subject_id int64 10M 20M | hadm_id int64 20M 30M | text sequencelengths 1 1 | cleaned_text stringlengths 382 57.3k | icd_code sequencelengths 1 39 | icd_descriptions sequencelengths 1 39 | code_commons sequencelengths 0 23 | code_rare sequencelengths 0 2 |
|---|---|---|---|---|---|---|---|
19,760,774 | 21,856,420 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeg pain\n \nMajor Surgical or Invasiv... | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Leg pain Major Surgical or Invasive Procedure: Skin Biopsy History of Present Illness: Ms. [MASKED] is a [MASKED] woman with history of hypertension who presents with leg pain. The patient is interviewed with the assistance of a [MASKED] translator. The patient reports that she began to develop bilateral leg pain [MASKED] weeks ago. She develop sored that began to weep fluid. The fluid was purulent and foul swelling. She reports that she has a severe pain in her legs, and also a cramping in the calves. She denies fevers or chills. Denies trauma to the leg. She saw her PCP for this issue, and was given a cream to apply that did not help. She has been using Tylenol without much relief of her pain. She has been able to ambulate, but is has been more difficult due to pain. In the ED, vitals: 97.7 103 146/68 18 100% RA Exam notable for significant bilateral lower extremity edema and chronic skin changes, with erythema and warmth most notable in the left leg. Erosion along left medial ankle. Wounds/legs are malodorous. Labs notable for: WBC 6.6, Hb 10.8 Imaging: Plain films negative for fracture; LENIs negative for DVT Patient given: [MASKED] 01:18 PO Acetaminophen 1000 mg [MASKED] 02:13 IV Piperacillin-Tazobactam 4.5 g [MASKED] 03:53 IV Vancomycin 1500 mg [MASKED] 03:53 IVF NS 1000 mL On arrival to the floor, she reports that her leg pain is a [MASKED] decreased from a [MASKED]. She implores us to help with her legs. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - Hypertension Social History: [MASKED] Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Ulcer of left medial ankle with purulent and malodorous drainage; edema and chronic brawny skin changes of left calf; right calf with thick crusting/scaling with appearance of healthy skin beneath with peau d'orange, hyperpigmentation, and nodules/plaques NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: Pleasant, appropriate affect Discharge Exam: Gen - not in distress. A&Ox3 RS: CTAB [MASKED]: S1S2 normal, no murmurs Abd: No tenderness, BS normal. Extremities: RLE: Extensive hyperkeratotic plaques from calf to foot with ulceration over L medial ankle with purulent drainage. Tender to palpation over calf LLE: Ulcer with purulent discharge over left medial malleolus and some hyperkeratotic plaques over foot. Very tender to touch over calf. BLE: Pulses palpable Pertinent Results: Labs: [MASKED] 10:40PM BLOOD WBC: 6.6 RBC: 4.03 Hgb: 10.8* Hct: 33.6* MCV: 83 MCH: 26.8 MCHC: 32.1 RDW: 16.1* RDWSD: 49.1* Plt Ct: 374 [MASKED] 10:40PM BLOOD Glucose: 100 UreaN: 7 Creat: 0.8 Na: 142 K: 4.7 Cl: 101 HCO3: 26 AnGap: 15 [MASKED] 10:41PM BLOOD Lactate: 1.8 Micro: - Blood cultures negative Imaging: - Bilateral ankle/tib/fib: Mild degenerative changes without evidence of acute fracture or dislocation. - LENIs: No evidence of deep venous thrombosis in the right or left lower extremity veins to the level of the popliteal fossa. Suboptimal imaging of the vessels in the calves limits their evaluation. [MASKED] 3:39 pm SWAB Source: left medial ankle ulcer. **FINAL REPORT [MASKED] WOUND CULTURE (Final [MASKED]: PROTEUS MIRABILIS. SPARSE GROWTH. STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this culture. Work-up of organism(s) listed discontinued (except screened organisms) due to the presence of mixed bacterial flora detected after further incubation. SENSITIVITIES: MIC expressed in MCG/ML [MASKED] PROTEUS MIRABILIS | STAPH AUREUS COAG + | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- <=0.25 S GENTAMICIN------------ <=1 S <=0.5 S MEROPENEM-------------<=0.25 S OXACILLIN------------- 0.5 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S Brief Hospital Course: Ms. [MASKED] is a [MASKED] woman with history of hypertension who presents with leg pain found to have retention hyperkeratosis complicated by superimposed cellulitis. # Skin and soft tissue infection - likely Retention hyperkeratosis based on prelim skin biopsy findings # L medial malleolus ulcer with infection - superimposed cellulitis # Leg pain Patient presented with several weeks of leg pain and skin changes. On left leg there is a purulent and malodorous ulcer. On both legs, there are brawny skin changes with overlying crusting. Plain films of legs without clear bony changes. LENIs negative for DVT. B/l pulses well-palpable. Venous stasis ulcer is a possibility. ESR 39. Ultimately treated for cellulitis and started on topical treatments for retention hyperkeratosis by dermatology as below. Referral placed to dermatology for outpatient follow up on discharge. She will continue to require daily dressing changes on discharge. Home [MASKED] was arranged for this though patient continues to be reluctant about home [MASKED] visits stating she will go to nearby clinic for her daily dressing changes instead. - Wound care recs: RLE: "urea cream or amlactin, then vaseline then wrapped in kerlix gauze from toes to knees" LLE: "mupirocin ointment then wrapped in kerlix gauze from toes to mid calf" -Change dressings daily -F/U blood and wound cultures - negative blood cultures, wound cultures positive for MSSA and proteus with sensitivities as listed. De-scalated antibiotics to Doxy and Keflex with plan to complete [MASKED] day course on discharge. - Tylenol for pain, Tramadol for breakthrough CHRONIC/STABLE PROBLEMS: # Hypertension: Not currently on any medications Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Cephalexin 500 mg PO Q6H RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth four times a day Disp #*20 Capsule Refills:*0 2. Doxycycline Hyclate 100 mg PO Q12H RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0 3. Mupirocin Ointment 2% 1 Appl TP DAILY RX *mupirocin 2 % 1 APP DAILY Refills:*1 4. TraMADol 25 mg PO Q6H:PRN Pain - Severe 5. Ureacin-20 (urea) 20 % topical DAILY RX *urea [Ureacin-20] 20 % 1 APP Daily Refills:*1 Discharge Disposition: Home With Service Facility: [MASKED] Discharge Diagnosis: Retention Hyperkeratosis Superimposed Cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Clean biopsy site with soap, water, then pad dry every day for 2 weeks. Cover with a thin layer of vaseline and perform dressing change every day for 2 weeks. - RIGHT lower extremity: urea cream or amlactin, then Vaseline then wrapped in kerlix gauze from toes to knees - for the LEFT lower extremity: mupirocin ointment then wrapped in kerlix gauze from toes to mid calf - Both of these dressings to be changed daily Continue with antibiotics for another 5 days. Followup Instructions: [MASKED] | [
"L03116",
"L97329",
"L570",
"I10"
] | [
"L03116: Cellulitis of left lower limb",
"L97329: Non-pressure chronic ulcer of left ankle with unspecified severity",
"L570: Actinic keratosis",
"I10: Essential (primary) hypertension"
] | [
"I10"
] | [] |
13,981,687 | 22,194,755 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nswollen ear, severe headache, fevers\n \... | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: swollen ear, severe headache, fevers Major Surgical or Invasive Procedure: intubation History of Present Illness: [MASKED] is a [MASKED] yo M with a history of afib on anticoag, diabetes, HTN who presented to [MASKED] with severe headache, fever 102, shaking chills, and toxic appearance. [MASKED] reports gradual onset headache that began 1 day ago, associated with right ear pain. Headache throbbing, dull, frontal. Subjective fevers, chills, nausea. Concern for mastoiditis vs meningitis, was started on Vanc, Zosyn, Ceftriaxone. CT head negative for acute pathology. and transferred to our [MASKED] remained A&Ox3. [MASKED] in Afib with RVR, stable BPs; given diltiazem with appropriate response by time of transfer to ICU. ENT consulted while in [MASKED] and thought to be auriculitis, were less concerned for meningitis and unable to do LP as [MASKED] on anticoag. [MASKED] continued on zosyn. In the [MASKED], Initial Vitals: T: 99.2 HR: 120 BP; 126/90 RR: 18 SpO2: 94% 4L NC Exam: no menigismus, neck stiffness erythematous and indurated R ear Labs: WBC 12.5 (82% neutrophils) Lactate: 2.0 Imaging: Consults: ENT Interventions: Diltiazem, Zosyn VS Prior to Transfer: T: 98.7 