventricular systolic function is severely depressed. The visually estimated left ventricular ejection fraction is 20%. Dilated right ventricular cavity with depressed free wall motion. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. There are simple atheroma in the aortic arch with simple atheroma in the descending aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is a central jet of severe [4+] mitral regurgitation. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is severe [4+] tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. ___ TTE The left atrial volume index is SEVERELY increased. The right atrium is moderately enlarged. There is normal left ventricular wall thickness with a SEVERELY increased/dialted cavity. There is SEVERE global left ventricular hypokinesis. No thrombus or mass is seen in the left ventricle. Quantitative biplane left ventricular ejection fraction is 14 %. Due to severity of mitral regurgitation, intrinsic left ventricular systolic function likely be lower. Left ventricular cardiac index is depressed (less than 2.0 L/ min/m2). There is no resting left ventricular outflow tract gradient. Moderately dilated right ventricular cavity with depressed free wall motion. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is an eccentric, inferolateral directed jet of moderate to severe [3+] mitral regurgitation. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. There is moderate to severe [3+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Severely dilated, severely hypokinetic left ventricle. Moderate to severe mitral regurgitation (volumetric assessment suggests moderate, but the eccentric nature of the jet in the apical 2 and 3 chamber views indicates this is an underestimation of true severity). Dilated hypoknetic right ventricle. Moderate to severe tricuspid regurgitation. At least mild pulmonary hypertension. Compared with the ___ TEE ___ , there has been a slight decreae in the severity of the mitral regurgitation likley post-diuresis. Brief Hospital Course: PATIENT SUMMARY ================ Mr. ___ is a ___ yo M w/ PMH with ___ MI (anterolateral wall), ischemic cardiomyopathy with resulting HFrEF (EF 20% w/ severe MR and TR), HTN, HLD, DM, who was directly admitted after TEE because of volume overload, due to likely exacerbation of patient's heart failure, now euvolemic after titration of diuresis and started on goal directed therapy for his HFrEF ACTIVE ISSUES: ============= #Acute on chronic HFrEF (EF 20%) #Ischemic Cardiomyopathy Patient presented with weight of 165. EF on TEE 20%, repeat after diuresis without significant changes. Subacute presentation, unclear etiology for exacerbation, but likely due to inadequate diuretic dose, and possibly worsening ischemic and/or valvular disease. The patient was initiated on IV diuresis, with Lasix drip as high as 30 mg/hr. The patient was net negative 16L of fluid, down to a weight of 125.7. We transitioned to 100mg PO Torsemide QD for preload. For afterload the patient was started on Lisinopril 2.5mg QD. For NHBK metoprolol 12.5 XL, spironolactone 25mg QD. It was decided during this admission that he should be trialed on goal directed medical therapy and defer any surgical intervention at this time. The patient saw palliative care who discussed his goals of care with him. #Severe MR #Severe TR Volume overload likely contributing to valvular disease, but severe MR and TR was noted on TTE even after patient was diuresed signficiantly. Discussed patient with cardiac surgery and structural cardiology. After discussion with them and patient, it was decided that intervention should be deferred right now until goal directed medical therapy was fully trialed. The patient would most likely require a repeat TEE when fully euvolemic ___ to any surgical intervention. The patient stated he did not think he would want to have any procedure that required opening of his chest. The structural heart team at ___ is aware of the patient and willing to consult for possible Mitraclip if the patient becomes symptomatic from his valvular disease in the future. #Cognitive impairment Patient without history of cognitive impairment noted but concern during admission. OT was consulted and say needs help with 100% of IADLs. MOCA ___ was 14. Recommend outpatient follow up of this issues as in transitional issues. #Thrombocytopenia 77 on recent check by PCP, down to 30's at admission, with improvement after IV diuresis. Heme-ONC consulted, with workup not revealing any evidence for evidence for TTP, ITP, or bone marrow suppression. It appears liver congestion most likely cause of patients thrombocytopenia and LFT abnormalities. #Transaminitis Patient had persistently mildly elevated AST/ALT, even after resolution of hypervolemia. RUQ with normal flows, hepatic congestion, no evidence of cholecystitis. Hepatitis serologies negative. Likely warrants further outpatient work up. #Anemia Not iron deficient per labs. MCV 99. B12 within normal limits. Unclear of chronicity and if related to above thrombocytopenia. #HLD Continued home atorvastatin 80 mg nightly #Diabetes Mellitus Patient describes as brittle diabetes, has labile sugars. Here the patient was maintained on lantus (he was unsure of his home dosing), Humalog SSI. The patient's sugars were persistently elevated but it was discovered two days ___ to discharge that the patient was taking glucose tabs he brought from home whenever he felt like his sugars might be low. TRANSITIONAL ISSUES: ===================== [] ___ structural heart team willing to consult in future if patient becomes symptomatic from his valvular disease [] Patient was 38 lbs over dry weight at presentation, please watch his fluid levels closely and continue to provide education on his medications and diet [] If volume overloaded at follow up, increase diuresis to 80mg torsemide [] neurology outpatient work up for cognitive impairment [] diabetes education and titration of meds [] work up of persistent transaminitis Discharge Cr: 1.4 Discharge Weight: 57.02 kg, 125.7 lb Discharge diuretic 60 mg torsemide daily Patient contact: ___ ___ Code status: full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Calcium Carbonate 600 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Glargine 10 Units Breakfast Glargine 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Lisinopril 2.5 mg PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Spironolactone 12.5 mg PO DAILY 9. Torsemide 30 mg PO BID 10. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Glargine 20 Units Breakfast Glargine 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Basaglar KwikPen U-100 Insulin] 100 unit/mL (3 mL) AS DIR 20 Units before BKFT; 5 Units before BED; Disp #3 Syringe Refills:0 RX blood-glucose meter ___ Aviva Plus Meter] DAILY Disp #1 Each Refills:0 RX blood-glucose meter ___ Aviva Plus Meter] Disp #1 Each Refills:0 2. Spironolactone 25 mg PO DAILY 3. Torsemide 60 mg PO DAILY RX torsemide 20 mg 3 tablet(s) by mouth EVERY DAY Disp #120 Tablet Refills:3 4. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth ONCE DAILY Disp #90 Tablet Refills:3 5. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet(s) by mouth ONCE DAILY Disp #90 Tablet Refills:3 6. Calcium Carbonate 600 mg PO DAILY RX calcium carbonate [Antacid (calcium carbonate)] 200 mg calcium (500 mg) 3 tablet(s) by mouth EVERY DAY Disp #90 Tablet Refills:3 7. Ferrous Sulfate 325 mg PO DAILY RX ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by mouth DAILY Disp #30 Tablet Refills:3 8. Lisinopril 2.5 mg PO DAILY RX lisinopril 2.5 mg 1 tablet(s) by mouth ONCE DAILY Disp #60 Tablet Refills:3 9. Metoprolol Succinate XL 12.5 mg PO DAILY RX metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth ONCE DAILY Disp #30 Tablet Refills:3 10. Vitamin D ___ UNIT PO DAILY RX ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth DAILY Disp #90 Tablet Refills:*3 11.Outpatient Lab Work Basic Metabolic Panel + Electrolytes (Ca, Mg, Phos) 428.2 Systolic Heart Failure Follow up: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Acute on chronic heart failure with reduced ejection fraction Ischemic Cardiomyopathy Severe Mitral Regurgitation Severe Tricuspid Regurgitation SECONDARY DIAGNOSIS =================== Thrombocytopenia Anemia Diabetes Mellitus Transaminitis Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care. Please read through the following information. WHY WAS I ADMITTED TO THE HOSPITAL? You were admitted to the hospital because you had been feeling short of breath and you were found to have fluid on your lungs. This was felt to be due to a condition called heart failure, where your heart does not pump hard enough and fluid backs up into your lungs. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? You were given a diuretic medication through the IV to help get the fluid out. You improved considerably and were ready to leave the hospital. We also took pictures of your heart which showed that your heart valves are not functioning very well. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs (increases to more than 128.7 lbs). Your weight on discharge is 125.7 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath. We wish you the best! -Your ___ Care Team Followup Instructions: ___	[ "I110", "I5023", "I252", "I255", "I081", "E785", "E119", "Z950", "G3184", "D696", "R740", "D649", "Z7982", "Z794" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weight Gain Major Surgical or Invasive Procedure: [MASKED] Transesophageal ECHO History of Present Illness: Mr. [MASKED] is a [MASKED] yo M w/ PMH with [MASKED] MI (anterolateral wall), ischemic cardiomyopathy with resulting HFrEF (EF 20% w/ severe MR and TR), HTN, HLD, DM, who is being directly admitted after TEE because of volume overload. The patient was at the BI to have a TEE. He was referred by his outpatient cardiologist. While here he was found to be in a heart failure exacerbation and was admitted to the hospital. According to outpatient records the patient was last seen by Dr. [MASKED] on [MASKED]. At that time he was also overloaded, but they were increasing his dose of torsemide in the outpatient setting. There was concern over his hypotension decreasing his ability to tolerate medications. It was felt he should be admitted if he became refractory to PO diuretics. His last dose of torsemide as an outpatient was 30 mg TID torsemide. The patient states he has not been feeling well since he was admitted with a broken pacemaker to [MASKED] [MASKED] years ago. He says he feels similar to how he felt then, now. He says that he switched to [MASKED] and is concerned they are not checking his pacemaker as well as they were before and that is what is wrong with him. He says that most recently he has leg issues. They are swollen and painful. He mostly sleeps in a chair with his legs up. He is able to lay flat without difficulty and does not wake at night with shortness of breath. He notes that his abdomen has felt more distended as well. He is able to do less leg raises and crunches than before [MASKED] years ago). He is unsure if he has gained weight. He says his last weight was 134 lbs at [MASKED] [MASKED] years ago. According to his son, the patient has been getting progressively worsen. He has felt awful, can't walk. He has been having memory issues. Things have not been as good since at [MASKED]. On ROS the patient reports that he does occasionally have constipation. Otherwise he does not have any other problems including fever, chills, headaches, shortness of breath, nausea, vomiting, diarrhea, bloody stools, urinary straining or frequency (except when taking torsemide). Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - type II - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Coronaries? CAD? - Pump 20% w/ dilated RV and depressed free wall motion. severe MR [MASKED] hx of decompensated heart failure - Pacemaker Social History: [MASKED] Family History: 1 brother with a stroke 1 brother with a heart attack in his [MASKED] Physical Exam: Admission Physical Exam ======================== GENERAL: Well developed, well nourished in NAD. Oriented x3. Tangential in conversation HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. NECK: Supple. JVD to the mandible CARDIAC: regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. No thrills or lifts. LUNGS: normal respiratory effort, rales at bases bilaterally ABDOMEN: Soft, non-tender, distended, soft. No hepatomegaly. No splenomegaly. EXTREMITIES: cool with 2+ peripheral edema up his legs bilaterally. Molted appearance of feet bilaterally very cold to touch. He has dopplerable pulses in the DP and [MASKED] SKIN: No significant skin lesions or rashes. Discharge Physical Exam ========================= 24 HR Data (last updated [MASKED] @ 409) Temp: 97.7 (Tm 98.8), BP: 101/57 (79-101/35-65), HR: 54 (54-69), RR: 20 ([MASKED]), O2 sat: 96% (92-100), Wt: 125.7 lb/57.02 kg Fluid Balance (last updated [MASKED] @ 626) Last 8 hours Total cumulative -10ml IN: Total 840ml, PO Amt 840ml OUT: Total 850ml, Urine Amt 850ml Last 24 hours Total cumulative -210ml IN: Total 840ml, PO Amt 840ml OUT: Total 1050ml, Urine Amt 1050ml General: Well appearing, in no acute distress. HEENT: PERRL, MMM Neck: JVP <10 when upright. Lungs: Improved, clear to auscultation bilaterally CV: RRR, nls1/s2, [MASKED] systolic murmur, best heard at apex and left sternal border. Abdomen: Moderate distension, soft, nontender. No masses or HSM noted. Extremities: No [MASKED]. WWP. Skin: No rash, stasis dermatitis, or ulcers noted. PULSES: Distal pulses palpable and symmetric Neuro: AOx3 Pertinent Results: Admission Labs [MASKED] 06:33PM GLUCOSE-283* UREA N-27* CREAT-1.2 SODIUM-135 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-14 [MASKED] 06:33PM estGFR-Using this [MASKED] 06:33PM ALT(SGPT)-27 AST(SGOT)-43* LD(LDH)-281* ALK PHOS-293* TOT BILI-1.4 [MASKED] 06:33PM proBNP-4683* [MASKED] 06:33PM proBNP-4683* [MASKED] 06:33PM calTIBC-389 VIT B12-1427* HAPTOGLOB-63 FERRITIN-62 TRF-299 [MASKED] 06:33PM HCV Ab-NEG [MASKED] 06:33PM WBC-4.8 RBC-3.02* HGB-9.7* HCT-29.8* MCV-99* MCH-32.1* MCHC-32.6 RDW-15.9* RDWSD-57.8* [MASKED] 06:33PM NEUTS-67.0 [MASKED] MONOS-10.7 EOS-2.7 BASOS-0.2 IM [MASKED] AbsNeut-3.20 AbsLymp-0.92* AbsMono-0.51 AbsEos-0.13 AbsBaso-0.01 [MASKED] 06:33PM HYPOCHROM-NORMAL ANISOCYT-1+* POIKILOCY-1+* MACROCYT-1+* MICROCYT-NORMAL POLYCHROM-1+* OVALOCYT-1+* TEARDROP-OCCASIONAL BITE-1+* ACANTHOCY-2+* FRAGMENT-2+* ELLIPTOCY-1+* [MASKED] 06:33PM PLT SMR-VERY LOW* PLT COUNT-32* [MASKED] 06:33PM [MASKED] PTT-33.1 [MASKED] [MASKED] 06:33PM RET AUT-2.2* ABS RET-0.07 [MASKED] 06:32PM LACTATE-1.8 Discharge Labs [MASKED] 07:37AM BLOOD WBC-5.1 RBC-3.72* Hgb-12.1* Hct-34.8* MCV-94 MCH-32.5* MCHC-34.8 RDW-15.1 RDWSD-51.3* Plt Ct-95* [MASKED] 08:08AM BLOOD Glucose-214* UreaN-50* Creat-1.4* Na-128* K-4.2 Cl-85* HCO3-31 AnGap-12 [MASKED] 08:08AM BLOOD ALT-41* AST-61* AlkPhos-271* TotBili-1.6* [MASKED] 08:08AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.6 Studies [MASKED] ECHO There is no spontaneous echo contrast in the body of the left atrium or left atrial appendage. There is no evidence for an atrial septal defect by 2D/color Doppler. The left ventricle has an increased/dilated cavity. Overall left ventricular systolic function is severely depressed. The visually estimated left ventricular ejection fraction is 20%. Dilated right ventricular cavity with depressed free wall motion. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. There are simple atheroma in the aortic arch with simple atheroma in the descending aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is a central jet of severe [4+] mitral regurgitation. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is severe [4+] tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. [MASKED] TTE The left atrial volume index is SEVERELY increased. The right atrium is moderately enlarged. There is normal left ventricular wall thickness with a SEVERELY increased/dialted cavity. There is SEVERE global left ventricular hypokinesis. No thrombus or mass is seen in the left ventricle. Quantitative biplane left ventricular ejection fraction is 14 %. Due to severity of mitral regurgitation, intrinsic left ventricular systolic function likely be lower. Left ventricular cardiac index is depressed (less than 2.0 L/ min/m2). There is no resting left ventricular outflow tract gradient. Moderately dilated right ventricular cavity with depressed free wall motion. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is an eccentric, inferolateral directed jet of moderate to severe [3+] mitral regurgitation. There is mild pulmonic regurgitation. The tricuspid valve leaflets appear structurally normal. There is moderate to severe [3+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation, the pulmonary artery systolic pressure may be UNDERestimated. There is no pericardial effusion. IMPRESSION: Severely dilated, severely hypokinetic left ventricle. Moderate to severe mitral regurgitation (volumetric assessment suggests moderate, but the eccentric nature of the jet in the apical 2 and 3 chamber views indicates this is an underestimation of true severity). Dilated hypoknetic right ventricle. Moderate to severe tricuspid regurgitation. At least mild pulmonary hypertension. Compared with the [MASKED] TEE [MASKED] , there has been a slight decreae in the severity of the mitral regurgitation likley post-diuresis. Brief Hospital Course: PATIENT SUMMARY ================ Mr. [MASKED] is a [MASKED] yo M w/ PMH with [MASKED] MI (anterolateral wall), ischemic cardiomyopathy with resulting HFrEF (EF 20% w/ severe MR and TR), HTN, HLD, DM, who was directly admitted after TEE because of volume overload, due to likely exacerbation of patient's heart failure, now euvolemic after titration of diuresis and started on goal directed therapy for his HFrEF ACTIVE ISSUES: ============= #Acute on chronic HFrEF (EF 20%) #Ischemic Cardiomyopathy Patient presented with weight of 165. EF on TEE 20%, repeat after diuresis without significant changes. Subacute presentation, unclear etiology for exacerbation, but likely due to inadequate diuretic dose, and possibly worsening ischemic and/or valvular disease. The patient was initiated on IV diuresis, with Lasix drip as high as 30 mg/hr. The patient was net negative 16L of fluid, down to a weight of 125.7. We transitioned to 100mg PO Torsemide QD for preload. For afterload the patient was started on Lisinopril 2.5mg QD. For NHBK metoprolol 12.5 XL, spironolactone 25mg QD. It was decided during this admission that he should be trialed on goal directed medical therapy and defer any surgical intervention at this time. The patient saw palliative care who discussed his goals of care with him. #Severe MR #Severe TR Volume overload likely contributing to valvular disease, but severe MR and TR was noted on TTE even after patient was diuresed signficiantly. Discussed patient with cardiac surgery and structural cardiology. After discussion with them and patient, it was decided that intervention should be deferred right now until goal directed medical therapy was fully trialed. The patient would most likely require a repeat TEE when fully euvolemic [MASKED] to any surgical intervention. The patient stated he did not think he would want to have any procedure that required opening of his chest. The structural heart team at [MASKED] is aware of the patient and willing to consult for possible Mitraclip if the patient becomes symptomatic from his valvular disease in the future. #Cognitive impairment Patient without history of cognitive impairment noted but concern during admission. OT was consulted and say needs help with 100% of IADLs. MOCA [MASKED] was 14. Recommend outpatient follow up of this issues as in transitional issues. #Thrombocytopenia 77 on recent check by PCP, down to 30's at admission, with improvement after IV diuresis. Heme-ONC consulted, with workup not revealing any evidence for evidence for TTP, ITP, or bone marrow suppression. It appears liver congestion most likely cause of patients thrombocytopenia and LFT abnormalities. #Transaminitis Patient had persistently mildly elevated AST/ALT, even after resolution of hypervolemia. RUQ with normal flows, hepatic congestion, no evidence of cholecystitis. Hepatitis serologies negative. Likely warrants further outpatient work up. #Anemia Not iron deficient per labs. MCV 99. B12 within normal limits. Unclear of chronicity and if related to above thrombocytopenia. #HLD Continued home atorvastatin 80 mg nightly #Diabetes Mellitus Patient describes as brittle diabetes, has labile sugars. Here the patient was maintained on lantus (he was unsure of his home dosing), Humalog SSI. The patient's sugars were persistently elevated but it was discovered two days [MASKED] to discharge that the patient was taking glucose tabs he brought from home whenever he felt like his sugars might be low. TRANSITIONAL ISSUES: ===================== [] [MASKED] structural heart team willing to consult in future if patient becomes symptomatic from his valvular disease [] Patient was 38 lbs over dry weight at presentation, please watch his fluid levels closely and continue to provide education on his medications and diet [] If volume overloaded at follow up, increase diuresis to 80mg torsemide [] neurology outpatient work up for cognitive impairment [] diabetes education and titration of meds [] work up of persistent transaminitis Discharge Cr: 1.4 Discharge Weight: 57.02 kg, 125.7 lb Discharge diuretic 60 mg torsemide daily Patient contact: [MASKED] [MASKED] Code status: full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Calcium Carbonate 600 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Glargine 10 Units Breakfast Glargine 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Lisinopril 2.5 mg PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Spironolactone 12.5 mg PO DAILY 9. Torsemide 30 mg PO BID 10. Vitamin D [MASKED] UNIT PO DAILY Discharge Medications: 1. Glargine 20 Units Breakfast Glargine 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX insulin glargine [Basaglar KwikPen U-100 Insulin] 100 unit/mL (3 mL) AS DIR 20 Units before BKFT; 5 Units before BED; Disp #3 Syringe Refills:0 RX blood-glucose meter [MASKED] Aviva Plus Meter] DAILY Disp #1 Each Refills:0 RX blood-glucose meter [MASKED] Aviva Plus Meter] Disp #1 Each Refills:0 2. Spironolactone 25 mg PO DAILY 3. Torsemide 60 mg PO DAILY RX torsemide 20 mg 3 tablet(s) by mouth EVERY DAY Disp #120 Tablet Refills:3 4. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth ONCE DAILY Disp #90 Tablet Refills:3 5. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet(s) by mouth ONCE DAILY Disp #90 Tablet Refills:3 6. Calcium Carbonate 600 mg PO DAILY RX calcium carbonate [Antacid (calcium carbonate)] 200 mg calcium (500 mg) 3 tablet(s) by mouth EVERY DAY Disp #90 Tablet Refills:3 7. Ferrous Sulfate 325 mg PO DAILY RX ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by mouth DAILY Disp #30 Tablet Refills:3 8. Lisinopril 2.5 mg PO DAILY RX lisinopril 2.5 mg 1 tablet(s) by mouth ONCE DAILY Disp #60 Tablet Refills:3 9. Metoprolol Succinate XL 12.5 mg PO DAILY RX metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth ONCE DAILY Disp #30 Tablet Refills:3 10. Vitamin D [MASKED] UNIT PO DAILY RX ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth DAILY Disp #90 Tablet Refills:*3 11.Outpatient Lab Work Basic Metabolic Panel + Electrolytes (Ca, Mg, Phos) 428.2 Systolic Heart Failure Follow up: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================= Acute on chronic heart failure with reduced ejection fraction Ischemic Cardiomyopathy Severe Mitral Regurgitation Severe Tricuspid Regurgitation SECONDARY DIAGNOSIS =================== Thrombocytopenia Anemia Diabetes Mellitus Transaminitis Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure participating in your care. Please read through the following information. WHY WAS I ADMITTED TO THE HOSPITAL? You were admitted to the hospital because you had been feeling short of breath and you were found to have fluid on your lungs. This was felt to be due to a condition called heart failure, where your heart does not pump hard enough and fluid backs up into your lungs. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? You were given a diuretic medication through the IV to help get the fluid out. You improved considerably and were ready to leave the hospital. We also took pictures of your heart which showed that your heart valves are not functioning very well. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs (increases to more than 128.7 lbs). Your weight on discharge is 125.7 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath. We wish you the best! -Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I110", "I252", "E785", "E119", "D696", "D649", "Z794" ]	[ "I110: Hypertensive heart disease with heart failure", "I5023: Acute on chronic systolic (congestive) heart failure", "I252: Old myocardial infarction", "I255: Ischemic cardiomyopathy", "I081: Rheumatic disorders of both mitral and tricuspid valves", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z950: Presence of cardiac pacemaker", "G3184: Mild cognitive impairment, so stated", "D696: Thrombocytopenia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "D649: Anemia, unspecified", "Z7982: Long term (current) use of aspirin", "Z794: Long term (current) use of insulin" ]
19,979,360	29,941,035	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weight gain, lower extremity edema, fatigue Major Surgical or Invasive Procedure: ___: ___ transfemoral approach History of Present Illness: Mr. ___ is a ___ year old man with a history of heart failure with reduced ejection fraction (LVEF 20%), severe mitral regurgitation who was recently admitted with decompensated heart failure. He was evaluated by the cardiac surgery service for surgical mitral valve replacement but the patient strongly preferred nonsurgical therapy instead. On that admission he was also found to be thrombocytopenic and the hematology service felt this was due to cardiac cirrhosis. He presents today electively for MitraClip for his severe mitral regurgitation and refractory heart failure. He complaints of ongoing exertional dyspnea, orthopnea, and lower extremity edema. He has had no bleeding problems. Past Medical History: 1. Heart failure with reduced ejection fraction * ___ CRT-D 2. Severe mitral regurgitation 3. Severe tricuspid regurgitation 4. Hypertension 5. Dyslipidemia 6. Status post pacemaker 7. Chronic kidney disease 8. Thrombocytopenia * Per hematology consult, felt to be due to congestive hepatopathy/cardiac cirrhosis Social History: ___ Family History: 1 brother with a stroke 1 brother with a heart attack in his ___ Physical Exam: Physical Exam on Admit: ========================= Vitals: Temperature: 98 Heart Rate: 67 Respiration: 22 Blood Pressure: Left arm: 94/79, Right arm: 101/76 Gen: Pleasant, calm. Talkative. Weight: 68 kg HEENT: Moist mucous membranes NECK: JVP 9cmH2O CV: Regular, holosystolic murmur LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: Soft, nontender EXT: Warm, well-perfused. 1+ edema to calves bilaterally. SKIN: No rashes/lesions, ecchymoses. Physical Exam on Discharge: ============================= VS: T 97.8 BP 98/69 HR 57 RR 16 SpO2 99% RA Weight: 60.7 kg Gen: Pleasant man sitting, ambulating hallways to solarium; steady and independent with ambulation NEURO: A&O x3, forgetful, steady on feet, gross intact. HEENT: Moist mucous membranes NECK: JVD to jaw CV: Regular, loud holosystolic murmur LUNGS: CTAB, Non-labored at rest and with slow ambulation. ABD: +BS, softly distended, nontender, no organomegaly. EXT: Warm, chronic venous stasis discoloration. 1+ pitting edema to knees bilaterally. SKIN: R groin site with soft ecchymosis from right thigh to scrotum, no hematoma, no oozing. Pertinent Results: Labs on Admit: ================= ___ 06:11PM BLOOD WBC-5.9 RBC-2.68* Hgb-8.6* Hct-26.3* MCV-98 MCH-32.1* MCHC-32.7 RDW-15.8* RDWSD-56.3* Plt Ct-69* ___ 06:11PM BLOOD UreaN-19 Creat-1.1 Na-139 K-3.4* ___ 06:11PM BLOOD Mg-2.1 ___ 06:20AM BLOOD ALT-23 AST-44* AlkPhos-218* TotBili-1.0 Results: ================= TEE (___): Pre-mitraclip deployment: Overall left ventricular systolic function is severely depressed (LVEF= ___. with moderate global RV free wall hypokinesis. Severe (4+) MR. ___ is restrictive movement of the mitral leaflets, with a broad MR jet between A2 and P2. Severe [4+]TR is seen. There is no pericardial effusion. Post-mitraclip deployment: A mitraclip is well-positioned on the A2 and P2 cusps. MR is now moderate. Mean pressure gradient across the mitral valve is 3 mmHg. Threre is a bi-directional atrial septal defect. There is a trace pericardial effusion seen around the right atrium. The remainder of the exam is unchanged. Portable CXR (___): IMPRESSION: In comparison with the study of ___, a there again is huge enlargement of the cardiac silhouette, now with a mitral clip in place. Mild vascular congestion with bilateral pleural effusions and compressive atelectasis at the bases. Multi channel pacer device is unchanged. TTE (___): IMPRESSION: Severely dilated left ventricule with severe global hypokinesis. Severe right ventricular dilation with severe global hypokinesis. Well-seated Mitraclip with moderate eccentric mitral regurgitation. Severe tricuspid regurgitation with hepatic vein flow reversal. LVEF ___. Labs on discharge: =================== ___ 07:14AM BLOOD WBC-5.5 RBC-3.18* Hgb-10.2* Hct-33.1* MCV-104* MCH-32.1* MCHC-30.8* RDW-15.9* RDWSD-60.6* Plt Ct-68* ___ 01:11PM BLOOD Plt ___ ___ 07:14AM BLOOD Glucose-213* UreaN-28* Creat-1.2 Na-138 K-4.0 Cl-95* HCO3-25 AnGap-___ssessment/Plan: ASSESSMENT & PLAN: ___ year old man with a history of heart failure with reduced ejection fraction (LVEF 20%), severe MR/TR who presents electively for ___. #) HEART FAILURE WITH REDUCED EJECTION FRACTION, CHRONIC #) SEVERE MITRAL REGURGITATION #) SEVERE TRICUSPID REGURGITATION Recent hospitalization in ___ for acute systolic HF exacerbation, with fluid loss of 40 lbs, down to new dry weight of 57 kg (125 lb). He was discharged home on goal directed medical therapy. However, he continued to have volume overload, and was admitted for elective ___ procedure on ___. Tolerated well, with MR improved to ___. He continues to have 4+ TR and LVEF ___. He is currently down 15 lbs and negative ~10,000 L. Weight still about 3 kg above dry weight, but diuresed well on Lasix drip. Lasix drip was discontinued the morning of ___, and Torsemide 80mg PO BID started. Creat stable at 1.2 on day of discharge. Ambulating hallways independently throughout day, without SOB. - Continue Torsemide 80mg BID (was on 60mg BID at home). ___ decrease dose once back to dry weight - Monitor electrolytes and creatinine daily via ___ while on increased Torsemide dose - Continue metoprolol succinate 12.5mg daily - Continue spironolactone 25mg daily - Hold lisinopril 2.5mg daily to leave room for diuresis with soft BPs. Consider resuming once back on decreased Torsemide dose - Anticoagulation plan: ASA 81mg daily lifelong and Plavix 75mg daily x 1 month - 1 month TTE and follow up with Dr. ___ - SBE prophylaxis x 6 months post procedure #) CORONARY ARTERY DISEASE: Denies anginal complaints. - Continue atorvastatin - Continue aspirin #) Ventricular ectopy: frequent PVCs with occasional runs of NSVT that are assymptomatic. Pt has ICD. - Monitor electrolytes and replete to maintain Mg >2.0 and K >4.2 #) THROMBOCYTOPENIA #) CARDIAC CIRRHOSIS: Heme-ONC consulted previous admit in ___, with workup not revealing any evidence for evidence for TTP, ITP, or bone marrow suppression. It appears liver congestion most likely cause of patients thrombocytopenia and LFT abnormalities. LFTs stable from previous admit in ___. Plts stable at 110 on discharge. Dr. ___, continue Plavix at shorter course x 1 month, and stop if any signs of bleeding. - Monitor closely for bleeding - Consider future intervention on tricuspid regurgitation if symptoms/congestive hepatopathy is refractory #) DIABETES MELLITUS, TYPE 2: 24 hr blood glucose range 88-306 day of discharge. Fasting 216 with AM labs. Patient did admit to taking his own glucose tabs during hospitalization. Discussion with patient, nurse and provider. Patient agreeable to call nurse when he feels he is having a hypoglycemia sx's, prior to taking glucose tablets. - Monitor blood sugar QACHS, diabetic diet - ___ was following while inpatient and made changes to Insulin Lantus dose and increased short acting sliding scale. Recommendations are as follows: Insulin glargine 20units with breakfast, 3 units at bedtime. Insulin Novolog sliding scale: Glucose Insulin Dose 120-159 5 units 160-199 6 units 200-239 7 units 240-279 8 units 280-319 9 units 320-359 10 units 360-400 11 units #) VITAMIN D DEFICIENCY - Continue vitamin D supplementation Dispo: Home today with services. Patient has ___ at home and was reinitiated by case manager. Requested daily labs and reiteration of insulin regimen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Calcium Carbonate 600 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Lisinopril 2.5 mg PO DAILY 6. Vitamin D ___ UNIT PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Torsemide 60 mg PO DAILY 9. Spironolactone 25 mg PO DAILY 10. Glargine 20 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Amoxicillin ___ mg PO ONCE 1 hour prior to dental procedure Duration: 1 Dose 2. Clopidogrel 75 mg PO DAILY 3. Glargine 20 Units Breakfast Glargine 3 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Torsemide 80 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Calcium Carbonate 600 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. Metoprolol Succinate XL 12.5 mg PO DAILY 10. Spironolactone 25 mg PO DAILY 11. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Severe mitral regurgitation Severe tricuspid regurgitation Chronic systolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). See discharge summary. Discharge Instructions: You were admitted for your mitral valve clip procedure. By repairing the valve your heart can pump blood more easily and your shortness of breath, fatigue, and lower extremity edema should improve. Your echocardiogram of the heart still shows tricuspid valve regurgitation (back flow), so it is very important that you continue to weigh yourself every day to monitor for fluid overload. You were given IV medication/diuretics to take off fluid. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 133.5 lbs. It is very important to take all of your heart healthy medications. In particular, you are now taking aspirin and plavix. These medications help to prevent blood clots from forming in/around the heart valve. If you stop these medications or miss ___ dose, you risk causing a blood clot forming on your heart valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking aspirin or Plavix without taking to your heart doctor, even if another doctor tells you to stop the medications. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure. One hour prior to your dental procedure take amoxicillin 2 gram once. The diabetes doctors were following ___ while you were in the hospital to make sure your blood sugars were under control. They changed your Insulin Lantus to 20 units with breakfast AND 3 units at bedtime. You are also on the sliding scale of Insulin Novolog with each meal. We have made changes to your medication list, so please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the ___ HeartLine at ___ to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health! Followup Instructions: ___	[ "I081", "I130", "I5022", "I472", "Z006", "E1122", "N189", "Z794", "E785", "I2510", "E559", "D6959", "I252", "I255", "K761", "E1165" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weight gain, lower extremity edema, fatigue Major Surgical or Invasive Procedure: [MASKED]: [MASKED] transfemoral approach History of Present Illness: Mr. [MASKED] is a [MASKED] year old man with a history of heart failure with reduced ejection fraction (LVEF 20%), severe mitral regurgitation who was recently admitted with decompensated heart failure. He was evaluated by the cardiac surgery service for surgical mitral valve replacement but the patient strongly preferred nonsurgical therapy instead. On that admission he was also found to be thrombocytopenic and the hematology service felt this was due to cardiac cirrhosis. He presents today electively for MitraClip for his severe mitral regurgitation and refractory heart failure. He complaints of ongoing exertional dyspnea, orthopnea, and lower extremity edema. He has had no bleeding problems. Past Medical History: 1. Heart failure with reduced ejection fraction * [MASKED] CRT-D 2. Severe mitral regurgitation 3. Severe tricuspid regurgitation 4. Hypertension 5. Dyslipidemia 6. Status post pacemaker 7. Chronic kidney disease 8. Thrombocytopenia * Per hematology consult, felt to be due to congestive hepatopathy/cardiac cirrhosis Social History: [MASKED] Family History: 1 brother with a stroke 1 brother with a heart attack in his [MASKED] Physical Exam: Physical Exam on Admit: ========================= Vitals: Temperature: 98 Heart Rate: 67 Respiration: 22 Blood Pressure: Left arm: 94/79, Right arm: 101/76 Gen: Pleasant, calm. Talkative. Weight: 68 kg HEENT: Moist mucous membranes NECK: JVP 9cmH2O CV: Regular, holosystolic murmur LUNGS: CTAB. No wheezes, rales, or rhonchi. ABD: Soft, nontender EXT: Warm, well-perfused. 1+ edema to calves bilaterally. SKIN: No rashes/lesions, ecchymoses. Physical Exam on Discharge: ============================= VS: T 97.8 BP 98/69 HR 57 RR 16 SpO2 99% RA Weight: 60.7 kg Gen: Pleasant man sitting, ambulating hallways to solarium; steady and independent with ambulation NEURO: A&O x3, forgetful, steady on feet, gross intact. HEENT: Moist mucous membranes NECK: JVD to jaw CV: Regular, loud holosystolic murmur LUNGS: CTAB, Non-labored at rest and with slow ambulation. ABD: +BS, softly distended, nontender, no organomegaly. EXT: Warm, chronic venous stasis discoloration. 1+ pitting edema to knees bilaterally. SKIN: R groin site with soft ecchymosis from right thigh to scrotum, no hematoma, no oozing. Pertinent Results: Labs on Admit: ================= [MASKED] 06:11PM BLOOD WBC-5.9 RBC-2.68* Hgb-8.6* Hct-26.3* MCV-98 MCH-32.1* MCHC-32.7 RDW-15.8* RDWSD-56.3* Plt Ct-69* [MASKED] 06:11PM BLOOD UreaN-19 Creat-1.1 Na-139 K-3.4* [MASKED] 06:11PM BLOOD Mg-2.1 [MASKED] 06:20AM BLOOD ALT-23 AST-44* AlkPhos-218* TotBili-1.0 Results: ================= TEE ([MASKED]): Pre-mitraclip deployment: Overall left ventricular systolic function is severely depressed (LVEF= [MASKED]. with moderate global RV free wall hypokinesis. Severe (4+) MR. [MASKED] is restrictive movement of the mitral leaflets, with a broad MR jet between A2 and P2. Severe [4+]TR is seen. There is no pericardial effusion. Post-mitraclip deployment: A mitraclip is well-positioned on the A2 and P2 cusps. MR is now moderate. Mean pressure gradient across the mitral valve is 3 mmHg. Threre is a bi-directional atrial septal defect. There is a trace pericardial effusion seen around the right atrium. The remainder of the exam is unchanged. Portable CXR ([MASKED]): IMPRESSION: In comparison with the study of [MASKED], a there again is huge enlargement of the cardiac silhouette, now with a mitral clip in place. Mild vascular congestion with bilateral pleural effusions and compressive atelectasis at the bases. Multi channel pacer device is unchanged. TTE ([MASKED]): IMPRESSION: Severely dilated left ventricule with severe global hypokinesis. Severe right ventricular dilation with severe global hypokinesis. Well-seated Mitraclip with moderate eccentric mitral regurgitation. Severe tricuspid regurgitation with hepatic vein flow reversal. LVEF [MASKED]. Labs on discharge: =================== [MASKED] 07:14AM BLOOD WBC-5.5 RBC-3.18* Hgb-10.2* Hct-33.1* MCV-104* MCH-32.1* MCHC-30.8* RDW-15.9* RDWSD-60.6* Plt Ct-68* [MASKED] 01:11PM BLOOD Plt [MASKED] [MASKED] 07:14AM BLOOD Glucose-213* UreaN-28* Creat-1.2 Na-138 K-4.0 Cl-95* HCO3-25 AnGap- ssessment/Plan: ASSESSMENT & PLAN: [MASKED] year old man with a history of heart failure with reduced ejection fraction (LVEF 20%), severe MR/TR who presents electively for [MASKED]. #) HEART FAILURE WITH REDUCED EJECTION FRACTION, CHRONIC #) SEVERE MITRAL REGURGITATION #) SEVERE TRICUSPID REGURGITATION Recent hospitalization in [MASKED] for acute systolic HF exacerbation, with fluid loss of 40 lbs, down to new dry weight of 57 kg (125 lb). He was discharged home on goal directed medical therapy. However, he continued to have volume overload, and was admitted for elective [MASKED] procedure on [MASKED]. Tolerated well, with MR improved to [MASKED]. He continues to have 4+ TR and LVEF [MASKED]. He is currently down 15 lbs and negative ~10,000 L. Weight still about 3 kg above dry weight, but diuresed well on Lasix drip. Lasix drip was discontinued the morning of [MASKED], and Torsemide 80mg PO BID started. Creat stable at 1.2 on day of discharge. Ambulating hallways independently throughout day, without SOB. - Continue Torsemide 80mg BID (was on 60mg BID at home). [MASKED] decrease dose once back to dry weight - Monitor electrolytes and creatinine daily via [MASKED] while on increased Torsemide dose - Continue metoprolol succinate 12.5mg daily - Continue spironolactone 25mg daily - Hold lisinopril 2.5mg daily to leave room for diuresis with soft BPs. Consider resuming once back on decreased Torsemide dose - Anticoagulation plan: ASA 81mg daily lifelong and Plavix 75mg daily x 1 month - 1 month TTE and follow up with Dr. [MASKED] - SBE prophylaxis x 6 months post procedure #) CORONARY ARTERY DISEASE: Denies anginal complaints. - Continue atorvastatin - Continue aspirin #) Ventricular ectopy: frequent PVCs with occasional runs of NSVT that are assymptomatic. Pt has ICD. - Monitor electrolytes and replete to maintain Mg >2.0 and K >4.2 #) THROMBOCYTOPENIA #) CARDIAC CIRRHOSIS: Heme-ONC consulted previous admit in [MASKED], with workup not revealing any evidence for evidence for TTP, ITP, or bone marrow suppression. It appears liver congestion most likely cause of patients thrombocytopenia and LFT abnormalities. LFTs stable from previous admit in [MASKED]. Plts stable at 110 on discharge. Dr. [MASKED], continue Plavix at shorter course x 1 month, and stop if any signs of bleeding. - Monitor closely for bleeding - Consider future intervention on tricuspid regurgitation if symptoms/congestive hepatopathy is refractory #) DIABETES MELLITUS, TYPE 2: 24 hr blood glucose range 88-306 day of discharge. Fasting 216 with AM labs. Patient did admit to taking his own glucose tabs during hospitalization. Discussion with patient, nurse and provider. Patient agreeable to call nurse when he feels he is having a hypoglycemia sx's, prior to taking glucose tablets. - Monitor blood sugar QACHS, diabetic diet - [MASKED] was following while inpatient and made changes to Insulin Lantus dose and increased short acting sliding scale. Recommendations are as follows: Insulin glargine 20units with breakfast, 3 units at bedtime. Insulin Novolog sliding scale: Glucose Insulin Dose 120-159 5 units 160-199 6 units 200-239 7 units 240-279 8 units 280-319 9 units 320-359 10 units 360-400 11 units #) VITAMIN D DEFICIENCY - Continue vitamin D supplementation Dispo: Home today with services. Patient has [MASKED] at home and was reinitiated by case manager. Requested daily labs and reiteration of insulin regimen. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Calcium Carbonate 600 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Lisinopril 2.5 mg PO DAILY 6. Vitamin D [MASKED] UNIT PO DAILY 7. Metoprolol Succinate XL 12.5 mg PO DAILY 8. Torsemide 60 mg PO DAILY 9. Spironolactone 25 mg PO DAILY 10. Glargine 20 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Amoxicillin [MASKED] mg PO ONCE 1 hour prior to dental procedure Duration: 1 Dose 2. Clopidogrel 75 mg PO DAILY 3. Glargine 20 Units Breakfast Glargine 3 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Torsemide 80 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Calcium Carbonate 600 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. Metoprolol Succinate XL 12.5 mg PO DAILY 10. Spironolactone 25 mg PO DAILY 11. Vitamin D [MASKED] UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Severe mitral regurgitation Severe tricuspid regurgitation Chronic systolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). See discharge summary. Discharge Instructions: You were admitted for your mitral valve clip procedure. By repairing the valve your heart can pump blood more easily and your shortness of breath, fatigue, and lower extremity edema should improve. Your echocardiogram of the heart still shows tricuspid valve regurgitation (back flow), so it is very important that you continue to weigh yourself every day to monitor for fluid overload. You were given IV medication/diuretics to take off fluid. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 133.5 lbs. It is very important to take all of your heart healthy medications. In particular, you are now taking aspirin and plavix. These medications help to prevent blood clots from forming in/around the heart valve. If you stop these medications or miss [MASKED] dose, you risk causing a blood clot forming on your heart valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking aspirin or Plavix without taking to your heart doctor, even if another doctor tells you to stop the medications. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure. One hour prior to your dental procedure take amoxicillin 2 gram once. The diabetes doctors were following [MASKED] while you were in the hospital to make sure your blood sugars were under control. They changed your Insulin Lantus to 20 units with breakfast AND 3 units at bedtime. You are also on the sliding scale of Insulin Novolog with each meal. We have made changes to your medication list, so please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the [MASKED] HeartLine at [MASKED] to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health! Followup Instructions: [MASKED]	[]	[ "I130", "E1122", "N189", "Z794", "E785", "I2510", "I252", "E1165" ]	[ "I081: Rheumatic disorders of both mitral and tricuspid valves", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "I472: Ventricular tachycardia", "Z006: Encounter for examination for normal comparison and control in clinical research program", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E559: Vitamin D deficiency, unspecified", "D6959: Other secondary thrombocytopenia", "I252: Old myocardial infarction", "I255: Ischemic cardiomyopathy", "K761: Chronic passive congestion of liver", "E1165: Type 2 diabetes mellitus with hyperglycemia" ]
19,979,419	23,347,172	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: ___ Aortic valve replacement History of Present Illness: Very nice ___ year old male ___'s witness with a history of pulmonary sarcoidosis and known aortic stenosis that has been followed for the last few years. His most recent echocardiogram revealed severe aortic stenosis. He has has symptoms of progressive dyspnea on exertion over the past six months. He was referred for a cardiac catheterization and was found to have insignificant coronary artery disease. He was originally scheduled for surgery last week however the knowledge of his refusal for blood product was not know until the morning of surgery. His surgery was thus delayed so that a discussion regarding his surgery could be held. He is preop for aortic valve replacement. Past Medical History: Aortic stenosis Hypercholesterolemia- has not required medication Hypertension Obstructive sleep apnea (CPAP) TIA ___ years ago Pulmonary sarcoidosis Obesity ___ Hepatitis A GERD ADHD Depression/Anxiety Ankle fracture Psoriasis Psoriatic arthritis Carpal tunnel surgery s/p surgery bilaterally Trigger finger s/p surgery Social History: ___ Family History: Premature coronary artery disease- Maternal uncles had heart disease. Two died suddenly in their ___ from ? cardiac disease. Another died from an MI in his ___. Physical Exam: BP: 131/98. Heart Rate: 73. Resp. Rate: 14. O2 Saturation%: 100. Height:5'8" Weight:119.7 kg General: NAD, obese Skin: Dry [x] intact [x] psoriatic plaques on knees HEENT: PERRLA [x] EOMI [x] Neck: Supple [] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade _3/6 systolic_ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _none_. Ingrown toenail is clinically not infected. Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ ___ Right: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: radiation of cardiac murmur Discharge Exam: VS: T: 97.9 HR 60-70's w/freq PVC BP: 100-110/60 RR: 18 Sats: 97% RA Wt: 117 kg General: ___ year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: RRR Resp: late crackles left lower lobe GI: obese benign Extr: warm no edema Wound: sternal clean dry intact. no erythema, no click Neuro: awake, alert oriented Pertinent Results: Echo ___: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the aortic root. There are simple atheroma in the descending thoracic aorta. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area <1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Preserved bi-ventriculr systolci function. 2. Bio-proshetic (tri-leaflet) valve seen in the aortic position. Well seated and stable with good leaflet excursion. No appreciable transvalvulart gradient. 3. No other change. Chest PA & Lat: ___ Mediastinal wires and right IJ central line are seen and unchanged position. There is unchanged cardiomegaly. There is improved aeration with improvement of the opacities within the right perihilar and lower lung fields. This likely represents improvement of the pulmonary interstitial edema. There are no pneumothoraces. Admission Labs: ___ WBC-31.6# RBC-4.88 Hgb-14.7 Hct-43.4 MCV-89 MCH-30.1 MCHC-33.9 RDW-12.4 RDWSD-40.2 Plt ___ ___ ___ PTT-26.6 ___ ___ UreaN-20 Creat-1.1 Na-143 K-3.6 Cl-110 HCO3-23 ___ Calcium-8.0* Phos-2.3* Mg-3.1* Discharge Labs: ___ WBC-8.8 RBC-4.19* Hgb-12.6* Hct-37.6* MCV-90 MCH-30.1 MCHC-33.5 RDW-12.3 RDWSD-39.6 Plt ___ ___ Glucose-137* UreaN-22* Creat-1.0 Na-134 K-4.6 Cl-95* HCO3-26 ___ Mg-2.4 Micro ___ MRSA SCREEN (Final ___: No MRSA isolated. Brief Hospital Course: Mr. ___ was a same day admit and on ___ was brought directly to the hospital where he underwent Aortic valve replacement with a ___ tissue valve, 25 mm. Cardiopulmonary bypass time 92 minutes, Cross-clamp time 63 minutes. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes 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 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Acetaminophen 300 mg-Codeine 30 mg 1 tablet BID PRN ProAir HFA 90 mcg/actuation aerosol inhaler 1 puff PRN Atenolol 50 mg Daily Advair Diskus 250 mcg-50 mcg/dose powder for inhalation BID Ibuprofen 600 mg BID PRN Concerta 36 mg Daiy Singulair 10 mg Daily Paroxetine 40 mg Daily (Not Taking:has not yet refilled) Aspirin 81 mg Daily Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezes 2. Aspirin EC 81 mg PO DAILY 3. Concerta (methylphenidate) 36 mg oral DAILY 4. Docusate Sodium 100 mg PO BID hold for loose stools 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Metoprolol Tartrate 50 mg PO BID replaces atenolol RX metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 7. Montelukast 10 mg PO DAILY 8. Furosemide 40 mg PO DAILY Duration: 7 Days RX furosemide 40 mg 1 tablet(s) by mouth once a day Disp #7 Tablet Refills:0 9. Potassium Chloride 10 mEq PO DAILY Duration: 7 Days take with lasix RX potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth once a day Disp #7 Tablet Refills:0 10. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 11. Amiodarone 400 mg PO BID Duration: 7 Days then 200 mg twice daily x 14 days then 200 mg daily x 1 month RX amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement Past Medical History: Hypercholesterolemia- has not required medication Hypertension Obstructive sleep apnea (CPAP) TIA ___ years ago Pulmonary sarcoidosis Obesity ___ Hepatitis A GERD ADHD Depression/Anxiety Ankle fracture Psoriasis Psoriatic arthritis Carpal tunnel surgery s/p surgery bilaterally Trigger finger s/p surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema: none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions: ___	[ "Q231", "Z6841", "D860", "L4050", "I10", "G4733", "Z8673", "F17210", "F909", "K219", "E669" ]	Allergies: Penicillins Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [MASKED] Aortic valve replacement History of Present Illness: Very nice [MASKED] year old male [MASKED]'s witness with a history of pulmonary sarcoidosis and known aortic stenosis that has been followed for the last few years. His most recent echocardiogram revealed severe aortic stenosis. He has has symptoms of progressive dyspnea on exertion over the past six months. He was referred for a cardiac catheterization and was found to have insignificant coronary artery disease. He was originally scheduled for surgery last week however the knowledge of his refusal for blood product was not know until the morning of surgery. His surgery was thus delayed so that a discussion regarding his surgery could be held. He is preop for aortic valve replacement. Past Medical History: Aortic stenosis Hypercholesterolemia- has not required medication Hypertension Obstructive sleep apnea (CPAP) TIA [MASKED] years ago Pulmonary sarcoidosis Obesity [MASKED] Hepatitis A GERD ADHD Depression/Anxiety Ankle fracture Psoriasis Psoriatic arthritis Carpal tunnel surgery s/p surgery bilaterally Trigger finger s/p surgery Social History: [MASKED] Family History: Premature coronary artery disease- Maternal uncles had heart disease. Two died suddenly in their [MASKED] from ? cardiac disease. Another died from an MI in his [MASKED]. Physical Exam: BP: 131/98. Heart Rate: 73. Resp. Rate: 14. O2 Saturation%: 100. Height:5'8" Weight:119.7 kg General: NAD, obese Skin: Dry [x] intact [x] psoriatic plaques on knees HEENT: PERRLA [x] EOMI [x] Neck: Supple [] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none . Ingrown toenail is clinically not infected. Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ [MASKED] Right: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: radiation of cardiac murmur Discharge Exam: VS: T: 97.9 HR 60-70's w/freq PVC BP: 100-110/60 RR: 18 Sats: 97% RA Wt: 117 kg General: [MASKED] year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: RRR Resp: late crackles left lower lobe GI: obese benign Extr: warm no edema Wound: sternal clean dry intact. no erythema, no click Neuro: awake, alert oriented Pertinent Results: Echo [MASKED]: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the aortic root. There are simple atheroma in the descending thoracic aorta. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area <1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Preserved bi-ventriculr systolci function. 2. Bio-proshetic (tri-leaflet) valve seen in the aortic position. Well seated and stable with good leaflet excursion. No appreciable transvalvulart gradient. 3. No other change. Chest PA & Lat: [MASKED] Mediastinal wires and right IJ central line are seen and unchanged position. There is unchanged cardiomegaly. There is improved aeration with improvement of the opacities within the right perihilar and lower lung fields. This likely represents improvement of the pulmonary interstitial edema. There are no pneumothoraces. Admission Labs: [MASKED] WBC-31.6# RBC-4.88 Hgb-14.7 Hct-43.4 MCV-89 MCH-30.1 MCHC-33.9 RDW-12.4 RDWSD-40.2 Plt [MASKED] [MASKED] [MASKED] PTT-26.6 [MASKED] [MASKED] UreaN-20 Creat-1.1 Na-143 K-3.6 Cl-110 HCO3-23 [MASKED] Calcium-8.0* Phos-2.3* Mg-3.1* Discharge Labs: [MASKED] WBC-8.8 RBC-4.19* Hgb-12.6* Hct-37.6* MCV-90 MCH-30.1 MCHC-33.5 RDW-12.3 RDWSD-39.6 Plt [MASKED] [MASKED] Glucose-137* UreaN-22* Creat-1.0 Na-134 K-4.6 Cl-95* HCO3-26 [MASKED] Mg-2.4 Micro [MASKED] MRSA SCREEN (Final [MASKED]: No MRSA isolated. Brief Hospital Course: Mr. [MASKED] was a same day admit and on [MASKED] was brought directly to the hospital where he underwent Aortic valve replacement with a [MASKED] tissue valve, 25 mm. Cardiopulmonary bypass time 92 minutes, Cross-clamp time 63 minutes. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes 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 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Acetaminophen 300 mg-Codeine 30 mg 1 tablet BID PRN ProAir HFA 90 mcg/actuation aerosol inhaler 1 puff PRN Atenolol 50 mg Daily Advair Diskus 250 mcg-50 mcg/dose powder for inhalation BID Ibuprofen 600 mg BID PRN Concerta 36 mg Daiy Singulair 10 mg Daily Paroxetine 40 mg Daily (Not Taking:has not yet refilled) Aspirin 81 mg Daily Discharge Medications: 1. Albuterol Inhaler [MASKED] PUFF IH Q4H:PRN wheezes 2. Aspirin EC 81 mg PO DAILY 3. Concerta (methylphenidate) 36 mg oral DAILY 4. Docusate Sodium 100 mg PO BID hold for loose stools 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. Metoprolol Tartrate 50 mg PO BID replaces atenolol RX metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:3 7. Montelukast 10 mg PO DAILY 8. Furosemide 40 mg PO DAILY Duration: 7 Days RX furosemide 40 mg 1 tablet(s) by mouth once a day Disp #7 Tablet Refills:0 9. Potassium Chloride 10 mEq PO DAILY Duration: 7 Days take with lasix RX potassium chloride [Klor-Con 10] 10 mEq 1 tablet(s) by mouth once a day Disp #7 Tablet Refills:0 10. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 11. Amiodarone 400 mg PO BID Duration: 7 Days then 200 mg twice daily x 14 days then 200 mg daily x 1 month RX amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours Disp #60 Tablet Refills:0 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Aortic stenosis s/p Aortic valve replacement Past Medical History: Hypercholesterolemia- has not required medication Hypertension Obstructive sleep apnea (CPAP) TIA [MASKED] years ago Pulmonary sarcoidosis Obesity [MASKED] Hepatitis A GERD ADHD Depression/Anxiety Ankle fracture Psoriasis Psoriatic arthritis Carpal tunnel surgery s/p surgery bilaterally Trigger finger s/p surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema: none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours Followup Instructions: [MASKED]	[]	[ "I10", "G4733", "Z8673", "F17210", "K219", "E669" ]	[ "Q231: Congenital insufficiency of aortic valve", "Z6841: Body mass index [BMI]40.0-44.9, adult", "D860: Sarcoidosis of lung", "L4050: Arthropathic psoriasis, unspecified", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F909: Attention-deficit hyperactivity disorder, unspecified type", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified" ]
19,979,529	27,918,561	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Benzocaine Attending: ___. Chief Complaint: PCP: ___ GI: ___ CC: ___ pain x 2 months Major Surgical or Invasive Procedure: EGD/colonoscopy History of Present Illness: HPI(4): Ms. ___ is a ___ female with a PMH of multinodular goiter (euthyroid), dysphonia, anxiety, and multiple orthopedic surgeries after an escalator accident who presents with two months of constant abdominal pain. She was referred here by her gastroenterologist, Dr. ___ expedited workup. The abdominal pain is diffuse, difficult to localize and feels like an gnawing pain. It is aggravated by having an empty stomach and sometimes wakes her up at night from sleep. Sometimes drinking hot tea with milk alleviates the pain. Tensing her abdomen does not make the pain worse. She denies associated nausea/vomiting and has not had any bladder or bowel issues. History of a cholecystectomy years ago but no other abdominal surgeries. Has had a lot of recent stressors including interpersonal issues with people at her group home and a stalled lawsuit over an escalator accident. On ___, patient called Dr. ___ at ___ with with persistent severe abdominal pain. Passing gas and having BMs. No nausea and vomiting. No fever. Patient very irritable and unable to provide further details of character of pain. Given severity they advised her to come to ED for expedited CT scan. However she did not want to come to ER and hung up. She did not want to try any medications such as tylenol/Bentyl. Per Dr. ___, pain seemed c/w some kind of ulcer or gastritis or possibly Gerd and may require egd, omeprazole and h pylori testing. ED Course: VS, PE, belly labs and CT unremarkable. GI consulted. Admitted for expedited workup. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative Past Medical History: PAST MEDICAL/SURGICAL HISTORY: MULTINODULAR GOITER - euthyroid, has recent benign biopsy for a nodule HYPERTENSION DYSPHONIA PSYCHIATRIC ILLNESS, ? TYPE -see ___ social service note- living in group home, no primary care, in process of changing- no records yet available - not sure who gave her her anti anxiety meds originally or who other than pcp is regulating SURGICAL HISTORY KNEE SURGERY - bilat tkr last ___ CHOLECYSTECTOMY ? when MULTIPLE ORTHOPEDIC OPERATIONS ON KNEES AND L SHOULDER escalator accident ___ unavailable Social History: ___ Family History: Father died of MI and had ulcers Physical Exam: EXAM(8) VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: nondistended, tender in focal areas in mid ax line lug and mid rectus to l and slightly below umbilicus, both hardly tender when pt relaxed or tenses. Negative ___. no lumps or masses appreciated. No 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 Pertinent Results: DATA: I have reviewed the relevant labs, radiology studies, tracings, medical records, and they are notable for: ___ 06:15AM BLOOD WBC: 7.5 Hgb: 13.___* ___ 06:15AM BLOOD Glucose: 98 UreaN: 20 Creat: 1.1 Na: 141 K: 5.1 Cl: 103 HCO3: 27 AnGap: 11 ___ 06:15AM BLOOD Lipase: 34 GGT: 13 ___ 06:15AM BLOOD 25VitD: 15* ___ 06:15AM BLOOD Hpy IgG: Pending ___ 06:20AM BLOOD Lactate: 1.0 ___ 10:00AM URINE Blood: NEG Nitrite: NEG Protein: NEG Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.0 Leuks: LG* ___ 10:00 am URINE URINE CULTURE (Pending): ___ 6:15 am BLOOD CULTURE Blood Culture, Routine (Pending): # Abd CT (___): 1. Mild intrahepatic biliary dilation and slightly increased CBD diameters are new since ___. No evidence of stones on CT however choledocholithiasis cannot be excluded. Correlation with hepatic function is recommended. 2. No bowel obstruction or ascites. # EGD/colonoscopy (___): prelim read. EGD showed nodular inflammation of the antrum. Mult biopsies taken. Colonoscopy was negative. Brief Hospital Course: ASSESSMENT & PLAN: ___ F h/o goiter, anxiety and multiple orthopedic injuries who presents from her group home with poorly localized abd pain of unclear etiology x 2 mos. Pain worse when tensing abd at ___ clinic, concerning for abdominal wall pain. ACUTE/ACTIVE PROBLEMS: #Abdominal pain. Ms. ___ was admitted with abdominal pain over the past 2 months. Extensive tests here were performed - including HPylori serologies, LFTS, and abd/pelvic CT scan were unremarkable. The thought was that this most c/w gastritis. She underwent EGD/colonoscopy which showed evidence of nodular inflammation of the antrum - c/w gastritis but could not rule out cancer. Multiple biopsies were taken. PPI was increased to 40 mg BID and sucralfate was added to her regimen. Colonoscopy was negative. Of note, her symptoms/complaints were out of proportion from objective markers and she was noted to be sleeping well, not tachycardic, fully mobile, and without distress otherwise. She was seen by her gastroenterologist - who will follow up with the results and follow up as outpt. #Anxiety- pt has had behavioral issues in the past and gotten agitated with staff. will work on getting social work involved to both get some history, figure out prior care, and to work with patient get old records from prior ___ care environment CHRONIC/STABLE PROBLEMS: #Anx: CLONAZEPAM - clonazepam 1 mg tablet. 1 tablet(s) by mouth three times a day - (Prescribed by Other Provider) #HTN: LISINOPRIL - lisinopril 40 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) #GERD: OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth at 4 pm #Urinary retention: OXYBUTYNIN CHLORIDE - oxybutynin chloride ER 5 mg tablet,extended release 24 hr. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) GENERAL/SUPPORTIVE CARE: # Nutrition/Hydration: clears tomorrow, moviprep. # Functional status: can complete ADLs # Bowel Function: miralax, moviprep # Lines/Tubes/Drains: PIV # Precautions: none # VTE prophylaxis: HSQ # Consulting Services: GI # Code: presumed full # Disposition: - Anticipate discharge to: assisted living home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Oxybutynin 5 mg PO BID 3. ClonazePAM 1 mg PO TID 4. Omeprazole 20 mg PO DAILY gerd Discharge Medications: 1. Sucralfate 1 gm PO QID RX sucralfate 1 gram/10 mL 1 ml by mouth four times a day Disp #1 Bottle Refills:2 2. Omeprazole 40 mg PO BID gerd RX omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. ClonazePAM 1 mg PO TID RX clonazepam 1 mg 1 tablet(s) by mouth three times a day Disp #6 Tablet Refills:*0 4. Lisinopril 40 mg PO DAILY 5. Oxybutynin 5 mg PO BID Discharge Disposition: Home Discharge Diagnosis: abdominal pain -- gastritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, As you know, you were admitted with abdominal pain. Extensive workup here was performed - including CT scan, blood tests, and endoscopy (EGD and colonoscopy). These studies revealed showed gastritis which is likely to respond to the acid suppressant medication, Prilosec and sucralfate (which coats the stomach). We anticipate that your pain will improve over time with this medication. There were biopsies taken of the stomach which will be followed up by Dr. ___. Please continue to take these 2 medications until your visit with Dr. ___. Your other medications otherwise remain unchanged. We wish you good health. Your ___ team Followup Instructions: ___	[ "K2970", "R1013", "R932", "E042", "R490", "F419", "I10", "K219", "R339", "Z1211", "E669", "Z6834" ]	Allergies: Benzocaine Chief Complaint: PCP: [MASKED] GI: [MASKED] CC: [MASKED] pain x 2 months Major Surgical or Invasive Procedure: EGD/colonoscopy History of Present Illness: HPI(4): Ms. [MASKED] is a [MASKED] female with a PMH of multinodular goiter (euthyroid), dysphonia, anxiety, and multiple orthopedic surgeries after an escalator accident who presents with two months of constant abdominal pain. She was referred here by her gastroenterologist, Dr. [MASKED] expedited workup. The abdominal pain is diffuse, difficult to localize and feels like an gnawing pain. It is aggravated by having an empty stomach and sometimes wakes her up at night from sleep. Sometimes drinking hot tea with milk alleviates the pain. Tensing her abdomen does not make the pain worse. She denies associated nausea/vomiting and has not had any bladder or bowel issues. History of a cholecystectomy years ago but no other abdominal surgeries. Has had a lot of recent stressors including interpersonal issues with people at her group home and a stalled lawsuit over an escalator accident. On [MASKED], patient called Dr. [MASKED] at [MASKED] with with persistent severe abdominal pain. Passing gas and having BMs. No nausea and vomiting. No fever. Patient very irritable and unable to provide further details of character of pain. Given severity they advised her to come to ED for expedited CT scan. However she did not want to come to ER and hung up. She did not want to try any medications such as tylenol/Bentyl. Per Dr. [MASKED], pain seemed c/w some kind of ulcer or gastritis or possibly Gerd and may require egd, omeprazole and h pylori testing. ED Course: VS, PE, belly labs and CT unremarkable. GI consulted. Admitted for expedited workup. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative Past Medical History: PAST MEDICAL/SURGICAL HISTORY: MULTINODULAR GOITER - euthyroid, has recent benign biopsy for a nodule HYPERTENSION DYSPHONIA PSYCHIATRIC ILLNESS, ? TYPE -see [MASKED] social service note- living in group home, no primary care, in process of changing- no records yet available - not sure who gave her her anti anxiety meds originally or who other than pcp is regulating SURGICAL HISTORY KNEE SURGERY - bilat tkr last [MASKED] CHOLECYSTECTOMY ? when MULTIPLE ORTHOPEDIC OPERATIONS ON KNEES AND L SHOULDER escalator accident [MASKED] unavailable Social History: [MASKED] Family History: Father died of MI and had ulcers Physical Exam: EXAM(8) VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: nondistended, tender in focal areas in mid ax line lug and mid rectus to l and slightly below umbilicus, both hardly tender when pt relaxed or tenses. Negative [MASKED]. no lumps or masses appreciated. No 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 Pertinent Results: DATA: I have reviewed the relevant labs, radiology studies, tracings, medical records, and they are notable for: [MASKED] 06:15AM BLOOD WBC: 7.5 Hgb: 13.[MASKED]* [MASKED] 06:15AM BLOOD Glucose: 98 UreaN: 20 Creat: 1.1 Na: 141 K: 5.1 Cl: 103 HCO3: 27 AnGap: 11 [MASKED] 06:15AM BLOOD Lipase: 34 GGT: 13 [MASKED] 06:15AM BLOOD 25VitD: 15* [MASKED] 06:15AM BLOOD Hpy IgG: Pending [MASKED] 06:20AM BLOOD Lactate: 1.0 [MASKED] 10:00AM URINE Blood: NEG Nitrite: NEG Protein: NEG Glucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.0 Leuks: LG* [MASKED] 10:00 am URINE URINE CULTURE (Pending): [MASKED] 6:15 am BLOOD CULTURE Blood Culture, Routine (Pending): # Abd CT ([MASKED]): 1. Mild intrahepatic biliary dilation and slightly increased CBD diameters are new since [MASKED]. No evidence of stones on CT however choledocholithiasis cannot be excluded. Correlation with hepatic function is recommended. 2. No bowel obstruction or ascites. # EGD/colonoscopy ([MASKED]): prelim read. EGD showed nodular inflammation of the antrum. Mult biopsies taken. Colonoscopy was negative. Brief Hospital Course: ASSESSMENT & PLAN: [MASKED] F h/o goiter, anxiety and multiple orthopedic injuries who presents from her group home with poorly localized abd pain of unclear etiology x 2 mos. Pain worse when tensing abd at [MASKED] clinic, concerning for abdominal wall pain. ACUTE/ACTIVE PROBLEMS: #Abdominal pain. Ms. [MASKED] was admitted with abdominal pain over the past 2 months. Extensive tests here were performed - including HPylori serologies, LFTS, and abd/pelvic CT scan were unremarkable. The thought was that this most c/w gastritis. She underwent EGD/colonoscopy which showed evidence of nodular inflammation of the antrum - c/w gastritis but could not rule out cancer. Multiple biopsies were taken. PPI was increased to 40 mg BID and sucralfate was added to her regimen. Colonoscopy was negative. Of note, her symptoms/complaints were out of proportion from objective markers and she was noted to be sleeping well, not tachycardic, fully mobile, and without distress otherwise. She was seen by her gastroenterologist - who will follow up with the results and follow up as outpt. #Anxiety- pt has had behavioral issues in the past and gotten agitated with staff. will work on getting social work involved to both get some history, figure out prior care, and to work with patient get old records from prior [MASKED] care environment CHRONIC/STABLE PROBLEMS: #Anx: CLONAZEPAM - clonazepam 1 mg tablet. 1 tablet(s) by mouth three times a day - (Prescribed by Other Provider) #HTN: LISINOPRIL - lisinopril 40 mg tablet. 1 tablet(s) by mouth daily - (Prescribed by Other Provider) #GERD: OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth at 4 pm #Urinary retention: OXYBUTYNIN CHLORIDE - oxybutynin chloride ER 5 mg tablet,extended release 24 hr. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) GENERAL/SUPPORTIVE CARE: # Nutrition/Hydration: clears tomorrow, moviprep. # Functional status: can complete ADLs # Bowel Function: miralax, moviprep # Lines/Tubes/Drains: PIV # Precautions: none # VTE prophylaxis: HSQ # Consulting Services: GI # Code: presumed full # Disposition: - Anticipate discharge to: assisted living home Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Oxybutynin 5 mg PO BID 3. ClonazePAM 1 mg PO TID 4. Omeprazole 20 mg PO DAILY gerd Discharge Medications: 1. Sucralfate 1 gm PO QID RX sucralfate 1 gram/10 mL 1 ml by mouth four times a day Disp #1 Bottle Refills:2 2. Omeprazole 40 mg PO BID gerd RX omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. ClonazePAM 1 mg PO TID RX clonazepam 1 mg 1 tablet(s) by mouth three times a day Disp #6 Tablet Refills:*0 4. Lisinopril 40 mg PO DAILY 5. Oxybutynin 5 mg PO BID Discharge Disposition: Home Discharge Diagnosis: abdominal pain -- gastritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], As you know, you were admitted with abdominal pain. Extensive workup here was performed - including CT scan, blood tests, and endoscopy (EGD and colonoscopy). These studies revealed showed gastritis which is likely to respond to the acid suppressant medication, Prilosec and sucralfate (which coats the stomach). We anticipate that your pain will improve over time with this medication. There were biopsies taken of the stomach which will be followed up by Dr. [MASKED]. Please continue to take these 2 medications until your visit with Dr. [MASKED]. Your other medications otherwise remain unchanged. We wish you good health. Your [MASKED] team Followup Instructions: [MASKED]	[]	[ "F419", "I10", "K219", "E669" ]	[ "K2970: Gastritis, unspecified, without bleeding", "R1013: Epigastric pain", "R932: Abnormal findings on diagnostic imaging of liver and biliary tract", "E042: Nontoxic multinodular goiter", "R490: Dysphonia", "F419: Anxiety disorder, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "R339: Retention of urine, unspecified", "Z1211: Encounter for screening for malignant neoplasm of colon", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult" ]
19,979,532	26,713,659	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Haldol Attending: ___. Chief Complaint: Tachycardia and malaise Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with a past medical history of IVDU, hypertension, asthma, and PTSD, who presents for the evaluation of flu-like symptoms, cough, abdominal pain, nausea and vomiting. The patient is homeless, and states that for about the past ___ days, he has felt chills and muscle aches. A few days ago, he developed a cough without hemoptysis. He also notes RUQ abdominal discomfort over the last few days associated with nausea and vomiting, and inability to keep anything down for the last ___ days. He also states that about 4 days ago, he developed a rash spreading over his whole body. He states he has been feeling like he is having a panic attack "all day." As a result, he was having shortness of breath and chest pain during this attack. He states he normally sees a psychiatrist, but lost this provider as result of missing too many appointments. He states he has anxiety and PTSD from childhood trauma. Of note the patient was admitted to ___ for MSSA bacteremia about ___ year ago. He has been sober from IV drug use for about 2 months. ED Course notable for: Initial vital signs: T 97.1, HR 145, BP 156/99, RR 24, O2 sat 99% RA Exam notable for: Appears anxious and slightly diaphoretic. HEENT exam unremarkable. Cardiac exam with regular tachycardia; no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. Abdomen is mildly tender to palpation in the periumbilical and right lower quadrant regions. Lower extremities are warm well perfused. The patient has a faint blanching petechial rash over his torso and extremities. Labs notable for: WBC 12.9, AST 85, ALT 133, Cr 1.1, lactate 2.6, utox positive for amphetamines Imaging notable for: CT A/P- No acute findings in the abdomen or pelvis to explain the patient's abdominal pain, nausea or vomiting. Specifically, the appendix is normal. EKG: Sinus rhythm 131. Normal PR, QRS, and QTc intervals. Normal axis. No clear ST segment deviation or T-wave inversion to suggest ischemia. Peaked T waves in the lateral precordial leads V3-V5 are new from his prior exam. The patient received 3L IVF, lorazepam, and was started on vancomycin and Zosyn for concern for endocarditis prior to transfer to the MICU. Vital signs prior to transfer: HR 135, BP 129/66, RR 19, O2 sat 98% RA On arrival to the MICU, the patient confirmed the above history. He states that he is beginning to feel better. He currently does not report fevers, chills, chest pain, shortness of breath, nausea, and vomiting. He still notes RUQ abdominal pain. Past Medical History: HTN Asthma PTSD IVDU Social History: ___ Family History: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITALS: T 97.7 BP 108 / 64 HR 94 RR 19 O2 Sat 96 RA GENERAL: Alert, oriented, no acute distress, appears anxious, pacing around the room 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, RUQ tenderness on palpation, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: red macular lesions on face and abdomen NEURO: A&Ox3, moving all 4 extremities with purpose DISCHARGE PHYSICAL EXAM: ========================== VS: T 97.4 BP 150 / 76 HR 81 RR 16 O2 Sat 93 Ra GENERAL: Well-appearing, eyes closed, in NAD HEENT: NC/AT, EOMI, MMM NECK: Supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: RRR, normal S1/S2, no murmurs ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing SKIN: no rashes appreciated, no diaphoresis NEURO: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS: ================ ___ 02:10AM WBC-12.9* RBC-4.97 HGB-15.4 HCT-45.2 MCV-91 MCH-31.0 MCHC-34.1 RDW-13.7 RDWSD-45.4 ___ 02:10AM NEUTS-73.3* LYMPHS-18.4* MONOS-7.3 EOS-0.1* BASOS-0.4 IM ___ AbsNeut-9.44* AbsLymp-2.37 AbsMono-0.94* AbsEos-0.01* AbsBaso-0.05 ___ 02:10AM cTropnT-<0.01 ___ 02:10AM LIPASE-19 ___ 02:10AM ALT(SGPT)-133* AST(SGOT)-85* ALK PHOS-81 TOT BILI-0.5 ___ 02:17AM LACTATE-2.6* PERTINENT LABS: ================ ___ Trend: ___ 04:40AM BLOOD WBC-9.7 Hgb-12.7* Hct-38.8* Plt ___ ___ 08:15AM BLOOD WBC-7.1 Hgb-13.7 Hct-41.8 Plt ___ ___ 09:54AM BLOOD WBC-6.6 Hgb-14.0 Hct-41.1 Plt ___ ___ 04:40AM BLOOD Neuts-59.9 ___ Monos-5.6 Eos-2.6 Baso-0.6 Im ___ AbsNeut-5.80 AbsLymp-2.99 AbsMono-0.54 AbsEos-0.25 AbsBaso-0.06 LFTs: ___ 04:40AM BLOOD ALT-90* AST-60* LD(LDH)-261* AlkPhos-66 TotBili-0.7 ___ 08:15AM BLOOD ALT-88* AST-56* AlkPhos-64 TotBili-0.3 ___ 04:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG ___ 04:40AM BLOOD HCV Ab-POS* ___ 04:40AM BLOOD HCV VL-PND ___ 04:40AM BLOOD TSH-3.3 ___ 04:40AM BLOOD Free T4-1.3 ___ 04:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 10:48AM BLOOD Lactate-1.5 DISCHARGE LABS: ================ ___ 06:30AM BLOOD WBC-7.5 Hgb-13.6* Hct-40.6 Plt ___ ___ 06:30AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-24 AnGap-14 IMAGING/STUDIES: ================= CXR ___ No focal consolidation or other acute cardiopulmonary abnormality. CT A/P ___ No acute findings in the abdomen or pelvis to explain the patient's abdominal pain, nausea or vomiting. Normal appendix. TTE ___ Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure. No 2D echocardiographic evidence for endocarditis. MICROBIOLOGY: ============== MRSA SCREEN (Final ___: No MRSA isolated. URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ 1:50 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date (as of ___ at 6PM) Brief Hospital Course: Mr. ___ is a ___ man with a past medical history of IVDU, hypertension, asthma, and PTSD, who presents for the evaluation of flu-like symptoms, cough, abdominal pain, nausea and vomiting, initially admitted to the MICU for sinus tachycardia to 140's, now with resolution of tachycardia and improvement in presenting symptoms. ACTIVE ISSUES: ============== # Tachycardia, resolved The etiology of his tachycardia was unclear but likely related to dehydration or viral infection. Other infection was ruled out, and although his lactate at presentation was 2.6, this resolved with fluids. He was briefly maintained on broad-spectrum antibiotics from ___. Of note, the patient had been missing a couple of dose of his psychiatric medications, so he may have had withdrawal sympathetic response. He did have a skin rash on presentation but this is likely a viral exanthema. # Abdominal pain/malaise # Transaminitis The etiology of his transaminases unclear but could be related to hepatitis C infection versus viral gastroenteritis. His hepatitis C viral load was pending at discharge. His liver labs trended down. LFTs at discharge: ALT 106 AST 68 LDH 226 Alk Phos 67 Tbili 0.2. # Homelessness: Importantly, the patient has been homeless for months. He has had multiple admissions to and from ___ and has not had good follow-up. Social worker helped with resources as inpatient, and patient decided to go to shelter today upon discharge. He continues to be on an expedited waiting list for ___. Patient is unable to return home to stay with his parents. # Normocytic anemia: Unclear etiology. Hgb fluctuating between 13 and 15 over past few days. No evidence of active bleeding on exam. No reason to suspect hemolysis and tbili normal. Concern for nutritional deficiency given history vs. anemia of inflammation. Discharge Hgb 13.6. CHRONIC ISSUES: ============== # Hx of IVDU: Reportedly sober for past 2 months. Serum tox positive only for amphetamines (on Adderall which was discontinud on discharge). He was continued on his Suboxone. # PTSD Continued home meds as confirmed by psychiatry. He was maintained on buspirone, gabapentin, Benadryl, clonidine as needed, Vistaril as needed, Effexor and Suboxone as above. He should follow-up with Bridge clinic at ___. TRANSITIONAL ISSUES: =============== [] HELD MEDICATION: Adderall given sinus tachycardia. Patient did well without Adderall while in-house. Restart as clinically indicated. [] Patient is willing to go to ___ today for ongoing assistance seeking substance use treatment. ___ will assign clinician work with him to identify appropriate treatment programs. ___ [] Please follow-up with LFTs at discharge. They were elevated, and HCV viral load was also pending at discharge. Patient will like to discuss hepatitis C treatment, but he should require close follow-up with his PCP prior to initiating HCV treatment. We set up an appointment with a PCP that he has not seen in years, Dr. ___. [] Patient should continue to follow up with Dr. ___ at the ___ clinic. Phone number for Dr. ___ is ___. [] No new medications or antibiotics Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CloNIDine 0.1 mg PO BID:PRN anxiety 2. Amphetamine-Dextroamphetamine 30 mg PO BID 3. Gabapentin 800 mg PO TID 4. BusPIRone 10 mg PO BID 5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 6. DiphenhydrAMINE 50 mg PO QHS 7. HydrOXYzine 50 mg PO BID:PRN anxiety 8. Venlafaxine XR 75 mg PO DAILY Discharge Medications: 1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 2. BusPIRone 10 mg PO BID 3. CloNIDine 0.1 mg PO BID:PRN anxiety 4. DiphenhydrAMINE 50 mg PO QHS 5. Gabapentin 800 mg PO TID 6. HydrOXYzine 50 mg PO BID:PRN anxiety 7. Venlafaxine XR 75 mg PO DAILY 8. HELD- Amphetamine-Dextroamphetamine 30 mg PO BID This medication was held. Do not restart Amphetamine-Dextroamphetamine until your doctor tells you to Discharge Disposition: Home Discharge Diagnosis: Sinus tachycardia related to dehydration Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. ___, Thank you for coming to ___! WHY WERE YOU ADMITTED? - You were admitted with a fast heart rate and were looking very sick WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were briefly in the ICU (Intensive Care Unit) to control your heart rate. Your heart rate improved with IV fluids - We gave you antibiotics for 2 days due to concern for infection. We did not find any infection so we stopped your antibiotics - We had our social worker see you. They offered some resources for addiction as well as shelters. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - It is important for you to follow up with a doctor. We set up an appointment with ___ MD for follow-up. They can also talk to you about hepatitis C treatment. - It is also important for you to follow up with your psychiatrist. - For housing, you agreed to go to a shelter today. We believe that this is very important for you, and if you should any other resources, please see below for other shelters that you can go to. - It is important for you to continue refraining from using any IV drugs. You can ask for a Homeless Outreach Team (HOT) when you stay at any emergency shelter in ___. They will continue to work with you to identify stable housing in the community. You can also walk in to the below clinics for psychiatric and substance use treatment: ___ for the Homeless Program (___) Address: ___ Phone: ___ Walk in hours: M-F 7a-11p Or ___ has a clinic at ___ (___): ___ at ___ offers primary care each weekday in the Medical Walk-in Unit, and coordinates and assists with care and discharge planning for homeless patients throughout ___. ___ You can walk in to ___ if you want help getting placement for substance use treatment Providing Access to Addictions Treatment, Hope and Support Address: ___ Walk in M-F 7:30AM-6PM Walk in S/S: 8AM-3PM Phone: ___re located at the Dr. ___ ___ ___ at ___ ___ Floor, ___ Or at the ___ ___. ___ Floor ___ Homeless Support Services ___ ___ ___ ___ ___ ___ ___ Floor ___ Walk-ins are welcome for enrollment (no appointment needed) Intakes: ___. ___., 9:00am 3:00pm (note: ___ until 1:00pm). Programs: ___. ___., 8:00am 4:00pm (note: ___ until 2:00pm). It was a pleasure taking care of you! We wish you all the best. - Your ___ Team Followup Instructions: ___	[ "R000", "E860", "I10", "J45909", "F4310", "D649", "Z590", "F1510", "Z87891", "F1010" ]	Allergies: Haldol Chief Complaint: Tachycardia and malaise Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] man with a past medical history of IVDU, hypertension, asthma, and PTSD, who presents for the evaluation of flu-like symptoms, cough, abdominal pain, nausea and vomiting. The patient is homeless, and states that for about the past [MASKED] days, he has felt chills and muscle aches. A few days ago, he developed a cough without hemoptysis. He also notes RUQ abdominal discomfort over the last few days associated with nausea and vomiting, and inability to keep anything down for the last [MASKED] days. He also states that about 4 days ago, he developed a rash spreading over his whole body. He states he has been feeling like he is having a panic attack "all day." As a result, he was having shortness of breath and chest pain during this attack. He states he normally sees a psychiatrist, but lost this provider as result of missing too many appointments. He states he has anxiety and PTSD from childhood trauma. Of note the patient was admitted to [MASKED] for MSSA bacteremia about [MASKED] year ago. He has been sober from IV drug use for about 2 months. ED Course notable for: Initial vital signs: T 97.1, HR 145, BP 156/99, RR 24, O2 sat 99% RA Exam notable for: Appears anxious and slightly diaphoretic. HEENT exam unremarkable. Cardiac exam with regular tachycardia; no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. Abdomen is mildly tender to palpation in the periumbilical and right lower quadrant regions. Lower extremities are warm well perfused. The patient has a faint blanching petechial rash over his torso and extremities. Labs notable for: WBC 12.9, AST 85, ALT 133, Cr 1.1, lactate 2.6, utox positive for amphetamines Imaging notable for: CT A/P- No acute findings in the abdomen or pelvis to explain the patient's abdominal pain, nausea or vomiting. Specifically, the appendix is normal. EKG: Sinus rhythm 131. Normal PR, QRS, and QTc intervals. Normal axis. No clear ST segment deviation or T-wave inversion to suggest ischemia. Peaked T waves in the lateral precordial leads V3-V5 are new from his prior exam. The patient received 3L IVF, lorazepam, and was started on vancomycin and Zosyn for concern for endocarditis prior to transfer to the MICU. Vital signs prior to transfer: HR 135, BP 129/66, RR 19, O2 sat 98% RA On arrival to the MICU, the patient confirmed the above history. He states that he is beginning to feel better. He currently does not report fevers, chills, chest pain, shortness of breath, nausea, and vomiting. He still notes RUQ abdominal pain. Past Medical History: HTN Asthma PTSD IVDU Social History: [MASKED] Family History: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VITALS: T 97.7 BP 108 / 64 HR 94 RR 19 O2 Sat 96 RA GENERAL: Alert, oriented, no acute distress, appears anxious, pacing around the room 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, RUQ tenderness on palpation, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: red macular lesions on face and abdomen NEURO: A&Ox3, moving all 4 extremities with purpose DISCHARGE PHYSICAL EXAM: ========================== VS: T 97.4 BP 150 / 76 HR 81 RR 16 O2 Sat 93 Ra GENERAL: Well-appearing, eyes closed, in NAD HEENT: NC/AT, EOMI, MMM NECK: Supple, JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: RRR, normal S1/S2, no murmurs ABD: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing SKIN: no rashes appreciated, no diaphoresis NEURO: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS: ================ [MASKED] 02:10AM WBC-12.9* RBC-4.97 HGB-15.4 HCT-45.2 MCV-91 MCH-31.0 MCHC-34.1 RDW-13.7 RDWSD-45.4 [MASKED] 02:10AM NEUTS-73.3* LYMPHS-18.4* MONOS-7.3 EOS-0.1* BASOS-0.4 IM [MASKED] AbsNeut-9.44* AbsLymp-2.37 AbsMono-0.94* AbsEos-0.01* AbsBaso-0.05 [MASKED] 02:10AM cTropnT-<0.01 [MASKED] 02:10AM LIPASE-19 [MASKED] 02:10AM ALT(SGPT)-133* AST(SGOT)-85* ALK PHOS-81 TOT BILI-0.5 [MASKED] 02:17AM LACTATE-2.6* PERTINENT LABS: ================ [MASKED] Trend: [MASKED] 04:40AM BLOOD WBC-9.7 Hgb-12.7* Hct-38.8* Plt [MASKED] [MASKED] 08:15AM BLOOD WBC-7.1 Hgb-13.7 Hct-41.8 Plt [MASKED] [MASKED] 09:54AM BLOOD WBC-6.6 Hgb-14.0 Hct-41.1 Plt [MASKED] [MASKED] 04:40AM BLOOD Neuts-59.9 [MASKED] Monos-5.6 Eos-2.6 Baso-0.6 Im [MASKED] AbsNeut-5.80 AbsLymp-2.99 AbsMono-0.54 AbsEos-0.25 AbsBaso-0.06 LFTs: [MASKED] 04:40AM BLOOD ALT-90* AST-60* LD(LDH)-261* AlkPhos-66 TotBili-0.7 [MASKED] 08:15AM BLOOD ALT-88* AST-56* AlkPhos-64 TotBili-0.3 [MASKED] 04:40AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG [MASKED] 04:40AM BLOOD HCV Ab-POS* [MASKED] 04:40AM BLOOD HCV VL-PND [MASKED] 04:40AM BLOOD TSH-3.3 [MASKED] 04:40AM BLOOD Free T4-1.3 [MASKED] 04:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG [MASKED] 10:48AM BLOOD Lactate-1.5 DISCHARGE LABS: ================ [MASKED] 06:30AM BLOOD WBC-7.5 Hgb-13.6* Hct-40.6 Plt [MASKED] [MASKED] 06:30AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-24 AnGap-14 IMAGING/STUDIES: ================= CXR [MASKED] No focal consolidation or other acute cardiopulmonary abnormality. CT A/P [MASKED] No acute findings in the abdomen or pelvis to explain the patient's abdominal pain, nausea or vomiting. Normal appendix. TTE [MASKED] Normal biventricular cavity sizes, regional/global systolic function. No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolic pressure. No 2D echocardiographic evidence for endocarditis. MICROBIOLOGY: ============== MRSA SCREEN (Final [MASKED]: No MRSA isolated. URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. [MASKED] 1:50 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date (as of [MASKED] at 6PM) Brief Hospital Course: Mr. [MASKED] is a [MASKED] man with a past medical history of IVDU, hypertension, asthma, and PTSD, who presents for the evaluation of flu-like symptoms, cough, abdominal pain, nausea and vomiting, initially admitted to the MICU for sinus tachycardia to 140's, now with resolution of tachycardia and improvement in presenting symptoms. ACTIVE ISSUES: ============== # Tachycardia, resolved The etiology of his tachycardia was unclear but likely related to dehydration or viral infection. Other infection was ruled out, and although his lactate at presentation was 2.6, this resolved with fluids. He was briefly maintained on broad-spectrum antibiotics from [MASKED]. Of note, the patient had been missing a couple of dose of his psychiatric medications, so he may have had withdrawal sympathetic response. He did have a skin rash on presentation but this is likely a viral exanthema. # Abdominal pain/malaise # Transaminitis The etiology of his transaminases unclear but could be related to hepatitis C infection versus viral gastroenteritis. His hepatitis C viral load was pending at discharge. His liver labs trended down. LFTs at discharge: ALT 106 AST 68 LDH 226 Alk Phos 67 Tbili 0.2. # Homelessness: Importantly, the patient has been homeless for months. He has had multiple admissions to and from [MASKED] and has not had good follow-up. Social worker helped with resources as inpatient, and patient decided to go to shelter today upon discharge. He continues to be on an expedited waiting list for [MASKED]. Patient is unable to return home to stay with his parents. # Normocytic anemia: Unclear etiology. Hgb fluctuating between 13 and 15 over past few days. No evidence of active bleeding on exam. No reason to suspect hemolysis and tbili normal. Concern for nutritional deficiency given history vs. anemia of inflammation. Discharge Hgb 13.6. CHRONIC ISSUES: ============== # Hx of IVDU: Reportedly sober for past 2 months. Serum tox positive only for amphetamines (on Adderall which was discontinud on discharge). He was continued on his Suboxone. # PTSD Continued home meds as confirmed by psychiatry. He was maintained on buspirone, gabapentin, Benadryl, clonidine as needed, Vistaril as needed, Effexor and Suboxone as above. He should follow-up with Bridge clinic at [MASKED]. TRANSITIONAL ISSUES: =============== [] HELD MEDICATION: Adderall given sinus tachycardia. Patient did well without Adderall while in-house. Restart as clinically indicated. [] Patient is willing to go to [MASKED] today for ongoing assistance seeking substance use treatment. [MASKED] will assign clinician work with him to identify appropriate treatment programs. [MASKED] [] Please follow-up with LFTs at discharge. They were elevated, and HCV viral load was also pending at discharge. Patient will like to discuss hepatitis C treatment, but he should require close follow-up with his PCP prior to initiating HCV treatment. We set up an appointment with a PCP that he has not seen in years, Dr. [MASKED]. [] Patient should continue to follow up with Dr. [MASKED] at the [MASKED] clinic. Phone number for Dr. [MASKED] is [MASKED]. [] No new medications or antibiotics Medications on Admission: The Preadmission Medication list is accurate and complete. 1. CloNIDine 0.1 mg PO BID:PRN anxiety 2. Amphetamine-Dextroamphetamine 30 mg PO BID 3. Gabapentin 800 mg PO TID 4. BusPIRone 10 mg PO BID 5. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 6. DiphenhydrAMINE 50 mg PO QHS 7. HydrOXYzine 50 mg PO BID:PRN anxiety 8. Venlafaxine XR 75 mg PO DAILY Discharge Medications: 1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 2. BusPIRone 10 mg PO BID 3. CloNIDine 0.1 mg PO BID:PRN anxiety 4. DiphenhydrAMINE 50 mg PO QHS 5. Gabapentin 800 mg PO TID 6. HydrOXYzine 50 mg PO BID:PRN anxiety 7. Venlafaxine XR 75 mg PO DAILY 8. HELD- Amphetamine-Dextroamphetamine 30 mg PO BID This medication was held. Do not restart Amphetamine-Dextroamphetamine until your doctor tells you to Discharge Disposition: Home Discharge Diagnosis: Sinus tachycardia related to dehydration Discharge Condition: Mental Status: Clear and coherent. Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Mr. [MASKED], Thank you for coming to [MASKED]! WHY WERE YOU ADMITTED? - You were admitted with a fast heart rate and were looking very sick WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - You were briefly in the ICU (Intensive Care Unit) to control your heart rate. Your heart rate improved with IV fluids - We gave you antibiotics for 2 days due to concern for infection. We did not find any infection so we stopped your antibiotics - We had our social worker see you. They offered some resources for addiction as well as shelters. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? - It is important for you to follow up with a doctor. We set up an appointment with [MASKED] MD for follow-up. They can also talk to you about hepatitis C treatment. - It is also important for you to follow up with your psychiatrist. - For housing, you agreed to go to a shelter today. We believe that this is very important for you, and if you should any other resources, please see below for other shelters that you can go to. - It is important for you to continue refraining from using any IV drugs. You can ask for a Homeless Outreach Team (HOT) when you stay at any emergency shelter in [MASKED]. They will continue to work with you to identify stable housing in the community. You can also walk in to the below clinics for psychiatric and substance use treatment: [MASKED] for the Homeless Program ([MASKED]) Address: [MASKED] Phone: [MASKED] Walk in hours: M-F 7a-11p Or [MASKED] has a clinic at [MASKED] ([MASKED]): [MASKED] at [MASKED] offers primary care each weekday in the Medical Walk-in Unit, and coordinates and assists with care and discharge planning for homeless patients throughout [MASKED]. [MASKED] You can walk in to [MASKED] if you want help getting placement for substance use treatment Providing Access to Addictions Treatment, Hope and Support Address: [MASKED] Walk in M-F 7:30AM-6PM Walk in S/S: 8AM-3PM Phone: re located at the Dr. [MASKED] [MASKED] [MASKED] at [MASKED] [MASKED] Floor, [MASKED] Or at the [MASKED] [MASKED]. [MASKED] Floor [MASKED] Homeless Support Services [MASKED] [MASKED] [MASKED] [MASKED] [MASKED] [MASKED] [MASKED] Floor [MASKED] Walk-ins are welcome for enrollment (no appointment needed) Intakes: [MASKED]. [MASKED]., 9:00am 3:00pm (note: [MASKED] until 1:00pm). Programs: [MASKED]. [MASKED]., 8:00am 4:00pm (note: [MASKED] until 2:00pm). It was a pleasure taking care of you! We wish you all the best. - Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "I10", "J45909", "D649", "Z87891" ]	[ "R000: Tachycardia, unspecified", "E860: Dehydration", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "F4310: Post-traumatic stress disorder, unspecified", "D649: Anemia, unspecified", "Z590: Homelessness", "F1510: Other stimulant abuse, uncomplicated", "Z87891: Personal history of nicotine dependence", "F1010: Alcohol abuse, uncomplicated" ]
19,979,651	27,852,917	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: L wrist pain Major Surgical or Invasive Procedure: L wrist ORIF History of Present Illness: ___ RHD woman was leaving the ___ at ___ this evening and tripped on the sidewalk, landed on outstretched left hand. Had immediate pain and obvious deformity. Presented with husband to ___. ED staff performed hematoma block and closed reduction, sugartong splinting and consulted Orthopedic surgery for evaluation of reduction acceptability. Patient denies any numbness, tingling, head strike, LOC, syncope, previous osteoporotic fracture. Past Medical History: Osteoporosis (recent diagnosis), no surgical hx Social History: ___ Family History: nc Physical Exam: PHYSICAL EXAMINATION: General: NAD, AOx3 RRR on peripheral vascular exam Regular WOB, Symmetric chest rise bilaterally, no audible wheezing Vitals: AVSS Right upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless AROM/PROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse Left upper extremity: - Splint c//di - Soft, non-tender arm and forearm - Full AROM/PROM of shoulder, elbow, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse, BCR distally all digits Right lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Left lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Pertinent Results: ___ 02:30AM GLUCOSE-117* UREA N-22* CREAT-0.5 SODIUM-139 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 ___ 02:30AM estGFR-Using this ___ 02:30AM WBC-9.2# RBC-4.51 HGB-13.9 HCT-42.0 MCV-93 MCH-30.8 MCHC-33.1 RDW-12.6 RDWSD-42.9 ___ 02:30AM NEUTS-83.9* LYMPHS-9.1* MONOS-5.9 EOS-0.4* BASOS-0.3 IM ___ AbsNeut-7.73* AbsLymp-0.84* AbsMono-0.54 AbsEos-0.04 AbsBaso-0.03 ___ 02:30AM PLT COUNT-255 ___ 02:30AM ___ PTT-29.0 ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have L wrist fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for L wrist ORIF, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the left upper extremity, 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: Nasacort, Fosamax Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every 6 hours as needed for pain Disp #120 Tablet Refills:0 2. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth once a day Disp #14 Tablet Refills:0 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet(s) by mouth daily as needed for constipation Disp #60 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day as needed for constipation Disp #60 Capsule Refills:0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Severe RX oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 4 hours as needed for pain Disp #70 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: left volar bartons fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - independent Discharge Instructions: Ms. ___, - ___ 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: - Nonweight bearing in the left upper extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so ___ should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin 325 mg at bedtime daily for two weeks WOUND CARE: - ___ may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if ___ experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. ___ will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Followup Instructions: ___	[ "S52572A", "W19XXXA", "Y929", "M810" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: L wrist pain Major Surgical or Invasive Procedure: L wrist ORIF History of Present Illness: [MASKED] RHD woman was leaving the [MASKED] at [MASKED] this evening and tripped on the sidewalk, landed on outstretched left hand. Had immediate pain and obvious deformity. Presented with husband to [MASKED]. ED staff performed hematoma block and closed reduction, sugartong splinting and consulted Orthopedic surgery for evaluation of reduction acceptability. Patient denies any numbness, tingling, head strike, LOC, syncope, previous osteoporotic fracture. Past Medical History: Osteoporosis (recent diagnosis), no surgical hx Social History: [MASKED] Family History: nc Physical Exam: PHYSICAL EXAMINATION: General: NAD, AOx3 RRR on peripheral vascular exam Regular WOB, Symmetric chest rise bilaterally, no audible wheezing Vitals: AVSS Right upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless AROM/PROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse Left upper extremity: - Splint c//di - Soft, non-tender arm and forearm - Full AROM/PROM of shoulder, elbow, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse, BCR distally all digits Right lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - [MASKED] fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ [MASKED] pulses, foot warm and well-perfused Left lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - [MASKED] fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ [MASKED] pulses, foot warm and well-perfused Pertinent Results: [MASKED] 02:30AM GLUCOSE-117* UREA N-22* CREAT-0.5 SODIUM-139 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 [MASKED] 02:30AM estGFR-Using this [MASKED] 02:30AM WBC-9.2# RBC-4.51 HGB-13.9 HCT-42.0 MCV-93 MCH-30.8 MCHC-33.1 RDW-12.6 RDWSD-42.9 [MASKED] 02:30AM NEUTS-83.9* LYMPHS-9.1* MONOS-5.9 EOS-0.4* BASOS-0.3 IM [MASKED] AbsNeut-7.73* AbsLymp-0.84* AbsMono-0.54 AbsEos-0.04 AbsBaso-0.03 [MASKED] 02:30AM PLT COUNT-255 [MASKED] 02:30AM [MASKED] PTT-29.0 [MASKED] Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have L wrist fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for L wrist ORIF, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to home was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the left upper extremity, 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: Nasacort, Fosamax Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every 6 hours as needed for pain Disp #120 Tablet Refills:0 2. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet(s) by mouth once a day Disp #14 Tablet Refills:0 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet(s) by mouth daily as needed for constipation Disp #60 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day as needed for constipation Disp #60 Capsule Refills:0 5. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Severe RX oxycodone [Oxaydo] 5 mg [MASKED] tablet(s) by mouth every 4 hours as needed for pain Disp #70 Tablet Refills:*0 6. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: left volar bartons fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - independent Discharge Instructions: Ms. [MASKED], - [MASKED] 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: - Nonweight bearing in the left upper extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so [MASKED] should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take aspirin 325 mg at bedtime daily for two weeks WOUND CARE: - [MASKED] may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if [MASKED] experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. [MASKED]. [MASKED] will have follow up with [MASKED], NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call [MASKED] to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within [MASKED] weeks and for and any new medications/refills. Followup Instructions: [MASKED]	[]	[ "Y929" ]	[ "S52572A: Other intraarticular fracture of lower end of left radius, initial encounter for closed fracture", "W19XXXA: Unspecified fall, initial encounter", "Y929: Unspecified place or not applicable", "M810: Age-related osteoporosis without current pathological fracture" ]
19,979,740	29,517,153	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: preterm contractions Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo G1P0 at 34w4d with painful contractions beginning tonight, has had ___ contractions in the past but these are much more intense. Denies VB, LOF. +FM. Past Medical History: PNC: - ___ ___ by US - Labs Rh +/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS unknown - Screening LR ERA - FFS normal - GTT 139 - Issues: none OBHx: - G1 current GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - denies PSH: - tonsillectomy Social History: ___ Family History: non-contributory Physical Exam: On admission: VS: MHR: 83 BP pending Gen: A&O, comfortable CV: RRR PULM: normal work of breathing Abd: soft, gravid, nontender, no fundal tenderness EFW small by Leopolds Ext: no calf tenderness SVE: 1/long/posterior, soft, high Toco q2-3min FHT 120/moderate varability/+accels/-decels, areas of maternal tracing and discontinuous tracing, patient moving frequently TAUS: vertex On discharge: Temp BP HR RR O2 afebrile 142 / 81 78 18 General: NAD, A&Ox3 Breasts: non-tender, no erythema, soft, nipples intact Lungs: No respiratory distress Abd: soft, nontender, fundus firm at 4 cm below umbilicus Extremities: no calf tenderness, no edema Pertinent Results: ___ WBC-13.9 RBC-4.07 Hgb-13.6 Hct-40.9 MCV-101 Plt-193 ___ WBC-15.0 RBC-3.51 Hgb-11.8 Hct-35.2 MCV-100 Plt-146 ___ WBC-20.3 RBC-3.22 Hgb-10.9 Hct-32.0 MCV-99 Plt-110 ___ WBC-15.8 RBC-3.47 Hgb-11.4 Hct-34.1 MCV-98 Plt-110 ___ WBC-15.5 RBC-3.50 Hgb-11.6 Hct-35.2 MCV-101 Plt-118 ___ WBC-16.3 RBC-3.44 Hgb-11.4 Hct-34.8 MCV-101 Plt-126 ___ WBC-18.3 RBC-3.14 Hgb-10.5 Hct-31.3 MCV-100 Plt-123 ___ ___ PTT-25.3 ___ ___ ___ PTT-24.4 ___ ___ ___ PTT-24.0 ___ ___ ___ PTT-24.7 ___ ___ Creat-0.6 ALT-39 AST-66 UricAcd-6.5 ___ Creat-0.8 ALT-51 AST-63 Hapto-79 ___ Creat-0.8 ALT-128 AST-183 LD(LDH)-357 TBili-<0.2 ___ Creat-0.7 ALT-232 AST-426 Hapto-40 ___ Creat-0.7 ALT-195 AST-344 ___ Creat-0.6 ALT-177 AST-264 Hapto-27 ___ Creat-0.7 ALT-155 AST-182 ___ Creat-0.7 ALT-131 AST-127 ___ Creat-0.7 ALT-85 AST-70 ___ URINE Blood-SM* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ URINE Hours-RANDOM Creat-33 TotProt-6 Prot/Cr-0.2 ___ URINE pH-6 Hours-24 Volume-2875 Creat-43 TotProt-7 Prot/Cr-0.2 ___ URINE 24Creat-1236 24Prot-201 ___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG URINE CULTURE (Final ___: < 10,000 CFU/mL. R/O GROUP B BETA STREP (Final ___: Negative for Group B beta streptococci Brief Hospital Course: ___ yo G1P0 admitted at 34w4d with preterm contractions and concern for preterm labor. On admission, she was contracting frequently but appeared comfortable with them. Her cervix was 1/long. Fetal testing was reassuring. She was admitted for observation and she was given a course of betamethasone for fetal lung maturity (complete ___. Repeat cervical exams were unchanged. She was also noted to have mild range blood pressures on admission. Preeclampsia labs were notable for an elevated uric acid (6.5) and AST (66). Her urine p/c was normal (0.2). She underwent a 24 hour urine collection and labs were followed. Prior to completion of her urine collection, she developed sudden onset of RUQ pain and had severe range blood pressures. Repeat labs showed a worsening transaminitis. She was started on Magnesium for seizure prophylaxis and underwent induction of labor. She subsequently had a spontaneous vaginal delivery of a liveborn male 2350 grams with Apgars of 9 and 9. NICU staff was present for delivery and transferred the neonate for prematurity. . She was continued on Magnesium for 24 hours postpartum. Her transaminities improved and her labs were otherwise stable. She was started on Nifedipine CR on ___ for persistently elevated blood pressures. At the time of discharge, her BPs were well controlled on Nifedipine CR 60mg daily. She otherwise had an uncomplicated postop course and was discharged to home on POD#4. Medications on Admission: prenatal vitamins Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Mild Pain 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 3. NIFEdipine (Extended Release) 60 mg PO DAILY RX nifedipine 60 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:2 Discharge Disposition: Home Discharge Diagnosis: induction of labor for severe preeclampsia vaginal delivery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Routine postpartum instructions Followup Instructions: ___	[ "O1414", "O9A23", "O7589", "Z3A34", "R1013", "O700", "Z370", "T474X5A", "Y92230" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: preterm contractions Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] yo G1P0 at 34w4d with painful contractions beginning tonight, has had [MASKED] contractions in the past but these are much more intense. Denies VB, LOF. +FM. Past Medical History: PNC: - [MASKED] [MASKED] by US - Labs Rh +/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS unknown - Screening LR ERA - FFS normal - GTT 139 - Issues: none OBHx: - G1 current GynHx: - denies abnormal Pap, fibroids, Gyn surgery, STIs PMH: - denies PSH: - tonsillectomy Social History: [MASKED] Family History: non-contributory Physical Exam: On admission: VS: MHR: 83 BP pending Gen: A&O, comfortable CV: RRR PULM: normal work of breathing Abd: soft, gravid, nontender, no fundal tenderness EFW small by Leopolds Ext: no calf tenderness SVE: 1/long/posterior, soft, high Toco q2-3min FHT 120/moderate varability/+accels/-decels, areas of maternal tracing and discontinuous tracing, patient moving frequently TAUS: vertex On discharge: Temp BP HR RR O2 afebrile 142 / 81 78 18 General: NAD, A&Ox3 Breasts: non-tender, no erythema, soft, nipples intact Lungs: No respiratory distress Abd: soft, nontender, fundus firm at 4 cm below umbilicus Extremities: no calf tenderness, no edema Pertinent Results: [MASKED] WBC-13.9 RBC-4.07 Hgb-13.6 Hct-40.9 MCV-101 Plt-193 [MASKED] WBC-15.0 RBC-3.51 Hgb-11.8 Hct-35.2 MCV-100 Plt-146 [MASKED] WBC-20.3 RBC-3.22 Hgb-10.9 Hct-32.0 MCV-99 Plt-110 [MASKED] WBC-15.8 RBC-3.47 Hgb-11.4 Hct-34.1 MCV-98 Plt-110 [MASKED] WBC-15.5 RBC-3.50 Hgb-11.6 Hct-35.2 MCV-101 Plt-118 [MASKED] WBC-16.3 RBC-3.44 Hgb-11.4 Hct-34.8 MCV-101 Plt-126 [MASKED] WBC-18.3 RBC-3.14 Hgb-10.5 Hct-31.3 MCV-100 Plt-123 [MASKED] [MASKED] PTT-25.3 [MASKED] [MASKED] [MASKED] PTT-24.4 [MASKED] [MASKED] [MASKED] PTT-24.0 [MASKED] [MASKED] [MASKED] PTT-24.7 [MASKED] [MASKED] Creat-0.6 ALT-39 AST-66 UricAcd-6.5 [MASKED] Creat-0.8 ALT-51 AST-63 Hapto-79 [MASKED] Creat-0.8 ALT-128 AST-183 LD(LDH)-357 TBili-<0.2 [MASKED] Creat-0.7 ALT-232 AST-426 Hapto-40 [MASKED] Creat-0.7 ALT-195 AST-344 [MASKED] Creat-0.6 ALT-177 AST-264 Hapto-27 [MASKED] Creat-0.7 ALT-155 AST-182 [MASKED] Creat-0.7 ALT-131 AST-127 [MASKED] Creat-0.7 ALT-85 AST-70 [MASKED] URINE Blood-SM* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] URINE Hours-RANDOM Creat-33 TotProt-6 Prot/Cr-0.2 [MASKED] URINE pH-6 Hours-24 Volume-2875 Creat-43 TotProt-7 Prot/Cr-0.2 [MASKED] URINE 24Creat-1236 24Prot-201 [MASKED] URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG URINE CULTURE (Final [MASKED]: < 10,000 CFU/mL. R/O GROUP B BETA STREP (Final [MASKED]: Negative for Group B beta streptococci Brief Hospital Course: [MASKED] yo G1P0 admitted at 34w4d with preterm contractions and concern for preterm labor. On admission, she was contracting frequently but appeared comfortable with them. Her cervix was 1/long. Fetal testing was reassuring. She was admitted for observation and she was given a course of betamethasone for fetal lung maturity (complete [MASKED]. Repeat cervical exams were unchanged. She was also noted to have mild range blood pressures on admission. Preeclampsia labs were notable for an elevated uric acid (6.5) and AST (66). Her urine p/c was normal (0.2). She underwent a 24 hour urine collection and labs were followed. Prior to completion of her urine collection, she developed sudden onset of RUQ pain and had severe range blood pressures. Repeat labs showed a worsening transaminitis. She was started on Magnesium for seizure prophylaxis and underwent induction of labor. She subsequently had a spontaneous vaginal delivery of a liveborn male 2350 grams with Apgars of 9 and 9. NICU staff was present for delivery and transferred the neonate for prematurity. . She was continued on Magnesium for 24 hours postpartum. Her transaminities improved and her labs were otherwise stable. She was started on Nifedipine CR on [MASKED] for persistently elevated blood pressures. At the time of discharge, her BPs were well controlled on Nifedipine CR 60mg daily. She otherwise had an uncomplicated postop course and was discharged to home on POD#4. Medications on Admission: prenatal vitamins Discharge Medications: 1. Acetaminophen [MASKED] mg PO Q6H:PRN Mild Pain 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate RX ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 3. NIFEdipine (Extended Release) 60 mg PO DAILY RX nifedipine 60 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:2 Discharge Disposition: Home Discharge Diagnosis: induction of labor for severe preeclampsia vaginal delivery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Routine postpartum instructions Followup Instructions: [MASKED]	[]	[ "Y92230" ]	[ "O1414: Severe pre-eclampsia complicating childbirth", "O9A23: Injury, poisoning and certain other consequences of external causes complicating the puerperium", "O7589: Other specified complications of labor and delivery", "Z3A34: 34 weeks gestation of pregnancy", "R1013: Epigastric pain", "O700: First degree perineal laceration during delivery", "Z370: Single live birth", "T474X5A: Adverse effect of other laxatives, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]
19,979,849	21,475,092	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: staghorn calculus; nephrolithiasis Major Surgical or Invasive Procedure: Cystoscopy, right retrograde pyelogram interpretation, right percutaneous nephrolithotomy for stone greater than 2 cm, creation of percutaneous right nephrostomy tube tract, right antegrade nephrostogram, right antegrade ureteroscopy, antegrade placement of right ureteral stent. History of Present Illness: ___ y/o male with PMH nephrolithiasis, s/p PCNL and URS/LL at outside institution ___ yrs ago. Subsequently referred to Dr. ___ microhematuria, subsequently underwent imaging showing ~2-3 cm right partial staghorn calculus as well as a ~1.7 cm exophytic contrast-enhancing mass concerning for RCC but with no change in size x ___ yrs. Given that the stone was radiolucent on KUB and patient had acidic urine with pH 5.5, a trial of dissolution therapy with potassium citrate was attempted but had no appreciable impact on stone size. After discussion he opted for definitive stone management with elective PCNL. Now s/p PCNL with somewhat high blood loss due to infundibular tear on access. Stone fragmented with lithoclast and basketed out in numerous pieces which were sent for analysis. ___ Fr straight-tip Foley to bladder, ___ ___ catheter over ___ Fr ureteral stent in right flank as PCN tube. ___ Fr x 26 cm double pigtail nephroureteral stent placed antegrade. Past Medical History: PMH/PSH: - nephrolithiasis - renal mass Social History: Country of Origin: ___ Marital status: Significant Other Name of ___ ___: Children: Yes: 1 son and 1 daughter Work: ___ Sexual Abuse: Denies Domestic violence: Denies Tobacco use: Never smoker Alcohol use: Present Alcohol use rarely comments: Recreational drugs Past (marijuana, heroin, crack pills or other): Recreational drugs marijuna up to ___ comments: Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: None Diet: not always healthy Family History: Father ___ ___ HEART DISEASE ALCOHOL ABUSE Brother ___ ___ DIABETES MELLITUS Physical Exam: WDWN male, nad, avss abdomen soft, nt/nd extremities w/out edema, pitting, pain Pertinent Results: ___ 07:15AM BLOOD WBC-13.5* RBC-3.68* Hgb-10.9* Hct-32.8* MCV-89 MCH-29.6 MCHC-33.2 RDW-13.8 RDWSD-44.7 Plt ___ ___ 03:25PM BLOOD WBC-16.9# RBC-4.22 Hgb-12.5* Hct-38.8* MCV-92 MCH-29.6 MCHC-32.2 RDW-13.9 RDWSD-46.1 Plt ___ ___ 07:15AM BLOOD Glucose-105* UreaN-16 Creat-1.1 Na-138 K-3.8 Cl-102 HCO3-27 AnGap-13 ___ 03:25PM BLOOD Glucose-95 UreaN-20 Creat-1.3* Na-138 K-4.6 Cl-104 HCO3-22 AnGap-17 ___ 07:15AM BLOOD Calcium-8.3* Mg-1.8 ___ 03:25PM BLOOD Calcium-8.7 Mg-2.0 ___ URINE URINE CULTURE-FINAL ___. ___ URINE URINE CULTURE-FINAL ___ Brief Hospital Course: Mr. ___ was admitted to Dr. ___ for nephrolithiasis management with a known staghorn calculus. He underwent the above procedure without complication. He tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD1, catheter was removed and CT scan for residual stone burden was obtained. Although his postoperative course was uncomplicated, he did have a brief syncopal episode when he got up for the CT scan Intravenous fluids, Toradol and Flomax were given to help facilitate passage of stones. At discharge on POD1, patients pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. Patient was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed and or exchanged and definitive management for the stone is required. Medications on Admission: MEDS: potassium citrate ALL: NKDA Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg ONE capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ONE tablet(s) by mouth q4hrs Disp #20 Tablet Refills:0 4. Phenazopyridine 100 mg PO TID:PRN dysuria Duration: 3 Days RX phenazopyridine [Pyridium] 100 mg one tablet(s) by mouth q8hrs Disp #30 Tablet Refills:0 5. Tamsulosin 0.4 mg PO DAILY RX tamsulosin [Flomax] 0.4 mg one capsule(s) by mouth daily Disp #30 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: NEPRHOLITHIASIS: BRANCH LOWER POLE (STAGHORN CALCULUS) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -No vigorous physical activity or sports for 4 weeks, including sexual. Avoid lifting/twistin/bending/pulling/pushing items weighing more than a ___ pounds. -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated Followup Instructions: ___	[ "N200", "G8918", "N9961", "Y838", "Y92234", "R55" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: staghorn calculus; nephrolithiasis Major Surgical or Invasive Procedure: Cystoscopy, right retrograde pyelogram interpretation, right percutaneous nephrolithotomy for stone greater than 2 cm, creation of percutaneous right nephrostomy tube tract, right antegrade nephrostogram, right antegrade ureteroscopy, antegrade placement of right ureteral stent. History of Present Illness: [MASKED] y/o male with PMH nephrolithiasis, s/p PCNL and URS/LL at outside institution [MASKED] yrs ago. Subsequently referred to Dr. [MASKED] microhematuria, subsequently underwent imaging showing ~2-3 cm right partial staghorn calculus as well as a ~1.7 cm exophytic contrast-enhancing mass concerning for RCC but with no change in size x [MASKED] yrs. Given that the stone was radiolucent on KUB and patient had acidic urine with pH 5.5, a trial of dissolution therapy with potassium citrate was attempted but had no appreciable impact on stone size. After discussion he opted for definitive stone management with elective PCNL. Now s/p PCNL with somewhat high blood loss due to infundibular tear on access. Stone fragmented with lithoclast and basketed out in numerous pieces which were sent for analysis. [MASKED] Fr straight-tip Foley to bladder, [MASKED] [MASKED] catheter over [MASKED] Fr ureteral stent in right flank as PCN tube. [MASKED] Fr x 26 cm double pigtail nephroureteral stent placed antegrade. Past Medical History: PMH/PSH: - nephrolithiasis - renal mass Social History: Country of Origin: [MASKED] Marital status: Significant Other Name of [MASKED] [MASKED]: Children: Yes: 1 son and 1 daughter Work: [MASKED] Sexual Abuse: Denies Domestic violence: Denies Tobacco use: Never smoker Alcohol use: Present Alcohol use rarely comments: Recreational drugs Past (marijuana, heroin, crack pills or other): Recreational drugs marijuna up to [MASKED] comments: Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: None Diet: not always healthy Family History: Father [MASKED] [MASKED] HEART DISEASE ALCOHOL ABUSE Brother [MASKED] [MASKED] DIABETES MELLITUS Physical Exam: WDWN male, nad, avss abdomen soft, nt/nd extremities w/out edema, pitting, pain Pertinent Results: [MASKED] 07:15AM BLOOD WBC-13.5* RBC-3.68* Hgb-10.9* Hct-32.8* MCV-89 MCH-29.6 MCHC-33.2 RDW-13.8 RDWSD-44.7 Plt [MASKED] [MASKED] 03:25PM BLOOD WBC-16.9# RBC-4.22 Hgb-12.5* Hct-38.8* MCV-92 MCH-29.6 MCHC-32.2 RDW-13.9 RDWSD-46.1 Plt [MASKED] [MASKED] 07:15AM BLOOD Glucose-105* UreaN-16 Creat-1.1 Na-138 K-3.8 Cl-102 HCO3-27 AnGap-13 [MASKED] 03:25PM BLOOD Glucose-95 UreaN-20 Creat-1.3* Na-138 K-4.6 Cl-104 HCO3-22 AnGap-17 [MASKED] 07:15AM BLOOD Calcium-8.3* Mg-1.8 [MASKED] 03:25PM BLOOD Calcium-8.7 Mg-2.0 [MASKED] URINE URINE CULTURE-FINAL [MASKED]. [MASKED] URINE URINE CULTURE-FINAL [MASKED] Brief Hospital Course: Mr. [MASKED] was admitted to Dr. [MASKED] for nephrolithiasis management with a known staghorn calculus. He underwent the above procedure without complication. He tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD1, catheter was removed and CT scan for residual stone burden was obtained. Although his postoperative course was uncomplicated, he did have a brief syncopal episode when he got up for the CT scan Intravenous fluids, Toradol and Flomax were given to help facilitate passage of stones. At discharge on POD1, patients pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. Patient was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed and or exchanged and definitive management for the stone is required. Medications on Admission: MEDS: potassium citrate ALL: NKDA Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg ONE capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ONE tablet(s) by mouth q4hrs Disp #20 Tablet Refills:0 4. Phenazopyridine 100 mg PO TID:PRN dysuria Duration: 3 Days RX phenazopyridine [Pyridium] 100 mg one tablet(s) by mouth q8hrs Disp #30 Tablet Refills:0 5. Tamsulosin 0.4 mg PO DAILY RX tamsulosin [Flomax] 0.4 mg one capsule(s) by mouth daily Disp #30 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: NEPRHOLITHIASIS: BRANCH LOWER POLE (STAGHORN CALCULUS) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -No vigorous physical activity or sports for 4 weeks, including sexual. Avoid lifting/twistin/bending/pulling/pushing items weighing more than a [MASKED] pounds. -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for [MASKED] weeks, drink plenty of fluids to keep hydrated Followup Instructions: [MASKED]	[]	[]	[ "N200: Calculus of kidney", "G8918: Other acute postprocedural pain", "N9961: Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "R55: Syncope and collapse" ]