HR: 115-131 BP: 170/87 RR: 20 92% 2L NC Past Medical History: A fib on anticoagulation Diabetes Hypertension esophageal cancer [MASKED] CRT in remission Heart failure with reduced ejection fraction T2DM Social History: [MASKED] Family History: Married. Lives with his wife. Physical Exam: ADMISSION EXAM: ================ VS: T: 98.5 BP:131/81 HR:93 afib RR: 16 GEN: pleasant, no apparent distress HEENT: right ear is erythematous indurated and edematous, behind the right ear is markedly tender and swollen, the right TM is erythematous, the canal is erythematous NECK: wide full CV: irregular rhythm RESP: CTAB GI: abd soft, non tender to palpation MSK: SKIN: NEURO: no gross deficits PSYCH: appropriate affect DISCHARGE EXAM =============== 24 HR Data (last updated [MASKED] @ 1308) Temp: 97.7 (Tm 98.4), BP: 123/77 (116-134/59-93), HR: 79 (68-103), RR: 18 ([MASKED]), O2 sat: 98% (92-98), O2 delivery: Ra, Wt: 231.8 lb/105.14 kg General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Scant crackles in lower lung bilaterally 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 Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAOx3. Some difficulty with months-of-year-backwards. Pertinent Results: ADMISSON LABS ============== [MASKED] 05:22AM BLOOD WBC-12.1* RBC-5.20 Hgb-15.1 Hct-46.6 MCV-90 MCH-29.0 MCHC-32.4 RDW-14.8 RDWSD-48.9* Plt [MASKED] [MASKED] 05:22AM BLOOD Neuts-78.6* Lymphs-13.9* Monos-6.6 Eos-0.1* Baso-0.4 Im [MASKED] AbsNeut-9.48* AbsLymp-1.67 AbsMono-0.79 AbsEos-0.01* AbsBaso-0.05 [MASKED] 05:22AM BLOOD [MASKED] PTT-47.2* [MASKED] [MASKED] 05:22AM BLOOD Glucose-101* UreaN-16 Creat-1.1 Na-142 K-4.1 Cl-105 HCO3-22 AnGap-15 [MASKED] 05:22AM BLOOD ALT-29 AST-25 LD(LDH)-209 AlkPhos-63 TotBili-0.6 [MASKED] 05:22AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.5 Mg-1.8 [MASKED] 02:15AM BLOOD [MASKED] pO2-83* pCO2-37 pH-7.43 calTCO2-25 Base XS-0 Comment-GREEN TOP [MASKED] 02:15AM BLOOD Lactate-1.5 DISCHARGE LABS: =============== [MASKED] 08:18AM BLOOD WBC-9.9 RBC-4.63 Hgb-13.2* Hct-42.2 MCV-91 MCH-28.5 MCHC-31.3* RDW-14.5 RDWSD-48.5* Plt [MASKED] [MASKED] 08:18AM BLOOD Glucose-248* UreaN-18 Creat-1.0 Na-138 K-4.8 Cl-98 HCO3-24 AnGap-16 [MASKED] 08:17AM URINE Color-Yellow Appear-Hazy* Sp [MASKED] [MASKED] 08:17AM URINE Blood-SM* Nitrite-NEG Protein-300* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-SM* [MASKED] 08:17AM URINE RBC-47* WBC-43* Bacteri-FEW* Yeast-NONE Epi-<1 MICRO ====== No significant micro data from admission IMAGING ======= CXR [MASKED] IMPRESSION: Retrocardiac opacities may reflect atelectasis and/or consolidation. Prominence of the hila bilaterally may reflect enlarged pulmonary arteries. Attention on follow-up imaging is recommended. CT Neck [MASKED] IMPRESSION: 1. Venous contrast pooling and dental amalgam streak artifact and [MASKED] body habitus limits study. 2. Edema and stranding inferior to the right external auditory canal involving the right parotid gland and right-sided platysma with slight prominence of the right tonsillar tissue relative to the left and suggestion of lymphadenopathy as described. Findings concerning for cellulitis and/or parotitis. 3. Asymmetric edema of right or occult compatible with provided history of Auriculitis. 4. Within limits of study, no definite evidence of focal peripherally enhancing fluid collections. 5. Limited imaging lungs demonstrate biapical septal thickening and patchy opacities. If concern for pulmonary edema or infectious/inflammatory etiologies, consider correlation with dedicated chest imaging. 6. Paranasal sinus disease, as described. 7. Multilevel cervical spondylosis with at least mild to moderate vertebral canal narrowing C5-6. CT Chest [MASKED] IMPRESSION: 1. Interlobular septal thickening and ground-glass opacification, predominantly within the mid to upper bilateral lungs, in an atypical distribution for pulmonary edema, although this cannot be excluded. Differential includes atypical multifocal infection, organizing pneumonia, hypersensitivity pneumonitis. 2. Nodular opacities measuring up to 1.3 cm are likely infectious or inflammatory with similar differential as mentioned above, although separate process cannot be excluded. 3. Trace bilateral pleural effusions. 4. Mediastinal lymphadenopathy is likely reactive. 5. Main pulmonary arterial dilatation suggests pulmonary hypertension. CXR [MASKED] IMPRESSION: Right-sided PICC line terminates at the level of the cavoatrial junction. No evidence of pneumothorax. Re-demonstrated are diffuse ill-defined bilateral opacities. Dense left basilar atelectasis and small left pleural effusion. TTE [MASKED] IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and mild-moderate global biventricular hypokinesis. Mild aortic regurgitation. Mildly dilated thoracic aorta. Mild pulmonary artery systolic hypertension. CLINICAL IMPLICATIONS: The [MASKED] LVEF is less than 40%; a threshold for which they may benefit from a beta blocker and an ACE inhibitor (or [MASKED] and a mineralocorticoid receptor antagonist. The [MASKED] has a mildly dilated ascending aorta. Based on [MASKED] ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in [MASKED] year; if previously known and stable, a follow-up echocardiogram is suggested in [MASKED] years. CXR [MASKED] IMPRESSION: Interval increase of ill-defined opacities at the bilateral lungs in the absence of mediastinal venous engorgement suggests differential diagnoses which include ARDS, pulmonary hemorrhage, drug reaction to antibiotics or infection. CXR [MASKED] IMPRESSION: Lungs are well expanded with moderate pulmonary edema. Cardiomediastinal silhouette is stable. Right-sided PICC line projects to the SVC. The ET tube and NG tube are unchanged. Left pleural effusions unchanged. No pneumothorax. CXR [MASKED] IMPRESSION: Pulmonary edema has improved. Right-sided PICC line is unchanged. The ET, NG tube are also unchanged. Cardiomediastinal silhouette is stable. Bilateral effusions right greater than left are also stable. No pneumothorax. CXR [MASKED] IMPRESSION: In comparison with the study of [MASKED], the monitoring and support devices are unchanged and in standard position. Cardiomediastinal silhouette is stable. There is little change in the degree of pulmonary vascular congestion. The bilateral pleural effusions, right greater than left, appear slightly less prominent, though this could merely reflect a more upright position of the [MASKED]. CXR [MASKED] IMPRESSION: Comparison to [MASKED]. Stable monitoring and support devices. Moderate cardiomegaly persists. Small right pleural effusion, minimal left pleural effusion. Bilateral areas of basilar atelectasis are unchanged. No pulmonary edema CXR [MASKED] IMPRESSION: Comparison to [MASKED]. The [MASKED] is now extubated, the feeding tube is removed. The right PICC line stays in correct position. Increased lung volumes likely reflect improved ventilation. The current radiograph shows mild cardiomegaly but no evidence of pneumonia, pulmonary edema or pneumothorax. Brief Hospital Course: Outpatient Providers: [MASKED] for Admission ============================== Mr. [MASKED] is a [MASKED] yo M with a history of afib on dabigitran, diabetes (A1c unknown, on oral antihyperglycemic meds at home), and HTN who presented to [MASKED] with a severe headache and right ear pain/swelling x 1 day, fever, and chills with concern for auriculitis. ENT was consulted. CT head was negative for acute pathology. He was started on Vanc, Zosyn, and Ceftriaxone, and transferred to [MASKED] [MASKED]. He was initially admitted to the general medicine floor but was then transferred to the ICU in the setting of hypoxemic respiratory failure. Respiratory failure felt to be mixed picture in the setting of multifocal pneumonia and fluid overload. He was treated with cefepime for a nd diuresed to euvolemia with Lasix. He was intubated for four days, and after extubation, transferred to a medicine floor. Post-extubation course complicated by agitation and ICU delirium. This improved with BID Seroquel which was weaned off once transferred back to medicine floor. Though [MASKED] was alert and oriented most of the time, at discharge he was still intermittently confused which was felt to be combination of ICU delirium resolving and possible UTI. Hospital course also complicated by rapid ventricular rates in the setting of his known atrial fibrillation and his home rate control medications were uptitrated. At discharge [MASKED] complained of dysuria and a UA revealed pyuria/bactiuria concerning for cystitis. He was afebrile and otherwise hemodynamically stable at this time and was felt safe to be discharged to rehab on an oral course of nitrofurantoin for 5 days. TRANSITIONAL ISSUES: ==================== [ ] [MASKED] was prescribed Macrobid (nitrofurantoin) for a urinary tract infection. He will take this antibiotic twice a day for five days ending [MASKED] [ ] Will need a repeat urinalysis after completion of the antibiotic to ensure the resolution of microscopic hematuria seen on UA [MASKED]. F/u with urology if repeat UA positive for blood. [ ] [MASKED] would likely benefit from weaning off diltiazem given heart failure with ejection fraction of 35%. Acute issues: ============= #Hypoxemic respiratory failure. #Pulmonary Edema #Multifocal Pneumonia [MASKED] was transferred to the ICU in the setting of respiratory failure requiring intubation. Hypoxia felt to be multifactorial in the setting of multifocal pneumonia and pulmonary edema related to acute on chronic HFrEF exacerbation. He received IV Lasix and a 7 day course of cefepime. Successfully extubated after several days. His hypoxia had resolved at the time of discharge. #Acute on Chronic HFrEF: LV EF 35-40%. [MASKED] has a history of Heart failure with reduced ejection fraction. Per cardiology records at [MASKED], the [MASKED] EF was 31% as far back as [MASKED]. Acute exacerbation of heart failure and volume overload felt to play a role in respiratory failure as above. Upon return to the medicine floor, the [MASKED] continued his outpatient Lasix schedule of 20mg Qday. Captopril was started to add ACEi for guideline directed medical therapy of HFrEF. Diltiazem was attempted to be weaned off during admission given increased mortality in heart failure however [MASKED] HRs would not tolerate lowering of his dose despite increased metoprolol dosing. #A fib w/ RVR: On dabigatran, diltiazem, digoxin, and metoprolol at home. The [MASKED] experienced rapid ventricular rate that was terminated using IV diltiazem. During his hospital course his heart rate fluctuated from the 100-150's. Per the patients wife, his heart rate is consistently over 100, even when on medications at home. His dosing of diltiazem and metoprolol were uptitrated over the course of his hospitalization and at discharge HRs mostly [MASKED]. Would benefit from weaning of dilt as outpatient if able given contraindication in HFrEF. #Delirium: Post-extubation [MASKED] became acutely agitated and delirium. Felt to be ICU delirium. He was treated with melatonin and quetiapine with improvement in mental status. Despite return to complete orientation, at discharge [MASKED] still intermittently confused occasionally forgetting he is in the hospital or that he is in fact in his own hospital room though able to complete [MASKED] backwards and recount hospitalization. [MASKED]: Developed an acute kidney injury with Cr uptrending to 1.3 from baseline 0.9 in the setting of IV diuresis for acute HFrEF exacerbation causing pulmonary edema. Further diuresis held with development [MASKED] and renal function improved. that was resolved by the time of discharge. #Auriculitis: Presented with a swollen ear, fevers, and chills concerning for auriculitis. ENT was consulted. A CT scan did not reveal any acute pathology such as mastoiditis. He complete a course of cefepime 7 days on [MASKED] for pneumonia as above which concomitantly treated his auriculitis. Can follow-up with ENT as outpatient if new symptoms but no indication for routine f/u. CHRONIC/RESOLVED ISSUES ======================= #Diabetes: Provided sliding scale scale insulin while hospitalized. The home medications, metformin, glipizide, and empagliflozin, were withheld then restarted at discharge. #HTN: -Home metoprolol and diltiazem were uptitrated as above. Started captopril while inpatient #Hyperlipidemia: Continued home atorvastatin 20mg daily #Abdominal pain: #heartburn -Continued home ppi, provided calcium carbonate prn #Constipation -Senna, bisacodyl, miralax [MASKED] was seen on day of discharge and examined. >30 minutes spent on discharge planning and care coordination on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Gabapentin 100 mg PO BID 3. Dabigatran Etexilate 150 mg PO BID 4. GlipiZIDE 5 mg PO BID 5. MetFORMIN (Glucophage) 500 mg PO 2 TABS IN AM, 1 TAB IN [MASKED] 6. Furosemide 20 mg PO DAILY 7. Jardiance (empagliflozin) 10 mg oral DAILY 8. Digoxin 0.125 mg PO DAILY 9. Diltiazem Extended-Release 360 mg PO DAILY 10. Atorvastatin 20 mg PO QPM 11. Omeprazole 40 mg PO BID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Bisacodyl AILY 3. Calcium Carbonate 500 mg PO QID:PRN gerd 4. Captopril 6.25 mg PO TID 5. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN throat irritation 6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H urinary tracr infection Duration: 7 Days 7. Polyethylene Glycol 17 g PO DAILY 8. Ramelteon 8 mg PO QPM:PRN sleep 9. Selenium Sulfide 5 mL TP Q12H:PRN seborrheic dermatitis on face and neck 10. Senna 8.6 mg PO BID Please hold for loose stools 11. Sodium Chloride Nasal [MASKED] SPRY NU TID:PRN dry mucous membranes 12. Diltiazem Extended-Release 240 mg PO DAILY 13. Metoprolol Succinate XL 200 mg PO DAILY 14. Omeprazole 40 mg PO DAILY 15. Atorvastatin 20 mg PO QPM 16. Dabigatran Etexilate 150 mg PO BID 17. Digoxin 0.125 mg PO DAILY 18. Furosemide 20 mg PO DAILY 19. Gabapentin 100 mg PO BID 20. GlipiZIDE 5 mg PO BID 21. Jardiance (empagliflozin) 10 mg oral DAILY 22. MetFORMIN (Glucophage) 500 mg PO 2 TABS IN AM, 1 TAB IN [MASKED] Discharge Disposition: Extended Care Facility: [MASKED] Discharge Diagnosis: Atrial Fibrilation with Rapid Ventricular Rates Acute Hypoxemic Respiratory Failure Multifocal Pneumonia Pulmonary Edema Volume OVerload Acute on Chronic Heart Failure with Reduced Ejection Fraction Delirium Deconditioning Acute Kidney Injury Diabetes Auriculitis HTN HLD GERD Constipation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear [MASKED] [MASKED] was a privilege taking care of you at [MASKED] [MASKED]. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted to the hospital for an infection of your ear (auriculitis). WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - You were treated with antibiotics for the infection in your ear - You needed to go to the intensive care unit because your heart was beating too fast and your oxygen levels dropped - You were unable to breathe on your own due to an infection and fluid in your lungs. You were intubated so a machine could help you breathe while you recovered from these things. Your pneumonia was treated with antibiotics and the fluid in your lungs was treated with a medication called Lasix which helps you pee out that extra fluid -The doses of the medications you are on for your blood pressure and heart rate were changed to help control your heart rate better - An infection developed in your bladder. You were given antibiotics to treat this when you go to rehab WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your [MASKED] appointments. -Please see your cardiologist for managing your Atrial Fibrillation. Changes were made to the medications that you take at home for your heart. -Please take the antibiotic (Macrobid) to treat an infection in your bladder. Follow up with your primary care doctor for [MASKED] repeat urine analysis to make sure the infection is cleared and there is no more blood in your urine We wish you all the best! Sincerely, Your [MASKED] Care Team Followup Instructions: [MASKED] | [
"H6011",
"J189",
"A419",
"J9601",
"I5023",
"E872",
"F05",
"N179",
"E119",
"I4891",
"E785",
"K5900",
"G4733",
"E669",
"E8770",
"I110",
"K219",
"N3090",
"Z8501"
] | [
"H6011: Cellulitis of right external ear",
"J189: Pneumonia, unspecified organism",
"A419: Sepsis, unspecified organism",
"J9601: Acute respiratory failure with hypoxia",
"I5023: Acute on chronic systolic (congestive) heart failure",
"E872: Acidosis",
"F05: Delirium due to known physiological condition"... | [
"J9601",
"E872",
"N179",
"E119",
"I4891",
"E785",
"K5900",
"G4733",
"E669",
"I110",
"K219"
] | [] |