19,979,849	21,842,247	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: pitted fruit Attending: ___. Chief Complaint: 2 obstructing right distal ureteral stones, acute kidney injury Major Surgical or Invasive Procedure: ___ Cystoscopy, right ureteroscopy, laser lithotripsy, right ureteral stent placement History of Present Illness: HPI: Patient is a ___ male who known to urology for a small right renal mass and nephrolithiasis s/p R PCNL by Dr. ___ in ___, who presents with right sided flank pain since ___. He has had nausea but no vomiting, no fevers or chills. He presented to the ER overnight a CT showed 2 distal right ureteral stones with hydronephrosis. His Cr was 1.8 from 0.9, and he was observed overnight. His Cr only improved to 1.6 with fluids and he required more morphine overnight. Past Medical History: PMH/PSH: - nephrolithiasis - renal mass Social History: Country of Origin: ___ Marital status: Significant Other Name of ___ ___: Children: Yes: 1 son and 1 daughter Work: ___ Sexual Abuse: Denies Domestic violence: Denies Tobacco use: Never smoker Alcohol use: Present Alcohol use rarely comments: Recreational drugs Past (marijuana, heroin, crack pills or other): Recreational drugs marijuna up to ___ comments: Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: None Diet: not always healthy Family History: Father ___ ___ HEART DISEASE ALCOHOL ABUSE Brother ___ ___ DIABETES MELLITUS Physical Exam: WdWn male, NAD, AVSS Interactive, cooperative Abdomen soft, Nt/Nd Lower extremities w/out edema or pitting and no report of calf pain Pertinent Results: ___ 05:40AM BLOOD WBC-12.5* RBC-4.55* Hgb-13.3* Hct-41.0 MCV-90 MCH-29.2 MCHC-32.4 RDW-14.0 RDWSD-46.3 Plt ___ ___ 07:15PM BLOOD WBC-13.5* RBC-4.75 Hgb-13.9 Hct-42.5 MCV-90 MCH-29.3 MCHC-32.7 RDW-14.3 RDWSD-46.5* Plt ___ ___ 07:15PM BLOOD Neuts-74.3* Lymphs-13.8* Monos-10.2 Eos-1.0 Baso-0.3 Im ___ AbsNeut-10.05* AbsLymp-1.87 AbsMono-1.38* AbsEos-0.13 AbsBaso-0.04 ___ 07:15PM BLOOD ___ PTT-26.7 ___ ___ 05:40AM BLOOD Glucose-95 UreaN-23* Creat-1.6* Na-140 K-4.7 Cl-103 HCO3-24 AnGap-13 ___ 07:15PM BLOOD Glucose-83 UreaN-29* Creat-1.8* Na-140 K-4.6 Cl-100 HCO3-26 AnGap-14 ___ 07:15PM BLOOD ALT-51* AST-35 AlkPhos-83 TotBili-0.6 ___ URINE URINE CULTURE-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL EMERGENCY WARD Brief Hospital Course: ___ was admitted to Dr. ___ for nephrolithiasis management with a known obstructing stone, from the ED. He was given pain control and Flomax and consented for urgent cystoscopy with right ureteral stent insertion. He underwent cystoscopy, right ureteroscopy, laser lithotripsy, right ureteral stent placement for known right ureteral stones, right renal stone and acute kidney injury. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD1, catheter was removed and he was prepped for discharge home. At discharge on POD1, patients pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. Patient was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed and or exchanged. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Phenazopyridine 100 mg PO Q8H:PRN pain 2. potassium citrate 15 mEq oral TID W/MEALS 3. Tamsulosin 0.4 mg PO DAILY 4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Cephalexin 500 mg PO ONCE Duration: 1 Dose RX cephalexin 500 mg 1 capsule(s) by mouth once Disp #1 Capsule Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg one capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain - Severe RX oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every four hours Disp #20 Tablet Refills:0 4. Tamsulosin 0.4 mg PO DAILY RX tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily Disp #30 Capsule Refills:0 5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 6. potassium citrate 15 mEq oral TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: Nephrolithiasis, right distal ureteral Acute kidney injury (creat to 1.6) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent . -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -You may be given prescriptions for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be health care spending account reimbursable. -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while Foley catheter is in place. Followup Instructions: ___	[ "N202", "N179" ]	Allergies: pitted fruit Chief Complaint: 2 obstructing right distal ureteral stones, acute kidney injury Major Surgical or Invasive Procedure: [MASKED] Cystoscopy, right ureteroscopy, laser lithotripsy, right ureteral stent placement History of Present Illness: HPI: Patient is a [MASKED] male who known to urology for a small right renal mass and nephrolithiasis s/p R PCNL by Dr. [MASKED] in [MASKED], who presents with right sided flank pain since [MASKED]. He has had nausea but no vomiting, no fevers or chills. He presented to the ER overnight a CT showed 2 distal right ureteral stones with hydronephrosis. His Cr was 1.8 from 0.9, and he was observed overnight. His Cr only improved to 1.6 with fluids and he required more morphine overnight. Past Medical History: PMH/PSH: - nephrolithiasis - renal mass Social History: Country of Origin: [MASKED] Marital status: Significant Other Name of [MASKED] [MASKED]: Children: Yes: 1 son and 1 daughter Work: [MASKED] Sexual Abuse: Denies Domestic violence: Denies Tobacco use: Never smoker Alcohol use: Present Alcohol use rarely comments: Recreational drugs Past (marijuana, heroin, crack pills or other): Recreational drugs marijuna up to [MASKED] comments: Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: None Diet: not always healthy Family History: Father [MASKED] [MASKED] HEART DISEASE ALCOHOL ABUSE Brother [MASKED] [MASKED] DIABETES MELLITUS Physical Exam: WdWn male, NAD, AVSS Interactive, cooperative Abdomen soft, Nt/Nd Lower extremities w/out edema or pitting and no report of calf pain Pertinent Results: [MASKED] 05:40AM BLOOD WBC-12.5* RBC-4.55* Hgb-13.3* Hct-41.0 MCV-90 MCH-29.2 MCHC-32.4 RDW-14.0 RDWSD-46.3 Plt [MASKED] [MASKED] 07:15PM BLOOD WBC-13.5* RBC-4.75 Hgb-13.9 Hct-42.5 MCV-90 MCH-29.3 MCHC-32.7 RDW-14.3 RDWSD-46.5* Plt [MASKED] [MASKED] 07:15PM BLOOD Neuts-74.3* Lymphs-13.8* Monos-10.2 Eos-1.0 Baso-0.3 Im [MASKED] AbsNeut-10.05* AbsLymp-1.87 AbsMono-1.38* AbsEos-0.13 AbsBaso-0.04 [MASKED] 07:15PM BLOOD [MASKED] PTT-26.7 [MASKED] [MASKED] 05:40AM BLOOD Glucose-95 UreaN-23* Creat-1.6* Na-140 K-4.7 Cl-103 HCO3-24 AnGap-13 [MASKED] 07:15PM BLOOD Glucose-83 UreaN-29* Creat-1.8* Na-140 K-4.6 Cl-100 HCO3-26 AnGap-14 [MASKED] 07:15PM BLOOD ALT-51* AST-35 AlkPhos-83 TotBili-0.6 [MASKED] URINE URINE CULTURE-FINAL INPATIENT [MASKED] URINE URINE CULTURE-FINAL INPATIENT [MASKED] URINE URINE CULTURE-FINAL EMERGENCY WARD Brief Hospital Course: [MASKED] was admitted to Dr. [MASKED] for nephrolithiasis management with a known obstructing stone, from the ED. He was given pain control and Flomax and consented for urgent cystoscopy with right ureteral stent insertion. He underwent cystoscopy, right ureteroscopy, laser lithotripsy, right ureteral stent placement for known right ureteral stones, right renal stone and acute kidney injury. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD1, catheter was removed and he was prepped for discharge home. At discharge on POD1, patients pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. Patient was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed and or exchanged. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Phenazopyridine 100 mg PO Q8H:PRN pain 2. potassium citrate 15 mEq oral TID W/MEALS 3. Tamsulosin 0.4 mg PO DAILY 4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild Discharge Medications: 1. Cephalexin 500 mg PO ONCE Duration: 1 Dose RX cephalexin 500 mg 1 capsule(s) by mouth once Disp #1 Capsule Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg one capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain - Severe RX oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth every four hours Disp #20 Tablet Refills:0 4. Tamsulosin 0.4 mg PO DAILY RX tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily Disp #30 Capsule Refills:0 5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 6. potassium citrate 15 mEq oral TID W/MEALS Discharge Disposition: Home Discharge Diagnosis: Nephrolithiasis, right distal ureteral Acute kidney injury (creat to 1.6) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent . -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -You may be given prescriptions for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be health care spending account reimbursable. -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -Do not eat constipating foods for [MASKED] weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while Foley catheter is in place. Followup Instructions: [MASKED]	[]	[ "N179" ]	[ "N202: Calculus of kidney with calculus of ureter", "N179: Acute kidney failure, unspecified" ]
19,979,849	24,517,136	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: UROLOGY Allergies: pitted fruit Attending: ___. Chief Complaint: 1.6cm right renal mass and h/o nephrolithiasis Major Surgical or Invasive Procedure: Robot-assisted laparoscopic right partial nephrectomy. History of Present Illness: ___ male with an renal mass. This was first noted by ___ and ___ during workup and treatment of his right kidney and ureteral stones. In ___ he had a right percutaneous nephrolithotomy by Dr. ___. And ___. Right ureteroscopy and laser lithotripsy and stent placement by Dr. ___ obstructing ureteral stones. He had 2 distal right ureteral stones as well as a large right renal stone that were all fragmented into tiny fragments. At the time impacted UVJ stone was seen, a 5 mm distal right ureteral stone was seen, I also performed a pyeloscopy at the time and a right and a 1 cm right renal pelvic stone was fragmented and stent was placed. This has not been associated with abdominal or flank pain There have not been associated UTIs or hematuria Prior kidney biopsy: Yes, ___, right renal neoplasm differential diagnosis includes clear cell renal cell carcinoma and clear-cell tubulopapillary carcinoma. No constitutional symptoms. In particular, denies fatigue, night sweats, new back or bony pain, weight loss. Past Medical History: 1. microhematuria 2. nephrolithiasis - s/p ureteroscopy and 3. ___, incidental right renal mass 1.6-cm 4. ___, renal u/s: stable right renal mass 1.6-cm 5. ___, right renal mass bx. 6. Pathology: renal neoplasm - differential diagnoses includes clear cell renal cell carcinoma and clear cell tubulopapillary carcinoma. 7. Hyperlipidemia Surgical Hx: noted above and STENT PLACEMENT for kidney stones x 3 TESTICULAR TORSION in his ___ Social History: Country of Origin: ___ Marital status: Significant Other Name of ___ ___: Children: Yes: 1 son and 2 daughters Work: ___ Sexual Abuse: Denies Domestic violence: Denies Tobacco use: Never smoker Alcohol use: Present Alcohol use rarely comments: Recreational drugs Past (marijuana, heroin, crack pills or other): Recreational drugs marijuna up to ___ comments: Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: None Diet: trying to eat healthy Family History: Father ___ ___ HEART DISEASE ALCOHOL ABUSE Brother ___ ___ DIABETES MELLITUS Physical Exam: WdWn, NAD, AVSS Interactive, cooperative Abdomen soft, appropriately tender along incisions Incisions otherwise c/d/I GU: foley removed. voiding independently. Uncircumcised. Drain removed from LLQ. Extremities w/out edema or pitting and there is no reported calf pain to deep palpation Pertinent Results: ___ 07:00AM BLOOD WBC-12.4* RBC-4.50* Hgb-13.0* Hct-40.1 MCV-89 MCH-28.9 MCHC-32.4 RDW-13.4 RDWSD-43.9 Plt ___ ___ 07:00AM BLOOD Glucose-118* UreaN-16 Creat-1.0 Na-140 K-3.9 Cl-101 HCO3-26 AnGap-13 Brief Hospital Course: Mr. ___ was admitted to Urology after undergoing robot-assisted laparoscopic right partial nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. Mr. ___ received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, and provided with pneumoboots and incentive spirometry for prophylaxis. On POD1, the patient ambulated, restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. On POD2, drain and urethral Foley catheter were removed without difficulty and diet was advanced as tolerated. The remainder of the hospital course was relatively unremarkable. Mr. ___ was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic in approximately four weeks time. Medications on Admission: Active Medication list as of ___: Medications - Prescription POTASSIUM CITRATE - potassium citrate ER 15 mEq (1,620 mg) tablet,extended release. 1 tablet(s) by mouth Tid with meals TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 capsule(s) by mouth once daily Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth to 2 tabs every 8 hours as needed - (OTC) DOCUSATE SODIUM [COLACE] - Dosage uncertain - (OTC) Allergies: NKDA Other allergies; Pitted fruits Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg ONE capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild RX ibuprofen 600 mg ONE tab by mouth Q8hrs Disp #25 Tablet Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ONE tab by mouth Q6hrs Disp #15 Tablet Refills:0 5. Senna 17.2 mg PO QHS 6. PAIN PILL LOG please keep a log of narcotics (pain pill) used over the week and return the log sheet at your follow up appointment. 7.PAIN PILL LOG please keep a log of narcotics (pain pill) used over the week and return the log sheet at your follow up appointment. Discharge Disposition: Home Discharge Diagnosis: Right renal mass; renal cell carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the provided handout that details instructions and expectations for your post-operative phase as made available by your urologist. **please keep a log of narcotics (pain pill) used over the week and return the log sheet at your follow up appointment. Remember to also bring the narcotic prescription bottle WITH YOU for your follow up appointment. -Resume your pre-admission/home medications except as noted. ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -___ reduce the strain/pressure on your abdomen and incision sites; remember to log roll onto your side and then use your hands to push yourself upright while taking advantage of the momentum of putting your legs/feet to the ground. --There may be bandage strips called steristrips which have been applied to reinforce wound closure. Allow these bandage strips to fall off on their own over time but PLEASE REMOVE ANY REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may get the steristrips wet. -UNLESS OTHERWISE NOTED; AVOID aspirin or aspirin containing products and supplements that may have blood-thinning effects (like Fish Oil, Vitamin E, etc.). This will be noted in your medication reconciliation. IF PRESCRIBED (see the MEDICATION RECONCILIATION): -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL (acetaminophen) FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Call your Urologist's office to schedule/confirm your follow-up appointment in 4 weeks AND if you have any questions. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised. Light household chores/activity and leisurely walking/activity is OK and should be continued. Do NOT be a couch potato -Tylenol should be your first-line pain medication. A narcotic pain medication has been prescribed for breakthrough pain ___. -Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams from ALL sources AVOID lifting/pushing/pulling items heavier than 10 pounds (or 3 kilos; about a gallon of milk) or participate in high intensity physical activity (which includes intercourse) until you are cleared by your Urologist in follow-up. -No DRIVING for THREE WEEKS or until you are cleared by your Urologist -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -You may be given prescriptions for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be health care spending account reimbursable. -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: ___	[ "C641", "E784" ]	Allergies: pitted fruit Chief Complaint: 1.6cm right renal mass and h/o nephrolithiasis Major Surgical or Invasive Procedure: Robot-assisted laparoscopic right partial nephrectomy. History of Present Illness: [MASKED] male with an renal mass. This was first noted by [MASKED] and [MASKED] during workup and treatment of his right kidney and ureteral stones. In [MASKED] he had a right percutaneous nephrolithotomy by Dr. [MASKED]. And [MASKED]. Right ureteroscopy and laser lithotripsy and stent placement by Dr. [MASKED] obstructing ureteral stones. He had 2 distal right ureteral stones as well as a large right renal stone that were all fragmented into tiny fragments. At the time impacted UVJ stone was seen, a 5 mm distal right ureteral stone was seen, I also performed a pyeloscopy at the time and a right and a 1 cm right renal pelvic stone was fragmented and stent was placed. This has not been associated with abdominal or flank pain There have not been associated UTIs or hematuria Prior kidney biopsy: Yes, [MASKED], right renal neoplasm differential diagnosis includes clear cell renal cell carcinoma and clear-cell tubulopapillary carcinoma. No constitutional symptoms. In particular, denies fatigue, night sweats, new back or bony pain, weight loss. Past Medical History: 1. microhematuria 2. nephrolithiasis - s/p ureteroscopy and 3. [MASKED], incidental right renal mass 1.6-cm 4. [MASKED], renal u/s: stable right renal mass 1.6-cm 5. [MASKED], right renal mass bx. 6. Pathology: renal neoplasm - differential diagnoses includes clear cell renal cell carcinoma and clear cell tubulopapillary carcinoma. 7. Hyperlipidemia Surgical Hx: noted above and STENT PLACEMENT for kidney stones x 3 TESTICULAR TORSION in his [MASKED] Social History: Country of Origin: [MASKED] Marital status: Significant Other Name of [MASKED] [MASKED]: Children: Yes: 1 son and 2 daughters Work: [MASKED] Sexual Abuse: Denies Domestic violence: Denies Tobacco use: Never smoker Alcohol use: Present Alcohol use rarely comments: Recreational drugs Past (marijuana, heroin, crack pills or other): Recreational drugs marijuna up to [MASKED] comments: Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: None Diet: trying to eat healthy Family History: Father [MASKED] [MASKED] HEART DISEASE ALCOHOL ABUSE Brother [MASKED] [MASKED] DIABETES MELLITUS Physical Exam: WdWn, NAD, AVSS Interactive, cooperative Abdomen soft, appropriately tender along incisions Incisions otherwise c/d/I GU: foley removed. voiding independently. Uncircumcised. Drain removed from LLQ. Extremities w/out edema or pitting and there is no reported calf pain to deep palpation Pertinent Results: [MASKED] 07:00AM BLOOD WBC-12.4* RBC-4.50* Hgb-13.0* Hct-40.1 MCV-89 MCH-28.9 MCHC-32.4 RDW-13.4 RDWSD-43.9 Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-118* UreaN-16 Creat-1.0 Na-140 K-3.9 Cl-101 HCO3-26 AnGap-13 Brief Hospital Course: Mr. [MASKED] was admitted to Urology after undergoing robot-assisted laparoscopic right partial nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. Mr. [MASKED] received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, and provided with pneumoboots and incentive spirometry for prophylaxis. On POD1, the patient ambulated, restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. On POD2, drain and urethral Foley catheter were removed without difficulty and diet was advanced as tolerated. The remainder of the hospital course was relatively unremarkable. Mr. [MASKED] was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic in approximately four weeks time. Medications on Admission: Active Medication list as of [MASKED]: Medications - Prescription POTASSIUM CITRATE - potassium citrate ER 15 mEq (1,620 mg) tablet,extended release. 1 tablet(s) by mouth Tid with meals TAMSULOSIN - tamsulosin 0.4 mg capsule. 1 capsule(s) by mouth once daily Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by mouth to 2 tabs every 8 hours as needed - (OTC) DOCUSATE SODIUM [COLACE] - Dosage uncertain - (OTC) Allergies: NKDA Other allergies; Pitted fruits Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg ONE capsule(s) by mouth twice a day Disp #60 Capsule Refills:0 3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild RX ibuprofen 600 mg ONE tab by mouth Q8hrs Disp #25 Tablet Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ONE tab by mouth Q6hrs Disp #15 Tablet Refills:0 5. Senna 17.2 mg PO QHS 6. PAIN PILL LOG please keep a log of narcotics (pain pill) used over the week and return the log sheet at your follow up appointment. 7.PAIN PILL LOG please keep a log of narcotics (pain pill) used over the week and return the log sheet at your follow up appointment. Discharge Disposition: Home Discharge Diagnosis: Right renal mass; renal cell carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the provided handout that details instructions and expectations for your post-operative phase as made available by your urologist. **please keep a log of narcotics (pain pill) used over the week and return the log sheet at your follow up appointment. Remember to also bring the narcotic prescription bottle WITH YOU for your follow up appointment. -Resume your pre-admission/home medications except as noted. ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -[MASKED] reduce the strain/pressure on your abdomen and incision sites; remember to log roll onto your side and then use your hands to push yourself upright while taking advantage of the momentum of putting your legs/feet to the ground. --There may be bandage strips called steristrips which have been applied to reinforce wound closure. Allow these bandage strips to fall off on their own over time but PLEASE REMOVE ANY REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may get the steristrips wet. -UNLESS OTHERWISE NOTED; AVOID aspirin or aspirin containing products and supplements that may have blood-thinning effects (like Fish Oil, Vitamin E, etc.). This will be noted in your medication reconciliation. IF PRESCRIBED (see the MEDICATION RECONCILIATION): -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL (acetaminophen) FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Call your Urologist's office to schedule/confirm your follow-up appointment in 4 weeks AND if you have any questions. -Do not eat constipating foods for [MASKED] weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised. Light household chores/activity and leisurely walking/activity is OK and should be continued. Do NOT be a couch potato -Tylenol should be your first-line pain medication. A narcotic pain medication has been prescribed for breakthrough pain [MASKED]. -Max daily Tylenol (acetaminophen) dose is THREE to FOUR grams from ALL sources AVOID lifting/pushing/pulling items heavier than 10 pounds (or 3 kilos; about a gallon of milk) or participate in high intensity physical activity (which includes intercourse) until you are cleared by your Urologist in follow-up. -No DRIVING for THREE WEEKS or until you are cleared by your Urologist -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -You may be given prescriptions for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be health care spending account reimbursable. -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room. Followup Instructions: [MASKED]	[]	[]	[ "C641: Malignant neoplasm of right kidney, except renal pelvis", "E784: Other hyperlipidemia" ]
19,979,915	29,148,528	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Volume overload Major Surgical or Invasive Procedure: ___: 1. Redo sternotomy. 2. Mitral valve replacement with a ___ mm Onyx valve serial ___, reference number is ONXM. 3. Tricuspid valve repair with a 30 mm ___ Contour 3D annuloplasty ring, model #690R, serial #___. 4. Coverage with Cor-Matrix History of Present Illness: Mr. ___ is a ___ year old man has a history of atrial fibrillation on Coumadin, s/p PPM in ___, aortic stenosis s/p porcine bioprosthetic AVR with Bentall procedure in ___ with subsequent cardiac tamponade, severe MR, who was admitted after receiving LHC and RHC as evaluation prior to MV replacement, found to have elevated filling pressures. ___ has had multiple exacerbations of congestive heart failure and shortness of breath. ___ initially BI in ___. ___ had a TTE, which showed mod-severe MR. ___ was then evaluated by cardiac surgery for MV surgery. As part of evaluation, ___ was scheduled to come in for LHC and RHC today. RHC showed PCWP in the 50's, CI 2.76, CO 5.85. During the procedure, ___ was slightly hypoxic to 89 and PaO2 done during the cath was 81. ___ received 40 mg IV Lasix and urinated 4 times. With regards to his LHC, ___ was found to have no significant CAD. His MV surgery was cancelled for tomorrow and was recommended to have further optimization. Access was right radial access and right AC for RHC. ___ reports having dyspnea on exertion, especially with climbing the stairs. ___ also has had intermittent ___ edema which has improved since placed on Lasix. ___ takes 20 mg daily usually but increases his dose intermittently. Upon arrival to the floor after cath, ___ denied any chest pain. ___ feels his breathing has improved. Notably, ___ states ___ also is on O2 at baseline 2.5 L intermittently and states ___ had "borderline COPD" on his PFTs as part of cardiac evaluation. ___ denies any ankle edema. ___ feels his weight is stable. Past Medical History: ___ procedure with 29mm Mosaic bioprosthesis with valve conduit constructed with 34mm gel weave graft. ___ ___, Dr. ___ to confirm make and model AFIB on Coumadin gout arthritis HTN Pericardial effusion Tamponade with subxiphoid pericardiocentesis Cardioversion Previous Cardiac Surgery?: AVR with Bentall, PPM Previous Balloon Valvuloplasty?: No Permanent Pacemaker/ICD in-situ?: Yes Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission Physical ================= VS: 97.6 108/65 58 18 91-92% 3L Weight: 94.4 kg GENERAL: Well developed, well nourished male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. NECK: Supple. JVP difficult to appreciate due to body habitus. CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ systolic murmur at RUSB, additionally subtle MR murmur heard laterally at left side LUNGS: Bibasilar crackles, no wheezes, rhonchi ABDOMEN: Soft, obese non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge vital signs: Temp 98.8 HR 68, BP 120/60, Resp 20, Sats RA 96% Wgt: 93.3kg Pertinent Results: Admission Labs ================= ___ 09:52PM BLOOD WBC-10.5* RBC-4.53* Hgb-13.7 Hct-43.1 MCV-95 MCH-30.2 MCHC-31.8* RDW-16.4* RDWSD-57.6* Plt ___ ___ 10:15AM BLOOD ___ ___ 09:52PM BLOOD Glucose-146* UreaN-19 Creat-0.8 Na-138 K-4.0 Cl-101 HCO3-24 AnGap-17 ___ 09:52PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.1 Imaging & Studies ================= TTE ___ The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen, but images could not determine valvular etiology. Due to the eccentric nature of the regurgitant jet, its severity ___ be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global/regional systolic function. Moderately dilated right ventricle with mild free wall hypokinesis. Moderate to severe eccentric mitral regurgitation. Moderate tricuspid regurgitation and pulmonary hypertension. ___ TEE Prebypass: The patient is V-paced. The left atrium is markedly dilated. Mild spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the left atrial appendage. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%) though in the setting of moderate to severe MR. ___ right ventricular cavity is dilated with normal free wall contractility, though in the setting of significant tricuspid regurgitation. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. Wires could be seen in both the right atrium and right ventricle. There are simple atheroma in the descending thoracic aorta. A bioprosthesis is seen in the aortic position. It appears well seated. Significant low pressure gradient aortic stenosis is present by dimensionless index (0.21) with ___ 1.1 by continuity equation. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. An eccentric, anteriorly directed jet of Moderate to severe (3+) mitral regurgitation is seen secondary to a restricted P2 cusp with mild A2 pseudoprolapse. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is a large calcification on the the anterior leaflet bordering the anterior annulus of the MV. Severe [4+] tricuspid regurgitation is seen with a markedly enlarged TV annulus, reversal of systolic flow in the hepatic veins and a vena contracta of 0.75cm. There is a trivial/physiologic pericardial effusion. Post-CPB s/p MVR and Tricsupid annuloplasty.: The patient is V- paced on ionotropes. Global biventricular function appears intact in the setting of extremely poor windows. Cannot rule out focal wall motion abnormalities. A bileaflet prosthesis is seen in the mitral position. It appears well seated with normal bileaflet motion and two centrally directed washing jets. A trace paravalvular leak resolved after administration of protamine. A peak pressure gradient of 7 mmHg and mean pressure gradient of 4mmHg is apparent across the mitral valve at a cardiac output of about 6 liters/minute. Annuplasty ring is seen well seated in the tricuspid position with trace TR and a mean pressure gradient across the tricuspid valve of 2mmHg. The rest of valvular function appears unchanged. The thoracic aorta is intact after decannulation. Cath report ___ Coronary Anatomy Dominance: Right left main: normal LAD, LCX, and RCA normal\ elevated filling pressures, severe pulmonary HTN giant V waves Impressions: left main: normal LAD, LCX, and RCA normal\ elevated filling pressures, severe pulmonary HTN PA&lat ___ There is a dual lead right-sided pacemaker with intact leads. There is unchanged cardiomegaly. Retrosternal soft tissue density, likely fluid, is again seen and stable. Tiny pleural effusion on the right side is seen, unchanged. There is no definite consolidation or signs for overt pulmonary edema. There are no pneumothoraces ___ 05:20PM BLOOD ___ ___ 06:15AM BLOOD ___ PTT-32.1 ___ ___ 06:15AM BLOOD Plt ___ ___ 06:27AM BLOOD ___ ___ 04:40AM BLOOD ___ ___ 04:40AM BLOOD Plt ___ ___ 04:40AM BLOOD Glucose-90 UreaN-20 Creat-0.6 Na-139 K-4.3 Cl-105 HCO3-24 AnGap-14 Brief Hospital Course: MEDICINE COURSE: ___ year old man has a history of atrial fibrillation on Coumadin, s/p PPM in ___, aortic stenosis s/p porcine bioprosthetic AVR with Bentall procedure in ___ with subsequent cardiac tamponade, severe MR, who was admitted after receiving LHC and RHC as evaluation prior to MV replacement, found to have a heart failure exacerbation with elevated filling pressures. Patient found to have heart failure exacerbation secondary to severe mitral regurgitation. ___ had a right heart cauterization that showed highly elevated filling pressures. Mitral regurgitation was not felt to be secondary to ischemia as there was no significant coronary artery disease on coronary angiogram. Given significant volume overload, patient was diuresed with lasix IV, with good improvement in volume status and exertional capacity. ___ was continued on his other home medications. ___ was evaluated by cardiac surgery who felt ___ was a good candidate for valvular replacement repair once his volume status was optimized. A TEE was conducted to evaluate his mitral and aortic valves. His aortic prothesis was found to be performing well and as such, only his mitral valve was planned for repair. # Acute CHF exacerbation secondary to severe mitral regurgitation: Patient initially presented with severe dyspnea, peripheral edema, along with a RHC showing elevated cardiac filling pressures. Based on TTE, this was felt to be due to severe MR, which was not felt to be ischemic given results from cardiac catheterization showing no significant CAD. Patient was diuresed with boluses of IV lasix with good effect with plan to undergo MVR when volume status was optimized. TTE was conducted to assess function of his aortic valve and found good function of the prosthesis with AV peak velocity of 2.6m/s with peak gradient of 27mmHg. ___ was continued on his home dose of metoprolol, amlodipine, and benazepril. # Atrial fibrillation: Patient with h/o AFib and CHADS-VASc score of 2. ___ was continued on his home dose of metoprolol for rate control. His warfarin was held pending surgery and ___ was placed on a heparin drip. = = = = = = = = = = = = = = ================================================================ Surgical Course ___ After standard preoperative work up was completed, on ___ ___ was taken to the operating room and underwent 1. Redo sternotomy. 2. Mitral valve replacement with a ___ mm Onyx valve. 3. Tricuspid valve repair with a 30 mm ___ Contour 3D annuloplasty ring 4. Coverage with Cor-Matrix. Please see operative report for further surgical details. ___ transferred to the CVICU in critical condition requiring vasopressor support for hemodynamic stability. Postoperatively ___ was hypoxemic and required high PEEP. Bronchoscopy was performed and an extrapleural hematoma was revealed. ___ had pulmonary edema which required aggressive diuresis with a Lasix drip. EP was consulted for postop PPM interrogation. His rhythm was in atrial flutter. Over the next few days ___ was weaned off of pressor support and his hemodynamics and hypoxemia improved. ___ weaned to extubate. ___ was febrile and pan cultured. Sputum was positive for Serratia and ___ was placed on Ceftriaxone. Chest tubes and pacing wires were discontinued per protocol without incident. ___ was started on anticoagulation for his mechanical MVR and chronic atrial fibrillation. ___ was transferred to the step down unit for further monitoring. ___ continue to progress well. ___ developed mid sternal drainage that resolved. ___ was seen by the Physical Therapy service and cleared for ___ was switched to levoquin at discharge to continue antibiotic course for serratia pneumonia to be dc'd ___. Patient was deemed safe for discharge to home on pod11. ___ was ambulating with assistance, wounds healing, drainage resolved, and pain controlled. All follow up appointments were advised. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amlodipine-benazepril ___ mg oral DAILY 2. Atorvastatin 20 mg PO QPM 3. benazepril 10 mg oral BID 4. Furosemide 20 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO BID 6. Warfarin 7.5 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB RX albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inh q 6 hours Disp #1 Inhaler Refills:0 3. Aspirin EC 81 mg PO DAILY RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 4. Docusate Sodium 100 mg PO BID 5. Fluticasone Propionate 110mcg 2 PUFF IH BID RX fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs inh twice a day Disp #1 Inhaler Refills:1 6. GuaiFENesin ER 1200 mg PO Q12H:PRN cough RX guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. Lactulose 30 mL PO DAILY:PRN constipation RX lactulose 10 gram/15 mL (15 mL) 30 ML by mouth daily Refills:0 8. Levofloxacin 500 mg PO Q24H Duration: 7 Days RX levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 9. Metoprolol Tartrate 25 mg PO Q8H 10. Potassium Chloride 20 mEq PO BID Duration: 10 Days RX potassium chloride 20 mEq 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:0 11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX tramadol [Ultram] 50 mg 1 tablet(s) by mouth q 4 hours Disp #60 Tablet Refills:0 12. Furosemide 40 mg PO BID Duration: 10 Days RX furosemide [Lasix] 40 mg 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:0 13. ___ MD to order daily dose PO DAILY16 to be dosed daily RX warfarin [Coumadin] 5 mg daily as directed tablet(s) by mouth daily as directed Disp #60 Tablet Refills:1 14. Atorvastatin 20 mg PO QPM RX atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home with Service Facility: ___ Discharge Diagnosis: 1. Severe mitral regurgitation. 2. Severe tricuspid regurgitation. Discharge Condition: Alert and oriented x3 non-focal Ambulating, deconditioned Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema +1 Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions: ___	[ "I081", "J156", "R570", "J9601", "I5023", "E873", "I4892", "D62", "I272", "I4891", "Z7901", "M109", "I10", "Z950", "Z87891", "Z953", "E785", "D6959" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Volume overload Major Surgical or Invasive Procedure: [MASKED]: 1. Redo sternotomy. 2. Mitral valve replacement with a [MASKED] mm Onyx valve serial [MASKED], reference number is ONXM. 3. Tricuspid valve repair with a 30 mm [MASKED] Contour 3D annuloplasty ring, model #690R, serial #[MASKED]. 4. Coverage with Cor-Matrix History of Present Illness: Mr. [MASKED] is a [MASKED] year old man has a history of atrial fibrillation on Coumadin, s/p PPM in [MASKED], aortic stenosis s/p porcine bioprosthetic AVR with Bentall procedure in [MASKED] with subsequent cardiac tamponade, severe MR, who was admitted after receiving LHC and RHC as evaluation prior to MV replacement, found to have elevated filling pressures. [MASKED] has had multiple exacerbations of congestive heart failure and shortness of breath. [MASKED] initially BI in [MASKED]. [MASKED] had a TTE, which showed mod-severe MR. [MASKED] was then evaluated by cardiac surgery for MV surgery. As part of evaluation, [MASKED] was scheduled to come in for LHC and RHC today. RHC showed PCWP in the 50's, CI 2.76, CO 5.85. During the procedure, [MASKED] was slightly hypoxic to 89 and PaO2 done during the cath was 81. [MASKED] received 40 mg IV Lasix and urinated 4 times. With regards to his LHC, [MASKED] was found to have no significant CAD. His MV surgery was cancelled for tomorrow and was recommended to have further optimization. Access was right radial access and right AC for RHC. [MASKED] reports having dyspnea on exertion, especially with climbing the stairs. [MASKED] also has had intermittent [MASKED] edema which has improved since placed on Lasix. [MASKED] takes 20 mg daily usually but increases his dose intermittently. Upon arrival to the floor after cath, [MASKED] denied any chest pain. [MASKED] feels his breathing has improved. Notably, [MASKED] states [MASKED] also is on O2 at baseline 2.5 L intermittently and states [MASKED] had "borderline COPD" on his PFTs as part of cardiac evaluation. [MASKED] denies any ankle edema. [MASKED] feels his weight is stable. Past Medical History: [MASKED] procedure with 29mm Mosaic bioprosthesis with valve conduit constructed with 34mm gel weave graft. [MASKED] [MASKED], Dr. [MASKED] to confirm make and model AFIB on Coumadin gout arthritis HTN Pericardial effusion Tamponade with subxiphoid pericardiocentesis Cardioversion Previous Cardiac Surgery?: AVR with Bentall, PPM Previous Balloon Valvuloplasty?: No Permanent Pacemaker/ICD in-situ?: Yes Social History: [MASKED] Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admission Physical ================= VS: 97.6 108/65 58 18 91-92% 3L Weight: 94.4 kg GENERAL: Well developed, well nourished male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. NECK: Supple. JVP difficult to appreciate due to body habitus. CARDIAC: Regular rate and rhythm. Normal S1, S2. [MASKED] systolic murmur at RUSB, additionally subtle MR murmur heard laterally at left side LUNGS: Bibasilar crackles, no wheezes, rhonchi ABDOMEN: Soft, obese non-tender, non-distended. No hepatomegaly. No splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Discharge vital signs: Temp 98.8 HR 68, BP 120/60, Resp 20, Sats RA 96% Wgt: 93.3kg Pertinent Results: Admission Labs ================= [MASKED] 09:52PM BLOOD WBC-10.5* RBC-4.53* Hgb-13.7 Hct-43.1 MCV-95 MCH-30.2 MCHC-31.8* RDW-16.4* RDWSD-57.6* Plt [MASKED] [MASKED] 10:15AM BLOOD [MASKED] [MASKED] 09:52PM BLOOD Glucose-146* UreaN-19 Creat-0.8 Na-138 K-4.0 Cl-101 HCO3-24 AnGap-17 [MASKED] 09:52PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.1 Imaging & Studies ================= TTE [MASKED] The left atrium is moderately dilated. The right atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen, but images could not determine valvular etiology. Due to the eccentric nature of the regurgitant jet, its severity [MASKED] be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global/regional systolic function. Moderately dilated right ventricle with mild free wall hypokinesis. Moderate to severe eccentric mitral regurgitation. Moderate tricuspid regurgitation and pulmonary hypertension. [MASKED] TEE Prebypass: The patient is V-paced. The left atrium is markedly dilated. Mild spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the left atrial appendage. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%) though in the setting of moderate to severe MR. [MASKED] right ventricular cavity is dilated with normal free wall contractility, though in the setting of significant tricuspid regurgitation. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. Wires could be seen in both the right atrium and right ventricle. There are simple atheroma in the descending thoracic aorta. A bioprosthesis is seen in the aortic position. It appears well seated. Significant low pressure gradient aortic stenosis is present by dimensionless index (0.21) with [MASKED] 1.1 by continuity equation. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. An eccentric, anteriorly directed jet of Moderate to severe (3+) mitral regurgitation is seen secondary to a restricted P2 cusp with mild A2 pseudoprolapse. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is a large calcification on the the anterior leaflet bordering the anterior annulus of the MV. Severe [4+] tricuspid regurgitation is seen with a markedly enlarged TV annulus, reversal of systolic flow in the hepatic veins and a vena contracta of 0.75cm. There is a trivial/physiologic pericardial effusion. Post-CPB s/p MVR and Tricsupid annuloplasty.: The patient is V- paced on ionotropes. Global biventricular function appears intact in the setting of extremely poor windows. Cannot rule out focal wall motion abnormalities. A bileaflet prosthesis is seen in the mitral position. It appears well seated with normal bileaflet motion and two centrally directed washing jets. A trace paravalvular leak resolved after administration of protamine. A peak pressure gradient of 7 mmHg and mean pressure gradient of 4mmHg is apparent across the mitral valve at a cardiac output of about 6 liters/minute. Annuplasty ring is seen well seated in the tricuspid position with trace TR and a mean pressure gradient across the tricuspid valve of 2mmHg. The rest of valvular function appears unchanged. The thoracic aorta is intact after decannulation. Cath report [MASKED] Coronary Anatomy Dominance: Right left main: normal LAD, LCX, and RCA normal\ elevated filling pressures, severe pulmonary HTN giant V waves Impressions: left main: normal LAD, LCX, and RCA normal\ elevated filling pressures, severe pulmonary HTN PA&lat [MASKED] There is a dual lead right-sided pacemaker with intact leads. There is unchanged cardiomegaly. Retrosternal soft tissue density, likely fluid, is again seen and stable. Tiny pleural effusion on the right side is seen, unchanged. There is no definite consolidation or signs for overt pulmonary edema. There are no pneumothoraces [MASKED] 05:20PM BLOOD [MASKED] [MASKED] 06:15AM BLOOD [MASKED] PTT-32.1 [MASKED] [MASKED] 06:15AM BLOOD Plt [MASKED] [MASKED] 06:27AM BLOOD [MASKED] [MASKED] 04:40AM BLOOD [MASKED] [MASKED] 04:40AM BLOOD Plt [MASKED] [MASKED] 04:40AM BLOOD Glucose-90 UreaN-20 Creat-0.6 Na-139 K-4.3 Cl-105 HCO3-24 AnGap-14 Brief Hospital Course: MEDICINE COURSE: [MASKED] year old man has a history of atrial fibrillation on Coumadin, s/p PPM in [MASKED], aortic stenosis s/p porcine bioprosthetic AVR with Bentall procedure in [MASKED] with subsequent cardiac tamponade, severe MR, who was admitted after receiving LHC and RHC as evaluation prior to MV replacement, found to have a heart failure exacerbation with elevated filling pressures. Patient found to have heart failure exacerbation secondary to severe mitral regurgitation. [MASKED] had a right heart cauterization that showed highly elevated filling pressures. Mitral regurgitation was not felt to be secondary to ischemia as there was no significant coronary artery disease on coronary angiogram. Given significant volume overload, patient was diuresed with lasix IV, with good improvement in volume status and exertional capacity. [MASKED] was continued on his other home medications. [MASKED] was evaluated by cardiac surgery who felt [MASKED] was a good candidate for valvular replacement repair once his volume status was optimized. A TEE was conducted to evaluate his mitral and aortic valves. His aortic prothesis was found to be performing well and as such, only his mitral valve was planned for repair. # Acute CHF exacerbation secondary to severe mitral regurgitation: Patient initially presented with severe dyspnea, peripheral edema, along with a RHC showing elevated cardiac filling pressures. Based on TTE, this was felt to be due to severe MR, which was not felt to be ischemic given results from cardiac catheterization showing no significant CAD. Patient was diuresed with boluses of IV lasix with good effect with plan to undergo MVR when volume status was optimized. TTE was conducted to assess function of his aortic valve and found good function of the prosthesis with AV peak velocity of 2.6m/s with peak gradient of 27mmHg. [MASKED] was continued on his home dose of metoprolol, amlodipine, and benazepril. # Atrial fibrillation: Patient with h/o AFib and CHADS-VASc score of 2. [MASKED] was continued on his home dose of metoprolol for rate control. His warfarin was held pending surgery and [MASKED] was placed on a heparin drip. = = = = = = = = = = = = = = ================================================================ Surgical Course [MASKED] After standard preoperative work up was completed, on [MASKED] [MASKED] was taken to the operating room and underwent 1. Redo sternotomy. 2. Mitral valve replacement with a [MASKED] mm Onyx valve. 3. Tricuspid valve repair with a 30 mm [MASKED] Contour 3D annuloplasty ring 4. Coverage with Cor-Matrix. Please see operative report for further surgical details. [MASKED] transferred to the CVICU in critical condition requiring vasopressor support for hemodynamic stability. Postoperatively [MASKED] was hypoxemic and required high PEEP. Bronchoscopy was performed and an extrapleural hematoma was revealed. [MASKED] had pulmonary edema which required aggressive diuresis with a Lasix drip. EP was consulted for postop PPM interrogation. His rhythm was in atrial flutter. Over the next few days [MASKED] was weaned off of pressor support and his hemodynamics and hypoxemia improved. [MASKED] weaned to extubate. [MASKED] was febrile and pan cultured. Sputum was positive for Serratia and [MASKED] was placed on Ceftriaxone. Chest tubes and pacing wires were discontinued per protocol without incident. [MASKED] was started on anticoagulation for his mechanical MVR and chronic atrial fibrillation. [MASKED] was transferred to the step down unit for further monitoring. [MASKED] continue to progress well. [MASKED] developed mid sternal drainage that resolved. [MASKED] was seen by the Physical Therapy service and cleared for [MASKED] was switched to levoquin at discharge to continue antibiotic course for serratia pneumonia to be dc'd [MASKED]. Patient was deemed safe for discharge to home on pod11. [MASKED] was ambulating with assistance, wounds healing, drainage resolved, and pain controlled. All follow up appointments were advised. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amlodipine-benazepril [MASKED] mg oral DAILY 2. Atorvastatin 20 mg PO QPM 3. benazepril 10 mg oral BID 4. Furosemide 20 mg PO DAILY 5. Metoprolol Succinate XL 100 mg PO BID 6. Warfarin 7.5 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB RX albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inh q 6 hours Disp #1 Inhaler Refills:0 3. Aspirin EC 81 mg PO DAILY RX aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 4. Docusate Sodium 100 mg PO BID 5. Fluticasone Propionate 110mcg 2 PUFF IH BID RX fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs inh twice a day Disp #1 Inhaler Refills:1 6. GuaiFENesin ER 1200 mg PO Q12H:PRN cough RX guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. Lactulose 30 mL PO DAILY:PRN constipation RX lactulose 10 gram/15 mL (15 mL) 30 ML by mouth daily Refills:0 8. Levofloxacin 500 mg PO Q24H Duration: 7 Days RX levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #7 Tablet Refills:0 9. Metoprolol Tartrate 25 mg PO Q8H 10. Potassium Chloride 20 mEq PO BID Duration: 10 Days RX potassium chloride 20 mEq 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:0 11. TraMADol 50 mg PO Q4H:PRN Pain - Moderate RX tramadol [Ultram] 50 mg 1 tablet(s) by mouth q 4 hours Disp #60 Tablet Refills:0 12. Furosemide 40 mg PO BID Duration: 10 Days RX furosemide [Lasix] 40 mg 1 tablet(s) by mouth twice a day Disp #20 Tablet Refills:0 13. [MASKED] MD to order daily dose PO DAILY16 to be dosed daily RX warfarin [Coumadin] 5 mg daily as directed tablet(s) by mouth daily as directed Disp #60 Tablet Refills:1 14. Atorvastatin 20 mg PO QPM RX atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home with Service Facility: [MASKED] Discharge Diagnosis: 1. Severe mitral regurgitation. 2. Severe tricuspid regurgitation. Discharge Condition: Alert and oriented x3 non-focal Ambulating, deconditioned Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Edema +1 Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [MASKED]. Answering service will contact on call person during off hours Followup Instructions: [MASKED]	[]	[ "J9601", "D62", "I4891", "Z7901", "M109", "I10", "Z87891", "E785" ]	[ "I081: Rheumatic disorders of both mitral and tricuspid valves", "J156: Pneumonia due to other Gram-negative bacteria", "R570: Cardiogenic shock", "J9601: Acute respiratory failure with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "E873: Alkalosis", "I4892: Unspecified atrial flutter", "D62: Acute posthemorrhagic anemia", "I272: Other secondary pulmonary hypertension", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "M109: Gout, unspecified", "I10: Essential (primary) hypertension", "Z950: Presence of cardiac pacemaker", "Z87891: Personal history of nicotine dependence", "Z953: Presence of xenogenic heart valve", "E785: Hyperlipidemia, unspecified", "D6959: Other secondary thrombocytopenia" ]
19,979,982	23,908,472	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___ Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: ___: ___ History of Present Illness: ___ is a ___ male with past medical history significant for HTN, BPH, renal insufficiency with creatinine 5.0-6.0, carotid stenosis, PAD and severe aortic stenosis. The patient noticed increased shortness of breath this ___ while on a family trip to ___. He saw his PCP and was referred to cardiologist, Dr. ___. A stress test was done and he was sent for cardiac catheterization. It showed no significant CAD, an echo showed severe aortic stenosis. Also reports symptoms of claudication in right lower extremity. He has a lower extremity ultrasound which showed mild to moderate digital ischemia and evidence of superficial stenosis above the knee. He has been followed by nephrologist for years for increasing creatinine. He is followed by Dr. ___ AV fistula placed on left arm 6 weeks ago possible for initiation of hemodialysis. He was seen by Cardiac Surgery and deemed high risk for surgical AVR. He presents today for ___ procedure. NYHA Class: II ROS: Reports no change in weight, change in appetite, headaches, visual changes, constipation, diarrhea, gait disturbances, muscle weakness, sensory deficits, or rash. All other are also negative. Past Medical History: Past Medical History: HTN HLD gout aortic stenosis CKD V, renal insufficiency carotid stenosis BPH Past Surgical History: hernia repair cataract sx Social History: ___ Family History: Father: deceased ___ cancer Mother: deceased stroke three adopted children Physical Exam: ADMISSION PE: VS: Temp 98.8,m BP 136/61, HR 67, RR 16, O2 sat 100% on 3L NC Tele: ___, SR, LBBB EKG: rate 67, Normal sinus rhythm. LBBB Weight: 68.04 kgs (150.00 lbs) General: Awake, pleasant lying in bed, NAD Neuro: Alert and oriented x4. Pleasant and cooperative. Speech clear, appropriate and comprehensible. Tongue midline, smile symmetric. Equal and strong hand grasps and foot pushes. HEENT: Neck supple, No JVD noted CV: RRR, Normal S1 S2, ___ systolic murmur Lungs: Clear ___ anteriorly, non-labored. No use of accessory muscles noted. GI/Abdomen: soft, non-tender, non-distended GU: due to void post-op PV: WWP, + ___, No edema. Access sites: Art line on right radial intact. CSM WNL. ___ femoral access site soft without hematoma, bleeding or ecchymosis. . DC exam: General/Neuro: Patient is A/O to person, place, time, and situation. Patient does not have focal deficits and PERRLA positive. Cardiac: Regular heart rhythm. No murmurs appreciated. Jugular vein distension 8 cm. Lungs: Lung sounds are clear. Patient has no respiratory distress. Abd: Patient has active bowel sounds, soft abdomen, non-distended, and non-tender. Extremities: Patient has no edema. Pedal pulses are palpable throughout. Access Sites: Bilateral femoral access sites are CDI. There is no bleeding, ecchymosis or hematoma present. Right radial site is CDI. Trace of swelling around the wrist. Bruising noted. No hematoma. Pertinent Results: DC labs: ___ 05:55AM BLOOD WBC-9.6 RBC-2.33* Hgb-7.0* Hct-22.3* MCV-96 MCH-30.0 MCHC-31.4* RDW-15.2 RDWSD-52.2* Plt ___ ___ 05:55AM BLOOD Plt ___ ___ 05:55AM BLOOD Glucose-119* UreaN-92* Creat-6.3* Na-141 K-4.4 Cl-108 HCO3-17* AnGap-16 ___ 05:55AM BLOOD Phos-5.9* Mg-2.4 . ECG ___: SR, LBBB . ECHO ___: CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 62 % (normal 54-73%). Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Diastolic function could not be assessed. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with a normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. A ___ 3 aortic valve bioprosthesis is present. There is a paravalvular jet of mild [1+] aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is severe mitral annular calcification. There is minimal functional mitral stenosis from the prominent mitral annular calcification. There is mild [1+] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Well-seated and normally functioning ___ with mild paravalvular aortic regurgitation. Compared with the prior TTE ___ , the aortic valve has been replaced with a normal functioning ___ with mild paravalvular aortic regurgitation. The severity of mitral regurgitation is reduced. Brief Hospital Course: # Severe aortic stenosis: s/p ___ 26 complicated with LBBB, now resolved. Gradients mildly elevated. -TTE completed ___ ___ PG: 64 MG: 36 EF: 55-60% ___ PG: 25 MG: 13 EF: 62% Mild AR -AC plan: Aspirin & Plavix -SBE instructions on discharge (needs antibiotics prior to dental work, lifelong) -ECHO and follow up visit f/u in 1 month -Event monitor ordered for 2 weeks given intermittent LBBB # Anemia of chronic disease: Hgb 6.9 prior to ___ today. Received 1 unit PRBC prior to start case. From chronic renal failure. no evidence of bleeding. # ESRD: rec'd 4cc of contrast during procedure. Baseline creat appears to be 6.0. AV fistula on left arm placed 6 weeks ago per pt. HD has not been initiated yet. Sees Dr. ___ at ___, ___. Still makes urine per pt. Holding Quinapril post procedure. Pt has a follow-up with Dr. ___ in 2 weeks # HTN: BP stable. Restarted metoprolol, holding quinapril as above # BPH: not a current issue # Carotid stenosis/PAD: Continued ASA and statin # Non-obstructive CAD: no chest pain. Continued ASA & Statin Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Quinapril 10 mg PO DAILY 2. Sodium Bicarbonate 650 mg PO BID 3. Allopurinol ___ mg PO DAILY 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Ferrous Sulfate 325 mg PO BID 7. Aspirin 81 mg PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Calcitriol 0.5 mcg PO 5 DAYS A WEEK 10. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY 11. Azopt (brinzolamide) 1 % ophthalmic (eye) BID Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Azopt (brinzolamide) 1 % ophthalmic (eye) BID 6. Calcitriol 0.5 mcg PO 5 DAYS A WEEK 7. Ferrous Sulfate 325 mg PO BID 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY 10. Metoprolol Succinate XL 12.5 mg PO DAILY 11. Sodium Bicarbonate 650 mg PO BID 12. HELD- Quinapril 10 mg PO DAILY This medication was held. Do not restart Quinapril until approved by your outpatient nephrologist. Discharge Disposition: Home Discharge Diagnosis: Aortic Valve Stenosis Hypertension Benign Prostate Hyperplasia End-Stage Renal Disease Peripheral Artery Disease Left Bundle Branch Block Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a trans catheter aortic valve replacement (___) to treat your aortic valve stenosis which was done on ___. By repairing the valve your heart can pump blood more easily and your shortness of breath should improve. It is very important to take all of your heart healthy medications. In particular, you are now taking Aspirin and Clopidogrel (Plavix). These medications help to prevent blood clots from forming on the new valve. If you stop these medications or miss ___ dose, you risk causing a blood clot forming on your new valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking Aspirin or Plavix without taking to your heart doctor, even if another doctor tells you to stop the medications. We will sent an electronic prescription to your pharmacy. Please take the time after your hospital discharge to pick up your medication. Any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 141 pounds. We may have made changes to your medication list, for example, we are holding your quinipril until your nephrologist provides further recommendation. Please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. You also need to have your labs checked tomorrow and the results should go to Dr. ___ The Structural Heart team should be calling you with a follow up/echo in 1 month if you don't have one scheduled already. If you don't hear from them by next week, please call ___ If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the ___ Heart Line at ___ to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health. Followup Instructions: ___	[ "I350", "N186", "I120", "I97190", "N400", "I447", "Y838", "Y92239", "I70201", "D631", "I2510", "M109", "Z006" ]	Allergies: All allergies / adverse drug reactions previously recorded have been deleted Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [MASKED]: [MASKED] History of Present Illness: [MASKED] is a [MASKED] male with past medical history significant for HTN, BPH, renal insufficiency with creatinine 5.0-6.0, carotid stenosis, PAD and severe aortic stenosis. The patient noticed increased shortness of breath this [MASKED] while on a family trip to [MASKED]. He saw his PCP and was referred to cardiologist, Dr. [MASKED]. A stress test was done and he was sent for cardiac catheterization. It showed no significant CAD, an echo showed severe aortic stenosis. Also reports symptoms of claudication in right lower extremity. He has a lower extremity ultrasound which showed mild to moderate digital ischemia and evidence of superficial stenosis above the knee. He has been followed by nephrologist for years for increasing creatinine. He is followed by Dr. [MASKED] AV fistula placed on left arm 6 weeks ago possible for initiation of hemodialysis. He was seen by Cardiac Surgery and deemed high risk for surgical AVR. He presents today for [MASKED] procedure. NYHA Class: II ROS: Reports no change in weight, change in appetite, headaches, visual changes, constipation, diarrhea, gait disturbances, muscle weakness, sensory deficits, or rash. All other are also negative. Past Medical History: Past Medical History: HTN HLD gout aortic stenosis CKD V, renal insufficiency carotid stenosis BPH Past Surgical History: hernia repair cataract sx Social History: [MASKED] Family History: Father: deceased [MASKED] cancer Mother: deceased stroke three adopted children Physical Exam: ADMISSION PE: VS: Temp 98.8,m BP 136/61, HR 67, RR 16, O2 sat 100% on 3L NC Tele: [MASKED], SR, LBBB EKG: rate 67, Normal sinus rhythm. LBBB Weight: 68.04 kgs (150.00 lbs) General: Awake, pleasant lying in bed, NAD Neuro: Alert and oriented x4. Pleasant and cooperative. Speech clear, appropriate and comprehensible. Tongue midline, smile symmetric. Equal and strong hand grasps and foot pushes. HEENT: Neck supple, No JVD noted CV: RRR, Normal S1 S2, [MASKED] systolic murmur Lungs: Clear [MASKED] anteriorly, non-labored. No use of accessory muscles noted. GI/Abdomen: soft, non-tender, non-distended GU: due to void post-op PV: WWP, + [MASKED], No edema. Access sites: Art line on right radial intact. CSM WNL. [MASKED] femoral access site soft without hematoma, bleeding or ecchymosis. . DC exam: General/Neuro: Patient is A/O to person, place, time, and situation. Patient does not have focal deficits and PERRLA positive. Cardiac: Regular heart rhythm. No murmurs appreciated. Jugular vein distension 8 cm. Lungs: Lung sounds are clear. Patient has no respiratory distress. Abd: Patient has active bowel sounds, soft abdomen, non-distended, and non-tender. Extremities: Patient has no edema. Pedal pulses are palpable throughout. Access Sites: Bilateral femoral access sites are CDI. There is no bleeding, ecchymosis or hematoma present. Right radial site is CDI. Trace of swelling around the wrist. Bruising noted. No hematoma. Pertinent Results: DC labs: [MASKED] 05:55AM BLOOD WBC-9.6 RBC-2.33* Hgb-7.0* Hct-22.3* MCV-96 MCH-30.0 MCHC-31.4* RDW-15.2 RDWSD-52.2* Plt [MASKED] [MASKED] 05:55AM BLOOD Plt [MASKED] [MASKED] 05:55AM BLOOD Glucose-119* UreaN-92* Creat-6.3* Na-141 K-4.4 Cl-108 HCO3-17* AnGap-16 [MASKED] 05:55AM BLOOD Phos-5.9* Mg-2.4 . ECG [MASKED]: SR, LBBB . ECHO [MASKED]: CONCLUSION: The left atrial volume index is normal. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 62 % (normal 54-73%). Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. Diastolic function could not be assessed. Normal right ventricular cavity size with normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with a normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. A [MASKED] 3 aortic valve bioprosthesis is present. There is a paravalvular jet of mild [1+] aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is severe mitral annular calcification. There is minimal functional mitral stenosis from the prominent mitral annular calcification. There is mild [1+] mitral regurgitation. Due to acoustic shadowing, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. Well-seated and normally functioning [MASKED] with mild paravalvular aortic regurgitation. Compared with the prior TTE [MASKED] , the aortic valve has been replaced with a normal functioning [MASKED] with mild paravalvular aortic regurgitation. The severity of mitral regurgitation is reduced. Brief Hospital Course: # Severe aortic stenosis: s/p [MASKED] 26 complicated with LBBB, now resolved. Gradients mildly elevated. -TTE completed [MASKED] [MASKED] PG: 64 MG: 36 EF: 55-60% [MASKED] PG: 25 MG: 13 EF: 62% Mild AR -AC plan: Aspirin & Plavix -SBE instructions on discharge (needs antibiotics prior to dental work, lifelong) -ECHO and follow up visit f/u in 1 month -Event monitor ordered for 2 weeks given intermittent LBBB # Anemia of chronic disease: Hgb 6.9 prior to [MASKED] today. Received 1 unit PRBC prior to start case. From chronic renal failure. no evidence of bleeding. # ESRD: rec'd 4cc of contrast during procedure. Baseline creat appears to be 6.0. AV fistula on left arm placed 6 weeks ago per pt. HD has not been initiated yet. Sees Dr. [MASKED] at [MASKED], [MASKED]. Still makes urine per pt. Holding Quinapril post procedure. Pt has a follow-up with Dr. [MASKED] in 2 weeks # HTN: BP stable. Restarted metoprolol, holding quinapril as above # BPH: not a current issue # Carotid stenosis/PAD: Continued ASA and statin # Non-obstructive CAD: no chest pain. Continued ASA & Statin Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Quinapril 10 mg PO DAILY 2. Sodium Bicarbonate 650 mg PO BID 3. Allopurinol [MASKED] mg PO DAILY 4. Metoprolol Succinate XL 12.5 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Ferrous Sulfate 325 mg PO BID 7. Aspirin 81 mg PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Calcitriol 0.5 mcg PO 5 DAYS A WEEK 10. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY 11. Azopt (brinzolamide) 1 % ophthalmic (eye) BID Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Allopurinol [MASKED] mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Azopt (brinzolamide) 1 % ophthalmic (eye) BID 6. Calcitriol 0.5 mcg PO 5 DAYS A WEEK 7. Ferrous Sulfate 325 mg PO BID 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY 10. Metoprolol Succinate XL 12.5 mg PO DAILY 11. Sodium Bicarbonate 650 mg PO BID 12. HELD- Quinapril 10 mg PO DAILY This medication was held. Do not restart Quinapril until approved by your outpatient nephrologist. Discharge Disposition: Home Discharge Diagnosis: Aortic Valve Stenosis Hypertension Benign Prostate Hyperplasia End-Stage Renal Disease Peripheral Artery Disease Left Bundle Branch Block Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a trans catheter aortic valve replacement ([MASKED]) to treat your aortic valve stenosis which was done on [MASKED]. By repairing the valve your heart can pump blood more easily and your shortness of breath should improve. It is very important to take all of your heart healthy medications. In particular, you are now taking Aspirin and Clopidogrel (Plavix). These medications help to prevent blood clots from forming on the new valve. If you stop these medications or miss [MASKED] dose, you risk causing a blood clot forming on your new valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking Aspirin or Plavix without taking to your heart doctor, even if another doctor tells you to stop the medications. We will sent an electronic prescription to your pharmacy. Please take the time after your hospital discharge to pick up your medication. Any future refills will need to be authorized by your outpatient providers, primary care or cardiologist. You will need prophylactic antibiotics prior to any dental procedure. Please inform your dentist about your recent cardiac procedure, and obtain a prescription from your doctor before any procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days, please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 141 pounds. We may have made changes to your medication list, for example, we are holding your quinipril until your nephrologist provides further recommendation. Please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. You also need to have your labs checked tomorrow and the results should go to Dr. [MASKED] The Structural Heart team should be calling you with a follow up/echo in 1 month if you don't have one scheduled already. If you don't hear from them by next week, please call [MASKED] If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the [MASKED] Heart Line at [MASKED] to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health. Followup Instructions: [MASKED]	[]	[ "N400", "I2510", "M109" ]	[ "I350: Nonrheumatic aortic (valve) stenosis", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I97190: Other postprocedural cardiac functional disturbances following cardiac surgery", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I447: Left bundle-branch block, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I70201: Unspecified atherosclerosis of native arteries of extremities, right leg", "D631: Anemia in chronic kidney disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M109: Gout, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]
19,981,190	24,364,972	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: amoxicillin / Penicillins Attending: ___. Chief Complaint: Left thigh pain Major Surgical or Invasive Procedure: Open reduction internal fixation of left periprosthetic femur fracture History of Present Illness: ___ y/o female residing in ___ Place w/ history of dementia, CKD, lymphoma s/ chemotherapy, parkinsons disease with worsening balance problems and frequent falls over the last year, left hip hemiarthroplasty in ___ for a fall at ___ by Dr. ___ admission to ___ for subdural hematoma in ___ here by transfer from ___ after a mechanical fall and left periprosthetic spiral femoral neck fracture. Patient is unable to provide collateral history. Past Medical History: ___ Disease CKD Peripheral Neuropathy Anemia Lymphoma Social History: ___ Family History: non-contributory Physical Exam: Vitals: ___ 0408 Temp: 98.3 PO BP: 133/74 R Lying HR: 101 RR: 16 O2 sat: 93% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: Sleeping General: Well-appearing, breathing comfortably MSK: LLE: Primary dressing to left lateral thigh in place Mild warmth and erythema without marked ecchymosis, stable from serial exams Patient did not participate in motor/sensory exam WWP Pertinent Results: ___ 06:30AM BLOOD WBC-8.3 RBC-2.84* Hgb-8.7* Hct-26.5* MCV-93 MCH-30.6 MCHC-32.8 RDW-16.2* RDWSD-54.9* Plt ___ ___ 06:15AM BLOOD WBC-8.1 RBC-2.66* Hgb-8.2* Hct-25.4* MCV-96 MCH-30.8 MCHC-32.3 RDW-15.8* RDWSD-54.7* Plt ___ ___ 06:15AM BLOOD Glucose-92 UreaN-18 Creat-1.1 Na-143 K-4.1 Cl-106 HCO3-25 AnGap-12 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left periprosthetic femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction and internal fixation of left periprosthetic femur fracture, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise remarkable for transfusion of 2 units of packed red blood cells, but her hemoglobin had stabilized and the patient did not demonstrate signs of symptomatic anemia on discharge. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touchdown weightbearing in the left lower extremity, and will be discharged on heparin 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: acetaminophen 325 mg capsule oral 2 capsule(s) Twice Daily amlodipine 5 mg tablet oral 1 tablet(s) Once Daily aspirin 81 mg tablet oral 1 tablet(s) Once Daily carbidopa ER 25 mg-levodopa 100 mg tablet,extended release oral 1 tablet extended release(s) Four times daily (9a, 12p, 1600, ___ metoprolol succinate ER 25 mg tablet,extended release 24 hr oral 1 tablet extended release 24 hr(s) Once Daily nitroglycerin 0.4 mg sublingual tablet sublingual 1 tablet, sublingual(s) Q5mins x3 doses) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX acetaminophen 325 mg 2 tablet(s) by mouth q6hr Disp #80 Tablet Refills:0 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX bisacodyl [Correctol] 5 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:0 3. Calcium Carbonate 1250 mg PO TID RX calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Heparin 5000 UNIT SC BID RX heparin (porcine) 5,000 unit/mL 5000 units subcutaneous twice a day Disp #56 Syringe Refills:0 6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q6hr Disp #30 Tablet Refills:0 7. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:0 8. Vitamin D 800 UNIT PO DAILY RX ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:0 9. amLODIPine 5 mg PO DAILY 10. Carbidopa-Levodopa (___) 1 TAB PO QID 11. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left periprosthetic femur fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Touchdown weightbearing to left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take heparin twice daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. -___ change the dressing to the thigh as needed. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: Touchdown weightbearing to the left lower extremity Treatments Frequency: Staples will remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively Followup Instructions: ___	[ "S72002A", "M9702XA", "W19XXXA", "Y92099", "G629", "D62", "G20", "F0280", "N189", "Z66", "Z9181", "Z8572", "Z87891" ]	Allergies: amoxicillin / Penicillins Chief Complaint: Left thigh pain Major Surgical or Invasive Procedure: Open reduction internal fixation of left periprosthetic femur fracture History of Present Illness: [MASKED] y/o female residing in [MASKED] Place w/ history of dementia, CKD, lymphoma s/ chemotherapy, parkinsons disease with worsening balance problems and frequent falls over the last year, left hip hemiarthroplasty in [MASKED] for a fall at [MASKED] by Dr. [MASKED] admission to [MASKED] for subdural hematoma in [MASKED] here by transfer from [MASKED] after a mechanical fall and left periprosthetic spiral femoral neck fracture. Patient is unable to provide collateral history. Past Medical History: [MASKED] Disease CKD Peripheral Neuropathy Anemia Lymphoma Social History: [MASKED] Family History: non-contributory Physical Exam: Vitals: [MASKED] 0408 Temp: 98.3 PO BP: 133/74 R Lying HR: 101 RR: 16 O2 sat: 93% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: Sleeping General: Well-appearing, breathing comfortably MSK: LLE: Primary dressing to left lateral thigh in place Mild warmth and erythema without marked ecchymosis, stable from serial exams Patient did not participate in motor/sensory exam WWP Pertinent Results: [MASKED] 06:30AM BLOOD WBC-8.3 RBC-2.84* Hgb-8.7* Hct-26.5* MCV-93 MCH-30.6 MCHC-32.8 RDW-16.2* RDWSD-54.9* Plt [MASKED] [MASKED] 06:15AM BLOOD WBC-8.1 RBC-2.66* Hgb-8.2* Hct-25.4* MCV-96 MCH-30.8 MCHC-32.3 RDW-15.8* RDWSD-54.7* Plt [MASKED] [MASKED] 06:15AM BLOOD Glucose-92 UreaN-18 Creat-1.1 Na-143 K-4.1 Cl-106 HCO3-25 AnGap-12 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left periprosthetic femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] for open reduction and internal fixation of left periprosthetic femur fracture, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. The [MASKED] hospital course was otherwise remarkable for transfusion of 2 units of packed red blood cells, but her hemoglobin had stabilized and the patient did not demonstrate signs of symptomatic anemia on discharge. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touchdown weightbearing in the left lower extremity, and will be discharged on heparin 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: acetaminophen 325 mg capsule oral 2 capsule(s) Twice Daily amlodipine 5 mg tablet oral 1 tablet(s) Once Daily aspirin 81 mg tablet oral 1 tablet(s) Once Daily carbidopa ER 25 mg-levodopa 100 mg tablet,extended release oral 1 tablet extended release(s) Four times daily (9a, 12p, 1600, [MASKED] metoprolol succinate ER 25 mg tablet,extended release 24 hr oral 1 tablet extended release 24 hr(s) Once Daily nitroglycerin 0.4 mg sublingual tablet sublingual 1 tablet, sublingual(s) Q5mins x3 doses) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX acetaminophen 325 mg 2 tablet(s) by mouth q6hr Disp #80 Tablet Refills:0 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX bisacodyl [Correctol] 5 mg 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:0 3. Calcium Carbonate 1250 mg PO TID RX calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 4. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Heparin 5000 UNIT SC BID RX heparin (porcine) 5,000 unit/mL 5000 units subcutaneous twice a day Disp #56 Syringe Refills:0 6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain RX oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q6hr Disp #30 Tablet Refills:0 7. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #60 Tablet Refills:0 8. Vitamin D 800 UNIT PO DAILY RX ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth once a day Disp #60 Tablet Refills:0 9. amLODIPine 5 mg PO DAILY 10. Carbidopa-Levodopa ([MASKED]) 1 TAB PO QID 11. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Left periprosthetic femur fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Touchdown weightbearing to left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take heparin twice daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. -[MASKED] change the dressing to the thigh as needed. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. [MASKED]. You will have follow up with [MASKED], NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call [MASKED] to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within [MASKED] weeks and for and any new medications/refills. Physical Therapy: Touchdown weightbearing to the left lower extremity Treatments Frequency: Staples will remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively Followup Instructions: [MASKED]	[]	[ "D62", "N189", "Z66", "Z87891" ]	[ "S72002A: Fracture of unspecified part of neck of left femur, initial encounter for closed fracture", "M9702XA: Periprosthetic fracture around internal prosthetic left hip joint, initial encounter", "W19XXXA: Unspecified fall, initial encounter", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "G629: Polyneuropathy, unspecified", "D62: Acute posthemorrhagic anemia", "G20: Parkinson's disease", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "N189: Chronic kidney disease, unspecified", "Z66: Do not resuscitate", "Z9181: History of falling", "Z8572: Personal history of non-Hodgkin lymphomas", "Z87891: Personal history of nicotine dependence" ]
19,981,190	29,531,963	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year old female on a ASA 325mg who lives in assisted living who has a mechanical fall this morning while getting out of bed. She reported having to go to the bathroom urgently and slipping on a throw rug. She had no loss of consciousness, but the assisted living home called EMS and had her brought to ___. At the OSH, she had a NCHCT which showed a small right SDH with no mass affect. She was transported to ___ for further evaluation. Past Medical History: ___ Disease CKD Peripheral Neuropathy Anemia Lymphoma Social History: ___ Family History: non-contributory Physical Exam: Gen: WD/WN, comfortable, NAD. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 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 full power ___ throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger to nose Pertinent Results: CT Head from OSH: 2-3mm SDH in R frontal cortex. No mass effect/midline shift Admission Labs: 143 109 29 ----/---/----< 86 4.0 24 1.0 10.0 6.0 >-----< 145 32.7 ___: 10.6 PTT: 28.9 INR: 1.0 Brief Hospital Course: Ms. ___ was admitted to the neurosurgery service under Dr. ___ on ___ with a small right subdural hematoma, no mass effect. She was started on Keppra 500mg bid x7 days. Aspirin was held on admission, no need for platelet administration. She remained neurologically intact throughout her hospitalization. Given her stable exam and the size of the bleed, no repeat imaging was indicated at this time. On HD#2 she was ambulating, tolerating PO diet, pain well controlled. She was evaluated by physical therapy, who recommended rehab at discharge. She was deemed stable to discharge ___. She will continue to hold Aspirin for 5 days and follow up with Dr. ___ in 8 weeks with a repeat head CT. Medications on Admission: Metoprolol Succinate 25mg daily Tylenol ___ Carba/Levodopa ___ TID ASA 325 Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. LevETIRAcetam 500 mg PO BID Duration: 7 Days 4. Senna 17.2 mg PO HS 5. Carbidopa-Levodopa (___) 1 TAB PO TID 6. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Brain Hemorrhage without Surgery Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. · No driving while taking any narcotic or sedating medication. · If you experienced a seizure while admitted, you are NOT allowed to drive by law. · No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications · You may resume Aspirin on ___. Please do NOT take any other blood thinning medication (Plavix, Coumadin) until cleared by the neurosurgeon. · You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication for a total of 7 days (through ___. It is important that you take this medication consistently and on time. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: · You may have difficulty paying attention, concentrating, and remembering new information. · Emotional and/or behavioral difficulties are common. · Feeling more tired, restlessness, irritability, and mood swings are also common. · Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: · Headache is one of the most common symptom after a brain bleed. · Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. · Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. · There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · Nausea and/or vomiting · Extreme sleepiness and not being able to stay awake · Severe headaches not relieved by pain relievers · Seizures · Any new problems with your vision or ability to speak · Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason Followup Instructions: ___	[ "S065X0A", "W010XXA", "Y92099", "G20", "N189", "G629", "C8590", "Z87891" ]	Allergies: No Allergies/ADRs on File Chief Complaint: fall Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] year old female on a ASA 325mg who lives in assisted living who has a mechanical fall this morning while getting out of bed. She reported having to go to the bathroom urgently and slipping on a throw rug. She had no loss of consciousness, but the assisted living home called EMS and had her brought to [MASKED]. At the OSH, she had a NCHCT which showed a small right SDH with no mass affect. She was transported to [MASKED] for further evaluation. Past Medical History: [MASKED] Disease CKD Peripheral Neuropathy Anemia Lymphoma Social History: [MASKED] Family History: non-contributory Physical Exam: Gen: WD/WN, comfortable, NAD. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 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 full power [MASKED] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger to nose Pertinent Results: CT Head from OSH: 2-3mm SDH in R frontal cortex. No mass effect/midline shift Admission Labs: 143 109 29 ----/---/----< 86 4.0 24 1.0 10.0 6.0 >-----< 145 32.7 [MASKED]: 10.6 PTT: 28.9 INR: 1.0 Brief Hospital Course: Ms. [MASKED] was admitted to the neurosurgery service under Dr. [MASKED] on [MASKED] with a small right subdural hematoma, no mass effect. She was started on Keppra 500mg bid x7 days. Aspirin was held on admission, no need for platelet administration. She remained neurologically intact throughout her hospitalization. Given her stable exam and the size of the bleed, no repeat imaging was indicated at this time. On HD#2 she was ambulating, tolerating PO diet, pain well controlled. She was evaluated by physical therapy, who recommended rehab at discharge. She was deemed stable to discharge [MASKED]. She will continue to hold Aspirin for 5 days and follow up with Dr. [MASKED] in 8 weeks with a repeat head CT. Medications on Admission: Metoprolol Succinate 25mg daily Tylenol [MASKED] Carba/Levodopa [MASKED] TID ASA 325 Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. LevETIRAcetam 500 mg PO BID Duration: 7 Days 4. Senna 17.2 mg PO HS 5. Carbidopa-Levodopa ([MASKED]) 1 TAB PO TID 6. Metoprolol Succinate XL 25 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] [MASKED] Diagnosis: subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Brain Hemorrhage without Surgery Activity · We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. · You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. · No driving while taking any narcotic or sedating medication. · If you experienced a seizure while admitted, you are NOT allowed to drive by law. · No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications · You may resume Aspirin on [MASKED]. Please do NOT take any other blood thinning medication (Plavix, Coumadin) until cleared by the neurosurgeon. · You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication for a total of 7 days (through [MASKED]. It is important that you take this medication consistently and on time. · You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience: · You may have difficulty paying attention, concentrating, and remembering new information. · Emotional and/or behavioral difficulties are common. · Feeling more tired, restlessness, irritability, and mood swings are also common. · Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: · Headache is one of the most common symptom after a brain bleed. · Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. · Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. · There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at [MASKED] for: · Severe pain, swelling, redness or drainage from the incision site. · Fever greater than 101.5 degrees Fahrenheit · Nausea and/or vomiting · Extreme sleepiness and not being able to stay awake · Severe headaches not relieved by pain relievers · Seizures · Any new problems with your vision or ability to speak · Weakness or changes in sensation in your face, arms, or leg Call [MASKED] and go to the nearest Emergency Room if you experience any of the following: · Sudden numbness or weakness in the face, arm, or leg · Sudden confusion or trouble speaking or understanding · Sudden trouble walking, dizziness, or loss of balance or coordination · Sudden severe headaches with no known reason Followup Instructions: [MASKED]	[]	[ "N189", "Z87891" ]	[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y92099: Unspecified place in other non-institutional residence as the place of occurrence of the external cause", "G20: Parkinson's disease", "N189: Chronic kidney disease, unspecified", "G629: Polyneuropathy, unspecified", "C8590: Non-Hodgkin lymphoma, unspecified, unspecified site", "Z87891: Personal history of nicotine dependence" ]
19,981,210	26,276,441	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast Media Attending: ___. Chief Complaint: ICD reaching ERI, worsening LVEF & HF, planned upgrade to CRT-P. Admit prior for heparin gtt bridge. Major Surgical or Invasive Procedure: CRT-P upgrade ___ History of Present Illness: ___ admitted for Heparin drip prior to planned CRT pacemaker upgrade in the setting of known mechanical aortic valve. He has had a decline in his LVEF (20%) and his pacemaker was recently noted to be nearing end of battery life, therefore the decision was made to upgrade his device at this time. Past Medical History: HFrEF (LVEF 20%) Bicuspid AV s/p mechanical AVR ___, on Coumadin CAD s/p CABG ___, subsequent stents Tachy-___ s/p PPM AFib/flutter Diabetes II Hypertension Hyperlipidemia CKD Amio-associated thyrotoxicosis GERD Social History: ___ Family History: Father with myocardial infarction at age ___. Mother died of natural causes at ___. No h/o arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Physical Examination on Admission: VS: 98.3, 108/67, 67, 18, 95% ra Weight: 63.8 kg (140.65 lbs.) General: Alert, no acute distress Cardiovascular: Regular rate/rhythm Respiratory: Lungs clear bilaterally, breathing appears slightly labored but patient denies subjective dyspnea Abdomen: Round, slightly distended, Non-tender, +BS Extremities: BLE warm with 2+ pitting BLE edema Skin: Warm, dry and intact Neuro: Alert, oriented x 3, appropriate At Discharge: VS: T 97.4 BP 114/67 HR 59 SpO2 96% RA Wt: 64.4 kg Gen: Patient is in no acute distress. HEENT: Face symmetrical, trachea midline. Neuro: A/Ox3. Speaking in complete, coherent sentences. No face, arm, or leg weakness. Pulm: Breathing unlabored. Breath sounds clear bilaterally. Cardiac: No JVD. No thrills or bruits heard on carotids bilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs, S3, S4 or friction rubs heard. Vasc: No edema noted in bilateral upper or lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, ___ pulses palpable 2+. ACCESS: L chest incision area is soft, non-tender with no swelling, drainage or hematoma noted. Abd: Rounded, soft, non-tender. Pertinent Results: Admission labs: ___ 09:20PM BLOOD WBC-11.1* RBC-3.61* Hgb-9.6* Hct-31.2* MCV-86 MCH-26.6 MCHC-30.8* RDW-16.8* RDWSD-53.5* Plt ___ ___ 09:20PM BLOOD ___ PTT-31.9 ___ ___ 09:20PM BLOOD Glucose-193* UreaN-32* Creat-1.5* Na-137 K-5.0 Cl-100 HCO3-28 AnGap-9* ___ 09:20PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.2 Discharge labs: ___ 07:10AM BLOOD WBC-17.4* RBC-3.53* Hgb-9.4* Hct-30.5* MCV-86 MCH-26.6 MCHC-30.8* RDW-17.0* RDWSD-53.2* Plt ___ ___ 07:10AM BLOOD ___ ___ 07:10AM BLOOD UreaN-25* Creat-1.2 Na-138 K-4.7 ___ 07:36AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.4 EP Brief Report ___: Conclusions Successful CS lead implantation with upgrade to a biventricular pacemaker. Subtotal left subclavian vein stensosis. There were no complications. CXR ___: FINDINGS: Median sternotomy wires are intact. Clips are again noted overlying the mediastinum. A chest wall pacing device is unchanged in position, with atrial biventricular leads te in standard placement. There is mild pulmonary vascular congestion, improved from prior. No focal consolidations. The cardiomediastinal silhouette is unchanged, with top-normal cardiac size. There no pleural effusions. No pneumothorax. IMPRESSION: 1. Atrial biventricular leads are in standard placement. No pneumothorax or mediastinal widening. 2. Mild pulmonary vascular congestion is improved. Brief Hospital Course: Mr. ___ is an ___ with CAD s/p CABG/PCI, bicuspid AV s/p mAVR ___ (on coumadin), AF/flutter on amio (reduced dose for thyroiditis), HFrEF, tachy-brady s/p dcPPM, now with worsening EF and heart failure symptoms, admitted for heparin bridge prior to gen change and consideration of CRT-P upgrade. # Chronic Systolic Heart Failure; EF 20%: Admitted for planned CRT-P upgrade for decreased LVEF for heparin bridging and diuresis. He was hypotensive post-procedure, asymptomatic. V scan showed no effusion. - Diuresis held post-op d/t hypotension. He has been euvolemic during hospitalization. Consider restarting as outpatient if needed. - Continue Metoprolol, Spironolactone & Entresto # Bicuspid Aortic Valve s/p mechanical AVR ___ # Atrial Fibrillation, Tachy-brady syndrome s/p PPM - Anticoagulation: Goal INR 2.5-3.5. INR 2.6 this morning. Continue Coumadin 4mg daily. Check INR at home on ___. Managed by PCP. # Diabetes, Type II: FSBG 120-240 - Metformin held while inpatient and managed with Humalog sliding scale as needed during admission # Chronic Kidney Disease: baseline Cr range 1.3-1.5 over the last year per our records. Cr today 1.2. - Avoid nephrotoxins, renal dose medications # Coronary Artery Disease: prior CABG & PCIs - Continue current regimen # Hypertension: clinically stable - Continue current regimen # Hyperlipidemia: continue Atorvastatin 80mg in the setting of known CAD # Dispo: Home today with services. ___ recommends ambulation with walker - rx given. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID 2. TRIAzolam 0.125 mg PO QHS:PRN sleep 3. Metoprolol Succinate XL 37.5 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO QHS 5. Amiodarone 100 mg PO DAILY 6. Warfarin 4 mg PO DAILY16 7. Atorvastatin 80 mg PO QPM 8. Montelukast 10 mg PO DAILY 9. Torsemide 20 mg PO DAILY 10. Spironolactone 12.5 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 15. Pantoprazole 40 mg PO Q24H 16. Aspirin 81 mg PO DAILY 17. Tamsulosin 0.4 mg PO QHS 18. albuterol sulfate 90 mcg/actuation inhalation QID:PRN shortness of breath 19. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 20. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___) 21. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 22. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 2. albuterol sulfate 90 mcg/actuation inhalation QID:PRN shortness of breath 3. Amiodarone 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___) 9. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___) 10. MetFORMIN (Glucophage) 500 mg PO QHS 11. Metoprolol Succinate XL 37.5 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 15. Pantoprazole 40 mg PO Q24H 16. PreserVision AREDS (vitamins A,C,E-zinc-copper) ___ unit-mg-unit oral DAILY 17. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID 18. Spironolactone 12.5 mg PO DAILY 19. Tamsulosin 0.4 mg PO QHS 20. TRIAzolam 0.125 mg PO QHS:PRN sleep 21. Warfarin 4 mg PO DAILY16 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Heart Failure with Reduced Ejection Fraction (20%) Discharge Condition: Mental Status: Clear and coherent. evel of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VS: T 97.4 BP 114/67 HR 59 SpO2 96% RA PE: Gen: Patient is in no acute distress. HEENT: Face symmetrical, trachea midline. Neuro: A/Ox3. Speaking in complete, coherent sentences. No face, arm, or leg weakness. Pulm: Breathing unlabored. Breath sounds clear bilaterally. Cardiac: No JVD. No thrills or bruits heard on carotids bilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs, S3, S4 or friction rubs heard. Vasc: No edema noted in bilateral upper or lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, ___ pulses palpable 2+. ACCESS: L chest incision area is soft, non-tender with no swelling, drainage or hematoma noted. Abd: Rounded, soft, non-tender. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted for a planned pacemaker device upgrade to CRT-P. WHAT HAPPENED IN THE HOSPITAL? ============================== - You received IV heparin while your INR was below goal. - You had your device upgraded to CRT-P. - Your INR is now therapeutic. Check your INR on ___, ___. Call your primary care doctor's office to see if your Coumadin dose needs to be adjusted. - Physical Therapy saw you and recommended that you use a walker when you are home and that you are discharged with nursing services. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Take all of your medications as prescribed (listed below). - Follow up with your doctors as listed below - You should call an ambulance for any chest pain, shortness of breath, lightheadedness, dizziness, fainting experienced after discharge. It was a pleasure participating in your care. If you have any urgent questions that are related to your recovery from your hospitalization or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the ___ HeartLine at ___ to speak to a cardiologist or cardiac nurse practitioner. -Your ___ Care Team Followup Instructions: ___	[ "I130", "I442", "I4892", "I871", "I5022", "I959", "E1122", "I428", "E0580", "I495", "I4891", "N189", "E785", "I2510", "K219", "Z7901", "Z952", "Z951", "Z87891" ]	Allergies: Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast Media Chief Complaint: ICD reaching ERI, worsening LVEF & HF, planned upgrade to CRT-P. Admit prior for heparin gtt bridge. Major Surgical or Invasive Procedure: CRT-P upgrade [MASKED] History of Present Illness: [MASKED] admitted for Heparin drip prior to planned CRT pacemaker upgrade in the setting of known mechanical aortic valve. He has had a decline in his LVEF (20%) and his pacemaker was recently noted to be nearing end of battery life, therefore the decision was made to upgrade his device at this time. Past Medical History: HFrEF (LVEF 20%) Bicuspid AV s/p mechanical AVR [MASKED], on Coumadin CAD s/p CABG [MASKED], subsequent stents Tachy-[MASKED] s/p PPM AFib/flutter Diabetes II Hypertension Hyperlipidemia CKD Amio-associated thyrotoxicosis GERD Social History: [MASKED] Family History: Father with myocardial infarction at age [MASKED]. Mother died of natural causes at [MASKED]. No h/o arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Physical Examination on Admission: VS: 98.3, 108/67, 67, 18, 95% ra Weight: 63.8 kg (140.65 lbs.) General: Alert, no acute distress Cardiovascular: Regular rate/rhythm Respiratory: Lungs clear bilaterally, breathing appears slightly labored but patient denies subjective dyspnea Abdomen: Round, slightly distended, Non-tender, +BS Extremities: BLE warm with 2+ pitting BLE edema Skin: Warm, dry and intact Neuro: Alert, oriented x 3, appropriate At Discharge: VS: T 97.4 BP 114/67 HR 59 SpO2 96% RA Wt: 64.4 kg Gen: Patient is in no acute distress. HEENT: Face symmetrical, trachea midline. Neuro: A/Ox3. Speaking in complete, coherent sentences. No face, arm, or leg weakness. Pulm: Breathing unlabored. Breath sounds clear bilaterally. Cardiac: No JVD. No thrills or bruits heard on carotids bilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs, S3, S4 or friction rubs heard. Vasc: No edema noted in bilateral upper or lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, [MASKED] pulses palpable 2+. ACCESS: L chest incision area is soft, non-tender with no swelling, drainage or hematoma noted. Abd: Rounded, soft, non-tender. Pertinent Results: Admission labs: [MASKED] 09:20PM BLOOD WBC-11.1* RBC-3.61* Hgb-9.6* Hct-31.2* MCV-86 MCH-26.6 MCHC-30.8* RDW-16.8* RDWSD-53.5* Plt [MASKED] [MASKED] 09:20PM BLOOD [MASKED] PTT-31.9 [MASKED] [MASKED] 09:20PM BLOOD Glucose-193* UreaN-32* Creat-1.5* Na-137 K-5.0 Cl-100 HCO3-28 AnGap-9* [MASKED] 09:20PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.2 Discharge labs: [MASKED] 07:10AM BLOOD WBC-17.4* RBC-3.53* Hgb-9.4* Hct-30.5* MCV-86 MCH-26.6 MCHC-30.8* RDW-17.0* RDWSD-53.2* Plt [MASKED] [MASKED] 07:10AM BLOOD [MASKED] [MASKED] 07:10AM BLOOD UreaN-25* Creat-1.2 Na-138 K-4.7 [MASKED] 07:36AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.4 EP Brief Report [MASKED]: Conclusions Successful CS lead implantation with upgrade to a biventricular pacemaker. Subtotal left subclavian vein stensosis. There were no complications. CXR [MASKED]: FINDINGS: Median sternotomy wires are intact. Clips are again noted overlying the mediastinum. A chest wall pacing device is unchanged in position, with atrial biventricular leads te in standard placement. There is mild pulmonary vascular congestion, improved from prior. No focal consolidations. The cardiomediastinal silhouette is unchanged, with top-normal cardiac size. There no pleural effusions. No pneumothorax. IMPRESSION: 1. Atrial biventricular leads are in standard placement. No pneumothorax or mediastinal widening. 2. Mild pulmonary vascular congestion is improved. Brief Hospital Course: Mr. [MASKED] is an [MASKED] with CAD s/p CABG/PCI, bicuspid AV s/p mAVR [MASKED] (on coumadin), AF/flutter on amio (reduced dose for thyroiditis), HFrEF, tachy-brady s/p dcPPM, now with worsening EF and heart failure symptoms, admitted for heparin bridge prior to gen change and consideration of CRT-P upgrade. # Chronic Systolic Heart Failure; EF 20%: Admitted for planned CRT-P upgrade for decreased LVEF for heparin bridging and diuresis. He was hypotensive post-procedure, asymptomatic. V scan showed no effusion. - Diuresis held post-op d/t hypotension. He has been euvolemic during hospitalization. Consider restarting as outpatient if needed. - Continue Metoprolol, Spironolactone & Entresto # Bicuspid Aortic Valve s/p mechanical AVR [MASKED] # Atrial Fibrillation, Tachy-brady syndrome s/p PPM - Anticoagulation: Goal INR 2.5-3.5. INR 2.6 this morning. Continue Coumadin 4mg daily. Check INR at home on [MASKED]. Managed by PCP. # Diabetes, Type II: FSBG 120-240 - Metformin held while inpatient and managed with Humalog sliding scale as needed during admission # Chronic Kidney Disease: baseline Cr range 1.3-1.5 over the last year per our records. Cr today 1.2. - Avoid nephrotoxins, renal dose medications # Coronary Artery Disease: prior CABG & PCIs - Continue current regimen # Hypertension: clinically stable - Continue current regimen # Hyperlipidemia: continue Atorvastatin 80mg in the setting of known CAD # Dispo: Home today with services. [MASKED] recommends ambulation with walker - rx given. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID 2. TRIAzolam 0.125 mg PO QHS:PRN sleep 3. Metoprolol Succinate XL 37.5 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO QHS 5. Amiodarone 100 mg PO DAILY 6. Warfarin 4 mg PO DAILY16 7. Atorvastatin 80 mg PO QPM 8. Montelukast 10 mg PO DAILY 9. Torsemide 20 mg PO DAILY 10. Spironolactone 12.5 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 15. Pantoprazole 40 mg PO Q24H 16. Aspirin 81 mg PO DAILY 17. Tamsulosin 0.4 mg PO QHS 18. albuterol sulfate 90 mcg/actuation inhalation QID:PRN shortness of breath 19. Levothyroxine Sodium 100 mcg PO 5X/WEEK ([MASKED]) 20. Levothyroxine Sodium 150 mcg PO 1X/WEEK ([MASKED]) 21. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 22. PreserVision AREDS (vitamins A,C,E-zinc-copper) [MASKED] unit-mg-unit oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever 2. albuterol sulfate 90 mcg/actuation inhalation QID:PRN shortness of breath 3. Amiodarone 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 8. Levothyroxine Sodium 100 mcg PO 5X/WEEK ([MASKED]) 9. Levothyroxine Sodium 150 mcg PO 1X/WEEK ([MASKED]) 10. MetFORMIN (Glucophage) 500 mg PO QHS 11. Metoprolol Succinate XL 37.5 mg PO DAILY 12. Montelukast 10 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 15. Pantoprazole 40 mg PO Q24H 16. PreserVision AREDS (vitamins A,C,E-zinc-copper) [MASKED] unit-mg-unit oral DAILY 17. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID 18. Spironolactone 12.5 mg PO DAILY 19. Tamsulosin 0.4 mg PO QHS 20. TRIAzolam 0.125 mg PO QHS:PRN sleep 21. Warfarin 4 mg PO DAILY16 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Heart Failure with Reduced Ejection Fraction (20%) Discharge Condition: Mental Status: Clear and coherent. evel of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. VS: T 97.4 BP 114/67 HR 59 SpO2 96% RA PE: Gen: Patient is in no acute distress. HEENT: Face symmetrical, trachea midline. Neuro: A/Ox3. Speaking in complete, coherent sentences. No face, arm, or leg weakness. Pulm: Breathing unlabored. Breath sounds clear bilaterally. Cardiac: No JVD. No thrills or bruits heard on carotids bilaterally. S1, S2 RRR. No splitting of heart sounds, murmurs, S3, S4 or friction rubs heard. Vasc: No edema noted in bilateral upper or lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry, warm. Bilateral radial, [MASKED] pulses palpable 2+. ACCESS: L chest incision area is soft, non-tender with no swelling, drainage or hematoma noted. Abd: Rounded, soft, non-tender. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at the [MASKED] [MASKED]! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted for a planned pacemaker device upgrade to CRT-P. WHAT HAPPENED IN THE HOSPITAL? ============================== - You received IV heparin while your INR was below goal. - You had your device upgraded to CRT-P. - Your INR is now therapeutic. Check your INR on [MASKED], [MASKED]. Call your primary care doctor's office to see if your Coumadin dose needs to be adjusted. - Physical Therapy saw you and recommended that you use a walker when you are home and that you are discharged with nursing services. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Take all of your medications as prescribed (listed below). - Follow up with your doctors as listed below - You should call an ambulance for any chest pain, shortness of breath, lightheadedness, dizziness, fainting experienced after discharge. It was a pleasure participating in your care. If you have any urgent questions that are related to your recovery from your hospitalization or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital, please call the [MASKED] HeartLine at [MASKED] to speak to a cardiologist or cardiac nurse practitioner. -Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I130", "E1122", "I4891", "N189", "E785", "I2510", "K219", "Z7901", "Z951", "Z87891" ]	[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I442: Atrioventricular block, complete", "I4892: Unspecified atrial flutter", "I871: Compression of vein", "I5022: Chronic systolic (congestive) heart failure", "I959: Hypotension, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I428: Other cardiomyopathies", "E0580: Other thyrotoxicosis without thyrotoxic crisis or storm", "I495: Sick sinus syndrome", "I4891: Unspecified atrial fibrillation", "N189: Chronic kidney disease, unspecified", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7901: Long term (current) use of anticoagulants", "Z952: Presence of prosthetic heart valve", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence" ]
19,981,210	27,919,282	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast Media Attending: ___ Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ male with a past medical history of CAD with a very complex course including multiple stents, CHF, DM who presents with substernal chest pain. Chest pain occurred last night at rest. Took nitro and was able to sleep and then woke up with worsened chest pain and mild SOB. The pain improved after 3 nitroglycerin from a 6 out of 10 to 3 out of 10 and decided to go to ___. Trop neg there and CXR neg, received NTG and then xfer to ___ for further eval given complex cardiac history. Trop here negative. CP is now ___, attributes to taking his home medicines. Took full dose aspirin this morning. In the ___ initial vitals were: 98.0 76 131/76 14 96% RA EKG: paced Labs/studies notable for: trop < 0.01 Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY 1. Coronary artery disease s/p t CABG & PCI. - NSTEMI ___ s/p cath and POBA to Ramus stent, - recath showing patent stent. - extremely complicated anatomy unamenable to complete revascularization 2. Bicuspid aortic valve s/p aortic valve replacement ___ 3. Atrial fibrillation and atrial flutter - dronedarone and warfarin - amiodarone - PPM 4. Amiodarone therapy complicated with thyroiditis managed by endocrine service. 5. Mild diastolic dysfunction. 6. Cath for positive stress test in ___: 3 vessel cad - 60-70% proximal lesion in the LCx. - 30% in-stent restenosis of the ramus. - Patent LIMA->LAD. Totally occluded SVG->OM1. USA ___ CTO PCI of Ramus with PTCA alone 7. EF - 50%-55%. 3. OTHER PAST MEDICAL HISTORY - Diabetes mellitus. - Hypertension. - Dyslipidemia. - Iron deficiency anemia (previously on iron supplementation, discontinued ___. - History of a colon polyp. - Asthma. - Macular degeneration. - Osteopenia. Social History: ___ Family History: Father with myocardial infarction at age ___. Mother died of natural causes at ___. No h/o arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION EXAM: VS: afebrile BP 133/72 HR 75 RR 18 O2 SAT 97 RA GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP non elevated CARDIAC: PMI located in ___ intercostal space, midclavicular line. RRR, systolic murmur, (+) click LUNGS:Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses dopplerable DISCHARGE EXAM: - VITALS: 119 / 54R Lying 76 20 96 RA - I/Os: even - WEIGHT: 67.7 kg - WEIGHT ON ADMISSION: 67.1 - TELEMETRY: paced GENERAL: WDWN M comfortable in bed. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP non elevated CARDIAC: PMI located in ___ intercostal space, midclavicular line. RRR, systolic murmur, (+) click LUNGS:Resp were unlabored, no accessory muscle use. Mild basilar crackles L>R ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. Pertinent Results: ADMISSION LABS: ___ 12:55PM cTropnT-<0.01 ___ 05:24PM WBC-10.6* RBC-3.87* HGB-9.4* HCT-30.3* MCV-78* MCH-24.3* MCHC-31.0* RDW-18.6* RDWSD-51.9* ___ 05:24PM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-2.1 ___ 05:24PM CK-MB-3 cTropnT-<0.01 ___ 05:24PM GLUCOSE-100 UREA N-26* CREAT-1.4* SODIUM-139 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15 ECHO ___ The left atrial volume index is moderately increased. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF = 50%) secondary to focal inferior posterior hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with normal free wall contractility. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, no major change. ___ CXR IMPRESSION: 1. Obscured right heart border may be secondary to atelectasis versus a consolidation. Recommend lateral view to further evaluate for a right middle lobe pneumonia. 2. Mild fluid overload new since the prior study. DISCHARGE LABS: ___ 07:55AM BLOOD WBC-11.1* RBC-4.62 Hgb-12.1* Hct-37.4* MCV-81* MCH-26.2 MCHC-32.4 RDW-20.2* RDWSD-56.4* Plt ___ ___ 08:20AM BLOOD Neuts-76* Bands-1 Lymphs-9* Monos-6 Eos-6 Baso-0 ___ Myelos-2* AbsNeut-8.78* AbsLymp-1.03* AbsMono-0.68 AbsEos-0.68* AbsBaso-0.00* ___ 07:55AM BLOOD Plt ___ ___ 07:55AM BLOOD Glucose-109* UreaN-31* Creat-1.6* Na-138 K-3.7 Cl-102 HCO3-23 AnGap-17 ___ 07:55AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.3 ___ 08:40AM BLOOD TSH-12* Brief Hospital Course: ___ h/o CAD, HFpEF, AF s/p PPM, DM p/w chest pain and negative trops, ecg at baseline. - CORONARIES: s/p CTO of ramus stent - PUMP: 50 - RHYTHM: paced ACTIVE ISSUES: ================================== #Chest Pain/CAD: c/f unstable angina improves with nitrates. Given known inoperable CAD, attempted medical optimization. This was complicated by HAP that developed on ___. After hemodynamic stabilization and antibiotics, his discharge regimen was metop 37.5 mg daily, imdur 30 daily, ASA/Plavix, atorva 80, spirono 12.5, and torsemide 20 mg daily. TSH elevate to 12, likely from nonadherence. Should have recheck in 4 weeks and titrate as outpt #HAP: ___ with new URI symptoms congestion. CXR on ___ c/f RML PNA given new obscuring of R heart border. Hypotension on ___ out of proportion to patient's medication regimen c/f septic shock requiring approx. 12 hours of pressor support. He was fluid resuscitated and transfused 1u prbc for downtrending Hb and outpt provider goal of ___ 10. Micro data was unrevealing though MRSA swab negative. Vanc/cefepime started ___ and stopped on ___. Transitioned to Levofloxacin 750 mg po q48hrs based on renal clearance on ___. Will have last dose ___. Should be monitored closely for COPD exacerbation, which did not occur while inpt. #CHF/HTN: meds as above. euvolemic on discharge. DC weight 67.7 #Afib, PPM: CHADS-5 cont amio 100 mg daily, daily dose warfarin. INR on dc was 2.5. Given levoflox, ___ w/ 4 mg daily. Needs INR check ___ #Iron Deficiency Anemia: Patient with history of MUGS, iron deficient anemia with MCV 78 ferritin <20. Patient with history of colon polyps. Per outpatient PCP, concern for GI bleed, plan outpatient was EGD +/- colonoscopy; patient has negative guiaiac stools card from PCP and no bloody bowel movements while inpatient. In terms of MGUS, patient follows with Dr. ___, ___ visit ___ noted stability of IgM kappa MGUS. Per GI will do outpt scope given better outcomes and intermittent CP in house and no urgency to scope at this time. ___ with po iron and bid ppi CHRONIC/STABLE ISSUES: ================================== #COPD: stable on RA. cont inhalers - symbicort not on formulary will use advair, cont singulair. Patient refused advair throughout admission for throat irritation. #CKD: developed ___ after septic shock. improving and stable by discharge. #DM: appears no long on metformin. ISS #Hypothyroid: cont home synthroid 88mcg ___ 132 mcg). TSH 12, needs outpt med titration and f/u #GERD: cont ppi #BPH: cont Flomax #MGUS: stable, outpt f/u. #insomnia: hold benzo, offer ramelteon TRANSITIONAL ISSUES: - Please ensure outpt GI workup - Please titrate anti-angina and anti-hypertensives. Discharged on metop 37.5 mg daily, imdur 30 mg daily, spironolactone 12.5 mg daily, torsemide 20 mg daily - Please restart ___ when able - HAP: ___ on levoflox 750mg q48 hrs. QTC 476. Last dose ___ - INR: 2.5 on dc. 4 mg daily given levoflox. please recheck ___ and adjust prn - Please get BMP at next visit to assess renal function Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Clopidogrel 75 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 6. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) 7. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___) 8. Metoprolol Succinate XL 50 mg PO BID 9. Montelukast 10 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 12. Pantoprazole 40 mg PO Q24H 13. Tamsulosin 0.4 mg PO QHS 14. TRIAzolam 0.125 mg PO QHS:PRN insomnia 15. Valsartan 80 mg PO DAILY 16. Warfarin 5 mg PO DAILY16 17. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 18. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 19. Spironolactone 12.5 mg PO DAILY 20. Torsemide 30 mg PO DAILY 21. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY Discharge Medications: 1. Benzonatate 100 mg PO TID:PRN cough RX benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #30 Capsule Refills:0 2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat RX dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5 mg-7.5 mg ___ lozenge(s) by mouth four times a day Disp #32 Lozenge Refills:0 3. GuaiFENesin ___ mL PO Q6H:PRN cough RX guaifenesin 100 mg/5 mL 5 ml by mouth four times a day Refills:0 4. Levofloxacin 750 mg PO Q48H RX levofloxacin 750 mg 1 tablet(s) by mouth every other day Disp #3 Tablet Refills:0 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Metoprolol Succinate XL 37.5 mg PO DAILY RX metoprolol succinate 25 mg 1.5 tablet(s) by mouth daily Disp #45 Tablet Refills:0 7. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:0 8. Torsemide 20 mg PO DAILY RX torsemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 9. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 10. Amiodarone 100 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Atorvastatin 80 mg PO QPM 13. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 14. Clopidogrel 75 mg PO DAILY 15. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) 16. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___) 17. Montelukast 10 mg PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 20. Spironolactone 12.5 mg PO DAILY 21. Tamsulosin 0.4 mg PO QHS 22. TRIAzolam 0.125 mg PO QHS:PRN insomnia 23. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY 24. Warfarin 5 mg PO DAILY16 25. HELD- Valsartan 80 mg PO DAILY This medication was held. Do not restart Valsartan until you see your doctor in clinic for blood pressure check Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Unstable angina HAP Secondary diagnoses: Iron deficiency anemia CAD Atrial fibrillation HTN COPD Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure to take care of you at ___. WHY DID I HAVE TO STAY IN THE HOSPITAL? You had to stay in the hospital because of chest pain. You also had to stay in the hospital because of a pneumonia, aka lung infection. WHAT WAS DONE FOR ME? Your medications were adjusted for your chest pain. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? You should take your medications as prescribed. Please take your antibiotics (levofloxacin) at 8 pm on ___, ___, and ___ Please do not take valsartan until you see your regular doctors in ___ and discuss it with them. Please check your blood pressure every day and call your doctor if the systolic blood pressure (the top number) is LESS THAN 90. Please have an INR check on ___. Please follow up with your regular doctors. ___ yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your Medical Team Followup Instructions: ___	[ "I25110", "J189", "N179", "R6521", "A419", "I130", "N183", "D62", "E1122", "I5032", "J440", "Z950", "Z7902", "Z9114", "D509", "E039", "K219", "N400", "D472", "G4700", "I252", "I480", "Z955", "Z952", "Z87891", "Z8249" ]	Allergies: Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast Media Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] male with a past medical history of CAD with a very complex course including multiple stents, CHF, DM who presents with substernal chest pain. Chest pain occurred last night at rest. Took nitro and was able to sleep and then woke up with worsened chest pain and mild SOB. The pain improved after 3 nitroglycerin from a 6 out of 10 to 3 out of 10 and decided to go to [MASKED]. Trop neg there and CXR neg, received NTG and then xfer to [MASKED] for further eval given complex cardiac history. Trop here negative. CP is now [MASKED], attributes to taking his home medicines. Took full dose aspirin this morning. In the [MASKED] initial vitals were: 98.0 76 131/76 14 96% RA EKG: paced Labs/studies notable for: trop < 0.01 Past Medical History: 1. CARDIAC RISK FACTORS - Diabetes - Hypertension - Dyslipidemia 2. CARDIAC HISTORY 1. Coronary artery disease s/p t CABG & PCI. - NSTEMI [MASKED] s/p cath and POBA to Ramus stent, - recath showing patent stent. - extremely complicated anatomy unamenable to complete revascularization 2. Bicuspid aortic valve s/p aortic valve replacement [MASKED] 3. Atrial fibrillation and atrial flutter - dronedarone and warfarin - amiodarone - PPM 4. Amiodarone therapy complicated with thyroiditis managed by endocrine service. 5. Mild diastolic dysfunction. 6. Cath for positive stress test in [MASKED]: 3 vessel cad - 60-70% proximal lesion in the LCx. - 30% in-stent restenosis of the ramus. - Patent LIMA->LAD. Totally occluded SVG->OM1. USA [MASKED] CTO PCI of Ramus with PTCA alone 7. EF - 50%-55%. 3. OTHER PAST MEDICAL HISTORY - Diabetes mellitus. - Hypertension. - Dyslipidemia. - Iron deficiency anemia (previously on iron supplementation, discontinued [MASKED]. - History of a colon polyp. - Asthma. - Macular degeneration. - Osteopenia. Social History: [MASKED] Family History: Father with myocardial infarction at age [MASKED]. Mother died of natural causes at [MASKED]. No h/o arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION EXAM: VS: afebrile BP 133/72 HR 75 RR 18 O2 SAT 97 RA GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP non elevated CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. RRR, systolic murmur, (+) click LUNGS:Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses dopplerable DISCHARGE EXAM: - VITALS: 119 / 54R Lying 76 20 96 RA - I/Os: even - WEIGHT: 67.7 kg - WEIGHT ON ADMISSION: 67.1 - TELEMETRY: paced GENERAL: WDWN M comfortable in bed. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP non elevated CARDIAC: PMI located in [MASKED] intercostal space, midclavicular line. RRR, systolic murmur, (+) click LUNGS:Resp were unlabored, no accessory muscle use. Mild basilar crackles L>R ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. Pertinent Results: ADMISSION LABS: [MASKED] 12:55PM cTropnT-<0.01 [MASKED] 05:24PM WBC-10.6* RBC-3.87* HGB-9.4* HCT-30.3* MCV-78* MCH-24.3* MCHC-31.0* RDW-18.6* RDWSD-51.9* [MASKED] 05:24PM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-2.1 [MASKED] 05:24PM CK-MB-3 cTropnT-<0.01 [MASKED] 05:24PM GLUCOSE-100 UREA N-26* CREAT-1.4* SODIUM-139 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15 ECHO [MASKED] The left atrial volume index is moderately increased. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF = 50%) secondary to focal inferior posterior hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. The right ventricular cavity is mildly dilated with normal free wall contractility. A bileaflet aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [MASKED], no major change. [MASKED] CXR IMPRESSION: 1. Obscured right heart border may be secondary to atelectasis versus a consolidation. Recommend lateral view to further evaluate for a right middle lobe pneumonia. 2. Mild fluid overload new since the prior study. DISCHARGE LABS: [MASKED] 07:55AM BLOOD WBC-11.1* RBC-4.62 Hgb-12.1* Hct-37.4* MCV-81* MCH-26.2 MCHC-32.4 RDW-20.2* RDWSD-56.4* Plt [MASKED] [MASKED] 08:20AM BLOOD Neuts-76* Bands-1 Lymphs-9* Monos-6 Eos-6 Baso-0 [MASKED] Myelos-2* AbsNeut-8.78* AbsLymp-1.03* AbsMono-0.68 AbsEos-0.68* AbsBaso-0.00* [MASKED] 07:55AM BLOOD Plt [MASKED] [MASKED] 07:55AM BLOOD Glucose-109* UreaN-31* Creat-1.6* Na-138 K-3.7 Cl-102 HCO3-23 AnGap-17 [MASKED] 07:55AM BLOOD Calcium-9.4 Phos-2.7 Mg-2.3 [MASKED] 08:40AM BLOOD TSH-12* Brief Hospital Course: [MASKED] h/o CAD, HFpEF, AF s/p PPM, DM p/w chest pain and negative trops, ecg at baseline. - CORONARIES: s/p CTO of ramus stent - PUMP: 50 - RHYTHM: paced ACTIVE ISSUES: ================================== #Chest Pain/CAD: c/f unstable angina improves with nitrates. Given known inoperable CAD, attempted medical optimization. This was complicated by HAP that developed on [MASKED]. After hemodynamic stabilization and antibiotics, his discharge regimen was metop 37.5 mg daily, imdur 30 daily, ASA/Plavix, atorva 80, spirono 12.5, and torsemide 20 mg daily. TSH elevate to 12, likely from nonadherence. Should have recheck in 4 weeks and titrate as outpt #HAP: [MASKED] with new URI symptoms congestion. CXR on [MASKED] c/f RML PNA given new obscuring of R heart border. Hypotension on [MASKED] out of proportion to patient's medication regimen c/f septic shock requiring approx. 12 hours of pressor support. He was fluid resuscitated and transfused 1u prbc for downtrending Hb and outpt provider goal of [MASKED] 10. Micro data was unrevealing though MRSA swab negative. Vanc/cefepime started [MASKED] and stopped on [MASKED]. Transitioned to Levofloxacin 750 mg po q48hrs based on renal clearance on [MASKED]. Will have last dose [MASKED]. Should be monitored closely for COPD exacerbation, which did not occur while inpt. #CHF/HTN: meds as above. euvolemic on discharge. DC weight 67.7 #Afib, PPM: CHADS-5 cont amio 100 mg daily, daily dose warfarin. INR on dc was 2.5. Given levoflox, [MASKED] w/ 4 mg daily. Needs INR check [MASKED] #Iron Deficiency Anemia: Patient with history of MUGS, iron deficient anemia with MCV 78 ferritin <20. Patient with history of colon polyps. Per outpatient PCP, concern for GI bleed, plan outpatient was EGD +/- colonoscopy; patient has negative guiaiac stools card from PCP and no bloody bowel movements while inpatient. In terms of MGUS, patient follows with Dr. [MASKED], [MASKED] visit [MASKED] noted stability of IgM kappa MGUS. Per GI will do outpt scope given better outcomes and intermittent CP in house and no urgency to scope at this time. [MASKED] with po iron and bid ppi CHRONIC/STABLE ISSUES: ================================== #COPD: stable on RA. cont inhalers - symbicort not on formulary will use advair, cont singulair. Patient refused advair throughout admission for throat irritation. #CKD: developed [MASKED] after septic shock. improving and stable by discharge. #DM: appears no long on metformin. ISS #Hypothyroid: cont home synthroid 88mcg [MASKED] 132 mcg). TSH 12, needs outpt med titration and f/u #GERD: cont ppi #BPH: cont Flomax #MGUS: stable, outpt f/u. #insomnia: hold benzo, offer ramelteon TRANSITIONAL ISSUES: - Please ensure outpt GI workup - Please titrate anti-angina and anti-hypertensives. Discharged on metop 37.5 mg daily, imdur 30 mg daily, spironolactone 12.5 mg daily, torsemide 20 mg daily - Please restart [MASKED] when able - HAP: [MASKED] on levoflox 750mg q48 hrs. QTC 476. Last dose [MASKED] - INR: 2.5 on dc. 4 mg daily given levoflox. please recheck [MASKED] and adjust prn - Please get BMP at next visit to assess renal function Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amiodarone 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Clopidogrel 75 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 6. Levothyroxine Sodium 88 mcg PO 6X/WEEK ([MASKED]) 7. Levothyroxine Sodium 132 mcg PO 1X/WEEK ([MASKED]) 8. Metoprolol Succinate XL 50 mg PO BID 9. Montelukast 10 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 12. Pantoprazole 40 mg PO Q24H 13. Tamsulosin 0.4 mg PO QHS 14. TRIAzolam 0.125 mg PO QHS:PRN insomnia 15. Valsartan 80 mg PO DAILY 16. Warfarin 5 mg PO DAILY16 17. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 18. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 19. Spironolactone 12.5 mg PO DAILY 20. Torsemide 30 mg PO DAILY 21. ubidecarenone-omega 3-vit E [MASKED] mg-mg-unit oral DAILY Discharge Medications: 1. Benzonatate 100 mg PO TID:PRN cough RX benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #30 Capsule Refills:0 2. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat RX dextromethorphan-benzocaine [Cepacol Sorethroat-Cough] 5 mg-7.5 mg [MASKED] lozenge(s) by mouth four times a day Disp #32 Lozenge Refills:0 3. GuaiFENesin [MASKED] mL PO Q6H:PRN cough RX guaifenesin 100 mg/5 mL 5 ml by mouth four times a day Refills:0 4. Levofloxacin 750 mg PO Q48H RX levofloxacin 750 mg 1 tablet(s) by mouth every other day Disp #3 Tablet Refills:0 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Metoprolol Succinate XL 37.5 mg PO DAILY RX metoprolol succinate 25 mg 1.5 tablet(s) by mouth daily Disp #45 Tablet Refills:0 7. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #28 Tablet Refills:0 8. Torsemide 20 mg PO DAILY RX torsemide 20 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:*0 9. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 10. Amiodarone 100 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Atorvastatin 80 mg PO QPM 13. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 14. Clopidogrel 75 mg PO DAILY 15. Levothyroxine Sodium 88 mcg PO 6X/WEEK ([MASKED]) 16. Levothyroxine Sodium 132 mcg PO 1X/WEEK ([MASKED]) 17. Montelukast 10 mg PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 20. Spironolactone 12.5 mg PO DAILY 21. Tamsulosin 0.4 mg PO QHS 22. TRIAzolam 0.125 mg PO QHS:PRN insomnia 23. ubidecarenone-omega 3-vit E [MASKED] mg-mg-unit oral DAILY 24. Warfarin 5 mg PO DAILY16 25. HELD- Valsartan 80 mg PO DAILY This medication was held. Do not restart Valsartan until you see your doctor in clinic for blood pressure check Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Unstable angina HAP Secondary diagnoses: Iron deficiency anemia CAD Atrial fibrillation HTN COPD Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], It was a pleasure to take care of you at [MASKED]. WHY DID I HAVE TO STAY IN THE HOSPITAL? You had to stay in the hospital because of chest pain. You also had to stay in the hospital because of a pneumonia, aka lung infection. WHAT WAS DONE FOR ME? Your medications were adjusted for your chest pain. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? You should take your medications as prescribed. Please take your antibiotics (levofloxacin) at 8 pm on [MASKED], [MASKED], and [MASKED] Please do not take valsartan until you see your regular doctors in [MASKED] and discuss it with them. Please check your blood pressure every day and call your doctor if the systolic blood pressure (the top number) is LESS THAN 90. Please have an INR check on [MASKED]. Please follow up with your regular doctors. [MASKED] yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your Medical Team Followup Instructions: [MASKED]	[]	[ "N179", "I130", "D62", "E1122", "I5032", "Z7902", "D509", "E039", "K219", "N400", "G4700", "I252", "I480", "Z955", "Z87891" ]	[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "J189: Pneumonia, unspecified organism", "N179: Acute kidney failure, unspecified", "R6521: Severe sepsis with septic shock", "A419: Sepsis, unspecified organism", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "D62: Acute posthemorrhagic anemia", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "Z950: Presence of cardiac pacemaker", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z9114: Patient's other noncompliance with medication regimen", "D509: Iron deficiency anemia, unspecified", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "D472: Monoclonal gammopathy", "G4700: Insomnia, unspecified", "I252: Old myocardial infarction", "I480: Paroxysmal atrial fibrillation", "Z955: Presence of coronary angioplasty implant and graft", "Z952: Presence of prosthetic heart valve", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]