19,573,705 | 23,263,183 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nshellfish derived\n \nAttending: ___\n \nChief Complaint:\nRight-sided weakness\n \nMajor Surgical or Invasive Procedure:\... | Allergies: shellfish derived Chief Complaint: Right-sided weakness Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: Mr. [MASKED] is a [MASKED] man with a past medical history of thyroid cancer status post resection followed by [MASKED], hyperlipidemia who presents with 10 days of discrete episodes of headache, lightheadedness, and focal neurologic deficits. History is obtained by wife at the bedside as patient not able to participate. On [MASKED], wife notes that patient had sudden onset "massive headache" with associated lightheadedness and tunnel vision. He also experienced numbness in his right arm. There was no vertigo. It is unclear how long this episode lasted but patient went to bed and slept for approximately 15 hours. On awakening the following day, patient felt back to baseline. He called his primary care physician and went in for evaluation that day. His PCP performed [MASKED] "lightheadedness workup" and found no neurologic deficits. He felt his symptoms were most likely secondary to migraine headache. Two days later, on [MASKED], patient sent wife "incoherent" text message via phone. She called him afterward and he had difficulty getting the words out when speaking with her. The wife took patient to [MASKED] where he had a noncontrast [MASKED] CT which was unremarkable. He would that he was diagnosed with migraine and sent home. The whole episode lasted approximately 1 hour. Patient and his wife followed up with a neurologist through [MASKED] the following day and he had an MRI brain without contrast/MRA [MASKED] and neck as an outpatient. Imaging was unremarkable. There are no notes to review from this encounter, but the wife reports the neurologist agreed the etiology of his symptoms was most likely migraine. The following day, patient complained of headache which felt like a headband putting pressure on his whole [MASKED], right worse than left side. The wife began to document his symptoms and she notes: 12 [MASKED] lightheadedness and vision issues 12:15 [MASKED] went to bed and slept until 2 [MASKED] 2:05 [MASKED] woke up with a raging headache behind eyes and photophobia. She documents an exaggerated startle, jumping every time she walks by her opens a soda can. He went to sleep shortly afterward and awoke 4 hours later. 6:15 [MASKED] awoke with continued lightheadedness and headache 9 [MASKED] out of bed, feeling better He slept until 8:30 AM. He was asymptomatic the following day. Today at 7 [MASKED] he experienced sudden onset right hand numbness which traveled to his right arm and leg. He also had twitching of his right face and clenched his right eye in pain. He also had difficulty speaking, getting any words out. EMS was called and he was brought to [MASKED] where code stroke was called. Noncontrast [MASKED] CT was negative for bleed or other intracranial abnormality. Shortly after arrival to the ED his symptoms resolved and TPA was deferred. He began to complain of a headache at this time. He was transferred to [MASKED] for further management. Neurology was consulted for question of seizures versus atypical migraine. Unable to complete review of systems, though positive neurologic review of systems are noted as above. Specifically, patient's wife denies a history of headache or migraines. She denies any recent fever or chills. Past Medical History: Thyroid cancer status post resection. No chemo or radiation. Diagnosed in [MASKED], managed at [MASKED]. On maintenance levothyroxine. Hyperlipidemia Social History: [MASKED] Family History: No family history of stroke, seizure, or migraine. Physical Exam: ============== ADMISSION EXAM ============== Vitals: Tm: 102.5 P: 40-70 r: 16 BP: 136/90 SaO2: 99% on room air Blood glucose 89 General: Agitated, thrashing in bed, pulling off telemetry leads, and trying to get out of bed, holding [MASKED] periodically and moaning HEENT: NC/AT, positive photophobia, no scleral icterus noted, MMM, no lesions noted in oropharynx, incessant yawning Neck: Supple, No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: Bradycardic, regular rhythm, warm, well-perfused Abdomen: soft, non-distended Extremities: No [MASKED] edema. He repeatedly lifts his left arm above his [MASKED] and then yawns and almost stereotyped fashion multiple times throughout the examination. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Agitated, moving back and forth in bed, appears uncomfortable, grimacing and moaning. Will attend to examiner briefly when shouting his name but then turns away and repositions himself. Does not track. When asked his name, he replies "okay." He perseverates on "I am sorry." He attempts to answer the question, but there is never a straight response. At times, he repeats "what?" over and over. He then appears to get agitated and says "leave me alone." Other spontaneous speech includes "oh God." It is difficult to say if he follows any commands. His speech does not sound dysarthric. He is unable to participate in any further language testing. -Cranial Nerves: He is severely photophobic so pupil examination is limited. Overall pupils appear symmetric and reactive. He moves eyes in both horizontal directions. He has bilateral blink to threat. Unable to visualize fundi bilaterally. No facial droop, facial musculature symmetric. Palate elevates symmetrically. Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No adventitious movements, such as tremor, noted. Arms and legs are antigravity and appear strong, though formal confrontational testing is not possible. -Sensory: He withdraws to noxious stimuli in all 4 extremities. -DTRs: Bi Tri [MASKED] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was flexor bilaterally. -Coordination: Grabs for his IV with his left hand and pulls off telemetry leads with his right hand. -Gait: Able to bring himself to a standing position unassisted. DISCHARGE EXAM: Nonfocal Pertinent Results: ==== LABS ==== - CBC [MASKED] 10:00PM BLOOD WBC-6.7 RBC-4.63 Hgb-14.0 Hct-42.4 MCV-92 MCH-30.2 MCHC-33.0 RDW-12.6 RDWSD-42.2 Plt [MASKED] [MASKED] 10:00PM BLOOD Neuts-57.0 [MASKED] Monos-8.8 Eos-2.1 Baso-0.3 Im [MASKED] AbsNeut-3.83 AbsLymp-2.13 AbsMono-0.59 AbsEos-0.14 AbsBaso-0.02 [MASKED] 05:59AM BLOOD WBC-7.8 RBC-4.43* Hgb-13.3* Hct-40.4 MCV-91 MCH-30.0 MCHC-32.9 RDW-12.4 RDWSD-41.8 Plt [MASKED] [MASKED] 05:25AM BLOOD WBC-4.8 RBC-4.46* Hgb-13.6* Hct-41.8 MCV-94 MCH-30.5 MCHC-32.5 RDW-12.7 RDWSD-43.9 Plt [MASKED] [MASKED] 05:25AM BLOOD Neuts-53.2 [MASKED] Monos-10.9 Eos-2.7 Baso-0.4 Im [MASKED] AbsNeut-2.52 AbsLymp-1.55 AbsMono-0.52 AbsEos-0.13 AbsBaso-0.02 - Coag [MASKED] 10:23PM BLOOD [MASKED] PTT-27.2 [MASKED] [MASKED] 05:59AM BLOOD [MASKED] PTT-26.5 [MASKED] - CMP [MASKED] 10:00PM BLOOD Glucose-98 UreaN-19 Creat-1.2 Na-140 K-3.7 Cl-100 HCO3-28 AnGap-16 [MASKED] 10:00PM BLOOD ALT-15 AST-16 CK(CPK)-56 AlkPhos-25* TotBili-0.2 [MASKED] 05:59AM BLOOD Glucose-126* UreaN-17 Creat-1.1 Na-139 K-3.9 Cl-103 HCO3-22 AnGap-18 [MASKED] 05:25AM BLOOD ALT-13 AST-17 AlkPhos-22* TotBili-0.3 [MASKED] 05:25AM BLOOD Glucose-125* UreaN-9 Creat-1.0 Na-141 K-4.2 Cl-103 HCO3-29 AnGap-13 [MASKED] 10:00PM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.8 Mg-2.0 [MASKED] 05:59AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8 [MASKED] 05:25AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1 - Other [MASKED] 10:00PM BLOOD cTropnT-<0.01 [MASKED] 05:59AM BLOOD TSH-0.37 [MASKED] 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [MASKED] 10:14PM BLOOD Lactate-1.0 - Urine [MASKED] 02:47AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [MASKED] 02:47AM URINE Color-Straw Appear-Clear Sp [MASKED] [MASKED] 02:47AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [MASKED] 02:47AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG - CSF [MASKED] 12:43AM CEREBROSPINAL FLUID (CSF) WBC-270 RBC-0 Polys-0 [MASKED] [MASKED] 12:43AM CEREBROSPINAL FLUID (CSF) WBC-244 RBC-0 Polys-0 [MASKED] Monos-4 Other-2 [MASKED] 12:43AM CEREBROSPINAL FLUID (CSF) TotProt-211* Glucose-63 [MASKED] 01:00PM CEREBROSPINAL FLUID (CSF) WBC-230 RBC-1* Polys-0 [MASKED] Monos-3 Other-3 [MASKED] 09:42AM CEREBROSPINAL FLUID (CSF) TotProt-212* Glucose-58 LD(LDH)-23 [MASKED] 09:42AM CEREBROSPINAL FLUID (CSF) HIV1 VL-NOT DETECT - Micro [MASKED] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): [MASKED] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY GRAM STAIN (Final [MASKED]: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count. FLUID CULTURE (Preliminary): [MASKED] CSF VDRL, VZV, CMV, EBB, Autoimmune Encephalopathy Panel, Paraneoplastic Panel, Enterovirus pending [MASKED] Blood (LYME) Lyme IgG-PENDING; Lyme IgM-PENDING [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING [MASKED] BLOOD CULTURE Blood Culture, Routine-PENDING [MASKED] URINE URINE CULTURE-PENDING [MASKED] 12:43AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-negative [MASKED] 05:10AM BLOOD WBC-5.6 RBC-4.46* Hgb-13.4* Hct-41.5 MCV-93 MCH-30.0 MCHC-32.3 RDW-12.7 RDWSD-43.0 Plt [MASKED] [MASKED] 05:10AM BLOOD [MASKED] PTT-25.8 [MASKED] [MASKED] 05:10AM BLOOD Glucose-94 UreaN-11 Creat-1.0 Na-140 K-3.8 Cl-100 HCO3-26 AnGap-18 [MASKED] 05:25AM BLOOD ALT-13 AST-17 AlkPhos-22* TotBili-0.3 [MASKED] 05:10AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0 [MASKED] 05:59AM BLOOD TSH-0.37 [MASKED] 05:10AM BLOOD HIV Ab-Negative ========= PATHOLOGY ========= [MASKED] CSF Cytology-negative for malignant cells [MASKED]- CSF Cytology pending ======= IMAGING ======= - [MASKED] MR [MASKED] CONTRAST 1. Study is moderately degraded by motion. 