19,981,210	28,800,493	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast Media Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization s/p CTO PCI of Ramus with PTCA alone History of Present Illness: The patient was seen for a routine visit today with his Heart Failure physician (___. He appears to be well controlled from a heart failure standpoint but mentioned that he is having indigestion and chest pain for which he is taking NTG SL with relief. The chest pain started approx. 1 month ago, sharp constant substernal, with heartburn symptoms. It lasts up to one hour. Most frequently he has it at 4am after he takes his levothyroxine but then can also have later in the day. He has baseline dyspnea with stairs or moderate activity and can have CP with DOE as well. He has been taking ___ SL NTG for cp. Pain is similar to pain with MI a few years ago. He also notes mild abd swelling and unintentional weight loss of 5 pounds over the last week. Denies N/V/ diaphoresis with CP. No change in appetite, bowel habits. Has chronic cough in the am ___ post nasal gtt. Occ has wheezes in the am with coughing. Last INR 3.0 1 week ago (goal 2.5-3.5 mechanical valve). Takes lovenox SC at home when INR < 2.0. Past Medical History: 1. CAD s/p CABG in ___ (2-vessel: LIMA-LAD, SVG-LPL), PCIs ___ Tetra stent placed in ramus intermedius; ___ Bare metal stent to LCx and balloon angioplasty to ramus; ___ ___ ___ x2 to ramus and LCx (bifurcation stenting), ___ POBA to ramus); ACS: NSTEMI ___. 2. Bicuspid aortic valve status ___ mechanical bileaflet prosthesis in ___ on warfarin 3. Tachy-brady syndrome status post dual chamber permanent pacemaker placement in ___ - Atrial fibrillation and atrial flutter on amiodarone s/p cardioversion ___, failed cardioversion ___ - Diastolic dysfunction (LVEF 70% in ___ - Diabetes - Dyslipidemia - Hypertension - Gastroesophageal reflux disease - IgM kappa monoclonal gammopathy - Asthma - Iron deficiency anemia - Macular degeneration - Osteopenia - Erectile Dysfunction - Tremor - Trigger finger - Cervical radiculopathy - Status post right cataract repair Social History: ___ Family History: Father with myocardial infarction at age ___. Mother died of natural causes at ___. No h/o arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admit PE: Physical Exam: Gen: A/O, good historian. NAD, denies CP Neuro: ___, no focal defects, memory intact, speech clear Neck/JVP: no JVD noted, no carotid bruit CV: RRR, mechanical diastolic click noted, rad to carotids Chest: clear bilat, no ABD: soft, NT, distended per pt Extr: mild ankle and calf edema Access sites: PIV Skin: warm and dry Discharge PE: VS T 98.4 HR 75 RR 18 BP 121/58 97% RA Tele vpaced 70's Gen: no c/o discomfort, looking forward to discharge today Neck/JVP: no elevation, flat, no carotid bruits CV: RRR, crisp mechanical sounds, rad to carotids CHEST: CTAB Abd: soft, NT, obese, +BS Extr: no edema noted b/l Skin: Warm and dry, no lesions noted Access site: Peripheral IV Pertinent Results: ADMISSION LABS: ___ 05:04PM BLOOD UreaN-41* Creat-2.1* Na-141 K-4.6 Cl-103 HCO3-27 AnGap-16 ___ 05:04PM BLOOD ALT-21 AST-31 AlkPhos-92 TotBili-0.3 ___ 05:04PM BLOOD Albumin-4.4 A1C: ___ 05:04PM BLOOD %HbA1c-6.6* eAG-143* TROPONIN TRENDS: ___ 06:50AM BLOOD cTropnT-<0.01 ___ 09:24PM BLOOD cTropnT-<0.01 ___ 06:35AM BLOOD cTropnT-<0.01 ___ 12:44AM BLOOD CK-MB-4 cTropnT-<0.01 DISCHARGE LABS: ___ 07:15AM BLOOD ___ PTT-68.4* ___ ___ 07:15AM BLOOD Plt ___ ___ 07:15AM BLOOD Glucose-135* UreaN-50* Creat-1.8* Na-141 K-4.4 Cl-101 HCO3-29 AnGap-15 ___ 07:15AM BLOOD Mg-2.8* CARDIAC CATHETERIZATION ___: Dominance: Left The LMCA mild ISR unchanged from prior. T he LAD was ostially occluded and filled via the LIMA with mild disease (40%) after the LIMA touchdown also unchanged from prior. The RCA was small and nondominant. The Cx stent was patent and filled the distal vessel. The Ramus stent was totally occluded once again. Interventional Details A 6 ___ XBLAD3.5 guiding catheter was used to engage the LMCA and provided sub-optimal support. A 180 cm ___ Pro12 guidewire was then successfully delivered across the lesion. This required a 6 ___ Guideliner and a Turnpike LP for support to cross as Pilot ___ and Samurai wires would not cross. The CP 12 appeared and felt free after the mid vessel but was free thereafter. Collateral flow could not confirm intraluminal position. With difficulty, advanced the Turnpike into the distal vessel. Injection showed a portion of the vessel to be dissected but the wire was in distal position. Performed PTCA with a 2.0 mm balloon in the ISR as well as the dissection, tacking it up. Prolonged inflations maintained flow. Final angiography revealed normal flow, stable Type A dissection in the mid vessel and 40% residual stenosis. In light of CKD and stable angioplasty result and the lack of desire to add more stents to this vessel that has developed recurrent CTO, we elected to leave a POBA result. Impressions: 1. Successful CTO PCI of Ramus with PTCA alone. Recommendations 1. Restart warfarin. 2. Secondary prevention CAD. Brief Hospital Course: The patient's course was marked by intermittent chest pain requiring PRN sublingual NTG. His Isosorbide was ultimately increased from 60 mg Daily to 90 mg daily. He was maintained on a heparin drip while he awaiting cardiac catheterization. For more details concerning the catheterization please refer to that report, detailed previously. He underwent POBA to 100% occluded RAMUS stent with TIMI flow 2. He reported relief of his symptoms and continued to ambulate the unit with no further chest pain. His troponins remained flat throughout his stay. His Torsemide and Spirinolactone were held post catheterization due to an increase in his creatinine to 1.9. He trended down to 1.8 on the day of discharge. He was advised to continue to hold these meds for an additional day and to resume them on ___, ___. His INR was therapeutic on the day of discharge at 3.1, up from 2.1 on ___. He will continue with all of his medications as prescribed with this one change in Isosorbide. This was escripted to his pharmacy and he was given a paper script as well so that he can get this filled at the ___ in the future. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 80 mg PO DAILY 2. olopatadine 0.1 % ophthalmic each eye 3. TRIAzolam 0.125 mg PO QHS:PRN insomnia 4. Metoprolol Succinate XL 50 mg PO BID 5. Amiodarone 100 mg PO DAILY 6. Warfarin 5 mg PO DAILY16 7. Atorvastatin 80 mg PO QPM 8. Montelukast 10 mg PO DAILY 9. Torsemide 30 mg PO DAILY 10. Spironolactone 12.5 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 15. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY 16. Clopidogrel 75 mg PO DAILY 17. Pantoprazole 40 mg PO Q24H 18. Calcium Carbonate 500 mg PO BID 19. Aspirin 81 mg PO DAILY 20. Tamsulosin 0.4 mg PO QHS 21. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 22. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) 23. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___) Discharge Medications: 1. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 3. Amiodarone 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 7. Calcium Carbonate 500 mg PO BID 8. Clopidogrel 75 mg PO DAILY 9. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___) 10. Levothyroxine Sodium 132 mcg PO 1X/WEEK (___) 11. Metoprolol Succinate XL 50 mg PO BID 12. Montelukast 10 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 15. olopatadine 0.1 % ophthalmic each eye 16. Pantoprazole 40 mg PO Q24H 17. Spironolactone 12.5 mg PO DAILY Resume this medication ___ 18. Tamsulosin 0.4 mg PO QHS 19. Torsemide 30 mg PO DAILY Resume this medication ___. TRIAzolam 0.125 mg PO QHS:PRN insomnia 21. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY 22. Valsartan 80 mg PO DAILY 23. Warfarin 5 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: CURRENT: 1.Angina s/p POBA to occluded ramus stent PMH: 1. CAD status post CABG in ___, subsequent PCIs and stents. 2. Bicuspid aortic valve status post bileaflet ___ mechanical prosthesis in ___. 3. Tachybrady syndrome, status post pacemaker. 4. Atrial fibrillation, atrial flutter on amiodarone and warfarin, has home monitor and dosing managed by Dr ___. 5. Chronic diastolic CHF. 6. Dyslipidemia. 7. Hypertension. 8. GERD. 9. Chronic renal insufficiency 10. Amiodarone associated thryotoxicosis 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 a heart catheterization to evaluate your anginal symptoms. You had a procedure to attempt to open up a blockage in one of your existing stents. The blockage was able to be partially opened. You continued to have some chest discomfort. Your Imdur was increased from 60 mg to 90mg, and you had no further chest discomfort. A prescription for this medication was sent to your Pharmacy at discharge and you may pick this up on your way home from the hospital today. You remained in the hospital on a heparin infusion until your INR was at least 2.5 and on the day of discharge was 3.1. You were deemed appropriate for discharge on ___. You were ambulatory on the unit with no further chest pain, tolerating a diet, and voiding without difficulty. You should continue your chronic Coumadin dosing as scheduled. Your creatinine trended up following your catheterization and several of your medications were held (due to the contrast dye load). Your Torsemide and Spironolactone were held and we recommend holding these medications one more day, and resume them on ___. Your creatinine was trending down to 1.8 (with a known baseline of 1.4 to 1.5. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. You indicated you wished to coordinate all of your follow up appointments at discharge, including that with Dr. ___. We recommend you follow up with the Heart Failure team as scheduled. Followup Instructions: ___	[ "T82855A", "I4891", "I130", "I5032", "J449", "E119", "D509", "I25110", "I252", "Z951", "Z952", "Z7901", "Z950", "E785", "K219", "J45909", "M8580", "Z87891", "Z8249", "E0580", "N183", "Y929" ]	Allergies: Iodine-Iodine Containing / IV Dye, Iodine Containing Contrast Media Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization s/p CTO PCI of Ramus with PTCA alone History of Present Illness: The patient was seen for a routine visit today with his Heart Failure physician ([MASKED]. He appears to be well controlled from a heart failure standpoint but mentioned that he is having indigestion and chest pain for which he is taking NTG SL with relief. The chest pain started approx. 1 month ago, sharp constant substernal, with heartburn symptoms. It lasts up to one hour. Most frequently he has it at 4am after he takes his levothyroxine but then can also have later in the day. He has baseline dyspnea with stairs or moderate activity and can have CP with DOE as well. He has been taking [MASKED] SL NTG for cp. Pain is similar to pain with MI a few years ago. He also notes mild abd swelling and unintentional weight loss of 5 pounds over the last week. Denies N/V/ diaphoresis with CP. No change in appetite, bowel habits. Has chronic cough in the am [MASKED] post nasal gtt. Occ has wheezes in the am with coughing. Last INR 3.0 1 week ago (goal 2.5-3.5 mechanical valve). Takes lovenox SC at home when INR < 2.0. Past Medical History: 1. CAD s/p CABG in [MASKED] (2-vessel: LIMA-LAD, SVG-LPL), PCIs [MASKED] Tetra stent placed in ramus intermedius; [MASKED] Bare metal stent to LCx and balloon angioplasty to ramus; [MASKED] [MASKED] [MASKED] x2 to ramus and LCx (bifurcation stenting), [MASKED] POBA to ramus); ACS: NSTEMI [MASKED]. 2. Bicuspid aortic valve status [MASKED] mechanical bileaflet prosthesis in [MASKED] on warfarin 3. Tachy-brady syndrome status post dual chamber permanent pacemaker placement in [MASKED] - Atrial fibrillation and atrial flutter on amiodarone s/p cardioversion [MASKED], failed cardioversion [MASKED] - Diastolic dysfunction (LVEF 70% in [MASKED] - Diabetes - Dyslipidemia - Hypertension - Gastroesophageal reflux disease - IgM kappa monoclonal gammopathy - Asthma - Iron deficiency anemia - Macular degeneration - Osteopenia - Erectile Dysfunction - Tremor - Trigger finger - Cervical radiculopathy - Status post right cataract repair Social History: [MASKED] Family History: Father with myocardial infarction at age [MASKED]. Mother died of natural causes at [MASKED]. No h/o arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Admit PE: Physical Exam: Gen: A/O, good historian. NAD, denies CP Neuro: [MASKED], no focal defects, memory intact, speech clear Neck/JVP: no JVD noted, no carotid bruit CV: RRR, mechanical diastolic click noted, rad to carotids Chest: clear bilat, no ABD: soft, NT, distended per pt Extr: mild ankle and calf edema Access sites: PIV Skin: warm and dry Discharge PE: VS T 98.4 HR 75 RR 18 BP 121/58 97% RA Tele vpaced 70's Gen: no c/o discomfort, looking forward to discharge today Neck/JVP: no elevation, flat, no carotid bruits CV: RRR, crisp mechanical sounds, rad to carotids CHEST: CTAB Abd: soft, NT, obese, +BS Extr: no edema noted b/l Skin: Warm and dry, no lesions noted Access site: Peripheral IV Pertinent Results: ADMISSION LABS: [MASKED] 05:04PM BLOOD UreaN-41* Creat-2.1* Na-141 K-4.6 Cl-103 HCO3-27 AnGap-16 [MASKED] 05:04PM BLOOD ALT-21 AST-31 AlkPhos-92 TotBili-0.3 [MASKED] 05:04PM BLOOD Albumin-4.4 A1C: [MASKED] 05:04PM BLOOD %HbA1c-6.6* eAG-143* TROPONIN TRENDS: [MASKED] 06:50AM BLOOD cTropnT-<0.01 [MASKED] 09:24PM BLOOD cTropnT-<0.01 [MASKED] 06:35AM BLOOD cTropnT-<0.01 [MASKED] 12:44AM BLOOD CK-MB-4 cTropnT-<0.01 DISCHARGE LABS: [MASKED] 07:15AM BLOOD [MASKED] PTT-68.4* [MASKED] [MASKED] 07:15AM BLOOD Plt [MASKED] [MASKED] 07:15AM BLOOD Glucose-135* UreaN-50* Creat-1.8* Na-141 K-4.4 Cl-101 HCO3-29 AnGap-15 [MASKED] 07:15AM BLOOD Mg-2.8* CARDIAC CATHETERIZATION [MASKED]: Dominance: Left The LMCA mild ISR unchanged from prior. T he LAD was ostially occluded and filled via the LIMA with mild disease (40%) after the LIMA touchdown also unchanged from prior. The RCA was small and nondominant. The Cx stent was patent and filled the distal vessel. The Ramus stent was totally occluded once again. Interventional Details A 6 [MASKED] XBLAD3.5 guiding catheter was used to engage the LMCA and provided sub-optimal support. A 180 cm [MASKED] Pro12 guidewire was then successfully delivered across the lesion. This required a 6 [MASKED] Guideliner and a Turnpike LP for support to cross as Pilot [MASKED] and Samurai wires would not cross. The CP 12 appeared and felt free after the mid vessel but was free thereafter. Collateral flow could not confirm intraluminal position. With difficulty, advanced the Turnpike into the distal vessel. Injection showed a portion of the vessel to be dissected but the wire was in distal position. Performed PTCA with a 2.0 mm balloon in the ISR as well as the dissection, tacking it up. Prolonged inflations maintained flow. Final angiography revealed normal flow, stable Type A dissection in the mid vessel and 40% residual stenosis. In light of CKD and stable angioplasty result and the lack of desire to add more stents to this vessel that has developed recurrent CTO, we elected to leave a POBA result. Impressions: 1. Successful CTO PCI of Ramus with PTCA alone. Recommendations 1. Restart warfarin. 2. Secondary prevention CAD. Brief Hospital Course: The patient's course was marked by intermittent chest pain requiring PRN sublingual NTG. His Isosorbide was ultimately increased from 60 mg Daily to 90 mg daily. He was maintained on a heparin drip while he awaiting cardiac catheterization. For more details concerning the catheterization please refer to that report, detailed previously. He underwent POBA to 100% occluded RAMUS stent with TIMI flow 2. He reported relief of his symptoms and continued to ambulate the unit with no further chest pain. His troponins remained flat throughout his stay. His Torsemide and Spirinolactone were held post catheterization due to an increase in his creatinine to 1.9. He trended down to 1.8 on the day of discharge. He was advised to continue to hold these meds for an additional day and to resume them on [MASKED], [MASKED]. His INR was therapeutic on the day of discharge at 3.1, up from 2.1 on [MASKED]. He will continue with all of his medications as prescribed with this one change in Isosorbide. This was escripted to his pharmacy and he was given a paper script as well so that he can get this filled at the [MASKED] in the future. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Valsartan 80 mg PO DAILY 2. olopatadine 0.1 % ophthalmic each eye 3. TRIAzolam 0.125 mg PO QHS:PRN insomnia 4. Metoprolol Succinate XL 50 mg PO BID 5. Amiodarone 100 mg PO DAILY 6. Warfarin 5 mg PO DAILY16 7. Atorvastatin 80 mg PO QPM 8. Montelukast 10 mg PO DAILY 9. Torsemide 30 mg PO DAILY 10. Spironolactone 12.5 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 14. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 15. ubidecarenone-omega 3-vit E [MASKED] mg-mg-unit oral DAILY 16. Clopidogrel 75 mg PO DAILY 17. Pantoprazole 40 mg PO Q24H 18. Calcium Carbonate 500 mg PO BID 19. Aspirin 81 mg PO DAILY 20. Tamsulosin 0.4 mg PO QHS 21. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 22. Levothyroxine Sodium 88 mcg PO 6X/WEEK ([MASKED]) 23. Levothyroxine Sodium 132 mcg PO 1X/WEEK ([MASKED]) Discharge Medications: 1. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN 3. Amiodarone 100 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID 7. Calcium Carbonate 500 mg PO BID 8. Clopidogrel 75 mg PO DAILY 9. Levothyroxine Sodium 88 mcg PO 6X/WEEK ([MASKED]) 10. Levothyroxine Sodium 132 mcg PO 1X/WEEK ([MASKED]) 11. Metoprolol Succinate XL 50 mg PO BID 12. Montelukast 10 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 15. olopatadine 0.1 % ophthalmic each eye 16. Pantoprazole 40 mg PO Q24H 17. Spironolactone 12.5 mg PO DAILY Resume this medication [MASKED] 18. Tamsulosin 0.4 mg PO QHS 19. Torsemide 30 mg PO DAILY Resume this medication [MASKED]. TRIAzolam 0.125 mg PO QHS:PRN insomnia 21. ubidecarenone-omega 3-vit E [MASKED] mg-mg-unit oral DAILY 22. Valsartan 80 mg PO DAILY 23. Warfarin 5 mg PO DAILY16 Discharge Disposition: Home Discharge Diagnosis: CURRENT: 1.Angina s/p POBA to occluded ramus stent PMH: 1. CAD status post CABG in [MASKED], subsequent PCIs and stents. 2. Bicuspid aortic valve status post bileaflet [MASKED] mechanical prosthesis in [MASKED]. 3. Tachybrady syndrome, status post pacemaker. 4. Atrial fibrillation, atrial flutter on amiodarone and warfarin, has home monitor and dosing managed by Dr [MASKED]. 5. Chronic diastolic CHF. 6. Dyslipidemia. 7. Hypertension. 8. GERD. 9. Chronic renal insufficiency 10. Amiodarone associated thryotoxicosis 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 a heart catheterization to evaluate your anginal symptoms. You had a procedure to attempt to open up a blockage in one of your existing stents. The blockage was able to be partially opened. You continued to have some chest discomfort. Your Imdur was increased from 60 mg to 90mg, and you had no further chest discomfort. A prescription for this medication was sent to your Pharmacy at discharge and you may pick this up on your way home from the hospital today. You remained in the hospital on a heparin infusion until your INR was at least 2.5 and on the day of discharge was 3.1. You were deemed appropriate for discharge on [MASKED]. You were ambulatory on the unit with no further chest pain, tolerating a diet, and voiding without difficulty. You should continue your chronic Coumadin dosing as scheduled. Your creatinine trended up following your catheterization and several of your medications were held (due to the contrast dye load). Your Torsemide and Spironolactone were held and we recommend holding these medications one more day, and resume them on [MASKED]. Your creatinine was trending down to 1.8 (with a known baseline of 1.4 to 1.5. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. You indicated you wished to coordinate all of your follow up appointments at discharge, including that with Dr. [MASKED]. We recommend you follow up with the Heart Failure team as scheduled. Followup Instructions: [MASKED]	[]	[ "I4891", "I130", "I5032", "J449", "E119", "D509", "I252", "Z951", "Z7901", "E785", "K219", "J45909", "Z87891", "Y929" ]	[ "T82855A: Stenosis of coronary artery stent, initial encounter", "I4891: Unspecified atrial fibrillation", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "D509: Iron deficiency anemia, unspecified", "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I252: Old myocardial infarction", "Z951: Presence of aortocoronary bypass graft", "Z952: Presence of prosthetic heart valve", "Z7901: Long term (current) use of anticoagulants", "Z950: Presence of cardiac pacemaker", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "M8580: Other specified disorders of bone density and structure, unspecified site", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "E0580: Other thyrotoxicosis without thyrotoxic crisis or storm", "N183: Chronic kidney disease, stage 3 (moderate)", "Y929: Unspecified place or not applicable" ]
19,981,958	21,856,502	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Cervical myelopathy Major Surgical or Invasive Procedure: ___: C3-C4 laminectomy, C3-C5 posterior cervical fusion History of Present Illness: Mr. ___ is ___ gentleman presenting with significant right upper extremity weakness, which has got worse over the last few months. More recently, this is associated with right lower extremity weakness, which has affected the patient's ambulation. MRI of the cervical spine has evidence of myelomalacia at the higher cervical spine, more on the right than the left. The patient was myelopathic only on the right side including upper extremity and lower extremity. Workup did not show any significant abnormalities on the lumbar spine to explain the leg weakness. Every time he moves his neck in a flexed or extended posture, he start feeling some strange feeling down his back. He has trouble holding objects as well as using his hand and using utensils to eat. EMG is significant for moderate chronic median neuropathy on the right wrist and moderate-to-severe ulnar neuropathy at the level of the right elbow. Evidence of chronic cervical polyradiculopathy on the right and generalized sensory motor polyneuropathy. Past Medical History: R carpal tunnel syndrome s/p surgical release Cervical spine arthritis ?Hx TIA HTN Anxiety Social History: ___ Family History: Mother - HTN, DM, strokes mGM - strokes Physical Exam: ON DISCHARGE ============ Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: Trap Delt Bi T Grip IP Q H AT ___ G Right 5 4+ 5 4+ 4 5 5 ___ 5 Left 5 4+ 5 4+ 5 5 5 ___ 5 No hoffmans. No clonus. Wound: Midline cervical incision: [x]Closed with staples Pertinent Results: See OMR Brief Hospital Course: #C3-C4 Laminectomy, C3-C5 Posterior Cervical Fusion On ___, Mr. ___ presented to ___ for elective posterior cervical laminectomy and fusion. Patient tolerated the procedure well and recovered in the PACU post op. Please see OR report for specific details of operation. While in PACU patient received some narcotics and desaturated so he was placd on 6L O2 through CPAP. Patient complained of chest pain at the time and an EKG was obtained which was stable and his Troponin was <0.01. Patient went to floor and was experiencing moderate pain and his pain medication regimen was adjusted accordingly. On ___ triggered for unresponsiveness, likely due to narcotics. Patient received total of 0.8 of Narcan before waking up. All opioids were discontinued and patient was transitioned to Tylenol for pain management. Patient was retaining urine overnight and was straight cath. His bowel regimen was increased due to constipation however patient was declining scheduled bowel medications at times. Patient was given x1 oxycodone for breakthrough pain. He continued with pain that limited his mobility so his valium was changed back to scheduled and he was started on IV Toradol x3 days. The pain service was consulted for assistance in management and recommended acetaminophen, duloxetine, tramadol, gabapentin. #Dispo ___ and OT evaluated the patient and recommended rehab. Upon discharge patient was ambulating with a walker, tolerating a diet and PO pain medication, voiding independently and vitals were stable. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. INHALE ___ PUFFS INHALED EVERY ___ HOURS AS NEEDED FOR SOB/WHEEZING OR COUGH CELECOXIB - celecoxib 200 mg capsule. TAKE ___ CAPSULE(S) BY MOUTH EVERY DAY AS NEEDED DULOXETINE - duloxetine 20 mg capsule,delayed release. TAKE 2 CAPSULES BY MOUTH EVERY DAY FINASTERIDE - finasteride 5 mg tablet. 1 tablet(s) by mouth once a day FLUTICASONE PROPIONATE [FLOVENT HFA] - Flovent HFA 110 mcg/actuation aerosol inhaler. INHALE 2 PUFFS TWO TIMES PER DAY. RINSE MOUTH AFTER USE. GABAPENTIN - gabapentin 300 mg capsule. 2 capsule(s) by mouth three times a day 300 mg po Every HS - (Prescribed by Other Provider: per inpatient d/c) KETOCONAZOLE - ketoconazole 2 % shampoo. use twice weekly KETOCONAZOLE - ketoconazole 2 % topical cream. apply twice a day LIDOCAINE - lidocaine 5 % topical ointment. apply daily to painful areas - (Prescribed by Other Provider: per inpatient d/c) METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. TAKE 1 TABLET BY MOUTH EVERY DAY SIMVASTATIN - simvastatin 40 mg tablet. TAKE 1 TABLET BY MOUTH EVERY DAY TAMSULOSIN - tamsulosin 0.4 mg capsule. TAKE ONE CAPSULE BY MOUTH AT BEDTIME Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by mouth every 8 hours as needed for pain - (Prescribed by Other Provider: per inpatient d/c) CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl ___AILY 3. Diazepam 5 mg PO Q8H 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 600 mg PO TID 6. Heparin 5000 UNIT SC BID 7. Polyethylene Glycol 17 g PO DAILY 8. Senna 17.2 mg PO QHS 9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:*0 10. DULoxetine ___ 40 mg PO DAILY 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Simvastatin 40 mg PO QPM 13. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Cervical myelopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Cervical Spinal Fusion Surgery Your dressing may come off on the second day after surgery. Your incision is closed with staples or sutures. You will need suture/staple removal. Do not apply any lotions or creams to the site. Please keep your incision dry until removal of your sutures/staples. Please avoid swimming for two weeks after suture/staple removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity You must wear your cervical collar at all times. The collar helps with healing and alignment of the fusion. You must wear your cervical collar while showering. You may remove your collar briefly for skin care (be sure not to twist or bend your neck too much while the collar is off). It is important to look at your skin and be sure there are no wounds of the skin forming. We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Do NOT smoke. Smoking can affect your healing and fusion. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc until cleared by your neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit New weakness or changes in sensation in your arms or legs. Followup Instructions: ___	[ "M4802", "G992", "G9589", "M5412", "R4182", "T402X5A", "Y92239", "I10", "G4733", "E785", "J4520", "F419", "Z823", "K5900" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Cervical myelopathy Major Surgical or Invasive Procedure: [MASKED]: C3-C4 laminectomy, C3-C5 posterior cervical fusion History of Present Illness: Mr. [MASKED] is [MASKED] gentleman presenting with significant right upper extremity weakness, which has got worse over the last few months. More recently, this is associated with right lower extremity weakness, which has affected the patient's ambulation. MRI of the cervical spine has evidence of myelomalacia at the higher cervical spine, more on the right than the left. The patient was myelopathic only on the right side including upper extremity and lower extremity. Workup did not show any significant abnormalities on the lumbar spine to explain the leg weakness. Every time he moves his neck in a flexed or extended posture, he start feeling some strange feeling down his back. He has trouble holding objects as well as using his hand and using utensils to eat. EMG is significant for moderate chronic median neuropathy on the right wrist and moderate-to-severe ulnar neuropathy at the level of the right elbow. Evidence of chronic cervical polyradiculopathy on the right and generalized sensory motor polyneuropathy. Past Medical History: R carpal tunnel syndrome s/p surgical release Cervical spine arthritis ?Hx TIA HTN Anxiety Social History: [MASKED] Family History: Mother - HTN, DM, strokes mGM - strokes Physical Exam: ON DISCHARGE ============ Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Person [x]Place [x]Time Follows commands: [ ]Simple [x]Complex [ ]None Speech Fluent: [x]Yes [ ]No Comprehension intact [x]Yes [ ]No Motor: Trap Delt Bi T Grip IP Q H AT [MASKED] G Right 5 4+ 5 4+ 4 5 5 [MASKED] 5 Left 5 4+ 5 4+ 5 5 5 [MASKED] 5 No hoffmans. No clonus. Wound: Midline cervical incision: [x]Closed with staples Pertinent Results: See OMR Brief Hospital Course: #C3-C4 Laminectomy, C3-C5 Posterior Cervical Fusion On [MASKED], Mr. [MASKED] presented to [MASKED] for elective posterior cervical laminectomy and fusion. Patient tolerated the procedure well and recovered in the PACU post op. Please see OR report for specific details of operation. While in PACU patient received some narcotics and desaturated so he was placd on 6L O2 through CPAP. Patient complained of chest pain at the time and an EKG was obtained which was stable and his Troponin was <0.01. Patient went to floor and was experiencing moderate pain and his pain medication regimen was adjusted accordingly. On [MASKED] triggered for unresponsiveness, likely due to narcotics. Patient received total of 0.8 of Narcan before waking up. All opioids were discontinued and patient was transitioned to Tylenol for pain management. Patient was retaining urine overnight and was straight cath. His bowel regimen was increased due to constipation however patient was declining scheduled bowel medications at times. Patient was given x1 oxycodone for breakthrough pain. He continued with pain that limited his mobility so his valium was changed back to scheduled and he was started on IV Toradol x3 days. The pain service was consulted for assistance in management and recommended acetaminophen, duloxetine, tramadol, gabapentin. #Dispo [MASKED] and OT evaluated the patient and recommended rehab. Upon discharge patient was ambulating with a walker, tolerating a diet and PO pain medication, voiding independently and vitals were stable. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. INHALE [MASKED] PUFFS INHALED EVERY [MASKED] HOURS AS NEEDED FOR SOB/WHEEZING OR COUGH CELECOXIB - celecoxib 200 mg capsule. TAKE [MASKED] CAPSULE(S) BY MOUTH EVERY DAY AS NEEDED DULOXETINE - duloxetine 20 mg capsule,delayed release. TAKE 2 CAPSULES BY MOUTH EVERY DAY FINASTERIDE - finasteride 5 mg tablet. 1 tablet(s) by mouth once a day FLUTICASONE PROPIONATE [FLOVENT HFA] - Flovent HFA 110 mcg/actuation aerosol inhaler. INHALE 2 PUFFS TWO TIMES PER DAY. RINSE MOUTH AFTER USE. GABAPENTIN - gabapentin 300 mg capsule. 2 capsule(s) by mouth three times a day 300 mg po Every HS - (Prescribed by Other Provider: per inpatient d/c) KETOCONAZOLE - ketoconazole 2 % shampoo. use twice weekly KETOCONAZOLE - ketoconazole 2 % topical cream. apply twice a day LIDOCAINE - lidocaine 5 % topical ointment. apply daily to painful areas - (Prescribed by Other Provider: per inpatient d/c) METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg tablet,extended release 24 hr. TAKE 1 TABLET BY MOUTH EVERY DAY SIMVASTATIN - simvastatin 40 mg tablet. TAKE 1 TABLET BY MOUTH EVERY DAY TAMSULOSIN - tamsulosin 0.4 mg capsule. TAKE ONE CAPSULE BY MOUTH AT BEDTIME Medications - OTC ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by mouth every 8 hours as needed for pain - (Prescribed by Other Provider: per inpatient d/c) CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Bisacodyl AILY 3. Diazepam 5 mg PO Q8H 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 600 mg PO TID 6. Heparin 5000 UNIT SC BID 7. Polyethylene Glycol 17 g PO DAILY 8. Senna 17.2 mg PO QHS 9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:*0 10. DULoxetine [MASKED] 40 mg PO DAILY 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Simvastatin 40 mg PO QPM 13. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Cervical myelopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Cervical Spinal Fusion Surgery Your dressing may come off on the second day after surgery. Your incision is closed with staples or sutures. You will need suture/staple removal. Do not apply any lotions or creams to the site. Please keep your incision dry until removal of your sutures/staples. Please avoid swimming for two weeks after suture/staple removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity You must wear your cervical collar at all times. The collar helps with healing and alignment of the fusion. You must wear your cervical collar while showering. You may remove your collar briefly for skin care (be sure not to twist or bend your neck too much while the collar is off). It is important to look at your skin and be sure there are no wounds of the skin forming. We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace. [MASKED] try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Do NOT smoke. Smoking can affect your healing and fusion. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc until cleared by your neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. When to Call Your Doctor at [MASKED] for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit New weakness or changes in sensation in your arms or legs. Followup Instructions: [MASKED]	[]	[ "I10", "G4733", "E785", "F419", "K5900" ]	[ "M4802: Spinal stenosis, cervical region", "G992: Myelopathy in diseases classified elsewhere", "G9589: Other specified diseases of spinal cord", "M5412: Radiculopathy, cervical region", "R4182: Altered mental status, unspecified", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E785: Hyperlipidemia, unspecified", "J4520: Mild intermittent asthma, uncomplicated", "F419: Anxiety disorder, unspecified", "Z823: Family history of stroke", "K5900: Constipation, unspecified" ]
19,981,958	26,578,519	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: right sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ man with hx HTN, R carpal tunnel syndrome s/p release, who presents as a transfer from ___ with R-sided weakness and C-spine MRI with concern for myelopathy. The patient reports a progressive weakness that started a few weeks ago. He first noticed R arm weakness, specifically difficulty with grip and dropping things. At the same time he developed neck pain that radiated to the right shoulder and was worse with movement of his head. The weakness was progressive to the point that he was unable to support himself with his R arm and had several falls due to this. Following his R arm weakness he noticed R leg weakness that manifested as a limp, started approximately 2 weeks ago and getting progressively worse. He denies any precipitating trauma or straining prior to the weakness. He has also noted some word-finding difficulty for the past 2 weeks but no dysphagia. He denies headache, vision changes, facial droop, dysphonia, difficulty breathing. He has experienced several falls due to the weakness but without LOC. The patient presented to ___ on ___ for the above symptoms. MRI brain showed no evidence of stroke. C-spine MRI showed moderate spinal stenosis as well as spinal cord flattening and T2 hyperintensity at the lateral aspect of the spinal cord concerning for myelopathy. He was not given steroids. Notably his vital signs were stable throughout admission. He had no leukocytosis or other major lab abnormalities. On interview, the patient reports persistent R-sided weakness that has not improved since admission as well as ongoing R neck and should pain. He has chronic numbness in the R ulnar distribution which is unchanged. Past Medical History: R carpal tunnel syndrome s/p surgical release Cervical spine arthritis ?Hx TIA HTN Anxiety Social History: ___ Family History: Mother - HTN, DM, strokes mGM - strokes Physical Exam: ADMISSION EXAM: VITALS: ___ ___ Temp: 98.3 PO BP: 156/91 R Lying HR: 61 RR: 19 O2 sat: 96% O2 delivery: RA GENERAL: Alert and interactive. In no acute distress but moves slowly. EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. BACK: mild cervical spine tenderness, with exacerbation of pain in R shoulder upon palpation of cervical spinous processes MSK: R scapular tenderness to palpation EXTR: no ___ edema SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: A/Ox3. Normal speech. CN2-12 intact. Decreased sensation in R ___ fingers, otherwise normal sensation. Reflexes 2+ throughout. Strength ___ on left. 4+/5 with R deltoid, biceps, triceps, hand extensor, finger abduction. ___ hip flexor, 4+/5 knee flexion/extension, ___ dorsiflexion, 4+/5 plantarflexion. PSYCH: appropriate mood and affect DISCHARGE EXAM: 24 HR Data (last updated ___ @ 1522) Temp: 98.1 (Tm 98.6), BP: 121/81 (121-149/81-90), HR: 78 (64-78), RR: 17 (___), O2 sat: 95% (93-96), O2 delivery: Ra GENERAL: NAD CARDIAC: RRR RESP: CTABL, no increased WOB ABDOMEN: +BS, soft, NT, ND BACK: mild cervical spine tenderness, with exacerbation of pain in R shoulder upon palpation of cervical spinous processes MSK: R scapular tenderness to palpation EXTR: no ___ edema NEUROLOGIC: A/Ox3. CN ___ tested and intact. Subjective decreased sensation in medial RLE. Strength ___ on left, 4+/5 through all muscle groups on the right side. R patellar hyperreflexia. Gait not observed this morning. Pertinent Results: ADMISSION LABS: ___ 05:33AM BLOOD WBC-7.6 RBC-5.47 Hgb-14.5 Hct-45.2 MCV-83 MCH-26.5 MCHC-32.1 RDW-12.7 RDWSD-38.2 Plt ___ ___ 05:33AM BLOOD Glucose-103* UreaN-13 Creat-0.8 Na-142 K-4.3 Cl-103 HCO3-25 AnGap-14 ___ 05:33AM BLOOD ALT-20 AST-16 LD(LDH)-149 AlkPhos-62 TotBili-0.9 ___ 05:33AM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.8 Mg-2.1 ___ 05:33AM BLOOD CRP-1.1 ___ 05:33AM BLOOD ESR-PND DISCHARGE LABS: ___ 05:58AM BLOOD WBC-8.4 RBC-5.51 Hgb-14.8 Hct-45.9 MCV-83 MCH-26.9 MCHC-32.2 RDW-12.8 RDWSD-38.8 Plt ___ ___ 05:58AM BLOOD Glucose-119* UreaN-22* Creat-0.8 Na-141 K-4.5 Cl-103 HCO3-27 AnGap-11 ___ 05:58AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.3 IMAGING: OSH Brain MRI ___. No evidence of acute intracranial hemorrhage or infarction. 2. Nonspecific T2/FLAIR hyperintensities are nonspecific, likely sequelae of chronic small vessel ischemic disease. Cervical Spine MRI ___. Multilevel degenerative changes of the cervical spine as described above which have progressed from the previous examination particularly at the C3-C4 level where there is now moderate spinal canal stenosis. At this level, there is spinal cord flattening and increased T2 signal in the lateral aspect of the spinal cord, which is somewhat more than typically expected for the degree of spinal cord flattening at this level. Although it could reflect myelopathic signal changes from spinal canal stenosis, inflammatory process is also a consideration. Postcontrast imaging of the cervical spine may be useful for further assessment. 2. Varying degrees of moderate to severe neural foraminal stenosis from the C3-C4 through C7-T1 levels, progressed at C3-C4 and similar to the previous exam at the remaining levels Head/Neck CTA ___. No acute intracranial abnormality. 2. Patent circle of ___ without evidence of stenosis, occlusion, or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. 4. Mildly ectatic ascending aorta measures 4.3 cm MRI C-spine w contrast ___ IMPRESSION: 1. Study is moderately degraded by motion. 2. Grossly stable multilevel cervical spondylosis as described compared to 2 day prior noncontrast cervical spine MRI. 3. Grossly stable C3-4 level spinal cord focal suggested volume loss and question lesion versus artifact as described. There is no definite enhancement of this finding on current examination, within limits of study. Findings are again suggestive of myelomalacia, with posttraumatic cord signal abnormality not excluded on the basis of this motion degraded examination. MRI L-spine w contrast ___ IMPRESSION: 1. Study is moderately degraded by motion. 2. Interval progression of multilevel lumbar spondylosis and epidural fat compared to ___ prior exam as described, most pronounced at L4-5, where there is moderate vertebral canal and moderate bilateral neural foraminal narrowing. 3. L2-3, L3-4 and L4-5 moderate bilateral, L5-S1 moderate right and severe left neural foraminal narrowing. 4. Question focal nerve root clumping at L3-4 versus volume averaging artifact. If not artifactual, findings may represent arachnoiditis. Brief Hospital Course: BRIEF HOSPITAL SUMMARY: ===================== ___ with hx cervical spine arthritis, HTN, possible hx TIA, who presents with weeks of insidiously progressive RUE and RLE weakness, with OSH imaging concerning for possibly cervical myelopathy vs inflammatory process. TRANSITIONAL ISSUES: ================== [] Patient noted drowsiness with gabapentin dosing 900 BID. Modified his regimen to ___ to try to balance symptomatic relief with less drowsiness. [] Follow-up in outpatient clinic in ___ weeks with Dr. ___. Return sooner for progressive neurologic deficits. Call ___ to schedule appointment. ACTIVE ISSUES: ============ # R-sided weakness # Multilevel cervical degenerative disk disease # C3-C4 with moderate canal stenosis Pt transferred from ___ for NSGY evaluation given concern for myelopathy on imaging. Thus far has had normal brain MRA other than chronic small vessel ischemic disease, C-spine MRI concerning for C3/C4 myelopathy vs inflammatory process. Unlikely to be stroke given negative brain imaging. Unlikely infectious process given normal WBC count and afebrile with weeks of symptoms and no IVDU or other major risk factors. CRP not elevated. NSGY feels most likely cervical degenerative disk disease with stenosis, possible brachial plexus component. Neurology was consulted and recommended consideration of urgent surgical intervention given cord signal changes and stenosis seen on imaging. Also obtained MRI L spine which demonstrated multilevel spondylosis. Given no urgent need for surgery (no definite enhancement on MRI C spine with contrast), patient elected to follow up as outpatient for surgical decompression planning. Patient was seen by ___ and was safe for home w/ a walker. # Word-finding difficulties Patient reported several weeks of word-finding difficulties at times. During admission, speech fluent without any abnormalities. MRI brain without evidence of acute stroke, although there was evidence of chronic small vessel ischemic disease. Patient was monitored and continued on home ASA and simvastatin. CHRONIC ISSUES: ============== #HTN: continued home metoprolol 50mg qd #HLD: continued home simvastatin #Chronic pain: continued home duloxetine 20mg BID. Altered gabapentin dosing to 600/600/900mg to better balance symptom improvement and drowsiness. #BPH: continued home tamsulosin 0.4mg qd #CODE: full, confirmed #CONTACT: Name of health care proxy: ___ Relationship: Wife Cell phone: ___ Greater than 30 minutes spent providing discharge services for this patient Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 900 mg PO BID 2. Aspirin EC 81 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS 5. Simvastatin 40 mg PO QPM 6. DULoxetine ___ 20 mg PO BID 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as needed for pain Disp #180 Tablet Refills:0 2. Lidocaine 5% Ointment 1 Appl TP DAILY RX lidocaine 5 % apply daily to painful areas Refills:0 3. Gabapentin 600 mg PO TID 4. Gabapentin 300 mg PO QHS RX gabapentin 300 mg 1 pill by mouth see below Disp #210 Capsule Refills:0 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob 6. Aspirin EC 81 mg PO DAILY 7. DULoxetine ___ 20 mg PO BID 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. Tamsulosin 0.4 mg PO QHS 11.Outpatient Physical Therapy Spinal stenosis ICD 10 48.02 Physical therapy R hemibody strengthening and balance deficits Discharge Disposition: Home Discharge Diagnosis: #Right sided weakness ___ multilevel cervical degenerative disc disease and canal stenosis #HTN #chronic pain #BPH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because of worsening right sided weakness. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had brain imaging that did not show any evidence of a stroke. - You had imaging of your spine that showed narrowing of your spinal canal, which would explain your progressive right sided weakness. - You were seen by both the neurology and neurosurgery teams, who recommended surgery in several weeks. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please take your medications and go to your follow up appointments as described in this discharge summary. - If you experience any of the danger signs listed below, please call your primary care doctor or go to the emergency department immediately. - Please do not drive until cleared by neurosurgery We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___	[ "M5011", "M4802", "I10", "N400", "E785", "G8929", "J449", "G629", "G4733", "M4722" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: right sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] man with hx HTN, R carpal tunnel syndrome s/p release, who presents as a transfer from [MASKED] with R-sided weakness and C-spine MRI with concern for myelopathy. The patient reports a progressive weakness that started a few weeks ago. He first noticed R arm weakness, specifically difficulty with grip and dropping things. At the same time he developed neck pain that radiated to the right shoulder and was worse with movement of his head. The weakness was progressive to the point that he was unable to support himself with his R arm and had several falls due to this. Following his R arm weakness he noticed R leg weakness that manifested as a limp, started approximately 2 weeks ago and getting progressively worse. He denies any precipitating trauma or straining prior to the weakness. He has also noted some word-finding difficulty for the past 2 weeks but no dysphagia. He denies headache, vision changes, facial droop, dysphonia, difficulty breathing. He has experienced several falls due to the weakness but without LOC. The patient presented to [MASKED] on [MASKED] for the above symptoms. MRI brain showed no evidence of stroke. C-spine MRI showed moderate spinal stenosis as well as spinal cord flattening and T2 hyperintensity at the lateral aspect of the spinal cord concerning for myelopathy. He was not given steroids. Notably his vital signs were stable throughout admission. He had no leukocytosis or other major lab abnormalities. On interview, the patient reports persistent R-sided weakness that has not improved since admission as well as ongoing R neck and should pain. He has chronic numbness in the R ulnar distribution which is unchanged. Past Medical History: R carpal tunnel syndrome s/p surgical release Cervical spine arthritis ?Hx TIA HTN Anxiety Social History: [MASKED] Family History: Mother - HTN, DM, strokes mGM - strokes Physical Exam: ADMISSION EXAM: VITALS: [MASKED] [MASKED] Temp: 98.3 PO BP: 156/91 R Lying HR: 61 RR: 19 O2 sat: 96% O2 delivery: RA GENERAL: Alert and interactive. In no acute distress but moves slowly. EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. ENT: MMM. No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. BACK: mild cervical spine tenderness, with exacerbation of pain in R shoulder upon palpation of cervical spinous processes MSK: R scapular tenderness to palpation EXTR: no [MASKED] edema SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: A/Ox3. Normal speech. CN2-12 intact. Decreased sensation in R [MASKED] fingers, otherwise normal sensation. Reflexes 2+ throughout. Strength [MASKED] on left. 4+/5 with R deltoid, biceps, triceps, hand extensor, finger abduction. [MASKED] hip flexor, 4+/5 knee flexion/extension, [MASKED] dorsiflexion, 4+/5 plantarflexion. PSYCH: appropriate mood and affect DISCHARGE EXAM: 24 HR Data (last updated [MASKED] @ 1522) Temp: 98.1 (Tm 98.6), BP: 121/81 (121-149/81-90), HR: 78 (64-78), RR: 17 ([MASKED]), O2 sat: 95% (93-96), O2 delivery: Ra GENERAL: NAD CARDIAC: RRR RESP: CTABL, no increased WOB ABDOMEN: +BS, soft, NT, ND BACK: mild cervical spine tenderness, with exacerbation of pain in R shoulder upon palpation of cervical spinous processes MSK: R scapular tenderness to palpation EXTR: no [MASKED] edema NEUROLOGIC: A/Ox3. CN [MASKED] tested and intact. Subjective decreased sensation in medial RLE. Strength [MASKED] on left, 4+/5 through all muscle groups on the right side. R patellar hyperreflexia. Gait not observed this morning. Pertinent Results: ADMISSION LABS: [MASKED] 05:33AM BLOOD WBC-7.6 RBC-5.47 Hgb-14.5 Hct-45.2 MCV-83 MCH-26.5 MCHC-32.1 RDW-12.7 RDWSD-38.2 Plt [MASKED] [MASKED] 05:33AM BLOOD Glucose-103* UreaN-13 Creat-0.8 Na-142 K-4.3 Cl-103 HCO3-25 AnGap-14 [MASKED] 05:33AM BLOOD ALT-20 AST-16 LD(LDH)-149 AlkPhos-62 TotBili-0.9 [MASKED] 05:33AM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.8 Mg-2.1 [MASKED] 05:33AM BLOOD CRP-1.1 [MASKED] 05:33AM BLOOD ESR-PND DISCHARGE LABS: [MASKED] 05:58AM BLOOD WBC-8.4 RBC-5.51 Hgb-14.8 Hct-45.9 MCV-83 MCH-26.9 MCHC-32.2 RDW-12.8 RDWSD-38.8 Plt [MASKED] [MASKED] 05:58AM BLOOD Glucose-119* UreaN-22* Creat-0.8 Na-141 K-4.5 Cl-103 HCO3-27 AnGap-11 [MASKED] 05:58AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.3 IMAGING: OSH Brain MRI [MASKED]. No evidence of acute intracranial hemorrhage or infarction. 2. Nonspecific T2/FLAIR hyperintensities are nonspecific, likely sequelae of chronic small vessel ischemic disease. Cervical Spine MRI [MASKED]. Multilevel degenerative changes of the cervical spine as described above which have progressed from the previous examination particularly at the C3-C4 level where there is now moderate spinal canal stenosis. At this level, there is spinal cord flattening and increased T2 signal in the lateral aspect of the spinal cord, which is somewhat more than typically expected for the degree of spinal cord flattening at this level. Although it could reflect myelopathic signal changes from spinal canal stenosis, inflammatory process is also a consideration. Postcontrast imaging of the cervical spine may be useful for further assessment. 2. Varying degrees of moderate to severe neural foraminal stenosis from the C3-C4 through C7-T1 levels, progressed at C3-C4 and similar to the previous exam at the remaining levels Head/Neck CTA [MASKED]. No acute intracranial abnormality. 2. Patent circle of [MASKED] without evidence of stenosis, occlusion, or aneurysm. 3. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion, or dissection. 4. Mildly ectatic ascending aorta measures 4.3 cm MRI C-spine w contrast [MASKED] IMPRESSION: 1. Study is moderately degraded by motion. 2. Grossly stable multilevel cervical spondylosis as described compared to 2 day prior noncontrast cervical spine MRI. 3. Grossly stable C3-4 level spinal cord focal suggested volume loss and question lesion versus artifact as described. There is no definite enhancement of this finding on current examination, within limits of study. Findings are again suggestive of myelomalacia, with posttraumatic cord signal abnormality not excluded on the basis of this motion degraded examination. MRI L-spine w contrast [MASKED] IMPRESSION: 1. Study is moderately degraded by motion. 2. Interval progression of multilevel lumbar spondylosis and epidural fat compared to [MASKED] prior exam as described, most pronounced at L4-5, where there is moderate vertebral canal and moderate bilateral neural foraminal narrowing. 3. L2-3, L3-4 and L4-5 moderate bilateral, L5-S1 moderate right and severe left neural foraminal narrowing. 4. Question focal nerve root clumping at L3-4 versus volume averaging artifact. If not artifactual, findings may represent arachnoiditis. Brief Hospital Course: BRIEF HOSPITAL SUMMARY: ===================== [MASKED] with hx cervical spine arthritis, HTN, possible hx TIA, who presents with weeks of insidiously progressive RUE and RLE weakness, with OSH imaging concerning for possibly cervical myelopathy vs inflammatory process. TRANSITIONAL ISSUES: ================== [] Patient noted drowsiness with gabapentin dosing 900 BID. Modified his regimen to [MASKED] to try to balance symptomatic relief with less drowsiness. [] Follow-up in outpatient clinic in [MASKED] weeks with Dr. [MASKED]. Return sooner for progressive neurologic deficits. Call [MASKED] to schedule appointment. ACTIVE ISSUES: ============ # R-sided weakness # Multilevel cervical degenerative disk disease # C3-C4 with moderate canal stenosis Pt transferred from [MASKED] for NSGY evaluation given concern for myelopathy on imaging. Thus far has had normal brain MRA other than chronic small vessel ischemic disease, C-spine MRI concerning for C3/C4 myelopathy vs inflammatory process. Unlikely to be stroke given negative brain imaging. Unlikely infectious process given normal WBC count and afebrile with weeks of symptoms and no IVDU or other major risk factors. CRP not elevated. NSGY feels most likely cervical degenerative disk disease with stenosis, possible brachial plexus component. Neurology was consulted and recommended consideration of urgent surgical intervention given cord signal changes and stenosis seen on imaging. Also obtained MRI L spine which demonstrated multilevel spondylosis. Given no urgent need for surgery (no definite enhancement on MRI C spine with contrast), patient elected to follow up as outpatient for surgical decompression planning. Patient was seen by [MASKED] and was safe for home w/ a walker. # Word-finding difficulties Patient reported several weeks of word-finding difficulties at times. During admission, speech fluent without any abnormalities. MRI brain without evidence of acute stroke, although there was evidence of chronic small vessel ischemic disease. Patient was monitored and continued on home ASA and simvastatin. CHRONIC ISSUES: ============== #HTN: continued home metoprolol 50mg qd #HLD: continued home simvastatin #Chronic pain: continued home duloxetine 20mg BID. Altered gabapentin dosing to 600/600/900mg to better balance symptom improvement and drowsiness. #BPH: continued home tamsulosin 0.4mg qd #CODE: full, confirmed #CONTACT: Name of health care proxy: [MASKED] Relationship: Wife Cell phone: [MASKED] Greater than 30 minutes spent providing discharge services for this patient Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 900 mg PO BID 2. Aspirin EC 81 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Tamsulosin 0.4 mg PO QHS 5. Simvastatin 40 mg PO QPM 6. DULoxetine [MASKED] 20 mg PO BID 7. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever RX acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as needed for pain Disp #180 Tablet Refills:0 2. Lidocaine 5% Ointment 1 Appl TP DAILY RX lidocaine 5 % apply daily to painful areas Refills:0 3. Gabapentin 600 mg PO TID 4. Gabapentin 300 mg PO QHS RX gabapentin 300 mg 1 pill by mouth see below Disp #210 Capsule Refills:0 5. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob 6. Aspirin EC 81 mg PO DAILY 7. DULoxetine [MASKED] 20 mg PO BID 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Simvastatin 40 mg PO QPM 10. Tamsulosin 0.4 mg PO QHS 11.Outpatient Physical Therapy Spinal stenosis ICD 10 48.02 Physical therapy R hemibody strengthening and balance deficits Discharge Disposition: Home Discharge Diagnosis: #Right sided weakness [MASKED] multilevel cervical degenerative disc disease and canal stenosis #HTN #chronic pain #BPH Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you at [MASKED] [MASKED]. WHY WAS I IN THE HOSPITAL? - You came to the hospital because of worsening right sided weakness. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had brain imaging that did not show any evidence of a stroke. - You had imaging of your spine that showed narrowing of your spinal canal, which would explain your progressive right sided weakness. - You were seen by both the neurology and neurosurgery teams, who recommended surgery in several weeks. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please take your medications and go to your follow up appointments as described in this discharge summary. - If you experience any of the danger signs listed below, please call your primary care doctor or go to the emergency department immediately. - Please do not drive until cleared by neurosurgery We wish you the best! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "I10", "N400", "E785", "G8929", "J449", "G4733" ]	[ "M5011: Cervical disc disorder with radiculopathy, high cervical region", "M4802: Spinal stenosis, cervical region", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E785: Hyperlipidemia, unspecified", "G8929: Other chronic pain", "J449: Chronic obstructive pulmonary disease, unspecified", "G629: Polyneuropathy, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M4722: Other spondylosis with radiculopathy, cervical region" ]
19,982,183	26,205,995	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ACE Inhibitors / house dust / ibuprofen Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission labs: =============== ___ 03:00PM BLOOD WBC-8.9 RBC-4.61 Hgb-13.4 Hct-43.5 MCV-94 MCH-29.1 MCHC-30.8* RDW-13.3 RDWSD-45.9 Plt ___ ___ 03:00PM BLOOD Neuts-68.0 ___ Monos-8.8 Eos-0.6* Baso-0.6 Im ___ AbsNeut-6.05 AbsLymp-1.85 AbsMono-0.78 AbsEos-0.05 AbsBaso-0.05 ___ 06:40AM BLOOD ___ PTT-27.7 ___ ___ 03:00PM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-141 K-4.1 Cl-102 HCO3-24 AnGap-15 Imaging: ======== ___ U/S ___ No evidence of deep venous thrombosis in the right lower extremity veins. ___ X-ray right ankle No acute osseous abnormality of the right ankle seen. ___ MRI right thigh 1. Stable postoperative changes in the right thigh post sarcoma resection without evidence of local recurrence. 2. Interval increase in nonspecific mild subcutaneous edema. Findings suggestive of mild myopathy most pronounced in the posterior compartment of the thigh, possibly posttreatment related. ___ PET-CT 1. Soft tissue mass invading the right sacrum and ilium with probable extension into the right common iliac vein. 2. Postoperative appearance of right thigh. Discharge Labs: =============== ___: WBC 6.7, Hgb 12.6, plt 200 BMP WNL (creatinine 0.6) calcium, phos, mg WNL Brief Hospital Course: Ms. ___ is a ___ y/o F w/ hx of right thigh sarcoma s/p resection who p/w worsening pain in sacrum and right leg (thigh, lower leg, and ankle) in setting of recently confirmed diagnosis of recurrence of her sarcoma with metastases to sacrum. # Recurrent sarcoma of sacrum # Right buttocks and lower extremity pain (below): Presented with extreme pain gradually building up over weeks-to-months. In consult with heme-onc/ortho-onc, felt the etiology was likely metastatic sarcoma causing nerve root compression/injury affecting the nerves to the RLE. Palliative care consulted for pain management. Placed initially on dilaudid PCA while uptitrating home fentanyl patch which had recently been started by radiation onc. X-ray showed no osseous abnormalities of R ankle. MRI thigh showed some increased soft tissue edema but no progression in size of sarcoma. PET-CT showed "1. Soft tissue mass invading the right sacrum and ilium with probable extension into the right common iliac vein. 2. Postoperative appearance of right thigh." Pt completed 5 sessions of XRT this admission. Given PET-CT findings, med-onc sarcoma specialist evaluated her and recommended local followup in ___ for port placement and Adriamycin with Dr. ___ ___. She will need Foundation 1 panel outpatient. Her final pain regimen includes Fentanyl, PRN PO Dilaudid, standing APAP, Gabepentin which is being uptitrated, completion of dexamethasone taper. NSAIDs were stopped due to GI upset. Anesthesia did not feel nerve block would be useful for her. She is on standing bowel regimen for opioid induced constipation. Palliative care followup was set up at ___. She will continue lovenox for DVT prophylaxis given possible vascular extension and RLE swelling which may put her at higher risk for DVT. She requested and was provided with pneumovax prior to discharge. # Intermittent mild hypoxia, resolved: Pt with minimal O2 need intermittent of 1L NC for sat in high ___, completely asymptomatic; has had negative US for PE and has been ambulating, though her sarcoma does raise the risk. Thought due to mild respiratory depression related to PCA as this largely resolved after discontinuation, however she said this always is noted when she's in the hospital. Called PCP for collateral but she has only seen an NP there once and there is no note of her being hypoxic ever. ___ need outpatient sleep study and further workup if recurrent. She was satting well on RA prior to discharge CHRONIC/STABLE PROBLEMS: # Abn EKG w bifascicular block: Noted, chronic, asymptomatic (confirmed on outpatient EKG received from PCP) # Asthma: Albuterol inhaler as needed # Hypertension: Patient reports that she has never taking a BP medication. Also does not think she has ever taken an ACE-I, and thinks that this allergy has been entered in error. # Hx of nephrolithiasis: No flank pain / dysuria / hematuria TRANSITIONAL ISSUES: ============== [] will have f/u with med onc Dr. ___ ortho onc Dr. ___ ___ at ___; their offices will call the patient [] reschedule existing ortho onc appointments and imaging for ___ [] f/u with Dr. ___, Med Onc in ___ [] plan for port placement and Adriamycin in ___ [] will need foundation 1 outpatient [] no scheduled rad-onc followup immediately necessary, she can follow up with ___ in ___ or Dr. ___ at ___ [] will need a local prescriber for pain medication; she may follow up at ___ for palliative care however the distance is not ideal [] discharged with a 1 week course for narcotics, ___ checked [] ___ need outpatient sleep study and further workup if hypoxia becomes recurrent. [] discharged with ___ for assistance with medication management CODE: Full Contacts/HCP/Surrogate and Communication: husband ___, ___ >30 minutes spent on day of DC planning Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN asthma 2. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain 3. Fentanyl Patch 50 mcg/h TD Q72H 4. Tizanidine 2 mg PO QHS 5. Diclofenac Sodium ___ 75 mg PO BID 6. Loratadine 10 mg PO DAILY 7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Dexamethasone 2 mg PO DAILY Duration: 7 Days RX dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #5 Tablet Refills:0 2. Docusate Sodium 200 mg PO BID RX docusate sodium 100 mg 2 capsule(s) by mouth 2 times per day Disp #60 Tablet Refills:0 3. Enoxaparin (Prophylaxis) 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #1 Syringe Refills:0 4. Gabapentin 300 mg PO BID Duration: 2 Days increase to three times a day after 3 days RX gabapentin 300 mg 1 capsule(s) by mouth 2 times per day Disp #30 Capsule Refills:0 5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate RX hydromorphone [Dilaudid] 4 mg ___ tablet(s) by mouth every six (6) hours Disp #60 Tablet Refills:0 6. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram 1 dose by mouth once a day Disp #30 Packet Refills:0 7. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tab by mouth 2 times per day Disp #60 Tablet Refills:0 8. Acetaminophen 1000 mg PO TID RX acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #120 Tablet Refills:0 9. Fentanyl Patch 100 mcg/h TD Q72H RX fentanyl 100 mcg/hour 1 patch every 3 days Disp #5 Patch Refills:*0 10. Albuterol Inhaler 1 PUFF IH Q6H:PRN asthma 11. Loratadine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Recurrent sarcoma with metastases # Cancer-related back and RLE pain # intermittent mild hypoxia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. DISCHARGE EXAM: GENERAL: Alert and in no apparent distress; breathing comfortably CV: RLE > LLE edema in the foot/ankle RESP: Breathing is non-labored, lungs CTA no c/r/w MSK: Neck supple, moves all extremities, strength grossly full GU: no suprapubic TTP GI: no abdominal TTP 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: calm Followup Instructions: ___	[ "C7951", "C7989", "G893", "R0902", "R000", "I10", "J45909", "K5903", "T402X5A", "Z85831", "Z87442", "Z87891" ]	Allergies: ACE Inhibitors / house dust / ibuprofen Major Surgical or Invasive Procedure: None attach Pertinent Results: Admission labs: =============== [MASKED] 03:00PM BLOOD WBC-8.9 RBC-4.61 Hgb-13.4 Hct-43.5 MCV-94 MCH-29.1 MCHC-30.8* RDW-13.3 RDWSD-45.9 Plt [MASKED] [MASKED] 03:00PM BLOOD Neuts-68.0 [MASKED] Monos-8.8 Eos-0.6* Baso-0.6 Im [MASKED] AbsNeut-6.05 AbsLymp-1.85 AbsMono-0.78 AbsEos-0.05 AbsBaso-0.05 [MASKED] 06:40AM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 03:00PM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-141 K-4.1 Cl-102 HCO3-24 AnGap-15 Imaging: ======== [MASKED] U/S [MASKED] No evidence of deep venous thrombosis in the right lower extremity veins. [MASKED] X-ray right ankle No acute osseous abnormality of the right ankle seen. [MASKED] MRI right thigh 1. Stable postoperative changes in the right thigh post sarcoma resection without evidence of local recurrence. 2. Interval increase in nonspecific mild subcutaneous edema. Findings suggestive of mild myopathy most pronounced in the posterior compartment of the thigh, possibly posttreatment related. [MASKED] PET-CT 1. Soft tissue mass invading the right sacrum and ilium with probable extension into the right common iliac vein. 2. Postoperative appearance of right thigh. Discharge Labs: =============== [MASKED]: WBC 6.7, Hgb 12.6, plt 200 BMP WNL (creatinine 0.6) calcium, phos, mg WNL Brief Hospital Course: Ms. [MASKED] is a [MASKED] y/o F w/ hx of right thigh sarcoma s/p resection who p/w worsening pain in sacrum and right leg (thigh, lower leg, and ankle) in setting of recently confirmed diagnosis of recurrence of her sarcoma with metastases to sacrum. # Recurrent sarcoma of sacrum # Right buttocks and lower extremity pain (below): Presented with extreme pain gradually building up over weeks-to-months. In consult with heme-onc/ortho-onc, felt the etiology was likely metastatic sarcoma causing nerve root compression/injury affecting the nerves to the RLE. Palliative care consulted for pain management. Placed initially on dilaudid PCA while uptitrating home fentanyl patch which had recently been started by radiation onc. X-ray showed no osseous abnormalities of R ankle. MRI thigh showed some increased soft tissue edema but no progression in size of sarcoma. PET-CT showed "1. Soft tissue mass invading the right sacrum and ilium with probable extension into the right common iliac vein. 2. Postoperative appearance of right thigh." Pt completed 5 sessions of XRT this admission. Given PET-CT findings, med-onc sarcoma specialist evaluated her and recommended local followup in [MASKED] for port placement and Adriamycin with Dr. [MASKED] [MASKED]. She will need Foundation 1 panel outpatient. Her final pain regimen includes Fentanyl, PRN PO Dilaudid, standing APAP, Gabepentin which is being uptitrated, completion of dexamethasone taper. NSAIDs were stopped due to GI upset. Anesthesia did not feel nerve block would be useful for her. She is on standing bowel regimen for opioid induced constipation. Palliative care followup was set up at [MASKED]. She will continue lovenox for DVT prophylaxis given possible vascular extension and RLE swelling which may put her at higher risk for DVT. She requested and was provided with pneumovax prior to discharge. # Intermittent mild hypoxia, resolved: Pt with minimal O2 need intermittent of 1L NC for sat in high [MASKED], completely asymptomatic; has had negative US for PE and has been ambulating, though her sarcoma does raise the risk. Thought due to mild respiratory depression related to PCA as this largely resolved after discontinuation, however she said this always is noted when she's in the hospital. Called PCP for collateral but she has only seen an NP there once and there is no note of her being hypoxic ever. [MASKED] need outpatient sleep study and further workup if recurrent. She was satting well on RA prior to discharge CHRONIC/STABLE PROBLEMS: # Abn EKG w bifascicular block: Noted, chronic, asymptomatic (confirmed on outpatient EKG received from PCP) # Asthma: Albuterol inhaler as needed # Hypertension: Patient reports that she has never taking a BP medication. Also does not think she has ever taken an ACE-I, and thinks that this allergy has been entered in error. # Hx of nephrolithiasis: No flank pain / dysuria / hematuria TRANSITIONAL ISSUES: ============== [] will have f/u with med onc Dr. [MASKED] ortho onc Dr. [MASKED] [MASKED] at [MASKED]; their offices will call the patient [] reschedule existing ortho onc appointments and imaging for [MASKED] [] f/u with Dr. [MASKED], Med Onc in [MASKED] [] plan for port placement and Adriamycin in [MASKED] [] will need foundation 1 outpatient [] no scheduled rad-onc followup immediately necessary, she can follow up with [MASKED] in [MASKED] or Dr. [MASKED] at [MASKED] [] will need a local prescriber for pain medication; she may follow up at [MASKED] for palliative care however the distance is not ideal [] discharged with a 1 week course for narcotics, [MASKED] checked [] [MASKED] need outpatient sleep study and further workup if hypoxia becomes recurrent. [] discharged with [MASKED] for assistance with medication management CODE: Full Contacts/HCP/Surrogate and Communication: husband [MASKED], [MASKED] >30 minutes spent on day of DC planning Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN asthma 2. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain 3. Fentanyl Patch 50 mcg/h TD Q72H 4. Tizanidine 2 mg PO QHS 5. Diclofenac Sodium [MASKED] 75 mg PO BID 6. Loratadine 10 mg PO DAILY 7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Dexamethasone 2 mg PO DAILY Duration: 7 Days RX dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #5 Tablet Refills:0 2. Docusate Sodium 200 mg PO BID RX docusate sodium 100 mg 2 capsule(s) by mouth 2 times per day Disp #60 Tablet Refills:0 3. Enoxaparin (Prophylaxis) 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #1 Syringe Refills:0 4. Gabapentin 300 mg PO BID Duration: 2 Days increase to three times a day after 3 days RX gabapentin 300 mg 1 capsule(s) by mouth 2 times per day Disp #30 Capsule Refills:0 5. HYDROmorphone (Dilaudid) [MASKED] mg PO Q4H:PRN Pain - Moderate RX hydromorphone [Dilaudid] 4 mg [MASKED] tablet(s) by mouth every six (6) hours Disp #60 Tablet Refills:0 6. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram 1 dose by mouth once a day Disp #30 Packet Refills:0 7. Senna 8.6 mg PO BID RX sennosides [senna] 8.6 mg 1 tab by mouth 2 times per day Disp #60 Tablet Refills:0 8. Acetaminophen 1000 mg PO TID RX acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #120 Tablet Refills:0 9. Fentanyl Patch 100 mcg/h TD Q72H RX fentanyl 100 mcg/hour 1 patch every 3 days Disp #5 Patch Refills:*0 10. Albuterol Inhaler 1 PUFF IH Q6H:PRN asthma 11. Loratadine 10 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: # Recurrent sarcoma with metastases # Cancer-related back and RLE pain # intermittent mild hypoxia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. DISCHARGE EXAM: GENERAL: Alert and in no apparent distress; breathing comfortably CV: RLE > LLE edema in the foot/ankle RESP: Breathing is non-labored, lungs CTA no c/r/w MSK: Neck supple, moves all extremities, strength grossly full GU: no suprapubic TTP GI: no abdominal TTP 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: calm Followup Instructions: [MASKED]	[]	[ "I10", "J45909", "Z87891" ]	[ "C7951: Secondary malignant neoplasm of bone", "C7989: Secondary malignant neoplasm of other specified sites", "G893: Neoplasm related pain (acute) (chronic)", "R0902: Hypoxemia", "R000: Tachycardia, unspecified", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "Z85831: Personal history of malignant neoplasm of soft tissue", "Z87442: Personal history of urinary calculi", "Z87891: Personal history of nicotine dependence" ]
19,982,183	26,600,502	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: ACE Inhibitors / house dust / ibuprofen Attending: ___. Chief Complaint: Right thigh sarcoma Major Surgical or Invasive Procedure: ___- removal of right thigh sarcoma History of Present Illness: Ms. ___ is a ___ female who first noticed a mass in her right posterior thigh at the end of last ___. She denies any trauma or any other obvious inciting factor. The mass was painless, but she says it has slightly grown since she first noticed it approximately three to four months ago. The patient was initially worked up by her primary care physician who referred her to a general surgeon who ordered an MRI. Based on appearance of the MRI, the patient was subsequently referred for a biopsy, which did show a pleomorphic soft tissue sarcoma of at least intermediate grade. After the biopsy, the patient was subsequently referred to an oncologist at ___, where CT of the chest, abdomen and pelvis and bone scan was performed, which did not show any disease in any other side of the body. Since the patient initially discovered her mass, she denies any pain, any fevers, chills, chest pain, shortness of breath or any other signs of systemic illness. The patient was subsequently referred to the Orthopedic Oncology Service at ___ after her biopsy and staging studies. Past Medical History: PAST MEDICAL HISTORY: Significant for recalcitrant nephrolithiasis status post stenting and lithotripsy. The patient is currently undergoing workup for underlying cause of her recurrent kidney stones. PAST SURGICAL HISTORY: The patient had a ventricular septal defect repaired at age ___ at ___. She has had no residual heart issues since the surgery. The patient had a left breast implant for what she describes as a left breast and failed to develop. The patient has also undergone stenting of her bilateral ureters on two separate occasions as well as undergone shockwave lithotripsy on two separate occasions for recurrent nephrolithiasis. Social History: ___ Family History: FAMILY HISTORY: The patient's mother had ovarian cancer and non-Hodgkin's lymphoma. There is no family history of sarcoma in the family. There is no family history of bleeding or clotting disorders. Brief Hospital Course: The patient underwent removal of a right posterior thigh sarcoma on ___. She had a sciatic nerve block for post-operative pain control. The surgery was uneventful and she was admitted to the floor post-operatively. She did not have a foley catheter placed. She was maintained on lovenox 40mg daily for blood clot prevention. She had a drain in place at the surgical site. She did have postop nausea and vomiting on POD 1, which resolved by POD 2. She was discharged to home after passing ___. Discharge Disposition: Home Discharge Diagnosis: Right thigh sarcoma Discharge Condition: Stable Discharge Instructions: Activity- you may weight bear as tolerated on your right lower extremity. You should use crutches or a walker for support until your leg function returns to normal. Dressing- Change your operative dressing on ___. You may remove the yellow strip of xeroform over the incision at this time. You should keep the incision covered with dry gauze until your follow up appointment. Change the dressing if there is any drainage on it. Incision- your incision has sutures which will be removed in approximately 3 weeks. You may shower and let water run over the incision starting ___, but do not submerge the incision until ok'd by Dr. ___. Medications- wean off pain medication as tolerated. Please take 81 mg aspirin daily to help prevent blood clots for 2 weeks. Followup Instructions: ___	[ "C4921", "J9620", "Z87891", "Z923", "Y831", "Y92239", "R112", "T40605A" ]	Allergies: ACE Inhibitors / house dust / ibuprofen Chief Complaint: Right thigh sarcoma Major Surgical or Invasive Procedure: [MASKED]- removal of right thigh sarcoma History of Present Illness: Ms. [MASKED] is a [MASKED] female who first noticed a mass in her right posterior thigh at the end of last [MASKED]. She denies any trauma or any other obvious inciting factor. The mass was painless, but she says it has slightly grown since she first noticed it approximately three to four months ago. The patient was initially worked up by her primary care physician who referred her to a general surgeon who ordered an MRI. Based on appearance of the MRI, the patient was subsequently referred for a biopsy, which did show a pleomorphic soft tissue sarcoma of at least intermediate grade. After the biopsy, the patient was subsequently referred to an oncologist at [MASKED], where CT of the chest, abdomen and pelvis and bone scan was performed, which did not show any disease in any other side of the body. Since the patient initially discovered her mass, she denies any pain, any fevers, chills, chest pain, shortness of breath or any other signs of systemic illness. The patient was subsequently referred to the Orthopedic Oncology Service at [MASKED] after her biopsy and staging studies. Past Medical History: PAST MEDICAL HISTORY: Significant for recalcitrant nephrolithiasis status post stenting and lithotripsy. The patient is currently undergoing workup for underlying cause of her recurrent kidney stones. PAST SURGICAL HISTORY: The patient had a ventricular septal defect repaired at age [MASKED] at [MASKED]. She has had no residual heart issues since the surgery. The patient had a left breast implant for what she describes as a left breast and failed to develop. The patient has also undergone stenting of her bilateral ureters on two separate occasions as well as undergone shockwave lithotripsy on two separate occasions for recurrent nephrolithiasis. Social History: [MASKED] Family History: FAMILY HISTORY: The patient's mother had ovarian cancer and non-Hodgkin's lymphoma. There is no family history of sarcoma in the family. There is no family history of bleeding or clotting disorders. Brief Hospital Course: The patient underwent removal of a right posterior thigh sarcoma on [MASKED]. She had a sciatic nerve block for post-operative pain control. The surgery was uneventful and she was admitted to the floor post-operatively. She did not have a foley catheter placed. She was maintained on lovenox 40mg daily for blood clot prevention. She had a drain in place at the surgical site. She did have postop nausea and vomiting on POD 1, which resolved by POD 2. She was discharged to home after passing [MASKED]. Discharge Disposition: Home Discharge Diagnosis: Right thigh sarcoma Discharge Condition: Stable Discharge Instructions: Activity- you may weight bear as tolerated on your right lower extremity. You should use crutches or a walker for support until your leg function returns to normal. Dressing- Change your operative dressing on [MASKED]. You may remove the yellow strip of xeroform over the incision at this time. You should keep the incision covered with dry gauze until your follow up appointment. Change the dressing if there is any drainage on it. Incision- your incision has sutures which will be removed in approximately 3 weeks. You may shower and let water run over the incision starting [MASKED], but do not submerge the incision until ok'd by Dr. [MASKED]. Medications- wean off pain medication as tolerated. Please take 81 mg aspirin daily to help prevent blood clots for 2 weeks. Followup Instructions: [MASKED]	[]	[ "Z87891" ]	[ "C4921: Malignant neoplasm of connective and soft tissue of right lower limb, including hip", "J9620: Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia", "Z87891: Personal history of nicotine dependence", "Z923: Personal history of irradiation", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R112: Nausea with vomiting, unspecified", "T40605A: Adverse effect of unspecified narcotics, initial encounter" ]
19,982,305	28,629,030	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left hip pain Major Surgical or Invasive Procedure: Left hemiarthroplasty History of Present Illness: ___ year old female with history of hypertension (untreated) presents after slip and fall on the stairs with immediate right hip pain and inability to ambulate. Denies HS, LOC, pain elsewhere. Denies dizziness, SOB, CP or other syncopal symptoms. Patient is a community ambulatory and lives with daughter and other family. She is able to walk for grocery shopping and getting up and stairs on her own at baseline. Past Medical History: Hypertension Social History: ___ Family History: NC Physical Exam: LLE: Dressing intact Fires ___ SILT DPN/SPN Foot perfused, palp DP pulse Pertinent Results: ___ 01:29PM K+-4.0 ___ 12:40PM URINE HOURS-RANDOM ___ 12:40PM URINE UHOLD-HOLD ___ 12:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 12:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR ___ 12:40PM URINE RBC-19* WBC-2 BACTERIA-FEW YEAST-NONE EPI-6 ___ 10:45AM GLUCOSE-126* UREA N-23* CREAT-0.8 SODIUM-137 POTASSIUM-5.7* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21* ___ 10:45AM estGFR-Using this ___ 10:45AM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.9 ___ 10:45AM WBC-11.2* RBC-4.41 HGB-14.3 HCT-42.8 MCV-97 MCH-32.4* MCHC-33.4 RDW-14.7 RDWSD-52.0* ___ 10:45AM NEUTS-81.7* LYMPHS-12.1* MONOS-5.4 EOS-0.1* BASOS-0.2 IM ___ AbsNeut-9.16# AbsLymp-1.36 AbsMono-0.61 AbsEos-0.01 AbsBaso-0.02 ___ 10:45AM PLT COUNT-175 ___ 10:45AM ___ PTT-28.2 ___ Brief Hospital Course: Hospitalization Summary The patient presented to the emergency left femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ after being preoperatively cleared by medical service, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #28 Syringe Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain RX oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #50 Tablet Refills:0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left femoral neck 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: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. Please do not bathe or soak for 4 weeks. - Please change dressing every ___ days or more frequently if needed for drainage. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with ___ in the Orthopaedic Trauma Clinic ___ days post-operation for evaluation. Please call ___ to schedule appointment. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Followup Instructions: ___	[ "S72032A", "E669", "I10", "W108XXA", "Y92038", "Z7902", "Z6831" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: left hip pain Major Surgical or Invasive Procedure: Left hemiarthroplasty History of Present Illness: [MASKED] year old female with history of hypertension (untreated) presents after slip and fall on the stairs with immediate right hip pain and inability to ambulate. Denies HS, LOC, pain elsewhere. Denies dizziness, SOB, CP or other syncopal symptoms. Patient is a community ambulatory and lives with daughter and other family. She is able to walk for grocery shopping and getting up and stairs on her own at baseline. Past Medical History: Hypertension Social History: [MASKED] Family History: NC Physical Exam: LLE: Dressing intact Fires [MASKED] SILT DPN/SPN Foot perfused, palp DP pulse Pertinent Results: [MASKED] 01:29PM K+-4.0 [MASKED] 12:40PM URINE HOURS-RANDOM [MASKED] 12:40PM URINE UHOLD-HOLD [MASKED] 12:40PM URINE COLOR-Yellow APPEAR-Hazy SP [MASKED] [MASKED] 12:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [MASKED] 12:40PM URINE RBC-19* WBC-2 BACTERIA-FEW YEAST-NONE EPI-6 [MASKED] 10:45AM GLUCOSE-126* UREA N-23* CREAT-0.8 SODIUM-137 POTASSIUM-5.7* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21* [MASKED] 10:45AM estGFR-Using this [MASKED] 10:45AM CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.9 [MASKED] 10:45AM WBC-11.2* RBC-4.41 HGB-14.3 HCT-42.8 MCV-97 MCH-32.4* MCHC-33.4 RDW-14.7 RDWSD-52.0* [MASKED] 10:45AM NEUTS-81.7* LYMPHS-12.1* MONOS-5.4 EOS-0.1* BASOS-0.2 IM [MASKED] AbsNeut-9.16# AbsLymp-1.36 AbsMono-0.61 AbsEos-0.01 AbsBaso-0.02 [MASKED] 10:45AM PLT COUNT-175 [MASKED] 10:45AM [MASKED] PTT-28.2 [MASKED] Brief Hospital Course: Hospitalization Summary The patient presented to the emergency left femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on [MASKED] after being preoperatively cleared by medical service, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with [MASKED] who determined that discharge to rehab was appropriate. The [MASKED] hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #28 Syringe Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain RX oxycodone 5 mg [MASKED] tablet(s) by mouth every 4 hours Disp #50 Tablet Refills:0 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Left femoral neck 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: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. Please do not bathe or soak for 4 weeks. - Please change dressing every [MASKED] days or more frequently if needed for drainage. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with [MASKED] in the Orthopaedic Trauma Clinic [MASKED] days post-operation for evaluation. Please call [MASKED] to schedule appointment. Please follow up with your primary care doctor regarding this admission within [MASKED] weeks and for and any new medications/refills. Followup Instructions: [MASKED]	[]	[ "E669", "I10", "Z7902" ]	[ "S72032A: Displaced midcervical fracture of left femur, initial encounter for closed fracture", "E669: Obesity, unspecified", "I10: Essential (primary) hypertension", "W108XXA: Fall (on) (from) other stairs and steps, initial encounter", "Y92038: Other place in apartment as the place of occurrence of the external cause", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z6831: Body mass index [BMI] 31.0-31.9, adult" ]
19,982,539	23,136,520	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R sided weakness, language difficulties Major Surgical or Invasive Procedure: ___ - Thrombectomy TICI IIb reperfusion ___ - Left hemicraniectomy for decompression ___ - PEG placement ___ - Right frontal EVD placement in OR ___ - Left wound washout and revision ___ - Removal of right frontal EVD ___ - Right VPS placement, ___ Strata History of Present Illness: Mr. ___ is a ___ yo man with history of poorly controlled HTN who presents as transfer from ___ with change in speech and right-sided weakness. Mr. ___ was LKW at 2300 ___ ___ when he was seen by his mother before going to bed. She heard a 'thump' at approx. 0200 and found him in the kitchen 'fumbling' in the sink. He said "I think I need some help, Mom". When she asked what was wrong, he said 'oatmeal' indicating he had dropped a bowl of oatmeal, leading to the thump. She helped him get dressed, and noted that he was dropping things out of his right hand. He was then taken to ___ at ___, where CTA reportedly showed M2 cutoff. Blood pressure on presentation was 208/101, HR 79. He was treated with IV labetalol 10 mg x3 then nicardipine gtt. He received ASA 325 at 0322. He was subsequently transferred for consideration of thrombectomy. Regarding his history, his mother states that he has known hypertension. He was recently experiencing severe headaches, went to his PCP, and was started on BP medications. Past Medical History: Hypertension Social History: ___ Family History: Father with hypertension and three strokes, CEA Mother with atrial myxoma and valve replacement Physical Exam: ADMISSION EXAM: ============== General: Awake, cooperative, NAD. HEENT: no scleral icterus, MMM, no oropharyngeal lesions. Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: RRR. Skin warm, well-perfused. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic Examination: - Mental status: Awake, alert. No speech, occasional nonsyllabic vocalizations. Does not repeat even monosyllabic words. Follows some very simple commands (open/close eyes, look up) but opens mouth when asked to stick out tongue and holds up forefinger when asked to show thumbs up. Some perseveration. -Cranial Nerves: Gaze conjugate. Gaze rests to the left, crosses midline with VOR. R facial droop. - Motor: Normal bulk. Decreased tone R hemibody. RUE 2 at bi/tri, no movement distally. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc L 5 ___ ___ 5 5 5 5 R 0 ___ 0 0 0 4 5 3 0 -DTRs: Bi Tri ___ Pat Ach Pec jerk Crossed Abductors L 2 2 2 1 R 0 2 2+ 2 Plantar response was flexor on the left, extensor on the right. -Sensory: Grimace to noxious R hemibody. Withdraws RLE from noxious. - Coordination: No dysmetria with finger to nose testing LUE. - Gait: unable to ambulate. DISCHARGE EXAM: ============== Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Nonverbal, patient with expressive aphasia, grunts Follows commands: [x]Simple [ ]Complex [ ]None Pupils: PERRL 4-3mm bilaterally EOM: Full throughout Speech Fluent: [ ]Yes [x]No - Expressive Aphasia Comprehension intact [x]Yes [ ]No Motor: LUE/LLE follows commands and moves purposely with ___ strength strength. RUE with no movement to noxious. RLE withdraws to noxious. Incision: Clean, dry and intact; closed with sutures and staples. Pertinent Results: Please see OMR for pertinent results Brief Hospital Course: #MCA infarct Pt presented w/ CTA showing L M2 cutoff. Underwent thrombectomy w/ TICI IIb reperfusion. He initially was transferred from PACU to ___ where he was found to have increased somnolence. Pt underwent stat CT which appeared stable and was transferred to NeuroICU. Upon arrival, pt's mentation appeared to improve. EEG was placed and was without seizure activity. On hospital day 2, he developed anisacoria secondary to cerebral edema and uncal herniation. Mannitol was started and his mental status improved. Mannitol was discontinued on ___ (within 48hrs) after Na >155 and sOsm>320. On ___, he developed an acute change with increasing somnulence and minimal responsiveness. STAT non-con head CT was obtained and he was found to have progression of cerebral edema with herniation. He was taken for STAT hemicraniectomy without complications. JP drain was removed on POD#2. He was extubated on ___. Once he was stable and transferred to to the ___. #Dyspgagia His swallowing was periodically evaluated and did not improve, therefore, a PEG tube was placed. He tolerated tube feeds. On ___, trials of nectar were initiated which the patient tolerated. #Seizure He had left arm seizure following hemicraniectomy and was started on Keppra 1g PO BID which should be taken as prescribed. #MRSA infection/External Hydrocephalus Hemicraniectomy incision had small amount of serous drainage and was closely monitored. Additional suture and staple was placed with improvement, however on ___ he was noted to have significant purulent, yellow drainage from craniectomy incision. Decision was made to place EVD for persistent CSF leak. He was taken to the OR for placement and given 1 unit platetes prior for recent Aspirin use. R frontal EVD was placed and wound was washed out. Pus was seen intraoperatively and cultures were sent. Please see operative report by Dr. ___ full details. He was transferred to the ___ for recovery and EVD was open to 10. Postop head CT showed expected surgical changes. Infectious disease was consulted and he was empirically started on Vancomycin and Cefepime ___. He was transferred to the ___ on Neurosurgery service. CSF culture grew MRSA and Cefepime was discontinued. Vanco was continued and adjusted per ID for therapeutic trough. He continued to have yellow drainage from incision. EVD height was lowered and tight head wrap was placed in attempt to divert flow. Unfortunately he continued to leak, and he was taken back to the OR on ___ for wound washout and revision with Dr. ___. Procedure was uncomplicated. For further procedure details, please see separately dictated operative report by Dr. ___ was extubated in the operating room and transported to the PACU for recovery. Once stable, he was transferred to the ___ for close neurological monitoring. Cultures were taken and eventually grew out MRSA. He was continued on Vancomycin per ID with dose adjusted according to trough. He underwent trial to wean EVD and incision began leaking. Patient was brought to the OR on ___ for VPS placement. The VPS was set to 1.0. He was extubated in the operating room and transferred to the PACU for recovery. He was later transferred to the ___ for close neurologic monitoring. Shunt adjusted to 2.0 on ___. Final ID plan is continue vancomycin until ___ then transition to doxycycline 100mg BID PO. Patient will follow up with ID outpatient. #Urinary Retention The patient's foley catheter was discontinued on ___. #Dispo Although physical therapy recommended rehab, his placement was complicated by the lack of a HCP. His mother elected to be the HCP but his placement required a guardian to be assigned. Guardianship was obtained and it was determined he would be medically ready for rehabilitation on ___. He was discharged to rehab on ___ in good condition with instructions for follow up. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (X) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (X) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No 4. LDL documented? (X) Yes (LDL = 114) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL >70, reason not given: held given bleeding risk [ ] Statin medication allergy [x ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL ] 6. Smoking cessation counseling given? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - x() No [if LDL >70, reason not given: [ ] Statin medication allergy [ x] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist --> bleeding risk [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? () Yes [Type: (x) Antiplatelet - Aspirin 325() 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. Metoprolol Tartrate 50 mg PO BID 2. lisinopril-hydrochlorothiazide ___ mg oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing 3. amLODIPine 10 mg PO DAILY 4. Aspirin 325 mg PO DAILY 5. Bisacodyl 10 mg PO/PR DAILY Constipation 6. Docusate Sodium 100 mg PO BID 7. FLUoxetine 20 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Heparin 5000 UNIT SC BID 10. Hydrochlorothiazide 50 mg PO DAILY 11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheezing 12. Labetalol 300 mg PO Q6H 13. LevETIRAcetam 1000 mg PO Q12H 14. Multivitamins W/minerals 1 TAB PO DAILY 15. Nicotine Patch 21 mg TD DAILY 16. Nystatin Oral Suspension 5 mL PO QID oral thrush 17. OLANZapine (Disintegrating Tablet) 2.5 mg PO TID:PRN agitation 18. Thiamine 100 mg PO DAILY 19. TraMADol 25 mg PO Q6H:PRN Pain - Moderate 20. Vancomycin 1000 mg IV Q 12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left MCA Infarct Uncal Herniation Hydrocephalus Wound Infection Dysphagia 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: Surgery You underwent a surgery called placement of a right VP shunt which is a ___ Strata Valve set to 2.0. You underwent a surgery called a craniectomy. A portion of your skull was removed to allow your brain to swell. You must wear a helmet when out of bed at all times. Please keep your sutures and staples along your incision dry until they are removed. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You have been discharged on Keppra (Levetiracetam) as you experienced a seizure during this hospitalization. This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. Infectious Disease Recommendations You have been discharged on Vancomycin 1000 mg IV Q12H which will be continued through ___. At that time, you will need to be transitioned to Doxycycline 100mg PO BID. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. You may also experience some ___ swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptoms after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: ___	[ "I63412", "G935", "G936", "G919", "R1310", "I110", "I5030", "G8191", "T814XXA", "E870", "B370", "R569", "F17210", "B9562", "Y838", "Y92230", "E878", "R0689", "Z781" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: R sided weakness, language difficulties Major Surgical or Invasive Procedure: [MASKED] - Thrombectomy TICI IIb reperfusion [MASKED] - Left hemicraniectomy for decompression [MASKED] - PEG placement [MASKED] - Right frontal EVD placement in OR [MASKED] - Left wound washout and revision [MASKED] - Removal of right frontal EVD [MASKED] - Right VPS placement, [MASKED] Strata History of Present Illness: Mr. [MASKED] is a [MASKED] yo man with history of poorly controlled HTN who presents as transfer from [MASKED] with change in speech and right-sided weakness. Mr. [MASKED] was LKW at 2300 [MASKED] [MASKED] when he was seen by his mother before going to bed. She heard a 'thump' at approx. 0200 and found him in the kitchen 'fumbling' in the sink. He said "I think I need some help, Mom". When she asked what was wrong, he said 'oatmeal' indicating he had dropped a bowl of oatmeal, leading to the thump. She helped him get dressed, and noted that he was dropping things out of his right hand. He was then taken to [MASKED] at [MASKED], where CTA reportedly showed M2 cutoff. Blood pressure on presentation was 208/101, HR 79. He was treated with IV labetalol 10 mg x3 then nicardipine gtt. He received ASA 325 at 0322. He was subsequently transferred for consideration of thrombectomy. Regarding his history, his mother states that he has known hypertension. He was recently experiencing severe headaches, went to his PCP, and was started on BP medications. Past Medical History: Hypertension Social History: [MASKED] Family History: Father with hypertension and three strokes, CEA Mother with atrial myxoma and valve replacement Physical Exam: ADMISSION EXAM: ============== General: Awake, cooperative, NAD. HEENT: no scleral icterus, MMM, no oropharyngeal lesions. Pulmonary: Breathing comfortably, no tachypnea nor increased WOB Cardiac: RRR. Skin warm, well-perfused. Abdomen: soft, ND Extremities: Symmetric, no edema. Neurologic Examination: - Mental status: Awake, alert. No speech, occasional nonsyllabic vocalizations. Does not repeat even monosyllabic words. Follows some very simple commands (open/close eyes, look up) but opens mouth when asked to stick out tongue and holds up forefinger when asked to show thumbs up. Some perseveration. -Cranial Nerves: Gaze conjugate. Gaze rests to the left, crosses midline with VOR. R facial droop. - Motor: Normal bulk. Decreased tone R hemibody. RUE 2 at bi/tri, no movement distally. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc L 5 [MASKED] [MASKED] 5 5 5 5 R 0 [MASKED] 0 0 0 4 5 3 0 -DTRs: Bi Tri [MASKED] Pat Ach Pec jerk Crossed Abductors L 2 2 2 1 R 0 2 2+ 2 Plantar response was flexor on the left, extensor on the right. -Sensory: Grimace to noxious R hemibody. Withdraws RLE from noxious. - Coordination: No dysmetria with finger to nose testing LUE. - Gait: unable to ambulate. DISCHARGE EXAM: ============== Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Orientation: [x]Nonverbal, patient with expressive aphasia, grunts Follows commands: [x]Simple [ ]Complex [ ]None Pupils: PERRL 4-3mm bilaterally EOM: Full throughout Speech Fluent: [ ]Yes [x]No - Expressive Aphasia Comprehension intact [x]Yes [ ]No Motor: LUE/LLE follows commands and moves purposely with [MASKED] strength strength. RUE with no movement to noxious. RLE withdraws to noxious. Incision: Clean, dry and intact; closed with sutures and staples. Pertinent Results: Please see OMR for pertinent results Brief Hospital Course: #MCA infarct Pt presented w/ CTA showing L M2 cutoff. Underwent thrombectomy w/ TICI IIb reperfusion. He initially was transferred from PACU to [MASKED] where he was found to have increased somnolence. Pt underwent stat CT which appeared stable and was transferred to NeuroICU. Upon arrival, pt's mentation appeared to improve. EEG was placed and was without seizure activity. On hospital day 2, he developed anisacoria secondary to cerebral edema and uncal herniation. Mannitol was started and his mental status improved. Mannitol was discontinued on [MASKED] (within 48hrs) after Na >155 and sOsm>320. On [MASKED], he developed an acute change with increasing somnulence and minimal responsiveness. STAT non-con head CT was obtained and he was found to have progression of cerebral edema with herniation. He was taken for STAT hemicraniectomy without complications. JP drain was removed on POD#2. He was extubated on [MASKED]. Once he was stable and transferred to to the [MASKED]. #Dyspgagia His swallowing was periodically evaluated and did not improve, therefore, a PEG tube was placed. He tolerated tube feeds. On [MASKED], trials of nectar were initiated which the patient tolerated. #Seizure He had left arm seizure following hemicraniectomy and was started on Keppra 1g PO BID which should be taken as prescribed. #MRSA infection/External Hydrocephalus Hemicraniectomy incision had small amount of serous drainage and was closely monitored. Additional suture and staple was placed with improvement, however on [MASKED] he was noted to have significant purulent, yellow drainage from craniectomy incision. Decision was made to place EVD for persistent CSF leak. He was taken to the OR for placement and given 1 unit platetes prior for recent Aspirin use. R frontal EVD was placed and wound was washed out. Pus was seen intraoperatively and cultures were sent. Please see operative report by Dr. [MASKED] full details. He was transferred to the [MASKED] for recovery and EVD was open to 10. Postop head CT showed expected surgical changes. Infectious disease was consulted and he was empirically started on Vancomycin and Cefepime [MASKED]. He was transferred to the [MASKED] on Neurosurgery service. CSF culture grew MRSA and Cefepime was discontinued. Vanco was continued and adjusted per ID for therapeutic trough. He continued to have yellow drainage from incision. EVD height was lowered and tight head wrap was placed in attempt to divert flow. Unfortunately he continued to leak, and he was taken back to the OR on [MASKED] for wound washout and revision with Dr. [MASKED]. Procedure was uncomplicated. For further procedure details, please see separately dictated operative report by Dr. [MASKED] was extubated in the operating room and transported to the PACU for recovery. Once stable, he was transferred to the [MASKED] for close neurological monitoring. Cultures were taken and eventually grew out MRSA. He was continued on Vancomycin per ID with dose adjusted according to trough. He underwent trial to wean EVD and incision began leaking. Patient was brought to the OR on [MASKED] for VPS placement. The VPS was set to 1.0. He was extubated in the operating room and transferred to the PACU for recovery. He was later transferred to the [MASKED] for close neurologic monitoring. Shunt adjusted to 2.0 on [MASKED]. Final ID plan is continue vancomycin until [MASKED] then transition to doxycycline 100mg BID PO. Patient will follow up with ID outpatient. #Urinary Retention The patient's foley catheter was discontinued on [MASKED]. #Dispo Although physical therapy recommended rehab, his placement was complicated by the lack of a HCP. His mother elected to be the HCP but his placement required a guardian to be assigned. Guardianship was obtained and it was determined he would be medically ready for rehabilitation on [MASKED]. He was discharged to rehab on [MASKED] in good condition with instructions for follow up. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (X) Yes, confirmed done - () Not confirmed () No 2. DVT Prophylaxis administered? (X) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (X) Yes - () No 4. LDL documented? (X) Yes (LDL = 114) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL >70, reason not given: held given bleeding risk [ ] Statin medication allergy [x ] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL ] 6. Smoking cessation counseling given? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - x() No [if LDL >70, reason not given: [ ] Statin medication allergy [ x] Other reasons documented by physician/advanced practice nurse/physician [MASKED] (physician/APN/PA) or pharmacist --> bleeding risk [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? () Yes [Type: (x) Antiplatelet - Aspirin 325() 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. Metoprolol Tartrate 50 mg PO BID 2. lisinopril-hydrochlorothiazide [MASKED] mg oral DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing 3. amLODIPine 10 mg PO DAILY 4. Aspirin 325 mg PO DAILY 5. Bisacodyl 10 mg PO/PR DAILY Constipation 6. Docusate Sodium 100 mg PO BID 7. FLUoxetine 20 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Heparin 5000 UNIT SC BID 10. Hydrochlorothiazide 50 mg PO DAILY 11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheezing 12. Labetalol 300 mg PO Q6H 13. LevETIRAcetam 1000 mg PO Q12H 14. Multivitamins W/minerals 1 TAB PO DAILY 15. Nicotine Patch 21 mg TD DAILY 16. Nystatin Oral Suspension 5 mL PO QID oral thrush 17. OLANZapine (Disintegrating Tablet) 2.5 mg PO TID:PRN agitation 18. Thiamine 100 mg PO DAILY 19. TraMADol 25 mg PO Q6H:PRN Pain - Moderate 20. Vancomycin 1000 mg IV Q 12H Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Left MCA Infarct Uncal Herniation Hydrocephalus Wound Infection Dysphagia 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: Surgery You underwent a surgery called placement of a right VP shunt which is a [MASKED] Strata Valve set to 2.0. You underwent a surgery called a craniectomy. A portion of your skull was removed to allow your brain to swell. You must wear a helmet when out of bed at all times. Please keep your sutures and staples along your incision dry until they are removed. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You have been discharged on Keppra (Levetiracetam) as you experienced a seizure during this hospitalization. This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. Infectious Disease Recommendations You have been discharged on Vancomycin 1000 mg IV Q12H which will be continued through [MASKED]. At that time, you will need to be transitioned to Doxycycline 100mg PO BID. What You [MASKED] Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. You may also experience some [MASKED] swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptoms after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at [MASKED] for: Severe pain, swelling, redness or drainage from the incision site Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call [MASKED] and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions: [MASKED]	[]	[ "I110", "F17210", "Y92230" ]	[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "G935: Compression of brain", "G936: Cerebral edema", "G919: Hydrocephalus, unspecified", "R1310: Dysphagia, unspecified", "I110: Hypertensive heart disease with heart failure", "I5030: Unspecified diastolic (congestive) heart failure", "G8191: Hemiplegia, unspecified affecting right dominant side", "T814XXA: Infection following a procedure", "E870: Hyperosmolality and hypernatremia", "B370: Candidal stomatitis", "R569: Unspecified convulsions", "F17210: Nicotine dependence, cigarettes, uncomplicated", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "R0689: Other abnormalities of breathing", "Z781: Physical restraint status" ]
19,982,539	29,368,457	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cranial Defect Major Surgical or Invasive Procedure: ___: Left cranioplasty History of Present Illness: ___ s/p left hemicraniectomy for malignant MCA stroke complicated by wound infection and placement of VP shunt in ___ presents today for elective cranioplasty. Past Medical History: Hypertension MCA stroke Hemicraniectomy Wound infection VP shunt placement Social History: ___ Family History: Father with hypertension and three strokes, CEA Mother with atrial myxoma and valve replacement Physical Exam: On Discharge: ============= Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Expressive aphasia - answers questions with yes/no head nod: Orientation: [x]Person [x]Place - ___ [x]Time - Month/year Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 4-3mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [ ]No - UTA d/t RUE plegia Speech Fluent: [ ]Yes [x]No - aphasic Comprehension intact [x]Yes [ ]No - shakes head yes/no to questions to show understanding and comprehension Motor: TrapDeltoidBicepTricepGrip Rightslightly withdraws to deep noxious ___ IPQuadHamATEHLGast RightBriskly withdraws to light noxious - increased tone Left5 5 5 5 5 5 [x]Sensation intact to light touch - in all four extremities - states (shakes head) that it is equal bilaterally Wound: [x]Clean, dry, intact [x]Suture Pertinent Results: Please see OMR for all pertinent results Brief Hospital Course: ___ s/p left hemicraniectomy for malignant MCA stroke complicated by wound infection and placement of VP shunt in ___ presented for elective cranioplasty. #Left Craniplasty Patient presented on ___ to the pre-operative area, was assessed by anesthesia, and taken to the OR for left side cranioplasty. Surgery was uncomplicated. Please see formal op report in OMR for further intraoperative details. Patient was extubated in the OR and transferred to PACU for post operative care. Patient remained stable in PACU and was transferred to the step down unit. A post op CT was obtained on POD1 which demonstrated normal post surgical changes. He remained in the ___ with neuro checks every two hours. He remained neurologically stable and medically stable. He was discharged back to his SNIF with instructions to follow up on POD ___ for suture removal and again in 4 weeks with Dr ___ a ___ at that time. Medications on Admission: - Amlodipine 10mg tablet, 1 tab PO daily, hold for SBP < 100 - Baclofen 10mg tablet, 1 tab PO TID - Doxycyline hyclate 100mg capsule, 1 capsule PO BID - Famotidine 20mg tab, 1 tab PO daily - Fluoxetine 20mg capsule, 1 capsule PO daily - Folic Acid 1mg tablet, 1 tab PO daily - Labetalol 200mg tablet, 1 tab PO TID - Keppra 1000mg tablet, 1 tab PO BID - Lidocaine, unknown dose and frequency - Lisinopril 5mg tablet, 1 tab PO BID - Lorazepam 0.5mg, 1 tab PO Q6hrs prn seizures - Maalox Plus Suspension 225-200-25mg/5ml, 30mL Q6hrs prn heartburn - Rivaroxaban (Xarelto) 10mg tablet, 1 tab PO daily - Acetominophen 325mg, 2 tab PO Q6hrs - Bisacodyl 10mg rectal supposity, 1 supposity recall prn constipation - Docusate Sodium 100mg capsule, 1 capsule PO BID - Magnesium Hydroxide (milk of magnesia) 500mg/5mL oral suspension, 30mL PO at bedtime prn no BM x 3days - Melatonin 3mg tablet, 1 tab PO at bedtime - Multivitamin w/minerals 1 capsule PO daily - Thiamine HcL (Vit B1) 100mg tablet, 1 tab GT daily - Eucerin topical cream, 1 application to dry skin BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four hours as needed Disp #10 Tablet Refills:0 4. amLODIPine 10 mg PO DAILY 5. Baclofen 10 mg PO TID 6. Famotidine 20 mg PO BID 7. FLUoxetine 20 mg PO DAILY 8. Labetalol 200 mg PO TID 9. LevETIRAcetam 1000 mg PO BID 10. Lisinopril 5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Cranial Defect - left 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: Surgery You underwent surgery to have your skull bone (or an artificial bone) placed back on. * Please keep your sutures or staples along your incision dry until they are removed. * It is best to keep your incision open to air but it is ok to cover it when outside. * Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity * We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. * You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. * No driving while taking any narcotic or sedating medication. * If you experienced a seizure while admitted, you are NOT allowed to drive by law. * No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications *Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: * Headache or pain along your incision. * You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. * You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. * Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. 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: ___	[ "M952", "Z982", "I10", "I69320", "F329", "G40909", "Z7902" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Cranial Defect Major Surgical or Invasive Procedure: [MASKED]: Left cranioplasty History of Present Illness: [MASKED] s/p left hemicraniectomy for malignant MCA stroke complicated by wound infection and placement of VP shunt in [MASKED] presents today for elective cranioplasty. Past Medical History: Hypertension MCA stroke Hemicraniectomy Wound infection VP shunt placement Social History: [MASKED] Family History: Father with hypertension and three strokes, CEA Mother with atrial myxoma and valve replacement Physical Exam: On Discharge: ============= Exam: Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious Expressive aphasia - answers questions with yes/no head nod: Orientation: [x]Person [x]Place - [MASKED] [x]Time - Month/year Follows commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL 4-3mm EOM: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No Pronator Drift [ ]Yes [ ]No - UTA d/t RUE plegia Speech Fluent: [ ]Yes [x]No - aphasic Comprehension intact [x]Yes [ ]No - shakes head yes/no to questions to show understanding and comprehension Motor: TrapDeltoidBicepTricepGrip Rightslightly withdraws to deep noxious [MASKED] IPQuadHamATEHLGast RightBriskly withdraws to light noxious - increased tone Left5 5 5 5 5 5 [x]Sensation intact to light touch - in all four extremities - states (shakes head) that it is equal bilaterally Wound: [x]Clean, dry, intact [x]Suture Pertinent Results: Please see OMR for all pertinent results Brief Hospital Course: [MASKED] s/p left hemicraniectomy for malignant MCA stroke complicated by wound infection and placement of VP shunt in [MASKED] presented for elective cranioplasty. #Left Craniplasty Patient presented on [MASKED] to the pre-operative area, was assessed by anesthesia, and taken to the OR for left side cranioplasty. Surgery was uncomplicated. Please see formal op report in OMR for further intraoperative details. Patient was extubated in the OR and transferred to PACU for post operative care. Patient remained stable in PACU and was transferred to the step down unit. A post op CT was obtained on POD1 which demonstrated normal post surgical changes. He remained in the [MASKED] with neuro checks every two hours. He remained neurologically stable and medically stable. He was discharged back to his SNIF with instructions to follow up on POD [MASKED] for suture removal and again in 4 weeks with Dr [MASKED] a [MASKED] at that time. Medications on Admission: - Amlodipine 10mg tablet, 1 tab PO daily, hold for SBP < 100 - Baclofen 10mg tablet, 1 tab PO TID - Doxycyline hyclate 100mg capsule, 1 capsule PO BID - Famotidine 20mg tab, 1 tab PO daily - Fluoxetine 20mg capsule, 1 capsule PO daily - Folic Acid 1mg tablet, 1 tab PO daily - Labetalol 200mg tablet, 1 tab PO TID - Keppra 1000mg tablet, 1 tab PO BID - Lidocaine, unknown dose and frequency - Lisinopril 5mg tablet, 1 tab PO BID - Lorazepam 0.5mg, 1 tab PO Q6hrs prn seizures - Maalox Plus Suspension 225-200-25mg/5ml, 30mL Q6hrs prn heartburn - Rivaroxaban (Xarelto) 10mg tablet, 1 tab PO daily - Acetominophen 325mg, 2 tab PO Q6hrs - Bisacodyl 10mg rectal supposity, 1 supposity recall prn constipation - Docusate Sodium 100mg capsule, 1 capsule PO BID - Magnesium Hydroxide (milk of magnesia) 500mg/5mL oral suspension, 30mL PO at bedtime prn no BM x 3days - Melatonin 3mg tablet, 1 tab PO at bedtime - Multivitamin w/minerals 1 capsule PO daily - Thiamine HcL (Vit B1) 100mg tablet, 1 tab GT daily - Eucerin topical cream, 1 application to dry skin BID Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth every four hours as needed Disp #10 Tablet Refills:0 4. amLODIPine 10 mg PO DAILY 5. Baclofen 10 mg PO TID 6. Famotidine 20 mg PO BID 7. FLUoxetine 20 mg PO DAILY 8. Labetalol 200 mg PO TID 9. LevETIRAcetam 1000 mg PO BID 10. Lisinopril 5 mg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Cranial Defect - left 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: Surgery You underwent surgery to have your skull bone (or an artificial bone) placed back on. * Please keep your sutures or staples along your incision dry until they are removed. * It is best to keep your incision open to air but it is ok to cover it when outside. * Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity * We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. * You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. * No driving while taking any narcotic or sedating medication. * If you experienced a seizure while admitted, you are NOT allowed to drive by law. * No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications *Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience: * Headache or pain along your incision. * You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. * You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. * Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at [MASKED] for: * Severe pain, swelling, redness or drainage from the incision site. * Fever greater than 101.5 degrees Fahrenheit * Nausea and/or vomiting * Extreme sleepiness and not being able to stay awake * Severe headaches not relieved by pain relievers * Seizures * Any new problems with your vision or ability to speak * Weakness or changes in sensation in your face, arms, or leg Call [MASKED] and go to the nearest Emergency Room if you experience any of the following: * Sudden numbness or weakness in the face, arm, or leg * Sudden confusion or trouble speaking or understanding * Sudden trouble walking, dizziness, or loss of balance or coordination * Sudden severe headaches with no known reason Followup Instructions: [MASKED]	[]	[ "I10", "F329", "Z7902" ]	[ "M952: Other acquired deformity of head", "Z982: Presence of cerebrospinal fluid drainage device", "I10: Essential (primary) hypertension", "I69320: Aphasia following cerebral infarction", "F329: Major depressive disorder, single episode, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]
19,982,541	20,860,014	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: Successful US-guided placement of ___ pigtail catheter into the gallbladder. History of Present Illness: Patient is a ___ male with a history of hypertension, stroke in ___, hyperlipidemia, question of MI in 1980s, who presents with several weeks of intermittent right upper quadrant abdominal pain. He reports he first had an episode of pain lasting 2 or 3 hours 3 weeks ago which resolved with Tylenol. He had a second episode of pain about a week ago, and today started having severe pain worse than his previous episodes that did not go away so he presented to ___ where he was found to have cholecystitis and a hepatic abscess. He was transferred to ___ for further management. He reports that since he received morphine he does not have any right upper quadrant abdominal pain, he denies fever/chills, nausea/vomiting, dyspnea or chest pain. He reports that he is lost approximately 40 pounds intentionally over the past 10 months. His last colonoscopy was ___ years ago and normal. He denies any blood in the stool. He has never had any abdominal surgeries. Past Medical History: Hypertension MI Hyperlipidemia Stroke Social History: ___ Family History: Non-contributory. Physical Exam: Physical Exam on Admission ___: Vitals: 101.3 86 130/62 16 99% RA GEN: A&Ox3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Breathing comfortably on room air ABD: Soft, nondistended, nontender, no rebound or guarding Ext: No ___ edema, ___ warm and well perfused Physical Exam on Discharge ___: VS: Temp 98.7 Oral BP 165/79 HR 76 RR 18 O2 Sat 94% RA GEN: NAD. A+Ox3. CV: Regular rate and rhythm Pulm: Lung sounds clear bilaterally Abd: Soft, large, non-tender. +BS. RLQ perc chole tube in place with bilious drainage. Dsg C/D/I. No erythema or hematoma noted. Ext: Warm, well-perfused. No pain or edema. Pertinent Results: Lab Values: ___ 05:30AM BLOOD WBC-6.5 RBC-3.83* Hgb-11.1* Hct-34.9* MCV-91 MCH-29.0 MCHC-31.8* RDW-13.8 RDWSD-46.2 Plt ___ ___ 06:02PM BLOOD Neuts-74.6* Lymphs-13.5* Monos-10.0 Eos-0.8* Baso-0.2 Im ___ AbsNeut-6.92* AbsLymp-1.25 AbsMono-0.93* AbsEos-0.07 AbsBaso-0.02 ___ 04:25AM BLOOD ___ ___ 05:30AM BLOOD Glucose-113* UreaN-12 Creat-1.4* Na-140 K-4.1 Cl-101 HCO3-26 AnGap-13 ___ 04:25AM BLOOD ALT-22 AST-15 AlkPhos-83 TotBili-0.4 ___ 05:30AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1 ___ 06:21PM BLOOD Lactate-0.7 Brief Hospital Course: Mr. ___ is a ___ year old male with a PMH significant for HTN, HLD, MI, and stroke (___), who presented to OSH and had CT imaging which showed acute cholecystitis and a hepatic abscess. He was transferred to ___ on ___ for further management. He was admitted to the Acute Care Surgery service and made NPO and started on IV fluids and IV antibiotics. The Interventional Radiology service was consulted for a percutaneous cholecystostomy, which was done on ___. Upon return to the floor, the patient was started on a clear liquid diet. The next day on HD1, he was advanced to a regular diet, which he was tolerating well. He was transitioned from IV antibiotics to PO antibiotics (Augmentin) on HD1 to finish a 10 day course. His abdominal pain had resolved. He was having bilious drainage from the percutaneous cholecystostomy tube. During this hospitalization, the patient voided without difficulty and was ambulating. The patient received subcutaneous heparin and venodyne boots were used during this stay. Nursing performed teaching with the patient on drain care and the patient verbalized understanding. At the time of discharge on ___, the patient was doing well. He was afebrile and vital signs were stable. The patient was discharged home with ___ services set up. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement. He will follow up in the Acute Care Surgery clinic and with his PCP. Medications on Admission: 1. amLODIPine 5 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Labetalol 300 mg PO BID 4. Lisinopril 20 mg PO DAILY 5. Simvastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever Please do not exceed 3gm in a 24 hour period. 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H End date ___. RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #18 Tablet Refills:0 3. amLODIPine 5 mg PO DAILY 4. Chlorthalidone 25 mg PO DAILY 5. Labetalol 300 mg PO BID 6. Lisinopril 20 mg PO DAILY 7. Simvastatin 40 mg PO QPM Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute cholecystitis Intrahepatic abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were transferred to ___ on ___ for evaluation of abdominal pain and were found to have acute cholecystitis (inflammation of your gallbladder) with an abscess in your liver. You were evaluated by the acute care surgery team and interventional radiology. You subsequently underwent placement of a percutaneous cholecystostomy tube. You tolerated this procedure well. You have since been tolerating a regular diet, ambulating, and your pain has resolved. You are now ready for discharge home with ___ services. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. DRAIN CARE: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___	[ "K810", "K750", "I10", "E785", "Z8673", "I252" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [MASKED]: Successful US-guided placement of [MASKED] pigtail catheter into the gallbladder. History of Present Illness: Patient is a [MASKED] male with a history of hypertension, stroke in [MASKED], hyperlipidemia, question of MI in 1980s, who presents with several weeks of intermittent right upper quadrant abdominal pain. He reports he first had an episode of pain lasting 2 or 3 hours 3 weeks ago which resolved with Tylenol. He had a second episode of pain about a week ago, and today started having severe pain worse than his previous episodes that did not go away so he presented to [MASKED] where he was found to have cholecystitis and a hepatic abscess. He was transferred to [MASKED] for further management. He reports that since he received morphine he does not have any right upper quadrant abdominal pain, he denies fever/chills, nausea/vomiting, dyspnea or chest pain. He reports that he is lost approximately 40 pounds intentionally over the past 10 months. His last colonoscopy was [MASKED] years ago and normal. He denies any blood in the stool. He has never had any abdominal surgeries. Past Medical History: Hypertension MI Hyperlipidemia Stroke Social History: [MASKED] Family History: Non-contributory. Physical Exam: Physical Exam on Admission [MASKED]: Vitals: 101.3 86 130/62 16 99% RA GEN: A&Ox3, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Breathing comfortably on room air ABD: Soft, nondistended, nontender, no rebound or guarding Ext: No [MASKED] edema, [MASKED] warm and well perfused Physical Exam on Discharge [MASKED]: VS: Temp 98.7 Oral BP 165/79 HR 76 RR 18 O2 Sat 94% RA GEN: NAD. A+Ox3. CV: Regular rate and rhythm Pulm: Lung sounds clear bilaterally Abd: Soft, large, non-tender. +BS. RLQ perc chole tube in place with bilious drainage. Dsg C/D/I. No erythema or hematoma noted. Ext: Warm, well-perfused. No pain or edema. Pertinent Results: Lab Values: [MASKED] 05:30AM BLOOD WBC-6.5 RBC-3.83* Hgb-11.1* Hct-34.9* MCV-91 MCH-29.0 MCHC-31.8* RDW-13.8 RDWSD-46.2 Plt [MASKED] [MASKED] 06:02PM BLOOD Neuts-74.6* Lymphs-13.5* Monos-10.0 Eos-0.8* Baso-0.2 Im [MASKED] AbsNeut-6.92* AbsLymp-1.25 AbsMono-0.93* AbsEos-0.07 AbsBaso-0.02 [MASKED] 04:25AM BLOOD [MASKED] [MASKED] 05:30AM BLOOD Glucose-113* UreaN-12 Creat-1.4* Na-140 K-4.1 Cl-101 HCO3-26 AnGap-13 [MASKED] 04:25AM BLOOD ALT-22 AST-15 AlkPhos-83 TotBili-0.4 [MASKED] 05:30AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1 [MASKED] 06:21PM BLOOD Lactate-0.7 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old male with a PMH significant for HTN, HLD, MI, and stroke ([MASKED]), who presented to OSH and had CT imaging which showed acute cholecystitis and a hepatic abscess. He was transferred to [MASKED] on [MASKED] for further management. He was admitted to the Acute Care Surgery service and made NPO and started on IV fluids and IV antibiotics. The Interventional Radiology service was consulted for a percutaneous cholecystostomy, which was done on [MASKED]. Upon return to the floor, the patient was started on a clear liquid diet. The next day on HD1, he was advanced to a regular diet, which he was tolerating well. He was transitioned from IV antibiotics to PO antibiotics (Augmentin) on HD1 to finish a 10 day course. His abdominal pain had resolved. He was having bilious drainage from the percutaneous cholecystostomy tube. During this hospitalization, the patient voided without difficulty and was ambulating. The patient received subcutaneous heparin and venodyne boots were used during this stay. Nursing performed teaching with the patient on drain care and the patient verbalized understanding. At the time of discharge on [MASKED], the patient was doing well. He was afebrile and vital signs were stable. The patient was discharged home with [MASKED] services set up. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement. He will follow up in the Acute Care Surgery clinic and with his PCP. Medications on Admission: 1. amLODIPine 5 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Labetalol 300 mg PO BID 4. Lisinopril 20 mg PO DAILY 5. Simvastatin 40 mg PO QPM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever Please do not exceed 3gm in a 24 hour period. 2. Amoxicillin-Clavulanic Acid [MASKED] mg PO Q12H End date [MASKED]. RX amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth every twelve (12) hours Disp #18 Tablet Refills:0 3. amLODIPine 5 mg PO DAILY 4. Chlorthalidone 25 mg PO DAILY 5. Labetalol 300 mg PO BID 6. Lisinopril 20 mg PO DAILY 7. Simvastatin 40 mg PO QPM Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Acute cholecystitis Intrahepatic abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED], You were transferred to [MASKED] on [MASKED] for evaluation of abdominal pain and were found to have acute cholecystitis (inflammation of your gallbladder) with an abscess in your liver. You were evaluated by the acute care surgery team and interventional radiology. You subsequently underwent placement of a percutaneous cholecystostomy tube. You tolerated this procedure well. You have since been tolerating a regular diet, ambulating, and your pain has resolved. You are now ready for discharge home with [MASKED] services. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within [MASKED] hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [MASKED] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. DRAIN CARE: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, [MASKED], or [MASKED] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. Wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: [MASKED]	[]	[ "I10", "E785", "Z8673", "I252" ]	[ "K810: Acute cholecystitis", "K750: Abscess of liver", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I252: Old myocardial infarction" ]