2. No evidence of venous sinus thrombosis. 3. Within limits of study, no definite leptomeningeal enhancement identified. 4. New nonspecific diffuse subarachnoid signal abnormality, as described. While finding is compatible with meningitis, differential considerations include subarachnoid hemorrhage, leptomeningeal carcinomatosis, sequelae of hyperoxygenation therapy or artifact. If clinically indicated, noncontrast [MASKED] CT may be obtained to evaluate for presence of new subarachnoid hemorrhage since [MASKED] noncontrast [MASKED] CT prior exam. 5. Paranasal sinus disease as described. - [MASKED] EEG This is an abnormal continuous ICU monitoring study because of continuous slowing on the left, maximal temporally, indicative of focal dysfunction. No pushbutton activations, epileptiform discharges, or seizures are recorded. Compared to the prior day's recording, there are no significant changes. Of note, sinus bradycardia to the [MASKED] is seen during portions of the record. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year old man with history of thyroid cancer (s/p resection in [MASKED] and hyperlipidemia who presented with a ten day course of episodic headaches, lightheadedness and focal neurological deficits (extremity numbness, aphasia). He was found to have CSF pleomorphic lymphocytosis, and nonspecific diffuse subarachnoid signal abnormality on MRI. He was given a provisional diagnosis of HaNDL syndrome, pending additional tests and CSF studies, and was discharged on Verapamil 120mg for prophylactic headache treatment. He will follow-up with outpatient neurologist. #Neuro On presentation at [MASKED], the patient was acutely agitated and confused, with a low grade fever and sinus bradycardia. He had a severe headache, multiple neurological deficits and exhibited stereotyped movements. [MASKED] at outside hospital revealed no acute intracranial process. Patient was admitted to the ICU for EEG and neurological monitoring, out of concern for meningoencephalitis vs seizure vs neoplastic process. LP ([MASKED]) revealed elevated opening pressure, lymphocytic pleiocytosis, elevated protein level, and no malignant cells. The patient was initially maintained on droplet precautions, and treated empirically for meningitis with ceftriaxone, vancomycin and acyclovir until HSV PCR was negative and CSF cultures showed no bacterial growth. His symptoms had largely resolved the morning after admission and he was subsequently transferred to the floor. His symptoms did not reoccur throughout the rest of his hospital stay. EEG showed continuous slowing on the left, maximal temporally, indicative of focal dysfunction, with no epileptiform discharges. MRI revealed new nonspecific diffuse subarachnoid FLAIR hyperintensities, but no evidence of venous sinus thrombosis or definite leptomeningeal enhancement. An additional [MASKED] LP was obtained on [MASKED] for further CSF studies, with results showing continued lymphocytic pleocytosis w/ elevated protein level but improved from previous tap. At the time of discharge, the patient most closely fit the criteria for syndrome of transient Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL). However, HaNDL remains a provisional diagnosis until all pending results are back and other etiologies are excluded. If HaNDL is deemed to be the final diagnosis, it should be noted that it is usually a self-limiting disease and only prophylactic therapy for associated headaches is recommended. The patient was thus started on verapamil 120mg for symptomatic improvement and headache prophylaxis. #Cardiovascular CXR showed no acute cardiopulmonary process. The patient was monitored on telemetry with no evidence of atrial fibrillation. Atorvastatin 40mg daily was continued per home regimen. Transition Issues: -Pt will need to continue taking Verapamil SR 120mg daily in the near future as prophylactic therapy for migrainous headaches -Pt will need to follow up with Neurology as scheduled -Pt instructed to present to ED for evaluation if develops recurrent neurologic deficits -Pt to be informed if abnormal CSF studies present Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 150 mcg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. ValACYclovir 2 g PO BID:PRN Cold sore Discharge Medications: 1. Verapamil SR 120 mg PO Q24H RX *verapamil 120 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*2 2. Atorvastatin 40 mg PO QPM 3. Levothyroxine Sodium 150 mcg PO DAILY 4. ValACYclovir 2 g PO BID:PRN Cold sore Discharge Disposition: Home Discharge Diagnosis: Migraine w/ focal neurologic deficits and lymphocytic pleocytosis 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] due to recurrent migraines associated w/ focal neurologic deficits. You were initially in the NeuroICU and later transferred to the general floor. You underwent extensive laboratory workup indicative of inflammation in your cerebrospinal fluid. You were empirically treated with antibiotics and antiviral agents which were stopped when subsequent cultures were negative. You underwent EEG which showed no sign of seizure activity. Due to appearing clinically stable on exam and w/ no recurrent symptoms, you will be discharged from the hospital. Please continue taking Verapamil SR 120mg daily at this time. Please continue your other home medications. Please follow up with your PCP and [MASKED] as listed below. If you find yourself having acute focal neurologic deficits in the future, please go to your nearest ED for evaluation. It was a pleasure taking care of you, [MASKED] Neurology Team Followup Instructions: [MASKED] | [
"G43809",
"R001",
"R29818",
"E785",
"R509",
"Z85850"
] | [
"G43809: Other migraine, not intractable, without status migrainosus",
"R001: Bradycardia, unspecified",
"R29818: Other symptoms and signs involving the nervous system",
"E785: Hyperlipidemia, unspecified",
"R509: Fever, unspecified",
"Z85850: Personal history of malignant neoplasm of thyroid"
] | [
"E785"
] | [] |
12,756,651 | 23,520,792 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBactrim / codeine / doxycycline / metronidazole\n \nAttending: ___.\n \nChief Complaint:\nacute onset dyspnea\n \nMajor Surgi... | Allergies: Bactrim / codeine / doxycycline / metronidazole Chief Complaint: acute onset dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: [MASKED] y/o F with history of CAD, CHF, and COPD presenting with SOB. Patient reports 1 month of gradually worsening SOB in the setting of stopping her HCTZ. However, her breathing became much worse in last 3 days, and she ultimately went to the [MASKED]. She had a mild non-productive cough but denied fevers, chills, paroxysmal nocturnal dyspnea, orthopnea, and weight gain. Patient also has had bilateral [MASKED] edema that has been worsening in the last [MASKED] days. At the OSH, she was hypoxic in the [MASKED] and CXR showed concern for CHF. She was given 40mg of Lasix and started on a nitro gtt. She became briefly hypotensive and was started on levophed via peripheral IV. She was placed on BiPAP for transport. Upon arrival to the Cardiology floor, she was hemodynamically stable and was satting comfortably on room air. She put out about 1L of urine after receiving Lasix and denied CP and SOB. Past Medical History: 3 vessel CAD (cath at [MASKED] in [MASKED] HTN COPD Depression/anxiety Social History: [MASKED] Family History: noncontributory Physical Exam: ADMISSION ========= PHYSICAL EXAMINATION: VS: T AF, BP 151-156/45-74, HR 64-91, RR 18, O2 sat [MASKED] RA Weight: 58.7 kg GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera CARDIAC: RRR, S1/S2, systolic murmur heard loudest at LLSB and apex, JVP ~ 11 LUNG: bibasilar crackles, no wheezing ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: WWP, trace [MASKED] edema, +DP b/l NEURO: CN II-XII grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE ========== VS: T Afebrile, BP 103-117/36-43, P 57-80, RR 18, O2sat 98-100% on RA Weight: 52.3 kg (58.7 on admission) I/O: since midnight [MASKED] 24 hours: 