19,982,872	28,775,791	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: gabapentin / atenolol / hydrochlorothiazide Attending: ___. Chief Complaint: left knee OA Major Surgical or Invasive Procedure: left knee replacement ___, ___ History of Present Illness: ___ year old female with left knee OA s/p L TKR. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. Hypertension 2. Reflux esophagitis, GERD 3. Osteoarthritis 4. Recurrent pharyngitis (scheduled for tonsillectomy) 5. Fibromyalgia 6. Unexplained chronic anemia (likely iron deficiency anemia; work-up by Dr. ___ in ___ 7. s/p appendectomy ___ years prior) 8. s/p tubal ligation 9. s/p Cesarean section 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 * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 07:02AM BLOOD WBC-8.0 RBC-2.86* Hgb-8.3* Hct-25.6* MCV-90 MCH-29.0 MCHC-32.4 RDW-12.4 RDWSD-40.2 Plt ___ ___ 03:10AM BLOOD WBC-10.2* RBC-2.99* Hgb-8.7* Hct-26.4* MCV-88 MCH-29.1 MCHC-33.0 RDW-12.2 RDWSD-39.7 Plt ___ ___ 07:02AM BLOOD Plt ___ ___ 03:10AM BLOOD Plt ___ ___ 07:02AM BLOOD Creat-1.0 Na-140 ___ 01:08PM BLOOD Na-134* ___ 03:10AM BLOOD Glucose-118* UreaN-18 Creat-1.0 Na-131* K-4.4 Cl-98 HCO3-23 AnGap-10 ___ 03:10AM BLOOD cTropnT-<0.01 ___ 07:02AM BLOOD Mg-2.4 ___ 03:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.5* Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD #0, patient was triggered for syncopal episode while sitting on the commode for ~ 1 min per ___. Patient was lifted back to bed and BPs noted to be ___. Patient placed on trendelenberg position and BPs improved to 100s/60. Patient given 500ml IV fluid bolus with appropriate response. POD #1, overnight, the patient complained of ___ numbness and sweating. BP low of systolics into ___ and was mildly tachycardic. She was given oral Ativan. An EKG was performed and showed no ischemic changes. Sodium was 131 and patient was given 1 liter LR bolus, which also helped with her low blood pressure. Recheck at 1300 was 134. Magnesium was 1.5 and repleted orally. Macrobid was also changed to Bactrim due to sensitivities on urine culture. POD #2, all her electrolytes came back stable - magnesium 2.4, sodium 140. She continued on Bactrim for treatment of her UTI. This medication will be continued for two additional doses to complete treatment of her urinary tract infection. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 325 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing 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 with no range of motion restrictions. Ms. ___ is discharged to home with services in stable condition. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H 2. Lisinopril 20 mg PO DAILY 3. Senna 8.6-17.2 mg PO DAILY 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Pantoprazole 40 mg PO Q24H 6. Loratadine 10 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin EC 325 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain ___ 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Doses 5. Acetaminophen 1000 mg PO Q8H 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Lisinopril 20 mg PO DAILY 8. Loratadine 10 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H Continue while on 4-week course of Aspirin 325 mg twice daily. 10. Senna 8.6-17.2 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left 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 Aspirin 325 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue home dose of Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 325 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please 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. Physical Therapy: WBAT LLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently 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: ___	[ "M1712", "N390", "E871", "I10", "K219", "J029", "D509", "B961", "F419", "I959", "E8342" ]	Allergies: gabapentin / atenolol / hydrochlorothiazide Chief Complaint: left knee OA Major Surgical or Invasive Procedure: left knee replacement [MASKED], [MASKED] History of Present Illness: [MASKED] year old female with left knee OA s/p L TKR. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. Hypertension 2. Reflux esophagitis, GERD 3. Osteoarthritis 4. Recurrent pharyngitis (scheduled for tonsillectomy) 5. Fibromyalgia 6. Unexplained chronic anemia (likely iron deficiency anemia; work-up by Dr. [MASKED] in [MASKED] 7. s/p appendectomy [MASKED] years prior) 8. s/p tubal ligation 9. s/p Cesarean section 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 * Thigh full but soft * No calf tenderness * [MASKED] strength * SILT, NVI distally * Toes warm Pertinent Results: [MASKED] 07:02AM BLOOD WBC-8.0 RBC-2.86* Hgb-8.3* Hct-25.6* MCV-90 MCH-29.0 MCHC-32.4 RDW-12.4 RDWSD-40.2 Plt [MASKED] [MASKED] 03:10AM BLOOD WBC-10.2* RBC-2.99* Hgb-8.7* Hct-26.4* MCV-88 MCH-29.1 MCHC-33.0 RDW-12.2 RDWSD-39.7 Plt [MASKED] [MASKED] 07:02AM BLOOD Plt [MASKED] [MASKED] 03:10AM BLOOD Plt [MASKED] [MASKED] 07:02AM BLOOD Creat-1.0 Na-140 [MASKED] 01:08PM BLOOD Na-134* [MASKED] 03:10AM BLOOD Glucose-118* UreaN-18 Creat-1.0 Na-131* K-4.4 Cl-98 HCO3-23 AnGap-10 [MASKED] 03:10AM BLOOD cTropnT-<0.01 [MASKED] 07:02AM BLOOD Mg-2.4 [MASKED] 03:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-1.5* Brief Hospital Course: The patient was admitted to the orthopedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: POD #0, patient was triggered for syncopal episode while sitting on the commode for ~ 1 min per [MASKED]. Patient was lifted back to bed and BPs noted to be [MASKED]. Patient placed on trendelenberg position and BPs improved to 100s/60. Patient given 500ml IV fluid bolus with appropriate response. POD #1, overnight, the patient complained of [MASKED] numbness and sweating. BP low of systolics into [MASKED] and was mildly tachycardic. She was given oral Ativan. An EKG was performed and showed no ischemic changes. Sodium was 131 and patient was given 1 liter LR bolus, which also helped with her low blood pressure. Recheck at 1300 was 134. Magnesium was 1.5 and repleted orally. Macrobid was also changed to Bactrim due to sensitivities on urine culture. POD #2, all her electrolytes came back stable - magnesium 2.4, sodium 140. She continued on Bactrim for treatment of her UTI. This medication will be continued for two additional doses to complete treatment of her urinary tract infection. Otherwise, pain was controlled with a combination of IV and oral pain medications. The patient received Aspirin 325 mg twice daily for DVT prophylaxis starting on the morning of POD#1. The surgical dressing 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 with no range of motion restrictions. Ms. [MASKED] is discharged to home with services in stable condition. Medications on Admission: 1. Acetaminophen 1000 mg PO Q8H 2. Lisinopril 20 mg PO DAILY 3. Senna 8.6-17.2 mg PO DAILY 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Pantoprazole 40 mg PO Q24H 6. Loratadine 10 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Aspirin EC 325 mg PO BID 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain [MASKED] 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Doses 5. Acetaminophen 1000 mg PO Q8H 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Lisinopril 20 mg PO DAILY 8. Loratadine 10 mg PO DAILY 9. Pantoprazole 40 mg PO Q24H Continue while on 4-week course of Aspirin 325 mg twice daily. 10. Senna 8.6-17.2 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: left 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 Aspirin 325 mg twice daily with food for four (4) weeks to help prevent deep vein thrombosis (blood clots). Continue home dose of Pantoprazole daily while on Aspirin to prevent GI upset (x 4 weeks). If you were taking Aspirin prior to your surgery, take it at 325 mg twice daily until the end of the 4 weeks, then you can go back to your normal dosing. 9. WOUND CARE: Please 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. Physical Therapy: WBAT LLE ROMAT Wean assistive device as able (i.e. 2 crutches or walker) Mobilize frequently 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]	[]	[ "N390", "E871", "I10", "K219", "D509", "F419" ]	[ "M1712: Unilateral primary osteoarthritis, left knee", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "J029: Acute pharyngitis, unspecified", "D509: Iron deficiency anemia, unspecified", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "F419: Anxiety disorder, unspecified", "I959: Hypotension, unspecified", "E8342: Hypomagnesemia" ]
19,982,989	22,784,267	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ y/o M w/ HFpEF (EF 55% in ___, possible COPD, CKD, dementia, T2DM, BPH, and recent admission from ___ for CHF exacerbation, presenting now for worsening dyspnea. Of note, patient was recently admitted from ___ for a CHF exacerbation, complicated by E.coli UTI treated with Bactrim, and acute on chronic kidney injury. At that time, patient initially presented with significant dyspnea, requiring BiPAP, which improved rapidly with diuresis. His ___ was originally thought secondary to cardiorenal, but worsened with continued diuresis, and thus there was some concern for prerenal azotemia. However, Cr improved prior to d/c. Per report, patient was evaluated 3 days ago for dyspnea, and was felt to have CXR concerning for PNA. He was started on an antibiotics (unknown what), and had his furosemide held given he was euvolemic. This morning, he was noted by nursing at his facility to have a worsened respiratory status, wheezing, non-productive cough, and an oxygen saturation to 86% on RA, which improved to 97% on 4L NC. In the ED: In the setting of his diuresis being held, and labs, imaging, and exam, he was felt to likely have repeat CHF exacerbation. This was possibly triggered by PNA, and thus patient was started on coverage for HCAP with cefepime and Vancomycin. In the setting of his uptrending cardiac markers there was also concern for possible ACS, and thus he was started on heparin IV. - Initial VS: Temp 97.8 HR 88 BP 110/64 RR 28 SpO2 97% 4L NC - Exam notable for: Confused at baseline. Wheezing throughout. Increased respiratory effort with abdominal breathing. No crackles appreciated. Mild swelling in bilateral legs. No JVD. No murmur rubs gallops. RRR. - EKG: Notable for new ST depression in lateral leads - Labs notable for: -- Lactate 3.1 -> 1.6 -- Trop: 0.44 -> 0.58 -- CK-MB: 29 w/ MBI: 6.02 -- ___: ___ -- Cr: 2.3 - Studies notable for: -- CXR: Mild to moderate pulmonary edema with moderate right pleural effusion and right basal opacity likely compressive atelectasis, difficult to exclude a developing pneumonia. - Consults: -- Cardiology: Agreed with admission to ___ and continuing Heparin in setting of uptrending cardiac markers - Patient was given: Nebulizers, Cefepime 2g, Vancomycin 1g, 40mg IV Lasix x2 - Vitals on transfer: Temp 98.3 HR 81 BP 112/61 RR 23 96% 4L NC On the floor, very little further history could be obtained as patient is a poor historian, and wife was not aware of all the details that had transpired over the last few days. She did confirm much of the story as above, and also noted he may have felt feverish and chills in the days prior to presentation. REVIEW OF SYSTEMS: Negative except as noted above Past Medical History: 1. CARDIAC RISK FACTORS - DMII - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Coronaries: Unknown - HFpEF, EF 55% ___ - NSR 3. OTHER PAST MEDICAL HISTORY -BPH -Head lesion after falling off a horse many years ago -Shoulder surgery status post motor vehicle accident -h/o prostate surgery -Olfactory groove Meningioma -L hip replacement -Hypothyroidism Social History: ___ Family History: Per report, has family history of lung cancer and heart disease, but unclear what disease specifically or in whom. Physical Exam: ADMISSION PHYSICAL EXAMINATION ============================== VS: Reviewed in ___ GENERAL: Well developed male in no acute distress HEENT: Mucus membranes dry, JVP elevated to below ear lobe at 65 degrees CARDIAC: RRR, no murmurs, rubs, or gallops LUNGS: Mildly increased work of breathing. Diffuse wheezing noted throughout, with decreased breath sounds in lower lung bases R>L. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. ___ edema up to mid-shin PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAMINATION ============================== 24 HR Data (last updated ___ @ 638) Temp: 98.8 (Tm 99.1), BP: 141/61 (102-141/58-66), HR: 80 (63-80), RR: 20 (___), O2 sat: 97% (81-100), O2 delivery: 2L (2L NCL-4L), Wt: 154.76 lb/70.2 kg GENERAL: Well developed male in no acute distress. Pleasant to speak with and smiling. Understands some ___. HEENT: Mucus membranes dry. NCAT CARDIAC: RRR, no murmurs, rubs, or gallops LUNGS: Breathing comfortable on RA. Transmitted upper airway sounds with decreased breath sounds in lower lung bases. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No lower extremity edema. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ ___ 12:40PM BLOOD Glucose-199* UreaN-46* Creat-2.3* Na-135 K-4.4 Cl-99 HCO3-22 AnGap-14 ___ 12:40PM BLOOD ___ PTT-33.3 ___ ___ 12:40PM BLOOD WBC-11.0* RBC-3.21* Hgb-9.1* Hct-30.0* MCV-94 MCH-28.3 MCHC-30.3* RDW-15.9* RDWSD-54.5* Plt ___ ___ 12:40PM BLOOD CK-MB-29* MB Indx-6.2* ___ ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== ___ 01:00PM BLOOD WBC-11.9* RBC-3.05* Hgb-8.6* Hct-28.8* MCV-94 MCH-28.2 MCHC-29.9* RDW-15.9* RDWSD-54.6* Plt ___ ___ 01:00PM BLOOD Glucose-138* UreaN-45* Creat-2.2* Na-139 K-4.3 Cl-98 HCO3-28 AnGap-13 ___ 08:11AM BLOOD ALT-36 AST-46* AlkPhos-222* TotBili-0.5 ___ 12:40PM BLOOD cTropnT-0.44* ___ 03:00PM BLOOD cTropnT-0.58* ___ 09:37PM BLOOD CK-MB-26* cTropnT-0.97* ___ 02:40PM BLOOD CK-MB-12* MB Indx-6.0 cTropnT-0.86* ___ 08:11AM BLOOD TSH-4.3* ___ 08:11AM BLOOD Free T4-1.0 =========================== REPORTS AND IMAGING STUDIES =========================== ___ CXR PA AND LAT FINDINGS: AP upright and lateral views of the chest provided. A right pleural effusion is mild to moderate in size. There is pulmonary vascular congestion with mild to moderate pulmonary edema. Opacity at the right lung base likely reflects compressive atelectasis, difficult to exclude a developing pneumonia. The heart remains mild to moderately enlarged. Mediastinal contour is stable. Bony structures are intact. IMPRESSION: Mild to moderate pulmonary edema with moderate right pleural effusion and right basal opacity likely compressive atelectasis, difficult to exclude a developing pneumonia. ___ TTE The left atrial volume index is mildly increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is a small area of regional left ventricular systolic dysfunction with hypokinesis of the basal-mid inferior walls (see schematic). Overall left ventricular systolic function is low normal. The visually estimated left ventricular ejection fraction is 50-55%. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Normal right ventricular cavity size with low normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. There is a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is an eccentric, inferolateral directed jet of mild to moderate [___] mitral regurgitation. Due to the Coanda effect, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. The effusion is echo dense, c/w blood, inflammation or other cellular elements. IMPRESSION: Low-normal biventricular systolic function with hypokinesis of the basal-mid inferior walls. Increased left ventricular filling pressure. Mild to moderate mitral regurgitation. Mild tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior TTE ___, the severity of mitral regurgitation has minimally increased and the severity of tricuspid regurgitation has minimally decreased. ============ MICROBIOLOGY ============ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>___ R CEFEPIME-------------- R CEFTAZIDIME----------- 16 I CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: ================= SUMMARY STATEMENT ================= Mr. ___ is an ___ y/o M w/ HFpEF, possible COPD, CKD, dementia, T2DM, BPH, and recent admission from ___ for CHF exacerbation who presented for hypoxia and dyspnea. He was found to have a type II NSTEMI that was likely related to acute heart failure with preserved ejection fraction. He was given IV diuretics. He was also found to have a healthcare associated pneumonia and was treated with a five day course of broad antibitoics. He was also found to have a multi-drug resistant UTI and was treated initially with nitrofurantoin and eventually with fosfomycin for this. He had episodes of hyperactive delirium and was treated with behavior redirection and low dose haloperidol on two occasions. =================== TRANSITIONAL ISSUES =================== - New Meds: None - Stopped/Held Meds: - Changed Meds: Metoprolol succinate 200mg BID was changed to 200mg daily - Post-Discharge Follow-up Labs Needed: Routine monitoring of CKD - Discharge weight: 70.2 kg (154.76 lb) [ ] Patient was treated for hyperactive delirium with PRN Haldol at a low dose. His delirium was thought to be related to a combination of a foreign environment in addition to both a pneumonia and a urinary tract infection. Should he have worsening delirium, low dose oral Haldol, such as 0.5mg PRN, could be considered going forward. He was not experiencing any delirium at the time of discharge. [ ] Patient noted to have episodes of nighttime hypoxia and should have evaluation for OSA. [ ] Patient should have daily standing weights to monitor for evidence of volume overload. If weight increases 3 pounds, consider increasing diuretic dose. ==================== ACUTE MEDICAL ISSUES ==================== #Acute HFpEF Exacerbation Presented in acute HFpEF, supported by elevated ___ ___: ___ -> ___: ___ as well as evidence of volume overload on exam and imaging, and hypoxia. Likely etiology is secondary to diuretics being held over last few days as well as possible infection. Also appears to have elevated cardiac markers, but suspect this likely represents a type II NSTEMI due to strain from acute HFpEF. The repeat echo ___ demonstrated LVEF 50-55% with increased LV filling pressure suggestive of volume overload. After IV diuresis, had improvement in volume exam and hypoxia. - PRELOAD: Resumed on home furosemide 40mg daily by discharge - AFTERLOAD: Continue on amlodipine 10mg daily and isosorbide mononitrate 30mg daily - NHBK: Metoprolol succinate 200mg BID was decreased due to acute heart failure and restarted at a reduced dose on discharge. Recommended 200mg daily and uptitrate as needed. #. Hypoxemic respiratory failure #. Possible PNA Likely patient's dyspnea represents HF exacerbation. However given findings concerning for PNA on outside images few days prior to presentation, mild white count elevation, and possiblefevers/chills prior to presentation, he was treated with hospital acquired pneumonia given recent hospital exposure and residence in a nursing facility. Patient also with questionable history of COPD (no PFTs in chart), which may be contributing to his hypoxia. Finally, his hypoxia was noted to worsen overnight and he may have an element of OSA. Treated with vancomycin and ceftazadime for a five day course ___ to ___. #. NSTEMI Elevated CK-MB and rising trops in setting of new ST-depression in ___ leads concerning for NSTEMI. Likely secondary to his HF exacerbation as well as possible infection, especially given patient without preceding chest discomfort. Trops and CK-MB downtrended. The repeat echo ___ demonstrated LVEF 50-55% with increased LV filling pressure suggestive of volume overload. Therefore, we presume this was a type II NSTEMI related to heart failure. He was continued on aspirin, atorvastatin, isosorbide mononitrate, and metoprolol. #. Acute on Chronic Kidney Disease Baseline Cr prior to last hospitalization appears 1.7-1.9, but was in the low 2's on last discharge. Currently similar to previous hospitalization, which may represent progression of underlying CKD vs cardiorenal. Given acute volume overload state, seems appropriate to continue to trial diuretics and monitor renal function. Renal U/S ___ w/o evidence of obstructive process/hydro. #. Urinary tract infection Patient without specific complaints of suprapubic pain, but his daughter reports that patient had endorsed frequency and urgency. He recently completed treatment for E.coli UTI w/ Bactrim. Covered by antibiotics as above. Ucx positive for e.coli >100,000. Initially treated with nitrofurantoin, but given his low GFR, he was ultimately given a single dose of fosfomycin to complete his treatment on ___. Delirium Patient experienced waxing and waning hyperactive delirium manifested as refusing vital signs and meds and at times being physically combative. We suspect this was due to a foreign environment and experiencing multiple infections and a heart failure exacerbation. Haloperidol was used on two occasions due to delirium with good effect. Should he continue to experience delirium, low dose oral haloperidol of 0.5mg may be useful. Other delirium precautions are as follows - Encourage movement (getting out of bed in order towalk)with necessary assistance to avoid falls - Having someone help during meals and having him sit upright to minimize the risk of aspiration PNA - Maintain a regular night-day/sleep-wake cycle when possible and avoiding sleep deprivation, and maintain a reassuring and familiar environment -Avoid overstimulation (eg, multiple visitors, loud noise) -Avoid understimulation (darkened room, complete silence) ====================== CHRONIC MEDICAL ISSUES ====================== #. Hypothyroidism: Continued levothyroxine #. T2DM: Continued glargine with low dose ISS #. BPH: Continue home finasteride, tamsulosin Discharge time 35 min Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. amLODIPine 10 mg PO DAILY 2. Docusate Sodium 100 mg PO QHS 3. Finasteride 5 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Polyethylene Glycol 17 g PO EVERY OTHER DAY 9. Senna 8.6 mg PO BID:PRN Constipation - First Line 10. Tamsulosin 0.4 mg PO QHS 11. Vitamin D 400 UNIT PO DAILY 12. Aspirin 81 mg PO DAILY 13. Atorvastatin 40 mg PO QPM 14. GuaiFENesin ___ mL PO BID 15. Lactulose 30 mL PO DAILY 16. melatonin 3 mg oral QHS 17. Metoprolol Succinate XL 200 mg PO BID 18. Glargine 9 Units Bedtime Discharge Medications: 1. Glargine 9 Units Bedtime 2. Metoprolol Succinate XL 200 mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Docusate Sodium 100 mg PO QHS 7. Finasteride 5 mg PO DAILY 8. Furosemide 40 mg PO DAILY 9. GuaiFENesin ___ mL PO BID 10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 11. Lactulose 30 mL PO DAILY 12. Levothyroxine Sodium 50 mcg PO DAILY 13. melatonin 3 mg oral QHS 14. Multivitamins 1 TAB PO DAILY 15. Polyethylene Glycol 17 g PO EVERY OTHER DAY 16. Senna 8.6 mg PO BID:PRN Constipation - First Line 17. Tamsulosin 0.4 mg PO QHS 18. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute heart failure with preserved ejection fraction Healthcare associated pneumonia Urinary tract infection Delirium Type II NSTEMI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you while you were admitted to ___ ___. WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were found to have a low oxygen level WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We gave you diuretic medications to get extra fluid off of your body - We treated you for a pneumonia - We treated you for a urinary tract infection - There was evidence of some strain on your heart from heart failure, and this improved as we got fluid off your body - You became confused at points and we think this is related to your infections WHAT SHOULD YOU DO WHEN YOU GO HOME? - Carefully review the attached medication list as we may have made changes to your medications. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your ___ Care team Followup Instructions: ___	[ "I130", "I5033", "I214", "J189", "J9691", "N179", "N390", "F05", "N189", "E1122", "Z7984", "B9620", "E039", "N400", "G4733", "Z96642" ]	Allergies: morphine Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is an [MASKED] y/o M w/ HFpEF (EF 55% in [MASKED], possible COPD, CKD, dementia, T2DM, BPH, and recent admission from [MASKED] for CHF exacerbation, presenting now for worsening dyspnea. Of note, patient was recently admitted from [MASKED] for a CHF exacerbation, complicated by E.coli UTI treated with Bactrim, and acute on chronic kidney injury. At that time, patient initially presented with significant dyspnea, requiring BiPAP, which improved rapidly with diuresis. His [MASKED] was originally thought secondary to cardiorenal, but worsened with continued diuresis, and thus there was some concern for prerenal azotemia. However, Cr improved prior to d/c. Per report, patient was evaluated 3 days ago for dyspnea, and was felt to have CXR concerning for PNA. He was started on an antibiotics (unknown what), and had his furosemide held given he was euvolemic. This morning, he was noted by nursing at his facility to have a worsened respiratory status, wheezing, non-productive cough, and an oxygen saturation to 86% on RA, which improved to 97% on 4L NC. In the ED: In the setting of his diuresis being held, and labs, imaging, and exam, he was felt to likely have repeat CHF exacerbation. This was possibly triggered by PNA, and thus patient was started on coverage for HCAP with cefepime and Vancomycin. In the setting of his uptrending cardiac markers there was also concern for possible ACS, and thus he was started on heparin IV. - Initial VS: Temp 97.8 HR 88 BP 110/64 RR 28 SpO2 97% 4L NC - Exam notable for: Confused at baseline. Wheezing throughout. Increased respiratory effort with abdominal breathing. No crackles appreciated. Mild swelling in bilateral legs. No JVD. No murmur rubs gallops. RRR. - EKG: Notable for new ST depression in lateral leads - Labs notable for: -- Lactate 3.1 -> 1.6 -- Trop: 0.44 -> 0.58 -- CK-MB: 29 w/ MBI: 6.02 -- [MASKED]: [MASKED] -- Cr: 2.3 - Studies notable for: -- CXR: Mild to moderate pulmonary edema with moderate right pleural effusion and right basal opacity likely compressive atelectasis, difficult to exclude a developing pneumonia. - Consults: -- Cardiology: Agreed with admission to [MASKED] and continuing Heparin in setting of uptrending cardiac markers - Patient was given: Nebulizers, Cefepime 2g, Vancomycin 1g, 40mg IV Lasix x2 - Vitals on transfer: Temp 98.3 HR 81 BP 112/61 RR 23 96% 4L NC On the floor, very little further history could be obtained as patient is a poor historian, and wife was not aware of all the details that had transpired over the last few days. She did confirm much of the story as above, and also noted he may have felt feverish and chills in the days prior to presentation. REVIEW OF SYSTEMS: Negative except as noted above Past Medical History: 1. CARDIAC RISK FACTORS - DMII - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Coronaries: Unknown - HFpEF, EF 55% [MASKED] - NSR 3. OTHER PAST MEDICAL HISTORY -BPH -Head lesion after falling off a horse many years ago -Shoulder surgery status post motor vehicle accident -h/o prostate surgery -Olfactory groove Meningioma -L hip replacement -Hypothyroidism Social History: [MASKED] Family History: Per report, has family history of lung cancer and heart disease, but unclear what disease specifically or in whom. Physical Exam: ADMISSION PHYSICAL EXAMINATION ============================== VS: Reviewed in [MASKED] GENERAL: Well developed male in no acute distress HEENT: Mucus membranes dry, JVP elevated to below ear lobe at 65 degrees CARDIAC: RRR, no murmurs, rubs, or gallops LUNGS: Mildly increased work of breathing. Diffuse wheezing noted throughout, with decreased breath sounds in lower lung bases R>L. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. [MASKED] edema up to mid-shin PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAMINATION ============================== 24 HR Data (last updated [MASKED] @ 638) Temp: 98.8 (Tm 99.1), BP: 141/61 (102-141/58-66), HR: 80 (63-80), RR: 20 ([MASKED]), O2 sat: 97% (81-100), O2 delivery: 2L (2L NCL-4L), Wt: 154.76 lb/70.2 kg GENERAL: Well developed male in no acute distress. Pleasant to speak with and smiling. Understands some [MASKED]. HEENT: Mucus membranes dry. NCAT CARDIAC: RRR, no murmurs, rubs, or gallops LUNGS: Breathing comfortable on RA. Transmitted upper airway sounds with decreased breath sounds in lower lung bases. ABDOMEN: Soft, non-tender, non-distended. EXTREMITIES: Warm, well perfused. No lower extremity edema. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ============================ ADMISSION LABORATORY STUDIES ============================ [MASKED] 12:40PM BLOOD Glucose-199* UreaN-46* Creat-2.3* Na-135 K-4.4 Cl-99 HCO3-22 AnGap-14 [MASKED] 12:40PM BLOOD [MASKED] PTT-33.3 [MASKED] [MASKED] 12:40PM BLOOD WBC-11.0* RBC-3.21* Hgb-9.1* Hct-30.0* MCV-94 MCH-28.3 MCHC-30.3* RDW-15.9* RDWSD-54.5* Plt [MASKED] [MASKED] 12:40PM BLOOD CK-MB-29* MB Indx-6.2* [MASKED] ========================================== DISCHARGE AND PERTINENT LABORATORY STUDIES ========================================== [MASKED] 01:00PM BLOOD WBC-11.9* RBC-3.05* Hgb-8.6* Hct-28.8* MCV-94 MCH-28.2 MCHC-29.9* RDW-15.9* RDWSD-54.6* Plt [MASKED] [MASKED] 01:00PM BLOOD Glucose-138* UreaN-45* Creat-2.2* Na-139 K-4.3 Cl-98 HCO3-28 AnGap-13 [MASKED] 08:11AM BLOOD ALT-36 AST-46* AlkPhos-222* TotBili-0.5 [MASKED] 12:40PM BLOOD cTropnT-0.44* [MASKED] 03:00PM BLOOD cTropnT-0.58* [MASKED] 09:37PM BLOOD CK-MB-26* cTropnT-0.97* [MASKED] 02:40PM BLOOD CK-MB-12* MB Indx-6.0 cTropnT-0.86* [MASKED] 08:11AM BLOOD TSH-4.3* [MASKED] 08:11AM BLOOD Free T4-1.0 =========================== REPORTS AND IMAGING STUDIES =========================== [MASKED] CXR PA AND LAT FINDINGS: AP upright and lateral views of the chest provided. A right pleural effusion is mild to moderate in size. There is pulmonary vascular congestion with mild to moderate pulmonary edema. Opacity at the right lung base likely reflects compressive atelectasis, difficult to exclude a developing pneumonia. The heart remains mild to moderately enlarged. Mediastinal contour is stable. Bony structures are intact. IMPRESSION: Mild to moderate pulmonary edema with moderate right pleural effusion and right basal opacity likely compressive atelectasis, difficult to exclude a developing pneumonia. [MASKED] TTE The left atrial volume index is mildly increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is [MASKED] mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is a small area of regional left ventricular systolic dysfunction with hypokinesis of the basal-mid inferior walls (see schematic). Overall left ventricular systolic function is low normal. The visually estimated left ventricular ejection fraction is 50-55%. Left ventricular cardiac index is normal (>2.5 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Normal right ventricular cavity size with low normal free wall motion. Tricuspid annular plane systolic excursion (TAPSE) is normal. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. There is a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is an eccentric, inferolateral directed jet of mild to moderate [[MASKED]] mitral regurgitation. Due to the Coanda effect, the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. The effusion is echo dense, c/w blood, inflammation or other cellular elements. IMPRESSION: Low-normal biventricular systolic function with hypokinesis of the basal-mid inferior walls. Increased left ventricular filling pressure. Mild to moderate mitral regurgitation. Mild tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior TTE [MASKED], the severity of mitral regurgitation has minimally increased and the severity of tricuspid regurgitation has minimally decreased. ============ MICROBIOLOGY ============ URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>[MASKED] R CEFEPIME-------------- R CEFTAZIDIME----------- 16 I CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: ================= SUMMARY STATEMENT ================= Mr. [MASKED] is an [MASKED] y/o M w/ HFpEF, possible COPD, CKD, dementia, T2DM, BPH, and recent admission from [MASKED] for CHF exacerbation who presented for hypoxia and dyspnea. He was found to have a type II NSTEMI that was likely related to acute heart failure with preserved ejection fraction. He was given IV diuretics. He was also found to have a healthcare associated pneumonia and was treated with a five day course of broad antibitoics. He was also found to have a multi-drug resistant UTI and was treated initially with nitrofurantoin and eventually with fosfomycin for this. He had episodes of hyperactive delirium and was treated with behavior redirection and low dose haloperidol on two occasions. =================== TRANSITIONAL ISSUES =================== - New Meds: None - Stopped/Held Meds: - Changed Meds: Metoprolol succinate 200mg BID was changed to 200mg daily - Post-Discharge Follow-up Labs Needed: Routine monitoring of CKD - Discharge weight: 70.2 kg (154.76 lb) [ ] Patient was treated for hyperactive delirium with PRN Haldol at a low dose. His delirium was thought to be related to a combination of a foreign environment in addition to both a pneumonia and a urinary tract infection. Should he have worsening delirium, low dose oral Haldol, such as 0.5mg PRN, could be considered going forward. He was not experiencing any delirium at the time of discharge. [ ] Patient noted to have episodes of nighttime hypoxia and should have evaluation for OSA. [ ] Patient should have daily standing weights to monitor for evidence of volume overload. If weight increases 3 pounds, consider increasing diuretic dose. ==================== ACUTE MEDICAL ISSUES ==================== #Acute HFpEF Exacerbation Presented in acute HFpEF, supported by elevated [MASKED] [MASKED]: [MASKED] -> [MASKED]: [MASKED] as well as evidence of volume overload on exam and imaging, and hypoxia. Likely etiology is secondary to diuretics being held over last few days as well as possible infection. Also appears to have elevated cardiac markers, but suspect this likely represents a type II NSTEMI due to strain from acute HFpEF. The repeat echo [MASKED] demonstrated LVEF 50-55% with increased LV filling pressure suggestive of volume overload. After IV diuresis, had improvement in volume exam and hypoxia. - PRELOAD: Resumed on home furosemide 40mg daily by discharge - AFTERLOAD: Continue on amlodipine 10mg daily and isosorbide mononitrate 30mg daily - NHBK: Metoprolol succinate 200mg BID was decreased due to acute heart failure and restarted at a reduced dose on discharge. Recommended 200mg daily and uptitrate as needed. #. Hypoxemic respiratory failure #. Possible PNA Likely patient's dyspnea represents HF exacerbation. However given findings concerning for PNA on outside images few days prior to presentation, mild white count elevation, and possiblefevers/chills prior to presentation, he was treated with hospital acquired pneumonia given recent hospital exposure and residence in a nursing facility. Patient also with questionable history of COPD (no PFTs in chart), which may be contributing to his hypoxia. Finally, his hypoxia was noted to worsen overnight and he may have an element of OSA. Treated with vancomycin and ceftazadime for a five day course [MASKED] to [MASKED]. #. NSTEMI Elevated CK-MB and rising trops in setting of new ST-depression in [MASKED] leads concerning for NSTEMI. Likely secondary to his HF exacerbation as well as possible infection, especially given patient without preceding chest discomfort. Trops and CK-MB downtrended. The repeat echo [MASKED] demonstrated LVEF 50-55% with increased LV filling pressure suggestive of volume overload. Therefore, we presume this was a type II NSTEMI related to heart failure. He was continued on aspirin, atorvastatin, isosorbide mononitrate, and metoprolol. #. Acute on Chronic Kidney Disease Baseline Cr prior to last hospitalization appears 1.7-1.9, but was in the low 2's on last discharge. Currently similar to previous hospitalization, which may represent progression of underlying CKD vs cardiorenal. Given acute volume overload state, seems appropriate to continue to trial diuretics and monitor renal function. Renal U/S [MASKED] w/o evidence of obstructive process/hydro. #. Urinary tract infection Patient without specific complaints of suprapubic pain, but his daughter reports that patient had endorsed frequency and urgency. He recently completed treatment for E.coli UTI w/ Bactrim. Covered by antibiotics as above. Ucx positive for e.coli >100,000. Initially treated with nitrofurantoin, but given his low GFR, he was ultimately given a single dose of fosfomycin to complete his treatment on [MASKED]. Delirium Patient experienced waxing and waning hyperactive delirium manifested as refusing vital signs and meds and at times being physically combative. We suspect this was due to a foreign environment and experiencing multiple infections and a heart failure exacerbation. Haloperidol was used on two occasions due to delirium with good effect. Should he continue to experience delirium, low dose oral haloperidol of 0.5mg may be useful. Other delirium precautions are as follows - Encourage movement (getting out of bed in order towalk)with necessary assistance to avoid falls - Having someone help during meals and having him sit upright to minimize the risk of aspiration PNA - Maintain a regular night-day/sleep-wake cycle when possible and avoiding sleep deprivation, and maintain a reassuring and familiar environment -Avoid overstimulation (eg, multiple visitors, loud noise) -Avoid understimulation (darkened room, complete silence) ====================== CHRONIC MEDICAL ISSUES ====================== #. Hypothyroidism: Continued levothyroxine #. T2DM: Continued glargine with low dose ISS #. BPH: Continue home finasteride, tamsulosin Discharge time 35 min Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. amLODIPine 10 mg PO DAILY 2. Docusate Sodium 100 mg PO QHS 3. Finasteride 5 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Polyethylene Glycol 17 g PO EVERY OTHER DAY 9. Senna 8.6 mg PO BID:PRN Constipation - First Line 10. Tamsulosin 0.4 mg PO QHS 11. Vitamin D 400 UNIT PO DAILY 12. Aspirin 81 mg PO DAILY 13. Atorvastatin 40 mg PO QPM 14. GuaiFENesin [MASKED] mL PO BID 15. Lactulose 30 mL PO DAILY 16. melatonin 3 mg oral QHS 17. Metoprolol Succinate XL 200 mg PO BID 18. Glargine 9 Units Bedtime Discharge Medications: 1. Glargine 9 Units Bedtime 2. Metoprolol Succinate XL 200 mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Docusate Sodium 100 mg PO QHS 7. Finasteride 5 mg PO DAILY 8. Furosemide 40 mg PO DAILY 9. GuaiFENesin [MASKED] mL PO BID 10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 11. Lactulose 30 mL PO DAILY 12. Levothyroxine Sodium 50 mcg PO DAILY 13. melatonin 3 mg oral QHS 14. Multivitamins 1 TAB PO DAILY 15. Polyethylene Glycol 17 g PO EVERY OTHER DAY 16. Senna 8.6 mg PO BID:PRN Constipation - First Line 17. Tamsulosin 0.4 mg PO QHS 18. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Acute heart failure with preserved ejection fraction Healthcare associated pneumonia Urinary tract infection Delirium Type II NSTEMI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure caring for you while you were admitted to [MASKED] [MASKED]. WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were found to have a low oxygen level WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We gave you diuretic medications to get extra fluid off of your body - We treated you for a pneumonia - We treated you for a urinary tract infection - There was evidence of some strain on your heart from heart failure, and this improved as we got fluid off your body - You became confused at points and we think this is related to your infections WHAT SHOULD YOU DO WHEN YOU GO HOME? - Carefully review the attached medication list as we may have made changes to your medications. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Sincerely, Your [MASKED] Care team Followup Instructions: [MASKED]	[]	[ "I130", "N179", "N390", "N189", "E1122", "E039", "N400", "G4733" ]	[ "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", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J189: Pneumonia, unspecified organism", "J9691: Respiratory failure, unspecified with hypoxia", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "F05: Delirium due to known physiological condition", "N189: Chronic kidney disease, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z7984: Long term (current) use of oral hypoglycemic drugs", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E039: Hypothyroidism, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z96642: Presence of left artificial hip joint" ]
19,982,989	27,049,214	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: NONE History of Present Illness: ___ y/o M w/ HFpEF (HFpEF, EF 50% ___, possible COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF exacerbation from ___ (discharge weight 70.2 kg (154.76 lb)) presenting from nursing facility with shortness of breath since this morning. He also endorses some chest pain. Further history is unavailable due to patient acuity. He arrives on BiPAP. In the ED, the patient was unable to be weaned off BiPAP and found to be in an acute heart failure exacerbation. - Initial vitals were: T97, BP 118-145/52-83, HR70s, RR low20s, Sat100% on BiPAP - Exam notable for: Bilateral peripheral edema. Scattered rales. Diminished at the right lower lung field. - Labs notable for: Hb 8.5, BUN 47, Cr 2.1 (baseline 2.1-2.3 per last admission), alk phos 173, trop 0.06, lactate 1.6, ___ 14416 (21,000 in previous admission) - Studies notable for: EKG Sinus rhythm with ventricular bigeminy - Patient was given: 40mg Lasix, then redosed with 80mg Lasix; Vanc+Zosyn, nitroglycerin SL On arrival to the CCU, patient continues on BiPAP and is overall confused. Family bedside and reports that the patient continues to experience shortness of breath although much less now that he has respiratory support. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS - DMII - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Coronaries: Unknown - HFpEF, EF 55% ___ (?46% on ___ - NSR 3. OTHER PAST MEDICAL HISTORY -BPH -Head lesion after falling off a horse many years ago -Shoulder surgery status post motor vehicle accident -h/o prostate surgery -Olfactory groove Meningioma -L hip replacement -Hypothyroidism Social History: ___ Family History: Per report, has family history of lung cancer and heart disease, but unclear what disease specifically or in whom. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= PHYSICAL EXAMINATION: VS: afebrile BP: HR:70s Sat 100% on BiPAP GENERAL: Well developed, well nourished. On BiPAP. Oriented to person and place but not situation, somewhat confused. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP at earlobe at 65 degrees. CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is labored with accessory muscle use. Scattered rales. Diminished at the right lower lung field. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: moves all extremities spontaneously without FND DISCHARGE PHYSICAL EXAM: ======================= GENERAL: Oriented x0. Delirious and agitated. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: CTAB. No chest wall deformities or tenderness. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. Trace peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: A&O x1. Pertinent Results: ADMISSION LABS: =============== ___ 10:18AM BLOOD WBC-8.2 RBC-3.02* Hgb-8.5* Hct-29.4* MCV-97 MCH-28.1 MCHC-28.9* RDW-17.3* RDWSD-62.2* Plt ___ ___ 10:18AM BLOOD Neuts-82.6* Lymphs-8.3* Monos-7.8 Eos-0.9* Baso-0.2 Im ___ AbsNeut-6.74* AbsLymp-0.68* AbsMono-0.64 AbsEos-0.07 AbsBaso-0.02 ___ 10:18AM BLOOD ___ PTT-34.2 ___ ___ 10:18AM BLOOD Glucose-137* UreaN-47* Creat-2.1* Na-139 K-4.6 Cl-101 HCO3-26 AnGap-12 ___ 10:18AM BLOOD ALT-18 AST-19 CK(CPK)-35* AlkPhos-173* TotBili-0.5 ___ 10:18AM BLOOD CK-MB-4 ___ ___ 10:18AM BLOOD Albumin-3.7 ___ 10:25AM BLOOD ___ pO2-23* pCO2-57* pH-7.30* calTCO2-29 Base XS--1 ___ 10:45AM BLOOD Type-ART PEEP-10 pO2-401* pCO2-47* pH-7.33* calTCO2-26 Base XS--1 Intubat-NOT INTUBA ___ 10:45AM BLOOD O2 Sat-98 ___ 01:42PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 01:42PM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE Epi-1 ___ 01:42PM URINE Mucous-RARE* PERTINENT LABS: ============== ___ 10:18AM BLOOD cTropnT-0.06* ___ 05:00PM BLOOD CK-MB-5 cTropnT-0.06* ___ 10:18AM BLOOD Lipase-16 ___ 10:25AM BLOOD Lactate-1.6 ___ 03:29PM BLOOD Lactate-1.4 DISCHARGE LABS: ============== ___ 07:53AM BLOOD WBC-6.7 RBC-3.20* Hgb-9.1* Hct-31.4* MCV-98 MCH-28.4 MCHC-29.0* RDW-16.3* RDWSD-58.0* Plt ___ ___ 05:34AM BLOOD ___ PTT-33.3 ___ ___ 07:53AM BLOOD Glucose-189* UreaN-43* Creat-2.4* Na-143 K-5.0 Cl-104 HCO3-24 AnGap-15 ___ 05:34AM BLOOD ALT-14 AST-33 ___ 05:46AM BLOOD ALT-15 AST-23 LD(LDH)-176 AlkPhos-155* TotBili-0.7 ___ 07:53AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.5 RELEVANT MICRO: ============== ___ 1:42 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: YEAST. < 10,000 CFU/mL. ___ 10:18 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 10:39 am BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): No growth to date. RELEVANT IMAGING: ================= ___ Cardiac Pefusion Pharm FINDINGS: Left ventricular cavity size is normal There is considerable soft tissue attenuation especially on the rest images, limiting interpretation. Rest and stress perfusion images reveal a probable moderate fixed perfusion defect in the inferolateral wall. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 55% IMPRESSION: Probable moderate fixed perfusion defect in the inferolateral wall. Soft tissue attenuation limits interpretation. ___ Stress (see above) INTERPRETATION: This ___ yo man with h/o HFpEF, CKD, possible COPD, and NIDDM was referred to the lab from the inpatient floor for evaluation of mild regional systolic dysfunction c/w CAD. The patient was administered 0.4 mg Regadenoson (Lexiscan) IV Bolus over 20 seconds. There were no reports of chest, back, neck, or arm discomforts during the study. In the setting of baseline STT abnormalities, the ST segments were uninterpretable for ischemia. Rhythm was sinus with rare isolated APBs and one VPB. There was an appropriate and heart rate response to the infusion. Post-MIBI, the Regadenoson was reversed with 60 mg Caffeine IV. IMPRESSION: No anginal type symptoms with uninterpretable EKG for ischemia. Nuclear report sent separately. ___ CT Head: FINDINGS: There is no evidence of infarction or hemorrhage. There is redemonstration of a hypodense extra-axial mass in the floor of the anterior cranial fossa with mild associated vasogenic edema measuring 3.7 x 3.2 cm, previously measuring 3.7 x 3.2 cm on prior study dated ___. There are bilateral periventricular and subcortical white matter hypodensities, nonspecific but compatible with sequelae of chronic small vessel ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. There is mild mucosal thickening of the left ethmoid air cells. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Stable olfactory groove meningioma, unchanged in size from prior study dated ___. ___ Renal Ultrasound: IMPRESSION: 1. No evidence of stones or hydronephrosis. 2. 1.4 cm cystic structure with thin avascular septations in the upper pole of the left kidney has decreased in size compared to prior, previously 1.9 cm. This likely represents a minimally complex cyst which requires no further follow-up, and is unlikely an abscess. ___ CXR: IMPRESSION: Cardiomegaly is severe, unchanged. Patient continues to be in interstitial pulmonary edema. Bilateral pleural effusion, large on the right and moderate on the left is unchanged. No pneumothorax. ___ TTE CONCLUSION: 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 a small area of regional left ventricular systolic dysfunction with hypokinesis of the inferoseptum, inferior, and inferolateral walls (see schematic) and preserved/normal contractility of the remaining segments. There is beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. Quantitative biplane left ventricular ejection fraction is 46 % (normal 54-73%). Normal right ventricular cavity size with normal free wall motion. The aortic valve is not well seen. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial pericardial effusion. A right pleural effusion is present IMPRESSION: Suboptimal image quality. Normal left ventricular wall thickness and cavity size with mild regional systolic dysfunction c/w CAD. Normal right ventricular cavity size and systolic function. Mild mitral regurgitation. Mild tricuspid regurgitation. ___ CXR IMPRESSION: Moderate pulmonary edema worsened slightly since ___. Moderate right pleural effusion is changed in distribution, but probably not in overall volume. Moderate cardiomegaly unchanged. No pneumothorax. ___ EKG Sinus rhythm Ventricular bigeminy Compared with the previous tracing of ___, ventricular ectopic activity now present. ___ CXR IMPRESSION: Moderate right and probable small left pleural effusion. Significant atelectasis in the right middle and lower lobes. Congestion with probable mild edema. Brief Hospital Course: ___ with a history of HFpEF (HFpEF, EF ___, possible COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF exacerbation from ___ presenting with shortness of breath from his nursing facility concerning for acute on chronic HFpEF exacerbation requiring CCU admission for BiPAP. Discharged euvolemic. TRANSITIONAL ISSUES ==================== Discharge wt: unknown Discharge Cr: ___: 2.4 (not at baseline) Discharge diuretic: torsemide 30mg PO daily [] discharged on torsemide 30 daily, may need titration to prevent future hospitalizations--please weight at ___ home daily and adjust diuretic accordingly [] can consider spiranolactone once patient's kidney function improves [] Consider ___ if renal function allows [] Ziopatch can be considered as an outpatient to assess if arrythmias are contributing to his presentation [] Would enforce daily weights at nursing home as well as 2g Na diet and 2L fluid restriction [] Patient has been having urinary retention during admission, needs f/u regarding this [] Patient discharged on Cr of 2.4 (somewhat above baseline), please recheck creatine ___ to ensure torsemide dose is appropriate [] needs f/u creatine in 1 week to assess for resolution of ___. [] Needs diet advanced as tolerated [] On olanzapine, need to monitor for medication adverse effects. [] Advance diet as tolerated [] Will need further evaluation for etiology of increased recent admissions for HF excerbation # CODE STATUS: Full (presumed) # CONTACT: ___ ___ (daughter) BRIEF HOSPITAL COURSE: ====================== ___ with a history of HFpEF (HFpEF, EF ___, possible COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF exacerbation from ___ presenting with shortness of breath from his nursing facility concerning for acute on chronic HFpEF exacerbation requiring CCU admission for BiPAP. He was diuresed with Lasix IV, along with Lasix gtt. Transferred to the floor where IV diuresis was continued but then transitioned to POs. Held PO diuresis for a few days in setting of ___. Then discharged on torsemide 30 daily PO. His course was complicated by severe agitation in the setting of delirium and dementia, improved with Foley removal. # CORONARIES: unknown # PUMP: HFpEF, EF 50% ___ # RHYTHM: normal sinus rhythm ACUTE ISSUES: ============= # Acute on chronic HFpEF Exacerbation: Previous admission mid ___ for HFrEF exacerbation, now with similar presentation with SOB, chest pain, BNP elevation, small bump in trop, and stable ECG. He required CCU admission for BiPAP. He was diuresed with Lasix IV, along with Lasix drip then transferred to the floor where IV diuresis was continued but then transitioned to POs. Held PO diuresis for a few days in setting of ___. Then resumed. Discharged on torsemide 30 daily. His course was complicated by severe agitation in the setting of delirium and dementia. Also discharged on metoprolol 25 daily, isosorbide mononitrate 30, atrovostatin 80, ASA 81, and torsemide 30 daily. Discharge dry weight unknown and discharge creatinine of 2.4 (not baseline creatinine due to ___. Goals of care discussion held with daughter who continues to prefer pursuing aggressive care. # Hypoxemic respiratory failure # Potential PNA: Likely patient's dyspnea represents HF exacerbation. Less likely PNA in light of lack of fever, elevation of WBC, however pulmonary exam on admission revealed decreased diminished lung sounds at the right lower lung field, concerning for PNA. CXR in ED showed moderate right and probable small left pleural effusion along with significant atelectasis in the right middle and lower lobes and congestion with probable mild edema. He was given vancomycin/Zosyn in the ED, but these were discontinued on admission given low likelihood for infection. Improved oxygenation with diuresis. Approrpiate sats on RA at discharge. # Chronic Kidney Disease: Baseline Cr in the low 2's on last discharge, at baseline. Likely underlying CKD vs cardiorenal. Given acute volume overload state, seemed appropriate to continue diuretic and monitor renal function. Renal U/S ___ without evidence of obstructive process/hydro. # Hyperactive delirium # Dementia: Patient with underlying dementia complicated by delirium in the ICU. Tried to regulate sleep wake cycle with ramelteon qhs and Zyprexa standing, required IV antipsychotic doses intermittently. No signs of metabolic disturbance, infection, worsened hypoxia or hypercarbia as contributing factors. Likely worse ___ hospital stay. Delerium improved over hospitalization. #Nutritional Status Had mental status changes that required patient to be NPO for a few days but then transitioned back to a diet. Please advance as tolerated. CHRONIC/STABLE/RESOLVED ISSUES: =============================== # Hypothyroidism Patient continued on home levothyroxine 50mcg daily # BPH Patient continued home finasteride 5mg daily and home tamsulosin 0.4mg daily # T2DM Monitored Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Docusate Sodium 100 mg PO QHS 6. Finasteride 5 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Tamsulosin 0.4 mg PO QHS 11. Vitamin D 400 UNIT PO DAILY 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Discharge Medications: 1. OLANZapine 5 mg PO QHS delerium 2. Torsemide 30 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Docusate Sodium 100 mg PO QHS 7. Finasteride 5 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Tamsulosin 0.4 mg PO QHS 12. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Acute on Chronic HFpEF Exacerbation Hypoxemic hypercapnic respiratory failure SECONDARY DIAGNOSES ==================== Acute Delirium Dementia Poor nutrition Chronic Kidney Disease Benign Prostatic Hyperplasia Hypothyroidism Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were having shortness of breath WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You were placed on a breathing mask to help you breathe - You were treated with a water pill to help clear the fluid in your lungs that made it hard for you to breathe - You were given medications to treat your high blood pressure - You were seen by our specialists in geriatrics who recommended medications to help with your behavior disturbances at night WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Weigh yourself every morning, seek medical attention if your weight goes up or down by more than 3 lbs in a day or 5 pounds in a week. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at ___! We wish you all the best! - Your ___ Care Team Followup Instructions: ___	[ "I130", "I5033", "J9692", "J9691", "F05", "E872", "E1122", "N189", "F0390", "E039", "Z96642", "E785", "N401", "R338", "Z781" ]	Allergies: morphine Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: NONE History of Present Illness: [MASKED] y/o M w/ HFpEF (HFpEF, EF 50% [MASKED], possible COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF exacerbation from [MASKED] (discharge weight 70.2 kg (154.76 lb)) presenting from nursing facility with shortness of breath since this morning. He also endorses some chest pain. Further history is unavailable due to patient acuity. He arrives on BiPAP. In the ED, the patient was unable to be weaned off BiPAP and found to be in an acute heart failure exacerbation. - Initial vitals were: T97, BP 118-145/52-83, HR70s, RR low20s, Sat100% on BiPAP - Exam notable for: Bilateral peripheral edema. Scattered rales. Diminished at the right lower lung field. - Labs notable for: Hb 8.5, BUN 47, Cr 2.1 (baseline 2.1-2.3 per last admission), alk phos 173, trop 0.06, lactate 1.6, [MASKED] 14416 (21,000 in previous admission) - Studies notable for: EKG Sinus rhythm with ventricular bigeminy - Patient was given: 40mg Lasix, then redosed with 80mg Lasix; Vanc+Zosyn, nitroglycerin SL On arrival to the CCU, patient continues on BiPAP and is overall confused. Family bedside and reports that the patient continues to experience shortness of breath although much less now that he has respiratory support. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS - DMII - Hypertension - Dyslipidemia 2. CARDIAC HISTORY - Coronaries: Unknown - HFpEF, EF 55% [MASKED] (?46% on [MASKED] - NSR 3. OTHER PAST MEDICAL HISTORY -BPH -Head lesion after falling off a horse many years ago -Shoulder surgery status post motor vehicle accident -h/o prostate surgery -Olfactory groove Meningioma -L hip replacement -Hypothyroidism Social History: [MASKED] Family History: Per report, has family history of lung cancer and heart disease, but unclear what disease specifically or in whom. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= PHYSICAL EXAMINATION: VS: afebrile BP: HR:70s Sat 100% on BiPAP GENERAL: Well developed, well nourished. On BiPAP. Oriented to person and place but not situation, somewhat confused. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. NECK: Supple. JVP at earlobe at 65 degrees. CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: No chest wall deformities or tenderness. Respiration is labored with accessory muscle use. Scattered rales. Diminished at the right lower lung field. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: moves all extremities spontaneously without FND DISCHARGE PHYSICAL EXAM: ======================= GENERAL: Oriented x0. Delirious and agitated. HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or gallops. LUNGS: CTAB. No chest wall deformities or tenderness. ABDOMEN: Soft, non-tender, non-distended. No palpable hepatomegaly or splenomegaly. EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. Trace peripheral edema. SKIN: No significant lesions or rashes. PULSES: Distal pulses palpable and symmetric. NEURO: A&O x1. Pertinent Results: ADMISSION LABS: =============== [MASKED] 10:18AM BLOOD WBC-8.2 RBC-3.02* Hgb-8.5* Hct-29.4* MCV-97 MCH-28.1 MCHC-28.9* RDW-17.3* RDWSD-62.2* Plt [MASKED] [MASKED] 10:18AM BLOOD Neuts-82.6* Lymphs-8.3* Monos-7.8 Eos-0.9* Baso-0.2 Im [MASKED] AbsNeut-6.74* AbsLymp-0.68* AbsMono-0.64 AbsEos-0.07 AbsBaso-0.02 [MASKED] 10:18AM BLOOD [MASKED] PTT-34.2 [MASKED] [MASKED] 10:18AM BLOOD Glucose-137* UreaN-47* Creat-2.1* Na-139 K-4.6 Cl-101 HCO3-26 AnGap-12 [MASKED] 10:18AM BLOOD ALT-18 AST-19 CK(CPK)-35* AlkPhos-173* TotBili-0.5 [MASKED] 10:18AM BLOOD CK-MB-4 [MASKED] [MASKED] 10:18AM BLOOD Albumin-3.7 [MASKED] 10:25AM BLOOD [MASKED] pO2-23* pCO2-57* pH-7.30* calTCO2-29 Base XS--1 [MASKED] 10:45AM BLOOD Type-ART PEEP-10 pO2-401* pCO2-47* pH-7.33* calTCO2-26 Base XS--1 Intubat-NOT INTUBA [MASKED] 10:45AM BLOOD O2 Sat-98 [MASKED] 01:42PM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 01:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* [MASKED] 01:42PM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE Epi-1 [MASKED] 01:42PM URINE Mucous-RARE* PERTINENT LABS: ============== [MASKED] 10:18AM BLOOD cTropnT-0.06* [MASKED] 05:00PM BLOOD CK-MB-5 cTropnT-0.06* [MASKED] 10:18AM BLOOD Lipase-16 [MASKED] 10:25AM BLOOD Lactate-1.6 [MASKED] 03:29PM BLOOD Lactate-1.4 DISCHARGE LABS: ============== [MASKED] 07:53AM BLOOD WBC-6.7 RBC-3.20* Hgb-9.1* Hct-31.4* MCV-98 MCH-28.4 MCHC-29.0* RDW-16.3* RDWSD-58.0* Plt [MASKED] [MASKED] 05:34AM BLOOD [MASKED] PTT-33.3 [MASKED] [MASKED] 07:53AM BLOOD Glucose-189* UreaN-43* Creat-2.4* Na-143 K-5.0 Cl-104 HCO3-24 AnGap-15 [MASKED] 05:34AM BLOOD ALT-14 AST-33 [MASKED] 05:46AM BLOOD ALT-15 AST-23 LD(LDH)-176 AlkPhos-155* TotBili-0.7 [MASKED] 07:53AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.5 RELEVANT MICRO: ============== [MASKED] 1:42 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: YEAST. < 10,000 CFU/mL. [MASKED] 10:18 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. [MASKED] 10:39 am BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): No growth to date. RELEVANT IMAGING: ================= [MASKED] Cardiac Pefusion Pharm FINDINGS: Left ventricular cavity size is normal There is considerable soft tissue attenuation especially on the rest images, limiting interpretation. Rest and stress perfusion images reveal a probable moderate fixed perfusion defect in the inferolateral wall. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 55% IMPRESSION: Probable moderate fixed perfusion defect in the inferolateral wall. Soft tissue attenuation limits interpretation. [MASKED] Stress (see above) INTERPRETATION: This [MASKED] yo man with h/o HFpEF, CKD, possible COPD, and NIDDM was referred to the lab from the inpatient floor for evaluation of mild regional systolic dysfunction c/w CAD. The patient was administered 0.4 mg Regadenoson (Lexiscan) IV Bolus over 20 seconds. There were no reports of chest, back, neck, or arm discomforts during the study. In the setting of baseline STT abnormalities, the ST segments were uninterpretable for ischemia. Rhythm was sinus with rare isolated APBs and one VPB. There was an appropriate and heart rate response to the infusion. Post-MIBI, the Regadenoson was reversed with 60 mg Caffeine IV. IMPRESSION: No anginal type symptoms with uninterpretable EKG for ischemia. Nuclear report sent separately. [MASKED] CT Head: FINDINGS: There is no evidence of infarction or hemorrhage. There is redemonstration of a hypodense extra-axial mass in the floor of the anterior cranial fossa with mild associated vasogenic edema measuring 3.7 x 3.2 cm, previously measuring 3.7 x 3.2 cm on prior study dated [MASKED]. There are bilateral periventricular and subcortical white matter hypodensities, nonspecific but compatible with sequelae of chronic small vessel ischemic disease. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. There is mild mucosal thickening of the left ethmoid air cells. Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Stable olfactory groove meningioma, unchanged in size from prior study dated [MASKED]. [MASKED] Renal Ultrasound: IMPRESSION: 1. No evidence of stones or hydronephrosis. 2. 1.4 cm cystic structure with thin avascular septations in the upper pole of the left kidney has decreased in size compared to prior, previously 1.9 cm. This likely represents a minimally complex cyst which requires no further follow-up, and is unlikely an abscess. [MASKED] CXR: IMPRESSION: Cardiomegaly is severe, unchanged. Patient continues to be in interstitial pulmonary edema. Bilateral pleural effusion, large on the right and moderate on the left is unchanged. No pneumothorax. [MASKED] TTE CONCLUSION: 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 a small area of regional left ventricular systolic dysfunction with hypokinesis of the inferoseptum, inferior, and inferolateral walls (see schematic) and preserved/normal contractility of the remaining segments. There is beat-to-beat variability in the left ventricular contractility due to the irregular rhythm. Quantitative biplane left ventricular ejection fraction is 46 % (normal 54-73%). Normal right ventricular cavity size with normal free wall motion. The aortic valve is not well seen. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial pericardial effusion. A right pleural effusion is present IMPRESSION: Suboptimal image quality. Normal left ventricular wall thickness and cavity size with mild regional systolic dysfunction c/w CAD. Normal right ventricular cavity size and systolic function. Mild mitral regurgitation. Mild tricuspid regurgitation. [MASKED] CXR IMPRESSION: Moderate pulmonary edema worsened slightly since [MASKED]. Moderate right pleural effusion is changed in distribution, but probably not in overall volume. Moderate cardiomegaly unchanged. No pneumothorax. [MASKED] EKG Sinus rhythm Ventricular bigeminy Compared with the previous tracing of [MASKED], ventricular ectopic activity now present. [MASKED] CXR IMPRESSION: Moderate right and probable small left pleural effusion. Significant atelectasis in the right middle and lower lobes. Congestion with probable mild edema. Brief Hospital Course: [MASKED] with a history of HFpEF (HFpEF, EF [MASKED], possible COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF exacerbation from [MASKED] presenting with shortness of breath from his nursing facility concerning for acute on chronic HFpEF exacerbation requiring CCU admission for BiPAP. Discharged euvolemic. TRANSITIONAL ISSUES ==================== Discharge wt: unknown Discharge Cr: [MASKED]: 2.4 (not at baseline) Discharge diuretic: torsemide 30mg PO daily [] discharged on torsemide 30 daily, may need titration to prevent future hospitalizations--please weight at [MASKED] home daily and adjust diuretic accordingly [] can consider spiranolactone once patient's kidney function improves [] Consider [MASKED] if renal function allows [] Ziopatch can be considered as an outpatient to assess if arrythmias are contributing to his presentation [] Would enforce daily weights at nursing home as well as 2g Na diet and 2L fluid restriction [] Patient has been having urinary retention during admission, needs f/u regarding this [] Patient discharged on Cr of 2.4 (somewhat above baseline), please recheck creatine [MASKED] to ensure torsemide dose is appropriate [] needs f/u creatine in 1 week to assess for resolution of [MASKED]. [] Needs diet advanced as tolerated [] On olanzapine, need to monitor for medication adverse effects. [] Advance diet as tolerated [] Will need further evaluation for etiology of increased recent admissions for HF excerbation # CODE STATUS: Full (presumed) # CONTACT: [MASKED] [MASKED] (daughter) BRIEF HOSPITAL COURSE: ====================== [MASKED] with a history of HFpEF (HFpEF, EF [MASKED], possible COPD, CKD, dementia, T2DM, BPH, and recent admission for CHF exacerbation from [MASKED] presenting with shortness of breath from his nursing facility concerning for acute on chronic HFpEF exacerbation requiring CCU admission for BiPAP. He was diuresed with Lasix IV, along with Lasix gtt. Transferred to the floor where IV diuresis was continued but then transitioned to POs. Held PO diuresis for a few days in setting of [MASKED]. Then discharged on torsemide 30 daily PO. His course was complicated by severe agitation in the setting of delirium and dementia, improved with Foley removal. # CORONARIES: unknown # PUMP: HFpEF, EF 50% [MASKED] # RHYTHM: normal sinus rhythm ACUTE ISSUES: ============= # Acute on chronic HFpEF Exacerbation: Previous admission mid [MASKED] for HFrEF exacerbation, now with similar presentation with SOB, chest pain, BNP elevation, small bump in trop, and stable ECG. He required CCU admission for BiPAP. He was diuresed with Lasix IV, along with Lasix drip then transferred to the floor where IV diuresis was continued but then transitioned to POs. Held PO diuresis for a few days in setting of [MASKED]. Then resumed. Discharged on torsemide 30 daily. His course was complicated by severe agitation in the setting of delirium and dementia. Also discharged on metoprolol 25 daily, isosorbide mononitrate 30, atrovostatin 80, ASA 81, and torsemide 30 daily. Discharge dry weight unknown and discharge creatinine of 2.4 (not baseline creatinine due to [MASKED]. Goals of care discussion held with daughter who continues to prefer pursuing aggressive care. # Hypoxemic respiratory failure # Potential PNA: Likely patient's dyspnea represents HF exacerbation. Less likely PNA in light of lack of fever, elevation of WBC, however pulmonary exam on admission revealed decreased diminished lung sounds at the right lower lung field, concerning for PNA. CXR in ED showed moderate right and probable small left pleural effusion along with significant atelectasis in the right middle and lower lobes and congestion with probable mild edema. He was given vancomycin/Zosyn in the ED, but these were discontinued on admission given low likelihood for infection. Improved oxygenation with diuresis. Approrpiate sats on RA at discharge. # Chronic Kidney Disease: Baseline Cr in the low 2's on last discharge, at baseline. Likely underlying CKD vs cardiorenal. Given acute volume overload state, seemed appropriate to continue diuretic and monitor renal function. Renal U/S [MASKED] without evidence of obstructive process/hydro. # Hyperactive delirium # Dementia: Patient with underlying dementia complicated by delirium in the ICU. Tried to regulate sleep wake cycle with ramelteon qhs and Zyprexa standing, required IV antipsychotic doses intermittently. No signs of metabolic disturbance, infection, worsened hypoxia or hypercarbia as contributing factors. Likely worse [MASKED] hospital stay. Delerium improved over hospitalization. #Nutritional Status Had mental status changes that required patient to be NPO for a few days but then transitioned back to a diet. Please advance as tolerated. CHRONIC/STABLE/RESOLVED ISSUES: =============================== # Hypothyroidism Patient continued on home levothyroxine 50mcg daily # BPH Patient continued home finasteride 5mg daily and home tamsulosin 0.4mg daily # T2DM Monitored Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Docusate Sodium 100 mg PO QHS 6. Finasteride 5 mg PO DAILY 7. Furosemide 40 mg PO DAILY 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Tamsulosin 0.4 mg PO QHS 11. Vitamin D 400 UNIT PO DAILY 12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Discharge Medications: 1. OLANZapine 5 mg PO QHS delerium 2. Torsemide 30 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Docusate Sodium 100 mg PO QHS 7. Finasteride 5 mg PO DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Tamsulosin 0.4 mg PO QHS 12. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Acute on Chronic HFpEF Exacerbation Hypoxemic hypercapnic respiratory failure SECONDARY DIAGNOSES ==================== Acute Delirium Dementia Poor nutrition Chronic Kidney Disease Benign Prostatic Hyperplasia Hypothyroidism Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [MASKED], WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were having shortness of breath WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - You were placed on a breathing mask to help you breathe - You were treated with a water pill to help clear the fluid in your lungs that made it hard for you to breathe - You were given medications to treat your high blood pressure - You were seen by our specialists in geriatrics who recommended medications to help with your behavior disturbances at night WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Follow up with your doctors as listed below - Weigh yourself every morning, seek medical attention if your weight goes up or down by more than 3 lbs in a day or 5 pounds in a week. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, abdominal distention, or shortness of breath at night. Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at [MASKED]! We wish you all the best! - Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I130", "E872", "E1122", "N189", "E039", "E785" ]	[ "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", "J9692: Respiratory failure, unspecified with hypercapnia", "J9691: Respiratory failure, unspecified with hypoxia", "F05: Delirium due to known physiological condition", "E872: Acidosis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "E039: Hypothyroidism, unspecified", "Z96642: Presence of left artificial hip joint", "E785: Hyperlipidemia, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "Z781: Physical restraint status" ]
19,982,989	27,296,476	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: Dyspnea, restlessness Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with PMH HTN, BPH, T2DM, dementia, COPD, recently diagnosed olfactory groove meningioma, sent in from nursing home for shortness of breath, restlessness, and disorientation. Per nursing home records, pt was satting 72-92% at nursing home and seemed short of breath. Has dementia at baseline, but seemed more disoriented than usual. In ED, pt denied fevers or cough. Denied chest pain, abd pain. Pt seemed restless and complained of wanting to urinate. ED staff unable to pass foley catheter. Bladder scan w/ 657mL urine - pt drained of ~325mL of clear urine, after which pt was more comfortable. In the ED, initial VS were 97.7 67 159/76 20 97% RA Labs showed: 135 98 33 AGap=21 -------------< 164 5.1 21 1.5 WBC: 18.2 (78%PMN, 11.5% L) H/H: 12.4/38.4 Plts 254 proBNP: 3286 Lactate 2.6 Flu A/B PCR: neg UA: unremarkable Imaging: CXR with pulmonary edema, cannot r/o superimposed PNA Received: ___ 03:56 IH Albuterol 0.083% Neb Soln 1 NEB ___ 03:56 IH Ipratropium Bromide Neb 1 NEB ___ 03:56 IV MethylPREDNISolone Sodium Succ 125 mg ___ 04:15 IH Albuterol 0.083% Neb Soln 1 NEB ___ 04:15 IH Ipratropium Bromide Neb 1 NEB ___ 07:02 PO/NG Azithromycin 500 mg ___ 11:38 PO/NG TraZODone 12.5 mg ___ 13:19 PO/NG amLODIPine 10 mg ___ 13:19 PO/NG Lisinopril 40 mg ___ 13:19 PO Metoprolol Succinate XL 200 mg Transfer VS were 98.3 73 171/68 18 96% RA Decision was made to admit to medicine for further management. On arrival to the floor, patient reports difficulty with urination. Denies any sob, n/v/f/c/d. Past Medical History: -BPH -Hypercholesterolemia. -Hypertension. -Head lesion after falling off a horse many years ago -Shoulder surgery status post motor vehicle accident -h/o prostate surgery -Olfactory groove Meningioma -T2DM -L hip replacement Social History: ___ Family History: Heart disease and lung cancer. Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== VS: 97.9 PO 145 / 48 78 16 96 Ra GENERAL: Elderly gentleman in NAD, speaks broken ___ and speech is difficult to understand, AAOx1, refused phone interpreter HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, large tongue, edentulous NECK: nontender supple neck, no LAD, unable to appreciate JVD due to body habitus HEART: irregularly irregular, S1/S2, no murmurs, gallops, or rubs LUNGS: Bibasilar crackles, pt able to speak in full sentences, no accessory muscle use ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: ___ pitting edema in b/l ___ to mid shin with chronic venous stasis changes in posterior aspect of R calf GU: Pt with urinal in place but unable to void PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: 97.3 PO 118 / 61 67 18 92 RA I/O: 24h -820 Weight: 81.5kg (standing) from 87.2 (bed weight) on ___. no weight on ___. GENERAL: Elderly gentleman in NAD, speaks broken ___ and speech is difficult to understand HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva NECK: nontender supple neck, unable to appreciate JVD due to body habitus HEART: irregularly irregular, S1/S2, no murmurs, gallops, or rubs LUNGS: Bibasilar crackles, pt able to speak in full sentences, no accessory muscle use ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding GU: no Foley EXTREMITIES: trace pitting edema in b/l ___ to mid shin with chronic venous stasis changes in posterior aspect of R calf NEURO: nonfocal SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ================ ADMISSION LABS ================ ___ 03:50AM BLOOD WBC-18.2# RBC-3.97 Hgb-12.4* Hct-38.4# MCV-97 MCH-31.2 MCHC-32.3 RDW-13.6 RDWSD-48.6 Plt ___ ___ 03:50AM BLOOD Neuts-77.9* Lymphs-11.5* Monos-8.1 Eos-1.2 Baso-0.5 Im ___ AbsNeut-14.20* AbsLymp-2.10 AbsMono-1.48* AbsEos-0.22 AbsBaso-0.09* ___ 03:50AM BLOOD Glucose-164* UreaN-33* Creat-1.5* Na-135 K-5.1 Cl-98 HCO3-21* AnGap-21* ___ 03:50AM BLOOD ALT-34 AST-36 AlkPhos-176* TotBili-0.7 ___ 09:15PM BLOOD CK-MB-5 cTropnT-<0.01 ___ 03:50AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-3286* ___ 09:15PM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3 ___ 03:55AM BLOOD Lactate-2.6* ================ INTERVAL LABS ================ ___ 03:00PM BLOOD GGT-299* ___ 03:00PM BLOOD TSH-8.6* ___ 03:00PM BLOOD calTIBC-316 VitB12-602 Folate-7 Ferritn-115 TRF-243 ================ IMAGING/STUDIES ================ ___ CXR IMPRESSION: Diffuse perihilar opacities, likely due to mild increased pulmonary Edema. However, superimposed pneumonia cannot be excluded in the appropriate clinical setting. ___ TTE The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to hypokinesis of the inferior and posterior walls. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. ================ DISCHARGE LABS ================ ___ 06:40AM BLOOD WBC-10.7* RBC-4.07* Hgb-12.2* Hct-38.5* MCV-95 MCH-30.0 MCHC-31.7* RDW-13.6 RDWSD-47.7* Plt ___ ___ 06:40AM BLOOD Glucose-95 UreaN-48* Creat-1.9* Na-139 K-3.8 Cl-98 HCO3-27 AnGap-18 ___ 06:40AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.___ yo M with PMH HTN, BPH, T2DM, dementia, COPD, recently diagnosed olfactory groove meningioma, sent in from nursing home for shortness of breath, restlessness, and disorientation, found to be volume overloaded with lower extremity edema and pulmonary edema on CXR c/f CHF exacerbation. #Dyspnea: #Acute CHF, diastolic: Pt presented with clinical evidence of volume overload given dyspnea and ___ edema, elevated BNP (3286) on admission, CXR with pulm edema. No recent echo for assessment of EF. Pt with limited records in BI EMR, so cardiac history unclear. Nursing home records with no mention of significant cardiac history. He was diuresed with serial doses of 80 IV Lasix with improvement in symptoms and exam. TTE was performed: study was severely limited due to poor windows but showed a low-normal EF (~50%) and hypokinesis of the basal inferior and posterior walls, as well as moderate pulmonary hypertension (TR gradient 41mmHg). Pt never required supplemental O2. Discharged on an increased dose of Lasix (40 Lasix BID) compared to prior to admission. #Inferior and Posterior Wall Hypokinesis: Seen on TTE performed ___ (ordered for workup of heart failure). Quality of study was poor due to very limited windows, however read as EF 50% with hypokinesis of inferior and posterior walls. This may correlate with an RCA distribution. Of note, troponins were negative x2 during his stay and EKG without evidence of present or past ischemic event. Given absence of chest pain or EKG findings, and negative troponins, plan was made for patient and his family to further discuss with his PCP, ___, as an outpatient. Outpatient referral to cardiology can be considered at that time if within his goals of care. #Hypertension: Continued home amlodipine 10 mg, Metoprolol Succinate XL 200 mg PO BID. Held home lisinopril i/s/o possible ___ (due to limited outpatient records we were unable to assess whether ___ or ___. Initiated 10mg hydralazine q6 for better BP control, which was discontinued on discharge and replaced with isosorbide mononitrate 30mg daily. #Possible COPD Exacerbation: In the ED, patient received IV MethylPREDNISolone Sodium Succ 125 mg. Does not appear to use any inhalers per nursing home records. No wheezes appreciable on exam. Dyspnea was more likely attributable to volume overload, but may be a component of COPD as well. Maintained on Duonebs q6 PRN, and Albuterol nebs q4 prn. Did not treat with any further steroids because CHF was the more likely culprit for his dyspnea. #Urinary Retention: pt c/o difficulty voiding, underwent straight catheterization in ED for ~600cc. H/o BPH and prostate surgery. Over course of admission, pt had intermittent issues with voiding, on several occasions had bladder scans with >400cc. An attempt was made to place a foley, but was unsuccessful. Besides once in the emergency department, he did not require straight catheterization, as he was always able to eventually void on his own, albeit with difficulty. We continued the patient's home tamsulosin, and started finasteride. On discharge, pt should be monitored for urinary retention at the nursing home, with frequent bladder scans and straight catheterization as needed for PVR >400cc. Urology followup can be considered as an outpatient. #Leukocytosis: WBC 18.2 with 77% PMNs on admission. Pt with no focal infectious symptoms. UA bland, CXR with possible superimposed PNA although pt afebrile and not producing any sputum. Alk phos slightly elevated, GGT high, AST/ALT wnl. No GI sx, no apparent skin impairments, no abd pain, no diarrhea. WBC downtrended over course of admission. All blood and urine cultures remained negative. He was not treated with any antibiotics. #Hypothyroidism: Continued home synthroid (37.5 3x weekly, 50 4x weekly). TSH was checked and was high (8.6), so dose was uptitrated to 50mcg daily on discharge. TSH should be rechecked in ___ weeks. ___: Presented with Cr 1.5, unclear baseline. ___ be cardiorenal i/s/o likely CHF exacerbation. Volume status was treated as above. Home lisinopril was held while in-house and held on discharge. Cr on discharge 1.9. #Arrhythmia: EKG from ED initially appeared to be consistent with AFib, however EKG on floor showed sinus rhythm with very frequent ectopy (including both PACs and PVCs). No history of atrial fibrillation per outside records. Pt was not anticoagulated as no indication for this in the absence of true atrial fibrillation. Telemetry during admission without any atrial fibrillation. If symptoms of heart failure persist or are difficult to control, please consider cardiology follow up for question of whether his frequent ectopy might be contributing to his heart failure symptoms. =================== TRANSITIONAL ISSUES =================== Medications STOPPED: Lisinopril Medications ADDED: Isosorbide mononitrate, Finasteride Medications CHANGED: Levothyroxide increased to 50mcg daily, furosemide increased to 40mg BID [ ] Recheck Chem-10 panel on ___ [ ] Recheck TSH in ___ weeks [ ] If pt complaining of inability to urinate, please bladder scan and straight cath for >400cc; consider urology referral if continues to be an issue [ ] Please monitor daily standing weights, and if weight increased by 3lbs, consider increasing Lasix dose [ ] PCP to discuss finding of hypokinesis of inferior and posterior walls on TTE at follow up. Can consider outpatient cardiology referral at that time if within goals of care. DISCHARGE WEIGHT: 81.5kg (standing) DISCHARGE CREATININE: 1.9 #HCP/Contact: Daughter ___ (H) ___ (C) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Bydureon (exenatide microspheres) 2 mg subcutaneous 1X/WEEK 3. Furosemide 40 mg PO DAILY 4. Glargine 7 Units Bedtime 5. Levothyroxine Sodium 50 mcg PO 4X/WEEK (___) 6. Levothyroxine Sodium 37.5 mcg PO 3X/WEEK (___) 7. Lisinopril 40 mg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Metoprolol Succinate XL 200 mg PO BID 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 50 mg PO QHS:PRN sleep 12. Vitamin D 400 UNIT PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Lactulose 30 mL PO DAILY 15. Senna 8.6 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Finasteride 5 mg PO DAILY 3. Isosorbide Mononitrate 30 mg PO DAILY 4. Furosemide 40 mg PO BID 5. Glargine 7 Units Bedtime 6. Levothyroxine Sodium 50 mcg PO DAILY 7. amLODIPine 10 mg PO DAILY 8. Bydureon (exenatide microspheres) 2 mg subcutaneous 1X/WEEK 9. Lactulose 30 mL PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Metoprolol Succinate XL 200 mg PO BID 12. Multivitamins 1 TAB PO DAILY 13. Senna 8.6 mg PO BID 14. Tamsulosin 0.4 mg PO QHS 15. TraZODone 50 mg PO QHS:PRN sleep 16. Vitamin D 400 UNIT PO DAILY 17.Outpatient Lab Work Labs to be drawn: Chem-10 panel Date: ___ ICD-10: ___ Please fax results to Dr. ___ (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Diastolic congestive heart failure, urinary retention Secondary diagnoses: leukocytosis, hypothyroidism, acute kidney injury, diabetes, hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. WHY DID YOU COME TO THE HOSPITAL? You were sent to the hospital because you were having some difficulty breathing, as well as some restlessness at your nursing home. WHAT HAPPENED WHILE YOU WERE HERE? We determined that you had some extra fluid on your lungs and legs. We gave you medicine through the IV to help you get ride of this fluid. We also did a test to make sure that there were no major issues with your heart. WHAT SHOULD YOU DO WHEN YOU GO BACK TO YOUR NURSING HOME? Please continue to take all the medications that we have prescribed. If you continue to have difficulty urinating, please let your nurse or doctor know. Again, it was a pleasure taking care of you! Sincerely, Your ___ Team Followup Instructions: ___	[ "I110", "J441", "N179", "F0390", "E119", "E7800", "Z96642", "I5031", "E039", "N401", "R338", "Z23" ]	Allergies: morphine Chief Complaint: Dyspnea, restlessness Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] yo M with PMH HTN, BPH, T2DM, dementia, COPD, recently diagnosed olfactory groove meningioma, sent in from nursing home for shortness of breath, restlessness, and disorientation. Per nursing home records, pt was satting 72-92% at nursing home and seemed short of breath. Has dementia at baseline, but seemed more disoriented than usual. In ED, pt denied fevers or cough. Denied chest pain, abd pain. Pt seemed restless and complained of wanting to urinate. ED staff unable to pass foley catheter. Bladder scan w/ 657mL urine - pt drained of ~325mL of clear urine, after which pt was more comfortable. In the ED, initial VS were 97.7 67 159/76 20 97% RA Labs showed: 135 98 33 AGap=21 -------------< 164 5.1 21 1.5 WBC: 18.2 (78%PMN, 11.5% L) H/H: 12.4/38.4 Plts 254 proBNP: 3286 Lactate 2.6 Flu A/B PCR: neg UA: unremarkable Imaging: CXR with pulmonary edema, cannot r/o superimposed PNA Received: [MASKED] 03:56 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 03:56 IH Ipratropium Bromide Neb 1 NEB [MASKED] 03:56 IV MethylPREDNISolone Sodium Succ 125 mg [MASKED] 04:15 IH Albuterol 0.083% Neb Soln 1 NEB [MASKED] 04:15 IH Ipratropium Bromide Neb 1 NEB [MASKED] 07:02 PO/NG Azithromycin 500 mg [MASKED] 11:38 PO/NG TraZODone 12.5 mg [MASKED] 13:19 PO/NG amLODIPine 10 mg [MASKED] 13:19 PO/NG Lisinopril 40 mg [MASKED] 13:19 PO Metoprolol Succinate XL 200 mg Transfer VS were 98.3 73 171/68 18 96% RA Decision was made to admit to medicine for further management. On arrival to the floor, patient reports difficulty with urination. Denies any sob, n/v/f/c/d. Past Medical History: -BPH -Hypercholesterolemia. -Hypertension. -Head lesion after falling off a horse many years ago -Shoulder surgery status post motor vehicle accident -h/o prostate surgery -Olfactory groove Meningioma -T2DM -L hip replacement Social History: [MASKED] Family History: Heart disease and lung cancer. Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== VS: 97.9 PO 145 / 48 78 16 96 Ra GENERAL: Elderly gentleman in NAD, speaks broken [MASKED] and speech is difficult to understand, AAOx1, refused phone interpreter HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, large tongue, edentulous NECK: nontender supple neck, no LAD, unable to appreciate JVD due to body habitus HEART: irregularly irregular, S1/S2, no murmurs, gallops, or rubs LUNGS: Bibasilar crackles, pt able to speak in full sentences, no accessory muscle use ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: [MASKED] pitting edema in b/l [MASKED] to mid shin with chronic venous stasis changes in posterior aspect of R calf GU: Pt with urinal in place but unable to void PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: 97.3 PO 118 / 61 67 18 92 RA I/O: 24h -820 Weight: 81.5kg (standing) from 87.2 (bed weight) on [MASKED]. no weight on [MASKED]. GENERAL: Elderly gentleman in NAD, speaks broken [MASKED] and speech is difficult to understand HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva NECK: nontender supple neck, unable to appreciate JVD due to body habitus HEART: irregularly irregular, S1/S2, no murmurs, gallops, or rubs LUNGS: Bibasilar crackles, pt able to speak in full sentences, no accessory muscle use ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding GU: no Foley EXTREMITIES: trace pitting edema in b/l [MASKED] to mid shin with chronic venous stasis changes in posterior aspect of R calf NEURO: nonfocal SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ================ ADMISSION LABS ================ [MASKED] 03:50AM BLOOD WBC-18.2# RBC-3.97 Hgb-12.4* Hct-38.4# MCV-97 MCH-31.2 MCHC-32.3 RDW-13.6 RDWSD-48.6 Plt [MASKED] [MASKED] 03:50AM BLOOD Neuts-77.9* Lymphs-11.5* Monos-8.1 Eos-1.2 Baso-0.5 Im [MASKED] AbsNeut-14.20* AbsLymp-2.10 AbsMono-1.48* AbsEos-0.22 AbsBaso-0.09* [MASKED] 03:50AM BLOOD Glucose-164* UreaN-33* Creat-1.5* Na-135 K-5.1 Cl-98 HCO3-21* AnGap-21* [MASKED] 03:50AM BLOOD ALT-34 AST-36 AlkPhos-176* TotBili-0.7 [MASKED] 09:15PM BLOOD CK-MB-5 cTropnT-<0.01 [MASKED] 03:50AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-3286* [MASKED] 09:15PM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3 [MASKED] 03:55AM BLOOD Lactate-2.6* ================ INTERVAL LABS ================ [MASKED] 03:00PM BLOOD GGT-299* [MASKED] 03:00PM BLOOD TSH-8.6* [MASKED] 03:00PM BLOOD calTIBC-316 VitB12-602 Folate-7 Ferritn-115 TRF-243 ================ IMAGING/STUDIES ================ [MASKED] CXR IMPRESSION: Diffuse perihilar opacities, likely due to mild increased pulmonary Edema. However, superimposed pneumonia cannot be excluded in the appropriate clinical setting. [MASKED] TTE The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to hypokinesis of the inferior and posterior walls. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. ================ DISCHARGE LABS ================ [MASKED] 06:40AM BLOOD WBC-10.7* RBC-4.07* Hgb-12.2* Hct-38.5* MCV-95 MCH-30.0 MCHC-31.7* RDW-13.6 RDWSD-47.7* Plt [MASKED] [MASKED] 06:40AM BLOOD Glucose-95 UreaN-48* Creat-1.9* Na-139 K-3.8 Cl-98 HCO3-27 AnGap-18 [MASKED] 06:40AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.[MASKED] yo M with PMH HTN, BPH, T2DM, dementia, COPD, recently diagnosed olfactory groove meningioma, sent in from nursing home for shortness of breath, restlessness, and disorientation, found to be volume overloaded with lower extremity edema and pulmonary edema on CXR c/f CHF exacerbation. #Dyspnea: #Acute CHF, diastolic: Pt presented with clinical evidence of volume overload given dyspnea and [MASKED] edema, elevated BNP (3286) on admission, CXR with pulm edema. No recent echo for assessment of EF. Pt with limited records in BI EMR, so cardiac history unclear. Nursing home records with no mention of significant cardiac history. He was diuresed with serial doses of 80 IV Lasix with improvement in symptoms and exam. TTE was performed: study was severely limited due to poor windows but showed a low-normal EF (~50%) and hypokinesis of the basal inferior and posterior walls, as well as moderate pulmonary hypertension (TR gradient 41mmHg). Pt never required supplemental O2. Discharged on an increased dose of Lasix (40 Lasix BID) compared to prior to admission. #Inferior and Posterior Wall Hypokinesis: Seen on TTE performed [MASKED] (ordered for workup of heart failure). Quality of study was poor due to very limited windows, however read as EF 50% with hypokinesis of inferior and posterior walls. This may correlate with an RCA distribution. Of note, troponins were negative x2 during his stay and EKG without evidence of present or past ischemic event. Given absence of chest pain or EKG findings, and negative troponins, plan was made for patient and his family to further discuss with his PCP, [MASKED], as an outpatient. Outpatient referral to cardiology can be considered at that time if within his goals of care. #Hypertension: Continued home amlodipine 10 mg, Metoprolol Succinate XL 200 mg PO BID. Held home lisinopril i/s/o possible [MASKED] (due to limited outpatient records we were unable to assess whether [MASKED] or [MASKED]. Initiated 10mg hydralazine q6 for better BP control, which was discontinued on discharge and replaced with isosorbide mononitrate 30mg daily. #Possible COPD Exacerbation: In the ED, patient received IV MethylPREDNISolone Sodium Succ 125 mg. Does not appear to use any inhalers per nursing home records. No wheezes appreciable on exam. Dyspnea was more likely attributable to volume overload, but may be a component of COPD as well. Maintained on Duonebs q6 PRN, and Albuterol nebs q4 prn. Did not treat with any further steroids because CHF was the more likely culprit for his dyspnea. #Urinary Retention: pt c/o difficulty voiding, underwent straight catheterization in ED for ~600cc. H/o BPH and prostate surgery. Over course of admission, pt had intermittent issues with voiding, on several occasions had bladder scans with >400cc. An attempt was made to place a foley, but was unsuccessful. Besides once in the emergency department, he did not require straight catheterization, as he was always able to eventually void on his own, albeit with difficulty. We continued the patient's home tamsulosin, and started finasteride. On discharge, pt should be monitored for urinary retention at the nursing home, with frequent bladder scans and straight catheterization as needed for PVR >400cc. Urology followup can be considered as an outpatient. #Leukocytosis: WBC 18.2 with 77% PMNs on admission. Pt with no focal infectious symptoms. UA bland, CXR with possible superimposed PNA although pt afebrile and not producing any sputum. Alk phos slightly elevated, GGT high, AST/ALT wnl. No GI sx, no apparent skin impairments, no abd pain, no diarrhea. WBC downtrended over course of admission. All blood and urine cultures remained negative. He was not treated with any antibiotics. #Hypothyroidism: Continued home synthroid (37.5 3x weekly, 50 4x weekly). TSH was checked and was high (8.6), so dose was uptitrated to 50mcg daily on discharge. TSH should be rechecked in [MASKED] weeks. [MASKED]: Presented with Cr 1.5, unclear baseline. [MASKED] be cardiorenal i/s/o likely CHF exacerbation. Volume status was treated as above. Home lisinopril was held while in-house and held on discharge. Cr on discharge 1.9. #Arrhythmia: EKG from ED initially appeared to be consistent with AFib, however EKG on floor showed sinus rhythm with very frequent ectopy (including both PACs and PVCs). No history of atrial fibrillation per outside records. Pt was not anticoagulated as no indication for this in the absence of true atrial fibrillation. Telemetry during admission without any atrial fibrillation. If symptoms of heart failure persist or are difficult to control, please consider cardiology follow up for question of whether his frequent ectopy might be contributing to his heart failure symptoms. =================== TRANSITIONAL ISSUES =================== Medications STOPPED: Lisinopril Medications ADDED: Isosorbide mononitrate, Finasteride Medications CHANGED: Levothyroxide increased to 50mcg daily, furosemide increased to 40mg BID [ ] Recheck Chem-10 panel on [MASKED] [ ] Recheck TSH in [MASKED] weeks [ ] If pt complaining of inability to urinate, please bladder scan and straight cath for >400cc; consider urology referral if continues to be an issue [ ] Please monitor daily standing weights, and if weight increased by 3lbs, consider increasing Lasix dose [ ] PCP to discuss finding of hypokinesis of inferior and posterior walls on TTE at follow up. Can consider outpatient cardiology referral at that time if within goals of care. DISCHARGE WEIGHT: 81.5kg (standing) DISCHARGE CREATININE: 1.9 #HCP/Contact: Daughter [MASKED] (H) [MASKED] (C) [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Bydureon (exenatide microspheres) 2 mg subcutaneous 1X/WEEK 3. Furosemide 40 mg PO DAILY 4. Glargine 7 Units Bedtime 5. Levothyroxine Sodium 50 mcg PO 4X/WEEK ([MASKED]) 6. Levothyroxine Sodium 37.5 mcg PO 3X/WEEK ([MASKED]) 7. Lisinopril 40 mg PO DAILY 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Metoprolol Succinate XL 200 mg PO BID 10. Tamsulosin 0.4 mg PO QHS 11. TraZODone 50 mg PO QHS:PRN sleep 12. Vitamin D 400 UNIT PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Lactulose 30 mL PO DAILY 15. Senna 8.6 mg PO BID Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Finasteride 5 mg PO DAILY 3. Isosorbide Mononitrate 30 mg PO DAILY 4. Furosemide 40 mg PO BID 5. Glargine 7 Units Bedtime 6. Levothyroxine Sodium 50 mcg PO DAILY 7. amLODIPine 10 mg PO DAILY 8. Bydureon (exenatide microspheres) 2 mg subcutaneous 1X/WEEK 9. Lactulose 30 mL PO DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Metoprolol Succinate XL 200 mg PO BID 12. Multivitamins 1 TAB PO DAILY 13. Senna 8.6 mg PO BID 14. Tamsulosin 0.4 mg PO QHS 15. TraZODone 50 mg PO QHS:PRN sleep 16. Vitamin D 400 UNIT PO DAILY 17.Outpatient Lab Work Labs to be drawn: Chem-10 panel Date: [MASKED] ICD-10: [MASKED] Please fax results to Dr. [MASKED] ([MASKED]) Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary Diagnosis: Diastolic congestive heart failure, urinary retention Secondary diagnoses: leukocytosis, hypothyroidism, acute kidney injury, diabetes, hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], It was a pleasure taking care of you at [MASKED]. WHY DID YOU COME TO THE HOSPITAL? You were sent to the hospital because you were having some difficulty breathing, as well as some restlessness at your nursing home. WHAT HAPPENED WHILE YOU WERE HERE? We determined that you had some extra fluid on your lungs and legs. We gave you medicine through the IV to help you get ride of this fluid. We also did a test to make sure that there were no major issues with your heart. WHAT SHOULD YOU DO WHEN YOU GO BACK TO YOUR NURSING HOME? Please continue to take all the medications that we have prescribed. If you continue to have difficulty urinating, please let your nurse or doctor know. Again, it was a pleasure taking care of you! Sincerely, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "I110", "N179", "E119", "E039" ]	[ "I110: Hypertensive heart disease with heart failure", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "N179: Acute kidney failure, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "E119: Type 2 diabetes mellitus without complications", "E7800: Pure hypercholesterolemia, unspecified", "Z96642: Presence of left artificial hip joint", "I5031: Acute diastolic (congestive) heart failure", "E039: Hypothyroidism, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "Z23: Encounter for immunization" ]
19,982,989	28,630,229	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: morphine Attending: ___. Chief Complaint: dyspnea, hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: ============================ This is an ___ ___ gentleman with a history notable for HFpEF (EF 50% in ___, ?COPD, dementia, T2DM and BPH who presents from nursing home with dyspnea and hypoxia. Per the patient's daughter, Mr. ___ was diagnosed with a UTI at his nursing home one week prior to admission and was treated with antibiotics (cefpodoxime?). He also endorsed shortness of breath and cough during this week. On ___ his lasix was changed from 40 mg PO QD to 20 mg PO TID, and on ___ he received 40 mg PO BID. On ___ he became more short of breath and was noted to be sating 77-83% on RA. He received 3 stacked nebs without improvement in his oxygenation. EMS was called and they placed him on CPAP with improvement in his O2 sat and he was taken to the ___ ED. In the ED, - Initial Vitals: T 103.8, HR 83, BP 151/78, RR 20, 99% on CPAP - Exam: General: On a BiPAP, alert and oriented HEENT: Normal oropharynx, no exudates/erythema Cardiac: RRR , no chest tenderness Pulmonary: Diffuse crackles bilaterally. Abdominal/GI: Normal bowel sounds, no tenderness or masses Renal: No CVA tenderness MSK: No deformities or signs of trauma, no focal deficits noted. 3+ pitting edema up to the knees Neuro: Sensation intact upper and lower extremities, strength ___ upper and lower, no focal deficits noted, moving all extremities - Labs: - WBC 14.8 (90% N), Hgb 11.3, Plt 248 - AST 26, ALT 21, AP 169, Tbili 1.2, Alb 3.3 - Na 142, K 4.6, Cl 102, HCO3 19, BUN 34, Cr 1.8, Gluc 152, AGap 21 - proBNP 2263, trop <0.01 - Lactate 3.5 - VBG: pH 7.38, pCO2 48 - UA: Large Leuk, Nitr Pos, >182 WBC, Mod Bact - Imaging: - CXR: Lungs are low volume with increase in volume of bilateral pleural effusions right greater than left. Pulmonary edema has worsened. Consolidative opacities in both lower lobes right greater than left have also worsened. No pneumothorax. There is worsening pulmonary vascular congestion - Consults: N/A - Interventions: Placed on BiPAP ___ FiO2 50%, cefepime 2g, metronidazole 500 mg, 40mg IV Lasix ROS: Positives as per HPI; otherwise negative. Past Medical History: -BPH -Hypercholesterolemia. -Hypertension. -Head lesion after falling off a horse many years ago -Shoulder surgery status post motor vehicle accident -h/o prostate surgery -Olfactory groove Meningioma -T2DM -L hip replacement Social History: ___ Family History: Heart disease and lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: Reviewed in ___ GENERAL: Elderly man, agitated and picking at IV lines. HEENT: NCAT. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. LUNGS: Bilateral expiratory wheezes, bilateral crackles at lung bases. ABDOMEN: Normal bowels sounds, non distended, non-tender to palpation EXTREMITIES: Warm, 2+ edema in b/l lower extremities NEUROLOGIC: Moving all extremities spontaneously DISCHARGE PHYSICAL EXAM ======================== VS: WNL GENERAL: Alert, smiling sitting up in bed with no conversational dyspnea, very animated this AM EYES: Anicteric, PERRL ENT: Ears and nose without visible erythema, masses, or trauma. MMM CV: RRR, +S1, +S2, no S3/S4, no murmurs, unable to assess JVD given large neck radius RESP: B/L crackles tracking to lower lung fields. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: Condom cath in place draining clear yellow urine. No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs, No ___ edema B/L SKIN: No rashes or ulcerations noted NEURO: A+O x 1.5 (identified hospital, his doctor and named family members not present, chronically unable to identify year/month/president) face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: ___ 05:24PM ___ PO2-33* PCO2-43 PH-7.42 TOTAL CO2-29 BASE XS-2 ___ 05:24PM LACTATE-3.7* ___ 02:40PM LACTATE-5.8* ___ 10:09AM URINE HOURS-RANDOM CREAT-24 SODIUM-101 ___ 10:09AM URINE OSMOLAL-334 ___ 10:09AM URINE COLOR-Straw APPEAR-Hazy* SP ___ ___ 10:09AM URINE BLOOD-SM* NITRITE-POS* PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG* ___ 10:09AM URINE RBC-6* WBC->182* BACTERIA-MOD* YEAST-NONE EPI-0 ___ 10:05AM ___ PO2-32* PCO2-48* PH-7.38 TOTAL CO2-29 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-PERIPHERAL ___ 10:05AM LACTATE-3.5* ___ 09:50AM GLUCOSE-152* UREA N-34* CREAT-1.8* SODIUM-142 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-21* ___ 09:50AM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-169* TOT BILI-1.2 ___ 09:50AM LIPASE-12 ___ 09:50AM cTropnT-<0.01 ___ 09:50AM proBNP-2263* ___ 09:50AM ALBUMIN-3.3* CALCIUM-9.1 PHOSPHATE-4.2 MAGNESIUM-1.8 ___ 09:50AM WBC-14.8* RBC-3.91* HGB-11.3* HCT-38.4* MCV-98 MCH-28.9 MCHC-29.4* RDW-14.6 RDWSD-51.8* ___ 09:50AM NEUTS-89.7* LYMPHS-5.3* MONOS-3.8* EOS-0.2* BASOS-0.3 IM ___ AbsNeut-13.31* AbsLymp-0.78* AbsMono-0.57 AbsEos-0.03* AbsBaso-0.04 ___ 09:50AM PLT COUNT-248 IMAGING ======= CXR ___ Lungs are low volume with increase in volume of bilateral pleural effusions right greater than left. Pulmonary edema has worsened. Consolidative opacities in both lower lobes right greater than left have also worsened. No pneumothorax. There is worsening pulmonary vascular congestion Renal US ___. No evidence of stones or hydronephrosis. 2. Complex cystic structure at the left upper renal pole measuring 1.9 cm without evidence of internal vascularity, possibly representing a complex cyst but cannot exclude the possibility of an abscess. Reccomend follow-up with dedicated CT or MRI with contrast for further characterization. TTE ___ There is mild regional left ventricular systolic dysfunction with basal to mid infeiror wall hypokinesis (see schematic) and preserved/normal contractility of the remaining segments. The visually estimated left ventricular ejection fraction is 55%. Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Moderate pulmonary hypertension. CXR (___) Bilateral pulmonary edema is mildly decreased. The pleural effusion with associated bibasilar atelectasis is unchanged, a superimposed focal consolidation cannot be excluded. Cardiomediastinal silhouette is stable. There is no pneumothorax. WBC: 8.5 <-- 11.3 <-- 14 <-- 20.7 Cr: 2.2 <-- 2.4 <-- 2.5 <-- 2.3 (B/L 1.8) HCO3: 31 <-- 28 <-- 29 <-- 30 <-- 22 Mg: 2.3 K: 4.0 Lac: 1.4 BNP: 2263 on admission VBG: pH 7.37, pCO2 55 UA: >182 WBC, Mod bacteria, +Nitrite, ___ BCx: Pending UCx: E Coli ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S No prior positive UCx Brief Hospital Course: This is an ___ gentleman with a history notable for HFpEF (EF 50% in ___, ?COPD, dementia, T2DM and BPH who presents from nursing home with 1 week of dyspnea found to have crackles and edema on exam, CXR with pulmonary edema and elevated proBNP all consistent with a heart failure exacerbation and pneumonia. In addition, he has a dirty UA, leukocytosis, and fever suggestive of acute complicated UTI. ACUTE ISSUES ======================= # HFpEF exacerbation # Hypercarbic respiratory failure Patient presented with dyspnea (sating 77-83% on RA at nursing home) which improved on non-invasive ventilation. Was treated with BiPAP in MICU and improved rapidly with diuresis and antibiotics. Time course of improvement (<24 hours) c/w diuresis and not PNA treatment. Furthermore, denies any cough and no focal consolidation on CXR (obscured by pulm edema and effusions). Treating for HF exacerbation. TTE shows LVEF 55% with mild inferior wall hypokinesis, elevated PCWP (>18), moderate pulmonary artery systolic hypertension. Concern that home Lasix dose (40mg QD) was recently changed to 20mg TID which may be contributing to HF Exac. Likely trigger is UTI (treatment below) Pump - C/w Lasix 40mg PO QD with goal Net even. Given that patient is on RA and improving ___ c/w home 40mg PO Lasix QD - Chem should be checked at facility on ___ to ensure improvement of creatinine. If Cr > 2.3, then hold Lasix and hydrate orally for 48 hours. If Cr equal to 2.3, then decrease Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg PO QD and resume home Metop Succ XL 200mg PO BID. - C/w home Isosorbide Mononitrate ER 30mg PO QD given SBP 150-170 - C/w home amlodipine 10mg PO QD - Incentive spirometry to stent open atelectatic alveoli in lower lung field due to shallow breathing Rhythm: NSR on ECG Ischemia: C/f CAD on TTE given mild inferior wall hypokinesis. Given neg trop and ECG w/o ischemic features, no concern for ACS event. Will empirically start atherosclerotic therapy - ASA 81mg QD - ___ year ASCVD risk 17.4%, started Atorva 40mg PO QD - Will need outpatient coronary angiogram pending patient/family preference # Acute complicated UTI # Leukocytosis Acute complicated E. Coli UTI sensitive to Bactrim and Macrobid. Given age > ___ and CrCl < ___, Macrobid is relatively contraindicated. Will start Bactrim knowing that this may artificially elevated serum Cr without changing CrCl. Given lack of productive cough, improving hypoxemia with diuresis, and no discrete focal consolidation on CXR, no need for empiric tx for PNA. Renal US with e/o renal cyst c/f abscess but given lack of fever, improving leukocytosis and clinical improvement with Abx, unlikely to be loculated abscess. - D/c Bactrim SS QD x 10 days (___) ___ on CKD (B/L Cr 1.8) Worsening chronologically with IV diuresis in ICU. Differential includes prerenal azotemia vs Type I CRS vs ATN. No e/o post-obstruction (renal US without hydro, bladder scan < 200cc). No e/o granular casts on ___. CKD likely ___ DM (A1c 7.0%). Improving with PO hydration on home Lasix 40mg PO QD. - C/w home 40mg PO Lasix - Encourage PO intake - Chem should be checked at facility on ___ to ensure improvement of creatinine. If Cr > 2.3, then hold Lasix and hydrate orally for 48 hours. If Cr equal to 2.3, then decrease Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg PO QD and resume home Metop Succ XL 200mg PO BID given HR ___. # Long QT # Dementia # Delirium Combination of toxic metabolic encephalopathy ___ UTI and in-hospital delirium. Mentation improved dramatically with treatment of UTI. Suspect continued improvement with transfer to a familiar setting (namely his nursing facility) CHRONIC ISSUES ======================= # Anemia Iron studies, B12, folate all wnl in ___. Potentially ___ chronic cardiac or renal disease # Hypothyroidism Continued home levothyroxine # T2DM Continued home glargine with low dose ISS # Hypertension Continued home amlodipine, isosorbide mononitrate # BPH Continued home finasteride, tamsulosin To Do: [] Complete Bactrim Bactrim SS QD x 10 days (___) [] Chem should be checked at facility on ___ to ensure improvement of creatinine. If Cr > 2.3, then hold Lasix and hydrate orally for 48 hours. If Cr equal to 2.3, then decrease Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg PO QD and resume home Metop Succ XL 200mg PO BID given HR ___. [] Once infection is complete and Cr and returned to baseline, consider outpatient cardiology evaluation for coronary angiogram to assess for CAD I spent 40 mins in discharge planning, coordination of care, and patient/family education. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO QHS 2. Tamsulosin 0.4 mg PO QHS 3. Polyethylene Glycol 17 g PO EVERY OTHER DAY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Finasteride 5 mg PO DAILY 8. Furosemide 40 mg PO DAILY 9. Lactulose 30 mL PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. GuaiFENesin ___ mL PO BID 12. Metoprolol Succinate XL 200 mg PO BID 13. Senna 8.6 mg PO BID:PRN Constipation - First Line 14. melatonin 3 mg oral QHS 15. Glargine 9 Units Bedtime 16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 9 Days 4. Glargine 9 Units Bedtime 5. amLODIPine 10 mg PO DAILY 6. Docusate Sodium 100 mg PO QHS 7. Finasteride 5 mg PO DAILY 8. Furosemide 40 mg PO DAILY 9. GuaiFENesin ___ mL PO BID 10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 11. Lactulose 30 mL PO DAILY 12. Levothyroxine Sodium 50 mcg PO DAILY 13. melatonin 3 mg oral QHS 14. Multivitamins 1 TAB PO DAILY 15. Polyethylene Glycol 17 g PO EVERY OTHER DAY 16. Senna 8.6 mg PO BID:PRN Constipation - First Line 17. Tamsulosin 0.4 mg PO QHS 18. Vitamin D 400 UNIT PO DAILY 19. HELD- Metoprolol Succinate XL 200 mg PO BID This medication was held. Do not restart Metoprolol Succinate XL until Pending repeat creatinine and potassium on ___, if stable or improving, can resume 20.Outpatient Lab Work Please check a chemistry on ___. If Creatinine >2.3, please hold Lasix for 48 hours and recheck creatinine. If Cr equal to 2.3, please decrease dose of Lasix to 20mg PO QD. If Cr <2.3, continue Lasix 40mg PO QD and resume home Metop (give SBP > 100, HR > 70). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Complicated UTI Heart failure exacerbation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted for a urinary tract infection causing a heart failure exacerbation requiring an ICU admission to assist with your bleeding. Fortunately, with getting you to urinate more and placing you on correct antibiotics, we have been able to get you back to breathing room air. We will need to check your kidney function on ___ to make sure you are on the best dose of Lasix. Weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. Followup Instructions: ___	[ "J9692", "G92", "I5033", "B9620", "J189", "N390", "N179", "I130", "F05", "E873", "N189", "I4581", "I2510", "J449", "F0390", "N400", "E1122", "Z794", "E039", "D649", "Z96642", "Z993" ]	Allergies: morphine Chief Complaint: dyspnea, hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: ============================ This is an [MASKED] [MASKED] gentleman with a history notable for HFpEF (EF 50% in [MASKED], ?COPD, dementia, T2DM and BPH who presents from nursing home with dyspnea and hypoxia. Per the patient's daughter, Mr. [MASKED] was diagnosed with a UTI at his nursing home one week prior to admission and was treated with antibiotics (cefpodoxime?). He also endorsed shortness of breath and cough during this week. On [MASKED] his lasix was changed from 40 mg PO QD to 20 mg PO TID, and on [MASKED] he received 40 mg PO BID. On [MASKED] he became more short of breath and was noted to be sating 77-83% on RA. He received 3 stacked nebs without improvement in his oxygenation. EMS was called and they placed him on CPAP with improvement in his O2 sat and he was taken to the [MASKED] ED. In the ED, - Initial Vitals: T 103.8, HR 83, BP 151/78, RR 20, 99% on CPAP - Exam: General: On a BiPAP, alert and oriented HEENT: Normal oropharynx, no exudates/erythema Cardiac: RRR , no chest tenderness Pulmonary: Diffuse crackles bilaterally. Abdominal/GI: Normal bowel sounds, no tenderness or masses Renal: No CVA tenderness MSK: No deformities or signs of trauma, no focal deficits noted. 3+ pitting edema up to the knees Neuro: Sensation intact upper and lower extremities, strength [MASKED] upper and lower, no focal deficits noted, moving all extremities - Labs: - WBC 14.8 (90% N), Hgb 11.3, Plt 248 - AST 26, ALT 21, AP 169, Tbili 1.2, Alb 3.3 - Na 142, K 4.6, Cl 102, HCO3 19, BUN 34, Cr 1.8, Gluc 152, AGap 21 - proBNP 2263, trop <0.01 - Lactate 3.5 - VBG: pH 7.38, pCO2 48 - UA: Large Leuk, Nitr Pos, >182 WBC, Mod Bact - Imaging: - CXR: Lungs are low volume with increase in volume of bilateral pleural effusions right greater than left. Pulmonary edema has worsened. Consolidative opacities in both lower lobes right greater than left have also worsened. No pneumothorax. There is worsening pulmonary vascular congestion - Consults: N/A - Interventions: Placed on BiPAP [MASKED] FiO2 50%, cefepime 2g, metronidazole 500 mg, 40mg IV Lasix ROS: Positives as per HPI; otherwise negative. Past Medical History: -BPH -Hypercholesterolemia. -Hypertension. -Head lesion after falling off a horse many years ago -Shoulder surgery status post motor vehicle accident -h/o prostate surgery -Olfactory groove Meningioma -T2DM -L hip replacement Social History: [MASKED] Family History: Heart disease and lung cancer. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: Reviewed in [MASKED] GENERAL: Elderly man, agitated and picking at IV lines. HEENT: NCAT. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. LUNGS: Bilateral expiratory wheezes, bilateral crackles at lung bases. ABDOMEN: Normal bowels sounds, non distended, non-tender to palpation EXTREMITIES: Warm, 2+ edema in b/l lower extremities NEUROLOGIC: Moving all extremities spontaneously DISCHARGE PHYSICAL EXAM ======================== VS: WNL GENERAL: Alert, smiling sitting up in bed with no conversational dyspnea, very animated this AM EYES: Anicteric, PERRL ENT: Ears and nose without visible erythema, masses, or trauma. MMM CV: RRR, +S1, +S2, no S3/S4, no murmurs, unable to assess JVD given large neck radius RESP: B/L crackles tracking to lower lung fields. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: Condom cath in place draining clear yellow urine. No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs, No [MASKED] edema B/L SKIN: No rashes or ulcerations noted NEURO: A+O x 1.5 (identified hospital, his doctor and named family members not present, chronically unable to identify year/month/president) face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs PSYCH: pleasant, appropriate affect Pertinent Results: [MASKED] 05:24PM [MASKED] PO2-33* PCO2-43 PH-7.42 TOTAL CO2-29 BASE XS-2 [MASKED] 05:24PM LACTATE-3.7* [MASKED] 02:40PM LACTATE-5.8* [MASKED] 10:09AM URINE HOURS-RANDOM CREAT-24 SODIUM-101 [MASKED] 10:09AM URINE OSMOLAL-334 [MASKED] 10:09AM URINE COLOR-Straw APPEAR-Hazy* SP [MASKED] [MASKED] 10:09AM URINE BLOOD-SM* NITRITE-POS* PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG* [MASKED] 10:09AM URINE RBC-6* WBC->182* BACTERIA-MOD* YEAST-NONE EPI-0 [MASKED] 10:05AM [MASKED] PO2-32* PCO2-48* PH-7.38 TOTAL CO2-29 BASE XS-1 INTUBATED-NOT INTUBA COMMENTS-PERIPHERAL [MASKED] 10:05AM LACTATE-3.5* [MASKED] 09:50AM GLUCOSE-152* UREA N-34* CREAT-1.8* SODIUM-142 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-21* [MASKED] 09:50AM ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-169* TOT BILI-1.2 [MASKED] 09:50AM LIPASE-12 [MASKED] 09:50AM cTropnT-<0.01 [MASKED] 09:50AM proBNP-2263* [MASKED] 09:50AM ALBUMIN-3.3* CALCIUM-9.1 PHOSPHATE-4.2 MAGNESIUM-1.8 [MASKED] 09:50AM WBC-14.8* RBC-3.91* HGB-11.3* HCT-38.4* MCV-98 MCH-28.9 MCHC-29.4* RDW-14.6 RDWSD-51.8* [MASKED] 09:50AM NEUTS-89.7* LYMPHS-5.3* MONOS-3.8* EOS-0.2* BASOS-0.3 IM [MASKED] AbsNeut-13.31* AbsLymp-0.78* AbsMono-0.57 AbsEos-0.03* AbsBaso-0.04 [MASKED] 09:50AM PLT COUNT-248 IMAGING ======= CXR [MASKED] Lungs are low volume with increase in volume of bilateral pleural effusions right greater than left. Pulmonary edema has worsened. Consolidative opacities in both lower lobes right greater than left have also worsened. No pneumothorax. There is worsening pulmonary vascular congestion Renal US [MASKED]. No evidence of stones or hydronephrosis. 2. Complex cystic structure at the left upper renal pole measuring 1.9 cm without evidence of internal vascularity, possibly representing a complex cyst but cannot exclude the possibility of an abscess. Reccomend follow-up with dedicated CT or MRI with contrast for further characterization. TTE [MASKED] There is mild regional left ventricular systolic dysfunction with basal to mid infeiror wall hypokinesis (see schematic) and preserved/normal contractility of the remaining segments. The visually estimated left ventricular ejection fraction is 55%. Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction most consistent with single vessel coronary artery disease (PDA distribution). Moderate pulmonary hypertension. CXR ([MASKED]) Bilateral pulmonary edema is mildly decreased. The pleural effusion with associated bibasilar atelectasis is unchanged, a superimposed focal consolidation cannot be excluded. Cardiomediastinal silhouette is stable. There is no pneumothorax. WBC: 8.5 <-- 11.3 <-- 14 <-- 20.7 Cr: 2.2 <-- 2.4 <-- 2.5 <-- 2.3 (B/L 1.8) HCO3: 31 <-- 28 <-- 29 <-- 30 <-- 22 Mg: 2.3 K: 4.0 Lac: 1.4 BNP: 2263 on admission VBG: pH 7.37, pCO2 55 UA: >182 WBC, Mod bacteria, +Nitrite, [MASKED] BCx: Pending UCx: E Coli ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- <=1 S No prior positive UCx Brief Hospital Course: This is an [MASKED] gentleman with a history notable for HFpEF (EF 50% in [MASKED], ?COPD, dementia, T2DM and BPH who presents from nursing home with 1 week of dyspnea found to have crackles and edema on exam, CXR with pulmonary edema and elevated proBNP all consistent with a heart failure exacerbation and pneumonia. In addition, he has a dirty UA, leukocytosis, and fever suggestive of acute complicated UTI. ACUTE ISSUES ======================= # HFpEF exacerbation # Hypercarbic respiratory failure Patient presented with dyspnea (sating 77-83% on RA at nursing home) which improved on non-invasive ventilation. Was treated with BiPAP in MICU and improved rapidly with diuresis and antibiotics. Time course of improvement (<24 hours) c/w diuresis and not PNA treatment. Furthermore, denies any cough and no focal consolidation on CXR (obscured by pulm edema and effusions). Treating for HF exacerbation. TTE shows LVEF 55% with mild inferior wall hypokinesis, elevated PCWP (>18), moderate pulmonary artery systolic hypertension. Concern that home Lasix dose (40mg QD) was recently changed to 20mg TID which may be contributing to HF Exac. Likely trigger is UTI (treatment below) Pump - C/w Lasix 40mg PO QD with goal Net even. Given that patient is on RA and improving [MASKED] c/w home 40mg PO Lasix QD - Chem should be checked at facility on [MASKED] to ensure improvement of creatinine. If Cr > 2.3, then hold Lasix and hydrate orally for 48 hours. If Cr equal to 2.3, then decrease Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg PO QD and resume home Metop Succ XL 200mg PO BID. - C/w home Isosorbide Mononitrate ER 30mg PO QD given SBP 150-170 - C/w home amlodipine 10mg PO QD - Incentive spirometry to stent open atelectatic alveoli in lower lung field due to shallow breathing Rhythm: NSR on ECG Ischemia: C/f CAD on TTE given mild inferior wall hypokinesis. Given neg trop and ECG w/o ischemic features, no concern for ACS event. Will empirically start atherosclerotic therapy - ASA 81mg QD - [MASKED] year ASCVD risk 17.4%, started Atorva 40mg PO QD - Will need outpatient coronary angiogram pending patient/family preference # Acute complicated UTI # Leukocytosis Acute complicated E. Coli UTI sensitive to Bactrim and Macrobid. Given age > [MASKED] and CrCl < [MASKED], Macrobid is relatively contraindicated. Will start Bactrim knowing that this may artificially elevated serum Cr without changing CrCl. Given lack of productive cough, improving hypoxemia with diuresis, and no discrete focal consolidation on CXR, no need for empiric tx for PNA. Renal US with e/o renal cyst c/f abscess but given lack of fever, improving leukocytosis and clinical improvement with Abx, unlikely to be loculated abscess. - D/c Bactrim SS QD x 10 days ([MASKED]) [MASKED] on CKD (B/L Cr 1.8) Worsening chronologically with IV diuresis in ICU. Differential includes prerenal azotemia vs Type I CRS vs ATN. No e/o post-obstruction (renal US without hydro, bladder scan < 200cc). No e/o granular casts on [MASKED]. CKD likely [MASKED] DM (A1c 7.0%). Improving with PO hydration on home Lasix 40mg PO QD. - C/w home 40mg PO Lasix - Encourage PO intake - Chem should be checked at facility on [MASKED] to ensure improvement of creatinine. If Cr > 2.3, then hold Lasix and hydrate orally for 48 hours. If Cr equal to 2.3, then decrease Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg PO QD and resume home Metop Succ XL 200mg PO BID given HR [MASKED]. # Long QT # Dementia # Delirium Combination of toxic metabolic encephalopathy [MASKED] UTI and in-hospital delirium. Mentation improved dramatically with treatment of UTI. Suspect continued improvement with transfer to a familiar setting (namely his nursing facility) CHRONIC ISSUES ======================= # Anemia Iron studies, B12, folate all wnl in [MASKED]. Potentially [MASKED] chronic cardiac or renal disease # Hypothyroidism Continued home levothyroxine # T2DM Continued home glargine with low dose ISS # Hypertension Continued home amlodipine, isosorbide mononitrate # BPH Continued home finasteride, tamsulosin To Do: [] Complete Bactrim Bactrim SS QD x 10 days ([MASKED]) [] Chem should be checked at facility on [MASKED] to ensure improvement of creatinine. If Cr > 2.3, then hold Lasix and hydrate orally for 48 hours. If Cr equal to 2.3, then decrease Lasix to 20mg PO QD. If Cr < 2.3 then continue with Lasix 40mg PO QD and resume home Metop Succ XL 200mg PO BID given HR [MASKED]. [] Once infection is complete and Cr and returned to baseline, consider outpatient cardiology evaluation for coronary angiogram to assess for CAD I spent 40 mins in discharge planning, coordination of care, and patient/family education. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO QHS 2. Tamsulosin 0.4 mg PO QHS 3. Polyethylene Glycol 17 g PO EVERY OTHER DAY 4. Levothyroxine Sodium 50 mcg PO DAILY 5. amLODIPine 10 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Finasteride 5 mg PO DAILY 8. Furosemide 40 mg PO DAILY 9. Lactulose 30 mL PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. GuaiFENesin [MASKED] mL PO BID 12. Metoprolol Succinate XL 200 mg PO BID 13. Senna 8.6 mg PO BID:PRN Constipation - First Line 14. melatonin 3 mg oral QHS 15. Glargine 9 Units Bedtime 16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 9 Days 4. Glargine 9 Units Bedtime 5. amLODIPine 10 mg PO DAILY 6. Docusate Sodium 100 mg PO QHS 7. Finasteride 5 mg PO DAILY 8. Furosemide 40 mg PO DAILY 9. GuaiFENesin [MASKED] mL PO BID 10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 11. Lactulose 30 mL PO DAILY 12. Levothyroxine Sodium 50 mcg PO DAILY 13. melatonin 3 mg oral QHS 14. Multivitamins 1 TAB PO DAILY 15. Polyethylene Glycol 17 g PO EVERY OTHER DAY 16. Senna 8.6 mg PO BID:PRN Constipation - First Line 17. Tamsulosin 0.4 mg PO QHS 18. Vitamin D 400 UNIT PO DAILY 19. HELD- Metoprolol Succinate XL 200 mg PO BID This medication was held. Do not restart Metoprolol Succinate XL until Pending repeat creatinine and potassium on [MASKED], if stable or improving, can resume 20.Outpatient Lab Work Please check a chemistry on [MASKED]. If Creatinine >2.3, please hold Lasix for 48 hours and recheck creatinine. If Cr equal to 2.3, please decrease dose of Lasix to 20mg PO QD. If Cr <2.3, continue Lasix 40mg PO QD and resume home Metop (give SBP > 100, HR > 70). Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Complicated UTI Heart failure exacerbation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted for a urinary tract infection causing a heart failure exacerbation requiring an ICU admission to assist with your bleeding. Fortunately, with getting you to urinate more and placing you on correct antibiotics, we have been able to get you back to breathing room air. We will need to check your kidney function on [MASKED] to make sure you are on the best dose of Lasix. Weigh yourself every morning, call your doctor if weight goes up more than 3 lbs. Followup Instructions: [MASKED]	[]	[ "N390", "N179", "I130", "N189", "I2510", "J449", "N400", "E1122", "Z794", "E039", "D649" ]	[ "J9692: Respiratory failure, unspecified with hypercapnia", "G92: Toxic encephalopathy", "I5033: Acute on chronic diastolic (congestive) heart failure", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "J189: Pneumonia, unspecified organism", "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "F05: Delirium due to known physiological condition", "E873: Alkalosis", "N189: Chronic kidney disease, unspecified", "I4581: Long QT syndrome", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "J449: Chronic obstructive pulmonary disease, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z794: Long term (current) use of insulin", "E039: Hypothyroidism, unspecified", "D649: Anemia, unspecified", "Z96642: Presence of left artificial hip joint", "Z993: Dependence on wheelchair" ]