1136/850 GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera CARDIAC: RRR, S1/S2, systolic murmur heard loudest at LLSB and apex, JVP not elevated LUNG: No audible crackles, no wheezing ABDOMEN: nondistended, nontender in all quadrants EXTREMITIES: no [MASKED] edema NEURO: CN II-XII grossly intact Pertinent Results: ADMISSION LABS: ===================== [MASKED] 09:00PM BLOOD WBC-13.2* RBC-4.27 Hgb-12.7 Hct-39.0 MCV-91 MCH-29.7 MCHC-32.6 RDW-13.8 RDWSD-46.5* Plt [MASKED] [MASKED] 09:00PM BLOOD Neuts-90.4* Lymphs-7.1* Monos-1.6* Eos-0.0* Baso-0.1 Im [MASKED] AbsNeut-11.89* AbsLymp-0.94* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.01 [MASKED] 10:29PM BLOOD [MASKED] PTT-29.3 [MASKED] [MASKED] 10:29PM BLOOD Glucose-128* UreaN-17 Creat-0.6 Na-136 K-3.6 Cl-99 HCO3-26 AnGap-15 [MASKED] 10:29PM BLOOD [MASKED] [MASKED] 10:29PM BLOOD cTropnT-0.15* [MASKED] 09:09PM BLOOD [MASKED] pO2-177* pCO2-34* pH-7.46* calTCO2-25 Base XS-1 Intubat-NOT INTUBA [MASKED] 09:09PM BLOOD Lactate-1.4 [MASKED] 09:09PM BLOOD O2 Sat-96 [MASKED] 09:00PM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 09:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [MASKED] 09:00PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [MASKED] 09:00PM URINE Mucous-RARE OTHER RELEVANT LABS: ======================== [MASKED] 05:34AM BLOOD WBC-11.8* RBC-3.97 Hgb-11.7 Hct-35.3 MCV-89 MCH-29.5 MCHC-33.1 RDW-13.7 RDWSD-44.9 Plt [MASKED] [MASKED] 07:00AM BLOOD WBC-6.0 RBC-3.73* Hgb-11.1* Hct-33.8* MCV-91 MCH-29.8 MCHC-32.8 RDW-14.2 RDWSD-47.0* Plt [MASKED] [MASKED] 09:20PM BLOOD PTT-40.7* [MASKED] 03:23AM BLOOD PTT-52.8* [MASKED] 03:49AM BLOOD PTT-70.9* [MASKED] 08:05AM BLOOD [MASKED] PTT-75.6* [MASKED] [MASKED] 03:05PM BLOOD Glucose-129* UreaN-24* Creat-0.8 Na-135 K-3.8 Cl-95* HCO3-29 AnGap-15 [MASKED] 07:00AM BLOOD Glucose-71 UreaN-24* Creat-0.7 Na-137 K-4.3 Cl-99 HCO3-29 AnGap-13 [MASKED] 07:00AM BLOOD Glucose-80 UreaN-15 Creat-0.7 Na-138 K-4.1 Cl-102 HCO3-27 AnGap-13 [MASKED] 07:00AM BLOOD ALT-31 AST-32 LD(LDH)-187 CK(CPK)-22* AlkPhos-91 TotBili-0.7 [MASKED] 07:00AM BLOOD ALT-30 AST-34 LD(LDH)-174 AlkPhos-88 TotBili-0.7 [MASKED] 02:01AM BLOOD CK-MB-13* cTropnT-0.13* [MASKED] 07:00AM BLOOD CK-MB-3 cTropnT-0.18* [MASKED] 09:05PM BLOOD CK-MB-2 cTropnT-0.18* [MASKED] 07:00AM BLOOD %HbA1c-5.5 eAG-111 URINE CULTURE (Final [MASKED]: NO GROWTH Staph aureus Screen (Final [MASKED]: NO STAPHYLOCOCCUS AUREUS ISOLATED. DISCHARGE LABS: ==================== [MASKED] 08:05AM BLOOD WBC-4.7 RBC-4.10 Hgb-11.8 Hct-37.6 MCV-92 MCH-28.8 MCHC-31.4* RDW-13.9 RDWSD-46.9* Plt [MASKED] [MASKED] 03:29PM BLOOD PTT-66.8* [MASKED] 08:05AM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-138 K-4.6 Cl-104 HCO3-25 AnGap-14 [MASKED] 08:05AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.3 TTE [MASKED]: The left atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([MASKED]) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Moderate aortic regurgitation. Mild to moderate mitral regurgitation. CXR ([MASKED]): IMPRESSION: Heart size is normal. Mediastinum is normal. Lungs are hyperinflated but overall clear. Minimal interstitial opacities are unchanged since the prior study. Mild increase in overall interstitial opacities might represent slight volume overload, similar to [MASKED] that had shown an interval resolution on [MASKED] and in can be seen again on today's radiograph. CT Chest w/o contrast ([MASKED]): RECOMMENDATION(S): 1. [MASKED] recommendations for follow up of pulmonary nodules: Solid nodules >4 - 6 mm: Low risk: Follow-up at 12 months and if no change, no further imaging needed. High risk: Follow-up at [MASKED] months and if no change, again at [MASKED] months. The [MASKED] pulmonary nodule recommendations are intended as guidelines for follow-up and management of newly incidentally detected pulmonary nodules smaller than 8 mm, in patients [MASKED] years of age or [MASKED]. Low risk patients have minimal or absent history of smoking or other known risk factors for primary lung neoplasm. High risk patients have a history of smoking or other known risk factors for primary lung neoplasm. 2. Echocardiography, if pop already performed elsewhere, for further evaluation of aortic valvular calcifications. 3. Diagnostic mammography and axillary ultrasound is recommended if mammography has not been obtained recently. Brief Hospital Course: Ms. [MASKED] is a [MASKED] F with 3 vessel CAD (had a cath at [MASKED] in [MASKED] that indicated need for CABG), HTN and COPD who presented with new acute CHF and elevated troponins c/f possible type 2 NSTEMI. She was hemodynamically stable at [MASKED] after having briefly been on NRB and pressors at [MASKED]. She was initially started on a heparin drip on [MASKED], diuresed for acute HFpEF, and had her BP medications optimized. Her Plavix was dc'd on [MASKED] to prepare for possible CABG later that week. She had a preop workup done, including CXR, CT chest, and ECHO. However, she was deemed to not be a surgical candidate and was managed medically. # Multivessel coronary artery disease- Patient had known 3 vessel disease on recent cath recommending CABG Cardiac Surgery was consulted to perform CABG this admission. In preparation for CABG, Plavix was dc'd [MASKED]. Cardiac surgery completed a preop workup including CXR, CT chest w/o contrast, and ECHO. Patient was deemed not a surgical candidate during this admission and managed medically with metoprolol tartate 12.5 mg BID, ISMN short acting 20 mg BID, ASA 81 mg daily, pravastatin 20 mg qPM, and lisinopril 20 mg BID. Heparin drip was discontinued and Plavix was restarted on [MASKED]. #Acute diastolic heart failure- New dx of acute heart failure during this admission. pBNP on admission was [MASKED]. Elevated troponin was thought to be secondary to demand from CHF given known severe CAD. She was started on a heparin drip [MASKED] that was discontinued on [MASKED] when patient was deemed not a surgical candidate. Patient appeared volume overloaded on admission and was given 40 mg IV Lasix x2. However, she did not require further diuresis during this admission. TTE was obtained [MASKED] that showed LVEF of >55%. To optimize her afterload reduction, home lisinopril was increased to 20 daily, isosorbide MN was increased to 20 BID, and her HCTZ was dc'd. She was continued on her home metoprolol tartrate 12.5 mg BID. #Oral thrush- Patient had oral thrush during this admission and was started on nystatin for a 2 week course ([MASKED]). #COPD: Patient was continued on her Advair and given Fluticasone Propionate NASAL 2 SPRY NU DAILY and Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID. #HTN: Patient was treated with ISMN, lisinopril, and metoprolol as above. #Depression/anxiety: Patient was continued on home Ativan and Duloxetine. TRANSITIONAL ISSUES: ========================= -Discharge weight: 115 lbs -Medications added: Aspirin 81, Nystatin Oral Solution (for thrush), Pravastatin 20 mg qpm -Medications changed: Isosorbide increased to 20 mg BID, Lisinopril 20 mg daily -Medications stopped: Blood pressures stable on above regimen, Hydrochlorothiazide 12.5 mg daily held, please resume as needed -Patient initially presented with shortness of breath, and was given IV Lasix 40x2. She did not need further diuresis and thus is not being discharged with PO Lasix. If symptoms re-develop, please consider low dose oral diuretic. -Patient was given a 1 month supply of all her medications through the [MASKED] Pharmacy at [MASKED]. Two home medications that could not be filled were: Duloxetine (may need prior authorization) and Methylphenidate. Please follow up. -On non-contrast CT chest, numerous pulmonary nodules measuring up to 6 mm for which follow-up chest CT is recommended in [MASKED] months. -On non-contrast CT chest there was borderline left axillary lymph node, which may be reactive. Correlation with axillary ultrasound and mammography is recommended, if not already performed elsewhere. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Metoprolol Tartrate 12.5 mg PO BID 4. DULoxetine 60 mg PO DAILY 5. MethylPHENIDATE (Ritalin) 10 mg PO QID 6. LORazepam 1 mg PO Q8H:PRN anxiety 7. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN SOB 8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 9. Isosorbide Mononitrate (Extended Release) 15 mg PO BID 10. Mirtazapine 15 mg PO QHS 11. Clopidogrel 75 mg PO DAILY 12. Fluticasone Propionate NASAL 2 SPRY NU DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Nicotine Patch 14 mg TD DAILY RX *nicotine 14 mg/24 hour once daily Disp #*15 Patch Refills:*0 3. Nystatin Oral Suspension 5 mL PO QID RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Refills:*0 4. Pravastatin 20 mg PO QPM RX *pravastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 5. Isosorbide Mononitrate 20 mg PO BID RX *isosorbide mononitrate 20 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Lisinopril 20 mg PO DAILY RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. Albuterol Inhaler [MASKED] PUFF IH Q6H:PRN SOB RX *albuterol sulfate [ProAir HFA] 90 mcg 1 inhalation every six (6) hours Disp #*1 Inhaler Refills:*0 8. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. DULoxetine 60 mg PO DAILY RX *duloxetine 60 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY RX *fluticasone 50 mcg/actuation 2 sprays once a day Disp #*1 Spray Refills:*0 11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID RX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/dose 1 inhalation twice a day Disp #*1 Disk Refills:*3 12. LORazepam 1 mg PO Q8H:PRN anxiety RX *lorazepam 1 mg 1 tablet by mouth every eight (8) hours Disp #*20 Tablet Refills:*0 13. MethylPHENIDATE (Ritalin) 10 mg PO QID RX *methylphenidate 10 mg 1 capsule(s) by mouth four times a day Disp #*120 Capsule Refills:*0 14. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 15. Mirtazapine 15 mg PO QHS RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 16. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until your doctor says it is okay to do so Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: -Multivessel coronary artery disease -Acute diastolic heart failure Secondary diagnosis: -Chronic obstructive pulmonary disease -Hypertension -Oral thrush -Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], You were admitted to [MASKED] on [MASKED] for shortness of breath. We gave you some medications to help your heart. We also talked to the heart surgeons. However, surgery was unable to be performed so we continued to manage your heart with medications that you should continue taking when you go home. Please follow up with your PCP and cardiologist. It was a pleasure taking care of you. Symptoms to look out for: -Shortness of Breath: you were given IV medications to get fluid out of your lungs, but did not need this medication in the last few days of your hospitalization. Please weigh yourself everyday. If you feel short of breath or your weight goes up by 3 lbs in a week, let Dr. [MASKED] know as you may need a water pill (diuretic). -Chest Pain: Please come to your nearest emergency room if you have any chest pain. Symptoms of pain from your heart can also be arm, shoulder and jaw pain, so if you are worried, please do not hesitate to seek out care. Sincerely, Your [MASKED] Team Followup Instructions: [MASKED] | [
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"I214: Non-ST elevation (NSTEMI) myocardial infarction",
"B370: Candidal stomatitis",
"Z006: Encounter for examination for normal comparison and control in clinical research program",
"J449: Chronic obstructive pulmonary disease, unspecified",
"F17210: Nicotine dependence, cigarettes, uncomplicated",
"I10... | [
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15,896,763 | 21,847,118 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Flagyl / Keflex / lactated \nringers / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttend... | Allergies: Sulfa (Sulfonamide Antibiotics) / Flagyl / Keflex / lactated ringers / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Chief Complaint: Headache, Left arm weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [MASKED] is a [MASKED] year-old right-handed man with a history of myoclonic and abdominal seizures, undifferentiated mitochondrial disorder, migraines, and radiculoneuropathy, recent prolonged hospitalization in [MASKED] for perforated diverticulitis s/p [MASKED] repair and stomal retraction, now s/p reversal of colostomy who presents for evaluation of an 11 day history of progressively severe headache and left arm weakness. History provided by the patient. Patient reports he was in his usual state of health until 11 days prior to presentation. At that time, he began developing gradual onset of a headache. The headache was different than his baseline headaches, which are discussed below. This pain was different and that it was described as pain "deep inside"his head, located over the occipital region with radiation towards the left neck. He notes that it was somewhat similar to the headache he experienced after having a post epidural headache during his recent hospitalization in [MASKED]. However, it is different from even that headache in that it is not as severe and is associated with left arm weakness. When the headache started 11 days ago, he did not make much of the headache as it was quite mild in severity. He was able to go about his usual activities. [MASKED] days after the headache started, he tried taking his home Zomig nasal spray, which typically aborts his migraines, and it did not help. He also tried taking over-the-counter Tylenol, Aleve, and Advil without relief. Over the last 11 days, the pain gradually became more severe and more debilitating. The pain began to spread throughout his head, not just occipital but spread into the right temporal area, and then the left temporal area. The headache eventually became so severe, that it did wake him up from sleep multiple times (he is explicit about this). Headache is not worsened with Valsalva. It is not positional. It is associated with mild phonophobia and nausea. He denies associated visual symptoms, denies any associated numbness/tingling, denies vomiting, denies lightheadedness/dizziness. It is not the worst headache of his life. Also, at some point throughout this time, his left arm began to feel weak. He cannot pinpoint when exactly this started. He noticed that the left arm did not have quite the same strength and was slower to move than the right. Nonetheless, he was able to do all the things with this arm that he wanted to do, including opening and closing hands, and opening and closing doors. He had never had associated weakness with his headaches before. Regarding his baseline headaches, he has what he describes as migraines. These are characterized by throbbing pain located between his eyes, associate with intense photophobia. These are relieved by lying in a dark room and taking his sumatriptan nasal spray. He has no preceding aura. He has mild nausea without vomiting associated with it. He has never had associated weakness or sensory symptoms with a headache. Headaches typically last for 6 hours and occur once a month. Given his ongoing, refractory headache, he was planned to see his outpatient neurologist Dr. [MASKED] 2 days ago, however the appointment was canceled due to the [MASKED] parade. As a result, due to ongoing symptoms that have led to his inability to function and sleep properly, he came to the emergency room today for further evaluation. Of note, prior to onset of the symptoms above, patient denies any recent changes in his routine. He denies any recent new or missed medications. His blood pressure have been running high recently, and his nephrologist have plan to start losartan, however patient was reluctant to do so due to difficulty tolerating losartan in the past. No recent illness. No fevers/chills, no recent upper respiratory symptoms. No recent trauma. No recent neck manipulations. He has gone to the barber shop where his hair was washed on the open end sink 5 weeks ago. Patient recently had a prolonged hospitalization in [MASKED], after presenting with perforated diverticulitis, status post repair and stoma retraction, subsequently status post reversal of colostomy on [MASKED]. He required epidural placement for the operation at T11/T12. Neurology was consulted postoperatively due to intermittent severe headache status post procedure. This headache was notably postural, worse with sitting or elevation and improved with lying flat. He was felt to be likely due to post epidural headache, less likely due to migraine. He improved with aggressive hydration and symptomatic treatment. For workup, he underwent MRI of the cervical spine which showed moderate to severe degenerative disease without cord enhancement. He did not require placement of an epidural blood patch. There also was a significant component of cervicalgia. Regarding the remainder of his neurologic history: - Per Dr. [MASKED] consult note in [MASKED]: "Mr. [MASKED] has a history of abdominal seizures, first diagnosed in [MASKED]. While abroad for work in [MASKED], he described eating