19,983,009	21,724,757	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, weakness (OSH); second opinion regarding bowel obstruction (___) Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of Metastatic Pancreatic Colloid Carcinoma (on ___, T2DM, HTN, DVT (lovenox), was transferred from ___ where he was hospitalized for SBO, pneumatosis intestinalis, ___, for which he was transferred to ___ for further care. As per review of notes from ___ patient initially presented for fatigue and weakness and was discharged on the ___ and returned a day later with persistent fatigue. During remaining hospital course he was noted to have worsening abdominal distention in setting of acute kidney injury so had CAT scan abdomen and pelvis which revealed right-sided hydronephrosis as well as small bowel obstruction with portal venous air intra-abdominal ascites and pneumatosis intestinalis concerning for intestinal ischemia. Surgical team was consulted who declined operative intervention given patient's pancreatic cancer, deconditioned state and low likelihood of surviving intervention. He was treated with IV antibiotics and fluids and kidney function improved over the next 3 days. Creatinine at peak was 1.9 on day of transfer was 1.0 On arrival to ___ patient noted that his abdominal distention may be slightly improved but persists, though he is without nausea, vomiting, abdominal pain. He noted that he is stooling ___ medium soft stools per day. Denied any fever or chills. has Foley in place for Urine output monitoring. As per long discussion with patient, his wife, his daughter, and extended family patient noted that given his improvement with supportive measures alone currently decline further imaging or second opinion by surgical teams as would not warrant surgical intervention at this moment. He noted that he understood that antibiotics and fluids is insufficient treatment for suspected bowel perforation, but noted that he feels too weak to undergo surgery right now. He noted that he would continue to discuss with his family and they would keep us posted should their feelings change. He noted that he understood a potentially ignoring a bowel perforation could be life-threatening and noted that he assume the risk. Patient noted that he is unsure about his CODE STATUS as he has not had a long time to think about and felt pressured by ___ to choose DNR. He would like to remain full code for now while he continues to discuss with his family REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY: As per last clinic note by Dr ___ was initially diagnosed with acute pancreatitis in ___. Imaging raised concern for intraductal papillary mucinous neoplasm (IPMN), and he was followed with serial MRI. MRI ___ identified interval change in the configuration of his known pseudocyst. The study was repeated on ___ at which time an enhancing soft tissue abnormality was seen. Upper endoscopy then identified a large amount of mucus at the pylorus. Biopsy by ___ did not show carcinoma. On ___ he was taken to the operating room by Dr. ___ and underwent ___'s pancreaticoduodenectomy. Pathology showed a 4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising from an intraductal IPMN. There was no lymphovascular/perineural invasion; 5 of 18 lymph nodes were involved. He was diagnosed with pT3N1Mx stage IIB mucinous noncystic carcinoma of the pancreas. He received six cycles of adjuvant gemcitabine under the care of Dr. ___, which completed in ___, followed by adjuvant radiation with concurrent capecitabine, which completed ___. He was then followed with surveillance imaging. CT in ___ identified a right upper lobe lung nodule for which he underwent CT-guided FNA. Cytology was suspicious for malignancy. He underwent repeat biopsy in ___ with similar results and was eventually taken to the operating room for VATS wedge resection ___. Pathology confirmed the finding of metastasis from his pancreatic colloid carcinoma. He initiated systemic chemotherapy with FOLFIRINOX ___. He completed 14 cycles as of ___ and then entered a treatment break. In ___ he developed peritoneal carcinomatosis with intra-abdominal ascites and a pulmonary embolism. He resumed cycle ___ FOLFIRINOX and completed an additional two cycles as of ___. Due to progression of peritoneal carcinomatosis he then transitioned to nab-paclitaxel/gemcitabine. He completed four cycles of this as of ___ at which time there was further disease progression. Mr. ___ initiated treatment with 5fu/nal-iri on ___. Snapshot analysis showed variants in ___ and p53" Past Medical History: 1. Pancreatic colloid carcinoma, as detailed in the history of present illness. 2. Diabetes mellitus. 3. GERD. 4. Tuberculosis, for which he had isoniazid and rifampin. 5. Hyperlipidemia. 6. Chronic pancreatitis. 7. Anemia. 8. Umbilical hernia repair in ___. 9. Appendectomy in ___. Social History: ___ Family History: His mother with diabetes, passed in her early ___ of jaundice. Father with diabetes Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.9 PO 100 / 65 71 18 97 RA GENERAL: laying in bed, appears cachectic, severely deconditioned, multiple family members at bedside EYES: PERRLA HEENT: OP clear, dry MM, stiches above left eyebrow NECK: supple LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR CV: RRR no m/r/g normal S1/S2, distal perfusion intact ABD: soft but extremely distended, resonant to percussion, no tenderness, normoactive BS GENITOURINARY: foley in place with clear yellow urine EXT: no deformity but poor muscle bulk SKIN: warm, dry, no rash NEURO: AOx3 fluent speech ACCESS: port with dressing c/d/I DISCHARGE PHYSICAL EXAM: VITALS: AF 110s-120s/68-80 HR ___ RR 16 O2 97% RA GENERAL: laying in bed, appears cachectic, severely deconditioned, family at bedside EYES: PERRLA, sclera anicteric HEENT: OP clear, dry MM, stiches above left eyebrow LUNGS: CTAB CV: RRR no m/r/g normal S1/S2 ABD: soft but very distended distended, normal BS, +large central palpable mass GENITOURINARY: foley removed ___ EXT: no deformity but poor muscle bulk SKIN: warm, dry, no rash NEURO: AOx3 fluent speech ACCESS: port with dressing c/d/I Pertinent Results: #ADMISSION LABS: ___ 01:30AM BLOOD WBC-4.9 RBC-3.08* Hgb-8.6* Hct-25.1* MCV-82 MCH-27.9 MCHC-34.3 RDW-17.9* RDWSD-52.4* Plt ___ ___ 01:30AM BLOOD Neuts-68.5 ___ Monos-8.6 Eos-1.6 Baso-1.0 Im ___ AbsNeut-3.33 AbsLymp-0.93* AbsMono-0.42 AbsEos-0.08 AbsBaso-0.05 ___ 01:30AM BLOOD ___ PTT-67.0* ___ ___ 01:30AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-143 K-3.2* Cl-111* HCO3-22 AnGap-10 ___ 01:30AM BLOOD ALT-10 AST-17 LD(LDH)-171 AlkPhos-104 TotBili-0.4 ___ 01:30AM BLOOD Albumin-1.6* Calcium-6.9* Phos-2.0* Mg-1.6 ___ 10:00AM BLOOD 25VitD-<5* #DISCHARGE LABS: ___ 05:11AM BLOOD WBC-9.1 RBC-2.78* Hgb-7.8* Hct-23.0* MCV-83 MCH-28.1 MCHC-33.9 RDW-17.7* RDWSD-53.5* Plt ___ ___ 06:14AM BLOOD Neuts-84.5* Lymphs-8.5* Monos-5.6 Eos-0.1* Baso-0.5 Im ___ AbsNeut-10.54* AbsLymp-1.06* AbsMono-0.70 AbsEos-0.01* AbsBaso-0.06 ___ 05:11AM BLOOD Glucose-127* UreaN-6 Creat-0.5 Na-141 K-3.4 Cl-100 HCO3-34* AnGap-7* ___ 06:14AM BLOOD ALT-14 AST-14 LD(LDH)-207 AlkPhos-117 TotBili-0.2 ___ 05:11AM BLOOD Calcium-7.2* Phos-2.6* Mg-1.9 ALB 1.6 #MICROBIOLOGY: ___ 11:19AM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 11:19AM URINE Blood-MOD* Nitrite-POS* Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 11:19AM URINE RBC-111* WBC-141* Bacteri-MOD* Yeast-NONE Epi-0 ___ 11:19AM URINE AmorphX-RARE* ___ 11:19AM URINE Mucous-RARE* URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML ESCHERICHIA COLI AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S STOOL CULTURE: FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. FINAL REPORT ___ Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. #IMAGING: NON CONTRAST CT ABDOMEN/PELVIS (OSH), IMPRESSION **PER ___ SECOND READ 1. Multiple dilated small and large bowel loops are identified. There is persistent stenosis of the sigmoid colon from the external compression caused by large pelvic masses, which is the likely the main site of bowel obstruction. 2. Pneumatosis intestinalis of the small bowel loops in the right abdomen is concerning for bowel ischemia and new from prior study. 3. Severe right hydronephrosis is new since ___, but similar compared to ___. 4. Multiple large peritoneal masses appear grossly similar to ___. Previously noted hepatic lesions are not demonstrated on this noncontrast exam. Brief Hospital Course: SUMMARY: ___ PMH of Metastatic Pancreatic Colloid Carcinoma (on ___, T2DM, HTN, DVT (lovenox), was transferred from OSH where he was hospitalized for SBO, pneumatosis intestinalis, ___, for which he was transferred to ___ for further care. ACTIVE ISSUES: #BOWEL OBSTRUCTION: #PNEUMATOSIS INTESTINALIS: #ACUTE KIDNEY INJURY: The patient presented to ___ on ___ with persistent fatigue and weakness after being discharged from there the day prior. His symptoms were in the setting of poor PO intake ___ thrush/esophageal candidiasis, leading to hypotension and resulting in a fall (required stitches above his left eyebrow). During his remaining hospital course he was noted to have worsening abdominal distention in setting of acute kidney injury. A CT abdomen/pelvis revealed a bowel obstruction (external compression from pelvic mass) in addition to pneumatosis intestinalis concerning for bowel ischemia. The surgical team was consulted and declined operative intervention. His symptoms, as well as his ___, resolved with conservative therapy, including aggressive IVF repletion and IV ciprofloxacin/flagyl. He was transferred to ___ for a second opinion regarding the utility of a surgical intervention; however, given that the acute obstruction had resolved, there was no indication for surgery. Per our evaluation, the patient likely developed hypotension ___ poor PO intake, leading to bowel ischemia and obstruction. His antibiotics were discontinued. His abdomen remained softly but severely distended throughout his hospitalization, which is baseline per patient and family. #IRINOTECAN INDUCED DIARRHEA: On ___, one day after admission to ___, the patient developed profuse, frequent diarrhea. C. diff was negative; Giardia, Cryptosporidium, salmonella, shigella and campylobacter were also negative. Per family, he often gets diarrhea following chemotherapy. His last dose of Irinotecan was ___. His diarrhea was attributed to an adverse effect from the chemotherapy and resolved with initiation of Imodium. #ELECTROLYTE ABNORMALITIES (hypoK, hypoMg, hypoP): At baseline, the patient has hypokalemia and hypomagnesemia for which he is on standing oral supplementation at home. However, due to the profuse diarrhea, he had extreme electrolyte loss requiring repletion every 8 hours and monitoring on telemetry. Upon resolution of the diarrhea, his electrolytes were back to his baseline. He was discharged on the same magnesium regimen (500 mg PO daily) and an increase in his potassium daily supplementation (60 mEq to 80 mEq daily). He was also discharged on a phosphorous supplement of 250 mg daily as well as 50,000 units of vitamin D to be taken once weekly for eight weeks. #URINARY RETENTION: #PARAPHIMOSIS: #CATHETER ASSOCIATED URINARY TRACT INFECTION: On presentation from OSH, the patient had a foley catheter in place ___ urinary retention. He was noted to have severe, non-painful paraphimosis on exam. Urology was consulted and retracted the skin without complication. He failed a voiding trial x2 and a foley catheter was re-inserted. On ___, he developed a leukocytosis with a grossly positive UA. UCx was positive for >100,000 GNR and he was initiated on Ceftriaxone 2gm q24h (___). The foley was removed and his urinary retention resolved. At discharge, his white count had resolved and he was sent out on Bactrim DS BID for completion of a 7 day course (___). Of note, the patient has chronic, stable, right hydronephrosis. #POOR NUTRITIONAL STATUS: #WEAKNESS: Prior to presentation, the patient endorses decreased PO intake with minimal appetite. He is quite cachectic on exam. Nutritional services were consulted and he was maintained on ensure clears and encouraged to eat small, frequent meals. We did not recommend TPN or tube feeds. He worked with physical therapy for improvement of balance and strength and was discharged to a rehab facility to continue working toward these goals. He was also given a prescription for a rolling walker. #SACRAL ULCER: Stage 2. Secondary to poor nutritional status, cachexia and decreased mobility. The patient does not want to lie on a pillow but does endorse some tenderness on exam. A mepilex is in place. #MUCINOUS NONCYSTIC COLLOID CARCINOMA OF THE PANCREAS: #GOALS OF CARE: The patient was diagnosed in ___ with pT3N1Mx stage IIB. He underwent a Whipple procedure and has had several cycles of palliative chemotherapy. Unfortunately, his disease continues to progress. He is followed by Dr. ___ and is currently undergoing chemotherapy with ___, last dose ___. Given lack of improvement and side effect of severe diarrhea, it is unclear whether he will proceed with chemotherapy. His family notes that they do not want to prolong suffering, but would like to extend his life as long as possible. He is currently full code. Future treatment options as well as goals of care was deferred to his outpatient oncologist. CHRONIC ISSUES: #HISTORY OF PULMONARY EMBOLISM: Decreased therapeutic Lovenox (1.5mg/kg/day) from 80mg SC daily to 70mg SC daily due to weight loss. #TYPE II DIABETES MELLITUS: Given poor nutritional status and current prognosis, we did not continue checking frequent blood glucose and did not give insulin. Generally, his AM fasting sugars were under 130. #HYPERTENSION: The patient was not hypertensive during admission and we did not require any antihypertensive medication. TRANSLATIONAL ISSUES: [ ] Stiches removal above left eyebrow (will likely remove in ___ clinic) [ ] Follow up electrolytes on ___, adjust oral supplementation as necessary [ ] Ensure that diarrhea is well controlled [ ] Continue vitamin D 50,000 units qweek for 8 weeks ___, received 1 dose ___. Last dose ___ [ ] Sacral ulcer, stage II: please ensure that the patient is turned every couple of hours and that the area is closely monitored and cared for [ ] Bactrim for CAUTI (complete course ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 80 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 3. Potassium Chloride 60 mEq PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Magnesium Oxide 500 mg PO DAILY Discharge Medications: 1. Famotidine 20 mg PO Q12H 2. LOPERamide 4 mg PO QID:PRN diarrhea 3. Phosphorus 250 mg PO DAILY 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 4 Days 5. Enoxaparin Sodium 70 mg SC Q24H 6. Potassium Chloride 80 mEq PO DAILY 7. Vitamin D ___ UNIT PO 1X/WEEK (___) Duration: 8 Doses 8. Magnesium Oxide 500 mg PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11.Rolling Walker DX: Pancreatic cancer PX: Good ___: 13 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Bowel obstruction SECONDARY DIAGNOSIS: Mucinous noncystic colloid carcinoma of the pancreas Acute kidney injury Irinotecan induced diarrhea Electrolyte abnormalities Urinary retention Urinary tract infection Paraphimosis Poor nutritional status, weakness Sacral ulcer, stage II History of pulmonary embolism Type II Diabetes Mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you felt weak, were having diarrhea, fell and hit your head, and had very bad abdominal pain. In the hospital you had a CT scan of your abdomen which was initially concerning for bowel obstruction and ischemia. However, your pain improved, and we did not do any surgery because we think the problem resolved on its own. We believe your diarrhea is from your irinotecan chemotherapy and we treated this with Imodium (loperamide). You continued to lose electrolytes (potassium, magnesium, and phosphorous) through your stool so we started some daily oral supplementation. You also developed a bladder infection while you were in the hospital. You were treated with an IV antibiotic for three days, and will be discharged on an oral antibiotic which you will need to take twice daily for four more days (___). You are also weaker than you were before, so we feel that it is safest for you to be discharged to rehab where you can get stronger again before going home. We recommend that you continue to drink ENSURE CLEARS with your meals to help keep up your strength. It was truly a pleasure taking part in your care. We wish you all the best with your future health. Sincerely, The team at ___ Followup Instructions: ___	[ "K56609", "E43", "N179", "K559", "C259", "L89152", "C772", "T83511A", "N390", "C7801", "C786", "K861", "Z681", "K521", "K6389", "K219", "I10", "E119", "Z86711", "Z7901", "E876", "N472", "E861", "R339", "T451X5A", "E8342", "Y846", "Y929", "E8339" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Fatigue, weakness (OSH); second opinion regarding bowel obstruction ([MASKED]) Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] PMH of Metastatic Pancreatic Colloid Carcinoma (on [MASKED], T2DM, HTN, DVT (lovenox), was transferred from [MASKED] where he was hospitalized for SBO, pneumatosis intestinalis, [MASKED], for which he was transferred to [MASKED] for further care. As per review of notes from [MASKED] patient initially presented for fatigue and weakness and was discharged on the [MASKED] and returned a day later with persistent fatigue. During remaining hospital course he was noted to have worsening abdominal distention in setting of acute kidney injury so had CAT scan abdomen and pelvis which revealed right-sided hydronephrosis as well as small bowel obstruction with portal venous air intra-abdominal ascites and pneumatosis intestinalis concerning for intestinal ischemia. Surgical team was consulted who declined operative intervention given patient's pancreatic cancer, deconditioned state and low likelihood of surviving intervention. He was treated with IV antibiotics and fluids and kidney function improved over the next 3 days. Creatinine at peak was 1.9 on day of transfer was 1.0 On arrival to [MASKED] patient noted that his abdominal distention may be slightly improved but persists, though he is without nausea, vomiting, abdominal pain. He noted that he is stooling [MASKED] medium soft stools per day. Denied any fever or chills. has Foley in place for Urine output monitoring. As per long discussion with patient, his wife, his daughter, and extended family patient noted that given his improvement with supportive measures alone currently decline further imaging or second opinion by surgical teams as would not warrant surgical intervention at this moment. He noted that he understood that antibiotics and fluids is insufficient treatment for suspected bowel perforation, but noted that he feels too weak to undergo surgery right now. He noted that he would continue to discuss with his family and they would keep us posted should their feelings change. He noted that he understood a potentially ignoring a bowel perforation could be life-threatening and noted that he assume the risk. Patient noted that he is unsure about his CODE STATUS as he has not had a long time to think about and felt pressured by [MASKED] to choose DNR. He would like to remain full code for now while he continues to discuss with his family REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY: As per last clinic note by Dr [MASKED] was initially diagnosed with acute pancreatitis in [MASKED]. Imaging raised concern for intraductal papillary mucinous neoplasm (IPMN), and he was followed with serial MRI. MRI [MASKED] identified interval change in the configuration of his known pseudocyst. The study was repeated on [MASKED] at which time an enhancing soft tissue abnormality was seen. Upper endoscopy then identified a large amount of mucus at the pylorus. Biopsy by [MASKED] did not show carcinoma. On [MASKED] he was taken to the operating room by Dr. [MASKED] and underwent [MASKED]'s pancreaticoduodenectomy. Pathology showed a 4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising from an intraductal IPMN. There was no lymphovascular/perineural invasion; 5 of 18 lymph nodes were involved. He was diagnosed with pT3N1Mx stage IIB mucinous noncystic carcinoma of the pancreas. He received six cycles of adjuvant gemcitabine under the care of Dr. [MASKED], which completed in [MASKED], followed by adjuvant radiation with concurrent capecitabine, which completed [MASKED]. He was then followed with surveillance imaging. CT in [MASKED] identified a right upper lobe lung nodule for which he underwent CT-guided FNA. Cytology was suspicious for malignancy. He underwent repeat biopsy in [MASKED] with similar results and was eventually taken to the operating room for VATS wedge resection [MASKED]. Pathology confirmed the finding of metastasis from his pancreatic colloid carcinoma. He initiated systemic chemotherapy with FOLFIRINOX [MASKED]. He completed 14 cycles as of [MASKED] and then entered a treatment break. In [MASKED] he developed peritoneal carcinomatosis with intra-abdominal ascites and a pulmonary embolism. He resumed cycle [MASKED] FOLFIRINOX and completed an additional two cycles as of [MASKED]. Due to progression of peritoneal carcinomatosis he then transitioned to nab-paclitaxel/gemcitabine. He completed four cycles of this as of [MASKED] at which time there was further disease progression. Mr. [MASKED] initiated treatment with 5fu/nal-iri on [MASKED]. Snapshot analysis showed variants in [MASKED] and p53" Past Medical History: 1. Pancreatic colloid carcinoma, as detailed in the history of present illness. 2. Diabetes mellitus. 3. GERD. 4. Tuberculosis, for which he had isoniazid and rifampin. 5. Hyperlipidemia. 6. Chronic pancreatitis. 7. Anemia. 8. Umbilical hernia repair in [MASKED]. 9. Appendectomy in [MASKED]. Social History: [MASKED] Family History: His mother with diabetes, passed in her early [MASKED] of jaundice. Father with diabetes Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.9 PO 100 / 65 71 18 97 RA GENERAL: laying in bed, appears cachectic, severely deconditioned, multiple family members at bedside EYES: PERRLA HEENT: OP clear, dry MM, stiches above left eyebrow NECK: supple LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR CV: RRR no m/r/g normal S1/S2, distal perfusion intact ABD: soft but extremely distended, resonant to percussion, no tenderness, normoactive BS GENITOURINARY: foley in place with clear yellow urine EXT: no deformity but poor muscle bulk SKIN: warm, dry, no rash NEURO: AOx3 fluent speech ACCESS: port with dressing c/d/I DISCHARGE PHYSICAL EXAM: VITALS: AF 110s-120s/68-80 HR [MASKED] RR 16 O2 97% RA GENERAL: laying in bed, appears cachectic, severely deconditioned, family at bedside EYES: PERRLA, sclera anicteric HEENT: OP clear, dry MM, stiches above left eyebrow LUNGS: CTAB CV: RRR no m/r/g normal S1/S2 ABD: soft but very distended distended, normal BS, +large central palpable mass GENITOURINARY: foley removed [MASKED] EXT: no deformity but poor muscle bulk SKIN: warm, dry, no rash NEURO: AOx3 fluent speech ACCESS: port with dressing c/d/I Pertinent Results: #ADMISSION LABS: [MASKED] 01:30AM BLOOD WBC-4.9 RBC-3.08* Hgb-8.6* Hct-25.1* MCV-82 MCH-27.9 MCHC-34.3 RDW-17.9* RDWSD-52.4* Plt [MASKED] [MASKED] 01:30AM BLOOD Neuts-68.5 [MASKED] Monos-8.6 Eos-1.6 Baso-1.0 Im [MASKED] AbsNeut-3.33 AbsLymp-0.93* AbsMono-0.42 AbsEos-0.08 AbsBaso-0.05 [MASKED] 01:30AM BLOOD [MASKED] PTT-67.0* [MASKED] [MASKED] 01:30AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-143 K-3.2* Cl-111* HCO3-22 AnGap-10 [MASKED] 01:30AM BLOOD ALT-10 AST-17 LD(LDH)-171 AlkPhos-104 TotBili-0.4 [MASKED] 01:30AM BLOOD Albumin-1.6* Calcium-6.9* Phos-2.0* Mg-1.6 [MASKED] 10:00AM BLOOD 25VitD-<5* #DISCHARGE LABS: [MASKED] 05:11AM BLOOD WBC-9.1 RBC-2.78* Hgb-7.8* Hct-23.0* MCV-83 MCH-28.1 MCHC-33.9 RDW-17.7* RDWSD-53.5* Plt [MASKED] [MASKED] 06:14AM BLOOD Neuts-84.5* Lymphs-8.5* Monos-5.6 Eos-0.1* Baso-0.5 Im [MASKED] AbsNeut-10.54* AbsLymp-1.06* AbsMono-0.70 AbsEos-0.01* AbsBaso-0.06 [MASKED] 05:11AM BLOOD Glucose-127* UreaN-6 Creat-0.5 Na-141 K-3.4 Cl-100 HCO3-34* AnGap-7* [MASKED] 06:14AM BLOOD ALT-14 AST-14 LD(LDH)-207 AlkPhos-117 TotBili-0.2 [MASKED] 05:11AM BLOOD Calcium-7.2* Phos-2.6* Mg-1.9 ALB 1.6 #MICROBIOLOGY: [MASKED] 11:19AM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 11:19AM URINE Blood-MOD* Nitrite-POS* Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* [MASKED] 11:19AM URINE RBC-111* WBC-141* Bacteri-MOD* Yeast-NONE Epi-0 [MASKED] 11:19AM URINE AmorphX-RARE* [MASKED] 11:19AM URINE Mucous-RARE* URINE CULTURE (Final [MASKED]: ESCHERICHIA COLI. >100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML ESCHERICHIA COLI AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 16 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S STOOL CULTURE: FINAL REPORT [MASKED] C. difficile DNA amplification assay (Final [MASKED]: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. FINAL REPORT [MASKED] Cryptosporidium/Giardia (DFA) (Final [MASKED]: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. FECAL CULTURE (Final [MASKED]: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [MASKED]: NO CAMPYLOBACTER FOUND. #IMAGING: NON CONTRAST CT ABDOMEN/PELVIS (OSH), IMPRESSION **PER [MASKED] SECOND READ 1. Multiple dilated small and large bowel loops are identified. There is persistent stenosis of the sigmoid colon from the external compression caused by large pelvic masses, which is the likely the main site of bowel obstruction. 2. Pneumatosis intestinalis of the small bowel loops in the right abdomen is concerning for bowel ischemia and new from prior study. 3. Severe right hydronephrosis is new since [MASKED], but similar compared to [MASKED]. 4. Multiple large peritoneal masses appear grossly similar to [MASKED]. Previously noted hepatic lesions are not demonstrated on this noncontrast exam. Brief Hospital Course: SUMMARY: [MASKED] PMH of Metastatic Pancreatic Colloid Carcinoma (on [MASKED], T2DM, HTN, DVT (lovenox), was transferred from OSH where he was hospitalized for SBO, pneumatosis intestinalis, [MASKED], for which he was transferred to [MASKED] for further care. ACTIVE ISSUES: #BOWEL OBSTRUCTION: #PNEUMATOSIS INTESTINALIS: #ACUTE KIDNEY INJURY: The patient presented to [MASKED] on [MASKED] with persistent fatigue and weakness after being discharged from there the day prior. His symptoms were in the setting of poor PO intake [MASKED] thrush/esophageal candidiasis, leading to hypotension and resulting in a fall (required stitches above his left eyebrow). During his remaining hospital course he was noted to have worsening abdominal distention in setting of acute kidney injury. A CT abdomen/pelvis revealed a bowel obstruction (external compression from pelvic mass) in addition to pneumatosis intestinalis concerning for bowel ischemia. The surgical team was consulted and declined operative intervention. His symptoms, as well as his [MASKED], resolved with conservative therapy, including aggressive IVF repletion and IV ciprofloxacin/flagyl. He was transferred to [MASKED] for a second opinion regarding the utility of a surgical intervention; however, given that the acute obstruction had resolved, there was no indication for surgery. Per our evaluation, the patient likely developed hypotension [MASKED] poor PO intake, leading to bowel ischemia and obstruction. His antibiotics were discontinued. His abdomen remained softly but severely distended throughout his hospitalization, which is baseline per patient and family. #IRINOTECAN INDUCED DIARRHEA: On [MASKED], one day after admission to [MASKED], the patient developed profuse, frequent diarrhea. C. diff was negative; Giardia, Cryptosporidium, salmonella, shigella and campylobacter were also negative. Per family, he often gets diarrhea following chemotherapy. His last dose of Irinotecan was [MASKED]. His diarrhea was attributed to an adverse effect from the chemotherapy and resolved with initiation of Imodium. #ELECTROLYTE ABNORMALITIES (hypoK, hypoMg, hypoP): At baseline, the patient has hypokalemia and hypomagnesemia for which he is on standing oral supplementation at home. However, due to the profuse diarrhea, he had extreme electrolyte loss requiring repletion every 8 hours and monitoring on telemetry. Upon resolution of the diarrhea, his electrolytes were back to his baseline. He was discharged on the same magnesium regimen (500 mg PO daily) and an increase in his potassium daily supplementation (60 mEq to 80 mEq daily). He was also discharged on a phosphorous supplement of 250 mg daily as well as 50,000 units of vitamin D to be taken once weekly for eight weeks. #URINARY RETENTION: #PARAPHIMOSIS: #CATHETER ASSOCIATED URINARY TRACT INFECTION: On presentation from OSH, the patient had a foley catheter in place [MASKED] urinary retention. He was noted to have severe, non-painful paraphimosis on exam. Urology was consulted and retracted the skin without complication. He failed a voiding trial x2 and a foley catheter was re-inserted. On [MASKED], he developed a leukocytosis with a grossly positive UA. UCx was positive for >100,000 GNR and he was initiated on Ceftriaxone 2gm q24h ([MASKED]). The foley was removed and his urinary retention resolved. At discharge, his white count had resolved and he was sent out on Bactrim DS BID for completion of a 7 day course ([MASKED]). Of note, the patient has chronic, stable, right hydronephrosis. #POOR NUTRITIONAL STATUS: #WEAKNESS: Prior to presentation, the patient endorses decreased PO intake with minimal appetite. He is quite cachectic on exam. Nutritional services were consulted and he was maintained on ensure clears and encouraged to eat small, frequent meals. We did not recommend TPN or tube feeds. He worked with physical therapy for improvement of balance and strength and was discharged to a rehab facility to continue working toward these goals. He was also given a prescription for a rolling walker. #SACRAL ULCER: Stage 2. Secondary to poor nutritional status, cachexia and decreased mobility. The patient does not want to lie on a pillow but does endorse some tenderness on exam. A mepilex is in place. #MUCINOUS NONCYSTIC COLLOID CARCINOMA OF THE PANCREAS: #GOALS OF CARE: The patient was diagnosed in [MASKED] with pT3N1Mx stage IIB. He underwent a Whipple procedure and has had several cycles of palliative chemotherapy. Unfortunately, his disease continues to progress. He is followed by Dr. [MASKED] and is currently undergoing chemotherapy with [MASKED], last dose [MASKED]. Given lack of improvement and side effect of severe diarrhea, it is unclear whether he will proceed with chemotherapy. His family notes that they do not want to prolong suffering, but would like to extend his life as long as possible. He is currently full code. Future treatment options as well as goals of care was deferred to his outpatient oncologist. CHRONIC ISSUES: #HISTORY OF PULMONARY EMBOLISM: Decreased therapeutic Lovenox (1.5mg/kg/day) from 80mg SC daily to 70mg SC daily due to weight loss. #TYPE II DIABETES MELLITUS: Given poor nutritional status and current prognosis, we did not continue checking frequent blood glucose and did not give insulin. Generally, his AM fasting sugars were under 130. #HYPERTENSION: The patient was not hypertensive during admission and we did not require any antihypertensive medication. TRANSLATIONAL ISSUES: [ ] Stiches removal above left eyebrow (will likely remove in [MASKED] clinic) [ ] Follow up electrolytes on [MASKED], adjust oral supplementation as necessary [ ] Ensure that diarrhea is well controlled [ ] Continue vitamin D 50,000 units qweek for 8 weeks [MASKED], received 1 dose [MASKED]. Last dose [MASKED] [ ] Sacral ulcer, stage II: please ensure that the patient is turned every couple of hours and that the area is closely monitored and cared for [ ] Bactrim for CAUTI (complete course [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 80 mg SC Q24H Start: [MASKED], First Dose: Next Routine Administration Time 2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 3. Potassium Chloride 60 mEq PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Prochlorperazine 10 mg PO Q6H:PRN nausea 6. Magnesium Oxide 500 mg PO DAILY Discharge Medications: 1. Famotidine 20 mg PO Q12H 2. LOPERamide 4 mg PO QID:PRN diarrhea 3. Phosphorus 250 mg PO DAILY 4. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 4 Days 5. Enoxaparin Sodium 70 mg SC Q24H 6. Potassium Chloride 80 mEq PO DAILY 7. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) Duration: 8 Doses 8. Magnesium Oxide 500 mg PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11.Rolling Walker DX: Pancreatic cancer PX: Good [MASKED]: 13 Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: PRIMARY DIAGNOSIS: Bowel obstruction SECONDARY DIAGNOSIS: Mucinous noncystic colloid carcinoma of the pancreas Acute kidney injury Irinotecan induced diarrhea Electrolyte abnormalities Urinary retention Urinary tract infection Paraphimosis Poor nutritional status, weakness Sacral ulcer, stage II History of pulmonary embolism Type II Diabetes Mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital because you felt weak, were having diarrhea, fell and hit your head, and had very bad abdominal pain. In the hospital you had a CT scan of your abdomen which was initially concerning for bowel obstruction and ischemia. However, your pain improved, and we did not do any surgery because we think the problem resolved on its own. We believe your diarrhea is from your irinotecan chemotherapy and we treated this with Imodium (loperamide). You continued to lose electrolytes (potassium, magnesium, and phosphorous) through your stool so we started some daily oral supplementation. You also developed a bladder infection while you were in the hospital. You were treated with an IV antibiotic for three days, and will be discharged on an oral antibiotic which you will need to take twice daily for four more days ([MASKED]). You are also weaker than you were before, so we feel that it is safest for you to be discharged to rehab where you can get stronger again before going home. We recommend that you continue to drink ENSURE CLEARS with your meals to help keep up your strength. It was truly a pleasure taking part in your care. We wish you all the best with your future health. Sincerely, The team at [MASKED] Followup Instructions: [MASKED]	[]	[ "N179", "N390", "K219", "I10", "E119", "Z7901", "Y929" ]	[ "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "K559: Vascular disorder of intestine, unspecified", "C259: Malignant neoplasm of pancreas, unspecified", "L89152: Pressure ulcer of sacral region, stage 2", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "N390: Urinary tract infection, site not specified", "C7801: Secondary malignant neoplasm of right lung", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "K861: Other chronic pancreatitis", "Z681: Body mass index [BMI] 19.9 or less, adult", "K521: Toxic gastroenteritis and colitis", "K6389: Other specified diseases of intestine", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "E876: Hypokalemia", "N472: Paraphimosis", "E861: Hypovolemia", "R339: Retention of urine, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "E8342: Hypomagnesemia", "Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "E8339: Other disorders of phosphorus metabolism" ]
19,983,009	25,448,442	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Shock and respiratory failure Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ y/o man with a PMH of recurrent, metastatic pancreatic colloid carcinoma (to lung and peritoneum, s/p FOLFIRINOX, nab-paclitaxel/gemcitabine, and nal-irinotecan), PE (on enoxaparin), who presented as a transfer from ___ ___ with hypotension, hypothermia, and possible syncope. At baseline, he requires frequent infusions of IV fluids at home given chronic losses from diarrhea. According to his wife, he was feeling otherwise well, when he had a scheduled appointment with oncology. At the end of his breakfast, he slumped over, and appeared to have passed out. His blood pressure was checked by his family and was reportedly very low. He denied preceding chest pain, fever, or abdominal pain. When EMS found the patient in his home, he was noted to be bradycardic to the ___, and they were unable to obtain a blood pressure at that time. He was reportedly unresponsive for several minutes. He was taken to ___, where he was found to be hypothermic, hypoglycemic, and hypotensive. He was placed on a Bair Hugger, given warm blankets, and underwent a CT abdomen that did not show acute changes. He was transfused one unit of pRBCs. CXR was performed, which was notable for a right lower lobe pneumonia and pleural effusion. Labs were notable for BNP 1700, INR 1.6, magnesium 1.4, and highly elevated TSH of 40. He was given vancomycin/cefepime, and 1L IVF. He also received 2 amps of D50. He remained on 2L NC, oxygenating 96-97%. A coude catheter was placed. He was transferred to ___. Of note, he saw his oncologist Dr. ___ on ___ for his cancer. He had declining performance status and multiple hospitalizations, abdominal pain, anorexia, and electrolyte abnormalities. At that point no further chemotherapies were planned and the focus was on palliation, although the patient declined hospice. He was receiving 500 mL IVF qd at home and agreed to monitor labs aggressively even if that meant he had to go to the ED for repletion and transfusions. Patient has a MOLST ___ that indicates full code. Per telephone conversation between Dr. ___ the ___ daughter, they are considering a palliative approach to his advanced cancer now. In the ED, initial vitals were T 95.0F BP 81/60 mmHg P 72 RR 23 O2 91% RA. Examination was notable for: cachectic, chronically ill-appearing, responding though speech is difficult to understand, NAD. 2+ edema to the knees bilaterally, stool guaiac negative. Bedside TTE demonstrated no pericardial effusion. Labs were notable for: WBC 2.5k (Diff 87%N, 10%L, 3%N), H/H 8.5/26.8, PLT 67,000, PTT 150, INR 1.6, ___ ___, ALT 203, AST 382, alk phos 680, Tbili 0.5, albumin 1.4, lipase 3, troponin-T 0.08, Na 142, K 5.0, Cl 109, HCO3 25, BUN/Cr ___, lactate 1.9. Imaging was notable for CXR with interval slight increase in the right lung interstitial opacities since earlier today, appearing slightly more confluent. His mental status worsened, and he developed worsening tachypnea, for which he was intubated. He received vancomycin/cefepime, and was started on norepinephrine (uptitrated to 0.3 mcg/kg/min) and vasopressin 2.4 units/hr. He received 2L IVF and 2g calcium gluconate. He required the addition of epinephrine for refractory hypotension. He was admitted to the FICU. Upon arrival to ___, he was intubated and sedated and unable to provide further history. Past Medical History: 1. Pancreatic colloid carcinoma, as detailed in the history of present illness. 2. Diabetes mellitus. 3. GERD. 4. Tuberculosis, for which he had isoniazid and rifampin. 5. Hyperlipidemia. 6. Chronic pancreatitis. 7. Anemia. 8. Umbilical hernia repair in ___. 9. Appendectomy in ___. Social History: ___ Family History: His mother with diabetes, passed in her early ___ of jaundice. Father with diabetes Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 36.5C BP 125/91 mmHg (on pressors) P 90 RR 16 O2 100% (on CMV ventilation) General: Intubated and sedated. Profoundly cachectic. HEENT: Severe temporal wasting bilaterally. Pupils pinpoint and reactive. EOMs intact, anicteric sclerae. MMM. Neck: No JVD. CV: Distant heart sounds. No MRGs; normal S1/S2. Pulm: Diminished breath sounds R>L on anterior examination. Intubated and mechanically ventilated. Abdomen: Distended; soft, NABS. Ext: 2+ pitting edema to knee; cool and mottled feet, with warm ankles and lower legs. Dopplerable DP pulses. Skin: Marked flaking over feet bilaterally. Neuro: Sedated. DISCHARGE PHYSICAL EXAM: Expired ___. Pertinent Results: ADMISSION LABS: ___ 05:33PM LACTATE-1.9 ___ 05:20PM ALBUMIN-1.4* CALCIUM-6.4* PHOSPHATE-3.0 MAGNESIUM-2.2 ___ 05:20PM GLUCOSE-163* UREA N-26* CREAT-0.5 SODIUM-142 POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-25 ANION GAP-8* ___ 05:20PM ALT(SGPT)-203* AST(SGOT)-382* ALK PHOS-680* TOT BILI-0.5 ___ 05:20PM ___ ___ 05:20PM cTropnT-0.08 ___ 05:20PM WBC-2.5* RBC-3.06* HGB-8.5* HCT-26.8* MCV-88 MCH-27.8 MCHC-31.7* RDW-15.9* RDWSD-51.0* ___ 05:20PM NEUTS-87* BANDS-0 LYMPHS-10* MONOS-3* EOS-0 BASOS-0 ___ MYELOS-0 AbsNeut-2.18 AbsLymp-0.25* AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00* ___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 05:20PM URINE RBC-3* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 PERTINENT LABS: ___ 02:39AM BLOOD ___ PTT-68.3* ___ ___ 12:00PM BLOOD ___ PTT-87.9* ___ ___ 05:20PM BLOOD Plt Smr-VERY LOW* Plt Ct-67* ___ 05:26PM BLOOD Plt Ct-27* ___ 02:22AM BLOOD Ret Aut-1.3 Abs Ret-0.04 ___ 12:00PM BLOOD ___ ___ 02:22AM BLOOD CK-MB-5 cTropnT-0.08* ___ 12:30PM BLOOD CK-MB-4 cTropnT-0.08___ ___ 02:22AM BLOOD TSH-39* ___ 07:26AM BLOOD TSH-23* ___ 02:22AM BLOOD T4-0.6* T3-40* Free T4-<0.1* ___ 07:26AM BLOOD T4-5.2 T3-48* Free T4-1.3 ___ 12:00PM BLOOD T4-4.2* T3-60* Free T4-1.1 ___ 11:00AM BLOOD Cortsol-56.8* ___ 02:58AM BLOOD Type-ART pO2-98 pCO2-41 pH-7.36 calTCO2-24 Base XS--1 ___ 08:56PM BLOOD Type-ART pO2-158* pCO2-34* pH-7.47* calTCO2-25 Base XS-2 ___ 06:11AM BLOOD Type-ART pO2-140* pCO2-45 pH-7.34* calTCO2-25 Base XS--1 ___ 02:58AM BLOOD Lactate-3.2* ___ 12:44PM BLOOD Lactate-2.1* ___ 12:46PM BLOOD Lactate-1.3 ___ 11:00AM BLOOD ACTH - FROZEN-PND ___ 12:34PM BLOOD RENIN - FROZEN-PND ___ 12:34PM BLOOD ALDOSTERONE-PND DISCHARGE LABS: Expired ___. PERTINENT IMAGING: ___ TTE Normal left ventricular wall thickness and cavity size with severe regional systolic dysfunction (EF ___ most c/w multivessel CAD, though Takotsubo cardiomyopathy, and nonischemic cardiomyopathy are possible. Moderate to large pericardial effusion without echocardiographic evidence of tamponade. Large echodense pericardial mass affixed to anterior right ventricular surface. Mild aortic regurgitation. Mild mitral regurgitation. Pulmonary artery diastolic hypertension. Brief Hospital Course: Mr. ___ is a ___ y/o man with a PMH of recurrent, metastatic pancreatic colloid carcinoma (to lung and peritoneum, s/p FOLFIRINOX, nab-paclitaxel/gemcitabine, and nal-irinotecan), PE, and T2DM, who presented as a transfer from ___ with shock and respiratory failure. He spent almost two weeks in the ICU being treated with antibiotics for septic shock and intubated for respiratory failure secondary to pneumonia. Unfortunately, the patient failed to be extubated and clinically deteriorated with worsening mental status. He was made DNR (but remained intubated) on ___ and with no further escalation of care. His immediate family members were awaiting other family members' arrival from ___, so they wished to prolong terminal extubation. He eventually passed on ___. # SHOCK, MIXED: Mr. ___ presented a mixed picture of shock, consistent with septic (pulmonary source vs. intra-abdominal source) vs. cardiogenic (EF ___ newly diagnosed on TTE). He initially required three pressors but was weaned to just levophed; his family agreed that further escalation of care was not indicated, so he was slowly weaned off on the levophed and passed on ___. # HYPOXEMIC RESPIRATORY FAILURE. # PNEUMONIA, HEALTHCARE ASSOCIATED Patient presented with respiratory failure requiring intubation, likely related to right-sided pneumonia. He was maintained on a lung-protective ventilation to prevent ARDS. # SEVERE HYPOTHYROIDISM: Patient presented with highly elevated TSH 39 with low T3/T4 (T4 0.6, T3 40, free T4 < 0.01) alongside hypothermia and hypoglycemia. Endocrinology felt that myxedema coma was low likelihood but did recommend treating for adrenal insufficiency (see below) prior to treating hypothyroidism. TSH decreased appropriately with levothyroxine and liothyroxine. # ADRENAL INSUFFICIENCY AI was suspected given given hypoglycemia, hypothermia, and bradycardia at presentation. He was started on hydrocortisone 50mg IV q6h (which was discontinued on ___ after his cortisol levels were noted to be normal), and ACTH, renin and aldosterone were found to be normal. # THROMBOCYTOPENIA. Patient had downtrending platelets from 60 -> 20 concerning for DIC in the setting of shock and acute illness. However, in the setting of his multiple comorbidities, no further management was indicated. # METASTATIC PANCREATIC COLLOID CARCINOMA. As above, patient progressed through multiple intensive chemotherapy regimens and was receiving maximal supportive therapy at home. With Palliative care's help, patient was ultimately made DNR and no further escalation of care. *** # ELEVATED LIVER ENZYMES. Markedly elevated, in a predominantly hepatocellular pattern with normal Tbili concern for possible shock liver. # R HYDRONEPHROSIS. Hydronephrosis was noted on OSH imaging but renal function was within normal limits, so further workup was not done. He was not a dialysis candidate. # ANEMIA. Patient presented with low serum iron with markedly elevated ferritin consistent with anemia of inflammation; there was no evidence of active bleeding. # DEMAND ISCHEMIA. Patient presented with troponin elevated to 0.08 which remained stable, likely representing demand ischemia in the setting of shock. # Hypoglycemia: Patient had low glood sugars to ___ thought related to adrenal insufficiency. He was maintained on a D10 infusion with improvement in his glucose levels. # PULMONARY EMBOLISM. Patient was initially maintained on enoxaparin SC 60 mg q24h, but transition to heparin drip was deferred in setting of thrombocytopenia and elevated PTT/INR. He notably had no evidence of RV strain on TTE. ================= CHRONIC ISSUES ================= # MALNUTRITION # HYPOALBUMINEMIA # CHRONIC PANCREATITIS. # CHRONIC DIARRHEA # GERD Patient found to have chronic malnutrition with profound hypoalbuminemia. He has chronic diarrhea leading to hypovolemia requiring frequent infusions of IV fluids at home. He was maintained on tube feeds. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LOPERamide 2 mg PO QID:PRN diarrhea 2. Vitamin D ___ UNIT PO 1X/WEEK (___) 3. Prochlorperazine 10 mg IV Q8H:PRN nausea 4. Famotidine 20 mg PO BID 5. Magnesium Oxide 400 mg PO DAILY 6. Mirtazapine 15 mg PO QHS 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. sod phos di, mono-K phos mono ___ mg oral daily 9. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit oral TID W/MEALS 10. Neutra-Phos 2 PKT PO TID 11. Potassium Chloride 40 mEq PO BID 12. Midodrine 10 mg PO TID 13. Enoxaparin Sodium 60 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 14. Sertraline 50 mg PO DAILY Discharge Medications: Expired ___ Discharge Disposition: Expired Discharge Diagnosis: Expired ___. Discharge Condition: Expired ___. Discharge Instructions: Expired ___. Followup Instructions: ___	[ "A4151", "J9601", "D65", "K7200", "R6521", "E43", "G92", "C259", "A0472", "J189", "C7800", "E2740", "R64", "C786", "I248", "Z681", "I429", "I5020", "E872", "K219", "E785", "Z66", "E039", "D649", "Z86711", "K529", "E11649", "Z7902", "E876" ]	Allergies: No Known Allergies / Adverse Drug Reactions [MASKED] Complaint: Shock and respiratory failure Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] y/o man with a PMH of recurrent, metastatic pancreatic colloid carcinoma (to lung and peritoneum, s/p FOLFIRINOX, nab-paclitaxel/gemcitabine, and nal-irinotecan), PE (on enoxaparin), who presented as a transfer from [MASKED] [MASKED] with hypotension, hypothermia, and possible syncope. At baseline, he requires frequent infusions of IV fluids at home given chronic losses from diarrhea. According to his wife, he was feeling otherwise well, when he had a scheduled appointment with oncology. At the end of his breakfast, he slumped over, and appeared to have passed out. His blood pressure was checked by his family and was reportedly very low. He denied preceding chest pain, fever, or abdominal pain. When EMS found the patient in his home, he was noted to be bradycardic to the [MASKED], and they were unable to obtain a blood pressure at that time. He was reportedly unresponsive for several minutes. He was taken to [MASKED], where he was found to be hypothermic, hypoglycemic, and hypotensive. He was placed on a Bair Hugger, given warm blankets, and underwent a CT abdomen that did not show acute changes. He was transfused one unit of pRBCs. CXR was performed, which was notable for a right lower lobe pneumonia and pleural effusion. Labs were notable for BNP 1700, INR 1.6, magnesium 1.4, and highly elevated TSH of 40. He was given vancomycin/cefepime, and 1L IVF. He also received 2 amps of D50. He remained on 2L NC, oxygenating 96-97%. A coude catheter was placed. He was transferred to [MASKED]. Of note, he saw his oncologist Dr. [MASKED] on [MASKED] for his cancer. He had declining performance status and multiple hospitalizations, abdominal pain, anorexia, and electrolyte abnormalities. At that point no further chemotherapies were planned and the focus was on palliation, although the patient declined hospice. He was receiving 500 mL IVF qd at home and agreed to monitor labs aggressively even if that meant he had to go to the ED for repletion and transfusions. Patient has a MOLST [MASKED] that indicates full code. Per telephone conversation between Dr. [MASKED] the [MASKED] daughter, they are considering a palliative approach to his advanced cancer now. In the ED, initial vitals were T 95.0F BP 81/60 mmHg P 72 RR 23 O2 91% RA. Examination was notable for: cachectic, chronically ill-appearing, responding though speech is difficult to understand, NAD. 2+ edema to the knees bilaterally, stool guaiac negative. Bedside TTE demonstrated no pericardial effusion. Labs were notable for: WBC 2.5k (Diff 87%N, 10%L, 3%N), H/H 8.5/26.8, PLT 67,000, PTT 150, INR 1.6, [MASKED] [MASKED], ALT 203, AST 382, alk phos 680, Tbili 0.5, albumin 1.4, lipase 3, troponin-T 0.08, Na 142, K 5.0, Cl 109, HCO3 25, BUN/Cr [MASKED], lactate 1.9. Imaging was notable for CXR with interval slight increase in the right lung interstitial opacities since earlier today, appearing slightly more confluent. His mental status worsened, and he developed worsening tachypnea, for which he was intubated. He received vancomycin/cefepime, and was started on norepinephrine (uptitrated to 0.3 mcg/kg/min) and vasopressin 2.4 units/hr. He received 2L IVF and 2g calcium gluconate. He required the addition of epinephrine for refractory hypotension. He was admitted to the FICU. Upon arrival to [MASKED], he was intubated and sedated and unable to provide further history. Past Medical History: 1. Pancreatic colloid carcinoma, as detailed in the history of present illness. 2. Diabetes mellitus. 3. GERD. 4. Tuberculosis, for which he had isoniazid and rifampin. 5. Hyperlipidemia. 6. Chronic pancreatitis. 7. Anemia. 8. Umbilical hernia repair in [MASKED]. 9. Appendectomy in [MASKED]. Social History: [MASKED] Family History: His mother with diabetes, passed in her early [MASKED] of jaundice. Father with diabetes Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 36.5C BP 125/91 mmHg (on pressors) P 90 RR 16 O2 100% (on CMV ventilation) General: Intubated and sedated. Profoundly cachectic. HEENT: Severe temporal wasting bilaterally. Pupils pinpoint and reactive. EOMs intact, anicteric sclerae. MMM. Neck: No JVD. CV: Distant heart sounds. No MRGs; normal S1/S2. Pulm: Diminished breath sounds R>L on anterior examination. Intubated and mechanically ventilated. Abdomen: Distended; soft, NABS. Ext: 2+ pitting edema to knee; cool and mottled feet, with warm ankles and lower legs. Dopplerable DP pulses. Skin: Marked flaking over feet bilaterally. Neuro: Sedated. DISCHARGE PHYSICAL EXAM: Expired [MASKED]. Pertinent Results: ADMISSION LABS: [MASKED] 05:33PM LACTATE-1.9 [MASKED] 05:20PM ALBUMIN-1.4* CALCIUM-6.4* PHOSPHATE-3.0 MAGNESIUM-2.2 [MASKED] 05:20PM GLUCOSE-163* UREA N-26* CREAT-0.5 SODIUM-142 POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-25 ANION GAP-8* [MASKED] 05:20PM ALT(SGPT)-203* AST(SGOT)-382* ALK PHOS-680* TOT BILI-0.5 [MASKED] 05:20PM [MASKED] [MASKED] 05:20PM cTropnT-0.08 [MASKED] 05:20PM WBC-2.5* RBC-3.06* HGB-8.5* HCT-26.8* MCV-88 MCH-27.8 MCHC-31.7* RDW-15.9* RDWSD-51.0* [MASKED] 05:20PM NEUTS-87* BANDS-0 LYMPHS-10* MONOS-3* EOS-0 BASOS-0 [MASKED] MYELOS-0 AbsNeut-2.18 AbsLymp-0.25* AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00* [MASKED] 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [MASKED] 05:20PM URINE RBC-3* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 PERTINENT LABS: [MASKED] 02:39AM BLOOD [MASKED] PTT-68.3* [MASKED] [MASKED] 12:00PM BLOOD [MASKED] PTT-87.9* [MASKED] [MASKED] 05:20PM BLOOD Plt Smr-VERY LOW* Plt Ct-67* [MASKED] 05:26PM BLOOD Plt Ct-27* [MASKED] 02:22AM BLOOD Ret Aut-1.3 Abs Ret-0.04 [MASKED] 12:00PM BLOOD [MASKED] [MASKED] 02:22AM BLOOD CK-MB-5 cTropnT-0.08* [MASKED] 12:30PM BLOOD CK-MB-4 cTropnT-0.08 [MASKED] 02:22AM BLOOD TSH-39* [MASKED] 07:26AM BLOOD TSH-23* [MASKED] 02:22AM BLOOD T4-0.6* T3-40* Free T4-<0.1* [MASKED] 07:26AM BLOOD T4-5.2 T3-48* Free T4-1.3 [MASKED] 12:00PM BLOOD T4-4.2* T3-60* Free T4-1.1 [MASKED] 11:00AM BLOOD Cortsol-56.8* [MASKED] 02:58AM BLOOD Type-ART pO2-98 pCO2-41 pH-7.36 calTCO2-24 Base XS--1 [MASKED] 08:56PM BLOOD Type-ART pO2-158* pCO2-34* pH-7.47* calTCO2-25 Base XS-2 [MASKED] 06:11AM BLOOD Type-ART pO2-140* pCO2-45 pH-7.34* calTCO2-25 Base XS--1 [MASKED] 02:58AM BLOOD Lactate-3.2* [MASKED] 12:44PM BLOOD Lactate-2.1* [MASKED] 12:46PM BLOOD Lactate-1.3 [MASKED] 11:00AM BLOOD ACTH - FROZEN-PND [MASKED] 12:34PM BLOOD RENIN - FROZEN-PND [MASKED] 12:34PM BLOOD ALDOSTERONE-PND DISCHARGE LABS: Expired [MASKED]. PERTINENT IMAGING: [MASKED] TTE Normal left ventricular wall thickness and cavity size with severe regional systolic dysfunction (EF [MASKED] most c/w multivessel CAD, though Takotsubo cardiomyopathy, and nonischemic cardiomyopathy are possible. Moderate to large pericardial effusion without echocardiographic evidence of tamponade. Large echodense pericardial mass affixed to anterior right ventricular surface. Mild aortic regurgitation. Mild mitral regurgitation. Pulmonary artery diastolic hypertension. Brief Hospital Course: Mr. [MASKED] is a [MASKED] y/o man with a PMH of recurrent, metastatic pancreatic colloid carcinoma (to lung and peritoneum, s/p FOLFIRINOX, nab-paclitaxel/gemcitabine, and nal-irinotecan), PE, and T2DM, who presented as a transfer from [MASKED] with shock and respiratory failure. He spent almost two weeks in the ICU being treated with antibiotics for septic shock and intubated for respiratory failure secondary to pneumonia. Unfortunately, the patient failed to be extubated and clinically deteriorated with worsening mental status. He was made DNR (but remained intubated) on [MASKED] and with no further escalation of care. His immediate family members were awaiting other family members' arrival from [MASKED], so they wished to prolong terminal extubation. He eventually passed on [MASKED]. # SHOCK, MIXED: Mr. [MASKED] presented a mixed picture of shock, consistent with septic (pulmonary source vs. intra-abdominal source) vs. cardiogenic (EF [MASKED] newly diagnosed on TTE). He initially required three pressors but was weaned to just levophed; his family agreed that further escalation of care was not indicated, so he was slowly weaned off on the levophed and passed on [MASKED]. # HYPOXEMIC RESPIRATORY FAILURE. # PNEUMONIA, HEALTHCARE ASSOCIATED Patient presented with respiratory failure requiring intubation, likely related to right-sided pneumonia. He was maintained on a lung-protective ventilation to prevent ARDS. # SEVERE HYPOTHYROIDISM: Patient presented with highly elevated TSH 39 with low T3/T4 (T4 0.6, T3 40, free T4 < 0.01) alongside hypothermia and hypoglycemia. Endocrinology felt that myxedema coma was low likelihood but did recommend treating for adrenal insufficiency (see below) prior to treating hypothyroidism. TSH decreased appropriately with levothyroxine and liothyroxine. # ADRENAL INSUFFICIENCY AI was suspected given given hypoglycemia, hypothermia, and bradycardia at presentation. He was started on hydrocortisone 50mg IV q6h (which was discontinued on [MASKED] after his cortisol levels were noted to be normal), and ACTH, renin and aldosterone were found to be normal. # THROMBOCYTOPENIA. Patient had downtrending platelets from 60 -> 20 concerning for DIC in the setting of shock and acute illness. However, in the setting of his multiple comorbidities, no further management was indicated. # METASTATIC PANCREATIC COLLOID CARCINOMA. As above, patient progressed through multiple intensive chemotherapy regimens and was receiving maximal supportive therapy at home. With Palliative care's help, patient was ultimately made DNR and no further escalation of care. *** # ELEVATED LIVER ENZYMES. Markedly elevated, in a predominantly hepatocellular pattern with normal Tbili concern for possible shock liver. # R HYDRONEPHROSIS. Hydronephrosis was noted on OSH imaging but renal function was within normal limits, so further workup was not done. He was not a dialysis candidate. # ANEMIA. Patient presented with low serum iron with markedly elevated ferritin consistent with anemia of inflammation; there was no evidence of active bleeding. # DEMAND ISCHEMIA. Patient presented with troponin elevated to 0.08 which remained stable, likely representing demand ischemia in the setting of shock. # Hypoglycemia: Patient had low glood sugars to [MASKED] thought related to adrenal insufficiency. He was maintained on a D10 infusion with improvement in his glucose levels. # PULMONARY EMBOLISM. Patient was initially maintained on enoxaparin SC 60 mg q24h, but transition to heparin drip was deferred in setting of thrombocytopenia and elevated PTT/INR. He notably had no evidence of RV strain on TTE. ================= CHRONIC ISSUES ================= # MALNUTRITION # HYPOALBUMINEMIA # CHRONIC PANCREATITIS. # CHRONIC DIARRHEA # GERD Patient found to have chronic malnutrition with profound hypoalbuminemia. He has chronic diarrhea leading to hypovolemia requiring frequent infusions of IV fluids at home. He was maintained on tube feeds. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. LOPERamide 2 mg PO QID:PRN diarrhea 2. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) 3. Prochlorperazine 10 mg IV Q8H:PRN nausea 4. Famotidine 20 mg PO BID 5. Magnesium Oxide 400 mg PO DAILY 6. Mirtazapine 15 mg PO QHS 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. sod phos di, mono-K phos mono [MASKED] mg oral daily 9. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit oral TID W/MEALS 10. Neutra-Phos 2 PKT PO TID 11. Potassium Chloride 40 mEq PO BID 12. Midodrine 10 mg PO TID 13. Enoxaparin Sodium 60 mg SC Q24H Start: [MASKED], First Dose: Next Routine Administration Time 14. Sertraline 50 mg PO DAILY Discharge Medications: Expired [MASKED] Discharge Disposition: Expired Discharge Diagnosis: Expired [MASKED]. Discharge Condition: Expired [MASKED]. Discharge Instructions: Expired [MASKED]. Followup Instructions: [MASKED]	[]	[ "J9601", "E872", "K219", "E785", "Z66", "E039", "D649", "Z7902" ]	[ "A4151: Sepsis due to Escherichia coli [E. coli]", "J9601: Acute respiratory failure with hypoxia", "D65: Disseminated intravascular coagulation [defibrination syndrome]", "K7200: Acute and subacute hepatic failure without coma", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "G92: Toxic encephalopathy", "C259: Malignant neoplasm of pancreas, unspecified", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "J189: Pneumonia, unspecified organism", "C7800: Secondary malignant neoplasm of unspecified lung", "E2740: Unspecified adrenocortical insufficiency", "R64: Cachexia", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "I248: Other forms of acute ischemic heart disease", "Z681: Body mass index [BMI] 19.9 or less, adult", "I429: Cardiomyopathy, unspecified", "I5020: Unspecified systolic (congestive) heart failure", "E872: Acidosis", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z66: Do not resuscitate", "E039: Hypothyroidism, unspecified", "D649: Anemia, unspecified", "Z86711: Personal history of pulmonary embolism", "K529: Noninfective gastroenteritis and colitis, unspecified", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E876: Hypokalemia" ]
19,983,009	26,466,419	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypokalemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o male w/ history of pancreatic cancer (please see below for history and current regimen), diabetes presenting with hypokalemia. Patient reports intermittent hypokalemia in the past, usually during chemotherapy. Last chemo was about a month ago. K was 1.9 in clinic yesterday, and received 40 IV and 60 PO KCl. Patient has no vomiting, minimal intermittent diarrhea and has been eating regularly. No chest pain, shortness of breath or syncope. Patient was recently in ___ for daughter's wedding. In the ED, initial vitals were: 98.2 66 116/71 18 100% RA - Exam notable for: Lungs CTAB, Heart RRR, Abdomen soft, minimally tender. - Labs notable for: K of 2.0 initially, which repeated was 2.1 and then 2.4 after repletion. Mild LFT elevation and anemia (Hgb 10) - Imaging was notable for: - Patient was given: 60meq Kcl x 2, 40meq IV Kcl x1, Mg Sulf 2g, LR, Transfer vitals: 97.5 56 115/79 16 100% RA Upon arrival to the floor, patient reports he feels well. He has not had any recent weakness or numbess, No muscle pain. No CP, SOB, Abd pain. Notes some diarrhea, ___ times per day recently, not significantly watery. This is normal for him. No fevers/chills. Past Medical History: ONCOLOGIC HISTORY: ___ was initially diagnosed with acute pancreatitis in ___. Imaging raised concern for intraductal papillary mucinous neoplasm (IPMN), and he was followed with serial MRI. MRI ___ identified interval change in the configuration of his known pseudocyst. The study was repeated on ___ at which time an enhancing soft tissue abnormality was seen. Upper endoscopy then identified a large amount of mucus at the pylorus. Biopsy by FNA did not show carcinoma. On ___ he was taken to the operating room by Dr. ___ and underwent Whipple's pancreaticoduodenectomy. Pathology showed a 4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising from an intraductal IPMN. There was no lymphovascular/perineural invasion; 5 of 18 lymph nodes were involved. He was diagnosed with pT3N1Mx stage IIB mucinous noncystic carcinoma of the pancreas. He received six cycles of adjuvant gemcitabine under the care of Dr. ___, which completed in ___, followed by adjuvant radiation with concurrent capecitabine, which completed ___. He was then followed with surveillance imaging. CT in ___ identified a right upper lobe lung nodule for which he underwent CT-guided FNA. Cytology was suspicious for malignancy. He underwent repeat biopsy in ___ with similar results and was eventually taken to the operating room for VATS wedge resection ___. Pathology confirmed the finding of metastasis from his pancreatic colloid carcinoma. He initiated systemic chemotherapy with FOLFIRINOX ___. He completed 14 cycles as of ___ and then entered a treatment break. In ___ he developed peritoneal carcinomatosis with intra-abdominal ascites and a pulmonary embolism. He resumed cycle ___ FOLFIRINOX and completed an additional two cycles as of ___. Due to progression of peritoneal carcinomatosis he then transitioned to nab-paclitaxel/gemcitabine. He completed four cycles of this as of ___ at which time there was further disease progression. Initiated treatment with 5fu/Liposomal irrinotican and LCV on ___. CURRENT TREATMENT PLAN: Liposomal irinotecan/ ___ CI D1 and D15 OTHER PAST MEDICAL HISTORY: 1. Pancreatic colloid carcinoma, as detailed in the history of present illness. 2. Diabetes mellitus. 3. GERD. 4. Tuberculosis, for which he had isoniazid and rifampin. 5. Hyperlipidemia. 6. Chronic pancreatitis. 7. Anemia. 8. Umbilical hernia repair in ___. 9. Appendectomy in ___. Social History: ___ Family History: His mother with diabetes, passed in her early ___ of jaundice. Father with diabetes Physical Exam: ADMISSION PHYSICAL EXAM ===================== VITAL SIGNS: 97.9 126/78 52 18 100% RA GENERAL: Patient appears comfortable, in NAD HEENT: MMM, no scleral icterus, CN II-XII intact NECK: supple CARDIAC: RRR, no m/g/r, normal s1 and s2 LUNGS: CTAB, no w/c/r ABDOMEN: L side is firm with multiple masses. No significant tenderness. R side is soft. Normal bowel sounds, nondistended, EXTREMITIES: WWP, no ___ edema NEUROLOGIC: CNII-XII intact, upper and lower extremity strength SKIN: Port in place on R chest appears c/d/i DISCHARGE PHYSICAL EXAM ====================== VITAL SIGNS: 98.0 PO 122 / 81 L Standing 97 18 100 RA GENERAL: Patient appears comfortable, in NAD HEENT: MMM, no scleral icterus, CN II-XII intact NECK: supple CARDIAC: RRR, no m/r/g, normal s1 and s2 LUNGS: CTAB ABDOMEN: LUQ and LLQ are firm, rigid with palpable ill-defined masses. No significant tenderness. R side is soft. Normal bowel sounds, nondistended, EXTREMITIES: WWP, no ___ edema NEUROLOGIC: CNII-XII intact, upper and lower extremity strength SKIN: Port in place on R chest appears c/d/i Pertinent Results: ADMISSION LAB RESULTS ==================== ___ 11:10AM BLOOD WBC-8.1 RBC-4.73 Hgb-10.4* Hct-33.4* MCV-71* MCH-22.0* MCHC-31.1* RDW-19.6* RDWSD-49.1* Plt ___ ___ 11:10AM BLOOD UreaN-8 Creat-0.7 Na-142 K-1.9* Cl-95* HCO3-35* AnGap-14 ___ 11:10AM BLOOD ALT-54* AST-169* AlkPhos-100 TotBili-0.4 ___ 11:10AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.8 Mg-1.8 Iron-32* ___ 11:10AM BLOOD calTIBC-185* Ferritn-1427* TRF-142* ___ 11:10AM BLOOD CEA-4.8* DISCHARGE LAB RESULTS ==================== ___ 05:28AM BLOOD WBC-5.8 RBC-3.95* Hgb-8.8* Hct-28.3* MCV-72* MCH-22.3* MCHC-31.1* RDW-19.9* RDWSD-50.0* Plt ___ ___ 05:28AM BLOOD Glucose-78 UreaN-7 Creat-0.6 Na-138 K-3.6 Cl-103 HCO3-27 AnGap-12 ___ 05:28AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8 MICROBIOLOGY ============ ___ Stool culture: negative ___ C diff: negative IMAGING ======= ___ RUQ Ultrasound: 1. Pneumobilia without intrahepatic or extrahepatic biliary dilatation. 2. The patient is status post cholecystectomy. 3. Mild right-sided hydronephrosis, stable when compared to the CT from an outside facility on ___. 4. A heterogeneously hyperechoic ill-defined Mass is identified within the left upper quadrant adjacent to the spleen and does not demonstrate flow on color Doppler imaging. This is of unclear etiology and could represent a heterogeneous mass, hematoma or fluid collection. Further evaluation with contrast-enhanced imaging such as a multiphasic CT is recommended. ___ CT Chest, Abdomen, and Pelvis: 1. No intrahepatic or extrahepatic biliary duct dilation. There is pneumobilia. 2. Interval increase in the size and mass effect related to bulky soft tissue peritoneal and mesenteric masses from metastatic disease representing progression of metastatic carcinomatosis. 3. There are multiple new subcapsular splenic lesions and increase in size of the previously seen splenic lesions, due to progression of to metastatic disease. 4. Moderate right hydronephrosis and proximal to mid hydroureter with a delayed nephrogram. Hydronephrosis is not significantly changed from prior and is due to extrinsic mass effect on the ureter in the pelvis. Brief Hospital Course: ___ h/o stage IIB pancreatic colloid carcinoma with progressive disease in lung and peritoneum, who presents with hypokalemia secondary to diarrhea: # Hypokalemia: Patient with severe hypokalemia to 1.9 initially in setting of some recent diarrhea, and chemo 6 weeks ago. Likely a combination of diarrhea and chemotherapy effect, patient's K has been low in the past. Given slow response to repletion, likely significant whole body depletion. He was aggressively repleted with IV and PO potassium. He was discharged on PO Potassium 60 mEq daily, with close heme/onc follow-up. # Diarrhea: Patient with nonbloody diarrhea, formed stools, ___ times/day, likely contributing to symptoms. No associated infectious symptoms and C. diff negative. However does have recent travel history to ___. Stool cultures and O&P studies negative. He was give loperamide 2mg QID, which helped with his symptoms. # Elevated transaminases: Patient with transaminitis in a hepatocellular pattern with AST > ALT. Differential would include chemotherapy effect, disease progression, GI infection. Based on imaging findings disease progression is most likely. # Metastatic pancreatic colloid carcinoma: h/o stage IIB pancreatic colloid carcinoma with progressive disease in lung and peritoneum. Progressive on FOLFIRINOX, now on ___. Missed C3D1 due to current episode of hypokalemia. CT torso now with progressive disease. He was discharged with close heme/onc follow-up on ___. # DMII. Patient had several episodes of morning hypoglycemia. His Lantus was decreased to Lantus 8U at bedtime because of morning hypoglycemia. He was told to check his blood sugars every morning and call his PCP if blood sugars remained low. # HTN. Continued home lisinopril. # Pancreatic cancer/pancreatitis. Continued enzyme replacement. Continued lovenox prophylaxis. TRANSITIONAL ISSUES ==================== - Discharge K: 3.6 - Discharge potassium regimen: 60 mEq Potassium daily - CT torso with contrast done while inpatient showing progression of peritoneal and splenic disease - The patient's PO magnesium was held while he was an inpatient, and he was repleted with IV magnesium. PO magnesium was restarted at discharge knowing that it may worsen his diarrhea. Please continue to monitor. - Patient to follow up on ___ with his outpatient oncology team. He should have his potassium rechecked at that time. # CODE: Full code (confirmed) # CONTACT: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Lisinopril 2.5 mg PO DAILY 3. Magnesium Oxide 500 mg PO DAILY 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID W/MEALS 6. Pegfilgrastim Onpro (On Body Injector) 6 mg SC Frequency is Unknown 7. Omeprazole 20 mg PO DAILY 8. Potassium Chloride 20 mEq PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Glargine 23 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. Enoxaparin Sodium 80 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time Discharge Medications: 1. LOPERamide 2 mg PO QID RX loperamide [Anti-Diarrhea] 2 mg 2 mg by mouth four times per day Disp #120 Tablet Refills:0 2. Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Potassium Chloride 60 mEq PO DAILY Hold for K > RX potassium chloride 10 mEq 6 capsule(s) by mouth daily Disp #180 Capsule Refills:0 4. Enoxaparin Sodium 80 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 5. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID W/MEALS 6. Lisinopril 2.5 mg PO DAILY 7. Magnesium Oxide 500 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11. Vitamin D 1000 UNIT PO DAILY 12. HELD- Pegfilgrastim Onpro (On Body Injector) 6 mg SC Frequency is Unknown This medication was held. Do not restart Pegfilgrastim Onpro (On Body Injector) until you speak with oncologist Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Diarrhea Hypokalemia Pancreatic cancer SECONDARY DIAGNOSIS: DMII GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___: You were hospitalized at ___. Why did you come to the hospital? ================================= You were admitted to ___ because your potassium was very low. You were also having diarrhea. What did we do for you? ======================= We gave you potassium both by IV and by mouth and your potassium slowly came back up. We did some stool studies to see if you had an infection causing diarrhea, and they have so far not showed an infection. What do you need to do? ======================= - Only take 8 Units of Lantus at bedtime since your blood sugars in the morning have been low. Check your blood sugar every morning, and decrease your bedtime Lantus dose if your blood sugars remain low. Call your primary care doctor if your sugars are low. - We have increased the amount of potassium that you should be taking at home as pills. You will follow up with your oncologist in clinic and discuss chemotherapy at that time. - Please get your potassium checked at your Heme/Onc appointment on ___. We wish you all the best! - Your ___ care team Followup Instructions: ___	[ "E876", "R64", "C259", "C786", "E11649", "C7801", "K861", "Z681", "R197", "Z794", "I10", "R740", "D6481", "T451X5A", "Y929", "Z8611", "E785" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Hypokalemia Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o male w/ history of pancreatic cancer (please see below for history and current regimen), diabetes presenting with hypokalemia. Patient reports intermittent hypokalemia in the past, usually during chemotherapy. Last chemo was about a month ago. K was 1.9 in clinic yesterday, and received 40 IV and 60 PO KCl. Patient has no vomiting, minimal intermittent diarrhea and has been eating regularly. No chest pain, shortness of breath or syncope. Patient was recently in [MASKED] for daughter's wedding. In the ED, initial vitals were: 98.2 66 116/71 18 100% RA - Exam notable for: Lungs CTAB, Heart RRR, Abdomen soft, minimally tender. - Labs notable for: K of 2.0 initially, which repeated was 2.1 and then 2.4 after repletion. Mild LFT elevation and anemia (Hgb 10) - Imaging was notable for: - Patient was given: 60meq Kcl x 2, 40meq IV Kcl x1, Mg Sulf 2g, LR, Transfer vitals: 97.5 56 115/79 16 100% RA Upon arrival to the floor, patient reports he feels well. He has not had any recent weakness or numbess, No muscle pain. No CP, SOB, Abd pain. Notes some diarrhea, [MASKED] times per day recently, not significantly watery. This is normal for him. No fevers/chills. Past Medical History: ONCOLOGIC HISTORY: [MASKED] was initially diagnosed with acute pancreatitis in [MASKED]. Imaging raised concern for intraductal papillary mucinous neoplasm (IPMN), and he was followed with serial MRI. MRI [MASKED] identified interval change in the configuration of his known pseudocyst. The study was repeated on [MASKED] at which time an enhancing soft tissue abnormality was seen. Upper endoscopy then identified a large amount of mucus at the pylorus. Biopsy by FNA did not show carcinoma. On [MASKED] he was taken to the operating room by Dr. [MASKED] and underwent Whipple's pancreaticoduodenectomy. Pathology showed a 4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising from an intraductal IPMN. There was no lymphovascular/perineural invasion; 5 of 18 lymph nodes were involved. He was diagnosed with pT3N1Mx stage IIB mucinous noncystic carcinoma of the pancreas. He received six cycles of adjuvant gemcitabine under the care of Dr. [MASKED], which completed in [MASKED], followed by adjuvant radiation with concurrent capecitabine, which completed [MASKED]. He was then followed with surveillance imaging. CT in [MASKED] identified a right upper lobe lung nodule for which he underwent CT-guided FNA. Cytology was suspicious for malignancy. He underwent repeat biopsy in [MASKED] with similar results and was eventually taken to the operating room for VATS wedge resection [MASKED]. Pathology confirmed the finding of metastasis from his pancreatic colloid carcinoma. He initiated systemic chemotherapy with FOLFIRINOX [MASKED]. He completed 14 cycles as of [MASKED] and then entered a treatment break. In [MASKED] he developed peritoneal carcinomatosis with intra-abdominal ascites and a pulmonary embolism. He resumed cycle [MASKED] FOLFIRINOX and completed an additional two cycles as of [MASKED]. Due to progression of peritoneal carcinomatosis he then transitioned to nab-paclitaxel/gemcitabine. He completed four cycles of this as of [MASKED] at which time there was further disease progression. Initiated treatment with 5fu/Liposomal irrinotican and LCV on [MASKED]. CURRENT TREATMENT PLAN: Liposomal irinotecan/ [MASKED] CI D1 and D15 OTHER PAST MEDICAL HISTORY: 1. Pancreatic colloid carcinoma, as detailed in the history of present illness. 2. Diabetes mellitus. 3. GERD. 4. Tuberculosis, for which he had isoniazid and rifampin. 5. Hyperlipidemia. 6. Chronic pancreatitis. 7. Anemia. 8. Umbilical hernia repair in [MASKED]. 9. Appendectomy in [MASKED]. Social History: [MASKED] Family History: His mother with diabetes, passed in her early [MASKED] of jaundice. Father with diabetes Physical Exam: ADMISSION PHYSICAL EXAM ===================== VITAL SIGNS: 97.9 126/78 52 18 100% RA GENERAL: Patient appears comfortable, in NAD HEENT: MMM, no scleral icterus, CN II-XII intact NECK: supple CARDIAC: RRR, no m/g/r, normal s1 and s2 LUNGS: CTAB, no w/c/r ABDOMEN: L side is firm with multiple masses. No significant tenderness. R side is soft. Normal bowel sounds, nondistended, EXTREMITIES: WWP, no [MASKED] edema NEUROLOGIC: CNII-XII intact, upper and lower extremity strength SKIN: Port in place on R chest appears c/d/i DISCHARGE PHYSICAL EXAM ====================== VITAL SIGNS: 98.0 PO 122 / 81 L Standing 97 18 100 RA GENERAL: Patient appears comfortable, in NAD HEENT: MMM, no scleral icterus, CN II-XII intact NECK: supple CARDIAC: RRR, no m/r/g, normal s1 and s2 LUNGS: CTAB ABDOMEN: LUQ and LLQ are firm, rigid with palpable ill-defined masses. No significant tenderness. R side is soft. Normal bowel sounds, nondistended, EXTREMITIES: WWP, no [MASKED] edema NEUROLOGIC: CNII-XII intact, upper and lower extremity strength SKIN: Port in place on R chest appears c/d/i Pertinent Results: ADMISSION LAB RESULTS ==================== [MASKED] 11:10AM BLOOD WBC-8.1 RBC-4.73 Hgb-10.4* Hct-33.4* MCV-71* MCH-22.0* MCHC-31.1* RDW-19.6* RDWSD-49.1* Plt [MASKED] [MASKED] 11:10AM BLOOD UreaN-8 Creat-0.7 Na-142 K-1.9* Cl-95* HCO3-35* AnGap-14 [MASKED] 11:10AM BLOOD ALT-54* AST-169* AlkPhos-100 TotBili-0.4 [MASKED] 11:10AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.8 Mg-1.8 Iron-32* [MASKED] 11:10AM BLOOD calTIBC-185* Ferritn-1427* TRF-142* [MASKED] 11:10AM BLOOD CEA-4.8* DISCHARGE LAB RESULTS ==================== [MASKED] 05:28AM BLOOD WBC-5.8 RBC-3.95* Hgb-8.8* Hct-28.3* MCV-72* MCH-22.3* MCHC-31.1* RDW-19.9* RDWSD-50.0* Plt [MASKED] [MASKED] 05:28AM BLOOD Glucose-78 UreaN-7 Creat-0.6 Na-138 K-3.6 Cl-103 HCO3-27 AnGap-12 [MASKED] 05:28AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8 MICROBIOLOGY ============ [MASKED] Stool culture: negative [MASKED] C diff: negative IMAGING ======= [MASKED] RUQ Ultrasound: 1. Pneumobilia without intrahepatic or extrahepatic biliary dilatation. 2. The patient is status post cholecystectomy. 3. Mild right-sided hydronephrosis, stable when compared to the CT from an outside facility on [MASKED]. 4. A heterogeneously hyperechoic ill-defined Mass is identified within the left upper quadrant adjacent to the spleen and does not demonstrate flow on color Doppler imaging. This is of unclear etiology and could represent a heterogeneous mass, hematoma or fluid collection. Further evaluation with contrast-enhanced imaging such as a multiphasic CT is recommended. [MASKED] CT Chest, Abdomen, and Pelvis: 1. No intrahepatic or extrahepatic biliary duct dilation. There is pneumobilia. 2. Interval increase in the size and mass effect related to bulky soft tissue peritoneal and mesenteric masses from metastatic disease representing progression of metastatic carcinomatosis. 3. There are multiple new subcapsular splenic lesions and increase in size of the previously seen splenic lesions, due to progression of to metastatic disease. 4. Moderate right hydronephrosis and proximal to mid hydroureter with a delayed nephrogram. Hydronephrosis is not significantly changed from prior and is due to extrinsic mass effect on the ureter in the pelvis. Brief Hospital Course: [MASKED] h/o stage IIB pancreatic colloid carcinoma with progressive disease in lung and peritoneum, who presents with hypokalemia secondary to diarrhea: # Hypokalemia: Patient with severe hypokalemia to 1.9 initially in setting of some recent diarrhea, and chemo 6 weeks ago. Likely a combination of diarrhea and chemotherapy effect, patient's K has been low in the past. Given slow response to repletion, likely significant whole body depletion. He was aggressively repleted with IV and PO potassium. He was discharged on PO Potassium 60 mEq daily, with close heme/onc follow-up. # Diarrhea: Patient with nonbloody diarrhea, formed stools, [MASKED] times/day, likely contributing to symptoms. No associated infectious symptoms and C. diff negative. However does have recent travel history to [MASKED]. Stool cultures and O&P studies negative. He was give loperamide 2mg QID, which helped with his symptoms. # Elevated transaminases: Patient with transaminitis in a hepatocellular pattern with AST > ALT. Differential would include chemotherapy effect, disease progression, GI infection. Based on imaging findings disease progression is most likely. # Metastatic pancreatic colloid carcinoma: h/o stage IIB pancreatic colloid carcinoma with progressive disease in lung and peritoneum. Progressive on FOLFIRINOX, now on [MASKED]. Missed C3D1 due to current episode of hypokalemia. CT torso now with progressive disease. He was discharged with close heme/onc follow-up on [MASKED]. # DMII. Patient had several episodes of morning hypoglycemia. His Lantus was decreased to Lantus 8U at bedtime because of morning hypoglycemia. He was told to check his blood sugars every morning and call his PCP if blood sugars remained low. # HTN. Continued home lisinopril. # Pancreatic cancer/pancreatitis. Continued enzyme replacement. Continued lovenox prophylaxis. TRANSITIONAL ISSUES ==================== - Discharge K: 3.6 - Discharge potassium regimen: 60 mEq Potassium daily - CT torso with contrast done while inpatient showing progression of peritoneal and splenic disease - The patient's PO magnesium was held while he was an inpatient, and he was repleted with IV magnesium. PO magnesium was restarted at discharge knowing that it may worsen his diarrhea. Please continue to monitor. - Patient to follow up on [MASKED] with his outpatient oncology team. He should have his potassium rechecked at that time. # CODE: Full code (confirmed) # CONTACT: [MASKED] [MASKED] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Lisinopril 2.5 mg PO DAILY 3. Magnesium Oxide 500 mg PO DAILY 4. Prochlorperazine 10 mg PO Q6H:PRN nausea 5. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID W/MEALS 6. Pegfilgrastim Onpro (On Body Injector) 6 mg SC Frequency is Unknown 7. Omeprazole 20 mg PO DAILY 8. Potassium Chloride 20 mEq PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Glargine 23 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 11. Enoxaparin Sodium 80 mg SC DAILY Start: Today - [MASKED], First Dose: Next Routine Administration Time Discharge Medications: 1. LOPERamide 2 mg PO QID RX loperamide [Anti-Diarrhea] 2 mg 2 mg by mouth four times per day Disp #120 Tablet Refills:0 2. Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Potassium Chloride 60 mEq PO DAILY Hold for K > RX potassium chloride 10 mEq 6 capsule(s) by mouth daily Disp #180 Capsule Refills:0 4. Enoxaparin Sodium 80 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 5. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID W/MEALS 6. Lisinopril 2.5 mg PO DAILY 7. Magnesium Oxide 500 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Prochlorperazine 10 mg PO Q6H:PRN nausea 11. Vitamin D 1000 UNIT PO DAILY 12. HELD- Pegfilgrastim Onpro (On Body Injector) 6 mg SC Frequency is Unknown This medication was held. Do not restart Pegfilgrastim Onpro (On Body Injector) until you speak with oncologist Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Diarrhea Hypokalemia Pancreatic cancer SECONDARY DIAGNOSIS: DMII GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [MASKED]: You were hospitalized at [MASKED]. Why did you come to the hospital? ================================= You were admitted to [MASKED] because your potassium was very low. You were also having diarrhea. What did we do for you? ======================= We gave you potassium both by IV and by mouth and your potassium slowly came back up. We did some stool studies to see if you had an infection causing diarrhea, and they have so far not showed an infection. What do you need to do? ======================= - Only take 8 Units of Lantus at bedtime since your blood sugars in the morning have been low. Check your blood sugar every morning, and decrease your bedtime Lantus dose if your blood sugars remain low. Call your primary care doctor if your sugars are low. - We have increased the amount of potassium that you should be taking at home as pills. You will follow up with your oncologist in clinic and discuss chemotherapy at that time. - Please get your potassium checked at your Heme/Onc appointment on [MASKED]. We wish you all the best! - Your [MASKED] care team Followup Instructions: [MASKED]	[]	[ "Z794", "I10", "Y929", "E785" ]	[ "E876: Hypokalemia", "R64: Cachexia", "C259: Malignant neoplasm of pancreas, unspecified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "C7801: Secondary malignant neoplasm of right lung", "K861: Other chronic pancreatitis", "Z681: Body mass index [BMI] 19.9 or less, adult", "R197: Diarrhea, unspecified", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "Z8611: Personal history of tuberculosis", "E785: Hyperlipidemia, unspecified" ]
19,983,009	27,741,621	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo M with PMH of metastatic pancreatic colloid carcinoma admitted from the ED with persistent fatigue, weakness, and poor po intake and new diarrhea of two days duration. Patient hospitilazed ___ - ___ with weakness, fatigue and diarrhea. He was found to have ___ and concern for bowel obstruction and intestinal necrosis, and improved with supportive therapy. He was discharged to rehab ___ and received single agent nal-iri on ___. Per oncology, pt with persistent weakness and poor po appetite since before his last admission which continued at ___. His weight at ___ was down to 74 lbs from 93lbs on admission and he was initiated on mirtazapine and ranitidine. He was brought to the ED for failure to thrive and persistent diarrhea x2 days. In the ED, initial VS were pain 0, T 98.8, HR 97, BP 92/67, RR 18, O2 100%RA. Initial labs: Na 142, K 5.2, HCT 25, Cr 0.7, Ca 7.7, Mg 1.6, P 3.8, WBC 5.2, HCT 24.5, PLT 340. Lactate 1.2. Patient was given 1L NS prior to transfer. ED exam notable for: Constitutional - No Fever/chills, +FTT, decreased appetitie, weight loss Head / Eyes - No Diplopia ENT / Neck - No Epistaxis Chest/Respiratory - No Cough, No Dyspnea Cardiovascular - No Chest pain GI / Abdominal - No Black stool, No Bloody stool GU/Flank - No Dysuria Musc/Extr/Back - No Back pain, No Joint pain Skin - No Rash, No Diaphoresis Neuro - No Headache Imaging: No new imaging CT abd ___: "IMPRESSION: 1. Multiple dilated small and large bowel loops are identified. There is persistent stenosis of the sigmoid colon from the external compression caused by large pelvic masses, which is the likely the main site of bowel obstruction. 2. Pneumatosis intestinalis of the small bowel loops in the right abdomen is concerning for bowel ischemia and new from prior study. 3. Severe right hydronephrosis is new since ___, but similar compared to ___. 4. Multiple large peritoneal masses appear grossly similar to ___. Previously noted hepatic lesions are not demonstrated on this noncontrast exam." Patient received: -CTX 1g x1 -1 L D51/2NS -lisnopril 2.5mg -norepi started at 0.12 Consults: Oncology in ED Vitals on transfer: 80s/60s, HR ___, RR 12 100% RA Upon arrival to ___, pt reports feeling tired but "better." He denies fever/chills, CP, cough, dyspnea, abdominal pain, N/V, or dysuria. He reports limited appetite or fluid consumption for several days. PAST ONCOLOGIC HISTORY: As per last clinic note by Dr ___ was initially diagnosed with acute pancreatitis in ___. Imaging raised concern for intraductal papillary mucinous neoplasm (IPMN), and he was followed with serial MRI. MRI ___ identified interval change in the configuration of his known pseudocyst. The study was repeated on ___ at which time an enhancing soft tissue abnormality was seen. Upper endoscopy then identified a large amount of mucus at the pylorus. Biopsy by ___ did not show carcinoma. On ___ he was taken to the operating room by Dr. ___ and underwent ___'s pancreaticoduodenectomy. Pathology showed a 4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising from an intraductal IPMN. There was no lymphovascular/perineural invasion; 5 of 18 lymph nodes were involved. He was diagnosed with pT3N1Mx stage IIB mucinous noncystic carcinoma of the pancreas. He received six cycles of adjuvant gemcitabine under the care of Dr. ___, which completed in ___, followed by adjuvant radiation with concurrent capecitabine, which completed ___. He was then followed with surveillance imaging. CT in ___ identified a right upper lobe lung nodule for which he underwent CT-guided FNA. Cytology was suspicious for malignancy. He underwent repeat biopsy in ___ with similar results and was eventually taken to the operating room for VATS wedge resection ___. Pathology confirmed the finding of metastasis from his pancreatic colloid carcinoma. He initiated systemic chemotherapy with FOLFIRINOX ___. He completed 14 cycles as of ___ and then entered a treatment break. In ___ he developed peritoneal carcinomatosis with intra-abdominal ascites and a pulmonary embolism. He resumed cycle ___ FOLFIRINOX and completed an additional two cycles as of ___. Due to progression of peritoneal carcinomatosis he then transitioned to nab-paclitaxel/gemcitabine. He completed four cycles of this as of ___ at which time there was further disease progression. Mr. ___ initiated treatment with 5fu/nal-iri on ___. Snapshot analysis showed variants in ___ and p53" He was hopitilazed ___ - ___ with weakness, fatigue and diarrhea, found to have ___ and concern for bowel obstruction and intestinal necrosis. Improved with supportive therapy. Discharged to rehab ___. Received single agent nal-iri on ___ as he cannot receive ___ infusion at SNF. Past Medical History: 1. Pancreatic colloid carcinoma, as detailed in the history of present illness. 2. Diabetes mellitus. 3. GERD. 4. Tuberculosis, for which he had isoniazid and rifampin. 5. Hyperlipidemia. 6. Chronic pancreatitis. 7. Anemia. 8. Umbilical hernia repair in ___. 9. Appendectomy in ___. Social History: ___ Family History: His mother with diabetes, passed in her early ___ of jaundice. Father with diabetes Physical Exam: ADMISSION PHYISCAL EXAM: ============================== VS: 87/95, HR 93, RR 10, 100% on RA GENERAL: cachetic appearing, NAD EYES: Anicteric sclerea, PERLLA, EOMI, no chemosis ENT: clear OP, no JVD, no LAD CARDIOVASCULAR: RRR, no m/r/g, 2+ radial and DP pulses RESPIRATORY: CTAB, no crackles, wheezes, or rhonchi GASTROINTESTINAL: rock hard L quadrants, soft RUQ, scaphoid, large central palpable mass, nontender without rebound or guarding MUSKULOSKELATAL: Warm, well perfused extremities, 2+ pitting edema to mid tibia NEURO: Alert, oriented, CN II-XII intact, no focal deficits SKIN: stage 2 pressure injury coccyx, no additional rash or lesions DISCAHRGE PHYISCAL EXAM: ============================== VS: ___ 2343 Temp: 98.3 PO BP: 119/82 HR: 65 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: Cachectic appearing man, appears older than stated age, laying in bed in NAD EYES: Sclera anicteric HEENT: OP clear, MMM, no OP lesions LUNGS: CTAB - no wheezes, rhonchi, or rales CV: RRR, no m/r/g ABD: +BS, S, NT, +large central palpable mass that is stable in size EXT: Poor muscle bulk SKIN: warm, no rashes appreciated NEURO: AOx3, no facial asymmetry Pertinent Results: ADMISSION LABS: ============================= ___:12AM BLOOD WBC-5.2 RBC-2.91* Hgb-8.2* Hct-24.5* MCV-84 MCH-28.2 MCHC-33.5 RDW-16.1* RDWSD-48.7* Plt ___ ___ 12:12AM BLOOD Neuts-77.0* Lymphs-18.3* Monos-2.9* Eos-0.8* Baso-0.2 Im ___ AbsNeut-4.00 AbsLymp-0.95* AbsMono-0.15* AbsEos-0.04 AbsBaso-0.01 ___ 12:12AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-142 K-5.2* Cl-107 HCO3-25 AnGap-10 ___ 12:12AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.6 ___ 08:53PM BLOOD ___ pO2-47* pCO2-37 pH-7.37 calTCO2-22 Base XS--3 ___ 12:16AM BLOOD Lactate-1.2 K-4.6 DISCHARGE LABS: ============================== ___ 03:18AM BLOOD WBC-3.4* RBC-3.03* Hgb-8.5* Hct-26.1* MCV-86 MCH-28.1 MCHC-32.6 RDW-16.2* RDWSD-50.4* Plt ___ ___ 04:50AM BLOOD Neuts-50.6 ___ Monos-10.8 Eos-1.7 Baso-0.4 Im ___ AbsNeut-1.22* AbsLymp-0.86* AbsMono-0.26 AbsEos-0.04 AbsBaso-0.01 ___ 04:19AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+* Target-1+* ___ 03:18AM BLOOD Glucose-102* UreaN-<3* Creat-0.3* Na-138 K-3.8 Cl-102 HCO3-30 AnGap-6* ___ 06:27AM BLOOD ALT-9 AST-13 LD(LDH)-189 AlkPhos-161* TotBili-0.2 ___ 03:18AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.7 MICROBIOLOGY: ============================== ___ BLOOD CULTURE X2 - NEGATIVE ___ URINE CULTURE - ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ STOOL - C. DIFF - NEGATIVE ___ FECAL CULTURE - NEGATIVE FOR GNR, CAMPYLOBACTER, SALMONELLA, SHIGELLA IMAGING: ============================== ___ KUB IMPRESSION: Dilated air-filled loops of large and small bowel may reflect ileus or early/partial obstruction. Fecal material is visualized within the rectum and is noted to project over the descending colon as well. Brief Hospital Course: FICU COURSE ___ ============================= ASSESSMENT AND PLAN ==================== Mr. ___ is a ___ male with a past medical history of metastatic pancreatic colloid carcinoma admitted from the ED with hypotension in the setting of poor PO intake and new diarrhea of two days duration concerning for septic shock and severe hypovolemia. ACTIVE ISSUES ============= #Septic shock The patient presented with hypotension and leukocytosis with diarrhea x2 days. On arrival, he was noted to have a positive UA. Hence, his sepsis was thought to be from either a GI or urinary source. It was thought that severe hypovolemia was also contributing to his hypertension. His abdominal exam was similar to previous examinations based on a review of records and hence, his presentation was less likely to be from a perforation although there was concern given that he was found to have bowel necrosis during her recent hospitalization. He was started on norepinephrine in the ED with the goal of maintaining MAPs >60. Repeat abdominal imaging was not pursued as they were multiple, very recent imaging studies in our system. He was volume resuscitated with crystalloid and was continued on ceftriaxone and metronidazole for antibiotic coverage based on the concern of GI or urinary source. He was eventually weaned off norepinephrine on ___ and remained stable. At this time, he was thought to be stable enough to transfer to the medical floor for further care. #Diarrhea His diarrhea was attributed to irinotecan during his last admission and the offending agent had been discontinued as of ___. At that time, C. diff and stool cultures were all negative. His current diarrhea was not temporally associated with chemotherapy so there was concern for an infectious etiology. C. difficile and stool culture were sent. He was continued on metronidazole. He was given fluids and his electrolytes were repleted as needed. His C. difficile came back negative and he was started on loperamide for symptomatic relief. #UTI Upon presentation, the patient's UA was found to be positive for possible UTI. Urine cultures were sent for further evaluation. However, the patient remained asymptomatic. Of note, during his last admission, he failed a voiding trial and a foley was re-inserted after which he developed a leukocytosis with positive UA. UCx grew >100,000 E. coli and he was initiated on Ceftriaxone 2gm q24h (___). The foley was removed and his urinary retention resolved. At discharge, his leukocytosis had resolved and he was discharged on Bactrim DS BID for completion of a 7-day course (___). He was started on ceftriaxone based on previous data. # Metastatic pancreatic cancer # Chronic partial bowel obstruction The patient had known bulky peritoneal and mesenteric metastatic disease. A palliative care consult was placed to further assist the family. The patient's outpatient oncology team was notified of his current admission. He was continued on ondansetron and Compazine as needed. # Anorexia # Severe protein calorie malnutrition This was in the setting of progressive metastatic pancreatic cancer. A nutrition consult was placed and the patient was given Ensure 3 times daily. PO intake was also encouraged. CHRONIC ISSUES ============== # Diabetes The patient was noted to be hypoglycemic on arrival. His home doses of insulin were held in the setting. He was placed on an insulin sliding scale. # GERD His home omeprazole 20mg QHS was restarted. # History of PE He was continued on Lovenox 60mg daily (1.5mg/kg/day) per prior oncology recommendations. ========================================= OMED COURSE: ___ - ___ ========================================= Mr. ___ is a ___ male with history of metastatic pancreatic cancer admitted from the ED with hypotension in the setting of poor PO intake and diarrhea of two days duration concerning for septic shock from a urinary source and severe hypovolemia initially admitted to the ICU requiring multiple liters of IVF and pressors. He was subsequently called out to the oncology floor where he was observed prior to discharge with course complicated by relative hypotension. #s/p Septic Shock: #E. Coli UTI Hypotension and leukocytosis requiring temporary levophed support which resolved with aggressive fluid resuscitation. Likely from severe dehydration secondary to poor PO intake, diarrhea as well as possible contribution from UTI. He completed a 7 day course of ceftriaxone (last day ___. #Relative ___ on ___ to 70/40, asymptomatic in the setting of not receiving IV fluids. He was responsive to IVF and had stable blood pressures. He will require IV fluids at home to manage his blood pressure and he was also written for low dose midodrine 10 mg TID. #Diarrhea: Likely secondary to chemotherapy. Stool studies negative. Continued loperamide and provided supportive therapy with IVF and electrolyte repletion. # Severe Protein-Calorie Malnutrition: Secondary to progressive metastatic pancreatic cancer. Supplemental Ensure continued at discharge. # Metastatic Pancreatic Cancer: # Chronic Partial Bowel Obstruction: Known bulky peritoneal and mesenteric metastatic disease. He will follow-up with outpatient Oncology on ___. Zofran and Compazine were as needed # GERD: Held due to diarrhea, can restart home omeprazole 20mg as an outpatient. # Pulmonary Embolism: Continued home lovenox. Transitional Issues: [ ] He should receive 500 ml IVF BID [ ] Continue vitamin D 50,000 units qweek for 8 weeks ___, received 1 dose ___. Last dose ___ [ ] Sacral ulcer, stage II: please ensure that the patient is turned every couple of hours and that the area is closely monitored and cared for [ ] Consider restarting omeprazole. [ ] New Medications: Midodrine 10 mg PO TID, Neutra-Phos 2 PKT PO/NG TID, Potassium Chloride 40 mEq PO BID, Simethicone 40-80 mg PO/NG QID:PRN bloating [ ] Held Medications: None CODE: Full Code (confirmed) EMERGENCY CONTACT HCP: ___ (wife) ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Lisinopril 2.5 mg PO DAILY 3. Mirtazapine 15 mg PO QHS 4. Enoxaparin Sodium 60 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 5. Omeprazole 20 mg PO DAILY 6. sod phos di, mono-K phos mono ___ mg oral daily 7. Vitamin D 5000 UNIT PO DAILY 8. lipase-protease-amylase 20,000-68,000 -109,000 unit oral BID 9. Glargine 23 Units Bedtime 10. insulin lispro 100 unit/mL subcutaneous SSI 11. Potassium Chloride 60 mEq PO BID 12. Prochlorperazine 10 mg IV Q8H:PRN nausea Discharge Medications: 1. Midodrine 10 mg PO TID RX midodrine 10 mg 1 tablet(s) by mouth three times per day Disp #90 Tablet Refills:0 2. Neutra-Phos 2 PKT PO TID RX potassium, sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg 2 powder(s) by mouth three times per day Disp #180 Packet Refills:0 3. Potassium Chloride 40 mEq PO BID RX potassium chloride 20 mEq 2 tablet(s) by mouth twice per day Disp #120 Tablet Refills:0 4. Enoxaparin Sodium 60 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time 5. Famotidine 20 mg PO BID 6. LOPERamide 2 mg PO QID:PRN diarrhea RX loperamide 2 mg 2 mg by mouth four times a day Disp #30 Capsule Refills:0 7. Magnesium Oxide 400 mg PO DAILY 8. Mirtazapine 15 mg PO QHS 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Prochlorperazine 10 mg IV Q8H:PRN nausea 11. sod phos di, mono-K phos mono ___ mg oral daily 12. Vitamin D ___ UNIT PO 1X/WEEK (___) 13. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit oral TID W/MEALS 14.Hospital Bed Name: ___ Date of Birth: ___ Diagnosis: Metastatic Pancreatic Cancer, pain due to emaciation Length of Need: 99 15.Standard Manual Wheelchair Including seat abd back cushion, elevating leg rests, anti-tip and break extensions. Length = 13 months. Diagnosis: metastatic pancreatic carcinoma Discharge Disposition: Home With Service Facility: ___ ___: PRIMARY DIAGNOSIS: Sepsis from a urinary source Urinary tract infection SECONDARY DIAGNOSIS: Mucinous noncystic colloid carcinoma of the pancreas Irinotecan induced diarrhea Urinary retention Poor nutritional status, weakness Sacral ulcer, stage II History of pulmonary embolism Type II Diabetes Mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you felt weak, were having diarrhea, your blood pressure was low and you had a urinary tract infection. You were initially admitted to the ICU due to the low blood pressure, but you were able to brought to the oncology floor once your blood pressure improved. We believe your diarrhea is from your irinotecan chemotherapy and we treated this with Imodium (loperamide). You also developed a bladder infection while you were in the hospital. You were treated with an IV antibiotic for 5 days. We discussed the best place for you to be discharged and after talking with your family, it seems that home with increased support will be the best. You will have a visiting nurse and IV fluids at home. It was truly a pleasure taking part in your care. We wish you all the best with your future health. Sincerely, The team at ___ Followup Instructions: ___	[ "A419", "R6521", "E43", "L89152", "K521", "C259", "D709", "C786", "E861", "K861", "N390", "Z681", "E119", "K219", "E785", "Z8611", "R627", "T451X5A", "Z86711", "Z7901", "D649", "I951" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Failure to thrive Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] yo M with PMH of metastatic pancreatic colloid carcinoma admitted from the ED with persistent fatigue, weakness, and poor po intake and new diarrhea of two days duration. Patient hospitilazed [MASKED] - [MASKED] with weakness, fatigue and diarrhea. He was found to have [MASKED] and concern for bowel obstruction and intestinal necrosis, and improved with supportive therapy. He was discharged to rehab [MASKED] and received single agent nal-iri on [MASKED]. Per oncology, pt with persistent weakness and poor po appetite since before his last admission which continued at [MASKED]. His weight at [MASKED] was down to 74 lbs from 93lbs on admission and he was initiated on mirtazapine and ranitidine. He was brought to the ED for failure to thrive and persistent diarrhea x2 days. In the ED, initial VS were pain 0, T 98.8, HR 97, BP 92/67, RR 18, O2 100%RA. Initial labs: Na 142, K 5.2, HCT 25, Cr 0.7, Ca 7.7, Mg 1.6, P 3.8, WBC 5.2, HCT 24.5, PLT 340. Lactate 1.2. Patient was given 1L NS prior to transfer. ED exam notable for: Constitutional - No Fever/chills, +FTT, decreased appetitie, weight loss Head / Eyes - No Diplopia ENT / Neck - No Epistaxis Chest/Respiratory - No Cough, No Dyspnea Cardiovascular - No Chest pain GI / Abdominal - No Black stool, No Bloody stool GU/Flank - No Dysuria Musc/Extr/Back - No Back pain, No Joint pain Skin - No Rash, No Diaphoresis Neuro - No Headache Imaging: No new imaging CT abd [MASKED]: "IMPRESSION: 1. Multiple dilated small and large bowel loops are identified. There is persistent stenosis of the sigmoid colon from the external compression caused by large pelvic masses, which is the likely the main site of bowel obstruction. 2. Pneumatosis intestinalis of the small bowel loops in the right abdomen is concerning for bowel ischemia and new from prior study. 3. Severe right hydronephrosis is new since [MASKED], but similar compared to [MASKED]. 4. Multiple large peritoneal masses appear grossly similar to [MASKED]. Previously noted hepatic lesions are not demonstrated on this noncontrast exam." Patient received: -CTX 1g x1 -1 L D51/2NS -lisnopril 2.5mg -norepi started at 0.12 Consults: Oncology in ED Vitals on transfer: 80s/60s, HR [MASKED], RR 12 100% RA Upon arrival to [MASKED], pt reports feeling tired but "better." He denies fever/chills, CP, cough, dyspnea, abdominal pain, N/V, or dysuria. He reports limited appetite or fluid consumption for several days. PAST ONCOLOGIC HISTORY: As per last clinic note by Dr [MASKED] was initially diagnosed with acute pancreatitis in [MASKED]. Imaging raised concern for intraductal papillary mucinous neoplasm (IPMN), and he was followed with serial MRI. MRI [MASKED] identified interval change in the configuration of his known pseudocyst. The study was repeated on [MASKED] at which time an enhancing soft tissue abnormality was seen. Upper endoscopy then identified a large amount of mucus at the pylorus. Biopsy by [MASKED] did not show carcinoma. On [MASKED] he was taken to the operating room by Dr. [MASKED] and underwent [MASKED]'s pancreaticoduodenectomy. Pathology showed a 4.4 cm colloid carcinoma (mucinous noncystic carcinoma) arising from an intraductal IPMN. There was no lymphovascular/perineural invasion; 5 of 18 lymph nodes were involved. He was diagnosed with pT3N1Mx stage IIB mucinous noncystic carcinoma of the pancreas. He received six cycles of adjuvant gemcitabine under the care of Dr. [MASKED], which completed in [MASKED], followed by adjuvant radiation with concurrent capecitabine, which completed [MASKED]. He was then followed with surveillance imaging. CT in [MASKED] identified a right upper lobe lung nodule for which he underwent CT-guided FNA. Cytology was suspicious for malignancy. He underwent repeat biopsy in [MASKED] with similar results and was eventually taken to the operating room for VATS wedge resection [MASKED]. Pathology confirmed the finding of metastasis from his pancreatic colloid carcinoma. He initiated systemic chemotherapy with FOLFIRINOX [MASKED]. He completed 14 cycles as of [MASKED] and then entered a treatment break. In [MASKED] he developed peritoneal carcinomatosis with intra-abdominal ascites and a pulmonary embolism. He resumed cycle [MASKED] FOLFIRINOX and completed an additional two cycles as of [MASKED]. Due to progression of peritoneal carcinomatosis he then transitioned to nab-paclitaxel/gemcitabine. He completed four cycles of this as of [MASKED] at which time there was further disease progression. Mr. [MASKED] initiated treatment with 5fu/nal-iri on [MASKED]. Snapshot analysis showed variants in [MASKED] and p53" He was hopitilazed [MASKED] - [MASKED] with weakness, fatigue and diarrhea, found to have [MASKED] and concern for bowel obstruction and intestinal necrosis. Improved with supportive therapy. Discharged to rehab [MASKED]. Received single agent nal-iri on [MASKED] as he cannot receive [MASKED] infusion at SNF. Past Medical History: 1. Pancreatic colloid carcinoma, as detailed in the history of present illness. 2. Diabetes mellitus. 3. GERD. 4. Tuberculosis, for which he had isoniazid and rifampin. 5. Hyperlipidemia. 6. Chronic pancreatitis. 7. Anemia. 8. Umbilical hernia repair in [MASKED]. 9. Appendectomy in [MASKED]. Social History: [MASKED] Family History: His mother with diabetes, passed in her early [MASKED] of jaundice. Father with diabetes Physical Exam: ADMISSION PHYISCAL EXAM: ============================== VS: 87/95, HR 93, RR 10, 100% on RA GENERAL: cachetic appearing, NAD EYES: Anicteric sclerea, PERLLA, EOMI, no chemosis ENT: clear OP, no JVD, no LAD CARDIOVASCULAR: RRR, no m/r/g, 2+ radial and DP pulses RESPIRATORY: CTAB, no crackles, wheezes, or rhonchi GASTROINTESTINAL: rock hard L quadrants, soft RUQ, scaphoid, large central palpable mass, nontender without rebound or guarding MUSKULOSKELATAL: Warm, well perfused extremities, 2+ pitting edema to mid tibia NEURO: Alert, oriented, CN II-XII intact, no focal deficits SKIN: stage 2 pressure injury coccyx, no additional rash or lesions DISCAHRGE PHYISCAL EXAM: ============================== VS: [MASKED] 2343 Temp: 98.3 PO BP: 119/82 HR: 65 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: Cachectic appearing man, appears older than stated age, laying in bed in NAD EYES: Sclera anicteric HEENT: OP clear, MMM, no OP lesions LUNGS: CTAB - no wheezes, rhonchi, or rales CV: RRR, no m/r/g ABD: +BS, S, NT, +large central palpable mass that is stable in size EXT: Poor muscle bulk SKIN: warm, no rashes appreciated NEURO: AOx3, no facial asymmetry Pertinent Results: ADMISSION LABS: ============================= [MASKED]:12AM BLOOD WBC-5.2 RBC-2.91* Hgb-8.2* Hct-24.5* MCV-84 MCH-28.2 MCHC-33.5 RDW-16.1* RDWSD-48.7* Plt [MASKED] [MASKED] 12:12AM BLOOD Neuts-77.0* Lymphs-18.3* Monos-2.9* Eos-0.8* Baso-0.2 Im [MASKED] AbsNeut-4.00 AbsLymp-0.95* AbsMono-0.15* AbsEos-0.04 AbsBaso-0.01 [MASKED] 12:12AM BLOOD Glucose-94 UreaN-13 Creat-0.7 Na-142 K-5.2* Cl-107 HCO3-25 AnGap-10 [MASKED] 12:12AM BLOOD Calcium-7.7* Phos-3.8 Mg-1.6 [MASKED] 08:53PM BLOOD [MASKED] pO2-47* pCO2-37 pH-7.37 calTCO2-22 Base XS--3 [MASKED] 12:16AM BLOOD Lactate-1.2 K-4.6 DISCHARGE LABS: ============================== [MASKED] 03:18AM BLOOD WBC-3.4* RBC-3.03* Hgb-8.5* Hct-26.1* MCV-86 MCH-28.1 MCHC-32.6 RDW-16.2* RDWSD-50.4* Plt [MASKED] [MASKED] 04:50AM BLOOD Neuts-50.6 [MASKED] Monos-10.8 Eos-1.7 Baso-0.4 Im [MASKED] AbsNeut-1.22* AbsLymp-0.86* AbsMono-0.26 AbsEos-0.04 AbsBaso-0.01 [MASKED] 04:19AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+* Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+* Target-1+* [MASKED] 03:18AM BLOOD Glucose-102* UreaN-<3* Creat-0.3* Na-138 K-3.8 Cl-102 HCO3-30 AnGap-6* [MASKED] 06:27AM BLOOD ALT-9 AST-13 LD(LDH)-189 AlkPhos-161* TotBili-0.2 [MASKED] 03:18AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.7 MICROBIOLOGY: ============================== [MASKED] BLOOD CULTURE X2 - NEGATIVE [MASKED] URINE CULTURE - ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] STOOL - C. DIFF - NEGATIVE [MASKED] FECAL CULTURE - NEGATIVE FOR GNR, CAMPYLOBACTER, SALMONELLA, SHIGELLA IMAGING: ============================== [MASKED] KUB IMPRESSION: Dilated air-filled loops of large and small bowel may reflect ileus or early/partial obstruction. Fecal material is visualized within the rectum and is noted to project over the descending colon as well. Brief Hospital Course: FICU COURSE [MASKED] ============================= ASSESSMENT AND PLAN ==================== Mr. [MASKED] is a [MASKED] male with a past medical history of metastatic pancreatic colloid carcinoma admitted from the ED with hypotension in the setting of poor PO intake and new diarrhea of two days duration concerning for septic shock and severe hypovolemia. ACTIVE ISSUES ============= #Septic shock The patient presented with hypotension and leukocytosis with diarrhea x2 days. On arrival, he was noted to have a positive UA. Hence, his sepsis was thought to be from either a GI or urinary source. It was thought that severe hypovolemia was also contributing to his hypertension. His abdominal exam was similar to previous examinations based on a review of records and hence, his presentation was less likely to be from a perforation although there was concern given that he was found to have bowel necrosis during her recent hospitalization. He was started on norepinephrine in the ED with the goal of maintaining MAPs >60. Repeat abdominal imaging was not pursued as they were multiple, very recent imaging studies in our system. He was volume resuscitated with crystalloid and was continued on ceftriaxone and metronidazole for antibiotic coverage based on the concern of GI or urinary source. He was eventually weaned off norepinephrine on [MASKED] and remained stable. At this time, he was thought to be stable enough to transfer to the medical floor for further care. #Diarrhea His diarrhea was attributed to irinotecan during his last admission and the offending agent had been discontinued as of [MASKED]. At that time, C. diff and stool cultures were all negative. His current diarrhea was not temporally associated with chemotherapy so there was concern for an infectious etiology. C. difficile and stool culture were sent. He was continued on metronidazole. He was given fluids and his electrolytes were repleted as needed. His C. difficile came back negative and he was started on loperamide for symptomatic relief. #UTI Upon presentation, the patient's UA was found to be positive for possible UTI. Urine cultures were sent for further evaluation. However, the patient remained asymptomatic. Of note, during his last admission, he failed a voiding trial and a foley was re-inserted after which he developed a leukocytosis with positive UA. UCx grew >100,000 E. coli and he was initiated on Ceftriaxone 2gm q24h ([MASKED]). The foley was removed and his urinary retention resolved. At discharge, his leukocytosis had resolved and he was discharged on Bactrim DS BID for completion of a 7-day course ([MASKED]). He was started on ceftriaxone based on previous data. # Metastatic pancreatic cancer # Chronic partial bowel obstruction The patient had known bulky peritoneal and mesenteric metastatic disease. A palliative care consult was placed to further assist the family. The patient's outpatient oncology team was notified of his current admission. He was continued on ondansetron and Compazine as needed. # Anorexia # Severe protein calorie malnutrition This was in the setting of progressive metastatic pancreatic cancer. A nutrition consult was placed and the patient was given Ensure 3 times daily. PO intake was also encouraged. CHRONIC ISSUES ============== # Diabetes The patient was noted to be hypoglycemic on arrival. His home doses of insulin were held in the setting. He was placed on an insulin sliding scale. # GERD His home omeprazole 20mg QHS was restarted. # History of PE He was continued on Lovenox 60mg daily (1.5mg/kg/day) per prior oncology recommendations. ========================================= OMED COURSE: [MASKED] - [MASKED] ========================================= Mr. [MASKED] is a [MASKED] male with history of metastatic pancreatic cancer admitted from the ED with hypotension in the setting of poor PO intake and diarrhea of two days duration concerning for septic shock from a urinary source and severe hypovolemia initially admitted to the ICU requiring multiple liters of IVF and pressors. He was subsequently called out to the oncology floor where he was observed prior to discharge with course complicated by relative hypotension. #s/p Septic Shock: #E. Coli UTI Hypotension and leukocytosis requiring temporary levophed support which resolved with aggressive fluid resuscitation. Likely from severe dehydration secondary to poor PO intake, diarrhea as well as possible contribution from UTI. He completed a 7 day course of ceftriaxone (last day [MASKED]. #Relative [MASKED] on [MASKED] to 70/40, asymptomatic in the setting of not receiving IV fluids. He was responsive to IVF and had stable blood pressures. He will require IV fluids at home to manage his blood pressure and he was also written for low dose midodrine 10 mg TID. #Diarrhea: Likely secondary to chemotherapy. Stool studies negative. Continued loperamide and provided supportive therapy with IVF and electrolyte repletion. # Severe Protein-Calorie Malnutrition: Secondary to progressive metastatic pancreatic cancer. Supplemental Ensure continued at discharge. # Metastatic Pancreatic Cancer: # Chronic Partial Bowel Obstruction: Known bulky peritoneal and mesenteric metastatic disease. He will follow-up with outpatient Oncology on [MASKED]. Zofran and Compazine were as needed # GERD: Held due to diarrhea, can restart home omeprazole 20mg as an outpatient. # Pulmonary Embolism: Continued home lovenox. Transitional Issues: [ ] He should receive 500 ml IVF BID [ ] Continue vitamin D 50,000 units qweek for 8 weeks [MASKED], received 1 dose [MASKED]. Last dose [MASKED] [ ] Sacral ulcer, stage II: please ensure that the patient is turned every couple of hours and that the area is closely monitored and cared for [ ] Consider restarting omeprazole. [ ] New Medications: Midodrine 10 mg PO TID, Neutra-Phos 2 PKT PO/NG TID, Potassium Chloride 40 mEq PO BID, Simethicone 40-80 mg PO/NG QID:PRN bloating [ ] Held Medications: None CODE: Full Code (confirmed) EMERGENCY CONTACT HCP: [MASKED] (wife) [MASKED] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Ondansetron 8 mg PO Q8H:PRN nausea 2. Lisinopril 2.5 mg PO DAILY 3. Mirtazapine 15 mg PO QHS 4. Enoxaparin Sodium 60 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 5. Omeprazole 20 mg PO DAILY 6. sod phos di, mono-K phos mono [MASKED] mg oral daily 7. Vitamin D 5000 UNIT PO DAILY 8. lipase-protease-amylase 20,000-68,000 -109,000 unit oral BID 9. Glargine 23 Units Bedtime 10. insulin lispro 100 unit/mL subcutaneous SSI 11. Potassium Chloride 60 mEq PO BID 12. Prochlorperazine 10 mg IV Q8H:PRN nausea Discharge Medications: 1. Midodrine 10 mg PO TID RX midodrine 10 mg 1 tablet(s) by mouth three times per day Disp #90 Tablet Refills:0 2. Neutra-Phos 2 PKT PO TID RX potassium, sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg 2 powder(s) by mouth three times per day Disp #180 Packet Refills:0 3. Potassium Chloride 40 mEq PO BID RX potassium chloride 20 mEq 2 tablet(s) by mouth twice per day Disp #120 Tablet Refills:0 4. Enoxaparin Sodium 60 mg SC DAILY Start: [MASKED], First Dose: Next Routine Administration Time 5. Famotidine 20 mg PO BID 6. LOPERamide 2 mg PO QID:PRN diarrhea RX loperamide 2 mg 2 mg by mouth four times a day Disp #30 Capsule Refills:0 7. Magnesium Oxide 400 mg PO DAILY 8. Mirtazapine 15 mg PO QHS 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. Prochlorperazine 10 mg IV Q8H:PRN nausea 11. sod phos di, mono-K phos mono [MASKED] mg oral daily 12. Vitamin D [MASKED] UNIT PO 1X/WEEK ([MASKED]) 13. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit oral TID W/MEALS 14.Hospital Bed Diagnosis: Metastatic Pancreatic Cancer, pain due to emaciation Length of Need: 99 15.Standard Manual Wheelchair Including seat abd back cushion, elevating leg rests, anti-tip and break extensions. Length = 13 months. Diagnosis: metastatic pancreatic carcinoma Discharge Disposition: Home With Service Facility: [MASKED] [MASKED]: PRIMARY DIAGNOSIS: Sepsis from a urinary source Urinary tract infection SECONDARY DIAGNOSIS: Mucinous noncystic colloid carcinoma of the pancreas Irinotecan induced diarrhea Urinary retention Poor nutritional status, weakness Sacral ulcer, stage II History of pulmonary embolism Type II Diabetes Mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [MASKED], You were admitted to the hospital because you felt weak, were having diarrhea, your blood pressure was low and you had a urinary tract infection. You were initially admitted to the ICU due to the low blood pressure, but you were able to brought to the oncology floor once your blood pressure improved. We believe your diarrhea is from your irinotecan chemotherapy and we treated this with Imodium (loperamide). You also developed a bladder infection while you were in the hospital. You were treated with an IV antibiotic for 5 days. We discussed the best place for you to be discharged and after talking with your family, it seems that home with increased support will be the best. You will have a visiting nurse and IV fluids at home. It was truly a pleasure taking part in your care. We wish you all the best with your future health. Sincerely, The team at [MASKED] Followup Instructions: [MASKED]	[]	[ "N390", "E119", "K219", "E785", "Z7901", "D649" ]	[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "L89152: Pressure ulcer of sacral region, stage 2", "K521: Toxic gastroenteritis and colitis", "C259: Malignant neoplasm of pancreas, unspecified", "D709: Neutropenia, unspecified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "E861: Hypovolemia", "K861: Other chronic pancreatitis", "N390: Urinary tract infection, site not specified", "Z681: Body mass index [BMI] 19.9 or less, adult", "E119: Type 2 diabetes mellitus without complications", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z8611: Personal history of tuberculosis", "R627: Adult failure to thrive", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "D649: Anemia, unspecified", "I951: Orthostatic hypotension" ]
19,983,145	29,647,630	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: cautery attempts and nasal packing bilaterally History of Present Illness: Ms. ___ is a ___ woman, who was admitted to ___ ___ the evening of ___ for recurrent epistaxis. She was reportedly seen in the ___ ED 4x in the past week for epistaxis. She has recently had cautery done in the past for a right anterior nose bleed which worked for a few days but then the bleeding restarted in the setting of blowing her nose. She was seen by ENT in the ___ ED who gave Afrin and topical cocaine. This controlled the bleeding. Her Hct dropped from 32 to 27 while in the ED. She was transferred to the medical floor for observation and initially was doing well. The evening of ___ she was noted to have approximately 600 cc of acute epistaxis. ENT again came to assess the patient and a right Epistat, left Merocel, and bilateral FloSeal were placed and ultimately stopped the bleeding. Hct was 21.7 at 8AM on ___. Decision was made at that time to transfer her to a tertiary care ___ possible embolization should she have recurrent bleeding. The patient has also been given Cefazolin for antibiotic coverage. Last Hct was 29.5 at 3:30pm on ___ which was after pRBC transfusion On arrival, patient is in good spirits. She relays the history above, denies any pain or fevers, history of bleeding disorder Past Medical History: PTSD (previously threatened physically in workplace) - Chronic back pain s/p MVA in her ___ Social History: ___ Family History: - AML (sister) - CAD (father) - Breast cancer (paternal aunts) - No family history of coagulopathy Physical Exam: ADMISSION PHYSICAL EXAM: ========================== Vitals: T 98.3, HR 81, BP 159/84, RR 17, 100%RA GENERAL: Alert, A&Ox3, no acute distress HEENT: Nares packed bilaterally with Epistat and Merocel, with ongoing oozing noted. 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 DISCHARGE PHYSICAL EXAM: ============================= Afeb VSS GENERAL: Alert, A&Ox3, 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 EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: ================ ___ 11:24PM BLOOD WBC-7.0 RBC-3.30* Hgb-10.1* Hct-30.4* MCV-92 MCH-30.6 MCHC-33.2 RDW-14.6 RDWSD-49.5* Plt ___ ___ 11:24PM BLOOD Neuts-73.9* ___ Monos-5.3 Eos-1.0 Baso-0.4 Im ___ AbsNeut-5.16 AbsLymp-1.33 AbsMono-0.37 AbsEos-0.07 AbsBaso-0.03 ___ 11:24PM BLOOD ___ PTT-27.7 ___ ___ 11:24PM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-136 K-3.8 Cl-103 HCO3-24 AnGap-13 ___ 11:24PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9 IMAGING: =========== ___ CTA Head and Neck: 1. Noncontrast head CT: No acute intracranial process. Extensive mucosal thickening of the ethmoid air cells and bilateral maxillary sinuses. Aerosolized fluid within the nasopharynx. Minimal fluid in the right frontal sinus. Increased soft tissue along the right side of the nasopharynx with adjacent bony erosion. This finding suggest chronic inflammation/chronic sinusitis. No arterially enhancing mass seen within the nasopharynx. 2. CTA head and neck: Patent cervical and intracranial vasculature. MRI BRAIN: ___ IMPRESSION: 1. A 1.5 cm ill-defined heterogeneous contrast enhancing soft tissue lesion in the posterior nasopharynx, encroaching on the left fossa of ___, suspicious for nasopharyngeal carcinoma. No pathologic lymphadenopathy by imaging criteria within the field of view. 2. Acute infarction in the right frontal lobe extending into the superior anterior right temporal lobe. ECHO: ___ No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. ___ 06:40AM BLOOD WBC-10.8* RBC-2.44* Hgb-7.2* Hct-22.5* MCV-92 MCH-29.5 MCHC-32.0 RDW-13.3 RDWSD-44.5 Plt ___ ___ 06:10AM BLOOD Glucose-88 UreaN-10 Creat-0.5 Na-133 K-4.1 Cl-96 HCO3-27 AnGap-14 ___ 05:50AM BLOOD %HbA1c-4.8 eAG-91 ___ 05:50AM BLOOD Triglyc-96 HDL-46 CHOL/HD-3.5 LDLcalc-95 ___ 05:50AM BLOOD TSH-2.___ with PTSD here with epistaxis refractory to cautery attempts at OSH and bilateral nasal packing, with refractory epistaxis. # Epistaxis: Patient with no history of coagulopathy in either patient or her family. There was history of trauma to the nose recently. She failed cautery attempt at OSH. She had significant bleeding with Hct drop from 30 to 21 at OSH requiring pRBCs. Bleeding resolved and stabilized and she was admitted to FICU for observation. ENT was consulted and recommended that packing to stay in for 5 days with need for telemetry and O2 monitoring. Patient was started on gram positive coverage with augmentin for prophylaxis for toxic shock syndrome. Once on the medical floor, she had ongoing bleeding and underwent ___ guided embolization on ___. Following this procedure she had continued bleeding and had additional repacking by ENT. Ultimately the patient went to the OR and had cauterization and biopsy. #Nasopharyngeal mass The patient was noted to have a nasopharyngeal mass on CTA. She then had an MRI which showed a small mass concerning for carcinoma. However in OR ENT found only simple cyst which was not the cause of bleeding and they biopsied. #Acute stroke On the MRI for tumor evaluation, the patient was found to have an acute CVA. This is likely related to the ___ embolization. She was seen by the neurology service and found to have no deficits on neuroligc exam. She had lipid testing and hemoglobin A1c which were normal. ECHO with bubble study did not reveal a PFO. The patient was given one dose of aspirin but given ongoing bleeding this was discontinued. Consider 30day holter/event monitor to rule out atrial fibrillation, although the patient had no episodes of Afib in the hospital. #Hypertension The patient was noted to have elevated blood pressures. Given ongoing epistaxis and concern for contribution of blood pressure, the patient was started on Captopril which was uptitrated. She was discharged on lisinopril 30mg Anxiety: - Klonopin 0.5mg TID PRN and sertraline 200 mg daily continued, in addition to seroquel and trazodone for sleep. TRANSITIONAL ISSUES: ====================== 1. ENT and neuro follow up 2. Tight blood pressure control, goal SBP<130 to prevent repeat epistaxis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia 2. TraZODone 100-200 mg PO QHS:PRN insomnia 3. Sertraline 200 mg PO DAILY 4. ClonazePAM 0.5 mg PO TID:PRN anxiety Discharge Medications: 1. ClonazePAM 0.5 mg PO TID:PRN anxiety 2. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia 3. Sertraline 200 mg PO DAILY 4. TraZODone 100-200 mg PO QHS:PRN insomnia 5. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 6. Docusate Sodium 100 mg PO BID 7. Senna 8.6 mg PO QHS constipation 8. Lisinopril 30 mg PO DAILY RX lisinopril 30 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #15 Tablet Refills:0 10. Acetaminophen 1000 mg PO Q8H headache Discharge Disposition: Home Discharge Diagnosis: Epistaxis Acute CVA Hypertension Nasopharyngeal cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted to ___ for management of your nose bleed. You were seen by the ___ doctors and ___ had packing placed. Despite this packing, you had continued bleeding so interventional radiology performed a procedure to embolize (block) the artery causing your bleeding. You had continued bleeding therefore you were taken to the OR by ENT and had cauterization to control the bleeding. You were also found to have a mass in your nose which was biopsied. Following the interventional radiology procedure you had an MRI which showed an acute stroke. You had no signs or symptoms of this stroke and you were seen by the neurologists who recommended an ultrasound of your heart which was normal. You were also diagnosed with high blood pressure and you will need to continue blood pressure medication after discharge. It is normal to have a small amount of pink blood tinged mucous oozing from around the dissolvable packing. Continue epistaxis precautions x2 weeks. (Avoid nose blowing. Sneeze with the mouth open. Avoid vigorous activity, straining, or heavy lifting.) Avoid trauma to the nose. This includes irritation from exploring digits (nose picking) and excessive nose blowing. Try to sneeze or cough with a widely open mouth to avoid excessive pressure buildup in the nose. Followup Instructions: ___	[ "R040", "I63411", "I97811", "E871", "J392", "I10", "Y848", "Y92238", "F4310", "Z87891", "Z806", "Z803", "Z8249", "F419", "G4700", "R51" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: cautery attempts and nasal packing bilaterally History of Present Illness: Ms. [MASKED] is a [MASKED] woman, who was admitted to [MASKED] [MASKED] the evening of [MASKED] for recurrent epistaxis. She was reportedly seen in the [MASKED] ED 4x in the past week for epistaxis. She has recently had cautery done in the past for a right anterior nose bleed which worked for a few days but then the bleeding restarted in the setting of blowing her nose. She was seen by ENT in the [MASKED] ED who gave Afrin and topical cocaine. This controlled the bleeding. Her Hct dropped from 32 to 27 while in the ED. She was transferred to the medical floor for observation and initially was doing well. The evening of [MASKED] she was noted to have approximately 600 cc of acute epistaxis. ENT again came to assess the patient and a right Epistat, left Merocel, and bilateral FloSeal were placed and ultimately stopped the bleeding. Hct was 21.7 at 8AM on [MASKED]. Decision was made at that time to transfer her to a tertiary care [MASKED] possible embolization should she have recurrent bleeding. The patient has also been given Cefazolin for antibiotic coverage. Last Hct was 29.5 at 3:30pm on [MASKED] which was after pRBC transfusion On arrival, patient is in good spirits. She relays the history above, denies any pain or fevers, history of bleeding disorder Past Medical History: PTSD (previously threatened physically in workplace) - Chronic back pain s/p MVA in her [MASKED] Social History: [MASKED] Family History: - AML (sister) - CAD (father) - Breast cancer (paternal aunts) - No family history of coagulopathy Physical Exam: ADMISSION PHYSICAL EXAM: ========================== Vitals: T 98.3, HR 81, BP 159/84, RR 17, 100%RA GENERAL: Alert, A&Ox3, no acute distress HEENT: Nares packed bilaterally with Epistat and Merocel, with ongoing oozing noted. 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 DISCHARGE PHYSICAL EXAM: ============================= Afeb VSS GENERAL: Alert, A&Ox3, 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 EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: ================ [MASKED] 11:24PM BLOOD WBC-7.0 RBC-3.30* Hgb-10.1* Hct-30.4* MCV-92 MCH-30.6 MCHC-33.2 RDW-14.6 RDWSD-49.5* Plt [MASKED] [MASKED] 11:24PM BLOOD Neuts-73.9* [MASKED] Monos-5.3 Eos-1.0 Baso-0.4 Im [MASKED] AbsNeut-5.16 AbsLymp-1.33 AbsMono-0.37 AbsEos-0.07 AbsBaso-0.03 [MASKED] 11:24PM BLOOD [MASKED] PTT-27.7 [MASKED] [MASKED] 11:24PM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-136 K-3.8 Cl-103 HCO3-24 AnGap-13 [MASKED] 11:24PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.9 IMAGING: =========== [MASKED] CTA Head and Neck: 1. Noncontrast head CT: No acute intracranial process. Extensive mucosal thickening of the ethmoid air cells and bilateral maxillary sinuses. Aerosolized fluid within the nasopharynx. Minimal fluid in the right frontal sinus. Increased soft tissue along the right side of the nasopharynx with adjacent bony erosion. This finding suggest chronic inflammation/chronic sinusitis. No arterially enhancing mass seen within the nasopharynx. 2. CTA head and neck: Patent cervical and intracranial vasculature. MRI BRAIN: [MASKED] IMPRESSION: 1. A 1.5 cm ill-defined heterogeneous contrast enhancing soft tissue lesion in the posterior nasopharynx, encroaching on the left fossa of [MASKED], suspicious for nasopharyngeal carcinoma. No pathologic lymphadenopathy by imaging criteria within the field of view. 2. Acute infarction in the right frontal lobe extending into the superior anterior right temporal lobe. ECHO: [MASKED] No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 70%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. [MASKED] 06:40AM BLOOD WBC-10.8* RBC-2.44* Hgb-7.2* Hct-22.5* MCV-92 MCH-29.5 MCHC-32.0 RDW-13.3 RDWSD-44.5 Plt [MASKED] [MASKED] 06:10AM BLOOD Glucose-88 UreaN-10 Creat-0.5 Na-133 K-4.1 Cl-96 HCO3-27 AnGap-14 [MASKED] 05:50AM BLOOD %HbA1c-4.8 eAG-91 [MASKED] 05:50AM BLOOD Triglyc-96 HDL-46 CHOL/HD-3.5 LDLcalc-95 [MASKED] 05:50AM BLOOD TSH-2.[MASKED] with PTSD here with epistaxis refractory to cautery attempts at OSH and bilateral nasal packing, with refractory epistaxis. # Epistaxis: Patient with no history of coagulopathy in either patient or her family. There was history of trauma to the nose recently. She failed cautery attempt at OSH. She had significant bleeding with Hct drop from 30 to 21 at OSH requiring pRBCs. Bleeding resolved and stabilized and she was admitted to FICU for observation. ENT was consulted and recommended that packing to stay in for 5 days with need for telemetry and O2 monitoring. Patient was started on gram positive coverage with augmentin for prophylaxis for toxic shock syndrome. Once on the medical floor, she had ongoing bleeding and underwent [MASKED] guided embolization on [MASKED]. Following this procedure she had continued bleeding and had additional repacking by ENT. Ultimately the patient went to the OR and had cauterization and biopsy. #Nasopharyngeal mass The patient was noted to have a nasopharyngeal mass on CTA. She then had an MRI which showed a small mass concerning for carcinoma. However in OR ENT found only simple cyst which was not the cause of bleeding and they biopsied. #Acute stroke On the MRI for tumor evaluation, the patient was found to have an acute CVA. This is likely related to the [MASKED] embolization. She was seen by the neurology service and found to have no deficits on neuroligc exam. She had lipid testing and hemoglobin A1c which were normal. ECHO with bubble study did not reveal a PFO. The patient was given one dose of aspirin but given ongoing bleeding this was discontinued. Consider 30day holter/event monitor to rule out atrial fibrillation, although the patient had no episodes of Afib in the hospital. #Hypertension The patient was noted to have elevated blood pressures. Given ongoing epistaxis and concern for contribution of blood pressure, the patient was started on Captopril which was uptitrated. She was discharged on lisinopril 30mg Anxiety: - Klonopin 0.5mg TID PRN and sertraline 200 mg daily continued, in addition to seroquel and trazodone for sleep. TRANSITIONAL ISSUES: ====================== 1. ENT and neuro follow up 2. Tight blood pressure control, goal SBP<130 to prevent repeat epistaxis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia 2. TraZODone 100-200 mg PO QHS:PRN insomnia 3. Sertraline 200 mg PO DAILY 4. ClonazePAM 0.5 mg PO TID:PRN anxiety Discharge Medications: 1. ClonazePAM 0.5 mg PO TID:PRN anxiety 2. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia 3. Sertraline 200 mg PO DAILY 4. TraZODone 100-200 mg PO QHS:PRN insomnia 5. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety 6. Docusate Sodium 100 mg PO BID 7. Senna 8.6 mg PO QHS constipation 8. Lisinopril 30 mg PO DAILY RX lisinopril 30 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 9. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours Disp #15 Tablet Refills:0 10. Acetaminophen 1000 mg PO Q8H headache Discharge Disposition: Home Discharge Diagnosis: Epistaxis Acute CVA Hypertension Nasopharyngeal cyst Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], You were admitted to [MASKED] for management of your nose bleed. You were seen by the [MASKED] doctors and [MASKED] had packing placed. Despite this packing, you had continued bleeding so interventional radiology performed a procedure to embolize (block) the artery causing your bleeding. You had continued bleeding therefore you were taken to the OR by ENT and had cauterization to control the bleeding. You were also found to have a mass in your nose which was biopsied. Following the interventional radiology procedure you had an MRI which showed an acute stroke. You had no signs or symptoms of this stroke and you were seen by the neurologists who recommended an ultrasound of your heart which was normal. You were also diagnosed with high blood pressure and you will need to continue blood pressure medication after discharge. It is normal to have a small amount of pink blood tinged mucous oozing from around the dissolvable packing. Continue epistaxis precautions x2 weeks. (Avoid nose blowing. Sneeze with the mouth open. Avoid vigorous activity, straining, or heavy lifting.) Avoid trauma to the nose. This includes irritation from exploring digits (nose picking) and excessive nose blowing. Try to sneeze or cough with a widely open mouth to avoid excessive pressure buildup in the nose. Followup Instructions: [MASKED]	[]	[ "E871", "I10", "Z87891", "F419", "G4700" ]	[ "R040: Epistaxis", "I63411: Cerebral infarction due to embolism of right middle cerebral artery", "I97811: Intraoperative cerebrovascular infarction during other surgery", "E871: Hypo-osmolality and hyponatremia", "J392: Other diseases of pharynx", "I10: Essential (primary) hypertension", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92238: Other place in hospital as the place of occurrence of the external cause", "F4310: Post-traumatic stress disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z806: Family history of leukemia", "Z803: Family history of malignant neoplasm of breast", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "R51: Headache" ]
19,983,847	27,793,534	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ generally healthy male (history of erectile dysfunction and LBP) who presents with chest pain. He states that two days ago he developed left shoulder and chest constant pain without radiation, which then became worse last night with associated chest pressure. Pain was ___. He denied any exacerbating or alleviating factors. He was unable to sleep, and so he saw his PCP today, where he had an EKG which showed normal sinus rhythm with RBBB pattern, ST elevation in III, aVF, V1, ST depression in I, II, aVL, V4-V6. No prior tracings were available for comparison. The patient was given 324mg chewable aspirin, was started on 2L NC supplemental O2, and was given 1 0.3mg SL NTG tablet, with improvement in his chest pain to ___. Other vitals at that time were notable for HR of 64 and BP of 112/90. He denied associated shortness of breath, nausea, dizziness. He was referred to ___ ED for further evaluation. In the ED, initial vitals were 98.2 80 126/83 20 98% RA -EKG showed: NSR at 80 BPM, RBBB, STE in III, aVF, V1, STD in I, II, aVL, V4-V6. -Labs were notable for: Trop-T <0.01 D-Dimer <150 WBC 7.8 H/H 15.0/44.1 Plt 204 Chemistry panel unremarkable (Cr 0.8) INR 1.0. -CXR showed oblong 1.6x0.7cm opacity projecting over right mid lung. -Cardiology was consulted in the ED, who did not feel that the patient's EKG was consistent with STEMI. Recommended ordering TTE and admission to cardiology for unstable angina/NSTEMI. -Given 2L NS, Nitro SL 0.4 x2 On the floor, the patient without chest pain. Patient notes that at the same time his chest pain started a few days ago, he developed a rash on his left chest and back. It was not painful at first. Now it is somewhat painful with palpation. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: None 2. CARDIAC HISTORY: None - CABG/PCI: None - PUMP FUNCTION: Unknown - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Low back pain - Erectile dysfunction - Acne - Rosacea Social History: ___ Family History: Denies family history of heart disease. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.5, 109/70, 64, 18, 97RA GENERAL: WDWN man, in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. No evidence of ocular vesicles. NECK: Supple, no JVP CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Distal pulses palpable and symmetric Skin: Several clusters of grouped vesicles with surrounding erythema in T4 dermatone extending from spinal process along left side of chest to nipple. Minimal tenderness to palpation. Neuro: cranial nerves grossly intact. No focal neurologic deficits appreciated. DISCHARGE PHYSICAL EXAM: VS: 98.3, 107/64, 68, 18, 95RA GENERAL: Well appearing man in NAD. Oriented x3. Mood, affect appropriate. HEENT:Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, no JVP CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Distal pulses palpable and symmetric Skin: Several clusters of grouped vesicles with surrounding erythema in T4 dermatone extending from spinal process along left side of chest to nipple. Tenderness to palpation overlying region. Neuro: cranial nerves grossly intact. No focal neurologic deficits appreciated. Pertinent Results: Admission Labs: ___ 02:25PM BLOOD WBC-7.8# RBC-5.00 Hgb-15.0 Hct-44.1 MCV-88 MCH-30.0 MCHC-34.0 RDW-12.5 RDWSD-39.8 Plt ___ ___ 02:25PM BLOOD Neuts-68.1 ___ Monos-8.3 Eos-3.2 Baso-0.5 Im ___ AbsNeut-5.30 AbsLymp-1.53 AbsMono-0.65 AbsEos-0.25 AbsBaso-0.04 ___ 02:25PM BLOOD ___ PTT-28.7 ___ ___ 02:25PM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-138 K-3.7 Cl-100 HCO3-25 AnGap-17 ___ 04:20AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1 Pertinent Labs: ___ 02:25PM BLOOD cTropnT-<0.01 ___ 09:20PM BLOOD cTropnT-<0.01 ___ 03:17PM BLOOD D-Dimer-<150 Studies: ___/ CXR: FINDINGS: There is an oblong 1.6 x 0.7 cm opacity projecting over the right mid lung which could relate to scarring however underlying pulmonary nodule is not excluded. This could be further assessed on non urgent chest CT. The left lung is clear. There is no pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes are unremarkable. No pulmonary edema is seen. IMPRESSION: Oblong 1.6 x 0.7 cm opacity projecting over the right mid lung without priors for comparison. Recommend nonemergent chest CT for further assessment. ___ TTE: The left atrium and right atrium are normal in cavity 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 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. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular regional/global systolic function. Brief Hospital Course: ___ yo M w/ no significant past medical history p/w two days of left sided chest pain which developed at the same time as a left-sided rash and not associated with exertion. # Herpes Zoster infection: Pt presented with 2 days of chest pain at rest with rash. The pain is constant and not alleviated or exacerbated by anything, including exertion of climbing 6 flights of stairs for work. Pain was initially described as pressure without radiation but became a sharp burning pain characterized as ___. He was seen by PCP and sent to the ED as EKG was concerning for ST depressions and new RBBB. He received ASA 324, O2, and NTG with improvement to ___. Biomarkers have been negative. TTE showed normal biventricular function. His symptoms are thought to be most c/w with herpes zoster. He is being discharged on valacyclovir and NSAIDs for pain management. Transitional Issues: [] Found to have oblong opacity on right lung on CXR. Please follow up with chest CT per radiology recs [] If patient has persistent chest pain despite resolution of zoster, recommendation would be outpatient stress test to further cardiac evaluation [] pt being discharged on course of valacyclovir and NSAIDs for pain Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea 2. Vitamin D 1000 UNIT PO DAILY 3. Ocuvite (vit C-vit E-lutein-min-om-3) unknown oral DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. ValACYclovir 1000 mg PO Q8H RX valacyclovir 1,000 mg 1 tablet(s) by mouth Every 8 hours Disp #19 Tablet Refills:0 2. Ibuprofen 400-600 mg PO Q8H:PRN Pain RX ibuprofen 200 mg ___ tablet(s) by mouth Every eight hours Disp #30 Tablet Refills:0 3. Vitamin D 1000 UNIT PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea 6. Ocuvite (vit C-vit E-lutein-min-om-3) 1 tablet ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Herpes zoster 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 ___ with concern for heart attack given chest pain and a change in your EKG. Thankfully it appears that your chest pain is related to shingles (herpes zoster) and not the heart as your labs were reassuring and the EKG was not consistent with heart attack. Please continue your antiviral medication for one week and follow up with your PCP. It was a pleasure caring for you, Your ___ Doctors ___ Instructions: ___	[ "B029", "R918", "R079" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [MASKED] is a [MASKED] generally healthy male (history of erectile dysfunction and LBP) who presents with chest pain. He states that two days ago he developed left shoulder and chest constant pain without radiation, which then became worse last night with associated chest pressure. Pain was [MASKED]. He denied any exacerbating or alleviating factors. He was unable to sleep, and so he saw his PCP today, where he had an EKG which showed normal sinus rhythm with RBBB pattern, ST elevation in III, aVF, V1, ST depression in I, II, aVL, V4-V6. No prior tracings were available for comparison. The patient was given 324mg chewable aspirin, was started on 2L NC supplemental O2, and was given 1 0.3mg SL NTG tablet, with improvement in his chest pain to [MASKED]. Other vitals at that time were notable for HR of 64 and BP of 112/90. He denied associated shortness of breath, nausea, dizziness. He was referred to [MASKED] ED for further evaluation. In the ED, initial vitals were 98.2 80 126/83 20 98% RA -EKG showed: NSR at 80 BPM, RBBB, STE in III, aVF, V1, STD in I, II, aVL, V4-V6. -Labs were notable for: Trop-T <0.01 D-Dimer <150 WBC 7.8 H/H 15.0/44.1 Plt 204 Chemistry panel unremarkable (Cr 0.8) INR 1.0. -CXR showed oblong 1.6x0.7cm opacity projecting over right mid lung. -Cardiology was consulted in the ED, who did not feel that the patient's EKG was consistent with STEMI. Recommended ordering TTE and admission to cardiology for unstable angina/NSTEMI. -Given 2L NS, Nitro SL 0.4 x2 On the floor, the patient without chest pain. Patient notes that at the same time his chest pain started a few days ago, he developed a rash on his left chest and back. It was not painful at first. Now it is somewhat painful with palpation. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: None 2. CARDIAC HISTORY: None - CABG/PCI: None - PUMP FUNCTION: Unknown - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Low back pain - Erectile dysfunction - Acne - Rosacea Social History: [MASKED] Family History: Denies family history of heart disease. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 98.5, 109/70, 64, 18, 97RA GENERAL: WDWN man, in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. No evidence of ocular vesicles. NECK: Supple, no JVP CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Distal pulses palpable and symmetric Skin: Several clusters of grouped vesicles with surrounding erythema in T4 dermatone extending from spinal process along left side of chest to nipple. Minimal tenderness to palpation. Neuro: cranial nerves grossly intact. No focal neurologic deficits appreciated. DISCHARGE PHYSICAL EXAM: VS: 98.3, 107/64, 68, 18, 95RA GENERAL: Well appearing man in NAD. Oriented x3. Mood, affect appropriate. HEENT:Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, no JVP CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. PULSES: Distal pulses palpable and symmetric Skin: Several clusters of grouped vesicles with surrounding erythema in T4 dermatone extending from spinal process along left side of chest to nipple. Tenderness to palpation overlying region. Neuro: cranial nerves grossly intact. No focal neurologic deficits appreciated. Pertinent Results: Admission Labs: [MASKED] 02:25PM BLOOD WBC-7.8# RBC-5.00 Hgb-15.0 Hct-44.1 MCV-88 MCH-30.0 MCHC-34.0 RDW-12.5 RDWSD-39.8 Plt [MASKED] [MASKED] 02:25PM BLOOD Neuts-68.1 [MASKED] Monos-8.3 Eos-3.2 Baso-0.5 Im [MASKED] AbsNeut-5.30 AbsLymp-1.53 AbsMono-0.65 AbsEos-0.25 AbsBaso-0.04 [MASKED] 02:25PM BLOOD [MASKED] PTT-28.7 [MASKED] [MASKED] 02:25PM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-138 K-3.7 Cl-100 HCO3-25 AnGap-17 [MASKED] 04:20AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1 Pertinent Labs: [MASKED] 02:25PM BLOOD cTropnT-<0.01 [MASKED] 09:20PM BLOOD cTropnT-<0.01 [MASKED] 03:17PM BLOOD D-Dimer-<150 Studies: [MASKED]/ CXR: FINDINGS: There is an oblong 1.6 x 0.7 cm opacity projecting over the right mid lung which could relate to scarring however underlying pulmonary nodule is not excluded. This could be further assessed on non urgent chest CT. The left lung is clear. There is no pleural effusion or pneumothorax. Cardiac and mediastinal silhouettes are unremarkable. No pulmonary edema is seen. IMPRESSION: Oblong 1.6 x 0.7 cm opacity projecting over the right mid lung without priors for comparison. Recommend nonemergent chest CT for further assessment. [MASKED] TTE: The left atrium and right atrium are normal in cavity 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 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. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal biventricular regional/global systolic function. Brief Hospital Course: [MASKED] yo M w/ no significant past medical history p/w two days of left sided chest pain which developed at the same time as a left-sided rash and not associated with exertion. # Herpes Zoster infection: Pt presented with 2 days of chest pain at rest with rash. The pain is constant and not alleviated or exacerbated by anything, including exertion of climbing 6 flights of stairs for work. Pain was initially described as pressure without radiation but became a sharp burning pain characterized as [MASKED]. He was seen by PCP and sent to the ED as EKG was concerning for ST depressions and new RBBB. He received ASA 324, O2, and NTG with improvement to [MASKED]. Biomarkers have been negative. TTE showed normal biventricular function. His symptoms are thought to be most c/w with herpes zoster. He is being discharged on valacyclovir and NSAIDs for pain management. Transitional Issues: [] Found to have oblong opacity on right lung on CXR. Please follow up with chest CT per radiology recs [] If patient has persistent chest pain despite resolution of zoster, recommendation would be outpatient stress test to further cardiac evaluation [] pt being discharged on course of valacyclovir and NSAIDs for pain Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea 2. Vitamin D 1000 UNIT PO DAILY 3. Ocuvite (vit C-vit E-lutein-min-om-3) unknown oral DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. ValACYclovir 1000 mg PO Q8H RX valacyclovir 1,000 mg 1 tablet(s) by mouth Every 8 hours Disp #19 Tablet Refills:0 2. Ibuprofen 400-600 mg PO Q8H:PRN Pain RX ibuprofen 200 mg [MASKED] tablet(s) by mouth Every eight hours Disp #30 Tablet Refills:0 3. Vitamin D 1000 UNIT PO DAILY 4. Fish Oil (Omega 3) 1000 mg PO DAILY 5. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea 6. Ocuvite (vit C-vit E-lutein-min-om-3) 1 tablet ORAL DAILY Discharge Disposition: Home Discharge Diagnosis: Primary: Herpes zoster 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] with concern for heart attack given chest pain and a change in your EKG. Thankfully it appears that your chest pain is related to shingles (herpes zoster) and not the heart as your labs were reassuring and the EKG was not consistent with heart attack. Please continue your antiviral medication for one week and follow up with your PCP. It was a pleasure caring for you, Your [MASKED] Doctors [MASKED] Instructions: [MASKED]	[]	[]	[ "B029: Zoster without complications", "R918: Other nonspecific abnormal finding of lung field", "R079: Chest pain, unspecified" ]
19,983,966	20,080,951	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: Penicillins Attending: ___. Chief Complaint: "Feeling very down" Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year old woman with bipolar II disorder, CAD ___ MI, who self-presented to the ED at the suggestion of her outpatient psychiatrist, Dr. ___, due to failure of response to outpatient treatment and recommendation for admission for ECT. . "Ms. ___ states her outpatient psychiatrist/therapist Dr. ___ she present to ___ ED for admission and ECT for treatment of depression (Dr. ___ call ahead to notify ED day team of her presentation, noted failure of outpatient treatment of depression as evidenced by difficulties caring for self and preference for admission to Deac 4 for inpatient ECT); she was evaluated by Dr. ___ for ECT in ___. . Ms. ___ describes feeling depressed for years, since her ___, but has noted worsening depression recently, particularly in the past few weeks. She describes strain in her relationship with her husband due to his dementia and due to financial troubles. She notes they took out a loan and she trusted her husband to manage the finances but $57,000 is now lost or missing. Ms. ___ states she cannot recall the last time she did not feel depressed. . She denies wanting to harm herself or others, although endorses passive suicidal ideation ("I pray God would take me or my husband, because I can't take it anymore."). She reports poor concentration, which is her historic baseline, poor motivation, anhedonia with hobbies. She notes a poor appetite with nausea, early morning waking despite medication, and poor daytime energy. She has lost 20 pounds in ___ months (during ___ ___. She says her self esteem "is zero" and feels her anxiety and worries are accelerating. Ms. ___ notes she has a history of Bipolar II, but denies any "excited episodes" in recent memory. . Has been hospitalized for an MI and COPD in the past year. Ms. ___ has 5 children with whom she is close, and she reports one daughter will stop by regularly and help with the shopping, although she still feels overwhelmed at home. She has one close friend who has been unavailable lately due to the friend's daughter having brain cancer, and Ms. ___ reports a general feeling of disconnect from her community. She additionally reports stress due to multiple health problems, including hospitalizations for an MI and COPD in the past year, recently rehabilitating from a surgery on her Achilles' tendon (affected her ability to walk), as well as chronic neck back pain." . In the ED, patient was med compliant and was in good behavioral control without need for chemical or physical restraints. . On interview today, patient confirmed above information. Patient sites recent stressors of having to take care of her increasingly medically complicated husband and recent financial stresses after her husband took out a "57,00 dollar loan" and stated that they "would have to sell the house." Patient states that her primary psychiatrist has been suggesting ECT for quite a while given concerns for considerable side effects from psychiatric medications. . Patient also reports recent unintentional weight loss of approximately 20 pounds over last 6 weeks which she attributes to her nausea and lack of appetite secondary to her worsening depression and anxiety. . REVIEW OF SYSTEMS: ---Depression: As per HPI. Endorses symptoms of depression such as depressed mood, fatigue/loss of energy, anhedonia, sleep disturbance including terminal insomnia, poor appetite, poor concentration, feelings of guilt and hopelessness, and passive SI without plan or intent. ---Anxiety: Endorses symptoms of anxiety such as worry, rumination. Denies intrusive thoughts, avoidance, phobias, panic. ---Mania: As per HPI. Denies recent symptoms of mania such as distractibility, erratic/risky behavior, grandiosity, flight of ideas, increased activity, decreased need for sleep, or talkativeness/pressured speech. ---Psychosis: Denies symptoms of psychosis such as auditory or visual hallucinations, or delusions of reference, paranoia, thought insertion/broadcasting/withdrawal. -General: Endorses fatigue, neck/back pain; denies other physical complaints. Past Medical History: PAST PSYCHIATRIC HISTORY: [Extracted from Dr. ___ ___ ED Initial Psychiatry Consult note, reviewed with patient, and updated as appropriate.] -Prior diagnoses: Bipolar II disorder, anxiety, MDD -Hospitalizations: Never before been psychiatrically hospitalized -Partial hospitalizations: Denies -Psychiatrist/Therapist: Dr. ___ trials: Denies trials of other medications than what she is currently taking -___ trials: Denies -Suicide attempts: Denies -Self-injurious behavior: Denies -Harm to others: Denies -Trauma: Sexual abuse as a child -Access to weapons: Denies PAST MEDICAL HISTORY: *PCP: ___ MD -___ MI (need to confirm) -Chronic neck/back pain (?DJD) -COPD -HTN -HLD -Mitral valve prolapse Denies history of head trauma, seizure. Social History: SUBSTANCE USE HISTORY: -Tobacco: Denies -Alcohol: Rarely, denies problematic use -Other Drugs: Denies . FORENSIC HISTORY: -Arrests: Denies -Convictions and jail terms: Denies -Current status (pending charges, probation, parole): Denies . SOCIAL HISTORY: ___ Family History: FAMILY PSYCHIATRIC HISTORY: -Psychiatric Diagnoses: Granddaughter with depression (?bipolar disorder); Father alcohol use disorder; Mother depression -___ Attempts/Completed Suicides: Distant cousin died by suicide Physical Exam: 97.7 PO; 158/85; 50; 17; 96% 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 rubs/gallops; systolic murmur noted. 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, slight intention tremor. Strength ___ throughout. -Sensory: No deficits to fine touch throughout -DTRs: 2 and symmetrical throughout Coordination: Normal on finger to nose test, slight intention tremor noted -Gait: Good initiation. Narrow-based, normal stride and arm swing. Walks with slight limp on left leg. Romberg absent. Cognition: -Wakefulness/alertness: Awake and alert -Attention: MOYb with 0 errors -Orientation: Oriented to person, time, place, situation -Executive function (go-no go, Luria, trails, FAS): Not formally tested -Memory: ___ registration, ___ recall after 5 ___ grossly intact -Fund of knowledge: Consistent with education, average -Calculations: 7 quarters = "$1.75" -Abstraction: Interprets "the grass is always greener on the other side" as "sometimes things look better than what you have, but then you find out they're not" -Visuospatial: Not assessed -Language: Native ___ speaker, no paraphasic errors, appropriate to conversation Mental Status: -Appearance: Elderly Caucasian woman appearing stated age, well groomed, good hygiene, 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: "Nauseous" -Affect: full range, occasionally laughing, somewhat mood incongruent, occasionally tearful -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Content: ---Safety: Denies SI/HI ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: Fair . Discharge Physical Exam: VS: 97.4 PO; 155/60; 50; 14; 98% RA Neurological: station and gait: Steady gait, slow pace, slight limp on left leg, no ataxia noted tone and strength: Moves all extremities symmetrically against gravity. Appearance: Elderly Caucasian woman appearing stated age, well groomed, good hygiene, pajamas and bath robe. Behavior: appropriate eye contact, no psychomotor retardation. Mood and Affect: 'Better'; appeared euthymic, full range of affect Thought process: linear, goal oriented, no LOA Thought Content: no active SI, violent ideation, or AVH Judgment and Insight: fair/fair Cognition: Attention, orientation, and executive function: AAOx3 Memory: grossly intact to recent and remote Fund of knowledge: average Speech: Normal rate, volume, and tone Language: Native ___ speaker, no paraphasic errors, appropriate to conversation Ambulatory status: Ambulates independently Pertinent Results: ___ 07:28PM GLUCOSE-98 UREA N-25* CREAT-1.5* SODIUM-133* POTASSIUM-5.1 CHLORIDE-93* TOTAL CO2-26 ANION GAP-14 ___ 07:28PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-90 TOT BILI-0.2 ___ 07:28PM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-2.3 IRON-38 CHOLEST-204* ___ 07:28PM calTIBC-399 TRF-307 ___ 07:28PM %HbA1c-4.9 eAG-94 ___ 07:28PM TRIGLYCER-101 HDL CHOL-95 CHOL/HDL-2.1 LDL(CALC)-89 ___ 07:28PM TSH-0.77 ___ 07:28PM HCG-<5 ___ 07:28PM WBC-5.2 RBC-4.02 HGB-10.9* HCT-33.1* MCV-82 MCH-27.1 MCHC-32.9 RDW-15.8* RDWSD-47.7* ___ 07:28PM PLT COUNT-229 ___ 12:11PM GLUCOSE-133* UREA N-21* CREAT-1.3* SODIUM-129* POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-23 ANION GAP-14 Brief Hospital Course: Mrs. ___ is a ___ year old woman with a history of Bipolar II disorder, recently evaluated by Dr. ___ as an outpatient for initiation of ECT, who presented to the ED with her daughter on the advice of her outpatient psychiatrist recommending inpatient ECT due to severity of symptoms. On initial and subsequent interviews, she describes worsening neurovegetative symptoms over the past ___ weeks (notable for diminished concentration, energy, appetite, sleep, and hedonic tone); however, denied current suicidal ideation. Presentation is consistent with depressive episode of longstanding bipolar affective illness. Given incomplete response to polypharmacy (in addition to side effects), complicated by social stressors, inpatient ECT was pursued for safety and stabilization. . #. Legal/Safety: patient admitted to ___ on a ___, upon admission, she signed a conditional voluntary form. Signed CV on ___, which was accepted. She maintained her safety throughout her psychiatric hospitalization on 15 minute checks and did not require physical or chemical restraints. . #. Bipolar Depression: per psychiatrist, with episodes in the past concerning for hypomania. Upon admission to the inpatient unit, all of the patient's home medications were resumed except her Escitalopram given concerns for mania induction and hyponatremia. Please see below for pre-admission med list. In addition to the patient's home medications, on nights prior to ECT the patient was offered Hydroxyzine for anxiety, which had good effect and was well tolerated, and she was offered Seroquel for sleep, which had good affect and was well tolerated. In addition, patient initiated a trial of ECT. Patient received a total of 3 ECT treatments, which were moderately tolerated. After patient's first treatment, she complained of nausea (a symptom she has had much difficulty controlling as an outpatient prior to hospitalization). After the other 2 treatments, patient had no complaints. Initiating and continuing these treatments however was complicated by the patient's difficult to control blood pressure. Prior to starting ECT, patient was seen by medicine for further aid in blood pressure control, and they made the recommendation that ECT be withheld if the patient's BP was not <160 systolic and <100 diastolic. Further discussion of the management of her blood pressure can be seen below. Ultimately, because patient's concerns regarding her elevated blood pressures during ECT (up to 220 systolic), she wanted to discontinue treatment for fear of possible stroke (given her family history of prior severe strokes). Given patient's improvement in depressive symptoms during her hospitalization, her reluctance to continue ECT treatment, her denial of interest in altering her psychiatric medication regimen, and her persistent denial of suicidal ideation, it was decided that it would be best for the patient to return home and continue with outpatient treatment. -During her hospitalization, a family meeting was held with attendance in person by the patient's two daughters ___ and ___, and one of the patient's sons via phone. During this meeting, the patient's family expressed concerns mostly centralized around the patient's husband who the family has raised concerns about possibly having dementia and making irresponsible financial decisions. It was during this meeting, which was further supported by separate encounters with the patient, that the patient and family expressed that the improvement in the patient's symptoms likely had little to do with ECT treatment and was likely primarily due to separation from the patient's home environment and linked life stressors. During this meeting, the patient expressed a desire to become more involved with some sort of social circle that was outside of her home life. This was encouraged, and patient will be provided with referrals to local senior centers upon discharge. - Of note, patient consistently denied suicidal ideation or thoughts of self harm throughout her psychiatric hospitalization and she was noted to attend to her ADL's well with no concerns for inability for her to care for herself. - Given her rapid resolution of depressive symptoms in the setting of the stabilizing environment of the milieu, I'm unsure if the ECT was efficacious in improving her depressive symptoms compared to the supportive environment of the milieu. Strongly recommend increasing supports as much as possible when discharged. Of note, patient declined referral to a partial program, in part due to transportation issues. However, as noted above, she was amenable to attending a senior day program upon discharge. . 3) Medical: #. HTN: At first, patient's home medications were resumed, but with the patient's home medication regimen her BP was not well controlled on the unit. Because of this, medicine was consulted to help manage the patient's blood pressure. The patient was continued on her home dose of Amlodipine of 10 mg daily and her home dose of Lasix 20 mg daily. Via recommendations made by medicine, the patient's Doxazosin was increased to 4 mg in the morning, and was started on Lisinopril 40 mg daily, and Clonidine 0.1 mg at bedtime was started. The patient's ___ was non-formulary, so the patient was started on Losartan, but this was eventually discontinued as it proved ineffective. Medicine tried to start the use of hydralazine, but patient was unable to tolerate this medication. By the end of her admission, the patient's blood pressures were better controlled. . #. Hypothyroidism: stable - Continued Levothyroxine 112 mcg qam. . #. GERD: stable - Continued Pantoprazole 40 mg qam. . #. COPD: stable - Continued Symbicort 160-4.5 mcg INH 1 puff BID. . #. Urinary Incontinence: stable - Continued Tolterodine ER 2 mg qam. . #. Hyponatremia: followed by medicine The patient has baseline hyponatremia which somewhat worsened during her hospitalization. During her stay, her serum sodium ranged from 134 to 125 on the day of discharge. Hyponatremia is suspected to be due to SIADH, and further investigation of her medication regimen upon discharge is warranted. The patient will be checking her electrolytes the ___ following discharged which is to be followed up by the patient's primary nephrologist Dr. ___ with whom the patient has a follow up appointment scheduled for ___, one week after discharge. Despite this hyponatremia, the patient remained asymptomatic. . #. CKD Stage 3 During hospitalization the patient's Cr ranged from 1.4 to 1.8, with the spike of 1.8 likely secondary to dehydration which was addressed by providing the patient IV fluids. Upon discharge, the patient's creatinine returned to 1.4 which is her baseline. . #. HLD Per medicine's recommendations, restarted patient's Pravastatin 80 mg QPM. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ARIPiprazole 5 mg PO DAILY 2. BusPIRone 20 mg PO QAM 3. Doxazosin 2 mg PO DAILY 4. BusPIRone 10 mg PO NOON 5. BusPIRone 10 mg PO QHS 6. LamoTRIgine 150 mg PO BID 7. Levothyroxine Sodium 112 mcg PO DAILY 8. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea 9. Pantoprazole 40 mg PO Q24H 10. Pramipexole 0.125 mg PO QAM 11. Pramipexole 0.25 mg PO QHS 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 13. Tolterodine 2 mg PO QAM 14. olmesartan 20 mg oral QAM 15. amLODIPine 10 mg PO DAILY 16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/shortness of breath 17. Aspirin 81 mg PO DAILY 18. FoLIC Acid 1 mg PO BID 19. Furosemide 20 mg PO DAILY 20. Metoclopramide 5 mg PO QIDACHS 21. Montelukast 10 mg PO DAILY 22. Ondansetron 4 mg PO Q6H:PRN nausea 23. Ondansetron ODT 4 mg PO Q8H:PRN nausea 24. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 25. Prochlorperazine 10 mg PO Q6H:PRN nausea 26. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 2,000 mcg oral BID 27. Vitamin D ___ UNIT PO DAILY 28. Escitalopram Oxalate 5 mg PO DAILY Discharge Medications: 1. CloNIDine 0.1 mg PO QHS 2. Lisinopril 40 mg PO DAILY Hypertension 3. Pravastatin 80 mg PO QPM 4. Doxazosin 4 mg PO QAM 5. amLODIPine 10 mg PO DAILY 6. ARIPiprazole 5 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. BusPIRone 20 mg PO QAM 9. BusPIRone 10 mg PO NOON 10. BusPIRone 10 mg PO QHS 11. FoLIC Acid 1 mg PO BID 12. LamoTRIgine 150 mg PO BID 13. Levothyroxine Sodium 112 mcg PO DAILY 14. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea 15. Metoclopramide 5 mg PO QIDACHS 16. Montelukast 10 mg PO DAILY 17. Ondansetron 4 mg PO Q6H:PRN nausea 18. Pantoprazole 40 mg PO Q24H 19. Pramipexole 0.125 mg PO QAM 20. Pramipexole 0.25 mg PO QHS 21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 22. Prochlorperazine 10 mg PO Q6H:PRN nausea 23. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 24. Tolterodine 2 mg PO QAM 25. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 2,000 mcg oral BID 26. Vitamin D ___ UNIT PO DAILY 27. HELD- Escitalopram Oxalate 5 mg PO DAILY This medication was held. Do not restart Escitalopram Oxalate until you see Dr. ___. 28. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until you speak with Dr. ___. 29. HELD- olmesartan 20 mg oral QAM This medication was held. Do not restart olmesartan until you see Dr. ___. 30.Outpatient Lab Work Blood Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN; Creatinine to be collected on ___. Diagnosis: Hyponatremia ICD: E87.1 To be followed up by Dr. ___, please fax the results to the following number. Phone: ___ Fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: - BPAD, type II, most recent episode depressed, without psychotic features - CAD ___ MI - COPD - Chronic neck pain - HTN - HLD - MVP Discharge Condition: VS: 97.4 PO; 155/60; 50; 14; 98% RA Neurological: station and gait: Steady gait, slow pace, slight limp on left leg, no ataxia noted tone and strength: Moves all extremities symmetrically against gravity. Appearance: Elderly Caucasian woman appearing stated age, well groomed, good hygiene, pajamas and bath robe. Behavior: appropriate eye contact, no psychomotor retardation. Mood and Affect: 'Better'; appeared euthymic, full range of affect Thought process: linear, goal oriented, no LOA Thought Content: no active SI, violent ideation, or AVH Judgment and Insight: fair/fair Cognition: Attention, orientation, and executive function: AAOx3 Memory: grossly intact to recent and remote Fund of knowledge: average Speech: Normal rate, volume, and tone *Language: Native ___ speaker, no paraphasic errors, appropriate to conversation Ambulatory status: Ambulates independently 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: ___	[ "F3181", "J449", "E222", "E860", "I129", "N183", "F419", "M542", "G8929", "E785", "E039", "K219", "R32", "G2581", "R110", "G4700", "I160", "Z96653", "Z85828", "Z823", "Z818" ]	Allergies: Penicillins Chief Complaint: "Feeling very down" Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] year old woman with bipolar II disorder, CAD [MASKED] MI, who self-presented to the ED at the suggestion of her outpatient psychiatrist, Dr. [MASKED], due to failure of response to outpatient treatment and recommendation for admission for ECT. . "Ms. [MASKED] states her outpatient psychiatrist/therapist Dr. [MASKED] she present to [MASKED] ED for admission and ECT for treatment of depression (Dr. [MASKED] call ahead to notify ED day team of her presentation, noted failure of outpatient treatment of depression as evidenced by difficulties caring for self and preference for admission to Deac 4 for inpatient ECT); she was evaluated by Dr. [MASKED] for ECT in [MASKED]. . Ms. [MASKED] describes feeling depressed for years, since her [MASKED], but has noted worsening depression recently, particularly in the past few weeks. She describes strain in her relationship with her husband due to his dementia and due to financial troubles. She notes they took out a loan and she trusted her husband to manage the finances but $57,000 is now lost or missing. Ms. [MASKED] states she cannot recall the last time she did not feel depressed. . She denies wanting to harm herself or others, although endorses passive suicidal ideation ("I pray God would take me or my husband, because I can't take it anymore."). She reports poor concentration, which is her historic baseline, poor motivation, anhedonia with hobbies. She notes a poor appetite with nausea, early morning waking despite medication, and poor daytime energy. She has lost 20 pounds in [MASKED] months (during [MASKED] [MASKED]. She says her self esteem "is zero" and feels her anxiety and worries are accelerating. Ms. [MASKED] notes she has a history of Bipolar II, but denies any "excited episodes" in recent memory. . Has been hospitalized for an MI and COPD in the past year. Ms. [MASKED] has 5 children with whom she is close, and she reports one daughter will stop by regularly and help with the shopping, although she still feels overwhelmed at home. She has one close friend who has been unavailable lately due to the friend's daughter having brain cancer, and Ms. [MASKED] reports a general feeling of disconnect from her community. She additionally reports stress due to multiple health problems, including hospitalizations for an MI and COPD in the past year, recently rehabilitating from a surgery on her Achilles' tendon (affected her ability to walk), as well as chronic neck back pain." . In the ED, patient was med compliant and was in good behavioral control without need for chemical or physical restraints. . On interview today, patient confirmed above information. Patient sites recent stressors of having to take care of her increasingly medically complicated husband and recent financial stresses after her husband took out a "57,00 dollar loan" and stated that they "would have to sell the house." Patient states that her primary psychiatrist has been suggesting ECT for quite a while given concerns for considerable side effects from psychiatric medications. . Patient also reports recent unintentional weight loss of approximately 20 pounds over last 6 weeks which she attributes to her nausea and lack of appetite secondary to her worsening depression and anxiety. . REVIEW OF SYSTEMS: ---Depression: As per HPI. Endorses symptoms of depression such as depressed mood, fatigue/loss of energy, anhedonia, sleep disturbance including terminal insomnia, poor appetite, poor concentration, feelings of guilt and hopelessness, and passive SI without plan or intent. ---Anxiety: Endorses symptoms of anxiety such as worry, rumination. Denies intrusive thoughts, avoidance, phobias, panic. ---Mania: As per HPI. Denies recent symptoms of mania such as distractibility, erratic/risky behavior, grandiosity, flight of ideas, increased activity, decreased need for sleep, or talkativeness/pressured speech. ---Psychosis: Denies symptoms of psychosis such as auditory or visual hallucinations, or delusions of reference, paranoia, thought insertion/broadcasting/withdrawal. -General: Endorses fatigue, neck/back pain; denies other physical complaints. Past Medical History: PAST PSYCHIATRIC HISTORY: [Extracted from Dr. [MASKED] [MASKED] ED Initial Psychiatry Consult note, reviewed with patient, and updated as appropriate.] -Prior diagnoses: Bipolar II disorder, anxiety, MDD -Hospitalizations: Never before been psychiatrically hospitalized -Partial hospitalizations: Denies -Psychiatrist/Therapist: Dr. [MASKED] trials: Denies trials of other medications than what she is currently taking -[MASKED] trials: Denies -Suicide attempts: Denies -Self-injurious behavior: Denies -Harm to others: Denies -Trauma: Sexual abuse as a child -Access to weapons: Denies PAST MEDICAL HISTORY: *PCP: [MASKED] MD -[MASKED] MI (need to confirm) -Chronic neck/back pain (?DJD) -COPD -HTN -HLD -Mitral valve prolapse Denies history of head trauma, seizure. Social History: SUBSTANCE USE HISTORY: -Tobacco: Denies -Alcohol: Rarely, denies problematic use -Other Drugs: Denies . FORENSIC HISTORY: -Arrests: Denies -Convictions and jail terms: Denies -Current status (pending charges, probation, parole): Denies . SOCIAL HISTORY: [MASKED] Family History: FAMILY PSYCHIATRIC HISTORY: -Psychiatric Diagnoses: Granddaughter with depression (?bipolar disorder); Father alcohol use disorder; Mother depression -[MASKED] Attempts/Completed Suicides: Distant cousin died by suicide Physical Exam: 97.7 PO; 158/85; 50; 17; 96% 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 rubs/gallops; systolic murmur noted. 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, slight intention tremor. Strength [MASKED] throughout. -Sensory: No deficits to fine touch throughout -DTRs: 2 and symmetrical throughout Coordination: Normal on finger to nose test, slight intention tremor noted -Gait: Good initiation. Narrow-based, normal stride and arm swing. Walks with slight limp on left leg. Romberg absent. Cognition: -Wakefulness/alertness: Awake and alert -Attention: MOYb with 0 errors -Orientation: Oriented to person, time, place, situation -Executive function (go-no go, Luria, trails, FAS): Not formally tested -Memory: [MASKED] registration, [MASKED] recall after 5 [MASKED] grossly intact -Fund of knowledge: Consistent with education, average -Calculations: 7 quarters = "$1.75" -Abstraction: Interprets "the grass is always greener on the other side" as "sometimes things look better than what you have, but then you find out they're not" -Visuospatial: Not assessed -Language: Native [MASKED] speaker, no paraphasic errors, appropriate to conversation Mental Status: -Appearance: Elderly Caucasian woman appearing stated age, well groomed, good hygiene, 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: "Nauseous" -Affect: full range, occasionally laughing, somewhat mood incongruent, occasionally tearful -Speech: Normal rate, volume, and tone -Thought process: Linear, coherent, goal-oriented, no loose associations -Thought Content: ---Safety: Denies SI/HI ---Delusions: No evidence of paranoia, etc. ---Obsessions/Compulsions: No evidence based on current encounter ---Hallucinations: Denies AVH, not appearing to be attending to internal stimuli -Insight: Limited -Judgment: Fair . Discharge Physical Exam: VS: 97.4 PO; 155/60; 50; 14; 98% RA Neurological: station and gait: Steady gait, slow pace, slight limp on left leg, no ataxia noted tone and strength: Moves all extremities symmetrically against gravity. Appearance: Elderly Caucasian woman appearing stated age, well groomed, good hygiene, pajamas and bath robe. Behavior: appropriate eye contact, no psychomotor retardation. Mood and Affect: 'Better'; appeared euthymic, full range of affect Thought process: linear, goal oriented, no LOA Thought Content: no active SI, violent ideation, or AVH Judgment and Insight: fair/fair Cognition: Attention, orientation, and executive function: AAOx3 Memory: grossly intact to recent and remote Fund of knowledge: average Speech: Normal rate, volume, and tone Language: Native [MASKED] speaker, no paraphasic errors, appropriate to conversation Ambulatory status: Ambulates independently Pertinent Results: [MASKED] 07:28PM GLUCOSE-98 UREA N-25* CREAT-1.5* SODIUM-133* POTASSIUM-5.1 CHLORIDE-93* TOTAL CO2-26 ANION GAP-14 [MASKED] 07:28PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-90 TOT BILI-0.2 [MASKED] 07:28PM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-2.3 IRON-38 CHOLEST-204* [MASKED] 07:28PM calTIBC-399 TRF-307 [MASKED] 07:28PM %HbA1c-4.9 eAG-94 [MASKED] 07:28PM TRIGLYCER-101 HDL CHOL-95 CHOL/HDL-2.1 LDL(CALC)-89 [MASKED] 07:28PM TSH-0.77 [MASKED] 07:28PM HCG-<5 [MASKED] 07:28PM WBC-5.2 RBC-4.02 HGB-10.9* HCT-33.1* MCV-82 MCH-27.1 MCHC-32.9 RDW-15.8* RDWSD-47.7* [MASKED] 07:28PM PLT COUNT-229 [MASKED] 12:11PM GLUCOSE-133* UREA N-21* CREAT-1.3* SODIUM-129* POTASSIUM-4.4 CHLORIDE-92* TOTAL CO2-23 ANION GAP-14 Brief Hospital Course: Mrs. [MASKED] is a [MASKED] year old woman with a history of Bipolar II disorder, recently evaluated by Dr. [MASKED] as an outpatient for initiation of ECT, who presented to the ED with her daughter on the advice of her outpatient psychiatrist recommending inpatient ECT due to severity of symptoms. On initial and subsequent interviews, she describes worsening neurovegetative symptoms over the past [MASKED] weeks (notable for diminished concentration, energy, appetite, sleep, and hedonic tone); however, denied current suicidal ideation. Presentation is consistent with depressive episode of longstanding bipolar affective illness. Given incomplete response to polypharmacy (in addition to side effects), complicated by social stressors, inpatient ECT was pursued for safety and stabilization. . #. Legal/Safety: patient admitted to [MASKED] on a [MASKED], upon admission, she signed a conditional voluntary form. Signed CV on [MASKED], which was accepted. She maintained her safety throughout her psychiatric hospitalization on 15 minute checks and did not require physical or chemical restraints. . #. Bipolar Depression: per psychiatrist, with episodes in the past concerning for hypomania. Upon admission to the inpatient unit, all of the patient's home medications were resumed except her Escitalopram given concerns for mania induction and hyponatremia. Please see below for pre-admission med list. In addition to the patient's home medications, on nights prior to ECT the patient was offered Hydroxyzine for anxiety, which had good effect and was well tolerated, and she was offered Seroquel for sleep, which had good affect and was well tolerated. In addition, patient initiated a trial of ECT. Patient received a total of 3 ECT treatments, which were moderately tolerated. After patient's first treatment, she complained of nausea (a symptom she has had much difficulty controlling as an outpatient prior to hospitalization). After the other 2 treatments, patient had no complaints. Initiating and continuing these treatments however was complicated by the patient's difficult to control blood pressure. Prior to starting ECT, patient was seen by medicine for further aid in blood pressure control, and they made the recommendation that ECT be withheld if the patient's BP was not <160 systolic and <100 diastolic. Further discussion of the management of her blood pressure can be seen below. Ultimately, because patient's concerns regarding her elevated blood pressures during ECT (up to 220 systolic), she wanted to discontinue treatment for fear of possible stroke (given her family history of prior severe strokes). Given patient's improvement in depressive symptoms during her hospitalization, her reluctance to continue ECT treatment, her denial of interest in altering her psychiatric medication regimen, and her persistent denial of suicidal ideation, it was decided that it would be best for the patient to return home and continue with outpatient treatment. -During her hospitalization, a family meeting was held with attendance in person by the patient's two daughters [MASKED] and [MASKED], and one of the patient's sons via phone. During this meeting, the patient's family expressed concerns mostly centralized around the patient's husband who the family has raised concerns about possibly having dementia and making irresponsible financial decisions. It was during this meeting, which was further supported by separate encounters with the patient, that the patient and family expressed that the improvement in the patient's symptoms likely had little to do with ECT treatment and was likely primarily due to separation from the patient's home environment and linked life stressors. During this meeting, the patient expressed a desire to become more involved with some sort of social circle that was outside of her home life. This was encouraged, and patient will be provided with referrals to local senior centers upon discharge. - Of note, patient consistently denied suicidal ideation or thoughts of self harm throughout her psychiatric hospitalization and she was noted to attend to her ADL's well with no concerns for inability for her to care for herself. - Given her rapid resolution of depressive symptoms in the setting of the stabilizing environment of the milieu, I'm unsure if the ECT was efficacious in improving her depressive symptoms compared to the supportive environment of the milieu. Strongly recommend increasing supports as much as possible when discharged. Of note, patient declined referral to a partial program, in part due to transportation issues. However, as noted above, she was amenable to attending a senior day program upon discharge. . 3) Medical: #. HTN: At first, patient's home medications were resumed, but with the patient's home medication regimen her BP was not well controlled on the unit. Because of this, medicine was consulted to help manage the patient's blood pressure. The patient was continued on her home dose of Amlodipine of 10 mg daily and her home dose of Lasix 20 mg daily. Via recommendations made by medicine, the patient's Doxazosin was increased to 4 mg in the morning, and was started on Lisinopril 40 mg daily, and Clonidine 0.1 mg at bedtime was started. The patient's [MASKED] was non-formulary, so the patient was started on Losartan, but this was eventually discontinued as it proved ineffective. Medicine tried to start the use of hydralazine, but patient was unable to tolerate this medication. By the end of her admission, the patient's blood pressures were better controlled. . #. Hypothyroidism: stable - Continued Levothyroxine 112 mcg qam. . #. GERD: stable - Continued Pantoprazole 40 mg qam. . #. COPD: stable - Continued Symbicort 160-4.5 mcg INH 1 puff BID. . #. Urinary Incontinence: stable - Continued Tolterodine ER 2 mg qam. . #. Hyponatremia: followed by medicine The patient has baseline hyponatremia which somewhat worsened during her hospitalization. During her stay, her serum sodium ranged from 134 to 125 on the day of discharge. Hyponatremia is suspected to be due to SIADH, and further investigation of her medication regimen upon discharge is warranted. The patient will be checking her electrolytes the [MASKED] following discharged which is to be followed up by the patient's primary nephrologist Dr. [MASKED] with whom the patient has a follow up appointment scheduled for [MASKED], one week after discharge. Despite this hyponatremia, the patient remained asymptomatic. . #. CKD Stage 3 During hospitalization the patient's Cr ranged from 1.4 to 1.8, with the spike of 1.8 likely secondary to dehydration which was addressed by providing the patient IV fluids. Upon discharge, the patient's creatinine returned to 1.4 which is her baseline. . #. HLD Per medicine's recommendations, restarted patient's Pravastatin 80 mg QPM. . Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ARIPiprazole 5 mg PO DAILY 2. BusPIRone 20 mg PO QAM 3. Doxazosin 2 mg PO DAILY 4. BusPIRone 10 mg PO NOON 5. BusPIRone 10 mg PO QHS 6. LamoTRIgine 150 mg PO BID 7. Levothyroxine Sodium 112 mcg PO DAILY 8. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea 9. Pantoprazole 40 mg PO Q24H 10. Pramipexole 0.125 mg PO QAM 11. Pramipexole 0.25 mg PO QHS 12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 13. Tolterodine 2 mg PO QAM 14. olmesartan 20 mg oral QAM 15. amLODIPine 10 mg PO DAILY 16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/shortness of breath 17. Aspirin 81 mg PO DAILY 18. FoLIC Acid 1 mg PO BID 19. Furosemide 20 mg PO DAILY 20. Metoclopramide 5 mg PO QIDACHS 21. Montelukast 10 mg PO DAILY 22. Ondansetron 4 mg PO Q6H:PRN nausea 23. Ondansetron ODT 4 mg PO Q8H:PRN nausea 24. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 25. Prochlorperazine 10 mg PO Q6H:PRN nausea 26. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 2,000 mcg oral BID 27. Vitamin D [MASKED] UNIT PO DAILY 28. Escitalopram Oxalate 5 mg PO DAILY Discharge Medications: 1. CloNIDine 0.1 mg PO QHS 2. Lisinopril 40 mg PO DAILY Hypertension 3. Pravastatin 80 mg PO QPM 4. Doxazosin 4 mg PO QAM 5. amLODIPine 10 mg PO DAILY 6. ARIPiprazole 5 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. BusPIRone 20 mg PO QAM 9. BusPIRone 10 mg PO NOON 10. BusPIRone 10 mg PO QHS 11. FoLIC Acid 1 mg PO BID 12. LamoTRIgine 150 mg PO BID 13. Levothyroxine Sodium 112 mcg PO DAILY 14. LORazepam 0.5 mg PO Q6H:PRN anxiety/nausea 15. Metoclopramide 5 mg PO QIDACHS 16. Montelukast 10 mg PO DAILY 17. Ondansetron 4 mg PO Q6H:PRN nausea 18. Pantoprazole 40 mg PO Q24H 19. Pramipexole 0.125 mg PO QAM 20. Pramipexole 0.25 mg PO QHS 21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 22. Prochlorperazine 10 mg PO Q6H:PRN nausea 23. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 24. Tolterodine 2 mg PO QAM 25. Vitamin B-12 (cyanocobalamin (vitamin B-12)) 2,000 mcg oral BID 26. Vitamin D [MASKED] UNIT PO DAILY 27. HELD- Escitalopram Oxalate 5 mg PO DAILY This medication was held. Do not restart Escitalopram Oxalate until you see Dr. [MASKED]. 28. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until you speak with Dr. [MASKED]. 29. HELD- olmesartan 20 mg oral QAM This medication was held. Do not restart olmesartan until you see Dr. [MASKED]. 30.Outpatient Lab Work Blood Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN; Creatinine to be collected on [MASKED]. Diagnosis: Hyponatremia ICD: E87.1 To be followed up by Dr. [MASKED], please fax the results to the following number. Phone: [MASKED] Fax: [MASKED] Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: - BPAD, type II, most recent episode depressed, without psychotic features - CAD [MASKED] MI - COPD - Chronic neck pain - HTN - HLD - MVP Discharge Condition: VS: 97.4 PO; 155/60; 50; 14; 98% RA Neurological: station and gait: Steady gait, slow pace, slight limp on left leg, no ataxia noted tone and strength: Moves all extremities symmetrically against gravity. Appearance: Elderly Caucasian woman appearing stated age, well groomed, good hygiene, pajamas and bath robe. Behavior: appropriate eye contact, no psychomotor retardation. Mood and Affect: 'Better'; appeared euthymic, full range of affect Thought process: linear, goal oriented, no LOA Thought Content: no active SI, violent ideation, or AVH Judgment and Insight: fair/fair Cognition: Attention, orientation, and executive function: AAOx3 Memory: grossly intact to recent and remote Fund of knowledge: average Speech: Normal rate, volume, and tone *Language: Native [MASKED] speaker, no paraphasic errors, appropriate to conversation Ambulatory status: Ambulates independently 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]	[]	[ "J449", "I129", "F419", "G8929", "E785", "E039", "K219", "G4700" ]	[ "F3181: Bipolar II disorder", "J449: Chronic obstructive pulmonary disease, unspecified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E860: Dehydration", "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)", "F419: Anxiety disorder, unspecified", "M542: Cervicalgia", "G8929: Other chronic pain", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R32: Unspecified urinary incontinence", "G2581: Restless legs syndrome", "R110: Nausea", "G4700: Insomnia, unspecified", "I160: Hypertensive urgency", "Z96653: Presence of artificial knee joint, bilateral", "Z85828: Personal history of other malignant neoplasm of skin", "Z823: Family history of stroke", "Z818: Family history of other mental and behavioral disorders" ]
19,984,052	25,784,208	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / bee venom (honey bee) / Cipro Attending: ___. Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male with history of CAD s/p CABG ___ with no acute complications post operative and was discharged to rehab on POD 4. He felt well for the first few days then was started having diarrhea multiple times a day decreasing strength and limited activity. Was still tolerating diet no nausea or vomiting but significant abdominal cramping. Stool sample sent from rehab (results pending per ___ lab ___ will be run tonight). Had periop antibiotics and also Bactrim for treatment of UTI. Left leg that is EVH leg has been increasing in size over the last ___ days per pt report discomfort with mild erythema on calf, and has been limited walking due to fatigue from diarrhea, ultrasound in ED revealed DVT starting on IV heparin. Dyspnea started this am with activity denies any shortness of breath at rest. Able to take deep breaths, oxygen saturation ___ on RA per transfer note in ED on 2 l NC with sat 92-96%. CXR revealed interstial edema no infiltrates. Respirations are easy and unlabored at rest and denies any wheezing Past Medical History: Coronary Artery Disease s/p CABG History of Myocardial Infarction Type II DM on Insulin Hyperlipidemia Hypertension Gastroesophageal Reflux Disease Obesity Benign Prostatic Hypertrophy s/p tonsillectomy s/p deviated septum repair s/p TURP with post op DVT left leg Social History: ___ Family History: Brother with CABG and valve replacement at age ___ Physical Exam: Physical Exam VS HR 100 BP 104/64 Resp: 22 O2 sat: 92% 2L NC General: Pleasant resting on stretcher in ED no acute distress Skin: Warm [x] Dry [x] Sternal incision healing no erythema or drainage sternum stable Left leg with mild ecchymosis, mild erythema at calf and +2 pitting edema Neck: Supple [x] Full ROM [x] No JVD Chest: Lungs clear bilaterally except decreased at bilateral bases Heart: RRR [x] no murmur or rub Abdomen: Soft [x] non-distended [x] +BS [x] no grimacing on palpations but verbalizes discomfort throughout Extremities: Warm [x] Right leg +1 Left Leg +2 edema ___ palpable Neuro: Alert and oriented x3 no focal deficits Pertinent Results: ___ 07:00AM BLOOD WBC-13.0* RBC-3.39* Hgb-10.7* Hct-32.8* MCV-97 MCH-31.6 MCHC-32.6 RDW-14.2 RDWSD-48.7* Plt ___ ___ 12:08PM BLOOD WBC-14.7# RBC-3.29 Hgb-10.6* Hct-31.9* MCV-97 MCH-32.2* MCHC-33.2 RDW-13.9 RDWSD-48.1* Plt ___ ___ 12:08PM BLOOD Neuts-87.0* Lymphs-5.7* Monos-5.7 Eos-0.1* Baso-0.4 NRBC-0.1* Im ___ AbsNeut-12.77* AbsLymp-0.83* AbsMono-0.83* AbsEos-0.01* AbsBaso-0.06 ___ 07:00AM BLOOD Plt ___ ___ 07:00AM BLOOD ___ PTT-42.6* ___ ___ 11:25PM BLOOD ___ PTT-35.6 ___ ___ 12:08PM BLOOD Plt ___ ___ 07:00AM BLOOD Glucose-201* UreaN-34* Creat-1.2 Na-136 K-4.7 Cl-99 HCO3-21* AnGap-21* ___ 12:08PM BLOOD Glucose-277* UreaN-37* Creat-1.5* Na-135 K-4.8 Cl-99 HCO3-22 AnGap-19 ___ 12:08PM BLOOD ALT-46* AST-29 LD(LDH)-374* AlkPhos-85 Amylase-51 TotBili-1.4 ___ 12:08PM BLOOD Lipase-39 ___ 07:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3 ___ 12:08PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.8 Mg-2.2 ___ 12:14PM BLOOD Lactate-2.0 Echocardiogram Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm LEFT VENTRICLE: Normal LV cavity size. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: Basal InferoseptalBasal AnteroseptalBasal Anterior Basal InferiorBasal InferolateralBasal Anterolateral Mid InferoseptalMid AnteroseptalMid Anterior Mid InferiorMid InferolateralMid Anterolateral Septal ApexAnterior Apex Inferior ApexLateral Apex Apex Conclusions The left ventricular cavity size is normal. There is regional systolic dysfunction with inferolateral hypokinesis. Not all of the remaining segments are well seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventriculary cavity size with regional systolic dysfunction. No pericardial effusion. CXR Again seen is mild postoperative widening of the cardiomediastinal silhouette, similar to prior. Median sternotomy wires are intact. Lung volumes are low, and there is a small left basilar pleural effusion with adjacent atelectasis. The presence of low lung volumes makes it difficult to exclude mild pulmonary edema. No pneumothorax. IMPRESSION: 1. Small left basilar pleural effusion with adjacent atelectasis. 2. Interstitial edema is mild if present. Abdominal Xray There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications. Median sternotomy wires visualized in the mid thorax. Metallic linear foci are seen overlying the left upper quadrant. Radiopaque focus seen within the descending colon. IMPRESSION: No evidence of obstruction or ileus. Ultrasound There is nonocclusive thrombus within the left common femoral vein. The proximal most extent was not evaluated. There is normal compressibility and flow of the right common femoral, bilateral femoral, and bilateral popliteal veins. Normal color flow and compressibility are demonstrated in the right tibial, 1 of the left tibial veins, and bilateral peroneal veins. Thrombus is seen within 1 of the left posterior tibial veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: 1. Non-occlusive deep venous thrombosis within left common femoral vein. Proximal most extent not evaluated. 2. Deep venous thrombosis within 1 of the left posterior tibial veins. 3. No right lower extremity deep venous thrombosis. Brief Hospital Course: Presented to emergency room from rehab with multiple days of diarrhea, left leg swelling and dyspnea on exertion. Started on treatment for Cdiff awaiting culture result from OSH. Noted for DVT on ultrasound and started on Heparin gtt in the emergency room with concern for potential PE but deferred on CT scan due to ___. Echocardiogram limited in emergency was no evidence of tamponade. He was placed on continuous oxygen sat monitoring and admitted to telemetry floor. His respirations remained easy at rest and he remained on nasal cannula. Early ___ he was walking to bathroom with RN oxygen sat 95% on 4 l NC. However acutely short of breath when sitting on toilet and became nonresponsive pulseless with sinus bradycardia on monitor. CPR initiated and code called see code sheet for resuscitation. He was unable to be revived and code was called at 1004 am. Family was notified. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. NPH 40 Units Breakfast NPH 20 Units Bedtime Insulin SC Sliding Scale using REG Insulin 4. Omeprazole 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Metoprolol Tartrate 75 mg PO TID 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. Docusate Sodium 100 mg PO BID 9. Furosemide 40 mg PO DAILY - completed 10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: not taking at rehab per pt 11. Potassium Chloride 20 mEq PO DAILY - completed 12. Sulfameth/Trimethoprim DS 1 TAB PO BID -completed 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezes 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY Kaopectate and lactobacillus only additional meds on sheets from rehab Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary Arrest Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: ___	[ "I82412", "N179", "I498", "Z951", "I469", "I82442", "I10", "I2510", "Z87891", "E118", "Z794", "E785", "K219", "E669", "Z6834", "N400", "I252", "R197", "R0602", "Z8249" ]	Allergies: Penicillins / bee venom (honey bee) / Cipro Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: none History of Present Illness: [MASKED] year old male with history of CAD s/p CABG [MASKED] with no acute complications post operative and was discharged to rehab on POD 4. He felt well for the first few days then was started having diarrhea multiple times a day decreasing strength and limited activity. Was still tolerating diet no nausea or vomiting but significant abdominal cramping. Stool sample sent from rehab (results pending per [MASKED] lab [MASKED] will be run tonight). Had periop antibiotics and also Bactrim for treatment of UTI. Left leg that is EVH leg has been increasing in size over the last [MASKED] days per pt report discomfort with mild erythema on calf, and has been limited walking due to fatigue from diarrhea, ultrasound in ED revealed DVT starting on IV heparin. Dyspnea started this am with activity denies any shortness of breath at rest. Able to take deep breaths, oxygen saturation [MASKED] on RA per transfer note in ED on 2 l NC with sat 92-96%. CXR revealed interstial edema no infiltrates. Respirations are easy and unlabored at rest and denies any wheezing Past Medical History: Coronary Artery Disease s/p CABG History of Myocardial Infarction Type II DM on Insulin Hyperlipidemia Hypertension Gastroesophageal Reflux Disease Obesity Benign Prostatic Hypertrophy s/p tonsillectomy s/p deviated septum repair s/p TURP with post op DVT left leg Social History: [MASKED] Family History: Brother with CABG and valve replacement at age [MASKED] Physical Exam: Physical Exam VS HR 100 BP 104/64 Resp: 22 O2 sat: 92% 2L NC General: Pleasant resting on stretcher in ED no acute distress Skin: Warm [x] Dry [x] Sternal incision healing no erythema or drainage sternum stable Left leg with mild ecchymosis, mild erythema at calf and +2 pitting edema Neck: Supple [x] Full ROM [x] No JVD Chest: Lungs clear bilaterally except decreased at bilateral bases Heart: RRR [x] no murmur or rub Abdomen: Soft [x] non-distended [x] +BS [x] no grimacing on palpations but verbalizes discomfort throughout Extremities: Warm [x] Right leg +1 Left Leg +2 edema [MASKED] palpable Neuro: Alert and oriented x3 no focal deficits Pertinent Results: [MASKED] 07:00AM BLOOD WBC-13.0* RBC-3.39* Hgb-10.7* Hct-32.8* MCV-97 MCH-31.6 MCHC-32.6 RDW-14.2 RDWSD-48.7* Plt [MASKED] [MASKED] 12:08PM BLOOD WBC-14.7# RBC-3.29 Hgb-10.6* Hct-31.9* MCV-97 MCH-32.2* MCHC-33.2 RDW-13.9 RDWSD-48.1* Plt [MASKED] [MASKED] 12:08PM BLOOD Neuts-87.0* Lymphs-5.7* Monos-5.7 Eos-0.1* Baso-0.4 NRBC-0.1* Im [MASKED] AbsNeut-12.77* AbsLymp-0.83* AbsMono-0.83* AbsEos-0.01* AbsBaso-0.06 [MASKED] 07:00AM BLOOD Plt [MASKED] [MASKED] 07:00AM BLOOD [MASKED] PTT-42.6* [MASKED] [MASKED] 11:25PM BLOOD [MASKED] PTT-35.6 [MASKED] [MASKED] 12:08PM BLOOD Plt [MASKED] [MASKED] 07:00AM BLOOD Glucose-201* UreaN-34* Creat-1.2 Na-136 K-4.7 Cl-99 HCO3-21* AnGap-21* [MASKED] 12:08PM BLOOD Glucose-277* UreaN-37* Creat-1.5* Na-135 K-4.8 Cl-99 HCO3-22 AnGap-19 [MASKED] 12:08PM BLOOD ALT-46* AST-29 LD(LDH)-374* AlkPhos-85 Amylase-51 TotBili-1.4 [MASKED] 12:08PM BLOOD Lipase-39 [MASKED] 07:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3 [MASKED] 12:08PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.8 Mg-2.2 [MASKED] 12:14PM BLOOD Lactate-2.0 Echocardiogram Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm LEFT VENTRICLE: Normal LV cavity size. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: Basal InferoseptalBasal AnteroseptalBasal Anterior Basal InferiorBasal InferolateralBasal Anterolateral Mid InferoseptalMid AnteroseptalMid Anterior Mid InferiorMid InferolateralMid Anterolateral Septal ApexAnterior Apex Inferior ApexLateral Apex Apex Conclusions The left ventricular cavity size is normal. There is regional systolic dysfunction with inferolateral hypokinesis. Not all of the remaining segments are well seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventriculary cavity size with regional systolic dysfunction. No pericardial effusion. CXR Again seen is mild postoperative widening of the cardiomediastinal silhouette, similar to prior. Median sternotomy wires are intact. Lung volumes are low, and there is a small left basilar pleural effusion with adjacent atelectasis. The presence of low lung volumes makes it difficult to exclude mild pulmonary edema. No pneumothorax. IMPRESSION: 1. Small left basilar pleural effusion with adjacent atelectasis. 2. Interstitial edema is mild if present. Abdominal Xray There are no abnormally dilated loops of large or small bowel. There is no free intraperitoneal air. Osseous structures are unremarkable. There are no unexplained soft tissue calcifications. Median sternotomy wires visualized in the mid thorax. Metallic linear foci are seen overlying the left upper quadrant. Radiopaque focus seen within the descending colon. IMPRESSION: No evidence of obstruction or ileus. Ultrasound There is nonocclusive thrombus within the left common femoral vein. The proximal most extent was not evaluated. There is normal compressibility and flow of the right common femoral, bilateral femoral, and bilateral popliteal veins. Normal color flow and compressibility are demonstrated in the right tibial, 1 of the left tibial veins, and bilateral peroneal veins. Thrombus is seen within 1 of the left posterior tibial veins. There is normal respiratory variation in the common femoral veins bilaterally. IMPRESSION: 1. Non-occlusive deep venous thrombosis within left common femoral vein. Proximal most extent not evaluated. 2. Deep venous thrombosis within 1 of the left posterior tibial veins. 3. No right lower extremity deep venous thrombosis. Brief Hospital Course: Presented to emergency room from rehab with multiple days of diarrhea, left leg swelling and dyspnea on exertion. Started on treatment for Cdiff awaiting culture result from OSH. Noted for DVT on ultrasound and started on Heparin gtt in the emergency room with concern for potential PE but deferred on CT scan due to [MASKED]. Echocardiogram limited in emergency was no evidence of tamponade. He was placed on continuous oxygen sat monitoring and admitted to telemetry floor. His respirations remained easy at rest and he remained on nasal cannula. Early [MASKED] he was walking to bathroom with RN oxygen sat 95% on 4 l NC. However acutely short of breath when sitting on toilet and became nonresponsive pulseless with sinus bradycardia on monitor. CPR initiated and code called see code sheet for resuscitation. He was unable to be revived and code was called at 1004 am. Family was notified. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. NPH 40 Units Breakfast NPH 20 Units Bedtime Insulin SC Sliding Scale using REG Insulin 4. Omeprazole 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Metoprolol Tartrate 75 mg PO TID 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. Docusate Sodium 100 mg PO BID 9. Furosemide 40 mg PO DAILY - completed 10. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: not taking at rehab per pt 11. Potassium Chloride 20 mEq PO DAILY - completed 12. Sulfameth/Trimethoprim DS 1 TAB PO BID -completed 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezes 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY Kaopectate and lactobacillus only additional meds on sheets from rehab Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary Arrest Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: [MASKED]	[]	[ "N179", "Z951", "I10", "I2510", "Z87891", "Z794", "E785", "K219", "E669", "N400", "I252" ]	[ "I82412: Acute embolism and thrombosis of left femoral vein", "N179: Acute kidney failure, unspecified", "I498: Other specified cardiac arrhythmias", "Z951: Presence of aortocoronary bypass graft", "I469: Cardiac arrest, cause unspecified", "I82442: Acute embolism and thrombosis of left tibial vein", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "E118: Type 2 diabetes mellitus with unspecified complications", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I252: Old myocardial infarction", "R197: Diarrhea, unspecified", "R0602: Shortness of breath", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]
19,984,052	28,687,121	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / bee venom (honey bee) / Cipro Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ Coronary Artery Bypass Grafting times six (LIMA to LAD, SVG to OM, SVG to PDA and PLV, SVG to Ramus and Diagonal) History of Present Illness: Mr. ___ is an ___ year old male with history of coronary artery disease who presented to ___ with chest and abdominal pain. He underwent cardiac catheterization which revealed severe three vessel coronary disease. He was stablized on medical therpay and transferred to ___ for surgical revascularization. Past Medical History: Coronary Artery Disease History of Myocardial Infarction Type II DM on Insulin Hyperlipidemia Hypertension Gastroesophageal Reflux Disease Obesity Benign Prostatic Hypertrophy s/p tonsillectomy s/p deviated septum repair s/p TURP Social History: ___ Family History: Brother with CABG and valve replacement at age ___ Physical Exam: PREOP EXAM VITALS: HR 53 BP 131/63 Resp:18 O2 sat: 97%RA Height: 6'2" Weight:255-260? General: A&Ox3, NAD,pleasant Skin: Warm [x] Dry [x] intact [x] HEENT: NCAT [] PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [] JVD[] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x] well-perfused [x] Edema [] Varicosities: None [x] Neuro: Grossly intact [x] non focal Pulses: Femoral Right: Left: DP Right: Left: ___ Right: Left: Radial Right: Left: Carotid Bruit : none . Pertinent Results: ___ ECHOCARDIOGRAPHY REPORT ___ ___ MRN: ___ TEE (Complete) Done ___ at 10:00:01 AM PRELIMINARY Referring Physician ___ ___ - Division of Cardiothora ___ Status: Inpatient DOB: ___ Age (years): ___ M Hgt (in): 70 BP (mm Hg): 123/67 Wgt (lb): 258 HR (bpm): 67 BSA (m2): 2.33 m2 Indication: Chest pain. Diagnosis: R06.02, R07.2 ___ Information Date/Time: ___ at 10:00 ___ MD: ___, MD ___ Type: TEE (Complete) Sonographer: ___, MD Doppler: Full Doppler and color Doppler ___ Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: ___-0:00 Machine: epiq Echocardiographic Measurements Results Measurements Normal Range Findings LEFT ATRIUM: Normal LA and RA cavity sizes. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. Minimal AS. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___ VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the ___. The ___ was under general anesthesia throughout the procedure. Conclusions Pre-bypass: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened There is a minimally increased gradient consistent with minimal aortic valve stenosis and an ___ of 1.9cm2. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Post-bypass: On phenylehrine gtt LVEF >55%, RV structure and function normal. No new valvular pathologies or RMWAs noted. Aorta intact post decannulation. . ___ 06:40AM BLOOD WBC-6.9 RBC-2.91* Hgb-9.4* Hct-27.6* MCV-95 MCH-32.3* MCHC-34.1 RDW-13.6 RDWSD-46.5* Plt Ct-95* ___ 02:20AM BLOOD WBC-8.7# RBC-2.86* Hgb-9.2* Hct-27.1* MCV-95 MCH-32.2* MCHC-33.9 RDW-13.3 RDWSD-46.0 Plt Ct-77* ___ 06:40AM BLOOD ___ ___ 06:40AM BLOOD Glucose-176* UreaN-32* Creat-1.2 Na-137 K-4.5 Cl-101 HCO3-26 AnGap-15 ___ 02:20AM BLOOD Glucose-102* UreaN-15 Creat-1.0 Na-139 K-4.2 Cl-110* HCO3-22 AnGap-11 ___ 09:50PM BLOOD ALT-25 AST-26 LD(LDH)-164 AlkPhos-84 Amylase-49 TotBili-1.5 ___ 02:33AM BLOOD ___ pH-7.45 Comment-GREEN TOP Brief Hospital Course: Mr. ___ was admitted under the cardiac surgical service and underwent routine preoperative evaluation. Workup was unremarkable and he was cleared for surgery. On ___, Dr. ___ coronary artery bypass grafting. For surgical details, please see operative note. Given inpatient stay prior to surgery was greater than 24 hours, Vancomycin was given for perioperative antiobiotic coverage. Following surgery, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. By the following day he was ready for transfer to the surgical step down unit. Home NPH dosing was resumed for blood glucose management. His chest tubes and wires were removed per protocol. He was seen in consultation by the physical therapy service who determined that the ___ would benefit from a shrot term stay at rehab. By post-operative day 4 he was ready for discharge to ___. Medications on Admission: ASA 81mg daily Atenolol 25mg daily Atorvastatin 10mg daily NPH,Humulin 20 units Q HS NPH,Humulin 30 units Q QM Flomax 0.4 QHS Fluocinonide 0.05% 1 appl Top BID Omeprazole 20mg daily Avapro 150mg daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. NPH 40 Units Breakfast NPH 20 Units Bedtime Insulin SC Sliding Scale using REG Insulin 4. Omeprazole 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Metoprolol Tartrate 75 mg PO TID 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. Docusate Sodium 100 mg PO BID 9. Furosemide 40 mg PO DAILY Duration: 7 Days 10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain: moderate/severe RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:0 11. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days 12. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezes 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Coronary Artery Disease, s/p CABG Type II DM on Insulin Hyperlipidemia Hypertension Obesity Discharge Condition: Alert and oriented x3 non-focal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg -Left - healing well, no erythema or drainage Trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours* Followup Instructions: ___	[ "I2510", "D696", "E119", "E669", "Z794", "I10", "R000", "E785", "K219", "Z6833", "N400", "I252", "Z87891" ]	Allergies: Penicillins / bee venom (honey bee) / Cipro Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [MASKED] Coronary Artery Bypass Grafting times six (LIMA to LAD, SVG to OM, SVG to PDA and PLV, SVG to Ramus and Diagonal) History of Present Illness: Mr. [MASKED] is an [MASKED] year old male with history of coronary artery disease who presented to [MASKED] with chest and abdominal pain. He underwent cardiac catheterization which revealed severe three vessel coronary disease. He was stablized on medical therpay and transferred to [MASKED] for surgical revascularization. Past Medical History: Coronary Artery Disease History of Myocardial Infarction Type II DM on Insulin Hyperlipidemia Hypertension Gastroesophageal Reflux Disease Obesity Benign Prostatic Hypertrophy s/p tonsillectomy s/p deviated septum repair s/p TURP Social History: [MASKED] Family History: Brother with CABG and valve replacement at age [MASKED] Physical Exam: PREOP EXAM VITALS: HR 53 BP 131/63 Resp:18 O2 sat: 97%RA Height: 6'2" Weight:255-260? General: A&Ox3, NAD,pleasant Skin: Warm [x] Dry [x] intact [x] HEENT: NCAT [] PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [] JVD[] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x] well-perfused [x] Edema [] Varicosities: None [x] Neuro: Grossly intact [x] non focal Pulses: Femoral Right: Left: DP Right: Left: [MASKED] Right: Left: Radial Right: Left: Carotid Bruit : none . Pertinent Results: [MASKED] ECHOCARDIOGRAPHY REPORT [MASKED] [MASKED] MRN: [MASKED] TEE (Complete) Done [MASKED] at 10:00:01 AM PRELIMINARY Referring Physician [MASKED] [MASKED] - Division of Cardiothora [MASKED] Status: Inpatient DOB: [MASKED] Age (years): [MASKED] M Hgt (in): 70 BP (mm Hg): 123/67 Wgt (lb): 258 HR (bpm): 67 BSA (m2): 2.33 m2 Indication: Chest pain. Diagnosis: R06.02, R07.2 [MASKED] Information Date/Time: [MASKED] at 10:00 [MASKED] MD: [MASKED], MD [MASKED] Type: TEE (Complete) Sonographer: [MASKED], MD Doppler: Full Doppler and color Doppler [MASKED] Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: [MASKED]-0:00 Machine: epiq Echocardiographic Measurements Results Measurements Normal Range Findings LEFT ATRIUM: Normal LA and RA cavity sizes. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. Minimal AS. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [MASKED] VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the [MASKED]. The [MASKED] was under general anesthesia throughout the procedure. Conclusions Pre-bypass: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened There is a minimally increased gradient consistent with minimal aortic valve stenosis and an [MASKED] of 1.9cm2. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. Post-bypass: On phenylehrine gtt LVEF >55%, RV structure and function normal. No new valvular pathologies or RMWAs noted. Aorta intact post decannulation. . [MASKED] 06:40AM BLOOD WBC-6.9 RBC-2.91* Hgb-9.4* Hct-27.6* MCV-95 MCH-32.3* MCHC-34.1 RDW-13.6 RDWSD-46.5* Plt Ct-95* [MASKED] 02:20AM BLOOD WBC-8.7# RBC-2.86* Hgb-9.2* Hct-27.1* MCV-95 MCH-32.2* MCHC-33.9 RDW-13.3 RDWSD-46.0 Plt Ct-77* [MASKED] 06:40AM BLOOD [MASKED] [MASKED] 06:40AM BLOOD Glucose-176* UreaN-32* Creat-1.2 Na-137 K-4.5 Cl-101 HCO3-26 AnGap-15 [MASKED] 02:20AM BLOOD Glucose-102* UreaN-15 Creat-1.0 Na-139 K-4.2 Cl-110* HCO3-22 AnGap-11 [MASKED] 09:50PM BLOOD ALT-25 AST-26 LD(LDH)-164 AlkPhos-84 Amylase-49 TotBili-1.5 [MASKED] 02:33AM BLOOD [MASKED] pH-7.45 Comment-GREEN TOP Brief Hospital Course: Mr. [MASKED] was admitted under the cardiac surgical service and underwent routine preoperative evaluation. Workup was unremarkable and he was cleared for surgery. On [MASKED], Dr. [MASKED] coronary artery bypass grafting. For surgical details, please see operative note. Given inpatient stay prior to surgery was greater than 24 hours, Vancomycin was given for perioperative antiobiotic coverage. Following surgery, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. By the following day he was ready for transfer to the surgical step down unit. Home NPH dosing was resumed for blood glucose management. His chest tubes and wires were removed per protocol. He was seen in consultation by the physical therapy service who determined that the [MASKED] would benefit from a shrot term stay at rehab. By post-operative day 4 he was ready for discharge to [MASKED]. Medications on Admission: ASA 81mg daily Atenolol 25mg daily Atorvastatin 10mg daily NPH,Humulin 20 units Q HS NPH,Humulin 30 units Q QM Flomax 0.4 QHS Fluocinonide 0.05% 1 appl Top BID Omeprazole 20mg daily Avapro 150mg daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. NPH 40 Units Breakfast NPH 20 Units Bedtime Insulin SC Sliding Scale using REG Insulin 4. Omeprazole 20 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Metoprolol Tartrate 75 mg PO TID 7. Acetaminophen 650 mg PO Q6H:PRN pain 8. Docusate Sodium 100 mg PO BID 9. Furosemide 40 mg PO DAILY Duration: 7 Days 10. OxycoDONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain: moderate/severe RX oxycodone 5 mg [MASKED] tablet(s) by mouth every four (4) hours Disp #50 Tablet Refills:0 11. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days 12. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezes 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Coronary Artery Disease, s/p CABG Type II DM on Insulin Hyperlipidemia Hypertension Obesity Discharge Condition: Alert and oriented x3 non-focal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg -Left - healing well, no erythema or drainage Trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [MASKED] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge 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", "D696", "E119", "E669", "Z794", "I10", "E785", "K219", "N400", "I252", "Z87891" ]	[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "D696: Thrombocytopenia, unspecified", "E119: Type 2 diabetes mellitus without complications", "E669: Obesity, unspecified", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "R000: Tachycardia, unspecified", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I252: Old myocardial infarction", "Z87891: Personal history of nicotine dependence" ]
19,984,119	29,504,429	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Table saw injury left hand Major Surgical or Invasive Procedure: ___ 1. Revision amputation of left index finger. 2. Replantation of left ring finger. 3. Left middle finger radial digital nerve, ulnar digital nerve repair using operating microscope. 4. Ulnar digital artery primary repair under operating microscope. 5. FDS tenodesis to index finger of proximal phalanx. 6. Complex closure of left thumb and small finger wounds (5 cm). History of Present Illness: HPI: ___ male RHD presents with left hand injury from table saw. The patiet was at home using a table saw at 1600 today when he suffered a traumatic injury to his left hand. He initially presented to OSH where he was given ancef and transferred to ___ for further management. Past Medical History: PMH: Depression Low back pain HLD PSHx: none Social History: ___ Family History: NC Physical Exam: Detailed examination of the L hand: Middle finger- warm, pink, 2 sec cap refill, strong ulnar Doppler signal Ring finger- warm, pink, 2 second capillary refill, strong radial arterial Doppler signal, strong ulnar venous signal, weak ulnar arterial signal. Small finger- warm, pink, 2 second capillary refill, strong radial Doppler signal Pertinent Results: ___ 02:03PM WBC-11.9# RBC-3.47# HGB-10.9# HCT-32.2# MCV-93 MCH-31.4 MCHC-33.9 RDW-12.8 RDWSD-43.2 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have left hand table saw injury and was admitted to the hand surgery service. The patient was taken to the operating room on ___ for left hand table saw injuries, 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#2. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. 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 upper extremity. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: MEDS: tramadol 50mg 4x/day Venlafaxine 375mg QD Pravastatin 20mg QD Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 162 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 5. Senna 8.6 mg PO BID:PRN constipation 6. Pravastatin 20 mg PO QPM 7. Venlafaxine XR 37.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Table saw injury left hand Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Follow-up Instructions: ___	[ "S68611A", "F329", "S65593A", "S68615A", "E785", "S64495A", "S64493A", "S61002A", "S61207A", "W270XXA", "Y92009", "F17210" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Table saw injury left hand Major Surgical or Invasive Procedure: [MASKED] 1. Revision amputation of left index finger. 2. Replantation of left ring finger. 3. Left middle finger radial digital nerve, ulnar digital nerve repair using operating microscope. 4. Ulnar digital artery primary repair under operating microscope. 5. FDS tenodesis to index finger of proximal phalanx. 6. Complex closure of left thumb and small finger wounds (5 cm). History of Present Illness: HPI: [MASKED] male RHD presents with left hand injury from table saw. The patiet was at home using a table saw at 1600 today when he suffered a traumatic injury to his left hand. He initially presented to OSH where he was given ancef and transferred to [MASKED] for further management. Past Medical History: PMH: Depression Low back pain HLD PSHx: none Social History: [MASKED] Family History: NC Physical Exam: Detailed examination of the L hand: Middle finger- warm, pink, 2 sec cap refill, strong ulnar Doppler signal Ring finger- warm, pink, 2 second capillary refill, strong radial arterial Doppler signal, strong ulnar venous signal, weak ulnar arterial signal. Small finger- warm, pink, 2 second capillary refill, strong radial Doppler signal Pertinent Results: [MASKED] 02:03PM WBC-11.9# RBC-3.47# HGB-10.9# HCT-32.2# MCV-93 MCH-31.4 MCHC-33.9 RDW-12.8 RDWSD-43.2 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have left hand table saw injury and was admitted to the hand surgery service. The patient was taken to the operating room on [MASKED] for left hand table saw injuries, 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#2. The patient was given [MASKED] antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. 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 upper extremity. The patient will follow up with Dr. [MASKED] routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: MEDS: tramadol 50mg 4x/day Venlafaxine 375mg QD Pravastatin 20mg QD Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 162 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) [MASKED] mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 5. Senna 8.6 mg PO BID:PRN constipation 6. Pravastatin 20 mg PO QPM 7. Venlafaxine XR 37.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Table saw injury left hand Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Follow-up Instructions: [MASKED]	[]	[ "F329", "E785", "F17210" ]	[ "S68611A: Complete traumatic transphalangeal amputation of left index finger, initial encounter", "F329: Major depressive disorder, single episode, unspecified", "S65593A: Other specified injury of blood vessel of left middle finger, initial encounter", "S68615A: Complete traumatic transphalangeal amputation of left ring finger, initial encounter", "E785: Hyperlipidemia, unspecified", "S64495A: Injury of digital nerve of left ring finger, initial encounter", "S64493A: Injury of digital nerve of left middle finger, initial encounter", "S61002A: Unspecified open wound of left thumb without damage to nail, initial encounter", "S61207A: Unspecified open wound of left little finger without damage to nail, initial encounter", "W270XXA: Contact with workbench tool, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]
19,984,260	29,117,959	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: codeine / corn / flour / nuts / pepper / shrimp / soy / wheat Attending: ___ Chief Complaint: Global weakness Dysphagia Major Surgical or Invasive Procedure: EMG - results pending Vit B1, Vit E, paraneoplastic panel, ACH receptor ab -- results pending History of Present Illness: Ms. ___ is a ___ woman w/ a PMH notable for polio, developmental delay, epilepsy, HLD, SVT w/ AVNRT s/p ablation, and possible Celiac disease who presents with new dysphagia and apnea with worsening dysarthria over the past week i/s/o progressive global weakness over the past year. History is primarily gathered from the patientÃ¢â¬â¢s sister ___, as the patient is unable to relate history fluently due to cognitive impairment and dysarthria. ___ does not know the age at which ___ was infected with polio, but is certain that she was younger than ___. ___ is unaware of any historical details related to ___ poliomyelitis or recovery. At her baseline, ___ was reportedly independent with activities of daily living. She ambulated with a walker, but was able to feed herself, bathe herself, use the toilet independently, and help to care for her aging mother with dementia (the two of them had lived together in a retirement facility; her sister states that ___ Ã¢â¬Åwas happy, and she had a lifeÃ¢â¬Â). Following a hospital admission for anaphylactic shock in late ___ that was complicated by an episode of bradycardia requiring pressors, ___ began to grow progressively weaker in all four extremities, and has not walked independently since late last ___. ___ had apparently experienced notable improvements with several weeks of intensive ___ at a rehabilitation facility in early ___, but has been unable to ambulate with assistance after her ___ was reduced to 1hr/week. She now moves only with assistance and a wheelchair. ___ was last able to feed herself approximately one month ago, and now cannot lift her left arm above shoulder height against gravity. She has reportedly been increasingly lethargic over the past month, with new loud snoring associated with gasping and choking when she falls asleep over the past week per her sister's report. She states that her legs feel heavy and that they ache; she cries when describing these symptoms, and her sister explains that ___ is frustrated that she can no longer walk. Also over the past week, she has had difficulty swallowing, experiencing coughing fits after swallowing liquids and solids. Her sister states that ___ has been speaking less over the past week, and that she is Ã¢â¬Ålosing her voice," and that her voice becomes especially weak near the end of longer conversations. Her sister states that she Ã¢â¬Åfeels like ___ is slipping away over the past several months, and faster over the past week.Ã¢â¬Â In the setting of increasing concern about ___ dysphagia, she had called ___ and accompanied ___ by ambulance to the ___ ED; transfer was then initiated to a ___ hospital, and ___ (where ___ had recently begun outpatient neurology work-up) were not accepting new patients. She was sent to ___ by ambulance. ___ expresses great frustration with difficulties in coordinating RamonaÃ¢â¬â¢s care, and states that she cannot accept that this is simply RamonaÃ¢â¬â¢s new baseline when there has been no thorough diagnostic work-up. When questioned specifically about it, she also states that ___ may have been diagnosed with Celiac disease in the past, but that she cannot recall definitively. ___ states that she wonders whether ___ may have post-polio syndrome. On review of records from RamonaÃ¢â¬â¢s last hospital stay at ___ in ___: MRI brain in ___ was notable for mild small vessel ischemic changes and mild diffuse cerebral atrophy. In a consult note from that admission, ___ neurologists stated their hypothesis that ___ decline may have been attributable to hypoxic brain injury sustained during her ___ hospital admission for anaphylaxis. Their note also alluded to a diagnosis of cerebral palsy, which ___ emphatically insists that ___ was never diagnosed with. ___ also states that a repeat MRI brain was performed through ___ in ___ and was reportedly unremarkable, showing no evidence of acute stroke. On neurological ___ denies HA, blurred vision, diplopia, vertigo, and tinnitus. She endorses weakness, dysarthria, dysphagia, chronic hearing difficulty, and chronic incontinence of urine. On general ___¢s sister denies that the patient has experienced recent fever or chills, recent weight loss or gain, cough, chest pain, nausea, vomiting, and recent diarrhea x1 wk. She states that ___ has chronic constipation, osteoarthritis of the knees bilaterally, and Ã¢â¬Åfrozen shoulderÃ¢â¬Â on the right. ___ was also diagnosed with a UTI one week ago and completed a 5d course of Bactrim on ___. At approximately the same time that she began taking the Bactrim, she developed an erythematous papular rash over her face. ___ sister ___ lives 90 minutes away in ___ and may not be able to visit until mid-week; she requests that the team update her via phone at ___. Additionally, she has copies of ___ records from ___ and ___ on a USB, which were briefly reviewed by the admitting resident and medical student. She is willing to bring these documents back when she visits so that they can be reviewed in greater detail and scanned into OMR. Past Medical History: -Childhood epilepsy -Polio (age at infection unknown, but reportedly ___ years old)mostly affected right foot. -Developmental delay -Celiac disease -Osteoporosis -Multiple compression fractures of thoracic and lumbar spine -SVT w/ AVNRT s/p ablation (___) -Thyroid nodule -Frozen left shoulder and chronic left clavicular fracture -Osteoarthritis of hips and knees -Pressure ulcer -Right knee replacement -Right hip replacement Social History: ___ Family History: -Mother: ___, DM, dementia, hip fracture -Father: HTN -Older sister: ParkinsonÃ¢â¬â¢s disease (dxÃ¢â¬â¢d in ___ -Younger sister: lymphoma (dxÃ¢â¬â¢d at ___) -Another sister: hypothyroidism -Brother: hyperthyroidism Physical ___: Admission Physical Exam: VS: T: 96.0F, BP 115/53, P 68, RR 18, SaO2 100% RA General: intermittently awake and alert, falling asleep without occasional stimulation, but arousable by voice; appears lethargic and in no acute distress HEENT: NC/AT, no scleral icterus or injection noted, mucosal membranes dry, poor dentition Neck: supple Pulmonary: diffuse expiratory wheezes Cardiac: RRR, no M/R/G, nl S1/S2 Abdomen: soft, NT/ND Extremities: WWP, 1+ pitting edema to knees bilaterally, longitudinal scar overlying R knee Skin: erythematous papular rash over face, with few small pustules Neurologic: Mental Status: Alert and oriented to self and to Ã¢â¬Åhospital,Ã¢â¬Â but not to time (could not state year or month without prompting). Unable to relate history, but can answer some yes/no questions. Inattentive, able to repeat 4 digits in sequence forwards but 0 digits backwards. Patient named a pen as Ã¢â¬Åa pencilÃ¢â¬Â, a computer as Ã¢â¬Åa machineÃ¢â¬Â, and could not name ___ stethoscope. Speech was dysarthric and sparse, with low volume. Able to attempt to follow midline and appendicular commands (touching her nose with her index finger), but limited by bilateral upper extremity weakness. Registered ___ objects and recalled ___ with prompts. Recalled own birthday, motherÃ¢â¬â¢s birthday; did not recall current President but smiled broadly when sister stated that Ã¢â¬Åshe doesnÃ¢â¬â¢t want to recall him.Ã¢â¬Â Inconsistent evidence of left-sided neglect on sensory exam, but unclear whether this was due to difficulty comprehending examinerÃ¢â¬â¢s questions. Of note, while her sister states that ___ is fluent in ___ and ___ began speaking to her sister in ___ shortly before admission to describe her fears of being left alone and desire for her IV to be removed; when addressed in ___, she was able to speak in longer sentences of up to 10 words in response to questions. Cranial Nerves: II, III, IV, VI: PERRL 3 to 2 mm and brisk. EOMI without nystagmus. Mild ptosis bilaterally V: facial sensation intact to light touch bilaterally VII: mild right-sided facial droop VIII: hearing intact to finger-rub bilaterally IX, X: unable to assess, as patient would not say "aaah" loudly enough to elevate palate XI: 4+/5 strength in trapezii and SCM bilaterally XII: tongue protrudes in midline Motor: Normal bulk, tone throughout. Bradykinesia throughout exam. No spasticity or rigidity. Unable to assess pronator drift due to UE weakness. No adventitious movements, such as tremor, noted. No asterixis noted. [___] L 2 3 4 3 4 1 3 3 4 5 4 R 2 3 5 4+ 4+ 1 3 3 4 5 4 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 1 1 1 0 0 R 1 1 1 0 0 Plantar response was extensor on left, equivocal on right Sensory: proprioception intact at great toes bilaterally, no deficits to light touch throughout, though exam was inconsistent when patient was asked which leg was being touched, responding Ã¢â¬ÅrightÃ¢â¬Â when both were being touched. Coordination: No intention tremor. Dysdiadochokinesia could be not assessed due to weakness. No obvious dysmetria on FNF, though exam was limited due to weakness and bradykinesia. Gait: Not assessed due to lower extremity weakness. Romberg not assessed. _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ DISCHARGE PHYSICAL EXAM Vitals: Temp: afebrile BP: 121-144/67-81 HR: ___ RR: ___ O2 sat: 93-97% on room air. General: awake, alert, labile mood, no acute distress HEENT: NC/AT, no scleral icterus or injection noted, mucosal membranes dry, poor dentition Neck: supple Pulmonary: diffuse expiratory wheezes Cardiac: RRR, no M/R/G, nl S1/S2 Abdomen: soft, NT/ND Extremities: WWP, 1+ pitting edema to knees bilaterally, longitudinal scar overlying R knee Skin: erythematous papular rash over face, with few small pustules Neurologic: Mental Status: Alert and oriented to self and place but not time. Inattentive, some difficulty with luria. Speaking in sentences, dysarthria noted. Able to follow axial commands, some difficulty with appendicular commands due to weakness but patient understood the task. Cranial Nerves: II, III, IV, VI: PERRL 4 to 3 mm and brisk. EOMI without nystagmus. Conjugate gaze. Mild ptosis bilaterally V: facial sensation intact to light touch bilaterally VII: right-sided facial droop less prominent with activation VIII: hearing intact to finger-rub bilaterally IX, X: symmetric palate elevation XI: 4+/5 strength in trapezii and SCM bilaterally XII: tongue protrudes in midline Motor: Normal bulk, tone throughout. Bradykinesia throughout exam. No spasticity or rigidity. Unable to assess pronator drift due to UE weakness. No adventitious movements, such as tremor, noted. No asterixis noted. [___] L 2 2 3 3 3 2 2 3 3 5 4 R 2 3 5 4+ 4+ 2 2 3 5 4 - Reflexes: [Bic] [Tri] [___] [Achilles] L 1 1 1 1 R 1 1 1 1 Plantar response was extensor b/l Sensory: proprioception intact at great toes bilaterally, no deficits to light touch throughout, though exam was inconsistent when patient was asked which leg was being touched, responding "right" when both were being touched. Coordination: No intention tremor. Dysdiadochokinesia could be not assessed due to weakness. No obvious dysmetria on FNF, though exam was limited due to weakness and bradykinesia. Gait: deferred. Pertinent Results: LAB DATA: ___ cbc:6.9/13.2/39.1/171 ___: Last PhT and PHB level 12.3 and 36.3 TSH/T4 2.5/5.7 Vit B12 409 and folate >20 troponin <0.01 ldl 57 ___ neg Sjogren's ab: neg alk phos 127 UA: pos for barbituates (on PHB) Lyme neg MMA: neg PEP (no abnormalities seen)IgG 1595 IgA 1053 IgM 89 IFE (no monoclonal immunoglobulin seen) Cu: 109 ESR: 19 , CRP: 2.8 RPR NR Vit B6: 4.6 Bcx/Ucx: prelim neg Pend: Vit B1, Vit E, paraneoplastic panel, ACH receptor ab MRI spine: 1. There are 7 cervical vertebrae with fusion of C6 and C7 anterior and posterior elements, 12 rib-bearing vertebrae, L1 with transitional anatomy, L2 through L5 with conventional anatomy, and a nearly completely lumbarized S1. 2. Normal appearance of the spinal cord. No pathologic contrast enhancement. 3. Mild chronic compression of T7 and T12 vertebral bodies. 4. Multilevel cervical, thoracic, and lumbar degenerative disease, as detailed above. No mass effect on the spinal cord or intrathecal nerve roots. Xray left shoulder shows chronic clavicular fracture EEG reveals generalized polyspikes but no seizures or asymmetry Brief Hospital Course: Ms. ___ is a ___ woman with PMH notable for polio, developmental delay, epilepsy, HLD, SVT w/ AVNRT s/p ablation, and possible Celiac disease who presents with new dysphagia and apnea with worsening dysarthria in the setting of progressive global weakness over the past year likely in setting of failure to thrive and loss of function due to perhaps hypoxic brain damage on top of underlying developmental delay, and depression. Neurological exam is notable for global weakness without a clear pattern, dysarthria, inattentiveness, mild ptosis bilaterally and mild right-sided facial droop, absent reflexes in lower extremities with positive Babinksi sign B/L with lack of spasticity and rigidity. Other DDX includes peripheral neuropathy (in setting of osteoporosis and reported celiac disease), myasthenia ___ myasthenic syndrome (no fatigability) or Post Polio syndrome. Hospital course by system: # Neuro: - Completed EMG on ___, results pending - EEG showed generalized polyspikes however no seizures - MRI spine performed which showed degenerative joint disease however no cord compression - Underwent extensive workup including AED levels, TSH, T4, Vit B12, Folate, Ua, Utox, CE, Cu, RPR, ESR, CRP, Bcx, Ucx, vitamin B1, vitamin B6, vitamin E, methylmalonic acid, RPR, ACH receptor AB Sjogren's antibodies, copper, Lyme, ___, paraneoplastic autoantibody panel - ___ consulted who recommend rehab however insurance denied approval. Will discharge home with outpatient services. - Speech consulted: Patient to have modified diet of puree solids with nectar thick liquids. 1:1 supervision with cues to swallow ___ times per bite/sip and alternate bites/sips. Consider alternative means of nutrition and hydration. - continued home PHT 100mg/200mg and PHB doses 64.8mg bid - continued home ASA dose 81mg qd - received Tramadol prn for pain # CV: -Monitored on telemetry, no Afib #Pulm: - occasional hypoxia while sleeping, consider outpt sleep study #Pysch - Started on Escitalopran 10mg qd, plan increase to 20mg in 1wk (___) # FEN: - initially received IVF at maintenance however discontinued prior to discharge - PPX: SQH, pneumoboots, senna/colace, +ppi - Precautions: fall - Code Status: Full - Health Care Proxy: ___, sister (cell: ___, office: ___ Transition of care: - please review prior records and trend AED levels carefully. Sometimes PHB and PHT toxicity can lead to gait issues. Consider transitioning to other AED slowly - consider sleepy study as outpatient for evaluation for OSA - hyperintensities noted in subcutaneous fat of MRI spine, per neuroradiology this is a normal finding - patient's HCP is arranging outpatient counseling for ___ - patient started on Escitalopram, increase to 20mg qd on ___ - pending labs Vit B1, Vit E, paraneoplastic panel, ACH receptor ab - EMG results pending - ___ recommended rehab, however insurance denied approval. HCP would like to take patient home and try for outpatient services. - Consider testing for HIV and order HIV ___ antibodies - Consider LP if above work-up unrevealing Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PHENObarbital 64.8 mg PO BID 2. Phenytoin Sodium Extended 100 mg PO QAM 3. Tolterodine 1 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. Alendronate Sodium 70 mg PO QMON 6. fluticasone 0.05 % topical BID 7. Ketoconazole 2% 1 Appl TP BID 8. Multivitamins 1 TAB PO DAILY 9. Vitamin D ___ UNIT PO DAILY 10. TraMADol 50 mg PO DAILY:PRN Pain - Moderate 11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 12. DiphenhydrAMINE 25 mg PO Q6H:PRN itching 13. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis 14. Phenytoin Sodium Extended 200 mg PO QPM 15. Calcium Carbonate 500 mg PO QID:PRN , 16. Milk of Magnesia 30 mL PO Q6H:PRN . Discharge Medications: 1. Escitalopram Oxalate 10 mg PO DAILY RX escitalopram oxalate 10 mg 1 tablet(s) by mouth daily Disp #60 Tablet Refills:*11 2. Alendronate Sodium 70 mg PO QMON 3. Calcium Carbonate 500 mg PO QID:PRN , 4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching 5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis 6. fluticasone 0.05 % topical BID 7. Ketoconazole 2% 1 Appl TP BID 8. Milk of Magnesia 30 mL PO Q6H:PRN . 9. Multivitamins 1 TAB PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Omeprazole 20 mg PO DAILY 12. PHENObarbital 64.8 mg PO BID 13. Phenytoin Sodium Extended 200 mg PO QPM 14. Phenytoin Sodium Extended 100 mg PO QAM 15. Tolterodine 1 mg PO BID 16. TraMADol 50 mg PO DAILY:PRN Pain - Moderate 17. Vitamin D ___ UNIT PO DAILY 18.Outpatient Occupational Therapy icd 9: 348.30 19.Outpatient Physical Therapy 348.30 20.Outpatient Speech/Swallowing Therapy 348.30 Discharge Disposition: Home Discharge Diagnosis: global weakness dysphagia epilepsy history of polio Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Activity Status: Bedbound. Discharge Instructions: Ms. ___ you were admitted to ___ hospital for workup of your weakness and trouble swallowing. Your EEG showed generalized polyspikes consistent with epilepsy however no current seizures. Your MRI spine showed signs of degenerative joint changes but no cord compression. You had an EMG which was done the results of which are pending at discharge. You failed your swallow study which means that when you eat the food is going to your lungs. You understood the risks of this and chose to continue to take food by mouth. We added Escitalopram to your medication regimen to help stabilize your mood. No other changes were made to your home medications. We will arrange follow up for you in our Neurology clinic (___). They will contact you with appointment details. You should also follow up with your PCP ___ 2weeks of discharge. Followup Instructions: ___	[ "M6281", "G931", "R0681", "R1310", "G40909", "R471", "R29810", "E785", "K219", "R0902", "F329", "M810", "R627", "M479", "R32", "E876", "Z96651", "Z96641", "Z8612" ]	Allergies: codeine / corn / flour / nuts / pepper / shrimp / soy / wheat Chief Complaint: Global weakness Dysphagia Major Surgical or Invasive Procedure: EMG - results pending Vit B1, Vit E, paraneoplastic panel, ACH receptor ab -- results pending History of Present Illness: Ms. [MASKED] is a [MASKED] woman w/ a PMH notable for polio, developmental delay, epilepsy, HLD, SVT w/ AVNRT s/p ablation, and possible Celiac disease who presents with new dysphagia and apnea with worsening dysarthria over the past week i/s/o progressive global weakness over the past year. History is primarily gathered from the patientÃ¢â¬â¢s sister [MASKED], as the patient is unable to relate history fluently due to cognitive impairment and dysarthria. [MASKED] does not know the age at which [MASKED] was infected with polio, but is certain that she was younger than [MASKED]. [MASKED] is unaware of any historical details related to [MASKED] poliomyelitis or recovery. At her baseline, [MASKED] was reportedly independent with activities of daily living. She ambulated with a walker, but was able to feed herself, bathe herself, use the toilet independently, and help to care for her aging mother with dementia (the two of them had lived together in a retirement facility; her sister states that [MASKED] Ã¢â¬Åwas happy, and she had a lifeÃ¢â¬Â). Following a hospital admission for anaphylactic shock in late [MASKED] that was complicated by an episode of bradycardia requiring pressors, [MASKED] began to grow progressively weaker in all four extremities, and has not walked independently since late last [MASKED]. [MASKED] had apparently experienced notable improvements with several weeks of intensive [MASKED] at a rehabilitation facility in early [MASKED], but has been unable to ambulate with assistance after her [MASKED] was reduced to 1hr/week. She now moves only with assistance and a wheelchair. [MASKED] was last able to feed herself approximately one month ago, and now cannot lift her left arm above shoulder height against gravity. She has reportedly been increasingly lethargic over the past month, with new loud snoring associated with gasping and choking when she falls asleep over the past week per her sister's report. She states that her legs feel heavy and that they ache; she cries when describing these symptoms, and her sister explains that [MASKED] is frustrated that she can no longer walk. Also over the past week, she has had difficulty swallowing, experiencing coughing fits after swallowing liquids and solids. Her sister states that [MASKED] has been speaking less over the past week, and that she is Ã¢â¬Ålosing her voice," and that her voice becomes especially weak near the end of longer conversations. Her sister states that she Ã¢â¬Åfeels like [MASKED] is slipping away over the past several months, and faster over the past week.Ã¢â¬Â In the setting of increasing concern about [MASKED] dysphagia, she had called [MASKED] and accompanied [MASKED] by ambulance to the [MASKED] ED; transfer was then initiated to a [MASKED] hospital, and [MASKED] (where [MASKED] had recently begun outpatient neurology work-up) were not accepting new patients. She was sent to [MASKED] by ambulance. [MASKED] expresses great frustration with difficulties in coordinating RamonaÃ¢â¬â¢s care, and states that she cannot accept that this is simply RamonaÃ¢â¬â¢s new baseline when there has been no thorough diagnostic work-up. When questioned specifically about it, she also states that [MASKED] may have been diagnosed with Celiac disease in the past, but that she cannot recall definitively. [MASKED] states that she wonders whether [MASKED] may have post-polio syndrome. On review of records from RamonaÃ¢â¬â¢s last hospital stay at [MASKED] in [MASKED]: MRI brain in [MASKED] was notable for mild small vessel ischemic changes and mild diffuse cerebral atrophy. In a consult note from that admission, [MASKED] neurologists stated their hypothesis that [MASKED] decline may have been attributable to hypoxic brain injury sustained during her [MASKED] hospital admission for anaphylaxis. Their note also alluded to a diagnosis of cerebral palsy, which [MASKED] emphatically insists that [MASKED] was never diagnosed with. [MASKED] also states that a repeat MRI brain was performed through [MASKED] in [MASKED] and was reportedly unremarkable, showing no evidence of acute stroke. On neurological [MASKED] denies HA, blurred vision, diplopia, vertigo, and tinnitus. She endorses weakness, dysarthria, dysphagia, chronic hearing difficulty, and chronic incontinence of urine. On general [MASKED]¢s sister denies that the patient has experienced recent fever or chills, recent weight loss or gain, cough, chest pain, nausea, vomiting, and recent diarrhea x1 wk. She states that [MASKED] has chronic constipation, osteoarthritis of the knees bilaterally, and Ã¢â¬Åfrozen shoulderÃ¢â¬Â on the right. [MASKED] was also diagnosed with a UTI one week ago and completed a 5d course of Bactrim on [MASKED]. At approximately the same time that she began taking the Bactrim, she developed an erythematous papular rash over her face. [MASKED] sister [MASKED] lives 90 minutes away in [MASKED] and may not be able to visit until mid-week; she requests that the team update her via phone at [MASKED]. Additionally, she has copies of [MASKED] records from [MASKED] and [MASKED] on a USB, which were briefly reviewed by the admitting resident and medical student. She is willing to bring these documents back when she visits so that they can be reviewed in greater detail and scanned into OMR. Past Medical History: -Childhood epilepsy -Polio (age at infection unknown, but reportedly [MASKED] years old)mostly affected right foot. -Developmental delay -Celiac disease -Osteoporosis -Multiple compression fractures of thoracic and lumbar spine -SVT w/ AVNRT s/p ablation ([MASKED]) -Thyroid nodule -Frozen left shoulder and chronic left clavicular fracture -Osteoarthritis of hips and knees -Pressure ulcer -Right knee replacement -Right hip replacement Social History: [MASKED] Family History: -Mother: [MASKED], DM, dementia, hip fracture -Father: HTN -Older sister: ParkinsonÃ¢â¬â¢s disease (dxÃ¢â¬â¢d in [MASKED] -Younger sister: lymphoma (dxÃ¢â¬â¢d at [MASKED]) -Another sister: hypothyroidism -Brother: hyperthyroidism Physical [MASKED]: Admission Physical Exam: VS: T: 96.0F, BP 115/53, P 68, RR 18, SaO2 100% RA General: intermittently awake and alert, falling asleep without occasional stimulation, but arousable by voice; appears lethargic and in no acute distress HEENT: NC/AT, no scleral icterus or injection noted, mucosal membranes dry, poor dentition Neck: supple Pulmonary: diffuse expiratory wheezes Cardiac: RRR, no M/R/G, nl S1/S2 Abdomen: soft, NT/ND Extremities: WWP, 1+ pitting edema to knees bilaterally, longitudinal scar overlying R knee Skin: erythematous papular rash over face, with few small pustules Neurologic: Mental Status: Alert and oriented to self and to Ã¢â¬Åhospital,Ã¢â¬Â but not to time (could not state year or month without prompting). Unable to relate history, but can answer some yes/no questions. Inattentive, able to repeat 4 digits in sequence forwards but 0 digits backwards. Patient named a pen as Ã¢â¬Åa pencilÃ¢â¬Â, a computer as Ã¢â¬Åa machineÃ¢â¬Â, and could not name [MASKED] stethoscope. Speech was dysarthric and sparse, with low volume. Able to attempt to follow midline and appendicular commands (touching her nose with her index finger), but limited by bilateral upper extremity weakness. Registered [MASKED] objects and recalled [MASKED] with prompts. Recalled own birthday, motherÃ¢â¬â¢s birthday; did not recall current President but smiled broadly when sister stated that Ã¢â¬Åshe doesnÃ¢â¬â¢t want to recall him.Ã¢â¬Â Inconsistent evidence of left-sided neglect on sensory exam, but unclear whether this was due to difficulty comprehending examinerÃ¢â¬â¢s questions. Of note, while her sister states that [MASKED] is fluent in [MASKED] and [MASKED] began speaking to her sister in [MASKED] shortly before admission to describe her fears of being left alone and desire for her IV to be removed; when addressed in [MASKED], she was able to speak in longer sentences of up to 10 words in response to questions. Cranial Nerves: II, III, IV, VI: PERRL 3 to 2 mm and brisk. EOMI without nystagmus. Mild ptosis bilaterally V: facial sensation intact to light touch bilaterally VII: mild right-sided facial droop VIII: hearing intact to finger-rub bilaterally IX, X: unable to assess, as patient would not say "aaah" loudly enough to elevate palate XI: 4+/5 strength in trapezii and SCM bilaterally XII: tongue protrudes in midline Motor: Normal bulk, tone throughout. Bradykinesia throughout exam. No spasticity or rigidity. Unable to assess pronator drift due to UE weakness. No adventitious movements, such as tremor, noted. No asterixis noted. [[MASKED]] L 2 3 4 3 4 1 3 3 4 5 4 R 2 3 5 4+ 4+ 1 3 3 4 5 4 - Reflexes: [Bic] [Tri] [[MASKED]] [Quad] [Gastroc] L 1 1 1 0 0 R 1 1 1 0 0 Plantar response was extensor on left, equivocal on right Sensory: proprioception intact at great toes bilaterally, no deficits to light touch throughout, though exam was inconsistent when patient was asked which leg was being touched, responding Ã¢â¬ÅrightÃ¢â¬Â when both were being touched. Coordination: No intention tremor. Dysdiadochokinesia could be not assessed due to weakness. No obvious dysmetria on FNF, though exam was limited due to weakness and bradykinesia. Gait: Not assessed due to lower extremity weakness. Romberg not assessed. [MASKED] DISCHARGE PHYSICAL EXAM Vitals: Temp: afebrile BP: 121-144/67-81 HR: [MASKED] RR: [MASKED] O2 sat: 93-97% on room air. General: awake, alert, labile mood, no acute distress HEENT: NC/AT, no scleral icterus or injection noted, mucosal membranes dry, poor dentition Neck: supple Pulmonary: diffuse expiratory wheezes Cardiac: RRR, no M/R/G, nl S1/S2 Abdomen: soft, NT/ND Extremities: WWP, 1+ pitting edema to knees bilaterally, longitudinal scar overlying R knee Skin: erythematous papular rash over face, with few small pustules Neurologic: Mental Status: Alert and oriented to self and place but not time. Inattentive, some difficulty with luria. Speaking in sentences, dysarthria noted. Able to follow axial commands, some difficulty with appendicular commands due to weakness but patient understood the task. Cranial Nerves: II, III, IV, VI: PERRL 4 to 3 mm and brisk. EOMI without nystagmus. Conjugate gaze. Mild ptosis bilaterally V: facial sensation intact to light touch bilaterally VII: right-sided facial droop less prominent with activation VIII: hearing intact to finger-rub bilaterally IX, X: symmetric palate elevation XI: 4+/5 strength in trapezii and SCM bilaterally XII: tongue protrudes in midline Motor: Normal bulk, tone throughout. Bradykinesia throughout exam. No spasticity or rigidity. Unable to assess pronator drift due to UE weakness. No adventitious movements, such as tremor, noted. No asterixis noted. [[MASKED]] L 2 2 3 3 3 2 2 3 3 5 4 R 2 3 5 4+ 4+ 2 2 3 5 4 - Reflexes: [Bic] [Tri] [[MASKED]] [Achilles] L 1 1 1 1 R 1 1 1 1 Plantar response was extensor b/l Sensory: proprioception intact at great toes bilaterally, no deficits to light touch throughout, though exam was inconsistent when patient was asked which leg was being touched, responding "right" when both were being touched. Coordination: No intention tremor. Dysdiadochokinesia could be not assessed due to weakness. No obvious dysmetria on FNF, though exam was limited due to weakness and bradykinesia. Gait: deferred. Pertinent Results: LAB DATA: [MASKED] cbc:6.9/13.2/39.1/171 [MASKED]: Last PhT and PHB level 12.3 and 36.3 TSH/T4 2.5/5.7 Vit B12 409 and folate >20 troponin <0.01 ldl 57 [MASKED] neg Sjogren's ab: neg alk phos 127 UA: pos for barbituates (on PHB) Lyme neg MMA: neg PEP (no abnormalities seen)IgG 1595 IgA 1053 IgM 89 IFE (no monoclonal immunoglobulin seen) Cu: 109 ESR: 19 , CRP: 2.8 RPR NR Vit B6: 4.6 Bcx/Ucx: prelim neg Pend: Vit B1, Vit E, paraneoplastic panel, ACH receptor ab MRI spine: 1. There are 7 cervical vertebrae with fusion of C6 and C7 anterior and posterior elements, 12 rib-bearing vertebrae, L1 with transitional anatomy, L2 through L5 with conventional anatomy, and a nearly completely lumbarized S1. 2. Normal appearance of the spinal cord. No pathologic contrast enhancement. 3. Mild chronic compression of T7 and T12 vertebral bodies. 4. Multilevel cervical, thoracic, and lumbar degenerative disease, as detailed above. No mass effect on the spinal cord or intrathecal nerve roots. Xray left shoulder shows chronic clavicular fracture EEG reveals generalized polyspikes but no seizures or asymmetry Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with PMH notable for polio, developmental delay, epilepsy, HLD, SVT w/ AVNRT s/p ablation, and possible Celiac disease who presents with new dysphagia and apnea with worsening dysarthria in the setting of progressive global weakness over the past year likely in setting of failure to thrive and loss of function due to perhaps hypoxic brain damage on top of underlying developmental delay, and depression. Neurological exam is notable for global weakness without a clear pattern, dysarthria, inattentiveness, mild ptosis bilaterally and mild right-sided facial droop, absent reflexes in lower extremities with positive Babinksi sign B/L with lack of spasticity and rigidity. Other DDX includes peripheral neuropathy (in setting of osteoporosis and reported celiac disease), myasthenia [MASKED] myasthenic syndrome (no fatigability) or Post Polio syndrome. Hospital course by system: # Neuro: - Completed EMG on [MASKED], results pending - EEG showed generalized polyspikes however no seizures - MRI spine performed which showed degenerative joint disease however no cord compression - Underwent extensive workup including AED levels, TSH, T4, Vit B12, Folate, Ua, Utox, CE, Cu, RPR, ESR, CRP, Bcx, Ucx, vitamin B1, vitamin B6, vitamin E, methylmalonic acid, RPR, ACH receptor AB Sjogren's antibodies, copper, Lyme, [MASKED], paraneoplastic autoantibody panel - [MASKED] consulted who recommend rehab however insurance denied approval. Will discharge home with outpatient services. - Speech consulted: Patient to have modified diet of puree solids with nectar thick liquids. 1:1 supervision with cues to swallow [MASKED] times per bite/sip and alternate bites/sips. Consider alternative means of nutrition and hydration. - continued home PHT 100mg/200mg and PHB doses 64.8mg bid - continued home ASA dose 81mg qd - received Tramadol prn for pain # CV: -Monitored on telemetry, no Afib #Pulm: - occasional hypoxia while sleeping, consider outpt sleep study #Pysch - Started on Escitalopran 10mg qd, plan increase to 20mg in 1wk ([MASKED]) # FEN: - initially received IVF at maintenance however discontinued prior to discharge - PPX: SQH, pneumoboots, senna/colace, +ppi - Precautions: fall - Code Status: Full - Health Care Proxy: [MASKED], sister (cell: [MASKED], office: [MASKED] Transition of care: - please review prior records and trend AED levels carefully. Sometimes PHB and PHT toxicity can lead to gait issues. Consider transitioning to other AED slowly - consider sleepy study as outpatient for evaluation for OSA - hyperintensities noted in subcutaneous fat of MRI spine, per neuroradiology this is a normal finding - patient's HCP is arranging outpatient counseling for [MASKED] - patient started on Escitalopram, increase to 20mg qd on [MASKED] - pending labs Vit B1, Vit E, paraneoplastic panel, ACH receptor ab - EMG results pending - [MASKED] recommended rehab, however insurance denied approval. HCP would like to take patient home and try for outpatient services. - Consider testing for HIV and order HIV [MASKED] antibodies - Consider LP if above work-up unrevealing Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PHENObarbital 64.8 mg PO BID 2. Phenytoin Sodium Extended 100 mg PO QAM 3. Tolterodine 1 mg PO BID 4. Omeprazole 20 mg PO DAILY 5. Alendronate Sodium 70 mg PO QMON 6. fluticasone 0.05 % topical BID 7. Ketoconazole 2% 1 Appl TP BID 8. Multivitamins 1 TAB PO DAILY 9. Vitamin D [MASKED] UNIT PO DAILY 10. TraMADol 50 mg PO DAILY:PRN Pain - Moderate 11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 12. DiphenhydrAMINE 25 mg PO Q6H:PRN itching 13. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis 14. Phenytoin Sodium Extended 200 mg PO QPM 15. Calcium Carbonate 500 mg PO QID:PRN , 16. Milk of Magnesia 30 mL PO Q6H:PRN . Discharge Medications: 1. Escitalopram Oxalate 10 mg PO DAILY RX escitalopram oxalate 10 mg 1 tablet(s) by mouth daily Disp #60 Tablet Refills:*11 2. Alendronate Sodium 70 mg PO QMON 3. Calcium Carbonate 500 mg PO QID:PRN , 4. DiphenhydrAMINE 25 mg PO Q6H:PRN itching 5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis 6. fluticasone 0.05 % topical BID 7. Ketoconazole 2% 1 Appl TP BID 8. Milk of Magnesia 30 mL PO Q6H:PRN . 9. Multivitamins 1 TAB PO DAILY 10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 11. Omeprazole 20 mg PO DAILY 12. PHENObarbital 64.8 mg PO BID 13. Phenytoin Sodium Extended 200 mg PO QPM 14. Phenytoin Sodium Extended 100 mg PO QAM 15. Tolterodine 1 mg PO BID 16. TraMADol 50 mg PO DAILY:PRN Pain - Moderate 17. Vitamin D [MASKED] UNIT PO DAILY 18.Outpatient Occupational Therapy icd 9: 348.30 19.Outpatient Physical Therapy 348.30 20.Outpatient Speech/Swallowing Therapy 348.30 Discharge Disposition: Home Discharge Diagnosis: global weakness dysphagia epilepsy history of polio Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Activity Status: Bedbound. Discharge Instructions: Ms. [MASKED] you were admitted to [MASKED] hospital for workup of your weakness and trouble swallowing. Your EEG showed generalized polyspikes consistent with epilepsy however no current seizures. Your MRI spine showed signs of degenerative joint changes but no cord compression. You had an EMG which was done the results of which are pending at discharge. You failed your swallow study which means that when you eat the food is going to your lungs. You understood the risks of this and chose to continue to take food by mouth. We added Escitalopram to your medication regimen to help stabilize your mood. No other changes were made to your home medications. We will arrange follow up for you in our Neurology clinic ([MASKED]). They will contact you with appointment details. You should also follow up with your PCP [MASKED] 2weeks of discharge. Followup Instructions: [MASKED]	[]	[ "E785", "K219", "F329" ]	[ "M6281: Muscle weakness (generalized)", "G931: Anoxic brain damage, not elsewhere classified", "R0681: Apnea, not elsewhere classified", "R1310: Dysphagia, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "R471: Dysarthria and anarthria", "R29810: Facial weakness", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R0902: Hypoxemia", "F329: Major depressive disorder, single episode, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "R627: Adult failure to thrive", "M479: Spondylosis, unspecified", "R32: Unspecified urinary incontinence", "E876: Hypokalemia", "Z96651: Presence of right artificial knee joint", "Z96641: Presence of right artificial hip joint", "Z8612: Personal history of poliomyelitis" ]
19,984,491	29,623,707	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: ___ female who presents to ___ on ___ with a mild TBI s/p fall at home around 9 AM, hit head on nightstand, found to have SDH at OSH acute right sided 5mm SDH On Coumadin, INR was 2.8. Given vitamin K at OSH. INR on arrival here improved to 2.6. Per the patient family she has a history of PE/DVT and AVR thrombus. =================== Medicine accept note: Ms. ___ is an ___ yoF with PMH sig for dementia, DVT, PE, AVR thrombus, on warfarin, HTN, HLD, and proximal aortic dissection s/p AVR who presented from assisted living facility to ___ on ___ with a mild TBI s/p fall. Of note, pt has no known recent history of cardiac ischemia, syncopal episodes, orthostasis, epileptic activity, or falls. Of note, patients baseline mental status is AOx1, her functional status is independent with ADLs, no walker or cane needed, in fact she is a brisk walker. On the morning of ___, the pt was found conscious, with a head contusion, on the ground by the side of her bed by aids at her assisted living facility where she lives with her husband and her disabled son. She was lying, in pajamas, on her right hip. The fall was unwitnessed, but the aid attributed the pt's contusion to having hit her head on the nightstand. No bowel or bladder incontinence or evidence of tongue biting. Pt does not remember the fall, nor the preceding events, the fall was not witnessed. Per daughter report, pt has not mentioned any recent episodes of dizziness, chest pain, or shortness of breath, and noted no fever, chills, night sweats, nausea, or vomiting. Prior to fall, pt ambulated with ease, not using walker or cane, and ascended and descended stairs without assistance. Pt has had no known recent sick contacts, though moved to an assisted living facility two months ago, and no recent travel. She has poor fluid intake throughout the day, though eats three full meals per day at her facility. Per daughter, pt has significant baseline dementia, though is always oriented to self and location. Pt presented to OSH where she was found to have acute right sided 5mm SDH on Coumadin (INR 2.8), and she received vitamin K. CT C-spine and head performed. Upon presentation to ___ ED, pt had INR of 2.6. Chest (PA&LAT), ankle, and hip x-rays performed all unremarkable. Pt was monitored by the neurosurgical service and is planned for follow-up CT scan in two months. Warfarin was restarted on ___ because of INR of 2.0, and she was started on Keppra 500 mg BID x7 days (end date ___ for seizure prophylaxis. UA was taken and was positive for large nitrite and leuk, treatment for asymptomatic UTI initiated with TMP/SMX (day 1: ___. Pt was transferred to the medicine service for fall work-up. On ___, pt was AOx1, alert, conversational, and responded to commands appropriately. Pt denied dizziness, headache, blurry vision, chest pain, SOB, fever, chills, dysuria, or urinary urgency. Pt reports no ankle or hip pain or stiffness. Per daughter, pt is back to baseline. Past Medical History: Dementia, HLD, DVT, PE, thrombus, HTN, OA, s/p AVR on Coumadin AVR, bilateral Hip replacements Social History: ___ Family History: NC Physical Exam: Admission Physical exam: GCS:15 Gen: WD/WN, comfortable, NAD. HEENT: bruise and scrape over r eye, swollen Neck: supple Extrem: warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect, pleasantly confused (baseline) Orientation: Oriented to person only. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 mm to 1.5 mm 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 full power ___ throughout. No pronator drift Sensation: Intact to light touch Handedness: Right Discharge physical exam: PE Vitals: Tmax=99.4 102-123/60-70 50-70 92-98%RA General: AOx2. Resting calmly. HEENT: Normocephalic, head, hair, scalp WNL. Ecchymosis with scrape over right eye. PERRLA. EOMI. MMM. No lesions on bucal mucosa, tongue, or lips. Neck: No LAD. No JVD. Lungs: Lungs clear do percussion posteriorly and clear to auscultation anteriorly and posteriorly. CV: RRR with nl S1 and S2. No rubs, murmurs, gallops. Abdomen: Abdomen non-tender to light and deep palpation in all 4 quadrants. Back: no CVA tenderness. No spinous process or paraspinal muscle pain. Ext: Warm and well-perfused. Tenderness to deep palpation on lateral aspect of dorsum of foot anterior to lateral malleolus. Neuro: CNs II-II in tact. Strength ___ throughout, ___ with R dorsiflexion. Light touch, vibration, and proprioception in tact throughout. Pertinent Results: =================== Admission labs: =================== ___ 01:28PM BLOOD WBC-5.6 RBC-4.37 Hgb-12.0 Hct-38.3 MCV-88 MCH-27.5 MCHC-31.3* RDW-14.2 RDWSD-45.9 Plt ___ ___ 01:28PM BLOOD Neuts-71.9* ___ Monos-5.7 Eos-0.9* Baso-0.7 Im ___ AbsNeut-4.01 AbsLymp-1.13* AbsMono-0.32 AbsEos-0.05 AbsBaso-0.04 ___ 01:28PM BLOOD ___ PTT-38.7* ___ =========== Micro =========== ___ 1:28 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 2:55 pm URINE URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ============ Radiology: ============ ___ NCHCT (OSH) 5mm SDH CT Cervical Spine: negative Chest XR FINDINGS: PA and lateral views of the chest provided. Sternotomy wires are noted. Linear opacities in the bilateral lower lobes likely represent bibasilar atelectasis versus scarring. There are atherosclerotic calcifications involving the aortic arch and descending thoracic aorta. No radiopaque cardiac valve is seen. S-shaped curvature of the thoracolumbar spine is noted. IMPRESSION: 1. No radio opaque cardiac valve is seen. 2. Bibasilar atelectasis. ___ Ankle XRAY FINDINGS: No fracture, dislocation, or degenerative change is detected. The mortise is congruent on this non stress view. The tibial talar joint space is preserved and no talar dome osteochondral lesion is identified. No suspicious lytic or sclerotic lesion is identified. No soft tissue calcification or radiopaque foreign body is identified. MPRESSION: No acute fracture or dislocation of the right ankle ___ Hip XRAY The patient is status post bilateral total hip arthroplasties with evidence of revision on the right. There is no acute fracture or dislocation identified. Evaluation the sacrum is however obscured by overlying bowel. There are no gross degenerative changes. There is no suspicious lytic or sclerotic lesion. Vascular calcification is present as are calcifications over the right gluteal region likely reflective of injection granulomas. IMPRESSION: Status post bilateral total hip arthroplasties. No evidence of an acute fracture of the pelvis or right hip. =================== Discharge labs: =================== ___ 04:50AM BLOOD WBC-5.0 RBC-3.78* Hgb-10.4* Hct-32.7* MCV-87 MCH-27.5 MCHC-31.8* RDW-14.2 RDWSD-44.7 Plt ___ ___ 04:50AM BLOOD Neuts-60.3 ___ Monos-11.3 Eos-1.2 Baso-0.6 Im ___ AbsNeut-3.00 AbsLymp-1.30 AbsMono-0.56 AbsEos-0.06 AbsBaso-0.03 ___ 04:50AM BLOOD Plt ___ ___ 04:50AM BLOOD Glucose-91 UreaN-32* Creat-1.5* Na-135 K-3.4 Cl-97 HCO3-23 AnGap-18 ___ 04:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8 Brief Hospital Course: Ms. ___ is an ___ year old woman with past medical history of dementia (AOx1), deep vein thrombosis, pulmonary embolism, and aortic dissection with aortic valve replacement on warfarin who presented to ___ with a mild traumatic brain injury following a fall at her assisted living facility. The fall was not witnessed and she does not remember the fall or the preceding events. On head CT, patient was found to have an acute, right-sided 5mm subdural hematoma while on Coumadin, with an INR of 2.8. She received vitamin K, which reduced her INR to 2.6. She received chest, hip, and ankle x-rays, with no concerning findings obviated. Urinalysis was performed finding positive leukocyte esterase and nitrites, and urine culture was positive for gram negative rods. A three-day course of TMP-SMZ was initiated (end-date ___. Patient was monitored by neurosurgical service, and transferred to medicine for work-up of possible syncope. Telemetry and orthostatics were non-concerning. Fall was likely mechanical. #SDH: Unwitnessed fall ___ with no focal neurological deficit. NCHT ___ done in OSH showing 5mm SDH, corroborated by ___ radiology and neurosurgery. SDH was small/stable so no intervention required. Neurological exam was completely benign and remained that way during hospital stay with ___ strength bilaterally in all extremities, 2+ DTR and symmetric facial tone. Per daughter at bedside, pt remained cognitively at baseline. Of note, pt was given vitamin K at OSH and her INR reduced from 2.8 to 2.6 after administration. Warfarin was held ___ and then resumed at an average home dose of 5mg Warfarin on ___. Pt did well with q4H neuro checks and remained stable. Per neurology recommendations, patient was restarted on warfarin and started Keppra 500mg x 7 days (end date ___. Pt requires follow up with neurosurgery with Dr. ___ in clinic in 10 weeks with a repeat NCHCT at that time. #UTI: She had an abnormal urinalysis on admission and was prescribed a three day course of Bactrim, end date ___. Urine cultures grew pan-sensitive E.coli. No complaints of dysuria. #Fall: Given no recent history of syncope, orthostasis, chest pain, SOB or any other concerning symptoms, her episode may have been ___ to mechanical fall. Please refer to the accept note for more details for the event of the fall. Other etiologies of fall that are likely in this situation include AMS more than baseline ___ to infectious cause(UTI). Another cause may be orthostasis ___ to poor fluid intake per daughters report, though patient does not c/o symptoms and orthostatic vitals were negative. Cardiac etiology of valvular defect is unlikely as this did not occur during exertion. Arrythmia cannot but ruled out, but again is less likely given no history of prior syncope and pt did not declare herself on telemetry. Medication list reviewed and no recent changes and no drug interactions likely to precipitate this event. No loss of bowel or bladder control reduce likelihood of seizure. We believe fall was most likely mechanical. Consider work up with holter monitor and echo if patient has another episode. #Hip and ankle pain: Pt reported right hip and knee pain s/p fall due to impact of fall from standing. No fracture visualized on ankle or hip x-ray. Pt is able to bear weight on ankle and has no pain at base of the fifth metatarsal. No further imaging needed. Pain well controlled with Acetaminophen 650 mg PO:PRN. ___ Pt presented with Cr of 1.1 and Cr level peaked on ___ to 1.5. Per patients daughter, nurses and patient herself, she does not like to drink water and has to be reminded to drink frequently. Cr may also be falsely elevated secondary to Bactrim for UTI treatment. Trial of 500IV NS given over 2 hours on ___. Of note, HCTZ was discontinued secondary to creatinine elevation. SBP remained <160 per neurosurgery requests. Follow up with Cr levels on ___ and consider restarting HCTZ. Discharge orthostatic vitals negative on discharge after 500IV NS. #Code status: currently full code, per HC proxy. Daughter plans to discuss this further with other family members. CHRONIC ISSUES ============== #Dementia: Pt is at baseline per daughter. AOx1 (name, location [hospital], year ___. Can state days of week and months backward and spell WORLD backward. Pt was encouraged normal sleep-wake schedule to minimize likelihood of delirium #Hypercoagulability: s/p DVT x3, PE, AVR thrombosis, protein S deficiency . Continued warfarin at a changed dose of 5 mg PO q24. See above for more details. INR monitored by Dr. ___ ___ (PCP - ___. Followed by cardiology at ___ (Dr. ___ #HTN: Continued home amlodipine 2.5 mg PO q24, atenolol 50 mg PO q24, held HCTZ 25mg ___ iso elevated Cr. #HLD: Continued home atorvastatin 20mg PO q24 #Depression :Continued home citalopram 10mg TRANSITIONAL ISSUES: 1. Continue Levetiracetam 500mg PO BID for 7 days (end date: ___ 2. Monitor INR closely given that warfarin was stopped ___ then restarted ___ with changes to home dose. Home dose 4mg MTWThF, 8mg ___, changed to 5mg PO once daily. Next INR check on ___. Follow-up head CT in 2 months (Approx: ___ 4. Consider echo for possible cardiac etiology of fall 5. Recheck Cr level ___. Rise 1.1-->1.5 secondary to either prerenal etiology or falsely elevated iso Bactrim for UTI treatment. HCTZ held starting ___. Can resume once Cr back to baseline at 1.0-1.1. -Code Status: Full code, further discussion needed -Communication: ___ - daughter (___) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. amLODIPine 2.5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Atenolol 50 mg PO BID 4. Vitamin D 1000 UNIT PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Warfarin 4 mg PO 5X/WEEK (___) 7. Warfarin 2 mg PO 2X/WEEK (___) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN itching 3. LevETIRAcetam 500 mg PO BID Duration: 3 Days End date ___. Senna 17.2 mg PO QHS:PRN constipation 5. Warfarin 5 mg PO DAILY Please follow up with INR and change accordingly. 6. amLODIPine 2.5 mg PO DAILY 7. Atenolol 50 mg PO BID 8. Atorvastatin 20 mg PO QPM 9. FoLIC Acid 1 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: xRight subdural hemorrhage without surgical intervention Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted after you fell and hit your head while getting out of bed at the assisted living facility. You were taken to an outside hospital where they performed a head CT and found a small amount of bleeding around your brain. You were given vitamin K to reduce your likelihood of further bleeding. Upon transfer to ___, you received chest (PA&LAT), ankle, and hip x-rays, all of which showed no concerning findings such as fracture. You were monitored by the neurosurgical service, and were transferred to medicine to help determine the cause of your fall. While at the hospital, it was also found that you had a urinary tract infection and treatment with an antibiotic was started. You did very well, and got less confused and stronger as your hospital stay progressed. Discharge Instructions: -We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. -You may 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. Medications -Your Coumadin was restarted while you were in the hospital. Please follow-up with your PCP (Dr. ___: ___ to closely monitor your INR. -You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated in your discharge instructions. It is important that you take this medication consistently and on time. THIS MEDICATION IS FOR 7 DAYS ONLY, PLEASE STOP ON ___ AFTER THE EVENING DOSE. -You may use Acetaminophen (Tylenol) for minor discomfort. What You ___ Experience: -You may have difficulty paying attention, concentrating, and remembering new information. -Emotional and/or behavioral difficulties are common. -Feeling more tiredness, restlessness, irritability, and mood swings are also common. -Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. Headaches: -Headache is one of the most common symptom after a brain bleed. -Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. -Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. -___ are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: -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 We are wishing you all the best. Sincerely, Your ___ team Followup Instructions: ___	[ "S065X0A", "N390", "N179", "D6859", "F0390", "Z96643", "Z86711", "Z7901", "Z86718", "I10", "Z952", "E785", "W1800XA", "Y92009", "B9620", "M25551", "M25561", "F329" ]	Allergies: Penicillins Chief Complaint: Subdural hematoma Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] female who presents to [MASKED] on [MASKED] with a mild TBI s/p fall at home around 9 AM, hit head on nightstand, found to have SDH at OSH acute right sided 5mm SDH On Coumadin, INR was 2.8. Given vitamin K at OSH. INR on arrival here improved to 2.6. Per the patient family she has a history of PE/DVT and AVR thrombus. =================== Medicine accept note: Ms. [MASKED] is an [MASKED] yoF with PMH sig for dementia, DVT, PE, AVR thrombus, on warfarin, HTN, HLD, and proximal aortic dissection s/p AVR who presented from assisted living facility to [MASKED] on [MASKED] with a mild TBI s/p fall. Of note, pt has no known recent history of cardiac ischemia, syncopal episodes, orthostasis, epileptic activity, or falls. Of note, patients baseline mental status is AOx1, her functional status is independent with ADLs, no walker or cane needed, in fact she is a brisk walker. On the morning of [MASKED], the pt was found conscious, with a head contusion, on the ground by the side of her bed by aids at her assisted living facility where she lives with her husband and her disabled son. She was lying, in pajamas, on her right hip. The fall was unwitnessed, but the aid attributed the pt's contusion to having hit her head on the nightstand. No bowel or bladder incontinence or evidence of tongue biting. Pt does not remember the fall, nor the preceding events, the fall was not witnessed. Per daughter report, pt has not mentioned any recent episodes of dizziness, chest pain, or shortness of breath, and noted no fever, chills, night sweats, nausea, or vomiting. Prior to fall, pt ambulated with ease, not using walker or cane, and ascended and descended stairs without assistance. Pt has had no known recent sick contacts, though moved to an assisted living facility two months ago, and no recent travel. She has poor fluid intake throughout the day, though eats three full meals per day at her facility. Per daughter, pt has significant baseline dementia, though is always oriented to self and location. Pt presented to OSH where she was found to have acute right sided 5mm SDH on Coumadin (INR 2.8), and she received vitamin K. CT C-spine and head performed. Upon presentation to [MASKED] ED, pt had INR of 2.6. Chest (PA&LAT), ankle, and hip x-rays performed all unremarkable. Pt was monitored by the neurosurgical service and is planned for follow-up CT scan in two months. Warfarin was restarted on [MASKED] because of INR of 2.0, and she was started on Keppra 500 mg BID x7 days (end date [MASKED] for seizure prophylaxis. UA was taken and was positive for large nitrite and leuk, treatment for asymptomatic UTI initiated with TMP/SMX (day 1: [MASKED]. Pt was transferred to the medicine service for fall work-up. On [MASKED], pt was AOx1, alert, conversational, and responded to commands appropriately. Pt denied dizziness, headache, blurry vision, chest pain, SOB, fever, chills, dysuria, or urinary urgency. Pt reports no ankle or hip pain or stiffness. Per daughter, pt is back to baseline. Past Medical History: Dementia, HLD, DVT, PE, thrombus, HTN, OA, s/p AVR on Coumadin AVR, bilateral Hip replacements Social History: [MASKED] Family History: NC Physical Exam: Admission Physical exam: GCS:15 Gen: WD/WN, comfortable, NAD. HEENT: bruise and scrape over r eye, swollen Neck: supple Extrem: warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam, normal affect, pleasantly confused (baseline) Orientation: Oriented to person only. Language: Speech is fluent with good comprehension. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 mm to 1.5 mm 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 full power [MASKED] throughout. No pronator drift Sensation: Intact to light touch Handedness: Right Discharge physical exam: PE Vitals: Tmax=99.4 102-123/60-70 50-70 92-98%RA General: AOx2. Resting calmly. HEENT: Normocephalic, head, hair, scalp WNL. Ecchymosis with scrape over right eye. PERRLA. EOMI. MMM. No lesions on bucal mucosa, tongue, or lips. Neck: No LAD. No JVD. Lungs: Lungs clear do percussion posteriorly and clear to auscultation anteriorly and posteriorly. CV: RRR with nl S1 and S2. No rubs, murmurs, gallops. Abdomen: Abdomen non-tender to light and deep palpation in all 4 quadrants. Back: no CVA tenderness. No spinous process or paraspinal muscle pain. Ext: Warm and well-perfused. Tenderness to deep palpation on lateral aspect of dorsum of foot anterior to lateral malleolus. Neuro: CNs II-II in tact. Strength [MASKED] throughout, [MASKED] with R dorsiflexion. Light touch, vibration, and proprioception in tact throughout. Pertinent Results: =================== Admission labs: =================== [MASKED] 01:28PM BLOOD WBC-5.6 RBC-4.37 Hgb-12.0 Hct-38.3 MCV-88 MCH-27.5 MCHC-31.3* RDW-14.2 RDWSD-45.9 Plt [MASKED] [MASKED] 01:28PM BLOOD Neuts-71.9* [MASKED] Monos-5.7 Eos-0.9* Baso-0.7 Im [MASKED] AbsNeut-4.01 AbsLymp-1.13* AbsMono-0.32 AbsEos-0.05 AbsBaso-0.04 [MASKED] 01:28PM BLOOD [MASKED] PTT-38.7* [MASKED] =========== Micro =========== [MASKED] 1:28 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] 2:55 pm URINE URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ============ Radiology: ============ [MASKED] NCHCT (OSH) 5mm SDH CT Cervical Spine: negative Chest XR FINDINGS: PA and lateral views of the chest provided. Sternotomy wires are noted. Linear opacities in the bilateral lower lobes likely represent bibasilar atelectasis versus scarring. There are atherosclerotic calcifications involving the aortic arch and descending thoracic aorta. No radiopaque cardiac valve is seen. S-shaped curvature of the thoracolumbar spine is noted. IMPRESSION: 1. No radio opaque cardiac valve is seen. 2. Bibasilar atelectasis. [MASKED] Ankle XRAY FINDINGS: No fracture, dislocation, or degenerative change is detected. The mortise is congruent on this non stress view. The tibial talar joint space is preserved and no talar dome osteochondral lesion is identified. No suspicious lytic or sclerotic lesion is identified. No soft tissue calcification or radiopaque foreign body is identified. MPRESSION: No acute fracture or dislocation of the right ankle [MASKED] Hip XRAY The patient is status post bilateral total hip arthroplasties with evidence of revision on the right. There is no acute fracture or dislocation identified. Evaluation the sacrum is however obscured by overlying bowel. There are no gross degenerative changes. There is no suspicious lytic or sclerotic lesion. Vascular calcification is present as are calcifications over the right gluteal region likely reflective of injection granulomas. IMPRESSION: Status post bilateral total hip arthroplasties. No evidence of an acute fracture of the pelvis or right hip. =================== Discharge labs: =================== [MASKED] 04:50AM BLOOD WBC-5.0 RBC-3.78* Hgb-10.4* Hct-32.7* MCV-87 MCH-27.5 MCHC-31.8* RDW-14.2 RDWSD-44.7 Plt [MASKED] [MASKED] 04:50AM BLOOD Neuts-60.3 [MASKED] Monos-11.3 Eos-1.2 Baso-0.6 Im [MASKED] AbsNeut-3.00 AbsLymp-1.30 AbsMono-0.56 AbsEos-0.06 AbsBaso-0.03 [MASKED] 04:50AM BLOOD Plt [MASKED] [MASKED] 04:50AM BLOOD Glucose-91 UreaN-32* Creat-1.5* Na-135 K-3.4 Cl-97 HCO3-23 AnGap-18 [MASKED] 04:50AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8 Brief Hospital Course: Ms. [MASKED] is an [MASKED] year old woman with past medical history of dementia (AOx1), deep vein thrombosis, pulmonary embolism, and aortic dissection with aortic valve replacement on warfarin who presented to [MASKED] with a mild traumatic brain injury following a fall at her assisted living facility. The fall was not witnessed and she does not remember the fall or the preceding events. On head CT, patient was found to have an acute, right-sided 5mm subdural hematoma while on Coumadin, with an INR of 2.8. She received vitamin K, which reduced her INR to 2.6. She received chest, hip, and ankle x-rays, with no concerning findings obviated. Urinalysis was performed finding positive leukocyte esterase and nitrites, and urine culture was positive for gram negative rods. A three-day course of TMP-SMZ was initiated (end-date [MASKED]. Patient was monitored by neurosurgical service, and transferred to medicine for work-up of possible syncope. Telemetry and orthostatics were non-concerning. Fall was likely mechanical. #SDH: Unwitnessed fall [MASKED] with no focal neurological deficit. NCHT [MASKED] done in OSH showing 5mm SDH, corroborated by [MASKED] radiology and neurosurgery. SDH was small/stable so no intervention required. Neurological exam was completely benign and remained that way during hospital stay with [MASKED] strength bilaterally in all extremities, 2+ DTR and symmetric facial tone. Per daughter at bedside, pt remained cognitively at baseline. Of note, pt was given vitamin K at OSH and her INR reduced from 2.8 to 2.6 after administration. Warfarin was held [MASKED] and then resumed at an average home dose of 5mg Warfarin on [MASKED]. Pt did well with q4H neuro checks and remained stable. Per neurology recommendations, patient was restarted on warfarin and started Keppra 500mg x 7 days (end date [MASKED]. Pt requires follow up with neurosurgery with Dr. [MASKED] in clinic in 10 weeks with a repeat NCHCT at that time. #UTI: She had an abnormal urinalysis on admission and was prescribed a three day course of Bactrim, end date [MASKED]. Urine cultures grew pan-sensitive E.coli. No complaints of dysuria. #Fall: Given no recent history of syncope, orthostasis, chest pain, SOB or any other concerning symptoms, her episode may have been [MASKED] to mechanical fall. Please refer to the accept note for more details for the event of the fall. Other etiologies of fall that are likely in this situation include AMS more than baseline [MASKED] to infectious cause(UTI). Another cause may be orthostasis [MASKED] to poor fluid intake per daughters report, though patient does not c/o symptoms and orthostatic vitals were negative. Cardiac etiology of valvular defect is unlikely as this did not occur during exertion. Arrythmia cannot but ruled out, but again is less likely given no history of prior syncope and pt did not declare herself on telemetry. Medication list reviewed and no recent changes and no drug interactions likely to precipitate this event. No loss of bowel or bladder control reduce likelihood of seizure. We believe fall was most likely mechanical. Consider work up with holter monitor and echo if patient has another episode. #Hip and ankle pain: Pt reported right hip and knee pain s/p fall due to impact of fall from standing. No fracture visualized on ankle or hip x-ray. Pt is able to bear weight on ankle and has no pain at base of the fifth metatarsal. No further imaging needed. Pain well controlled with Acetaminophen 650 mg PO:PRN. [MASKED] Pt presented with Cr of 1.1 and Cr level peaked on [MASKED] to 1.5. Per patients daughter, nurses and patient herself, she does not like to drink water and has to be reminded to drink frequently. Cr may also be falsely elevated secondary to Bactrim for UTI treatment. Trial of 500IV NS given over 2 hours on [MASKED]. Of note, HCTZ was discontinued secondary to creatinine elevation. SBP remained <160 per neurosurgery requests. Follow up with Cr levels on [MASKED] and consider restarting HCTZ. Discharge orthostatic vitals negative on discharge after 500IV NS. #Code status: currently full code, per HC proxy. Daughter plans to discuss this further with other family members. CHRONIC ISSUES ============== #Dementia: Pt is at baseline per daughter. AOx1 (name, location [hospital], year [MASKED]. Can state days of week and months backward and spell WORLD backward. Pt was encouraged normal sleep-wake schedule to minimize likelihood of delirium #Hypercoagulability: s/p DVT x3, PE, AVR thrombosis, protein S deficiency . Continued warfarin at a changed dose of 5 mg PO q24. See above for more details. INR monitored by Dr. [MASKED] [MASKED] (PCP - [MASKED]. Followed by cardiology at [MASKED] (Dr. [MASKED] #HTN: Continued home amlodipine 2.5 mg PO q24, atenolol 50 mg PO q24, held HCTZ 25mg [MASKED] iso elevated Cr. #HLD: Continued home atorvastatin 20mg PO q24 #Depression :Continued home citalopram 10mg TRANSITIONAL ISSUES: 1. Continue Levetiracetam 500mg PO BID for 7 days (end date: [MASKED] 2. Monitor INR closely given that warfarin was stopped [MASKED] then restarted [MASKED] with changes to home dose. Home dose 4mg MTWThF, 8mg [MASKED], changed to 5mg PO once daily. Next INR check on [MASKED]. Follow-up head CT in 2 months (Approx: [MASKED] 4. Consider echo for possible cardiac etiology of fall 5. Recheck Cr level [MASKED]. Rise 1.1-->1.5 secondary to either prerenal etiology or falsely elevated iso Bactrim for UTI treatment. HCTZ held starting [MASKED]. Can resume once Cr back to baseline at 1.0-1.1. -Code Status: Full code, further discussion needed -Communication: [MASKED] - daughter ([MASKED]) Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. amLODIPine 2.5 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Atenolol 50 mg PO BID 4. Vitamin D 1000 UNIT PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Warfarin 4 mg PO 5X/WEEK ([MASKED]) 7. Warfarin 2 mg PO 2X/WEEK ([MASKED]) Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Hydrocortisone [MASKED]. Cream 0.2% 1 Appl TP BID:PRN itching 3. LevETIRAcetam 500 mg PO BID Duration: 3 Days End date [MASKED]. Senna 17.2 mg PO QHS:PRN constipation 5. Warfarin 5 mg PO DAILY Please follow up with INR and change accordingly. 6. amLODIPine 2.5 mg PO DAILY 7. Atenolol 50 mg PO BID 8. Atorvastatin 20 mg PO QPM 9. FoLIC Acid 1 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Primary diagnosis: xRight subdural hemorrhage without surgical intervention Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted after you fell and hit your head while getting out of bed at the assisted living facility. You were taken to an outside hospital where they performed a head CT and found a small amount of bleeding around your brain. You were given vitamin K to reduce your likelihood of further bleeding. Upon transfer to [MASKED], you received chest (PA&LAT), ankle, and hip x-rays, all of which showed no concerning findings such as fracture. You were monitored by the neurosurgical service, and were transferred to medicine to help determine the cause of your fall. While at the hospital, it was also found that you had a urinary tract infection and treatment with an antibiotic was started. You did very well, and got less confused and stronger as your hospital stay progressed. Discharge Instructions: -We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. -You may 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. Medications -Your Coumadin was restarted while you were in the hospital. Please follow-up with your PCP (Dr. [MASKED]: [MASKED] to closely monitor your INR. -You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated in your discharge instructions. It is important that you take this medication consistently and on time. THIS MEDICATION IS FOR 7 DAYS ONLY, PLEASE STOP ON [MASKED] AFTER THE EVENING DOSE. -You may use Acetaminophen (Tylenol) for minor discomfort. What You [MASKED] Experience: -You may have difficulty paying attention, concentrating, and remembering new information. -Emotional and/or behavioral difficulties are common. -Feeling more tiredness, restlessness, irritability, and mood swings are also common. -Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. Headaches: -Headache is one of the most common symptom after a brain bleed. -Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. -Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. -[MASKED] are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at [MASKED] for: -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 We are wishing you all the best. Sincerely, Your [MASKED] team Followup Instructions: [MASKED]	[]	[ "N390", "N179", "Z7901", "Z86718", "I10", "E785", "F329" ]	[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "N390: Urinary tract infection, site not specified", "N179: Acute kidney failure, unspecified", "D6859: Other primary thrombophilia", "F0390: Unspecified dementia without behavioral disturbance", "Z96643: Presence of artificial hip joint, bilateral", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "Z86718: Personal history of other venous thrombosis and embolism", "I10: Essential (primary) hypertension", "Z952: Presence of prosthetic heart valve", "E785: Hyperlipidemia, unspecified", "W1800XA: Striking against unspecified object with subsequent fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "M25551: Pain in right hip", "M25561: Pain in right knee", "F329: Major depressive disorder, single episode, unspecified" ]
19,984,710	29,213,398	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / amoxicillin / Augmentin / Keflex / erythromycin base / tramadol Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: endoscopy mild erythema in the lower esophagus consistent with mild esophagitis ___ A) Stomach: Lumen: Evidence of a previous Roux-en-Y Gastric Bypass was seen. Mucosa: Erythema and edema of the mucosa was noted in the stomach consistent with gastritis. Cold forceps biopsies were performed for histology at the stomach. Excavated Lesions A single non-bleeding 12 mm ulcer was found in the near gastro-jejunal anastamosis. Other A suture was seen. Duodenum: Other duodenum was not seen due to post surgical anatomy. The efferent and blind jejunal limbs were without abnormality. Impression: Mild erythema in the lower esophagus consistent with mild esophagitis ___ A) esophagitis Previous Roux-en-Y Gastric Bypass of the stomach Erythema and edema of the mucosa in the stomach (biopsy) Ulcer in the near gastro-jejunal anastamosis A suture was seen. Duodenum was not seen due to post surgical anatomy. The efferent and blind jejunal limbs were without abnormality. Otherwise normal EGD to post-anastamotic jejunal limbs Recommendations: - high dose BID PO PPI - no NSAID use - further care per inpatient team History of Present Illness: ___ with h/o gastric bypass surgery, active injection cocaine use, methadone maintenance treatment presentingwith ___ days of upper abdominal pain. Pain started without incident or trauma, progressed to become severe and has impaired appetite and oral intake. Pain is currently ___ and located above umbilicus and is non-radiating. She has not eaten meals for the past 5 days due to low appetite and pain. She did say eating improves pain. She had two episodes of hematemesis that were a teaspoon or less. She is passing flatus. She has not moved her bowels in this period. She was diagnosed with strep pharyngitis and prescribed clindamycin recently. She recently approx. 3 d ago binged on cocaine and shared a needle. She has had a mild cough without SOB, but productive of green phlegm for the past few days. She has also developed mid and lower back pain in this time without associated weakness. She has had fevers to 102 in the past week. ROS: She denies incontinence, dysuria, or hematuria. She last took methadone yesterday. 10pt ROS as per HPI In the ED she received analgesics, underwent CT abdomen that did not show bowel obstruction and had ___ surgery consultation. PMH: s/[ gastric bypass at ___ withj dr. ___ ___ years ago s/p ccy h/o lap surgery for sbo s/p bil oopheroectomy for chronic cysts h/o endometriosis h/o fibromyalgia h/o interstitial cystitis IBS s/p umbilical hernia repair sh; smokes ___ ppd, recently in drug/psych treatment at ___ in mid ___ for 10 days. active cocaine use, recently shared needle. homeless, no alcohol use. fh not pertinent for management of current chief complaint allergies: throat closes to amox, augmentin, penicillin, erythromycin, hives to Keflex meds last written on ___ for ___ pharmacy in ___ baclofen chlorpromazine docusate folic acid gabapentin gylcolax powder multivitamin prazosin sertraline sucralafate thiamine prescribed by ___ on ___: clindamycin Physical Exam: 97.9 108/70 74 fatigued but non toxic ctab rrr nmrg slight tenderness pain to percussion of mid upper back between scapula and midline lower back just above hips epigastric discomfort and pain to palpation, no rebound or guarding, no palpable organomegaly no suprapubic discomfort normal steady gait full ___ motor strength in all extremities calm and attentive, aox3, fluent speech symmetric facial features discharge avss aox3 calm and cooperative standing up and breathing easily conversant soft abdomen Pertinent Results: ___ 07:15AM BLOOD WBC-9.6 RBC-4.09 Hgb-11.3 Hct-35.1 MCV-86 MCH-27.6 MCHC-32.2 RDW-13.0 RDWSD-40.9 Plt ___ ___ 07:15AM BLOOD Glucose-89 UreaN-5* Creat-0.5 Na-142 K-4.8 Cl-102 HCO3-29 AnGap-11 ___ 08:40PM BLOOD ALT-18 AST-19 AlkPhos-115* TotBili-<0.2 ___ 08:40PM BLOOD Albumin-4.0 Iron-23* ___ 08:40PM BLOOD calTIBC-399 VitB12-327 Ferritn-19 TRF-307 ___ 07:15AM BLOOD 25VitD-38 ___ 09:05AM BLOOD CRP-6.6* ___ 09:05AM BLOOD HIV Ab-NEG ___ 09:05AM BLOOD HCV Ab-POS* HCV Viral Load Not Detected log10 IU/mL MRI spine 1. No evidence of infection orspinal cord compression in the thoracic or lumbar spine. 2. Minimal degenerative changes of the lumbar spine as described above. CXR IMPRESSION: Lungs are low volume with an ill-defined parenchymal opacity in the lingula concerning for pneumonia and posterior segment of the left upper lobe. Heart size is normal. Cardiomediastinal silhouette is unremarkable. There is no pleural effusion. No pneumothorax is seen Abdominal CT IMPRESSION: 1. No acute process within the abdomen or pelvis. Specifically, no small bowel obstruction. 2. Moderate stool burden from ascending to descending colon. 3. Unchanged splenomegaly. Brief Hospital Course: use, methadone maintenance treatment presenting with ___ days of upper abdominal pain found to have marginal ulcer on endoscopy performed on ___. Contributing factors to ulcer include past gastric bypass surgery and ongoing NSAID use (taken for dental pain). PPI BID Sucralafate. She was found to have low iron level and relatively low ferritin as well. Will treat with PO iron and vitamin C with awareness that absorption may be influenced by PPI and that it may exacerbate constipation. If she does not respond or tolerate, IV iron infusion would be a good option for her. Supplementing nutrition with MVI, thiamine, folate, B12. HCV VL detected, but unquantifiable. HIV VL negative Because she had back pain and active IVDU, we obtained imaging and MRI spine did not show evidence of osteomyelitis. CRP 6, ESR 29 Treating a diagnosed pneumonia (minimally symptomatic with cough but no hypoxia) with doxycycline 100mg BID for 7d, ___. Methadone maintenance: 150mg daily per patient receives at ___ ___, last dose given during admission on ___ transitional she will f/u with gi for repeat endoscopy f/u h. pylori serology f/u gi path biopsy f/u with her usual gastric bypass surgeon get referral to ___ treatment of hepatitis C Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clindamycin 300 mg PO Q8H 2. Thiamine 100 mg PO DAILY 3. Sucralfate 1 gm PO QID 4. Sertraline 50 mg PO QHS 5. Prazosin 2 mg PO QHS 6. Multivitamins 1 TAB PO DAILY 7. Miralax (polyethylene glycol 3350) 17 gram oral DAILY:PRN 8. Docusate Sodium 100 mg PO BID 9. ChlorproMAZINE 50 mg PO Q4H:PRN agitation 10. Baclofen 10 mg PO TID 11. Methadone 150 mg PO DAILY Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY 2. Cyanocobalamin 250 mcg PO DAILY RX cyanocobalamin (vitamin B-12) 250 mcg 1 lozenge(s) by mouth daily Disp #100 Lozenge Refills:0 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #12 Tablet Refills:0 4. Ferrous Sulfate 325 mg PO DAILY RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 7. Senna 8.6 mg PO BID:PRN Constipation 8. Baclofen 10 mg PO TID 9. Docusate Sodium 100 mg PO BID 10. Methadone 150 mg PO DAILY 11. Miralax (polyethylene glycol 3350) 17 gram oral DAILY:PRN 12. Multivitamins 1 TAB PO DAILY 13. Prazosin 2 mg PO QHS 14. Sertraline 50 mg PO QHS 15. Sucralfate 1 gm PO QID 16. Thiamine 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: marginal ulcer pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: you were hospitalized for evaluation of abdomoinal pain and had endoscopy that showed you had an ulcer in the stomach near the connection to the intestines. we recommend you take a proton pump inhibitor, pantoprazole for the next 8 weeks. you will require repeat endoscopy to schedule another look at this ulcer to see how it is healing. we are treating you with doxycycline an antibiotic to treat pneumonia. be aware it can cause photosensivity, and irritate the esophagus, so drink plenty of water with it and sit upright after taking it. we diagnosed low iron levels and recommend iron therapy. take iron ___ apart from the pantoprazole and take it with a vitamin c tablet or some orange juice Followup Instructions: ___	[ "K9589", "J159", "F1120", "K289", "F1410", "D509", "K209", "Z9884", "Y838", "B1920", "F17219", "K2970", "M797", "K029", "K5900", "M5489", "Z791", "Z590" ]	Allergies: Penicillins / amoxicillin / Augmentin / Keflex / erythromycin base / tramadol Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: endoscopy mild erythema in the lower esophagus consistent with mild esophagitis [MASKED] A) Stomach: Lumen: Evidence of a previous Roux-en-Y Gastric Bypass was seen. Mucosa: Erythema and edema of the mucosa was noted in the stomach consistent with gastritis. Cold forceps biopsies were performed for histology at the stomach. Excavated Lesions A single non-bleeding 12 mm ulcer was found in the near gastro-jejunal anastamosis. Other A suture was seen. Duodenum: Other duodenum was not seen due to post surgical anatomy. The efferent and blind jejunal limbs were without abnormality. Impression: Mild erythema in the lower esophagus consistent with mild esophagitis [MASKED] A) esophagitis Previous Roux-en-Y Gastric Bypass of the stomach Erythema and edema of the mucosa in the stomach (biopsy) Ulcer in the near gastro-jejunal anastamosis A suture was seen. Duodenum was not seen due to post surgical anatomy. The efferent and blind jejunal limbs were without abnormality. Otherwise normal EGD to post-anastamotic jejunal limbs Recommendations: - high dose BID PO PPI - no NSAID use - further care per inpatient team History of Present Illness: [MASKED] with h/o gastric bypass surgery, active injection cocaine use, methadone maintenance treatment presentingwith [MASKED] days of upper abdominal pain. Pain started without incident or trauma, progressed to become severe and has impaired appetite and oral intake. Pain is currently [MASKED] and located above umbilicus and is non-radiating. She has not eaten meals for the past 5 days due to low appetite and pain. She did say eating improves pain. She had two episodes of hematemesis that were a teaspoon or less. She is passing flatus. She has not moved her bowels in this period. She was diagnosed with strep pharyngitis and prescribed clindamycin recently. She recently approx. 3 d ago binged on cocaine and shared a needle. She has had a mild cough without SOB, but productive of green phlegm for the past few days. She has also developed mid and lower back pain in this time without associated weakness. She has had fevers to 102 in the past week. ROS: She denies incontinence, dysuria, or hematuria. She last took methadone yesterday. 10pt ROS as per HPI In the ED she received analgesics, underwent CT abdomen that did not show bowel obstruction and had [MASKED] surgery consultation. PMH: s/[ gastric bypass at [MASKED] withj dr. [MASKED] [MASKED] years ago s/p ccy h/o lap surgery for sbo s/p bil oopheroectomy for chronic cysts h/o endometriosis h/o fibromyalgia h/o interstitial cystitis IBS s/p umbilical hernia repair sh; smokes [MASKED] ppd, recently in drug/psych treatment at [MASKED] in mid [MASKED] for 10 days. active cocaine use, recently shared needle. homeless, no alcohol use. fh not pertinent for management of current chief complaint allergies: throat closes to amox, augmentin, penicillin, erythromycin, hives to Keflex meds last written on [MASKED] for [MASKED] pharmacy in [MASKED] baclofen chlorpromazine docusate folic acid gabapentin gylcolax powder multivitamin prazosin sertraline sucralafate thiamine prescribed by [MASKED] on [MASKED]: clindamycin Physical Exam: 97.9 108/70 74 fatigued but non toxic ctab rrr nmrg slight tenderness pain to percussion of mid upper back between scapula and midline lower back just above hips epigastric discomfort and pain to palpation, no rebound or guarding, no palpable organomegaly no suprapubic discomfort normal steady gait full [MASKED] motor strength in all extremities calm and attentive, aox3, fluent speech symmetric facial features discharge avss aox3 calm and cooperative standing up and breathing easily conversant soft abdomen Pertinent Results: [MASKED] 07:15AM BLOOD WBC-9.6 RBC-4.09 Hgb-11.3 Hct-35.1 MCV-86 MCH-27.6 MCHC-32.2 RDW-13.0 RDWSD-40.9 Plt [MASKED] [MASKED] 07:15AM BLOOD Glucose-89 UreaN-5* Creat-0.5 Na-142 K-4.8 Cl-102 HCO3-29 AnGap-11 [MASKED] 08:40PM BLOOD ALT-18 AST-19 AlkPhos-115* TotBili-<0.2 [MASKED] 08:40PM BLOOD Albumin-4.0 Iron-23* [MASKED] 08:40PM BLOOD calTIBC-399 VitB12-327 Ferritn-19 TRF-307 [MASKED] 07:15AM BLOOD 25VitD-38 [MASKED] 09:05AM BLOOD CRP-6.6* [MASKED] 09:05AM BLOOD HIV Ab-NEG [MASKED] 09:05AM BLOOD HCV Ab-POS* HCV Viral Load Not Detected log10 IU/mL MRI spine 1. No evidence of infection orspinal cord compression in the thoracic or lumbar spine. 2. Minimal degenerative changes of the lumbar spine as described above. CXR IMPRESSION: Lungs are low volume with an ill-defined parenchymal opacity in the lingula concerning for pneumonia and posterior segment of the left upper lobe. Heart size is normal. Cardiomediastinal silhouette is unremarkable. There is no pleural effusion. No pneumothorax is seen Abdominal CT IMPRESSION: 1. No acute process within the abdomen or pelvis. Specifically, no small bowel obstruction. 2. Moderate stool burden from ascending to descending colon. 3. Unchanged splenomegaly. Brief Hospital Course: use, methadone maintenance treatment presenting with [MASKED] days of upper abdominal pain found to have marginal ulcer on endoscopy performed on [MASKED]. Contributing factors to ulcer include past gastric bypass surgery and ongoing NSAID use (taken for dental pain). PPI BID Sucralafate. She was found to have low iron level and relatively low ferritin as well. Will treat with PO iron and vitamin C with awareness that absorption may be influenced by PPI and that it may exacerbate constipation. If she does not respond or tolerate, IV iron infusion would be a good option for her. Supplementing nutrition with MVI, thiamine, folate, B12. HCV VL detected, but unquantifiable. HIV VL negative Because she had back pain and active IVDU, we obtained imaging and MRI spine did not show evidence of osteomyelitis. CRP 6, ESR 29 Treating a diagnosed pneumonia (minimally symptomatic with cough but no hypoxia) with doxycycline 100mg BID for 7d, [MASKED]. Methadone maintenance: 150mg daily per patient receives at [MASKED] [MASKED], last dose given during admission on [MASKED] transitional she will f/u with gi for repeat endoscopy f/u h. pylori serology f/u gi path biopsy f/u with her usual gastric bypass surgeon get referral to [MASKED] treatment of hepatitis C Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clindamycin 300 mg PO Q8H 2. Thiamine 100 mg PO DAILY 3. Sucralfate 1 gm PO QID 4. Sertraline 50 mg PO QHS 5. Prazosin 2 mg PO QHS 6. Multivitamins 1 TAB PO DAILY 7. Miralax (polyethylene glycol 3350) 17 gram oral DAILY:PRN 8. Docusate Sodium 100 mg PO BID 9. ChlorproMAZINE 50 mg PO Q4H:PRN agitation 10. Baclofen 10 mg PO TID 11. Methadone 150 mg PO DAILY Discharge Medications: 1. Ascorbic Acid [MASKED] mg PO DAILY 2. Cyanocobalamin 250 mcg PO DAILY RX cyanocobalamin (vitamin B-12) 250 mcg 1 lozenge(s) by mouth daily Disp #100 Lozenge Refills:0 3. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #12 Tablet Refills:0 4. Ferrous Sulfate 325 mg PO DAILY RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:*0 7. Senna 8.6 mg PO BID:PRN Constipation 8. Baclofen 10 mg PO TID 9. Docusate Sodium 100 mg PO BID 10. Methadone 150 mg PO DAILY 11. Miralax (polyethylene glycol 3350) 17 gram oral DAILY:PRN 12. Multivitamins 1 TAB PO DAILY 13. Prazosin 2 mg PO QHS 14. Sertraline 50 mg PO QHS 15. Sucralfate 1 gm PO QID 16. Thiamine 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: marginal ulcer pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: you were hospitalized for evaluation of abdomoinal pain and had endoscopy that showed you had an ulcer in the stomach near the connection to the intestines. we recommend you take a proton pump inhibitor, pantoprazole for the next 8 weeks. you will require repeat endoscopy to schedule another look at this ulcer to see how it is healing. we are treating you with doxycycline an antibiotic to treat pneumonia. be aware it can cause photosensivity, and irritate the esophagus, so drink plenty of water with it and sit upright after taking it. we diagnosed low iron levels and recommend iron therapy. take iron [MASKED] apart from the pantoprazole and take it with a vitamin c tablet or some orange juice Followup Instructions: [MASKED]	[]	[ "D509", "K5900" ]	[ "K9589: Other complications of other bariatric procedure", "J159: Unspecified bacterial pneumonia", "F1120: Opioid dependence, uncomplicated", "K289: Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "F1410: Cocaine abuse, uncomplicated", "D509: Iron deficiency anemia, unspecified", "K209: Esophagitis, unspecified", "Z9884: Bariatric surgery status", "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", "B1920: Unspecified viral hepatitis C without hepatic coma", "F17219: Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders", "K2970: Gastritis, unspecified, without bleeding", "M797: Fibromyalgia", "K029: Dental caries, unspecified", "K5900: Constipation, unspecified", "M5489: Other dorsalgia", "Z791: Long term (current) use of non-steroidal anti-inflammatories (NSAID)", "Z590: Homelessness" ]
19,984,781	23,944,999	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: ___ woman with a history of hypertension, hypothyroidism, and insomnia , osteoarthritis, sjogrens syndromw who presents with weakness, abdominal discomfort and fever. Patient was in her usual state of health until ___ morning. She went out the grab coffee, started walking up her steps and felt significantly light headed, dizzy and very weak. She held on to her railing for support and very slowly made it up her 16 steps. Symptoms continued and worsened with activity. That night, generalize malaise continued, she checked her temperature at 101.5, she did not take anything and slept. ___, she went to visit her PCP, and needed support just to stand up. On ___ she also noticed worsening lower abdominal discomfort. Her PCP was very concerned for urosepsis so sent her to the ED. Of note, patient recently became very sexually active again for the first time in ___ years. She shares that since its been so long, at first it was not very comfortable and that she felt a UTI coming along. No dysuria, just lower abdominal discomfort/awareness. No spotting, malodorous discharge (though her sense of smell is not very good), increased discharge, back pain. Positive for constipation which has been chronic. Past Medical History: hypothyroidism, xerosis/eczema of the skin history of mosquito bite reactions eosinophilia fibromyalgia right hip greater trochanteric bursitis s/p right total hip replacement SJOGREN'S SYNDROME right knee osteoarthritis disc disease s/p discectomy postmenopausal/atrophic vaginitis L5/S1 disc disease/herniation s/p discectomy ___ (no hardware); p/w severe back pain following a fall; MRI ___ showed a large right sided disc herniation with free fragment formation of L5- S1 with some compromise of the thecal sac and the right sided neural foramen h/o erythema nodosum ___ years ago; developed while in ___. Seen by dermatologist but did not undergo etiologic evaluation HTN 6. h/o pneumonia x2; microbiologic etiology unknown IBS Raynaud's phenomenon Infertility hip osteoarthritis elbow fracture s/p fall ___ Social History: ___ Family History: Positive for diabetes, brother, osteoporosis father, and arthritis mother Physical ___: ADMISSION PHYSICAL EXAM: VS: 98.8 PO 132 / 74 L Lying 71 18 97 Ra GENERAL: NAD, smiling, conversing HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, some TTP in lower quadrants/suprapubic superficially, more tender to deep palpation b/l, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS: 98.8 110 / 62 75 18 98 Ra GENERAL: NAD, smiling, conversing HEENT: mildly icteric sclera, pale conjunctiva, icterus under tongue HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, very mild discomfort with deep palpation of the lower abdomen NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, diffuse macular rash on the back with papular rash on thighs Pertinent Results: ADMISSION LABS: ================ ___ 09:08PM URINE ___ ___ 09:08PM URINE ___ ___ 09:08PM URINE ___ ___ 09:08PM URINE ___ ___ 09:08PM URINE ___ SP ___ ___ 09:08PM URINE ___ ___ ___ ___ 09:08PM URINE RBC-<1 ___ ___ ___ 06:42PM ___ ___ 06:20PM ___ UREA ___ ___ TOTAL ___ ANION ___ ___ 06:20PM ___ this ___ 06:20PM ___ ___ 06:20PM ___ ___ ___ 06:20PM ___ ___ IM ___ ___ ___ 06:20PM PLT ___ DISCHARGE LABS: ================ ___ 04:50AM BLOOD ___ ___ Plt ___ ___ 04:50AM BLOOD ___ ___ ___ 04:50AM BLOOD ___ LD(___)-373* ___ ___ 04:50AM BLOOD ___ INTERVAL LABS: ============== ___ 04:10AM BLOOD Ret ___ Abs ___ ___ 04:10AM BLOOD ___ LD(LDH)-390* ___ ___ ___ 04:50AM BLOOD ___ LD(___)-447* ___ ___ 06:36AM BLOOD ___ LD(LDH)-455* ___ ___ 04:42AM BLOOD ___ LD(___)-418* ___ ___ 04:10AM BLOOD ___ cTropnT-<0.01 ___ 06:20PM BLOOD ___ ___ 04:10AM BLOOD ___ Hapto-<10* ___ ___ 04:10AM BLOOD ___ ___ 04:10AM BLOOD Free ___ ___ 04:10AM BLOOD ___ HAV ___ ___ 06:36AM BLOOD ___ ___ 04:50AM BLOOD ___ F ___ ___ ___ 01:15PM BLOOD HIV ___ ___ 04:10AM BLOOD HCV ___ ___ 03:50PM BLOOD HCV ___ DETECT URINE: ====== ___ 01:15AM URINE ___ ___ ___ 05:27AM URINE ___ ___ 09:08PM URINE ___ MICROBIOLOGY ============= ___ 4:42 am Blood (CMV AB) FINAL REPORT ___ CMV IgG ANTIBODY (Final ___: NEGATIVE FOR CMV IgG ANTIBODY BY EIA. <4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final ___: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. Greatly elevated serum protein with IgG levels ___ mg/dl may cause interference with CMV IgM results. ___ 4:50 am SEROLOGY/BLOOD TAKE FROM CHEM # ___ ___. FINAL REPORT ___ MONOSPOT (Final ___: NEGATIVE by Latex Agglutination. ___ 4:10 am SEROLOGY/BLOOD ADDED DBIL ___. FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: ___. ___ 2:29 am SWAB Source: Vaginal. FINAL REPORT ___ SMEAR FOR BACTERIAL VAGINOSIS (Final ___: Indeterminate. Altered vaginal flora that does not meet criteria for diagnosis of bacterial vaginosis. If signs and/or symptoms persist, repeat testing may be warranted. Interpretive criteria have only been established for ___ women and ___ women on hormone replacement therapy. As low estrogen levels alter vaginal flora, results should be interpreted with caution in ___ women. Refer to the on line laboratory manual. Note, neither lactobacilli nor Gardnerella/Bacteroides/Mobiluncus morphotypes observed. The absence of these morphotypes likely represents normal flora in ___ women. YEAST VAGINITIS CULTURE (Final ___: NEGATIVE FOR YEAST. IMAGING: ======== ___ CT ABD & PELVIS WITH CO IMPRESSION: 1. No acute ___ or pelvic findings to correlate with patient's symptoms. 2. Extensive stool burden is visualized throughout the colon and rectum. 3. Narrowing of the proximal celiac axis which can be normal variant or potentially seen in median arcuate ligament syndrome, to be correlated clinically. ___ PELVIS U.S., TRANSVAGIN IMPRESSION: No free pelvic fluid. The ovaries are not visualized. ___ LIVER OR GALLBLADDER US IMPRESSION: Normal abdominal ultrasound with no focal findings to correlate with recent findings of transaminitis. Brief Hospital Course: Ms. ___ is an ___ female with a past medical history of osteoarthritis, diverticulosis, fibromyalgia, Raynaud's phenomenon who presented with fever, generalized weakness and abdominal pain. In the ED, abdominal pain was evaluated with a CT abdomen that revealed a high stool burden but was otherwise negative. Abdominal pain was initially treated with Doxycycline/Unasyn for suspicion of pelvic inflammatory disease that was ruled out with negative STI panel and TVUS, and improved bowel regimen. Labs on arrival were significant for anemia (9.7) and transaminitis. Her anemia was eventually found to be cold autoimmune hemolytic anemia with unclear trigger, with largely negative workup. Transaminitis also had unclear etiology and at discharge her LFTs were stable. Patient also had a diffuse macular rash on her back that improved with steroid cream and sarna lotion. At discharge cryoglobulins, ___, antismooth antibodies, SPEP, Mycoplasma antibodies and flow cytometry were pending. #Cold Autoimmune Hemolytic Anemia: Patient presented with a history of generalized fatigue with elevated LFTs. Direct Coomb's test was positive with negative IgG and 3+ C3 and positive cold agglutinins, indicative of cold autoimmune hemolytic anemia. Trigger for hemolysis is unclear, however, patient has a history of positive ___ and ___, with occasional h/o dry eyes and dry mouth. Patient also had decreased IgG and slight elevated IgM. RF positive. Hepatitis serology, HIV serology, CMV, monospot, RPR, STI panel negative. At discharge cryoglobulins, ___, antismooth antibodies, SPEP, Mycoplasma antibodies and flow cytometry were pending. She was treated with folic acid and B12, is responding appropriately (retic:7.9%) and did not approach transfusion threshold this hospitalization. #Transaminitis: Patient had elevated LFTs this hospitalization with unclear etiology, that stabilized and started to decrease at discharge. Infectious workup negative as above with blood cultures pending and negative UA and urine culture. Unlikely DILI given very short course of antibiotics. RUQ US without any obvious pathology. CMV negative. Possible autoimmune hepatitis with CMV viral load and antismooth antibodies pending at discharge. #Rash: Patient had diffuse itchy macular rash on her back with a papular rash on her thighs that proved with Triamcinolone Acetonide 0.1% Cream and Sarna Lotion. #Hypothyroidism: Patients thyroid function tests were within normal limits. Patient continued levothyroxine #HTN: Patient was continued HCTZ. #Depression: Patient was continued duloxetine TRANSITIONAL ISSUES: ===================== # Cold agglutinin hemolytic anemia. Will have follow up with primary care and hematology; pending results as above for investigation of etiology. #CODE: Full (presumed) #Name of health care proxy: ___ Relationship: Friend Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 60 mg PO DAILY 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Hydrochlorothiazide 12.5 mg PO DAILY 4. Systane (propylene glycol) (peg ___ glycol) ___ % ophthalmic (eye) DAILY Discharge Medications: 1. Cyanocobalamin 50 mcg PO DAILY RX cyanocobalamin (vitamin ___ [Vitamin ___ 50 mcg 1 tablet(s) by mouth DAILY Disp #60 Tablet Refills:0 2. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #60 Tablet Refills:0 3. Sarna Lotion 1 Appl TP BID RX ___ [Sarna ___ 0.5 %-0.5 % TP 1 Appl twice a ___ Refills:0 4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID RX triamcinolone acetonide 0.1 % TP 1 Appl three times a ___ Refills:*0 5. DULoxetine 60 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Systane (propylene glycol) (peg ___ glycol) ___ % ophthalmic (eye) DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== 1. Cold autoimmune hemolytic anemia 2. transaminitis SECONDARY DIAGNOSIS =================== 1. Hypothyroidism 2. HTN 3. Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to ___ because you experienced fever, fatigue and abdominal pain. Please see more details listed below about what happened while you were in the hospital and your instructions for what to do after leaving the hospital. It was a pleasure participating in your care. We wish you the best! Sincerely, Your ___ Care Team =================================== WHAT HAPPENED AT THE HOSPITAL? =================================== - You were evaluated for your abdominal pain and were ruled out for infection, and it was treated with a bowel regimen. - You fatigue and weakness was assessed and was determined to be secondary to an autoimmune condition (cold autoimmune hemolytic anemia. You were treated with medication (folic acid and vitamin B12). You were also evaluated for possible causes triggering this condition, however your workup was negative. ================================================== WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL? ================================================== - Please, follow up with your primary care provider - ___, follow up with hematology Your ___ care team Followup Instructions: ___	[ "D591", "K581", "M3500", "I10", "R740", "E039", "G4700", "M797", "Z96641", "I7300", "R21", "F329" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Weakness Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] woman with a history of hypertension, hypothyroidism, and insomnia , osteoarthritis, sjogrens syndromw who presents with weakness, abdominal discomfort and fever. Patient was in her usual state of health until [MASKED] morning. She went out the grab coffee, started walking up her steps and felt significantly light headed, dizzy and very weak. She held on to her railing for support and very slowly made it up her 16 steps. Symptoms continued and worsened with activity. That night, generalize malaise continued, she checked her temperature at 101.5, she did not take anything and slept. [MASKED], she went to visit her PCP, and needed support just to stand up. On [MASKED] she also noticed worsening lower abdominal discomfort. Her PCP was very concerned for urosepsis so sent her to the ED. Of note, patient recently became very sexually active again for the first time in [MASKED] years. She shares that since its been so long, at first it was not very comfortable and that she felt a UTI coming along. No dysuria, just lower abdominal discomfort/awareness. No spotting, malodorous discharge (though her sense of smell is not very good), increased discharge, back pain. Positive for constipation which has been chronic. Past Medical History: hypothyroidism, xerosis/eczema of the skin history of mosquito bite reactions eosinophilia fibromyalgia right hip greater trochanteric bursitis s/p right total hip replacement SJOGREN'S SYNDROME right knee osteoarthritis disc disease s/p discectomy postmenopausal/atrophic vaginitis L5/S1 disc disease/herniation s/p discectomy [MASKED] (no hardware); p/w severe back pain following a fall; MRI [MASKED] showed a large right sided disc herniation with free fragment formation of L5- S1 with some compromise of the thecal sac and the right sided neural foramen h/o erythema nodosum [MASKED] years ago; developed while in [MASKED]. Seen by dermatologist but did not undergo etiologic evaluation HTN 6. h/o pneumonia x2; microbiologic etiology unknown IBS Raynaud's phenomenon Infertility hip osteoarthritis elbow fracture s/p fall [MASKED] Social History: [MASKED] Family History: Positive for diabetes, brother, osteoporosis father, and arthritis mother Physical [MASKED]: ADMISSION PHYSICAL EXAM: VS: 98.8 PO 132 / 74 L Lying 71 18 97 Ra GENERAL: NAD, smiling, conversing HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, some TTP in lower quadrants/suprapubic superficially, more tender to deep palpation b/l, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: VS: 98.8 110 / 62 75 18 98 Ra GENERAL: NAD, smiling, conversing HEENT: mildly icteric sclera, pale conjunctiva, icterus under tongue HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, very mild discomfort with deep palpation of the lower abdomen NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, diffuse macular rash on the back with papular rash on thighs Pertinent Results: ADMISSION LABS: ================ [MASKED] 09:08PM URINE [MASKED] [MASKED] 09:08PM URINE [MASKED] [MASKED] 09:08PM URINE [MASKED] [MASKED] 09:08PM URINE [MASKED] [MASKED] 09:08PM URINE [MASKED] SP [MASKED] [MASKED] 09:08PM URINE [MASKED] [MASKED] [MASKED] [MASKED] 09:08PM URINE RBC-<1 [MASKED] [MASKED] [MASKED] 06:42PM [MASKED] [MASKED] 06:20PM [MASKED] UREA [MASKED] [MASKED] TOTAL [MASKED] ANION [MASKED] [MASKED] 06:20PM [MASKED] this [MASKED] 06:20PM [MASKED] [MASKED] 06:20PM [MASKED] [MASKED] [MASKED] 06:20PM [MASKED] [MASKED] IM [MASKED] [MASKED] [MASKED] 06:20PM PLT [MASKED] DISCHARGE LABS: ================ [MASKED] 04:50AM BLOOD [MASKED] [MASKED] Plt [MASKED] [MASKED] 04:50AM BLOOD [MASKED] [MASKED] [MASKED] 04:50AM BLOOD [MASKED] LD([MASKED])-373* [MASKED] [MASKED] 04:50AM BLOOD [MASKED] INTERVAL LABS: ============== [MASKED] 04:10AM BLOOD Ret [MASKED] Abs [MASKED] [MASKED] 04:10AM BLOOD [MASKED] LD(LDH)-390* [MASKED] [MASKED] [MASKED] 04:50AM BLOOD [MASKED] LD([MASKED])-447* [MASKED] [MASKED] 06:36AM BLOOD [MASKED] LD(LDH)-455* [MASKED] [MASKED] 04:42AM BLOOD [MASKED] LD([MASKED])-418* [MASKED] [MASKED] 04:10AM BLOOD [MASKED] cTropnT-<0.01 [MASKED] 06:20PM BLOOD [MASKED] [MASKED] 04:10AM BLOOD [MASKED] Hapto-<10* [MASKED] [MASKED] 04:10AM BLOOD [MASKED] [MASKED] 04:10AM BLOOD Free [MASKED] [MASKED] 04:10AM BLOOD [MASKED] HAV [MASKED] [MASKED] 06:36AM BLOOD [MASKED] [MASKED] 04:50AM BLOOD [MASKED] F [MASKED] [MASKED] [MASKED] 01:15PM BLOOD HIV [MASKED] [MASKED] 04:10AM BLOOD HCV [MASKED] [MASKED] 03:50PM BLOOD HCV [MASKED] DETECT URINE: ====== [MASKED] 01:15AM URINE [MASKED] [MASKED] [MASKED] 05:27AM URINE [MASKED] [MASKED] 09:08PM URINE [MASKED] MICROBIOLOGY ============= [MASKED] 4:42 am Blood (CMV AB) FINAL REPORT [MASKED] CMV IgG ANTIBODY (Final [MASKED]: NEGATIVE FOR CMV IgG ANTIBODY BY EIA. <4 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [MASKED]: NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. Greatly elevated serum protein with IgG levels [MASKED] mg/dl may cause interference with CMV IgM results. [MASKED] 4:50 am SEROLOGY/BLOOD TAKE FROM CHEM # [MASKED] [MASKED]. FINAL REPORT [MASKED] MONOSPOT (Final [MASKED]: NEGATIVE by Latex Agglutination. [MASKED] 4:10 am SEROLOGY/BLOOD ADDED DBIL [MASKED]. FINAL REPORT [MASKED] RAPID PLASMA REAGIN TEST (Final [MASKED]: NONREACTIVE. Reference Range: [MASKED]. [MASKED] 2:29 am SWAB Source: Vaginal. FINAL REPORT [MASKED] SMEAR FOR BACTERIAL VAGINOSIS (Final [MASKED]: Indeterminate. Altered vaginal flora that does not meet criteria for diagnosis of bacterial vaginosis. If signs and/or symptoms persist, repeat testing may be warranted. Interpretive criteria have only been established for [MASKED] women and [MASKED] women on hormone replacement therapy. As low estrogen levels alter vaginal flora, results should be interpreted with caution in [MASKED] women. Refer to the on line laboratory manual. Note, neither lactobacilli nor Gardnerella/Bacteroides/Mobiluncus morphotypes observed. The absence of these morphotypes likely represents normal flora in [MASKED] women. YEAST VAGINITIS CULTURE (Final [MASKED]: NEGATIVE FOR YEAST. IMAGING: ======== [MASKED] CT ABD & PELVIS WITH CO IMPRESSION: 1. No acute [MASKED] or pelvic findings to correlate with patient's symptoms. 2. Extensive stool burden is visualized throughout the colon and rectum. 3. Narrowing of the proximal celiac axis which can be normal variant or potentially seen in median arcuate ligament syndrome, to be correlated clinically. [MASKED] PELVIS U.S., TRANSVAGIN IMPRESSION: No free pelvic fluid. The ovaries are not visualized. [MASKED] LIVER OR GALLBLADDER US IMPRESSION: Normal abdominal ultrasound with no focal findings to correlate with recent findings of transaminitis. Brief Hospital Course: Ms. [MASKED] is an [MASKED] female with a past medical history of osteoarthritis, diverticulosis, fibromyalgia, Raynaud's phenomenon who presented with fever, generalized weakness and abdominal pain. In the ED, abdominal pain was evaluated with a CT abdomen that revealed a high stool burden but was otherwise negative. Abdominal pain was initially treated with Doxycycline/Unasyn for suspicion of pelvic inflammatory disease that was ruled out with negative STI panel and TVUS, and improved bowel regimen. Labs on arrival were significant for anemia (9.7) and transaminitis. Her anemia was eventually found to be cold autoimmune hemolytic anemia with unclear trigger, with largely negative workup. Transaminitis also had unclear etiology and at discharge her LFTs were stable. Patient also had a diffuse macular rash on her back that improved with steroid cream and sarna lotion. At discharge cryoglobulins, [MASKED], antismooth antibodies, SPEP, Mycoplasma antibodies and flow cytometry were pending. #Cold Autoimmune Hemolytic Anemia: Patient presented with a history of generalized fatigue with elevated LFTs. Direct Coomb's test was positive with negative IgG and 3+ C3 and positive cold agglutinins, indicative of cold autoimmune hemolytic anemia. Trigger for hemolysis is unclear, however, patient has a history of positive [MASKED] and [MASKED], with occasional h/o dry eyes and dry mouth. Patient also had decreased IgG and slight elevated IgM. RF positive. Hepatitis serology, HIV serology, CMV, monospot, RPR, STI panel negative. At discharge cryoglobulins, [MASKED], antismooth antibodies, SPEP, Mycoplasma antibodies and flow cytometry were pending. She was treated with folic acid and B12, is responding appropriately (retic:7.9%) and did not approach transfusion threshold this hospitalization. #Transaminitis: Patient had elevated LFTs this hospitalization with unclear etiology, that stabilized and started to decrease at discharge. Infectious workup negative as above with blood cultures pending and negative UA and urine culture. Unlikely DILI given very short course of antibiotics. RUQ US without any obvious pathology. CMV negative. Possible autoimmune hepatitis with CMV viral load and antismooth antibodies pending at discharge. #Rash: Patient had diffuse itchy macular rash on her back with a papular rash on her thighs that proved with Triamcinolone Acetonide 0.1% Cream and Sarna Lotion. #Hypothyroidism: Patients thyroid function tests were within normal limits. Patient continued levothyroxine #HTN: Patient was continued HCTZ. #Depression: Patient was continued duloxetine TRANSITIONAL ISSUES: ===================== # Cold agglutinin hemolytic anemia. Will have follow up with primary care and hematology; pending results as above for investigation of etiology. #CODE: Full (presumed) #Name of health care proxy: [MASKED] Relationship: Friend Phone number: [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 60 mg PO DAILY 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Hydrochlorothiazide 12.5 mg PO DAILY 4. Systane (propylene glycol) (peg [MASKED] glycol) [MASKED] % ophthalmic (eye) DAILY Discharge Medications: 1. Cyanocobalamin 50 mcg PO DAILY RX cyanocobalamin (vitamin [MASKED] [Vitamin [MASKED] 50 mcg 1 tablet(s) by mouth DAILY Disp #60 Tablet Refills:0 2. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #60 Tablet Refills:0 3. Sarna Lotion 1 Appl TP BID RX [MASKED] [Sarna [MASKED] 0.5 %-0.5 % TP 1 Appl twice a [MASKED] Refills:0 4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID RX triamcinolone acetonide 0.1 % TP 1 Appl three times a [MASKED] Refills:*0 5. DULoxetine 60 mg PO DAILY 6. Hydrochlorothiazide 12.5 mg PO DAILY 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Systane (propylene glycol) (peg [MASKED] glycol) [MASKED] % ophthalmic (eye) DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== 1. Cold autoimmune hemolytic anemia 2. transaminitis SECONDARY DIAGNOSIS =================== 1. Hypothyroidism 2. HTN 3. Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You came to [MASKED] because you experienced fever, fatigue and abdominal pain. Please see more details listed below about what happened while you were in the hospital and your instructions for what to do after leaving the hospital. It was a pleasure participating in your care. We wish you the best! Sincerely, Your [MASKED] Care Team =================================== WHAT HAPPENED AT THE HOSPITAL? =================================== - You were evaluated for your abdominal pain and were ruled out for infection, and it was treated with a bowel regimen. - You fatigue and weakness was assessed and was determined to be secondary to an autoimmune condition (cold autoimmune hemolytic anemia. You were treated with medication (folic acid and vitamin B12). You were also evaluated for possible causes triggering this condition, however your workup was negative. ================================================== WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL? ================================================== - Please, follow up with your primary care provider - [MASKED], follow up with hematology Your [MASKED] care team Followup Instructions: [MASKED]	[]	[ "I10", "E039", "G4700", "F329" ]	[ "D591: Other autoimmune hemolytic anemias", "K581: Irritable bowel syndrome with constipation", "M3500: Sicca syndrome, unspecified", "I10: Essential (primary) hypertension", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "E039: Hypothyroidism, unspecified", "G4700: Insomnia, unspecified", "M797: Fibromyalgia", "Z96641: Presence of right artificial hip joint", "I7300: Raynaud's syndrome without gangrene", "R21: Rash and other nonspecific skin eruption", "F329: Major depressive disorder, single episode, unspecified" ]
19,984,781	28,904,296	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fever, SOB and cough Major Surgical or Invasive Procedure: left sided chest tube ___ Left VATS decorticattion History of Present Illness: ___ PMH of Sjogrens, Hypothyroidism, Atypical CLL, Cold Agglutin Hemolytic Anemia (s/p rituxan), who presented to ED with cough, found to have worsening anemia thought to be ___ hemolysis for which she was admitted to oncology Patient noted that in late ___ patient had been in ___ for 3 weeks. Was visiting a her new partner with a grandchild who had a viral illness. Patient subsequently had temp 103, CXR at the time was reportedly negative, was seen in ___ urgent care, thought to have bronchitis, was given inhalers which helped, but then developed worsening fevers while in ___ over the past few days so presented to urgent care after flying home where she was found to have profound leukocytosis/anemia for which she was referred to the ED Pt reports that she has had gradual worsening of fatigue, dyspnea, cough, and fevers. She denied headache, nasal congestion, sore throat, nausea, vomiting, diarrhea. She noted that she had been constipated the past few days which is normal for her. Described white sputum which is new for her. She noted that symptoms were so bad in ___ that she thought "I would die before I made it back home". In the ED initial vitals were 98.1F 94 165/68 18 99% 2L NC. Tmax in ED was 102.2, BP remained stable, was eventually weaned back to room air. Labs significant for WBC: 41.1, HGB: 5.7. Plt Count: 828. Chemistry: Na: 132. K: 4.7. Cl: 93. CO2: 22. BUN: 19. Creat: 0.7. Ca: 9.0. Mg: 2.6. PO4: 4.4, Lactate: 1.4, Coags: INR: 1.4. PTT: 26.6, LFTs: ALT: 15. AST: 17. Alk Phos: 124. Total Bili: 3.0. LDH 335, Haptoglobin 197, UA: 1 WBC. Flu A/B PCR: negative CXR: "Left lower lobe consolidation with small pleural effusion concerning for pneumonia with parapneumonic effusion". EKG unchanged from baseline with normal QTc. ED management significant for: 500cc NS, Pip-tazo 4.5g, Vancomycin 1g, 2U PRBCs Past Medical History: -HTN -Fibromyalgia -Bunion of great toe -Hearing loss in left ear -Depression -Raynaud's syndrome -Osteopenia -Radiculopathy, cervical -Restless leg -Degenerative arthritis of hip s/p THR -Right knee DJD - Hypothyroidism, adult -Acquired hemolytic anemia, cold agglutinin disease -CLL (chronic lymphocytic leukemia) -Sjogrens -Hypothyroidism Social History: ___ Family History: Positive for diabetes, brother, osteoporosis father, and arthritis mother Physical ___: Temp: 98.6 PO BP: 148/56 HR: 94 RR: 36 O2 sat: 95% O2 delivery: RA GENERAL: sitting in bed, appears fatigued/tired, NAD EYES: PERRLA, anicteric HEENT: OP clear, dry MM NECK: supple LUNGS: CTA grossly in posterior lung fields, but did not sit forward long enough to hear deepest aspect of bases, has slightly increased RR when talking but speaks in full sentences, dry sounding cough CV: RRR normal distal perfusion without edema ABD: soft, NT, ND, normoactive BS GENITOURINARY: no foley EXT: no deformity, muscle bulk appropriate with age SKIN: warm, dry NEURO: AOx3, fluent speech, able to speak about recent/distant events ACCESS: PIV Pertinent Results: WBC RBC Hgb Hct MCV ___ ___ RDW RDWSD Plt Ct ___ 08:45 9.5 2.74 8.6* 25.5* 93 31.4 33.7 20.2* 64.4* 780* ___ 09:00 14.7* 2.02* 6.3* 19.7* 98 31.2 32.0 19.0* 66.3* 828* ___ 09:10 27.4* 2.35* 7.3* 22.6* 96 31.1 32.3 19.5* 66.7* 10231 ___ 07:20 29.1 2.92* 9.3* 28.5* 98 31.8 32.6 19.9* 70.3* 885* ___ 07:35 20.8* 2.65* 8.3* 24.9* 94 31.3 33.3 20.6* 68.4* 788* ___ 07:23 25.2* 2.69* 8.4* 25.5* 95 31.2 32.9 21.2* 68.1* 769* ___ 07:25 24.6* 2.68* 8.3* 25.3* 94 31.0 32.8 21.4* 65.8* 705* ___ 07:10 32.7* 2.66* 8.3* 24.6* 93 31.2 33.7 20.2* 62.3* 742* ___ 07:25 31.1* 2.27* 7.3* 21.9* 97 32.2* 33.3 18.2* 56.5* 689* ___ 06:35 33.5* 2.58* 8.4* 24.6* 95 32.6* 34.1 18.1* 57.4* 695* ___ 17:18 32.2* 2.71* 8.7* 25.2* 93 32.1* 34.5 18.2* 55.2* 685* ___ 06:50 31.5* 2.46* 8.4* 23.3* 95 34.1* 36.1 18.3* 57.5* 641* ___ 18:50 36.6* 2.71* 8.9* 25.2* 93 32.8* 35.3 16.8* 51.8* 657* ___ 07:45 36.5* 2.08* 6.9* 19.8* 95 33.2* 34.8 15.1 48.5* 665* ___ 12:00 41.1* 1.69* 5.7* 16.8* 99* 33.7* 33.9 14.9 51.5* 828* Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 09:00 ___ 1352 4.1 100 22 132 ___ 09:10 ___ 1342 3.7 100 20 142 ___ 07:20 811 6 0.5 1402 4.0 101 21* 182 ___ 07:35 ___ 1422 3.6 104 20* 182 ___ 07:23 ___ 1372 3.7 100 21* 162 ___ 07:25 ___ 1392 3.9 101 21* 172 ___ 07:10 ___ 4.3 101 19* 172 ___ 07:25 ___ 1372 4.1 102 20* 152 ___ 06:35 ___ 1362 4.5 100 22 142 ___ 17:18 ___ 1342 4.0 98 22 142 ___ 06:50 ___ 1382 4.4 102 20 162 ___ 07:45 ___ 1382 4.2 ___ ___ 12:00 ___ 1322 4.7 93 22 172 Ret Aut Abs Ret (absolute) ___ 09:00 10.7* 0.22* ___ 07:10 11.9* 0.32* ___ 12:00 9.2* 0.15* ___ 3:29 pm PLEURAL FLUID FINAL REPORT ___ GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1 PLATE. ANAEROBIC CULTURE (Final ___: Reported to and read back by ___ ___ 1130AM. NO ANAEROBES ISOLATED. GRAM POSITIVE COCCUS(COCCI). 1 COLONY ON 1 PLATE. SEE FURTHER IDENTIFICATION IN THE FLUID CULTURE. ___ 9:00 am PLEURAL FLUID GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ___ 10:49 am URINE Source: Catheter. FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ Chest CT : -Small to moderate left hydropneumothorax is partially loculated, with a pigtail in place. -Left lower lobe consolidation is likely combination of pneumonia possibly aspiration, and atelectasis. -Bronchitis and bronchiolitis is widespread in the right lung. -No mass lesion is identified. ___ Chest CT : Multi loculated left pleural effusions slightly increased in volume since the prior study. Left-sided pigtail catheter remains in place. The partially loculated right pleural effusion is unchanged since the prior study. Dense consolidation in the left lower lobe could represent combination of atelectasis and pneumonia. Multifocal opacities throughout the right lung have slightly improved and could represent a resolving pneumonia. Stable small mediastinal lymph nodes which are most likely reactive. New ground-glass opacities in the right apex could be inflammatory could represent early edema or could represent new focus of pneumonia. ___ CXR : As compared to the prior radiograph, there has been interval stability of moderate left and small right pleural effusion. No new focal consolidations. Brief Hospital Course: ___ y/o F with PMhx of CLL on rituxan c/b cold agglutinin hemolytic anemia, Sjogrens and hypothyroid who p/w 2 weeks of cough complicated by new fevers and SOB found to have a LLL PNA and acute on chronic anemia likely secondary to flare of cold agglutinin hemolytic anemia. #LLL PNA with new loculated pleural effusion and thoracenteis was c/w empyema. IP Consult and chest tube placed on ___, and pt was treated with vanc and Ceftriaxone. The chest tube clogged multiple times, resulting in a thoracic surgery consultation on ___. VATS/decortication was recommended and done on ___. She tolerated the procedure well and had 2 chest tubes placed to suction. Cultures were sent intraop which are currently negative and she was maintained on Ceftriaxone, Vancomycin and Flagyl up until ___. Her chest tubes were removed on ___ and her post pull chest xray showed small B/L effusions and no pneumothorax. Her oxygen was weaned off and her room air saturations were 95%. Her port sites were healing well. She has 2 chest tube sutures in place which will be removed at her visit with Dr. ___ on ___. #Acute hemolytic anemia-cold agglutinins: got 3units prbcs on admission for a Hct of 16.8 which brought her to 25. Post op her hematocrit trended down to 19 and she received 2 UPC on ___ which brought her back to 25 on ___. Her retic count was 10.7 with a normal LDH. The hematology service followed her and will see her as an out patient on ___ with blood work ordered for ___ (see Pg1 referral. #Urinary retention developed during this hospital stay although she had no urinary complaints. She was placed on Flomax and her Foley catherer remained in place until ___ when she became more ambulatory. Her catheter was removed at 8AM and she is due to void around 4PM. A urine culture was done on ___ which was negative. The Physical Therapy service evaluated her on numerous occasions and recommended a short term rehab prior to returning home to help increase her mobility and endurance and maintain her independence. She was discharged to rehab on ___ and will follow up with Dr. ___ in 2 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 60 mg PO DAILY 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 7. Fluticasone Propionate 110mcg 1 PUFF IH BID 8. TraZODone 50-100 mg PO QHS:PRN insomnia Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID 4. Lidocaine 5% Patch 2 PTCH TD QAM chest wall pain 5. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN sore mouth 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First line 8. Senna 17.2 mg PO BID 9. Tamsulosin 0.4 mg PO QHS 10. TraZODone 25 mg PO QHS:PRN Insomnia 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 12. Cyanocobalamin 1000 mcg PO DAILY 13. DULoxetine 60 mg PO DAILY 14. Fluticasone Propionate 110mcg 1 PUFF IH BID 15. FoLIC Acid 1 mg PO DAILY 16. Levothyroxine Sodium 50 mcg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Pneumonia Left parapneumonic effusion/empyema Urinary retention Hemolytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital with pneumonia and a parapneumonic effusion which required eventual lung surgery. You've recovered well and are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. Dr. ___ will remove the chest tube stitches in the office. * You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol ___ mg every 6 hours . * 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 -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: ___	[ "A419", "J189", "J869", "J918", "C9110", "D591", "J984", "E871", "E869", "T85698A", "T451X5S", "R339", "M3500", "E039", "I10", "M797", "F329", "I7300", "M8580", "M5412", "G2581", "Z96649", "Y831", "Y92239", "D473", "H9190", "Z87891", "B957" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: fever, SOB and cough Major Surgical or Invasive Procedure: left sided chest tube [MASKED] Left VATS decorticattion History of Present Illness: [MASKED] PMH of Sjogrens, Hypothyroidism, Atypical CLL, Cold Agglutin Hemolytic Anemia (s/p rituxan), who presented to ED with cough, found to have worsening anemia thought to be [MASKED] hemolysis for which she was admitted to oncology Patient noted that in late [MASKED] patient had been in [MASKED] for 3 weeks. Was visiting a her new partner with a grandchild who had a viral illness. Patient subsequently had temp 103, CXR at the time was reportedly negative, was seen in [MASKED] urgent care, thought to have bronchitis, was given inhalers which helped, but then developed worsening fevers while in [MASKED] over the past few days so presented to urgent care after flying home where she was found to have profound leukocytosis/anemia for which she was referred to the ED Pt reports that she has had gradual worsening of fatigue, dyspnea, cough, and fevers. She denied headache, nasal congestion, sore throat, nausea, vomiting, diarrhea. She noted that she had been constipated the past few days which is normal for her. Described white sputum which is new for her. She noted that symptoms were so bad in [MASKED] that she thought "I would die before I made it back home". In the ED initial vitals were 98.1F 94 165/68 18 99% 2L NC. Tmax in ED was 102.2, BP remained stable, was eventually weaned back to room air. Labs significant for WBC: 41.1, HGB: 5.7. Plt Count: 828. Chemistry: Na: 132. K: 4.7. Cl: 93. CO2: 22. BUN: 19. Creat: 0.7. Ca: 9.0. Mg: 2.6. PO4: 4.4, Lactate: 1.4, Coags: INR: 1.4. PTT: 26.6, LFTs: ALT: 15. AST: 17. Alk Phos: 124. Total Bili: 3.0. LDH 335, Haptoglobin 197, UA: 1 WBC. Flu A/B PCR: negative CXR: "Left lower lobe consolidation with small pleural effusion concerning for pneumonia with parapneumonic effusion". EKG unchanged from baseline with normal QTc. ED management significant for: 500cc NS, Pip-tazo 4.5g, Vancomycin 1g, 2U PRBCs Past Medical History: -HTN -Fibromyalgia -Bunion of great toe -Hearing loss in left ear -Depression -Raynaud's syndrome -Osteopenia -Radiculopathy, cervical -Restless leg -Degenerative arthritis of hip s/p THR -Right knee DJD - Hypothyroidism, adult -Acquired hemolytic anemia, cold agglutinin disease -CLL (chronic lymphocytic leukemia) -Sjogrens -Hypothyroidism Social History: [MASKED] Family History: Positive for diabetes, brother, osteoporosis father, and arthritis mother Physical [MASKED]: Temp: 98.6 PO BP: 148/56 HR: 94 RR: 36 O2 sat: 95% O2 delivery: RA GENERAL: sitting in bed, appears fatigued/tired, NAD EYES: PERRLA, anicteric HEENT: OP clear, dry MM NECK: supple LUNGS: CTA grossly in posterior lung fields, but did not sit forward long enough to hear deepest aspect of bases, has slightly increased RR when talking but speaks in full sentences, dry sounding cough CV: RRR normal distal perfusion without edema ABD: soft, NT, ND, normoactive BS GENITOURINARY: no foley EXT: no deformity, muscle bulk appropriate with age SKIN: warm, dry NEURO: AOx3, fluent speech, able to speak about recent/distant events ACCESS: PIV Pertinent Results: WBC RBC Hgb Hct MCV [MASKED] [MASKED] RDW RDWSD Plt Ct [MASKED] 08:45 9.5 2.74 8.6* 25.5* 93 31.4 33.7 20.2* 64.4* 780* [MASKED] 09:00 14.7* 2.02* 6.3* 19.7* 98 31.2 32.0 19.0* 66.3* 828* [MASKED] 09:10 27.4* 2.35* 7.3* 22.6* 96 31.1 32.3 19.5* 66.7* 10231 [MASKED] 07:20 29.1 2.92* 9.3* 28.5* 98 31.8 32.6 19.9* 70.3* 885* [MASKED] 07:35 20.8* 2.65* 8.3* 24.9* 94 31.3 33.3 20.6* 68.4* 788* [MASKED] 07:23 25.2* 2.69* 8.4* 25.5* 95 31.2 32.9 21.2* 68.1* 769* [MASKED] 07:25 24.6* 2.68* 8.3* 25.3* 94 31.0 32.8 21.4* 65.8* 705* [MASKED] 07:10 32.7* 2.66* 8.3* 24.6* 93 31.2 33.7 20.2* 62.3* 742* [MASKED] 07:25 31.1* 2.27* 7.3* 21.9* 97 32.2* 33.3 18.2* 56.5* 689* [MASKED] 06:35 33.5* 2.58* 8.4* 24.6* 95 32.6* 34.1 18.1* 57.4* 695* [MASKED] 17:18 32.2* 2.71* 8.7* 25.2* 93 32.1* 34.5 18.2* 55.2* 685* [MASKED] 06:50 31.5* 2.46* 8.4* 23.3* 95 34.1* 36.1 18.3* 57.5* 641* [MASKED] 18:50 36.6* 2.71* 8.9* 25.2* 93 32.8* 35.3 16.8* 51.8* 657* [MASKED] 07:45 36.5* 2.08* 6.9* 19.8* 95 33.2* 34.8 15.1 48.5* 665* [MASKED] 12:00 41.1* 1.69* 5.7* 16.8* 99* 33.7* 33.9 14.9 51.5* 828* Glucose UreaN Creat Na K Cl HCO3 AnGap [MASKED] 09:00 [MASKED] 1352 4.1 100 22 132 [MASKED] 09:10 [MASKED] 1342 3.7 100 20 142 [MASKED] 07:20 811 6 0.5 1402 4.0 101 21* 182 [MASKED] 07:35 [MASKED] 1422 3.6 104 20* 182 [MASKED] 07:23 [MASKED] 1372 3.7 100 21* 162 [MASKED] 07:25 [MASKED] 1392 3.9 101 21* 172 [MASKED] 07:10 [MASKED] 4.3 101 19* 172 [MASKED] 07:25 [MASKED] 1372 4.1 102 20* 152 [MASKED] 06:35 [MASKED] 1362 4.5 100 22 142 [MASKED] 17:18 [MASKED] 1342 4.0 98 22 142 [MASKED] 06:50 [MASKED] 1382 4.4 102 20 162 [MASKED] 07:45 [MASKED] 1382 4.2 [MASKED] [MASKED] 12:00 [MASKED] 1322 4.7 93 22 172 Ret Aut Abs Ret (absolute) [MASKED] 09:00 10.7* 0.22* [MASKED] 07:10 11.9* 0.32* [MASKED] 12:00 9.2* 0.15* [MASKED] 3:29 pm PLEURAL FLUID FINAL REPORT [MASKED] GRAM STAIN (Final [MASKED]: 2+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [MASKED]: STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1 PLATE. ANAEROBIC CULTURE (Final [MASKED]: Reported to and read back by [MASKED] [MASKED] 1130AM. NO ANAEROBES ISOLATED. GRAM POSITIVE COCCUS(COCCI). 1 COLONY ON 1 PLATE. SEE FURTHER IDENTIFICATION IN THE FLUID CULTURE. [MASKED] 9:00 am PLEURAL FLUID GRAM STAIN (Final [MASKED]: 3+ [MASKED] per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [MASKED] 10:49 am URINE Source: Catheter. FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: NO GROWTH. [MASKED] Chest CT : -Small to moderate left hydropneumothorax is partially loculated, with a pigtail in place. -Left lower lobe consolidation is likely combination of pneumonia possibly aspiration, and atelectasis. -Bronchitis and bronchiolitis is widespread in the right lung. -No mass lesion is identified. [MASKED] Chest CT : Multi loculated left pleural effusions slightly increased in volume since the prior study. Left-sided pigtail catheter remains in place. The partially loculated right pleural effusion is unchanged since the prior study. Dense consolidation in the left lower lobe could represent combination of atelectasis and pneumonia. Multifocal opacities throughout the right lung have slightly improved and could represent a resolving pneumonia. Stable small mediastinal lymph nodes which are most likely reactive. New ground-glass opacities in the right apex could be inflammatory could represent early edema or could represent new focus of pneumonia. [MASKED] CXR : As compared to the prior radiograph, there has been interval stability of moderate left and small right pleural effusion. No new focal consolidations. Brief Hospital Course: [MASKED] y/o F with PMhx of CLL on rituxan c/b cold agglutinin hemolytic anemia, Sjogrens and hypothyroid who p/w 2 weeks of cough complicated by new fevers and SOB found to have a LLL PNA and acute on chronic anemia likely secondary to flare of cold agglutinin hemolytic anemia. #LLL PNA with new loculated pleural effusion and thoracenteis was c/w empyema. IP Consult and chest tube placed on [MASKED], and pt was treated with vanc and Ceftriaxone. The chest tube clogged multiple times, resulting in a thoracic surgery consultation on [MASKED]. VATS/decortication was recommended and done on [MASKED]. She tolerated the procedure well and had 2 chest tubes placed to suction. Cultures were sent intraop which are currently negative and she was maintained on Ceftriaxone, Vancomycin and Flagyl up until [MASKED]. Her chest tubes were removed on [MASKED] and her post pull chest xray showed small B/L effusions and no pneumothorax. Her oxygen was weaned off and her room air saturations were 95%. Her port sites were healing well. She has 2 chest tube sutures in place which will be removed at her visit with Dr. [MASKED] on [MASKED]. #Acute hemolytic anemia-cold agglutinins: got 3units prbcs on admission for a Hct of 16.8 which brought her to 25. Post op her hematocrit trended down to 19 and she received 2 UPC on [MASKED] which brought her back to 25 on [MASKED]. Her retic count was 10.7 with a normal LDH. The hematology service followed her and will see her as an out patient on [MASKED] with blood work ordered for [MASKED] (see Pg1 referral. #Urinary retention developed during this hospital stay although she had no urinary complaints. She was placed on Flomax and her Foley catherer remained in place until [MASKED] when she became more ambulatory. Her catheter was removed at 8AM and she is due to void around 4PM. A urine culture was done on [MASKED] which was negative. The Physical Therapy service evaluated her on numerous occasions and recommended a short term rehab prior to returning home to help increase her mobility and endurance and maintain her independence. She was discharged to rehab on [MASKED] and will follow up with Dr. [MASKED] in 2 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. DULoxetine 60 mg PO DAILY 2. Levothyroxine Sodium 50 mcg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Guaifenesin-CODEINE Phosphate [MASKED] mL PO HS:PRN cough 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 7. Fluticasone Propionate 110mcg 1 PUFF IH BID 8. TraZODone 50-100 mg PO QHS:PRN insomnia Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID 4. Lidocaine 5% Patch 2 PTCH TD QAM chest wall pain 5. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN sore mouth 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First line 8. Senna 17.2 mg PO BID 9. Tamsulosin 0.4 mg PO QHS 10. TraZODone 25 mg PO QHS:PRN Insomnia 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 12. Cyanocobalamin 1000 mcg PO DAILY 13. DULoxetine 60 mg PO DAILY 14. Fluticasone Propionate 110mcg 1 PUFF IH BID 15. FoLIC Acid 1 mg PO DAILY 16. Levothyroxine Sodium 50 mcg PO DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Pneumonia Left parapneumonic effusion/empyema Urinary retention Hemolytic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: * You were admitted to the hospital with pneumonia and a parapneumonic effusion which required eventual lung surgery. You've recovered well and are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. Dr. [MASKED] will remove the chest tube stitches in the office. * You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol [MASKED] mg every 6 hours . * 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 -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: [MASKED]	[]	[ "E871", "E039", "I10", "F329", "Z87891" ]	[ "A419: Sepsis, unspecified organism", "J189: Pneumonia, unspecified organism", "J869: Pyothorax without fistula", "J918: Pleural effusion in other conditions classified elsewhere", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "D591: Other autoimmune hemolytic anemias", "J984: Other disorders of lung", "E871: Hypo-osmolality and hyponatremia", "E869: Volume depletion, unspecified", "T85698A: Other mechanical complication of other specified internal prosthetic devices, implants and grafts, initial encounter", "T451X5S: Adverse effect of antineoplastic and immunosuppressive drugs, sequela", "R339: Retention of urine, unspecified", "M3500: Sicca syndrome, unspecified", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "M797: Fibromyalgia", "F329: Major depressive disorder, single episode, unspecified", "I7300: Raynaud's syndrome without gangrene", "M8580: Other specified disorders of bone density and structure, unspecified site", "M5412: Radiculopathy, cervical region", "G2581: Restless legs syndrome", "Z96649: Presence of unspecified artificial hip joint", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "D473: Essential (hemorrhagic) thrombocythemia", "H9190: Unspecified hearing loss, unspecified ear", "Z87891: Personal history of nicotine dependence", "B957: Other staphylococcus as the cause of diseases classified elsewhere" ]
19,984,875	22,068,002	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / latex Attending: ___ Chief Complaint: Aphasia Major Surgical or Invasive Procedure: None History of Present Illness: Ms ___ is a ___ year old woman with history of lung cancer and status post right lobectomy in ___, seizure disorder and status post resection of a solitary brain metastasis from the left temporal lobe of the brain, who presents to the ED after her family noticed speech difficulty, confusion, and right sided weakness. Code stroke was activated for these deficits. She was last seen to be well by her nephews when she went to bed last night, around midnight. She woke up this morning and was able to use the bathroom, get dressed, and prepare breakfast as she usually does. However, when her nephew first spoke to her, she was only able to say ___ to his questions. She was able to say her own name but otherwise had difficulty producing any coherent speech. They did not notice any facial droop or focal weakness at that time. He does not think her speech was slurred. These symptoms continued throughout the morning. They called the ___ clinic, who recommended taking an additional 4mg of Dexamethasone, which she did around noon. Symptoms did not seem to improve over the next few hours. They again spoke to the ___ clinic taking an additional 4 mg of dexamethasone at dinnertime. At approximately 3:30 ___, when her nephew went to him for something, she seemed to be weak in the right arm. He is unable to say further what exactly seemed weak. Shortly thereafter, when she was trying to eat some toast with her right hand, he noticed that she actually had her hands in her mouth, and not the toast. They told her to lie down the couch for a while. About an hour later, she got up to use the bathroom. After she did so she seemed to have difficulty pulling up her pants. Her nephews think that both the right arm and right leg seemed somewhat weak. At this point they brought her to the emergency department for evaluation. Code stroke was subsequently activated given her weakness. To briefly review her history, she had her first seizure on ___. This was witnessed by her nephews. She had a sudden onset of nonsense speech lasting for about 1 minute, followed by shaking of her upper & lower extremities. She was unresponsive and fell out of her chair, striking the right side of her face. She had a similar episode of speech difficulty in ___. An initial non-contrast head CT from the emergency department showed a right posterior temporal lobe mass with vasogenic edema. She was admitted to the neurosurgery service. A gadolinium-enhanced head MRI performed on ___ showed a 3.5 cm left temporal rim enhancing lesion with chronic blood products and surrounding edema suggestive of metastatic disease. She underwent a neurosurgical resection on ___ by Dr. ___. She was again admitted from the emergency department on ___ after a seizure manifesting as focal motor seizure in the right arm and word-finding difficulty. Keppra was increased from 1000mg BID to ___ TID during that admission. Past Medical History: Per admitting Neurosurgery Team: - arthritis - iron deficiency anemia - lung cancer status post lobectomy - panic disorder - status post hip replacement in ___ Social History: ___ Family History: Per admitting Neurosurgery Team: Noncontributory Physical Exam: Admission exam: Vitals: T: 99.1 BP: 129/56 HR: 101 RR: 18 SaO2: 98% RA General: Awake, appears uncomfortable. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: She is awake and alert and keenly responsive. She is unable to answer most orientation questions, and instead perseverates on such statements as "I want to go home" and "I'll be fine in a bit". Requires multiple prompts to follow commands and even then only does so intermittently. Is able to mimic. Not cooperative with tests of attention. She cannot name or repeat, but this seems to mostly be due to difficulty with attention and/or understanding the task. Speech is very mildly dysarthric. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. Blink to threat present bilaterally. No facial droop, facial musculature symmetric. Palate elevates symmetrically. Tongue protrudes in midline. -Motor: Normal bulk and tone throughout. She does not participate in focused strength testing. She is able to lift all extremities off the bed and maintain them there for at least 10 seconds, with some downward drift in only the right leg. -Sensory: Unable to participate but does withdraw from pinch in all extremities. -Reflexes: Restless, cannot participate -Coordination: No obvious dysmetria when reaching for objects. -Gait: Not tested ================================= Discharge exam: Expired Pertinent Results: LABS: ===== ___ 09:45PM K+-3.9 ___ 08:20PM URINE HOURS-RANDOM ___ 08:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 08:20PM URINE COLOR-Straw APPEAR-Hazy* SP ___ ___ 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG ___ 08:20PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 ___ 08:20PM URINE AMORPH-RARE* ___ 07:55PM ___ PTT-27.6 ___ ___ 07:33PM WBC-3.3* RBC-3.57* HGB-11.7 HCT-35.3 MCV-99* MCH-32.8* MCHC-33.1 RDW-13.7 RDWSD-50.4* ___ 07:33PM NEUTS-78.5* LYMPHS-13.5* MONOS-6.5 EOS-0.0* BASOS-0.9 IM ___ AbsNeut-2.55 AbsLymp-0.44* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.03 ___ 07:33PM PLT COUNT-262 ___ 07:06PM LACTATE-1.8 ___ 06:45PM GLUCOSE-154* UREA N-9 CREAT-0.5 SODIUM-132* POTASSIUM-6.8* CHLORIDE-96 TOTAL CO2-23 ANION GAP-13 ___ 06:45PM estGFR-Using this ___ 06:45PM CALCIUM-9.7 PHOSPHATE-4.4 MAGNESIUM-2.2 ___ 06:45PM HCT-UNABLE TO ___ 06:45PM ___ TO PTT-UNABLE TO ___ TO ___ 06:45PM ___ TO PTT-UNABLE TO ___ TO CSF: ==== ___ 06:15PM CEREBROSPINAL FLUID (CSF) TNC-56* RBC-2 Polys-0 ___ Monos-8 Other-2 ___ 06:15PM CEREBROSPINAL FLUID (CSF) TNC-75* RBC-8* Polys-1 ___ Monos-6 Other-10 ___ 06:15PM CEREBROSPINAL FLUID (CSF) TotProt-270* Glucose-15 MRI brain w/wo ___ ================== IMPRESSION: 1. Significant worsening of enhancing mass surrounding surgical cavity, worsened surrounding edema, likely represents tumor progression. ASL, DSC perfusion would be helpful to exclude radiation necrosis. 2. New 1.5 cm left middle cranial fossa mass consistent with metastasis. 3. Suggestion of small inferior right cerebellar lesion, area is motion degraded. 4. Improved right frontal lesion. Brief Hospital Course: ___ year old woman with known metastatic NSCLC with L temporal lesion s/p L temporal lobectomy (___) and radiation (___) and R frontal lesion currently undergoing cyberknife, and resulting seizure d/o on Keppra who presented with acute on subacute inattentiveness and worsening aphasia on ___. Per additional collateral from family, she had a subacute course of confusion and mixed aphasia over the last several weeks. Acutely, on the morning of presentation she was found repeatedly saying "yes" to her family members, expressive aphasia, and right sided weakness. This did not improve after receiving an extra dose of dexamethasone. She was brought to our ED for further evaluation. Exam during her course notable for mixed, primarily receptive aphasia with significant inattention and perseveration. She can follow simple commands. She can name some high frequency objects and repeat simple phrases. Motor exam is without any clear laterality and difficult given her aphasia, but she is at least antigravity bilaterally. DTRs are brisker on right and right toe is upgoing. Workup notable for EEG which revealed PLEDs but no seizures; she was loaded with VPA without improvement, and we decided to not ___ the PLEDs further as it was likely related to her underlying lesion and not clearly symptomatic. LP revealed WBC 75/56 with lymphocytic predominance, RBC ___, protein 270, glucose 15; cytology was positive for metastatic adenocarcinoma. She was initially covered w/ acyclovir empirically for possible HSV given recent mouth lesions and immunosuppression, but then stopped as HSV PCR was neg. MRI brain w/ and w/o contrast revealed significantly increased FLAIR hyperintensities in this L temporal lesion extending beyond the radiation bed. We discussed the case with neuro-radiology who felt that overall this was consistent with disease progression, and could not be explained by post-radiation changes. This together with carcinomatous meningitis made her prognosis very poor and following discussion with her neuro-oncologist further interventions or treatments would not be able to improve this. The patient was ultimately transitioned to CMO status and palliative care was consulted. She died on the evening of ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 5 mg PO TID 2. Dexamethasone 4 mg PO DAILY 3. Famotidine 20 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. LevETIRAcetam 1000 mg PO TID 6. Nystatin Oral Suspension 5 mL PO QID 7. ValACYclovir 1000 mg PO DAILY 8. Acetaminophen 325-650 mg PO BID:PRN Pain - Mild Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Carcinomatous meningitis Metastatic NSCLC Seizures Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: ___	[ "C7931", "G936", "J9691", "R4701", "Z515", "C3491", "G8191", "B370", "R64", "Z6821", "Z66", "G131", "G40909", "Z87891", "R471", "D509", "N318", "R338" ]	Allergies: Sulfa (Sulfonamide Antibiotics) / latex Chief Complaint: Aphasia Major Surgical or Invasive Procedure: None History of Present Illness: Ms [MASKED] is a [MASKED] year old woman with history of lung cancer and status post right lobectomy in [MASKED], seizure disorder and status post resection of a solitary brain metastasis from the left temporal lobe of the brain, who presents to the ED after her family noticed speech difficulty, confusion, and right sided weakness. Code stroke was activated for these deficits. She was last seen to be well by her nephews when she went to bed last night, around midnight. She woke up this morning and was able to use the bathroom, get dressed, and prepare breakfast as she usually does. However, when her nephew first spoke to her, she was only able to say [MASKED] to his questions. She was able to say her own name but otherwise had difficulty producing any coherent speech. They did not notice any facial droop or focal weakness at that time. He does not think her speech was slurred. These symptoms continued throughout the morning. They called the [MASKED] clinic, who recommended taking an additional 4mg of Dexamethasone, which she did around noon. Symptoms did not seem to improve over the next few hours. They again spoke to the [MASKED] clinic taking an additional 4 mg of dexamethasone at dinnertime. At approximately 3:30 [MASKED], when her nephew went to him for something, she seemed to be weak in the right arm. He is unable to say further what exactly seemed weak. Shortly thereafter, when she was trying to eat some toast with her right hand, he noticed that she actually had her hands in her mouth, and not the toast. They told her to lie down the couch for a while. About an hour later, she got up to use the bathroom. After she did so she seemed to have difficulty pulling up her pants. Her nephews think that both the right arm and right leg seemed somewhat weak. At this point they brought her to the emergency department for evaluation. Code stroke was subsequently activated given her weakness. To briefly review her history, she had her first seizure on [MASKED]. This was witnessed by her nephews. She had a sudden onset of nonsense speech lasting for about 1 minute, followed by shaking of her upper & lower extremities. She was unresponsive and fell out of her chair, striking the right side of her face. She had a similar episode of speech difficulty in [MASKED]. An initial non-contrast head CT from the emergency department showed a right posterior temporal lobe mass with vasogenic edema. She was admitted to the neurosurgery service. A gadolinium-enhanced head MRI performed on [MASKED] showed a 3.5 cm left temporal rim enhancing lesion with chronic blood products and surrounding edema suggestive of metastatic disease. She underwent a neurosurgical resection on [MASKED] by Dr. [MASKED]. She was again admitted from the emergency department on [MASKED] after a seizure manifesting as focal motor seizure in the right arm and word-finding difficulty. Keppra was increased from 1000mg BID to [MASKED] TID during that admission. Past Medical History: Per admitting Neurosurgery Team: - arthritis - iron deficiency anemia - lung cancer status post lobectomy - panic disorder - status post hip replacement in [MASKED] Social History: [MASKED] Family History: Per admitting Neurosurgery Team: Noncontributory Physical Exam: Admission exam: Vitals: T: 99.1 BP: 129/56 HR: 101 RR: 18 SaO2: 98% RA General: Awake, appears uncomfortable. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No [MASKED] edema. Skin: No rashes or lesions noted. Neurologic: -Mental Status: She is awake and alert and keenly responsive. She is unable to answer most orientation questions, and instead perseverates on such statements as "I want to go home" and "I'll be fine in a bit". Requires multiple prompts to follow commands and even then only does so intermittently. Is able to mimic. Not cooperative with tests of attention. She cannot name or repeat, but this seems to mostly be due to difficulty with attention and/or understanding the task. Speech is very mildly dysarthric. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. Blink to threat present bilaterally. No facial droop, facial musculature symmetric. Palate elevates symmetrically. Tongue protrudes in midline. -Motor: Normal bulk and tone throughout. She does not participate in focused strength testing. She is able to lift all extremities off the bed and maintain them there for at least 10 seconds, with some downward drift in only the right leg. -Sensory: Unable to participate but does withdraw from pinch in all extremities. -Reflexes: Restless, cannot participate -Coordination: No obvious dysmetria when reaching for objects. -Gait: Not tested ================================= Discharge exam: Expired Pertinent Results: LABS: ===== [MASKED] 09:45PM K+-3.9 [MASKED] 08:20PM URINE HOURS-RANDOM [MASKED] 08:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG [MASKED] 08:20PM URINE COLOR-Straw APPEAR-Hazy* SP [MASKED] [MASKED] 08:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [MASKED] 08:20PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE EPI-0 [MASKED] 08:20PM URINE AMORPH-RARE* [MASKED] 07:55PM [MASKED] PTT-27.6 [MASKED] [MASKED] 07:33PM WBC-3.3* RBC-3.57* HGB-11.7 HCT-35.3 MCV-99* MCH-32.8* MCHC-33.1 RDW-13.7 RDWSD-50.4* [MASKED] 07:33PM NEUTS-78.5* LYMPHS-13.5* MONOS-6.5 EOS-0.0* BASOS-0.9 IM [MASKED] AbsNeut-2.55 AbsLymp-0.44* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.03 [MASKED] 07:33PM PLT COUNT-262 [MASKED] 07:06PM LACTATE-1.8 [MASKED] 06:45PM GLUCOSE-154* UREA N-9 CREAT-0.5 SODIUM-132* POTASSIUM-6.8* CHLORIDE-96 TOTAL CO2-23 ANION GAP-13 [MASKED] 06:45PM estGFR-Using this [MASKED] 06:45PM CALCIUM-9.7 PHOSPHATE-4.4 MAGNESIUM-2.2 [MASKED] 06:45PM HCT-UNABLE TO [MASKED] 06:45PM [MASKED] TO PTT-UNABLE TO [MASKED] TO [MASKED] 06:45PM [MASKED] TO PTT-UNABLE TO [MASKED] TO CSF: ==== [MASKED] 06:15PM CEREBROSPINAL FLUID (CSF) TNC-56* RBC-2 Polys-0 [MASKED] Monos-8 Other-2 [MASKED] 06:15PM CEREBROSPINAL FLUID (CSF) TNC-75* RBC-8* Polys-1 [MASKED] Monos-6 Other-10 [MASKED] 06:15PM CEREBROSPINAL FLUID (CSF) TotProt-270* Glucose-15 MRI brain w/wo [MASKED] ================== IMPRESSION: 1. Significant worsening of enhancing mass surrounding surgical cavity, worsened surrounding edema, likely represents tumor progression. ASL, DSC perfusion would be helpful to exclude radiation necrosis. 2. New 1.5 cm left middle cranial fossa mass consistent with metastasis. 3. Suggestion of small inferior right cerebellar lesion, area is motion degraded. 4. Improved right frontal lesion. Brief Hospital Course: [MASKED] year old woman with known metastatic NSCLC with L temporal lesion s/p L temporal lobectomy ([MASKED]) and radiation ([MASKED]) and R frontal lesion currently undergoing cyberknife, and resulting seizure d/o on Keppra who presented with acute on subacute inattentiveness and worsening aphasia on [MASKED]. Per additional collateral from family, she had a subacute course of confusion and mixed aphasia over the last several weeks. Acutely, on the morning of presentation she was found repeatedly saying "yes" to her family members, expressive aphasia, and right sided weakness. This did not improve after receiving an extra dose of dexamethasone. She was brought to our ED for further evaluation. Exam during her course notable for mixed, primarily receptive aphasia with significant inattention and perseveration. She can follow simple commands. She can name some high frequency objects and repeat simple phrases. Motor exam is without any clear laterality and difficult given her aphasia, but she is at least antigravity bilaterally. DTRs are brisker on right and right toe is upgoing. Workup notable for EEG which revealed PLEDs but no seizures; she was loaded with VPA without improvement, and we decided to not [MASKED] the PLEDs further as it was likely related to her underlying lesion and not clearly symptomatic. LP revealed WBC 75/56 with lymphocytic predominance, RBC [MASKED], protein 270, glucose 15; cytology was positive for metastatic adenocarcinoma. She was initially covered w/ acyclovir empirically for possible HSV given recent mouth lesions and immunosuppression, but then stopped as HSV PCR was neg. MRI brain w/ and w/o contrast revealed significantly increased FLAIR hyperintensities in this L temporal lesion extending beyond the radiation bed. We discussed the case with neuro-radiology who felt that overall this was consistent with disease progression, and could not be explained by post-radiation changes. This together with carcinomatous meningitis made her prognosis very poor and following discussion with her neuro-oncologist further interventions or treatments would not be able to improve this. The patient was ultimately transitioned to CMO status and palliative care was consulted. She died on the evening of [MASKED]. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 5 mg PO TID 2. Dexamethasone 4 mg PO DAILY 3. Famotidine 20 mg PO DAILY 4. Furosemide 20 mg PO DAILY 5. LevETIRAcetam 1000 mg PO TID 6. Nystatin Oral Suspension 5 mL PO QID 7. ValACYclovir 1000 mg PO DAILY 8. Acetaminophen 325-650 mg PO BID:PRN Pain - Mild Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Carcinomatous meningitis Metastatic NSCLC Seizures Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: [MASKED]	[]	[ "Z515", "Z66", "Z87891", "D509" ]	[ "C7931: Secondary malignant neoplasm of brain", "G936: Cerebral edema", "J9691: Respiratory failure, unspecified with hypoxia", "R4701: Aphasia", "Z515: Encounter for palliative care", "C3491: Malignant neoplasm of unspecified part of right bronchus or lung", "G8191: Hemiplegia, unspecified affecting right dominant side", "B370: Candidal stomatitis", "R64: Cachexia", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "Z66: Do not resuscitate", "G131: Other systemic atrophy primarily affecting central nervous system in neoplastic disease", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z87891: Personal history of nicotine dependence", "R471: Dysarthria and anarthria", "D509: Iron deficiency anemia, unspecified", "N318: Other neuromuscular dysfunction of bladder", "R338: Other retention of urine" ]
19,984,875	24,610,259	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / latex Attending: ___. Chief Complaint: Per admitting Neurosurgery Team: Left posterior parietal mets Major Surgical or Invasive Procedure: None History of Present Illness: Per admitting Neurosurgery Team: ___ year old female with history of lung cancer and left posterior parietal mets to brain (s/p resection ___ presented to ___ with right-arm focal seizure, and word-finding difficulty. She received 10mg IV dexamethasone and underwent a NCHCT with increased edema. She was transferred to ___. Of note, the patient recently started Cyberknife on ___. She was admitted to the ___ for close neurologic monitoring. Past Medical History: Per admitting Neurosurgery Team: - arthritis - iron deficiency anemia - lung cancer status post lobectomy - panic disorder - status post hip replacement in ___ Social History: ___ Family History: Per admitting Neurosurgery Team: Noncontributory Physical Exam: Per admitting Neurosurgery Team: PHYSICAL EXAMINATION ON ADMISSION: =================================== Gen: alert, cachectic. Pupils: ___ EOMs: unable to formally assess, tracks examiner Extrem: Warm and well-perfused. RUE with notable focal sz activity Neuro: Mental status: Awake and alert, partially cooperative with exam Orientation: expressive aphasia, with fluent non-relevant speech. Unable to orient. Language: expressive aphasia, with fluent non-relevant. Some receptive language intact with intermittent ability to follow simple commands Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1mm bilaterally. III, IV, VI: Extraocular movements unable to formally assess, tracks examiner. V, VII: Facial strength unable to formally assess, but no notable facial droop. VIII: Hearing intact to voice. XII: would not stick out tongue to command Motor: Right upper extremity with focal seizure activity. Right lower extremity withdraws to noxious. Left upper and left lower extremities assessed with confrontational motor exam, patient able to participate with simple commands and is 4+/5. Sensation: left-side intact to light touch PHYSICAL EXAMINATION ON DISCHARGE: ================================== VS: 97.9 128/76 70 18 98%RA GENERAL: Well-appearing lady, in no distress sitting in chair in solarium comfortably. HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx clear. 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: Non-distended, normal bowel sounds, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. No lower extremity edema. No erythema or tenderness. NEURO: Comprehensive aphasia but with linear thought process, mentating coherently. CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: Neurosurgery course: ##Brain lesion, metastatic lung carcinoma with cerebral edema The patient was admitted to the ___ on ___ with right upper extremity seizure activity. She underwent a CT of the head which showed edema. On ___, she underwent a MRI of the brain which revealed edema but no new lesions. On ___, the patient remained neurologically stable and it was determined she would be transferred to the ___ service on ___ to start Cyberknife treatment. Medical oncology course: Ms. ___ is a ___ year-old lady with metastatic NSCLC (s/p lobectomy, brain mets) c/b seizures s/p resection of R post temporal lobe mass (___) who presented with seizure and aphasia finding progression of residual disease seen on brain MRI, started on high dose steroids, uptitrated antiepileptics and received 5 fractions of SRS with significant improvement. . #Seizure disorder #Comprehensive aphasia #Encephalopathy #CNS metastatic disease #Cerebral edema Encephalopathy is likely post-ictal and resolved during the course of the admission. Aphasia and seizure episode possible triggered by edema in setting of progression of residual disease. With marked improvement in encephephalopathy and aphasia since ___ likely secondary to high-dose steroids, uptitrated levetiracetam. OT Received 5 fractions of SRS while in-house. OT recommended home with 24h care +ADL/IADL assistance which family was able to provide. Initially on dexamethasone 4mg q6h, tapered to 4mg q12h. Was started on dapson for PJP ppx and famotidine for PUD ppx. #Anxiety #Panic disorder Treated with BusPIRone 5 mg PO TID and LORazepam 1 mg PO/NG DAILY:PRN xrt to good effect. #Cancer associated chronic pain: Received intermittent tramadol 25 mg PO Q6H:PRN pain with minimal requirement by the end of the admission. #Metastatic NSCLC: With cerebral metastatic recurrence after lobectomy. Next steps in systemic treatment per Dr. ___ ___ ISSUES =================== 1. Started on dexamethasone 4mg q6h, tapered to 4mg q12h prior to discharge. Taper per Dr. ___. 2. Started on dapsone 100mg daily for PJP prophylaxis 40 minutes spent formulating and coordinating this patient's discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain 2. Dexamethasone 2 mg PO/NG DAILY This is dose # 5 of 5 tapered doses Tapered dose - DOWN 3. Docusate Sodium 100 mg PO/NG BID:PRN Constipation 4. Furosemide 20 mg PO/NG DAILY 5. Famotidine 20 mg PO/NG BID 6. LevETIRAcetam 1000 mg PO BID 7. Senna 17.2 mg PO/NG QHS:PRN Constipation 8. Heparin 5000 UNIT SC BID 9. OxyCODONE (Immediate Release) ___ mg PO/NG Q6H:PRN Pain 10. Dexamethasone 2 mg PO/NG Q12H This is dose # 4 of 5 tapered doses Tapered dose - DOWN Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain RX acetaminophen 325 mg ___ capsule(s) by mouth four times a day Disp #60 Capsule Refills:0 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line RX bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #60 Tablet Refills:0 3. BusPIRone 5 mg PO TID RX buspirone 5 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 4. Dapsone 100 mg PO DAILY PJP ppx RX dapsone 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Docusate Sodium 100 mg PO BID:PRN Constipation RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 6. Famotidine 20 mg PO BID RX famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. Dexamethasone 4 mg PO Q12H RX dexamethasone [Decadron] 4 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 8. LevETIRAcetam 1000 mg PO TID RX levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 9. Senna 8.6 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity 10. Furosemide 20 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Seizure disorder Secondary neoplasm of the brain, progression Vasogenic cerebral edema Wernicke's aphasia Non-small cell lung cancer Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted for seizures due to growth in your brain tumor. You were started on steroids, anti-seizure medications and were given Cyberknife radiosurgery. You improved significantly. You are ready to continue recovering at home. It was a pleasure to take care of you. Your ___ Team Followup Instructions: ___	[ "C7931", "G936", "G9349", "G8191", "G40109", "R64", "Z6826", "F802", "Z85118", "F419", "F410", "G893", "D509", "Z96641", "Z87891", "Z902", "E7800" ]	Allergies: Sulfa (Sulfonamide Antibiotics) / latex Chief Complaint: Per admitting Neurosurgery Team: Left posterior parietal mets Major Surgical or Invasive Procedure: None History of Present Illness: Per admitting Neurosurgery Team: [MASKED] year old female with history of lung cancer and left posterior parietal mets to brain (s/p resection [MASKED] presented to [MASKED] with right-arm focal seizure, and word-finding difficulty. She received 10mg IV dexamethasone and underwent a NCHCT with increased edema. She was transferred to [MASKED]. Of note, the patient recently started Cyberknife on [MASKED]. She was admitted to the [MASKED] for close neurologic monitoring. Past Medical History: Per admitting Neurosurgery Team: - arthritis - iron deficiency anemia - lung cancer status post lobectomy - panic disorder - status post hip replacement in [MASKED] Social History: [MASKED] Family History: Per admitting Neurosurgery Team: Noncontributory Physical Exam: Per admitting Neurosurgery Team: PHYSICAL EXAMINATION ON ADMISSION: =================================== Gen: alert, cachectic. Pupils: [MASKED] EOMs: unable to formally assess, tracks examiner Extrem: Warm and well-perfused. RUE with notable focal sz activity Neuro: Mental status: Awake and alert, partially cooperative with exam Orientation: expressive aphasia, with fluent non-relevant speech. Unable to orient. Language: expressive aphasia, with fluent non-relevant. Some receptive language intact with intermittent ability to follow simple commands Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1mm bilaterally. III, IV, VI: Extraocular movements unable to formally assess, tracks examiner. V, VII: Facial strength unable to formally assess, but no notable facial droop. VIII: Hearing intact to voice. XII: would not stick out tongue to command Motor: Right upper extremity with focal seizure activity. Right lower extremity withdraws to noxious. Left upper and left lower extremities assessed with confrontational motor exam, patient able to participate with simple commands and is 4+/5. Sensation: left-side intact to light touch PHYSICAL EXAMINATION ON DISCHARGE: ================================== VS: 97.9 128/76 70 18 98%RA GENERAL: Well-appearing lady, in no distress sitting in chair in solarium comfortably. HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx clear. 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: Non-distended, normal bowel sounds, soft, non-tender, no guarding, no palpable masses, no organomegaly. EXT: Warm, well perfused. No lower extremity edema. No erythema or tenderness. NEURO: Comprehensive aphasia but with linear thought process, mentating coherently. CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: Neurosurgery course: ##Brain lesion, metastatic lung carcinoma with cerebral edema The patient was admitted to the [MASKED] on [MASKED] with right upper extremity seizure activity. She underwent a CT of the head which showed edema. On [MASKED], she underwent a MRI of the brain which revealed edema but no new lesions. On [MASKED], the patient remained neurologically stable and it was determined she would be transferred to the [MASKED] service on [MASKED] to start Cyberknife treatment. Medical oncology course: Ms. [MASKED] is a [MASKED] year-old lady with metastatic NSCLC (s/p lobectomy, brain mets) c/b seizures s/p resection of R post temporal lobe mass ([MASKED]) who presented with seizure and aphasia finding progression of residual disease seen on brain MRI, started on high dose steroids, uptitrated antiepileptics and received 5 fractions of SRS with significant improvement. . #Seizure disorder #Comprehensive aphasia #Encephalopathy #CNS metastatic disease #Cerebral edema Encephalopathy is likely post-ictal and resolved during the course of the admission. Aphasia and seizure episode possible triggered by edema in setting of progression of residual disease. With marked improvement in encephephalopathy and aphasia since [MASKED] likely secondary to high-dose steroids, uptitrated levetiracetam. OT Received 5 fractions of SRS while in-house. OT recommended home with 24h care +ADL/IADL assistance which family was able to provide. Initially on dexamethasone 4mg q6h, tapered to 4mg q12h. Was started on dapson for PJP ppx and famotidine for PUD ppx. #Anxiety #Panic disorder Treated with BusPIRone 5 mg PO TID and LORazepam 1 mg PO/NG DAILY:PRN xrt to good effect. #Cancer associated chronic pain: Received intermittent tramadol 25 mg PO Q6H:PRN pain with minimal requirement by the end of the admission. #Metastatic NSCLC: With cerebral metastatic recurrence after lobectomy. Next steps in systemic treatment per Dr. [MASKED] [MASKED] ISSUES =================== 1. Started on dexamethasone 4mg q6h, tapered to 4mg q12h prior to discharge. Taper per Dr. [MASKED]. 2. Started on dapsone 100mg daily for PJP prophylaxis 40 minutes spent formulating and coordinating this patient's discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain 2. Dexamethasone 2 mg PO/NG DAILY This is dose # 5 of 5 tapered doses Tapered dose - DOWN 3. Docusate Sodium 100 mg PO/NG BID:PRN Constipation 4. Furosemide 20 mg PO/NG DAILY 5. Famotidine 20 mg PO/NG BID 6. LevETIRAcetam 1000 mg PO BID 7. Senna 17.2 mg PO/NG QHS:PRN Constipation 8. Heparin 5000 UNIT SC BID 9. OxyCODONE (Immediate Release) [MASKED] mg PO/NG Q6H:PRN Pain 10. Dexamethasone 2 mg PO/NG Q12H This is dose # 4 of 5 tapered doses Tapered dose - DOWN Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain RX acetaminophen 325 mg [MASKED] capsule(s) by mouth four times a day Disp #60 Capsule Refills:0 2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line RX bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #60 Tablet Refills:0 3. BusPIRone 5 mg PO TID RX buspirone 5 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 4. Dapsone 100 mg PO DAILY PJP ppx RX dapsone 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 5. Docusate Sodium 100 mg PO BID:PRN Constipation RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 6. Famotidine 20 mg PO BID RX famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 7. Dexamethasone 4 mg PO Q12H RX dexamethasone [Decadron] 4 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 8. LevETIRAcetam 1000 mg PO TID RX levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 9. Senna 8.6 mg PO BID:PRN Constipation - First Line Reason for PRN duplicate override: Alternating agents for similar severity 10. Furosemide 20 mg PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Seizure disorder Secondary neoplasm of the brain, progression Vasogenic cerebral edema Wernicke's aphasia Non-small cell lung cancer Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [MASKED], You were admitted for seizures due to growth in your brain tumor. You were started on steroids, anti-seizure medications and were given Cyberknife radiosurgery. You improved significantly. You are ready to continue recovering at home. It was a pleasure to take care of you. Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "F419", "D509", "Z87891" ]	[ "C7931: Secondary malignant neoplasm of brain", "G936: Cerebral edema", "G9349: Other encephalopathy", "G8191: Hemiplegia, unspecified affecting right dominant side", "G40109: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus", "R64: Cachexia", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "F802: Mixed receptive-expressive language disorder", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "F419: Anxiety disorder, unspecified", "F410: Panic disorder [episodic paroxysmal anxiety]", "G893: Neoplasm related pain (acute) (chronic)", "D509: Iron deficiency anemia, unspecified", "Z96641: Presence of right artificial hip joint", "Z87891: Personal history of nicotine dependence", "Z902: Acquired absence of lung [part of]", "E7800: Pure hypercholesterolemia, unspecified" ]
19,984,875	26,828,045	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Left temporal ___ lesion Major Surgical or Invasive Procedure: ___ - Left craniotomy for resection of left temporal ___ lesion History of Present Illness: ___ is a ___ year old female with a history of lung cancer who presented to the Emergency Department on ___ with a new onset seizure. CT of the head concerning for a left temporal ___ lesion. The Neurosurgery Service was consulted for question of acute neurosurgical intervention. Patient was admitted to ___ further evaluation and management. Past Medical History: - arthritis - iron deficiency anemia - lung cancer status post lobectomy - panic disorder - status post hip replacement in ___ Social History: ___ Family History: Noncontributory Physical Exam: On Admission: ------------- Vital Signs: T 97.7F, HR 115, BP 133/70, RR 18, O2Sat 99% room air General: Elderly female laying on stretcher. Head, Eyes, Ears, Nose, Throat: Right periorbital ecchymosis and edema. Pupils equal, round, and reactive to light. Extraocular movements full. Lungs: No respiratory distress. Extremities: Warm and well perfused. Neurologic: Mental status: Awake and alert, follows simple commands. Orientation: Oriented to person only. Language: Nonfluent speech. Perseverative. Impaired naming. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No drift. Sensation: Intact to light touch. On Discharge: ------------- General: Vital Signs: T 98.1F, HR 74, BP 125/61, RR 16, O2Sat 96% room air Exam: Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place - With options [x]Time - With options Follows Commands: [ ]Simple [x]Complex [ ]None Pupils: Pupils equal, round, and reactive to light Extraocular Movements: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trapezius Deltoid Biceps Triceps Grip Right5 5 5 5 5 Left 5 5 5 5 5 IP Quadriceps Hamstring AT ___ Gastrocnemius Right5 5 5 5 5 5 Left 4+* 4+* 4+* 5 5 5 *Pain limited. [x]Sensation intact to light touch Surgical Incision: [x]Clean, dry, intact [x]Staples Pertinent Results: Please see OMR for relevant laboratory and imaging results. Brief Hospital Course: ___ year old female with a left temporal ___ lesion. #Left Temporal ___ Lesion MRI of the ___ was obtained and confirmed the presence of a left temporal ___ lesion. Patient was started on Keppra to treat her seizures. She was also started on dexamethasone for cerebral edema. CT of the chest, abdomen, and pelvis did not reveal any areas of lung cancer recurrence or other metastases. Neuro Oncology and Radiation Oncology were consulted. Patient was taken to the operating room on ___ for a left craniotomy for resection of the left temporal ___ lesion. The procedure was uncomplicated and well tolerated. Tissue was sent for pathology. Patient was extubated in the operating room and recovered in the PACU. Patient was transferred to the step down unit postoperatively for close neurologic monitoring. Postoperative CT of the head showed expected postoperative changes and was negative for any acute intracranial hemorrhage. Postoperative MRI of the ___ also showed expected postoperative changes. Patient was eventually transferred to the floor. Patient was evaluated by Physical Therapy and Occupational Therapy, both of whom recommended rehabilitation. On ___, patient was neurologically stable. Patient was afebrile with stable vital signs, tolerating activity, tolerating a regular diet, voiding and stooling without difficulty, and her pain was well controlled with oral pain medications. She was discharged to ___ ___ in ___ on ___ in stable condition. She will follow-up in the ___ with Dr. ___ ___ days after surgery for staple removal. She will also follow-up in the ___ Tumor Clinic with Dr. ___ on ___ to determine further treatment. #History of Lung Cancer Medical Oncology was consulted given the patient's history of lung cancer. Patient will follow-up with Medical Oncology after discharge as an outpatient. #T4 Compression Fracture There was an age indeterminate T4 anterior compression deformity noted on CT of the chest. Patient does not have any tenderness to palpation. No activity restrictions or bracing indicated. #Left Lower Extremity Pain There was no acute fracture on x-ray of the left lower extremity, however there was a small knee joint effusion. Ultrasound of the left lower extremity was negative for deep vein thrombosis. Medications on Admission: - furosemide 20mg by mouth once daily - lorazepam 0.5mg by mouth three times daily - oxycodone 15mg by mouth Q6H as needed for pain Discharge Medications: 1. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain Do not exceed 3000mg in 24 hours. 2. Dexamethasone 2 mg PO/NG DAILY Duration: 1 Dose Please take on ___ at 08:00. This is dose # 5 of 5 tapered doses Tapered dose - DOWN 3. Dexamethasone 2 mg PO/NG Q12H Duration: 2 Doses Please take on ___ at 20:00 and ___ at 08:00. This is dose # 4 of 5 tapered doses Tapered dose - DOWN 4. Docusate Sodium 100 mg PO/NG BID:PRN Constipation While taking oxycodone. ___ discontinue once off oxycodone. Hold for loose stools. 5. Famotidine 20 mg PO/NG BID Duration: 5 Doses While taking dexamethasone. ___ discontinue once off dexamethasone. 6. Heparin 5000 UNIT SC BID ___ discontinue once patient is mobilizing adequately and consistently. 7. LevETIRAcetam 1000 mg PO BID 8. OxyCODONE (Immediate Release) ___ mg PO/NG Q6H:PRN Pain Duration: 7 Days Home medication is 15mg Q6H PRN pain. 9. Senna 17.2 mg PO/NG QHS:PRN Constipation While taking oxycodone. ___ discontinue once off oxycodone. Hold for loose stools. 10. Furosemide 20 mg PO/NG DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left temporal ___ lesion Discharge Condition: Mental Status: Confused, sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory, requires assistance or aid, cane or walker. Discharge Instructions: Surgery: - You underwent surgery to remove a ___ lesion from your ___. - Please keep your incision dry until your staples are removed. - You may shower at this time, but keep your incision dry. - It is best to keep your incision open to air, but it is okay to cover it when outside. - Call your neurosurgeon if there are any signs of infection like fever, redness, or drainage. Activity: - We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. - You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. - No driving while taking any narcotic or sedating medication. - If you experienced a seizure while admitted, you are NOT allowed to drive by law. - No contact sports until cleared by your neurosurgeon. You should avoid contact sports for six months. Medications: - Please do NOT take any blood thinning medication (aspirin, Coumadin, ibuprofen, Plavix, etc.) until cleared by your neurosurgeon. - You have been discharged on levetiracetam (Keppra). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instructions. It is important that you take this medication consistently and on time. - You may use acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: - You may experience headaches and incisional pain. - You may also experience some postoperative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day after surgery. You may apply ice or a cool or warm washcloth to help with the swelling. The swelling will be its worst in the morning after laying flat from sleeping, but will decrease when up. - You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. - Feeling more tired or restlessness is also common. - Constipation is common. Be sure to drink plenty of fluids and eat a high fiber diet. If you are taking narcotics (prescription pain medications), try an over the counter stool softener. When To Call Your Neurosurgeon At ___: - Severe pain, redness, swelling, or drainage from the incision site. - Fever greater than 101.5 degrees Fahrenheit. - Nausea or vomiting. - Extreme sleepiness or 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 legs. Call ___ And Go To The Nearest Emergency Department If You Experience Any Of The Following: - Sudden numbness or weakness in the face, arms, or legs. - 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: ___	[ "C7931", "G936", "G9340", "Z85118", "F419", "D509", "Z902", "Z96641", "Z87891" ]	Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Left temporal [MASKED] lesion Major Surgical or Invasive Procedure: [MASKED] - Left craniotomy for resection of left temporal [MASKED] lesion History of Present Illness: [MASKED] is a [MASKED] year old female with a history of lung cancer who presented to the Emergency Department on [MASKED] with a new onset seizure. CT of the head concerning for a left temporal [MASKED] lesion. The Neurosurgery Service was consulted for question of acute neurosurgical intervention. Patient was admitted to [MASKED] further evaluation and management. Past Medical History: - arthritis - iron deficiency anemia - lung cancer status post lobectomy - panic disorder - status post hip replacement in [MASKED] Social History: [MASKED] Family History: Noncontributory Physical Exam: On Admission: ------------- Vital Signs: T 97.7F, HR 115, BP 133/70, RR 18, O2Sat 99% room air General: Elderly female laying on stretcher. Head, Eyes, Ears, Nose, Throat: Right periorbital ecchymosis and edema. Pupils equal, round, and reactive to light. Extraocular movements full. Lungs: No respiratory distress. Extremities: Warm and well perfused. Neurologic: Mental status: Awake and alert, follows simple commands. Orientation: Oriented to person only. Language: Nonfluent speech. Perseverative. Impaired naming. Cranial Nerves: I: Not tested. II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [MASKED] throughout. No drift. Sensation: Intact to light touch. On Discharge: ------------- General: Vital Signs: T 98.1F, HR 74, BP 125/61, RR 16, O2Sat 96% room air Exam: Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious Orientation: [x]Person [x]Place - With options [x]Time - With options Follows Commands: [ ]Simple [x]Complex [ ]None Pupils: Pupils equal, round, and reactive to light Extraocular Movements: [x]Full [ ]Restricted Face Symmetric: [x]Yes [ ]No Tongue Midline: [x]Yes [ ]No Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trapezius Deltoid Biceps Triceps Grip Right5 5 5 5 5 Left 5 5 5 5 5 IP Quadriceps Hamstring AT [MASKED] Gastrocnemius Right5 5 5 5 5 5 Left 4+* 4+* 4+* 5 5 5 *Pain limited. [x]Sensation intact to light touch Surgical Incision: [x]Clean, dry, intact [x]Staples Pertinent Results: Please see OMR for relevant laboratory and imaging results. Brief Hospital Course: [MASKED] year old female with a left temporal [MASKED] lesion. #Left Temporal [MASKED] Lesion MRI of the [MASKED] was obtained and confirmed the presence of a left temporal [MASKED] lesion. Patient was started on Keppra to treat her seizures. She was also started on dexamethasone for cerebral edema. CT of the chest, abdomen, and pelvis did not reveal any areas of lung cancer recurrence or other metastases. Neuro Oncology and Radiation Oncology were consulted. Patient was taken to the operating room on [MASKED] for a left craniotomy for resection of the left temporal [MASKED] lesion. The procedure was uncomplicated and well tolerated. Tissue was sent for pathology. Patient was extubated in the operating room and recovered in the PACU. Patient was transferred to the step down unit postoperatively for close neurologic monitoring. Postoperative CT of the head showed expected postoperative changes and was negative for any acute intracranial hemorrhage. Postoperative MRI of the [MASKED] also showed expected postoperative changes. Patient was eventually transferred to the floor. Patient was evaluated by Physical Therapy and Occupational Therapy, both of whom recommended rehabilitation. On [MASKED], patient was neurologically stable. Patient was afebrile with stable vital signs, tolerating activity, tolerating a regular diet, voiding and stooling without difficulty, and her pain was well controlled with oral pain medications. She was discharged to [MASKED] [MASKED] in [MASKED] on [MASKED] in stable condition. She will follow-up in the [MASKED] with Dr. [MASKED] [MASKED] days after surgery for staple removal. She will also follow-up in the [MASKED] Tumor Clinic with Dr. [MASKED] on [MASKED] to determine further treatment. #History of Lung Cancer Medical Oncology was consulted given the patient's history of lung cancer. Patient will follow-up with Medical Oncology after discharge as an outpatient. #T4 Compression Fracture There was an age indeterminate T4 anterior compression deformity noted on CT of the chest. Patient does not have any tenderness to palpation. No activity restrictions or bracing indicated. #Left Lower Extremity Pain There was no acute fracture on x-ray of the left lower extremity, however there was a small knee joint effusion. Ultrasound of the left lower extremity was negative for deep vein thrombosis. Medications on Admission: - furosemide 20mg by mouth once daily - lorazepam 0.5mg by mouth three times daily - oxycodone 15mg by mouth Q6H as needed for pain Discharge Medications: 1. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain Do not exceed 3000mg in 24 hours. 2. Dexamethasone 2 mg PO/NG DAILY Duration: 1 Dose Please take on [MASKED] at 08:00. This is dose # 5 of 5 tapered doses Tapered dose - DOWN 3. Dexamethasone 2 mg PO/NG Q12H Duration: 2 Doses Please take on [MASKED] at 20:00 and [MASKED] at 08:00. This is dose # 4 of 5 tapered doses Tapered dose - DOWN 4. Docusate Sodium 100 mg PO/NG BID:PRN Constipation While taking oxycodone. [MASKED] discontinue once off oxycodone. Hold for loose stools. 5. Famotidine 20 mg PO/NG BID Duration: 5 Doses While taking dexamethasone. [MASKED] discontinue once off dexamethasone. 6. Heparin 5000 UNIT SC BID [MASKED] discontinue once patient is mobilizing adequately and consistently. 7. LevETIRAcetam 1000 mg PO BID 8. OxyCODONE (Immediate Release) [MASKED] mg PO/NG Q6H:PRN Pain Duration: 7 Days Home medication is 15mg Q6H PRN pain. 9. Senna 17.2 mg PO/NG QHS:PRN Constipation While taking oxycodone. [MASKED] discontinue once off oxycodone. Hold for loose stools. 10. Furosemide 20 mg PO/NG DAILY Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Left temporal [MASKED] lesion Discharge Condition: Mental Status: Confused, sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory, requires assistance or aid, cane or walker. Discharge Instructions: Surgery: - You underwent surgery to remove a [MASKED] lesion from your [MASKED]. - Please keep your incision dry until your staples are removed. - You may shower at this time, but keep your incision dry. - It is best to keep your incision open to air, but it is okay to cover it when outside. - Call your neurosurgeon if there are any signs of infection like fever, redness, or drainage. Activity: - We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. - You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. [MASKED] try to do too much all at once. - No driving while taking any narcotic or sedating medication. - If you experienced a seizure while admitted, you are NOT allowed to drive by law. - No contact sports until cleared by your neurosurgeon. You should avoid contact sports for six months. Medications: - Please do NOT take any blood thinning medication (aspirin, Coumadin, ibuprofen, Plavix, etc.) until cleared by your neurosurgeon. - You have been discharged on levetiracetam (Keppra). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instructions. It is important that you take this medication consistently and on time. - You may use acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You [MASKED] Experience: - You may experience headaches and incisional pain. - You may also experience some postoperative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day after surgery. You may apply ice or a cool or warm washcloth to help with the swelling. The swelling will be its worst in the morning after laying flat from sleeping, but will decrease when up. - You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. - Feeling more tired or restlessness is also common. - Constipation is common. Be sure to drink plenty of fluids and eat a high fiber diet. If you are taking narcotics (prescription pain medications), try an over the counter stool softener. When To Call Your Neurosurgeon At [MASKED]: - Severe pain, redness, swelling, or drainage from the incision site. - Fever greater than 101.5 degrees Fahrenheit. - Nausea or vomiting. - Extreme sleepiness or 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 legs. Call [MASKED] And Go To The Nearest Emergency Department If You Experience Any Of The Following: - Sudden numbness or weakness in the face, arms, or legs. - 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]	[]	[ "F419", "D509", "Z87891" ]	[ "C7931: Secondary malignant neoplasm of brain", "G936: Cerebral edema", "G9340: Encephalopathy, unspecified", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "F419: Anxiety disorder, unspecified", "D509: Iron deficiency anemia, unspecified", "Z902: Acquired absence of lung [part of]", "Z96641: Presence of right artificial hip joint", "Z87891: Personal history of nicotine dependence" ]
19,985,000	25,555,862	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Keflex / morphine / Dilaudid Attending: ___. Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ yo woman with PMH of Crohn's and recurrent C. diff colitis (last in ___ presenting with several days of worsening abdominal pain and diarrhea in the context of one month of weight loss. The patient has a complex Crohn's history, complicated by recurrent C. diff. Please see Dr. ___ notes in ___ for detailed GI hx. In brief, she has disease of the ileum and colon and was diagnosed at age ___. Past treatments have including ___ (stopped around ___, Remicade (___), Humira, placement of hookworms every three months, prednisolone at varying doses which continues, probiotics which she continues to take, vedolizumab (last infusion ___, and various alternative therapies such as pine bark/frankincense. She has had about 17cm of terminal ileum removed in ___ and has 45cm of diseased ileum with 15cm of possibly normal ileum between 2 areas of diseased bowel. Her initial C. diff was in ___ with possible recurrence ___ and definite recurrence ___ which was treated with stool transplant. Per Dr. ___ from ___, the patient presented tearfully "feeling terrible" pain has become constant and unbearable in the right mid to lower side with bad diarrhea (greater than 10 episodes/day) despite Entyvio tx. She had been started on a specific carbohydrate diet with improvement in anal fistula and fissure pain but 3 days ago her abdominal pain, diarrhea, and rectal pain got worse. She is on 3.5 ml of prednisolone (10.5mg). She has a history of worse diarrhea around her menstrual period, which is occurring now. The patient reports that her daughter recently had a stomach virus at the beginning of this week and the patient has been feeling worse over the last few days. Her decline started earlier, however, as she has had about 7 lb weight loss over the last month with frequent bowel movements (as many as 12 per day yesterday, ___ today). She notes the stools are mostly liquid with some mucous. She does have mild abd pain, more than usual, over the past few days. She also reports that over the last month or so she has had blood in the bowl with BMs, which she attributes to her known rectal fissure/fistula. This has not changed significantly over the time (ie no increase in the amount of blood). She saw Dr. ___ but today was feeling particularly bad and had a fever to 100 during the day so felt like she needed to come into the hospital. She had one egg today but has not eaten much, though she reports taking a lot of PO fluids. She felt somewhat lightheaded today but denies SOB, CP. She denies oral ulcers. She denies change in urine, dysuria, rhinorrhea, sore throat, or other sx. She denies emesis. She reports that she is unsure if this is infectious or Crohn's related, as she can only tell the difference if she vomits since she NEVER has vomiting with Crohn's flares. On arrival to floor, the patient states she feels "pretty crappy" and is interested in knowing the plan for her admission. ROS: Positive as per HPI, all systems reviewed and otherwise negative Past Medical History: - Crohn's disease of the terminal ileum and colon, mostly in the cecum and ascending colon. She is status post an ileocecectomy via laparoscopy ___ and had a Meckel's diverticulum removed at that same time - C diff colitis in ___ (s/p fecal transplant ___ Social History: ___ Family History: Father and paternal grandmother with ulcerative colitis. Mother healthy and older brother. Physical Exam: Admission Physical Exam: VS: 98.5 91/62 96 18 98%RA General: Thin, tired but well appearing young woman lying in bed in NAD Eyes: PERLL, EOMI, sclera anicteric ENT: MMM, oropharynx clear without exudate or lesions Lymph: No supraclavicular or cervical lymphadenopathy Respiratory: CTAB without crackles, wheeze, rhonchi. Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or gallops Gastrointestinal: Soft, minimally tender to palpation diffusely, nondistended, +BS, no masses or HSM Extremities: Warm and well perfused, no peripheral edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert and oriented x3, motor and sensory exam grossly intact Rectal: Declined 88-92/40-60 68 AFEBRILE thin adult female ___ site without redness calm and attentive she declined my exam of her abdomen Pertinent Results: Admission labs: ___ 06:32AM BLOOD WBC-14.0* RBC-4.28 Hgb-10.5* Hct-33.8* MCV-79* MCH-24.5* MCHC-31.1* RDW-13.9 RDWSD-40.1 Plt ___ ___ 01:40PM BLOOD WBC-13.0* RBC-4.71 Hgb-11.6 Hct-38.2 MCV-81* MCH-24.6* MCHC-30.4* RDW-14.9 RDWSD-43.9 Plt ___ ___ 05:58AM BLOOD Glucose-119* UreaN-13 Creat-0.5 Na-138 K-4.4 Cl-103 HCO3-29 AnGap-10 ___ 01:40PM BLOOD UreaN-13 Creat-0.6 Na-135 K-4.5 Cl-96 HCO3-26 AnGap-18 ___ 06:01AM BLOOD ALT-11 AST-10 AlkPhos-61 TotBili-<0.2 ___ 06:20AM BLOOD calTIBC-250* Ferritn-38 TRF-192* ___ 01:40PM BLOOD VitB12-907* ___ 05:55AM BLOOD Triglyc-97 ___ 06:20AM BLOOD CRP-27.4* ___ 06:32AM BLOOD WBC-14.0* RBC-4.28 Hgb-10.5* Hct-33.8* MCV-79* MCH-24.5* MCHC-31.1* RDW-13.9 RDWSD-40.1 Plt ___ ___ 05:58AM BLOOD Glucose-119* UreaN-13 Creat-0.5 Na-138 K-4.4 Cl-103 HCO3-29 AnGap-10 ___ 06:20AM BLOOD calTIBC-250* Ferritn-38 TRF-192* ___ 06:20AM BLOOD CRP-27.4* ___ 06:20AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.4 Iron-14* Brief Hospital Course: ___ yo woman with PMH of Crohn's and recurrent C. diff colitis (last in ___ presenting with several days of worsening abdominal pain and diarrhea in the context of one month of weight loss. #Abdominal pain/diarrhea/Crohn's disease: Etiology of sx unclear at this time as infectious enteritis is certainly possible given recent exposure but overall history seems more consistent with worsening Crohn's given subacute nature of decline. Unclear if temperature to 100 during the day today is representative of infection vs inflammation or is even pathological. Patient is followed closely by Dr. ___ in GI and was referred to the hospital with a specific plan including GI consultation with close management. According to Dr. ___ are very limited options at this point for treatment including NPO with TPN temporarily as well as IV steroids to decrease inflammation and pain, Stelara, or surgery (which would result in at least 60cm of small bowel resection, which would then be minimum of 77cm of small bowel removed) as vedolizumab seems to have failed. Her weight loss is likely mostly due to the specific carbohydrate diet, but also with decreased intake. The patient was initiated on bowel rest, IV TPN and received IV steroids. IV steroids were delayed until at least 72hrs after diagnosis of norovirus was made. She had intolerance to IV TPN containing lipid emulsion and described increased nausea when she was receiving this. Although Dr. ___ I did not suspect that lipid emulsion was causative for her symptoms, we followed the patient's request to only infuse non-lipid TPN formula. The patient chose to be discharged OFF of TPN and to return to her low carb diet that she and Dr. ___. She received approx. 48-72hrs IV solumedrol and her CRP before this was started was 27. She will take oral prednisolone 15mg/5ml 14ml per day (42mg) on her return home. She will discuss anti-crohn's therapy with Dr. ___. #Fe Deficiency: She has low iron to TIBC ratio. Emailed PCP about management of fe deficient anemia with iv iron. TRANSITIONAL ISSUES []GI F/U []MANAGEMENT OF FE DEFICIENCY ANEMIA Medications on Admission: The Preadmission Medication list is accurate and complete 1. prednisoLONE 15 mg/5 mL oral DAILY 2. LOPERamide 2 mg PO QID:PRN diarrhea 3. Enzyme Digest (digestive enzymes) oral DAILY 4. Multivitamins 1 TAB PO DAILY 5. prasterone (dhea)-calcium carb unknown unknown oral DAILY 6. turmeric root extract ___ mg oral BID 7. pregnenolone 60 mg miscellaneous DAILY 8. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 500 mg calcium -250 mg oral DAILY 9. FLUoxetine 20 mg PO DAILY 10. TraZODone 100 mg PO QHS:PRN insomnia 11. Vitamin D 6000 UNIT PO DAILY 12. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral DAILY 13. Adrenal supplement (unknown details, gets online or from acupuncturist, not currently taking) 14. Frankincense (unknown details) 15. Pine Bark (unknown details, not currently taking) 16. Medical marijuana (has MA certificate) Discharge Medications: 1. Anusol-HC (hydrocorTISone;<br>hydrocorTISone Acetate) 2.5 % topical Q12H:PRN rectal pain RX hydrocortisone [Anusol-HC] 2.5 % 1 twice a day Refills:0 2. Witch ___ 50% Pad ___SDIR 3. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 500 mg calcium -250 mg oral DAILY 4. Enzyme Digest (digestive enzymes) oral DAILY 5. FLUoxetine 20 mg PO DAILY 6. LOPERamide 2 mg PO QID:PRN diarrhea 7. Multivitamins 1 TAB PO DAILY 8. prasterone (dhea)-calcium carb unknown oral DAILY 9. prednisoLONE 15 mg/5 mL oral DAILY 14ml (approx. 42mg) RX prednisolone 15 mg/5 mL 14 ml by mouth daily Refills:0 10. pregnenolone 60 mg miscellaneous DAILY 11. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn ___ acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral DAILY 12. TraZODone 100 mg PO QHS:PRN insomnia 13. turmeric root extract ___ mg oral BID 14. Vitamin D 6000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: norovirus crohn's disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: you were hospitalized for abdominal pain and diarrhea and diagnosed with norovirus and symptoms of chronic crohn's disease. you briefly received IV TPN via PICC and IV steroids. you will return to oral prednisolone at a higher dose than you were taking before Followup Instructions: ___	[ "A0811", "Z9489", "K50818", "K921", "Z681", "R1031", "K605", "Z9049", "Z8619", "Z79899", "Z7952", "K6289", "R634", "D509" ]	Allergies: Keflex / morphine / Dilaudid Chief Complaint: Abdominal pain, diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman with PMH of Crohn's and recurrent C. diff colitis (last in [MASKED] presenting with several days of worsening abdominal pain and diarrhea in the context of one month of weight loss. The patient has a complex Crohn's history, complicated by recurrent C. diff. Please see Dr. [MASKED] notes in [MASKED] for detailed GI hx. In brief, she has disease of the ileum and colon and was diagnosed at age [MASKED]. Past treatments have including [MASKED] (stopped around [MASKED], Remicade ([MASKED]), Humira, placement of hookworms every three months, prednisolone at varying doses which continues, probiotics which she continues to take, vedolizumab (last infusion [MASKED], and various alternative therapies such as pine bark/frankincense. She has had about 17cm of terminal ileum removed in [MASKED] and has 45cm of diseased ileum with 15cm of possibly normal ileum between 2 areas of diseased bowel. Her initial C. diff was in [MASKED] with possible recurrence [MASKED] and definite recurrence [MASKED] which was treated with stool transplant. Per Dr. [MASKED] from [MASKED], the patient presented tearfully "feeling terrible" pain has become constant and unbearable in the right mid to lower side with bad diarrhea (greater than 10 episodes/day) despite Entyvio tx. She had been started on a specific carbohydrate diet with improvement in anal fistula and fissure pain but 3 days ago her abdominal pain, diarrhea, and rectal pain got worse. She is on 3.5 ml of prednisolone (10.5mg). She has a history of worse diarrhea around her menstrual period, which is occurring now. The patient reports that her daughter recently had a stomach virus at the beginning of this week and the patient has been feeling worse over the last few days. Her decline started earlier, however, as she has had about 7 lb weight loss over the last month with frequent bowel movements (as many as 12 per day yesterday, [MASKED] today). She notes the stools are mostly liquid with some mucous. She does have mild abd pain, more than usual, over the past few days. She also reports that over the last month or so she has had blood in the bowl with BMs, which she attributes to her known rectal fissure/fistula. This has not changed significantly over the time (ie no increase in the amount of blood). She saw Dr. [MASKED] but today was feeling particularly bad and had a fever to 100 during the day so felt like she needed to come into the hospital. She had one egg today but has not eaten much, though she reports taking a lot of PO fluids. She felt somewhat lightheaded today but denies SOB, CP. She denies oral ulcers. She denies change in urine, dysuria, rhinorrhea, sore throat, or other sx. She denies emesis. She reports that she is unsure if this is infectious or Crohn's related, as she can only tell the difference if she vomits since she NEVER has vomiting with Crohn's flares. On arrival to floor, the patient states she feels "pretty crappy" and is interested in knowing the plan for her admission. ROS: Positive as per HPI, all systems reviewed and otherwise negative Past Medical History: - Crohn's disease of the terminal ileum and colon, mostly in the cecum and ascending colon. She is status post an ileocecectomy via laparoscopy [MASKED] and had a Meckel's diverticulum removed at that same time - C diff colitis in [MASKED] (s/p fecal transplant [MASKED] Social History: [MASKED] Family History: Father and paternal grandmother with ulcerative colitis. Mother healthy and older brother. Physical Exam: Admission Physical Exam: VS: 98.5 91/62 96 18 98%RA General: Thin, tired but well appearing young woman lying in bed in NAD Eyes: PERLL, EOMI, sclera anicteric ENT: MMM, oropharynx clear without exudate or lesions Lymph: No supraclavicular or cervical lymphadenopathy Respiratory: CTAB without crackles, wheeze, rhonchi. Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or gallops Gastrointestinal: Soft, minimally tender to palpation diffusely, nondistended, +BS, no masses or HSM Extremities: Warm and well perfused, no peripheral edema Skin: warm, no rashes/no jaundice/no skin ulcerations noted Neurological: Alert and oriented x3, motor and sensory exam grossly intact Rectal: Declined 88-92/40-60 68 AFEBRILE thin adult female [MASKED] site without redness calm and attentive she declined my exam of her abdomen Pertinent Results: Admission labs: [MASKED] 06:32AM BLOOD WBC-14.0* RBC-4.28 Hgb-10.5* Hct-33.8* MCV-79* MCH-24.5* MCHC-31.1* RDW-13.9 RDWSD-40.1 Plt [MASKED] [MASKED] 01:40PM BLOOD WBC-13.0* RBC-4.71 Hgb-11.6 Hct-38.2 MCV-81* MCH-24.6* MCHC-30.4* RDW-14.9 RDWSD-43.9 Plt [MASKED] [MASKED] 05:58AM BLOOD Glucose-119* UreaN-13 Creat-0.5 Na-138 K-4.4 Cl-103 HCO3-29 AnGap-10 [MASKED] 01:40PM BLOOD UreaN-13 Creat-0.6 Na-135 K-4.5 Cl-96 HCO3-26 AnGap-18 [MASKED] 06:01AM BLOOD ALT-11 AST-10 AlkPhos-61 TotBili-<0.2 [MASKED] 06:20AM BLOOD calTIBC-250* Ferritn-38 TRF-192* [MASKED] 01:40PM BLOOD VitB12-907* [MASKED] 05:55AM BLOOD Triglyc-97 [MASKED] 06:20AM BLOOD CRP-27.4* [MASKED] 06:32AM BLOOD WBC-14.0* RBC-4.28 Hgb-10.5* Hct-33.8* MCV-79* MCH-24.5* MCHC-31.1* RDW-13.9 RDWSD-40.1 Plt [MASKED] [MASKED] 05:58AM BLOOD Glucose-119* UreaN-13 Creat-0.5 Na-138 K-4.4 Cl-103 HCO3-29 AnGap-10 [MASKED] 06:20AM BLOOD calTIBC-250* Ferritn-38 TRF-192* [MASKED] 06:20AM BLOOD CRP-27.4* [MASKED] 06:20AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.4 Iron-14* Brief Hospital Course: [MASKED] yo woman with PMH of Crohn's and recurrent C. diff colitis (last in [MASKED] presenting with several days of worsening abdominal pain and diarrhea in the context of one month of weight loss. #Abdominal pain/diarrhea/Crohn's disease: Etiology of sx unclear at this time as infectious enteritis is certainly possible given recent exposure but overall history seems more consistent with worsening Crohn's given subacute nature of decline. Unclear if temperature to 100 during the day today is representative of infection vs inflammation or is even pathological. Patient is followed closely by Dr. [MASKED] in GI and was referred to the hospital with a specific plan including GI consultation with close management. According to Dr. [MASKED] are very limited options at this point for treatment including NPO with TPN temporarily as well as IV steroids to decrease inflammation and pain, Stelara, or surgery (which would result in at least 60cm of small bowel resection, which would then be minimum of 77cm of small bowel removed) as vedolizumab seems to have failed. Her weight loss is likely mostly due to the specific carbohydrate diet, but also with decreased intake. The patient was initiated on bowel rest, IV TPN and received IV steroids. IV steroids were delayed until at least 72hrs after diagnosis of norovirus was made. She had intolerance to IV TPN containing lipid emulsion and described increased nausea when she was receiving this. Although Dr. [MASKED] I did not suspect that lipid emulsion was causative for her symptoms, we followed the patient's request to only infuse non-lipid TPN formula. The patient chose to be discharged OFF of TPN and to return to her low carb diet that she and Dr. [MASKED]. She received approx. 48-72hrs IV solumedrol and her CRP before this was started was 27. She will take oral prednisolone 15mg/5ml 14ml per day (42mg) on her return home. She will discuss anti-crohn's therapy with Dr. [MASKED]. #Fe Deficiency: She has low iron to TIBC ratio. Emailed PCP about management of fe deficient anemia with iv iron. TRANSITIONAL ISSUES []GI F/U []MANAGEMENT OF FE DEFICIENCY ANEMIA Medications on Admission: The Preadmission Medication list is accurate and complete 1. prednisoLONE 15 mg/5 mL oral DAILY 2. LOPERamide 2 mg PO QID:PRN diarrhea 3. Enzyme Digest (digestive enzymes) oral DAILY 4. Multivitamins 1 TAB PO DAILY 5. prasterone (dhea)-calcium carb unknown unknown oral DAILY 6. turmeric root extract [MASKED] mg oral BID 7. pregnenolone 60 mg miscellaneous DAILY 8. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 500 mg calcium -250 mg oral DAILY 9. FLUoxetine 20 mg PO DAILY 10. TraZODone 100 mg PO QHS:PRN insomnia 11. Vitamin D 6000 UNIT PO DAILY 12. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn [MASKED] acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral DAILY 13. Adrenal supplement (unknown details, gets online or from acupuncturist, not currently taking) 14. Frankincense (unknown details) 15. Pine Bark (unknown details, not currently taking) 16. Medical marijuana (has MA certificate) Discharge Medications: 1. Anusol-HC (hydrocorTISone;<br>hydrocorTISone Acetate) 2.5 % topical Q12H:PRN rectal pain RX hydrocortisone [Anusol-HC] 2.5 % 1 twice a day Refills:0 2. Witch [MASKED] 50% Pad SDIR 3. Calcium Magnesium (Ca carb-Ca gluc-Mg ox-Mg gluco) 500 mg calcium -250 mg oral DAILY 4. Enzyme Digest (digestive enzymes) oral DAILY 5. FLUoxetine 20 mg PO DAILY 6. LOPERamide 2 mg PO QID:PRN diarrhea 7. Multivitamins 1 TAB PO DAILY 8. prasterone (dhea)-calcium carb unknown oral DAILY 9. prednisoLONE 15 mg/5 mL oral DAILY 14ml (approx. 42mg) RX prednisolone 15 mg/5 mL 14 ml by mouth daily Refills:0 10. pregnenolone 60 mg miscellaneous DAILY 11. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. acidophilus-L. rhamnosus;<br>L.acidophilus-Bif. animalis;<br>L.rhamn [MASKED] acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus combination no.4;<br>lactobacillus combo no.11) 10 billion cell oral DAILY 12. TraZODone 100 mg PO QHS:PRN insomnia 13. turmeric root extract [MASKED] mg oral BID 14. Vitamin D 6000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: norovirus crohn's disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: you were hospitalized for abdominal pain and diarrhea and diagnosed with norovirus and symptoms of chronic crohn's disease. you briefly received IV TPN via PICC and IV steroids. you will return to oral prednisolone at a higher dose than you were taking before Followup Instructions: [MASKED]	[]	[ "D509" ]	[ "A0811: Acute gastroenteropathy due to Norwalk agent", "Z9489: Other transplanted organ and tissue status", "K50818: Crohn's disease of both small and large intestine with other complication", "K921: Melena", "Z681: Body mass index [BMI] 19.9 or less, adult", "R1031: Right lower quadrant pain", "K605: Anorectal fistula", "Z9049: Acquired absence of other specified parts of digestive tract", "Z8619: Personal history of other infectious and parasitic diseases", "Z79899: Other long term (current) drug therapy", "Z7952: Long term (current) use of systemic steroids", "K6289: Other specified diseases of anus and rectum", "R634: Abnormal weight loss", "D509: Iron deficiency anemia, unspecified" ]
19,985,259	20,852,380	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: shellfish derived Attending: ___. Chief Complaint: ICD shocks Major Surgical or Invasive Procedure: VT ablation ___ History of Present Illness: ___ year old gentleman with HTN, CAD s/p MI, dilated ischemic CMY (EF ___ with recent admission for sustained polymorphic VT s/p cardiac catheterization showing CAD and ICD placement who presented to the ED with palpitations and 3 ICD shocks this morning. Mr. ___ was admitted from ___ after presenting with dyspnea, abdominal pain and anxiety and was subsequently found to have sustained monomorphic VT. Multiple pharmacologic therapies were unsuccessful and he eventually required cardioversion with subsequent reversion to sinus rhythm. However, shortly afterward, he had STE with recipirocal STD, for which code STEMI was called. During cardiac catheterization he was found to have branch vessel CAD (70% stenosis of a small first diagonal branch, and severe mid-disease in a small ___ marginal branch). No intervention was performed. VT was felt to be likely originating in the LV posterior-lateral apical free wall secondary to ischemia and/or scar. He was stabilized on lidocaine drip and then transitioned to metoprolol. He underwent ICD placement on ___ with DDD lower rate of 75 bpm. EP felt that the area of VT may be amenable to VT ablation, but patient did not want to undergo procedure due to risk of arrhythmia. He was feeling well at home today when he was cleaning and developed a similar "rolling" feeling in his epigastrium and then had a scary, sudden thump in his chest. He called ___ and he was shocked ___ more times in transit to ___ and then he states this occurred around ___ more times in the ER. In the ED, initial vitals were: T98.0, HR 76, BP 137/57, RR 15, SpO2 96% RA. He had two ICD shocks in the ED for VT. ECG: rate 78, sinus rhythm, normal axis, normal intervals, STE in V1 likely J point elevation, 2mm STD in I and II, poor R wave progression Labs: notable for slight hemoglobin drop 14->13.2, normal chem panel, troponin 0.63. Imaging: CXR showed ICD in correct position and no pulmonary edema. EP consultation in the ED interrogated the ICD which showed that he had several episodes of VT on ___ and ___ (>30, 9 requiring ICD shock). Episodes on ___ responded to ATP, but episodes of ___ did not, leading to shock. They recommended administering lidocaine with bolus and then starting on a gtt with admission to CCU for further management. Patient was given: amiodarone 150mg IV initially and then, lidocaine 80mg IV with gtt following at 2mg/min and then increased to 4mg/min which suppressed further VT. He was also given 1mg IV Ativan. On the floor, patient reports no pain, dyspnea, cough, neurologic change, headache, weakness, leg pain. Past Medical History: -HTN -HLD not on therapy -CAD s/p MI cardiac catheterization ___ without significant CAD -ICD placement ___ for sustained VT -Dilated Cardiomyopathy diagnosed ___ at ___ (EF 30% ___ cardiac MR showed transmural late gadolinium enhancement c/w myocardial infarction with findings are most suggestive of an ischemic cardiomyopathy. Social History: ___ Family History: Father CAD/PVD Mother diabetes, Died on hospice, dementia Sister ___ Cancer No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 36.6 HR 75 (100% atrial paced) BP 153/64 RR 18 Sa02 99% ___: 80.5 kg GEN: well, appearing, alert, oriented HEENT: moist mouth NECK: no jvd CV: rrr, no m/r/g; left chest without fluctuance or erythema over dressed ICD LUNGS: clear bilaterally ABD: soft, nt, nd EXT: warm, 2+ dp and radial pulses SKIN: no rash NEURO: alert, oriented, conversant, cranial nerves intact, moves all extremities normally DISCHARGE PHYSICAL EXAM: VS: 98 108/47 (108-116/40s-60s) 59 (59-75) 18 97RA I/O: not recorded ___: 79.7kg -> 78.3 Tele: alarm for PVCs Exam: Gen: WDWN, no acute distress, resting comfortably in bed HEENT: NCAT, MMM Neck: supple CV: RRR, no m/r/g Resp: CTAB, no wheezes or rhonchi ABD: soft, nontender, nondistended Extr: no peripheral edema Skin: L chest wall dressing and epigastric dressings C/D/I Neuro: grossly intact Pertinent Results: ADMISSION LABS: =============== ___ 06:26AM BLOOD WBC-5.9 RBC-3.99* Hgb-13.8 Hct-40.8 MCV-102* MCH-34.6* MCHC-33.8 RDW-13.6 RDWSD-51.2* Plt ___ ___ 11:00AM BLOOD Neuts-51.6 ___ Monos-12.3 Eos-2.4 Baso-0.8 Im ___ AbsNeut-2.61 AbsLymp-1.65 AbsMono-0.62 AbsEos-0.12 AbsBaso-0.04 ___ 11:00AM BLOOD ___ PTT-26.7 ___ ___ 06:26AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137 K-4.8 Cl-104 HCO3-23 AnGap-15 ___ 07:42AM BLOOD ALT-60* AST-50* LD(LDH)-276* AlkPhos-48 TotBili-0.6 ___ 11:00AM BLOOD proBNP-740* ___ 11:00AM BLOOD cTropnT-0.63* ___ 07:42AM BLOOD CK-MB-4 cTropnT-0.39* ___ 06:26AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1 ___ 04:53AM BLOOD VitB12-688 ___ 04:53AM BLOOD TSH-6.8* ___ 04:53AM BLOOD Free T4-1.5 ___ 04:04PM BLOOD Type-ART pO2-222* pCO2-43 pH-7.33* calTCO2-24 Base XS--3 ___ 01:23PM BLOOD K-3.8 ___ 11:02PM BLOOD freeCa-1.02* OTHER PERTINENT/DISCHARGE LABS: ================= ___ 08:09AM BLOOD WBC-6.7 RBC-3.62* Hgb-12.7* Hct-37.2* MCV-103* MCH-35.1* MCHC-34.1 RDW-13.7 RDWSD-51.9* Plt ___ ___ 07:30AM BLOOD ___ PTT-23.0* ___ ___ 08:09AM BLOOD Glucose-146* UreaN-26* Creat-0.7 Na-139 K-4.3 Cl-102 HCO3-26 AnGap-15 ___ 07:30AM BLOOD ALT-41* AST-41* AlkPhos-44 TotBili-0.4 ___ 08:09AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.0 IMAGING/STUDIES: ================= ___ CXR Stable position of the left ICD. No pulmonary edema. ___ TTE Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). No masses or thrombi are seen in the left ventricle. Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Moderately depressed left ventricular systolic function. Mild to moderate aortic regurgitation. Mild mitral regurgitation. Due to the limited nature of the current study a comprehensive comparison of all previously assessed findings (images reviewed of ___ could not be made. Brief Hospital Course: ___ year old gentleman with HTN, CAD s/p MI, dilated ischemic CMY (EF ___ with recent admission for sustained polymorphic VT s/p cardiac catheterization ___ with 3VD that did not require intervention, and ICD placement ___ who presented to the ED ___, 1 day after discharge for recurrent ICD shocks. He was initially on dual lidocaine and procainamide gtts to suppress his VT. He went for EP study and VT ablation ___ and was started on sotalol 120mg BID. His rhythm at discharge was atrial-paced with native conduction and ECG showed stable intraventricular conduction delay (132ms) with left axis. FMLA paperwork was completed for the patient. ___ M with CAD s/p MI and dilated ischemic CMY (EF ___ with recent admission for sustained polymorphic VT in the setting of MI s/p ICD placement on ___ who presented to the ED with palpitations and found to have >30 episodes of VT with 9 shocks ICD shocks upon interrogation. # CORONARIES: ___ diag with 70% stenosis, ___ marginal severe mid-disease # PUMP: EF ___ # RHYTHM: telemetry indicates atrial pacing at 75 bpm with no ventricular pacing #) VENTRICULAR TACHYCARDIA STORM: Patient with recurrent VT successfully aborted with ICD shocks. Likely nidus is scarring from prior MI (late gadolinium enhacement seen in mid-distal anterior, anteroseptal walls, mid-distal anterolateral wall and in the apex on recent cardiac MRI felt to be most c/w myocardial infarction). Given known CAD, however, must also rule out transient causes, such as ACS, heart failure or electrolyte disturbances. He has troponin elevation here but is without chest pain, so this may be attributable to ICD shocks themselves. s/p VT ablation ___. On sotalol NF 120 mg oral BID with no significant EKG changes/QTc prolongation. SW consulted for patient coping given multiple shocks prior to admission. #) Elevated troponin- in setting of multiple ICD shocks, downtrending on admission. #) COMPENSATED HEART FAILURE with REDUCED EJECTION FRACTION: LVEF 30%. Discharge ___ 80mg on ___. Patient on room air on arrival, Not grossly volume overloaded but net positive 3L for stay. Diuresed after procedure, otherwise maintained on home furosemide, spironolactone, losartan, atorvastatin. #) MACROCYTIC ANEMIA: pt with slight decrease in hemoglobin over course of hospitalization from 14 to 13.2 (nadir 12.7). Likely secondary to phlebotomy while inpatient. CHRONIC ISSUES: #) HTN: home Losartan Potassium 100 mg PO/NG DAILY, spironolactone 25mg daily, Furosemide 20 mg PO/NG DAILY TRANSITIONAL ISSUES: []f/u with Dr. ___ ___ to assess QTc and tolerance of sotalol []f/u FMLA paperwork Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Losartan Potassium 100 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO BID 5. Cephalexin 500 mg PO Q8H Discharge Medications: 1. Aspirin 325 mg PO DAILY Duration: 30 Days 2. Furosemide 20 mg PO DAILY 3. Losartan Potassium 100 mg PO DAILY 4. Atorvastatin 20 mg PO QPM RX atorvastatin 20 mg 1 tablet(s) by mouth qPM Disp #60 Tablet Refills:0 5. sotalol 120 mg oral BID RX sotalol 120 mg 1 tablet(s) by mouth twice a day Disp #120 Tablet Refills:0 6. Spironolactone 25 mg PO DAILY RX spironolactone 25 mg 1 tablet(s) by mouth daily Disp #60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: #Monomorphic ventricular tachycardia #Coronary artery disease s/p MI #Dilated ischemic cardiomyopathy (EF ___ 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 caring for you at ___ ___. You were admitted because your heart was going into an abnormal rhythm (ventricular tachycardia), causing your ICD to fire. You underwent an ablation (treatment procedure) of the irritable areas in your heart that were causing the arrhythmias. You did well after the procedure and we felt you were safe for discharge. When you go home you will be on a full dose aspirin (325mg) for 1 month and then decrease to 81mg daily. You will also be on a new medication called sotalol to prevent recurrent arrhythmias. Weigh yourself every morning, call MD if ___ goes up more than 3 lbs. Followup Instructions: ___	[ "I472", "I5022", "I2510", "I255", "F419", "D539", "Z87891", "Z95810" ]	Allergies: shellfish derived Chief Complaint: ICD shocks Major Surgical or Invasive Procedure: VT ablation [MASKED] History of Present Illness: [MASKED] year old gentleman with HTN, CAD s/p MI, dilated ischemic CMY (EF [MASKED] with recent admission for sustained polymorphic VT s/p cardiac catheterization showing CAD and ICD placement who presented to the ED with palpitations and 3 ICD shocks this morning. Mr. [MASKED] was admitted from [MASKED] after presenting with dyspnea, abdominal pain and anxiety and was subsequently found to have sustained monomorphic VT. Multiple pharmacologic therapies were unsuccessful and he eventually required cardioversion with subsequent reversion to sinus rhythm. However, shortly afterward, he had STE with recipirocal STD, for which code STEMI was called. During cardiac catheterization he was found to have branch vessel CAD (70% stenosis of a small first diagonal branch, and severe mid-disease in a small [MASKED] marginal branch). No intervention was performed. VT was felt to be likely originating in the LV posterior-lateral apical free wall secondary to ischemia and/or scar. He was stabilized on lidocaine drip and then transitioned to metoprolol. He underwent ICD placement on [MASKED] with DDD lower rate of 75 bpm. EP felt that the area of VT may be amenable to VT ablation, but patient did not want to undergo procedure due to risk of arrhythmia. He was feeling well at home today when he was cleaning and developed a similar "rolling" feeling in his epigastrium and then had a scary, sudden thump in his chest. He called [MASKED] and he was shocked [MASKED] more times in transit to [MASKED] and then he states this occurred around [MASKED] more times in the ER. In the ED, initial vitals were: T98.0, HR 76, BP 137/57, RR 15, SpO2 96% RA. He had two ICD shocks in the ED for VT. ECG: rate 78, sinus rhythm, normal axis, normal intervals, STE in V1 likely J point elevation, 2mm STD in I and II, poor R wave progression Labs: notable for slight hemoglobin drop 14->13.2, normal chem panel, troponin 0.63. Imaging: CXR showed ICD in correct position and no pulmonary edema. EP consultation in the ED interrogated the ICD which showed that he had several episodes of VT on [MASKED] and [MASKED] (>30, 9 requiring ICD shock). Episodes on [MASKED] responded to ATP, but episodes of [MASKED] did not, leading to shock. They recommended administering lidocaine with bolus and then starting on a gtt with admission to CCU for further management. Patient was given: amiodarone 150mg IV initially and then, lidocaine 80mg IV with gtt following at 2mg/min and then increased to 4mg/min which suppressed further VT. He was also given 1mg IV Ativan. On the floor, patient reports no pain, dyspnea, cough, neurologic change, headache, weakness, leg pain. Past Medical History: -HTN -HLD not on therapy -CAD s/p MI cardiac catheterization [MASKED] without significant CAD -ICD placement [MASKED] for sustained VT -Dilated Cardiomyopathy diagnosed [MASKED] at [MASKED] (EF 30% [MASKED] cardiac MR showed transmural late gadolinium enhancement c/w myocardial infarction with findings are most suggestive of an ischemic cardiomyopathy. Social History: [MASKED] Family History: Father CAD/PVD Mother diabetes, Died on hospice, dementia Sister [MASKED] Cancer No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 36.6 HR 75 (100% atrial paced) BP 153/64 RR 18 Sa02 99% [MASKED]: 80.5 kg GEN: well, appearing, alert, oriented HEENT: moist mouth NECK: no jvd CV: rrr, no m/r/g; left chest without fluctuance or erythema over dressed ICD LUNGS: clear bilaterally ABD: soft, nt, nd EXT: warm, 2+ dp and radial pulses SKIN: no rash NEURO: alert, oriented, conversant, cranial nerves intact, moves all extremities normally DISCHARGE PHYSICAL EXAM: VS: 98 108/47 (108-116/40s-60s) 59 (59-75) 18 97RA I/O: not recorded [MASKED]: 79.7kg -> 78.3 Tele: alarm for PVCs Exam: Gen: WDWN, no acute distress, resting comfortably in bed HEENT: NCAT, MMM Neck: supple CV: RRR, no m/r/g Resp: CTAB, no wheezes or rhonchi ABD: soft, nontender, nondistended Extr: no peripheral edema Skin: L chest wall dressing and epigastric dressings C/D/I Neuro: grossly intact Pertinent Results: ADMISSION LABS: =============== [MASKED] 06:26AM BLOOD WBC-5.9 RBC-3.99* Hgb-13.8 Hct-40.8 MCV-102* MCH-34.6* MCHC-33.8 RDW-13.6 RDWSD-51.2* Plt [MASKED] [MASKED] 11:00AM BLOOD Neuts-51.6 [MASKED] Monos-12.3 Eos-2.4 Baso-0.8 Im [MASKED] AbsNeut-2.61 AbsLymp-1.65 AbsMono-0.62 AbsEos-0.12 AbsBaso-0.04 [MASKED] 11:00AM BLOOD [MASKED] PTT-26.7 [MASKED] [MASKED] 06:26AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137 K-4.8 Cl-104 HCO3-23 AnGap-15 [MASKED] 07:42AM BLOOD ALT-60* AST-50* LD(LDH)-276* AlkPhos-48 TotBili-0.6 [MASKED] 11:00AM BLOOD proBNP-740* [MASKED] 11:00AM BLOOD cTropnT-0.63* [MASKED] 07:42AM BLOOD CK-MB-4 cTropnT-0.39* [MASKED] 06:26AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1 [MASKED] 04:53AM BLOOD VitB12-688 [MASKED] 04:53AM BLOOD TSH-6.8* [MASKED] 04:53AM BLOOD Free T4-1.5 [MASKED] 04:04PM BLOOD Type-ART pO2-222* pCO2-43 pH-7.33* calTCO2-24 Base XS--3 [MASKED] 01:23PM BLOOD K-3.8 [MASKED] 11:02PM BLOOD freeCa-1.02* OTHER PERTINENT/DISCHARGE LABS: ================= [MASKED] 08:09AM BLOOD WBC-6.7 RBC-3.62* Hgb-12.7* Hct-37.2* MCV-103* MCH-35.1* MCHC-34.1 RDW-13.7 RDWSD-51.9* Plt [MASKED] [MASKED] 07:30AM BLOOD [MASKED] PTT-23.0* [MASKED] [MASKED] 08:09AM BLOOD Glucose-146* UreaN-26* Creat-0.7 Na-139 K-4.3 Cl-102 HCO3-26 AnGap-15 [MASKED] 07:30AM BLOOD ALT-41* AST-41* AlkPhos-44 TotBili-0.4 [MASKED] 08:09AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.0 IMAGING/STUDIES: ================= [MASKED] CXR Stable position of the left ICD. No pulmonary edema. [MASKED] TTE Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). No masses or thrombi are seen in the left ventricle. Mild to moderate ([MASKED]) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Moderately depressed left ventricular systolic function. Mild to moderate aortic regurgitation. Mild mitral regurgitation. Due to the limited nature of the current study a comprehensive comparison of all previously assessed findings (images reviewed of [MASKED] could not be made. Brief Hospital Course: [MASKED] year old gentleman with HTN, CAD s/p MI, dilated ischemic CMY (EF [MASKED] with recent admission for sustained polymorphic VT s/p cardiac catheterization [MASKED] with 3VD that did not require intervention, and ICD placement [MASKED] who presented to the ED [MASKED], 1 day after discharge for recurrent ICD shocks. He was initially on dual lidocaine and procainamide gtts to suppress his VT. He went for EP study and VT ablation [MASKED] and was started on sotalol 120mg BID. His rhythm at discharge was atrial-paced with native conduction and ECG showed stable intraventricular conduction delay (132ms) with left axis. FMLA paperwork was completed for the patient. [MASKED] M with CAD s/p MI and dilated ischemic CMY (EF [MASKED] with recent admission for sustained polymorphic VT in the setting of MI s/p ICD placement on [MASKED] who presented to the ED with palpitations and found to have >30 episodes of VT with 9 shocks ICD shocks upon interrogation. # CORONARIES: [MASKED] diag with 70% stenosis, [MASKED] marginal severe mid-disease # PUMP: EF [MASKED] # RHYTHM: telemetry indicates atrial pacing at 75 bpm with no ventricular pacing #) VENTRICULAR TACHYCARDIA STORM: Patient with recurrent VT successfully aborted with ICD shocks. Likely nidus is scarring from prior MI (late gadolinium enhacement seen in mid-distal anterior, anteroseptal walls, mid-distal anterolateral wall and in the apex on recent cardiac MRI felt to be most c/w myocardial infarction). Given known CAD, however, must also rule out transient causes, such as ACS, heart failure or electrolyte disturbances. He has troponin elevation here but is without chest pain, so this may be attributable to ICD shocks themselves. s/p VT ablation [MASKED]. On sotalol NF 120 mg oral BID with no significant EKG changes/QTc prolongation. SW consulted for patient coping given multiple shocks prior to admission. #) Elevated troponin- in setting of multiple ICD shocks, downtrending on admission. #) COMPENSATED HEART FAILURE with REDUCED EJECTION FRACTION: LVEF 30%. Discharge [MASKED] 80mg on [MASKED]. Patient on room air on arrival, Not grossly volume overloaded but net positive 3L for stay. Diuresed after procedure, otherwise maintained on home furosemide, spironolactone, losartan, atorvastatin. #) MACROCYTIC ANEMIA: pt with slight decrease in hemoglobin over course of hospitalization from 14 to 13.2 (nadir 12.7). Likely secondary to phlebotomy while inpatient. CHRONIC ISSUES: #) HTN: home Losartan Potassium 100 mg PO/NG DAILY, spironolactone 25mg daily, Furosemide 20 mg PO/NG DAILY TRANSITIONAL ISSUES: []f/u with Dr. [MASKED] [MASKED] to assess QTc and tolerance of sotalol []f/u FMLA paperwork Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Losartan Potassium 100 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO BID 5. Cephalexin 500 mg PO Q8H Discharge Medications: 1. Aspirin 325 mg PO DAILY Duration: 30 Days 2. Furosemide 20 mg PO DAILY 3. Losartan Potassium 100 mg PO DAILY 4. Atorvastatin 20 mg PO QPM RX atorvastatin 20 mg 1 tablet(s) by mouth qPM Disp #60 Tablet Refills:0 5. sotalol 120 mg oral BID RX sotalol 120 mg 1 tablet(s) by mouth twice a day Disp #120 Tablet Refills:0 6. Spironolactone 25 mg PO DAILY RX spironolactone 25 mg 1 tablet(s) by mouth daily Disp #60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: #Monomorphic ventricular tachycardia #Coronary artery disease s/p MI #Dilated ischemic cardiomyopathy (EF [MASKED] 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 caring for you at [MASKED] [MASKED]. You were admitted because your heart was going into an abnormal rhythm (ventricular tachycardia), causing your ICD to fire. You underwent an ablation (treatment procedure) of the irritable areas in your heart that were causing the arrhythmias. You did well after the procedure and we felt you were safe for discharge. When you go home you will be on a full dose aspirin (325mg) for 1 month and then decrease to 81mg daily. You will also be on a new medication called sotalol to prevent recurrent arrhythmias. Weigh yourself every morning, call MD if [MASKED] goes up more than 3 lbs. Followup Instructions: [MASKED]	[]	[ "I2510", "F419", "Z87891" ]	[ "I472: Ventricular tachycardia", "I5022: Chronic systolic (congestive) heart failure", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I255: Ischemic cardiomyopathy", "F419: Anxiety disorder, unspecified", "D539: Nutritional anemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z95810: Presence of automatic (implantable) cardiac defibrillator" ]
19,985,259	23,988,340	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: shellfish derived Attending: ___ Chief Complaint: dyspnea, LUQ abdominal pain, anxiety Major Surgical or Invasive Procedure: cardiac catheterization ___ ICD placement ___ History of Present Illness: Mr. ___ is a ___ year old gentleman with history of HTN, HLD, CAD, dilated CMY (EF 40-45% ___ presenting with dyspnea, abdominal pain and anxiety. Patient reported shortness of breath and ongoing LUQ, intermittent abdominal pain described as a "rolling sensation" that began 1 hour prior to presentation. He denies chest pain, shortness of breath, cough, nausea, vomiting, diarrhea, lower extremity swelling. Vitals on arrival: 97.0 74 136/84 18 98% RA Labs: notable for normal CBC with elevated MCV 100, bicarb 21, K 3.9, Mg 2.1, Cr 1.0, glucose 224, lactate 4.0, troponin T 0.02, normal coags. LFTs notable for normal alk phos and tbili, elevated AST 184 ALT 81. Imaging: CXR showed Interstitial opacities noted bilaterally suggestive of possible interstitial edema. Subsequent to arrival patient developed wide complex tachycardia with ECG showing monomorphic VT. He received adenosine 6mg, 12mg IV with no change. He was subsequently loaded with amiodarone 150mg x1 and started on gtt. Subsequently received metoprolol 5mg IV x1`, lidocaine 100mg IV x1, without conversion and subsequently hypotensive requiring cardioverted at 200J x1 with subsequent to normal sinus rhythm. At that time he was noted to have ECG with sinus rhythm, rate 75, normal axis, >1mm ST elevations in leads V1-V2, ST depressions in II, III, avF as well as V4-V6 concerning for anterior STEMI and CODE STEMI was called. Patient went to the cath lab where he was found to have LAD with small first diag with 70% stenosis not amenable to intervention. No other significant lesion noted. Patient had R radial access but was not able to engage catheter, subsequently R femoral access, sheath was pulled in the cath lab at the conclusion of the procedure. He received lidocaine gtt at 2mg/min, aspirin 325mg PO. On arrival to the CCU, patient reports feeling well, overwhelmed with ED course and frustrated that his pants were cut off. He denies chest pain, lightheadedness, shortness of breath. Abdominal discomfort has resolved. He refuses statin as he states it causes his muscles to ache. REVIEW OF SYSTEMS: (+) per HPI Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All If the other review of systems were negative. Past Medical History: HTN HLD CAD Dilated Cardiomyopathy diagnosed ___ at ___, (EF 40-45% ___ Social History: ___ Family History: Father CAD/PVD Mother diabetes, Died on hospice, dementia Sister ___ Cancer No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION: VS: 98.7 74 139/71 26 94% on 4L Weight: 85kg (83.4kg at ___ ___ GEN: older gentleman lying flat in bed, anxious appearing but speaking in full sentences in NAD HEENT: PERRL, EOMI, no scleral icterus, MMM NECK: supple, JVP elevated at 10cmH20 CV: RRR, S1, S2 without appreciable m/r/g LUNGS: crackles at bilateral bases, no wheezes or rhonchi ABD: soft, non distended, non tender to palpation EXT: warm, well perfused, 1+ DP and ___ pulses bilaterally SKIN: warm, well perfused, no rashes, R groin with dressing in place, c/d/I no palpable thrill or audible bruit NEURO: axoxIII, CNII-XII grossly intact, gait not assessed DISCHARGE: VS: Tm98.0 123-153/55-69 ___ 18 97-100RA Weight: 80.1kg GENERAL: Well-appearing, alert, no NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM NECK: Supple with flat JVP CARDIAC: RRR, normal S1S2; no murmurs LUNGS: Resp were unlabored. No crackles, wheezes or rhonchi. Good air movement ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c. Trace ___ edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION: ================================ ___ 08:17PM BLOOD WBC-5.6 RBC-4.06* Hgb-14.0 Hct-40.7 MCV-100* MCH-34.5* MCHC-34.4 RDW-13.5 RDWSD-49.4* Plt ___ ___ 08:17PM BLOOD Neuts-52.5 ___ Monos-11.3 Eos-1.6 Baso-0.5 Im ___ AbsNeut-2.93 AbsLymp-1.88 AbsMono-0.63 AbsEos-0.09 AbsBaso-0.03 ___ 08:17PM BLOOD ___ PTT-25.9 ___ ___ 08:17PM BLOOD Glucose-224* UreaN-18 Creat-1.0 Na-133 K-7.4* Cl-100 HCO3-21* AnGap-19 ___ 08:17PM BLOOD ALT-81* AST-184* AlkPhos-50 TotBili-0.4 ___ 08:17PM BLOOD Lipase-56 ___ 08:17PM BLOOD cTropnT-0.02* ___ 08:17PM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.1 Mg-2.1 ___ 08:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:30PM BLOOD Glucose-224* Lactate-4.0* Na-140 K-3.9 Cl-106 calHCO3-21 IMAGING/STUDIES: ================================ + CARDIAC CATH (___): Right dominant LMCA short without significant disease LAD 30% proximal ___ diagonal is small with 70% stenosis circumflex without significant disease ___ marginal very small with severe mid disease ___ marginal is large caliber without significant disease AV groove continues as a small vessel RCA is with 30% mid Right PDA is without significant disease Impressions: Branch vessel coronary artery disease Guideline directed medical therapy for CAD Admit to CCU for management of ventricular tachycardia + TTE ___ The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF=30- 35%) secondary to moderate global hypokinesis with akinesis of the lateral wall. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate (___) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality requiring the use of contrast for better endocardial border definition. Moderately dilated left ventricular cavity with moderate global systolic dysfunction and regional involvement as described above. Mild-moderate aortic regurgitation. Mild mitral regurgitation. + Cardiac MRI ___ Please note that this report only pertains to extracardiac findings. There are no extracardiac findings. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. PRELIMINARY RESULTS: suggestive of ischemic cardiomyopathy. LVEF 34%. LV end diastolic volume index: 139ml/m2 (severely increased). RVEF 68% (normal). There is transmural late gadolinium enhancement in the basal-distal anterior and anteroseptal walls, distal anterolateral wall, and apex and subendocardial (___) based LGE in the mid anterolateral wall most consistent with myocardial infarction ___ CXR In comparison with study of ___, there has been placement of a left subclavian pacer with leads extending to the right atrium and apex of the right ventricle. No postprocedure pneumothorax. The cardiac silhouette is again enlarged without definite vascular congestion or evidence of acute focal pneumonia. DISCHARGE: ================================ ___ 06:26AM BLOOD WBC-5.9 RBC-3.99* Hgb-13.8 Hct-40.8 MCV-102* MCH-34.6* MCHC-33.8 RDW-13.6 RDWSD-51.2* Plt ___ ___ 06:26AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137 K-4.8 Cl-104 HCO3-23 AnGap-15 ___ 06:26AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1 Brief Hospital Course: Mr. ___ is a ___ year old gentleman with history of HTN, HLD, CAD, dilated CMY (EF 40-45% ___ presented with dyspnea and left upper quadrant pain found to have sustained polymorphic ventricular tachycardia with subsequent ST elevations in setting of prolonged episode of sustained VT and adenosine administration. Admitted to CCU due to monomorphic VT. # CORONARIES: See cath report, ___ diag with 70% stenosis # PUMP: this admission - EF ___ # RHYTHM: normal sinus, previously wide complex tachycardia # VENTRICULAR TACHYCARDIA: Patient was found to be in wide complex tachycardia consistent with monomorphic VT. Patient was evaluated by EP who felt VT likely originating in the LV apical region secondary to scar and may be amenable to VT ablation. Stabilized on lidocaine gtt and remained stable off drip with continued episodes of non-sustained ventricular tachycardia. Increased home metoprolol XL to 50mg BID. Repeated discussions were had regarding VT ablation and/or antiarrhythmic medications. Mr. ___ was adamant about not doing either. He was also very resistant to ICD implant, but eventually agreed. He underwent ICD placement ___ without complications. # ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE: LVEF 40-45% secondary to dilated cardiomyopathy per ___ records. Patient had previous workup at ___ that was reportedly negative for sarcoid, hemochromatosis, amyloid, HIV, syphilis, hypothyroidism. Now with new O2 requirement, CXR with increased vascular congestion and crackles on exam consistent with acute decompensated sCHF. Secondary to prolonged VT. Repeat TTE EF of ___, nml RV, no AS, mild to moderate AR, akinesis of the lateral wall of the LV. Global hypokinesis. Diuresed well with 80mg IV Lasix. Appeared euvolemic on physical exam, and ambulating on own without SOB. # CAD: Patient presented with VT, received adenosine x 2, after defibrillation and conversion to sinus rhythm had ST elevations in V1-V2, ST depressions in II, III, aVF concerning for anterior STEMI. Cardiac cath showed branch vessel CAD with 70% occlusion of ___ diag not amenable to intervention and no other significant CAD or evidence of acute plaque rupture. Medical management included aspirin, atorvastatin 20mg (pt refused higher dose due to myalgias), metoprolol, losartan. Cardiac MRI consistent with ischemic cardiomyopathy. CHRONIC ISSUES: #HTN: continued home losartan after achieving hemodynamic stability #HLD: Statin as above TRANSITIONAL ISSUES: -pt to complete 3 days of abx, 500mg TID Keflex (day 3 = ___ for post-ICD placement prophylaxis # Discharge weight: 80kg # Code: Full # Contact: son ___ ___, ex wife ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Losartan Potassium 100 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO BID RX metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Cephalexin 500 mg PO Q8H Duration: 1 Day RX cephalexin 500 mg 1 capsule(s) by mouth three times a day Disp #4 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia due to ischemic cardiomyopathy, treated with ICD placement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. You were admitted to the Cardiac ICU for an abnormal heart beat. You required electric shock of your heart to regain a regular rhythm. To prevent this in the future, an ICD device was placed to help keep your heart in a regular rhythm. During your admission, you also had a imaging of your heart that showed scarring of your heart muscle likely due to a heart attack in the past. However, imaging of your heart did not show occlusions of the blood vessels around your heart. You are now doing well and are ready for discharge. Please continue to take your medications subscribed you to and follow-up with your cardiologist. We wish you the best of health, Your ___ Care Team Followup Instructions: ___	[ "I472", "I5023", "I959", "I252", "I2510", "I255", "I10", "E785", "Z87891", "Z4502", "Z9114", "F419", "D539" ]	Allergies: shellfish derived Chief Complaint: dyspnea, LUQ abdominal pain, anxiety Major Surgical or Invasive Procedure: cardiac catheterization [MASKED] ICD placement [MASKED] History of Present Illness: Mr. [MASKED] is a [MASKED] year old gentleman with history of HTN, HLD, CAD, dilated CMY (EF 40-45% [MASKED] presenting with dyspnea, abdominal pain and anxiety. Patient reported shortness of breath and ongoing LUQ, intermittent abdominal pain described as a "rolling sensation" that began 1 hour prior to presentation. He denies chest pain, shortness of breath, cough, nausea, vomiting, diarrhea, lower extremity swelling. Vitals on arrival: 97.0 74 136/84 18 98% RA Labs: notable for normal CBC with elevated MCV 100, bicarb 21, K 3.9, Mg 2.1, Cr 1.0, glucose 224, lactate 4.0, troponin T 0.02, normal coags. LFTs notable for normal alk phos and tbili, elevated AST 184 ALT 81. Imaging: CXR showed Interstitial opacities noted bilaterally suggestive of possible interstitial edema. Subsequent to arrival patient developed wide complex tachycardia with ECG showing monomorphic VT. He received adenosine 6mg, 12mg IV with no change. He was subsequently loaded with amiodarone 150mg x1 and started on gtt. Subsequently received metoprolol 5mg IV x1`, lidocaine 100mg IV x1, without conversion and subsequently hypotensive requiring cardioverted at 200J x1 with subsequent to normal sinus rhythm. At that time he was noted to have ECG with sinus rhythm, rate 75, normal axis, >1mm ST elevations in leads V1-V2, ST depressions in II, III, avF as well as V4-V6 concerning for anterior STEMI and CODE STEMI was called. Patient went to the cath lab where he was found to have LAD with small first diag with 70% stenosis not amenable to intervention. No other significant lesion noted. Patient had R radial access but was not able to engage catheter, subsequently R femoral access, sheath was pulled in the cath lab at the conclusion of the procedure. He received lidocaine gtt at 2mg/min, aspirin 325mg PO. On arrival to the CCU, patient reports feeling well, overwhelmed with ED course and frustrated that his pants were cut off. He denies chest pain, lightheadedness, shortness of breath. Abdominal discomfort has resolved. He refuses statin as he states it causes his muscles to ache. REVIEW OF SYSTEMS: (+) per HPI Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, joint pains, cough, hemoptysis, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. All If the other review of systems were negative. Past Medical History: HTN HLD CAD Dilated Cardiomyopathy diagnosed [MASKED] at [MASKED], (EF 40-45% [MASKED] Social History: [MASKED] Family History: Father CAD/PVD Mother diabetes, Died on hospice, dementia Sister [MASKED] Cancer No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION: VS: 98.7 74 139/71 26 94% on 4L Weight: 85kg (83.4kg at [MASKED] [MASKED] GEN: older gentleman lying flat in bed, anxious appearing but speaking in full sentences in NAD HEENT: PERRL, EOMI, no scleral icterus, MMM NECK: supple, JVP elevated at 10cmH20 CV: RRR, S1, S2 without appreciable m/r/g LUNGS: crackles at bilateral bases, no wheezes or rhonchi ABD: soft, non distended, non tender to palpation EXT: warm, well perfused, 1+ DP and [MASKED] pulses bilaterally SKIN: warm, well perfused, no rashes, R groin with dressing in place, c/d/I no palpable thrill or audible bruit NEURO: axoxIII, CNII-XII grossly intact, gait not assessed DISCHARGE: VS: Tm98.0 123-153/55-69 [MASKED] 18 97-100RA Weight: 80.1kg GENERAL: Well-appearing, alert, no NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM NECK: Supple with flat JVP CARDIAC: RRR, normal S1S2; no murmurs LUNGS: Resp were unlabored. No crackles, wheezes or rhonchi. Good air movement ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c. Trace [MASKED] edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION: ================================ [MASKED] 08:17PM BLOOD WBC-5.6 RBC-4.06* Hgb-14.0 Hct-40.7 MCV-100* MCH-34.5* MCHC-34.4 RDW-13.5 RDWSD-49.4* Plt [MASKED] [MASKED] 08:17PM BLOOD Neuts-52.5 [MASKED] Monos-11.3 Eos-1.6 Baso-0.5 Im [MASKED] AbsNeut-2.93 AbsLymp-1.88 AbsMono-0.63 AbsEos-0.09 AbsBaso-0.03 [MASKED] 08:17PM BLOOD [MASKED] PTT-25.9 [MASKED] [MASKED] 08:17PM BLOOD Glucose-224* UreaN-18 Creat-1.0 Na-133 K-7.4* Cl-100 HCO3-21* AnGap-19 [MASKED] 08:17PM BLOOD ALT-81* AST-184* AlkPhos-50 TotBili-0.4 [MASKED] 08:17PM BLOOD Lipase-56 [MASKED] 08:17PM BLOOD cTropnT-0.02* [MASKED] 08:17PM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.1 Mg-2.1 [MASKED] 08:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 08:30PM BLOOD Glucose-224* Lactate-4.0* Na-140 K-3.9 Cl-106 calHCO3-21 IMAGING/STUDIES: ================================ + CARDIAC CATH ([MASKED]): Right dominant LMCA short without significant disease LAD 30% proximal [MASKED] diagonal is small with 70% stenosis circumflex without significant disease [MASKED] marginal very small with severe mid disease [MASKED] marginal is large caliber without significant disease AV groove continues as a small vessel RCA is with 30% mid Right PDA is without significant disease Impressions: Branch vessel coronary artery disease Guideline directed medical therapy for CAD Admit to CCU for management of ventricular tachycardia + TTE [MASKED] The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF=30- 35%) secondary to moderate global hypokinesis with akinesis of the lateral wall. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([MASKED]) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality requiring the use of contrast for better endocardial border definition. Moderately dilated left ventricular cavity with moderate global systolic dysfunction and regional involvement as described above. Mild-moderate aortic regurgitation. Mild mitral regurgitation. + Cardiac MRI [MASKED] Please note that this report only pertains to extracardiac findings. There are no extracardiac findings. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. PRELIMINARY RESULTS: suggestive of ischemic cardiomyopathy. LVEF 34%. LV end diastolic volume index: 139ml/m2 (severely increased). RVEF 68% (normal). There is transmural late gadolinium enhancement in the basal-distal anterior and anteroseptal walls, distal anterolateral wall, and apex and subendocardial ([MASKED]) based LGE in the mid anterolateral wall most consistent with myocardial infarction [MASKED] CXR In comparison with study of [MASKED], there has been placement of a left subclavian pacer with leads extending to the right atrium and apex of the right ventricle. No postprocedure pneumothorax. The cardiac silhouette is again enlarged without definite vascular congestion or evidence of acute focal pneumonia. DISCHARGE: ================================ [MASKED] 06:26AM BLOOD WBC-5.9 RBC-3.99* Hgb-13.8 Hct-40.8 MCV-102* MCH-34.6* MCHC-33.8 RDW-13.6 RDWSD-51.2* Plt [MASKED] [MASKED] 06:26AM BLOOD Glucose-116* UreaN-20 Creat-0.7 Na-137 K-4.8 Cl-104 HCO3-23 AnGap-15 [MASKED] 06:26AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1 Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old gentleman with history of HTN, HLD, CAD, dilated CMY (EF 40-45% [MASKED] presented with dyspnea and left upper quadrant pain found to have sustained polymorphic ventricular tachycardia with subsequent ST elevations in setting of prolonged episode of sustained VT and adenosine administration. Admitted to CCU due to monomorphic VT. # CORONARIES: See cath report, [MASKED] diag with 70% stenosis # PUMP: this admission - EF [MASKED] # RHYTHM: normal sinus, previously wide complex tachycardia # VENTRICULAR TACHYCARDIA: Patient was found to be in wide complex tachycardia consistent with monomorphic VT. Patient was evaluated by EP who felt VT likely originating in the LV apical region secondary to scar and may be amenable to VT ablation. Stabilized on lidocaine gtt and remained stable off drip with continued episodes of non-sustained ventricular tachycardia. Increased home metoprolol XL to 50mg BID. Repeated discussions were had regarding VT ablation and/or antiarrhythmic medications. Mr. [MASKED] was adamant about not doing either. He was also very resistant to ICD implant, but eventually agreed. He underwent ICD placement [MASKED] without complications. # ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE: LVEF 40-45% secondary to dilated cardiomyopathy per [MASKED] records. Patient had previous workup at [MASKED] that was reportedly negative for sarcoid, hemochromatosis, amyloid, HIV, syphilis, hypothyroidism. Now with new O2 requirement, CXR with increased vascular congestion and crackles on exam consistent with acute decompensated sCHF. Secondary to prolonged VT. Repeat TTE EF of [MASKED], nml RV, no AS, mild to moderate AR, akinesis of the lateral wall of the LV. Global hypokinesis. Diuresed well with 80mg IV Lasix. Appeared euvolemic on physical exam, and ambulating on own without SOB. # CAD: Patient presented with VT, received adenosine x 2, after defibrillation and conversion to sinus rhythm had ST elevations in V1-V2, ST depressions in II, III, aVF concerning for anterior STEMI. Cardiac cath showed branch vessel CAD with 70% occlusion of [MASKED] diag not amenable to intervention and no other significant CAD or evidence of acute plaque rupture. Medical management included aspirin, atorvastatin 20mg (pt refused higher dose due to myalgias), metoprolol, losartan. Cardiac MRI consistent with ischemic cardiomyopathy. CHRONIC ISSUES: #HTN: continued home losartan after achieving hemodynamic stability #HLD: Statin as above TRANSITIONAL ISSUES: -pt to complete 3 days of abx, 500mg TID Keflex (day 3 = [MASKED] for post-ICD placement prophylaxis # Discharge weight: 80kg # Code: Full # Contact: son [MASKED] [MASKED], ex wife [MASKED] [MASKED] [MASKED] on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Losartan Potassium 100 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO BID RX metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Cephalexin 500 mg PO Q8H Duration: 1 Day RX cephalexin 500 mg 1 capsule(s) by mouth three times a day Disp #4 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia due to ischemic cardiomyopathy, treated with ICD placement 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]. You were admitted to the Cardiac ICU for an abnormal heart beat. You required electric shock of your heart to regain a regular rhythm. To prevent this in the future, an ICD device was placed to help keep your heart in a regular rhythm. During your admission, you also had a imaging of your heart that showed scarring of your heart muscle likely due to a heart attack in the past. However, imaging of your heart did not show occlusions of the blood vessels around your heart. You are now doing well and are ready for discharge. Please continue to take your medications subscribed you to and follow-up with your cardiologist. We wish you the best of health, Your [MASKED] Care Team Followup Instructions: [MASKED]	[]	[ "I252", "I2510", "I10", "E785", "Z87891", "F419" ]	[ "I472: Ventricular tachycardia", "I5023: Acute on chronic systolic (congestive) heart failure", "I959: Hypotension, unspecified", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I255: Ischemic cardiomyopathy", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "Z9114: Patient's other noncompliance with medication regimen", "F419: Anxiety disorder, unspecified", "D539: Nutritional anemia, unspecified" ]
19,985,293	20,950,938	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: tramadol / lisinopril Attending: ___ Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: cholangiogram with drain tube removed ___ by ___ History of Present Illness: ___ female with history of lap gastrojejunostomy in ___ for duodenal stricture, causing gastric outlet obstruction, nonresectable pancreatic cancer, resultant biliary obstruction status post multiple draining stent placements by ___ (see below, but last on ___ had cholangiogram with balloon dilation and extenson of existing stent, and exchange of existing PTBD catheter), now presents with worsening epigastric pain x1 day. Regarding complicated biliary anatomy: note she is s/p initial PTBD placement ___. She was deemed a non-operable candidate and underwent cholangiogram on ___ with metallic stenting of her CBD. Her biliary drain was removed and her access site was gel-foam embolized. She developed rising LFTs post procedure and required a PTDB on ___. Cholangiogram showed an occluded stent was was balloon sweep and a ___ Fr. int/ext drain was placed. She was doing fairly well on oxycodone at home but today had worsening of abdominal pain which prompted her to go to ___. No vomiting, diarrhea, headache, chest pain, shortness of breath. At ___ a CT scan was negative for acute pathology. The patient had reassuring labs there, and was transferred for further care. The patient has been requiring IV morphine for pain control. Past Medical History: Locally advanced pancreatic adenocarcinoma diagnosed ___ Malignant CBD obstruction s/p PTBD HTN HLD Moderate AS Remote carotid endarterectomy Gastric outlet obstruction s/p gastrojejunostomy ___ Social History: ___ Family History: No known cancer is first degree relatives. Physical Exam: Admission Exam: VITAL SIGNS: 98.2 113/75 100 18 95%RA General: mild distress/abd pain HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, small firm nodule palpable just lateral to the left side of the midline in mid-lower quadrant LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Oriented x3. Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar, and Achilles tendons, toes are down bilaterally; gait is normal, coordination is intact. Discharge exam Vitals: 97.4 PO 97 / 57 80 18 97 Gen: pleasant, no acute distress 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, mildly distended, bowel sounds present, +mild epigastric tenderness. MSK: No edema Skin: No rashes or ulcerations evident Neurological: interactive, speech fluent, face symmetric, moving all extremities Psychiatric: pleasant, appropriate affect Pertinent Results: ___ 01:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 02:29AM LACTATE-1.6 ___ 07:25AM UREA N-21* CREAT-1.1 SODIUM-140 POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-25 ANION GAP-22* ___ 07:25AM ALT(SGPT)-19 AST(SGOT)-26 ALK PHOS-213* TOT BILI-1.1 ___ 07:25AM CALCIUM-8.9 PHOSPHATE-4.4 MAGNESIUM-1.7 Cholangiogram with ___ on ___ female with history of lap gastrojejunostomy in ___ for duodenal stricture, causing gastric outlet obstruction, nonresectable pancreatic cancer, resultant biliary obstruction status post multiple draining stent placements by ___ (see below, but last on ___ had cholangiogram with balloon dilation and extenson of existing stent, and exchange of existing PTBD catheter), now presents with worsening epigastric pain x1 day. # Abdominal pain # Constipation # Advanced Pancreatic Adenocarcinoma Per pt description this is consistent with her chronic epigastric band-like pain and not a new type of pain, just worsening significantly on the day of admission. She reported no bowel movements for several days and some abdominal distention. She has recently been taking increasing doses of oxycodone to help with pain. Initially pain thought secondary to progression of malignancy, biliary obstruction, or constipation. CT was without biliary obstruction or acute bowel obstruction. Patient's pain improved greatly with aggressive bowel regimen and large bowel movement on ___ ___. On ___ she underwent planned cholangiogram with ___ and removal of PTBD. She then began to tolerate diet and was discharged on ___ with oncology follow-up. When she leaves the hospital she should. -Continue aggressive bowel regimen with senna, miralax, bisacodyl PRN sup -Has Pain Clinic appointment to evaluate for celiac Plexus block at ___ ___. -F/u with Dr. ___ -___ provided patient and family with palliative care clinic resources if they would like to f/u for symptom management # Tachycardia -Improved with gentle IVF and pain control. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 7. Vitamin D 1000 UNIT PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Senna 17.2 mg PO BID 5. Aspirin 81 mg PO DAILY 6. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral DAILY 7. Cyanocobalamin 1000 mcg PO DAILY 8. Fish Oil (Omega 3) 1000 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # Abdominal pain # Constipation # Pancreatic cancer # Cholangiogram with PTBD removal # Gastric outlet obstruction # Tachycardia from hypovolemia. # moderate AS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for worsening epigastric pain x1 day that is felt to be secondary to constipation, much improved after large bowel movement on evening of admission. During hospitalization, ___ was consulted and you had a cholangiogram on ___ with drain tube removed without problems. This morning, blood count was lower than baseline, however, not confirmed upon rechecking. Potassium was low and was easily supplemented orally. Followup Instructions: ___	[ "R1013", "K5900", "C259", "K311", "R000", "E861", "I350" ]	Allergies: tramadol / lisinopril Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: cholangiogram with drain tube removed [MASKED] by [MASKED] History of Present Illness: [MASKED] female with history of lap gastrojejunostomy in [MASKED] for duodenal stricture, causing gastric outlet obstruction, nonresectable pancreatic cancer, resultant biliary obstruction status post multiple draining stent placements by [MASKED] (see below, but last on [MASKED] had cholangiogram with balloon dilation and extenson of existing stent, and exchange of existing PTBD catheter), now presents with worsening epigastric pain x1 day. Regarding complicated biliary anatomy: note she is s/p initial PTBD placement [MASKED]. She was deemed a non-operable candidate and underwent cholangiogram on [MASKED] with metallic stenting of her CBD. Her biliary drain was removed and her access site was gel-foam embolized. She developed rising LFTs post procedure and required a PTDB on [MASKED]. Cholangiogram showed an occluded stent was was balloon sweep and a [MASKED] Fr. int/ext drain was placed. She was doing fairly well on oxycodone at home but today had worsening of abdominal pain which prompted her to go to [MASKED]. No vomiting, diarrhea, headache, chest pain, shortness of breath. At [MASKED] a CT scan was negative for acute pathology. The patient had reassuring labs there, and was transferred for further care. The patient has been requiring IV morphine for pain control. Past Medical History: Locally advanced pancreatic adenocarcinoma diagnosed [MASKED] Malignant CBD obstruction s/p PTBD HTN HLD Moderate AS Remote carotid endarterectomy Gastric outlet obstruction s/p gastrojejunostomy [MASKED] Social History: [MASKED] Family History: No known cancer is first degree relatives. Physical Exam: Admission Exam: VITAL SIGNS: 98.2 113/75 100 18 95%RA General: mild distress/abd pain HEENT: MMM, no OP lesions, no cervical, supraclavicular, or axillary adenopathy, no thyromegaly CV: RR, NL S1S2 no S3S4 MRG PULM: CTAB GI: BS+, soft, NTND, small firm nodule palpable just lateral to the left side of the midline in mid-lower quadrant LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal adenopathy SKIN: No rashes or skin breakdown NEURO: Oriented x3. Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is [MASKED] of the proximal and distal upper and lower extremities; reflexes are 2+ of the biceps, triceps, patellar, and Achilles tendons, toes are down bilaterally; gait is normal, coordination is intact. Discharge exam Vitals: 97.4 PO 97 / 57 80 18 97 Gen: pleasant, no acute distress 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, mildly distended, bowel sounds present, +mild epigastric tenderness. MSK: No edema Skin: No rashes or ulcerations evident Neurological: interactive, speech fluent, face symmetric, moving all extremities Psychiatric: pleasant, appropriate affect Pertinent Results: [MASKED] 01:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [MASKED] 02:29AM LACTATE-1.6 [MASKED] 07:25AM UREA N-21* CREAT-1.1 SODIUM-140 POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-25 ANION GAP-22* [MASKED] 07:25AM ALT(SGPT)-19 AST(SGOT)-26 ALK PHOS-213* TOT BILI-1.1 [MASKED] 07:25AM CALCIUM-8.9 PHOSPHATE-4.4 MAGNESIUM-1.7 Cholangiogram with [MASKED] on [MASKED] female with history of lap gastrojejunostomy in [MASKED] for duodenal stricture, causing gastric outlet obstruction, nonresectable pancreatic cancer, resultant biliary obstruction status post multiple draining stent placements by [MASKED] (see below, but last on [MASKED] had cholangiogram with balloon dilation and extenson of existing stent, and exchange of existing PTBD catheter), now presents with worsening epigastric pain x1 day. # Abdominal pain # Constipation # Advanced Pancreatic Adenocarcinoma Per pt description this is consistent with her chronic epigastric band-like pain and not a new type of pain, just worsening significantly on the day of admission. She reported no bowel movements for several days and some abdominal distention. She has recently been taking increasing doses of oxycodone to help with pain. Initially pain thought secondary to progression of malignancy, biliary obstruction, or constipation. CT was without biliary obstruction or acute bowel obstruction. Patient's pain improved greatly with aggressive bowel regimen and large bowel movement on [MASKED] [MASKED]. On [MASKED] she underwent planned cholangiogram with [MASKED] and removal of PTBD. She then began to tolerate diet and was discharged on [MASKED] with oncology follow-up. When she leaves the hospital she should. -Continue aggressive bowel regimen with senna, miralax, bisacodyl PRN sup -Has Pain Clinic appointment to evaluate for celiac Plexus block at [MASKED] [MASKED]. -F/u with Dr. [MASKED] -[MASKED] provided patient and family with palliative care clinic resources if they would like to f/u for symptom management # Tachycardia -Improved with gentle IVF and pain control. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral DAILY 3. Fish Oil (Omega 3) 1000 mg PO DAILY 4. Omeprazole 40 mg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 7. Vitamin D 1000 UNIT PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN constipation 2. Docusate Sodium 100 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Senna 17.2 mg PO BID 5. Aspirin 81 mg PO DAILY 6. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral DAILY 7. Cyanocobalamin 1000 mcg PO DAILY 8. Fish Oil (Omega 3) 1000 mg PO DAILY 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Omeprazole 40 mg PO DAILY 11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: # Abdominal pain # Constipation # Pancreatic cancer # Cholangiogram with PTBD removal # Gastric outlet obstruction # Tachycardia from hypovolemia. # moderate AS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for worsening epigastric pain x1 day that is felt to be secondary to constipation, much improved after large bowel movement on evening of admission. During hospitalization, [MASKED] was consulted and you had a cholangiogram on [MASKED] with drain tube removed without problems. This morning, blood count was lower than baseline, however, not confirmed upon rechecking. Potassium was low and was easily supplemented orally. Followup Instructions: [MASKED]	[]	[ "K5900" ]	[ "R1013: Epigastric pain", "K5900: Constipation, unspecified", "C259: Malignant neoplasm of pancreas, unspecified", "K311: Adult hypertrophic pyloric stenosis", "R000: Tachycardia, unspecified", "E861: Hypovolemia", "I350: Nonrheumatic aortic (valve) stenosis" ]
19,985,293	21,731,208	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: tramadol / lisinopril Attending: ___ Chief Complaint: Fever and chills Major Surgical or Invasive Procedure: PICC placement and removal History of Present Illness: ___ female with history of lap gastrojejunostomy in ___ for duodenal stricture, causing gastric outlet obstruction, nonresectable pancreatic cancer now on chemo, resultant biliary obstruction status post multiple draining stent placements by ___ (see below, but last on ___ had cholangiogram with balloon dilation and extenson of existing stent, and exchange of existing PTBD catheter), now presents with diaphoretic episodes, chills, and found to have bacteremia. History was obtained from the daughter/HCP. She reports that patient began having low-grade fevers five days prior to admission. She then developed intermittent chills for a few days, but no abdominal pain. She had her first day of chemotherapy (gemcitabine, C1D1 ___ the day prior to presentation. Routine blood cultures were drawn at her chemotherapy session, and they returned positive on ___. The family was notified to bring the patient to the ED. In the ED, initial vitals: T 97.8, HR 86, BP 124/58, 16, O2 94% RA - Exam notable for: normal mental status - Labs were notable for: WBC 8.4 -> 10.8, Hgb 7.5 -> 6.8, Plt 299, INR 1.1, Cr 1.1 -> 0.9, Mg 1.7, Albumin 2.7, Lactate 2.1 -> 1.4, UA normal, - Imaging: CXR showed patchy bibasilar opacities. CT demonstrated new air fluid collection near the lesser sac of the stomach concerning for contained duodenal perforation with abscess. She was evaluated by surgery who did not feel she was a surgical candidate. - Patient was given: 3.5L NS, Vancomycin, Cefepime, Oxycodone for pain She was initially going to be admitted to ___, but developed hypotension while getting a CT scan. She was fluid resuscitated and a right IJ line was placed. She was started on levophed (0.12) for low MAPs. She was given 1u pRBC transfusion for hgb 6.8, during which she had a blood transfusion reaction with rigors. Coombs was negative. She then spiked a fever to 104.8. Goals of care were discussed with the family, but no conclusion was reached. On arrival to the MICU, she was alert and oriented x3. She denied any abdominal pain or overall discomfort. She required increasing doses of lovophed at 0.3 mcg/kg/min to maintain MAP > 65. A 500 cc LR bolus was given. A goals of care conversation was had with the family, who determined that she would like to be DNR/DNI. Past Medical History: Locally advanced pancreatic adenocarcinoma diagnosed ___ Malignant CBD obstruction s/p PTBD HTN HLD Moderate AS Remote carotid endarterectomy Gastric outlet obstruction s/p gastrojejunostomy ___ Social History: ___ Family History: No known cancer is first degree relatives. Physical Exam: ADMISSION PHYSICAL EXAM ========================== VITALS: 98.8, HR 103, BP 113/60, RR 19, 95% RA GENERAL: Alert and oriented, lying in bed, denies pain HEENT: AT/NC, EOMI, PERRL NECK: nontender supple neck, no LAD, no JVD, right IJ pain CARDIAC: RRR, S1/S2, ___ systolic crescendo decrescendo murmur in the USB LUNG: CTA, no wheezes ABDOMEN: nondistended, +BS, nontender EXTREMITIES: WWP, no ___ edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact DISCHARGE PHYSICAL EXAM ========================== Vitlas: 97.8 106/71 86 18 97% RA General: alert, sitting in bed, no acute distress Neuro: oriented, moving all extremities Abd: soft, nontender throughout Pertinent Results: ADMISSION LABS ============================= ___ 08:39AM BLOOD WBC-7.3 RBC-2.89* Hgb-8.7* Hct-26.4* MCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 RDWSD-47.6* Plt ___ ___ 11:30AM BLOOD Neuts-88* Bands-0 Lymphs-9* Monos-1* Eos-1 Baso-1 ___ Myelos-0 AbsNeut-7.39* AbsLymp-0.76* AbsMono-0.08* AbsEos-0.08 AbsBaso-0.08 ___ 11:30AM BLOOD ___ PTT-31.7 ___ ___ 08:39AM BLOOD UreaN-24* Creat-1.0 Na-131* K-3.5 Cl-94* HCO3-28 AnGap-13 ___ 08:39AM BLOOD ALT-15 AST-25 AlkPhos-178* TotBili-0.6 ___ 11:30AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.3 Mg-1.7 ___ 11:46AM BLOOD Lactate-2.1* DISCHARGE LAB ============================== ___ 06:10AM BLOOD WBC-8.0 RBC-3.60# Hgb-10.6# Hct-31.2# MCV-87 MCH-29.4 MCHC-34.0 RDW-14.9 RDWSD-48.1 Plt ___ ___ 05:56AM BLOOD Glucose-65* UreaN-10 Creat-1.0 Na-133 K-3.5 Cl-100 HCO3-21* AnGap-16 MICROBIOLOGY ============================= ___ 12:01 pm BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 4:25 am BLOOD CULTURE Source: Line-RIJ TLC. Blood Culture, Routine (Preliminary): LACTOBACILLUS SPECIES. Isolated from only one set in the previous five days. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE ROD(S). Reported to and read back by ___. (___) AT ___ ON ___. IMAGING ============================= CT abdomen/pelvis ___ IMPRESSION: 1. Interval development of an approximately 3.3 x 4.1 cm air and fluid collection anterior to the common hepatic artery within the lesser sac of the stomach, which likely represents a contained perforation/abscess originating from the stomach/duodenum, where the pancreatic mass is invading. 2. Chronically obstructed and distended gallbladder containing multiple small gallstones and sludge. New pericholecystic fluid is nonspecific and may be reactive to the adjacent inflammatory process. 3. Interval removal of right-sided PTBD, with mild right intrahepatic biliary ductal dilatation. Trace perihepatic fluid. 4. Interval increase in size of nonspecific hyperattenuating and soft tissue density rounded areas in the left rectus abdominus muscle possibly hematomas. metastatic implants would be unusual in this location, but cannot be completely excluded and attention to this region on follow-up imaging is recommended. 5. Small amount of pelvic free fluid. CXR ___ IMPRESSION: Patchy bibasilar opacities likely reflect atelectasis. Brief Hospital Course: Ms. ___ is an ___ female with history of lap gastrojejunostomy (___) for duodenal stricture causing gastric outlet obstruction, non-resectable pancreatic cancer now on chemo, biliary obstruction status post multiple draining stent placements by ___, who p/w septic shock and GNR bacteremia in the setting of a contained duodenal perforation. # Goals of care: Given patient's grave clinical status, a family meeting was held during which it was decided that the patient and her family would prefer to prioritize quality of life and discharge from hospital. Thus, patient was discharged home on hospice and confirmed DNR/DNI. # Septic shock: # GNR Bacteremia: Patient in septic shock secondary to GNR/GPR bacteremia in the setting of duodenal perforation and abscess, likely caused by pancreatic mass invasion. Initially on norepinephrine for hypotension, which was weaned. Per ID, treated with zosyn for coverage of intra-abdominal organisms. Blood cultures grew E. coli. Surgery was consulted but did not feel there were any surgical options at this time given that the perforation is contained. The patient's pain was well controlled on minimal IV dilaudid. Patient was kept NPO ___, but started on clears on ___ per surgery recommendations. Her diet was advanced to regular and it was well tolerated. Per ID, she was transitioned to PO levofloxacin and flagyl for an indefinite course. Will defer to hospice to help patient transition off antibiotics. # Anemia: Normocytic anemia with baseline hgb ___. Likely from ACD and malignancy. Hb droped to 6.5 and she was transfused 2 units to aid with weakness symptoms and improved to 10 at discharge. Family requested additional work-up for transfusions in the future, but this was discouraged given goals of care as above. # Pancreatic cancer: Diagnosed in ___. It is locally advanced and unresectable (encases vasculature). C1D1 of gemcitabine on ___. She has had numerous prior biliary stents, with the last PTBD exchange on ___. Per communications with outpatient oncologist, there is no plan for additional chemotherapy given infection and complications as noted above. > 30 minutes were spent on discharge care, planning, and coordination. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Cyanocobalamin 1000 mcg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 5. Vitamin D 1000 UNIT PO DAILY 6. Bisacodyl 10 mg PR QHS:PRN constipation 7. Docusate Sodium 100 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Senna 17.2 mg PO BID 10. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral DAILY 11. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Levofloxacin 500 mg PO Q48H RX levofloxacin 500 mg 1 tablet(s) by mouth Q48H Disp #14 Tablet Refills:0 2. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #60 Tablet Refills:0 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Omeprazole 40 mg PO DAILY 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN RX oxycodone 5 mg 1 tablet(s) by mouth Q4h:prn Disp #10 Tablet Refills:0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 17.2 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: pancreatic cancer duodenal perforation with abscess formation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure caring for you during your stay at ___ ___. You were admitted for abdominal pain and a CT scan found that this was likely caused by a small perforation (a hole) in a part of your intestine. This hole caused an abscess (a collection of bacteria - an infection) because bacteria from the gut leaked into the surrounding area. You were treated with antibiotics. Fortunately, from your last CT scan, it appears as though the perforation (hole) seemed to close and nothing is leaking from your small intestines anymore. It is safe for you to eat. The abscess size is stable. Unfortunately, there is no further treatment for your cancer at this time given the many complications you have had. The surgeons evaluated you and your scans and did not think any operation would be beneficial. We are treating you with antibiotics, but this is more of a "Band-Aid" to hopefully prevent significant progression of the abscess, but it will not work forever. You should discuss with your hospice team when would be a good time to stop these antibiotics. You and your family discussed the treatment options with many of your providers in the hospital and you decided that it would be best to focus on the quality of your life rather than on treating these individual problems. We hope that you are comfortable at home and enjoy the remainder of your days with loved ones. The hospice team will help with this transition and help you manage your symptoms at home. Please take care, Your ___ Team Followup Instructions: ___	[ "A4151", "K265", "K651", "R6521", "E871", "C250", "I10", "B9620", "D630", "Z66", "I350", "I999", "K219", "R0902" ]	Allergies: tramadol / lisinopril Chief Complaint: Fever and chills Major Surgical or Invasive Procedure: PICC placement and removal History of Present Illness: [MASKED] female with history of lap gastrojejunostomy in [MASKED] for duodenal stricture, causing gastric outlet obstruction, nonresectable pancreatic cancer now on chemo, resultant biliary obstruction status post multiple draining stent placements by [MASKED] (see below, but last on [MASKED] had cholangiogram with balloon dilation and extenson of existing stent, and exchange of existing PTBD catheter), now presents with diaphoretic episodes, chills, and found to have bacteremia. History was obtained from the daughter/HCP. She reports that patient began having low-grade fevers five days prior to admission. She then developed intermittent chills for a few days, but no abdominal pain. She had her first day of chemotherapy (gemcitabine, C1D1 [MASKED] the day prior to presentation. Routine blood cultures were drawn at her chemotherapy session, and they returned positive on [MASKED]. The family was notified to bring the patient to the ED. In the ED, initial vitals: T 97.8, HR 86, BP 124/58, 16, O2 94% RA - Exam notable for: normal mental status - Labs were notable for: WBC 8.4 -> 10.8, Hgb 7.5 -> 6.8, Plt 299, INR 1.1, Cr 1.1 -> 0.9, Mg 1.7, Albumin 2.7, Lactate 2.1 -> 1.4, UA normal, - Imaging: CXR showed patchy bibasilar opacities. CT demonstrated new air fluid collection near the lesser sac of the stomach concerning for contained duodenal perforation with abscess. She was evaluated by surgery who did not feel she was a surgical candidate. - Patient was given: 3.5L NS, Vancomycin, Cefepime, Oxycodone for pain She was initially going to be admitted to [MASKED], but developed hypotension while getting a CT scan. She was fluid resuscitated and a right IJ line was placed. She was started on levophed (0.12) for low MAPs. She was given 1u pRBC transfusion for hgb 6.8, during which she had a blood transfusion reaction with rigors. Coombs was negative. She then spiked a fever to 104.8. Goals of care were discussed with the family, but no conclusion was reached. On arrival to the MICU, she was alert and oriented x3. She denied any abdominal pain or overall discomfort. She required increasing doses of lovophed at 0.3 mcg/kg/min to maintain MAP > 65. A 500 cc LR bolus was given. A goals of care conversation was had with the family, who determined that she would like to be DNR/DNI. Past Medical History: Locally advanced pancreatic adenocarcinoma diagnosed [MASKED] Malignant CBD obstruction s/p PTBD HTN HLD Moderate AS Remote carotid endarterectomy Gastric outlet obstruction s/p gastrojejunostomy [MASKED] Social History: [MASKED] Family History: No known cancer is first degree relatives. Physical Exam: ADMISSION PHYSICAL EXAM ========================== VITALS: 98.8, HR 103, BP 113/60, RR 19, 95% RA GENERAL: Alert and oriented, lying in bed, denies pain HEENT: AT/NC, EOMI, PERRL NECK: nontender supple neck, no LAD, no JVD, right IJ pain CARDIAC: RRR, S1/S2, [MASKED] systolic crescendo decrescendo murmur in the USB LUNG: CTA, no wheezes ABDOMEN: nondistended, +BS, nontender EXTREMITIES: WWP, no [MASKED] edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact DISCHARGE PHYSICAL EXAM ========================== Vitlas: 97.8 106/71 86 18 97% RA General: alert, sitting in bed, no acute distress Neuro: oriented, moving all extremities Abd: soft, nontender throughout Pertinent Results: ADMISSION LABS ============================= [MASKED] 08:39AM BLOOD WBC-7.3 RBC-2.89* Hgb-8.7* Hct-26.4* MCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 RDWSD-47.6* Plt [MASKED] [MASKED] 11:30AM BLOOD Neuts-88* Bands-0 Lymphs-9* Monos-1* Eos-1 Baso-1 [MASKED] Myelos-0 AbsNeut-7.39* AbsLymp-0.76* AbsMono-0.08* AbsEos-0.08 AbsBaso-0.08 [MASKED] 11:30AM BLOOD [MASKED] PTT-31.7 [MASKED] [MASKED] 08:39AM BLOOD UreaN-24* Creat-1.0 Na-131* K-3.5 Cl-94* HCO3-28 AnGap-13 [MASKED] 08:39AM BLOOD ALT-15 AST-25 AlkPhos-178* TotBili-0.6 [MASKED] 11:30AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.3 Mg-1.7 [MASKED] 11:46AM BLOOD Lactate-2.1* DISCHARGE LAB ============================== [MASKED] 06:10AM BLOOD WBC-8.0 RBC-3.60# Hgb-10.6# Hct-31.2# MCV-87 MCH-29.4 MCHC-34.0 RDW-14.9 RDWSD-48.1 Plt [MASKED] [MASKED] 05:56AM BLOOD Glucose-65* UreaN-10 Creat-1.0 Na-133 K-3.5 Cl-100 HCO3-21* AnGap-16 MICROBIOLOGY ============================= [MASKED] 12:01 pm BLOOD CULTURE *FINAL REPORT [MASKED] Blood Culture, Routine (Final [MASKED]: ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [MASKED] 4:25 am BLOOD CULTURE Source: Line-RIJ TLC. Blood Culture, Routine (Preliminary): LACTOBACILLUS SPECIES. Isolated from only one set in the previous five days. Anaerobic Bottle Gram Stain (Final [MASKED]: GRAM POSITIVE ROD(S). Reported to and read back by [MASKED]. ([MASKED]) AT [MASKED] ON [MASKED]. IMAGING ============================= CT abdomen/pelvis [MASKED] IMPRESSION: 1. Interval development of an approximately 3.3 x 4.1 cm air and fluid collection anterior to the common hepatic artery within the lesser sac of the stomach, which likely represents a contained perforation/abscess originating from the stomach/duodenum, where the pancreatic mass is invading. 2. Chronically obstructed and distended gallbladder containing multiple small gallstones and sludge. New pericholecystic fluid is nonspecific and may be reactive to the adjacent inflammatory process. 3. Interval removal of right-sided PTBD, with mild right intrahepatic biliary ductal dilatation. Trace perihepatic fluid. 4. Interval increase in size of nonspecific hyperattenuating and soft tissue density rounded areas in the left rectus abdominus muscle possibly hematomas. metastatic implants would be unusual in this location, but cannot be completely excluded and attention to this region on follow-up imaging is recommended. 5. Small amount of pelvic free fluid. CXR [MASKED] IMPRESSION: Patchy bibasilar opacities likely reflect atelectasis. Brief Hospital Course: Ms. [MASKED] is an [MASKED] female with history of lap gastrojejunostomy ([MASKED]) for duodenal stricture causing gastric outlet obstruction, non-resectable pancreatic cancer now on chemo, biliary obstruction status post multiple draining stent placements by [MASKED], who p/w septic shock and GNR bacteremia in the setting of a contained duodenal perforation. # Goals of care: Given patient's grave clinical status, a family meeting was held during which it was decided that the patient and her family would prefer to prioritize quality of life and discharge from hospital. Thus, patient was discharged home on hospice and confirmed DNR/DNI. # Septic shock: # GNR Bacteremia: Patient in septic shock secondary to GNR/GPR bacteremia in the setting of duodenal perforation and abscess, likely caused by pancreatic mass invasion. Initially on norepinephrine for hypotension, which was weaned. Per ID, treated with zosyn for coverage of intra-abdominal organisms. Blood cultures grew E. coli. Surgery was consulted but did not feel there were any surgical options at this time given that the perforation is contained. The patient's pain was well controlled on minimal IV dilaudid. Patient was kept NPO [MASKED], but started on clears on [MASKED] per surgery recommendations. Her diet was advanced to regular and it was well tolerated. Per ID, she was transitioned to PO levofloxacin and flagyl for an indefinite course. Will defer to hospice to help patient transition off antibiotics. # Anemia: Normocytic anemia with baseline hgb [MASKED]. Likely from ACD and malignancy. Hb droped to 6.5 and she was transfused 2 units to aid with weakness symptoms and improved to 10 at discharge. Family requested additional work-up for transfusions in the future, but this was discouraged given goals of care as above. # Pancreatic cancer: Diagnosed in [MASKED]. It is locally advanced and unresectable (encases vasculature). C1D1 of gemcitabine on [MASKED]. She has had numerous prior biliary stents, with the last PTBD exchange on [MASKED]. Per communications with outpatient oncologist, there is no plan for additional chemotherapy given infection and complications as noted above. > 30 minutes were spent on discharge care, planning, and coordination. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Cyanocobalamin 1000 mcg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Omeprazole 40 mg PO DAILY 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN 5. Vitamin D 1000 UNIT PO DAILY 6. Bisacodyl 10 mg PR QHS:PRN constipation 7. Docusate Sodium 100 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY:PRN constipation 9. Senna 17.2 mg PO BID 10. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral DAILY 11. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Medications: 1. Levofloxacin 500 mg PO Q48H RX levofloxacin 500 mg 1 tablet(s) by mouth Q48H Disp #14 Tablet Refills:0 2. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #60 Tablet Refills:0 3. Bisacodyl 10 mg PR QHS:PRN constipation 4. Docusate Sodium 100 mg PO BID 5. Omeprazole 40 mg PO DAILY 6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH PAIN RX oxycodone 5 mg 1 tablet(s) by mouth Q4h:prn Disp #10 Tablet Refills:0 7. Polyethylene Glycol 17 g PO DAILY:PRN constipation 8. Senna 17.2 mg PO BID Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: pancreatic cancer duodenal perforation with abscess formation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [MASKED], It was a pleasure caring for you during your stay at [MASKED] [MASKED]. You were admitted for abdominal pain and a CT scan found that this was likely caused by a small perforation (a hole) in a part of your intestine. This hole caused an abscess (a collection of bacteria - an infection) because bacteria from the gut leaked into the surrounding area. You were treated with antibiotics. Fortunately, from your last CT scan, it appears as though the perforation (hole) seemed to close and nothing is leaking from your small intestines anymore. It is safe for you to eat. The abscess size is stable. Unfortunately, there is no further treatment for your cancer at this time given the many complications you have had. The surgeons evaluated you and your scans and did not think any operation would be beneficial. We are treating you with antibiotics, but this is more of a "Band-Aid" to hopefully prevent significant progression of the abscess, but it will not work forever. You should discuss with your hospice team when would be a good time to stop these antibiotics. You and your family discussed the treatment options with many of your providers in the hospital and you decided that it would be best to focus on the quality of your life rather than on treating these individual problems. We hope that you are comfortable at home and enjoy the remainder of your days with loved ones. The hospice team will help with this transition and help you manage your symptoms at home. Please take care, Your [MASKED] Team Followup Instructions: [MASKED]	[]	[ "E871", "I10", "Z66", "K219" ]	[ "A4151: Sepsis due to Escherichia coli [E. coli]", "K265: Chronic or unspecified duodenal ulcer with perforation", "K651: Peritoneal abscess", "R6521: Severe sepsis with septic shock", "E871: Hypo-osmolality and hyponatremia", "C250: Malignant neoplasm of head of pancreas", "I10: Essential (primary) hypertension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "D630: Anemia in neoplastic disease", "Z66: Do not resuscitate", "I350: Nonrheumatic aortic (valve) stenosis", "I999: Unspecified disorder of circulatory system", "K219: Gastro-esophageal reflux disease without esophagitis", "R0902: Hypoxemia" ]

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.