tainted fish that made him feel nauseous. On his trip back to [MASKED], he had fits of vomiting followed by severe fatigue. His vomiting continued whenever he ate, and he lost 55 lb in 3 months. Around this time, he experienced myoclonic seizures with full-body jerks as well, with occasional waves of pain that felt like lanceting electrical shocks down the anterior aspects of his thighs. He began seeing Dr. [MASKED] at [MASKED] for his seizures in [MASKED], and reports that his seizures have been well-controlled on Lamictal 400mg/500mg and Onfi 20mg qhs with recent lamictal level in [MASKED] being therapeutic. He reports that he has not had a seizure in several years. Dr. [MASKED] notes that Mr. [MASKED] previously has had temporal seizures where he feels a sense of familiarity/ unfamiliarity. These episodes usually last a minute and are followed by fatigue." - He has an undifferentiated Mitochondrial encephalomyopathy, for which he also follows w/ Dr. [MASKED]. Per OMR, in [MASKED], Mr. [MASKED] developed myoclonic jerks and lost 55 pounds in 3.5 months. He had additional symptoms including elevated lactic acid, global fatigue, exercise-induced myalgias, small fiber polyneuropathy, pain, and intermittent hypoxia with REM hypoventilation. He was on a feeding tube for [MASKED] years and was diagnosed with abdominal epilepsy. -At baseline, on neurologic exam he has "significant decreased rapid coordinated function, specifically,rapid finger movements, forearm alterations, hand tapping and also some cerebellar signs with dysdiadochokinesis where he has difficulty doing finger-nose-finger testing" per Dr. [MASKED]. Past Medical History: - recent hospitalization for diverticulitis as above - Mitochondrial encephalomyopathy - Migraines -Benign prostatic hypertrophy -OSA: Mild; Failed CPAP [MASKED] inability to tolerate mask. -Radicular leg pain: s/p epidural injections -Positive PPD -Ulceration in the terminal ileum [MASKED] - Diverticulosis of the sigmoid colon & descending colon [MASKED] - Anal fistula repair -Right knee partial medial menisectomy -Transurethral prostate resection [MASKED] adenocarcinoma [MASKED] Social History: [MASKED] Family History: - Mother had dementia and died at [MASKED] [MASKED] stroke. - Father had DM and died at [MASKED] [MASKED] "old age". - Oldest brother has colon and prostate cancer. - Another brother has ankylosing spondylitis. Physical Exam: ============== ADMISSION EXAM ============== Physical Exam: Vitals: T 98.5F, HR 94, BP 153/90, RR 18, O2 97% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: no palpable muscle tension in neck. Supple, No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: No [MASKED] edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [MASKED] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands.There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Fundoscopic exam performed, revealed no papilledema, exudates, or hemorrhages. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: [MASKED] strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. + Orbiting around L hand Delt Bic Tri WrE FE IP Quad Ham TA [MASKED] [MASKED] L 4+* 5 4+* 5 4+* 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 4+/5 in bilateral ADM *there is a give way weakness component, but even when asked to give 2 seconds of best effort it is easily breakable. -Sensory: No deficits to light touch, pinprick, proprioception throughout. No extinction to DSS. Romberg with sway but not positive. -DTRs: Bi Tri [MASKED] Pat Ach L [MASKED] 1 0 R [MASKED] 1 0 Plantar response was flexor on right, extensor on left. -Coordination: No intention tremor. reduced speed and amplitude of rapid alternating movements of hands, though not overtly ataxic. No clear overshoot on cerebellar mirroring. No dysmetria on HKS bilaterally. -Gait: Good initiation. Gait is hesistant and somewhat wide base, sways back and forth but not to either direction. No truncal ataxia. Falls back in bed when asked to do tandem walk. Can take a few steps without assistance, but is unsteady. Unable to do Unteberger due to unsteadiness. ============== DISCHARGE EXAM ============== Unchanged except as noted below: -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Delt Bic Tri WrE FE IP Quad Ham TA [MASKED] [MASKED] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 * Give-way weakness on every muscle tested on left side. All were full strength on momentary best effort. -Sensory: Proprioception intact to fine movements of bilateral index fingers and great toes. No deficits to light touch throughout. -Coordination: FNF intact bilaterally. -Gait: Ambulating independently with normal gait, stride, base. Pertinent Results: ==== LABS ==== [MASKED] 04:30AM BLOOD WBC-11.1* RBC-4.75 Hgb-15.5 Hct-46.2 MCV-97 MCH-32.6* MCHC-33.5 RDW-12.9 RDWSD-46.5* Plt [MASKED] [MASKED] 04:30AM BLOOD Neuts-44.2 [MASKED] Monos-6.7 Eos-3.9 Baso-0.5 Im [MASKED] AbsNeut-4.90 AbsLymp-4.91* AbsMono-0.74 AbsEos-0.43 AbsBaso-0.06 [MASKED] 04:30AM BLOOD Glucose-83 UreaN-18 Creat-1.0 Na-145 K-4.7 Cl-105 HCO3-26 AnGap-14 [MASKED] 10:50AM BLOOD ALT-16 AST-14 CK(CPK)-70 AlkPhos-75 TotBili-0.3 [MASKED] 04:30AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.9 [MASKED] 10:50AM BLOOD Triglyc-275* HDL-35* CHOL/HD-6.1 LDLcalc-123 [MASKED] 10:50AM BLOOD %HbA1c-5.4 eAG-108 [MASKED] 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ======= IMAGING ======= - [MASKED] MRI & MRA Brain WITHOUT Contrast, MRA Neck WITH Contrast 1. No significant intracranial abnormality. No evidence of acute infarction, hemorrhage or mass. 2. Patent intracranial and cervical vasculature without evidence of dissection, stenosis, occlusion or aneurysm formation. Brief Hospital Course: Mr. [MASKED] is a [MASKED] year-old right-handed man with a history of myoclonic and abdominal seizures, undifferentiated mitochondrial disorder, migraines, and radiculoneuropathy, recent prolonged hospitalization in [MASKED] for perforated diverticulitis s/p [MASKED] repair and stomal retraction, now s/p reversal of colostomy who presents for evaluation of an 11 day history of progressively severe headache and left arm weakness. Given his history and constellation of symptoms, he was admitted for neuroimaging to evaluate for central process. MRI was negative for stroke or other CNS lesion. Exam was notable for give-way weakness on left side with normal proprioception and sensation. His headache improved moderately with a migraine cocktail. He endorsed significant musculoskeletal discomfort and was seen by [MASKED]. He will be discharged home with a cervical soft collar and will follow-up with Dr. [MASKED] week. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clobazam 20 mg PO QHS 2. ZOLMitriptan 5 mg nasal ASDIR 3. TraZODone [MASKED] mg PO QHS:PRN insomnia 4. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder Discharge Medications: 1. Clobazam 20 mg PO QHS 2. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder 3. TraZODone [MASKED] mg PO QHS:PRN insomnia 4. ZOLMitriptan 5 mg nasal ASDIR 5.Outpatient Physical Therapy Cervical musculoskeletal pain Discharge Disposition: Home Discharge Diagnosis: Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [MASKED], You were admitted to the neurology service for symptoms of left arm weakness which was concerning for stroke. Your brain MRI was normal and did not show any stroke or other abnormalities. On examination, you did not have physiologic weakness. We recommended a cervical soft-collar for your neck pain which was exacerbating your headache. You were seen by physical therapy who recommended outpatient [MASKED]. Please follow-up with Dr. [MASKED] as already scheduled. Best, Your [MASKED] Neurology Team Followup Instructions: [MASKED] | [
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"R51: Headache",
"R531: Weakness",
"Z23: Encounter for immunization",
"G40802: Other epilepsy, not intractable, without status epilepticus",
"E8840: Mitochondrial metabolism disorder, unspecified",
"G43909: Migraine, unspecified, not intractable, without status migrainosus",
"M5410: Radiculopathy, site ... | [
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16,921,126 | 24,116,257 | [
" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest Pain\n\n \nMajor Surgical or In... | Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [MASKED] is a [MASKED] yo woman originally from [MASKED] with PMHx pos for hypertension, asthma, OSA (has APAP, doesn't use), obesity, GERD, depression, presenting with sx concerning for pericarditis. She recently had a laparascopic cholecystectomy on [MASKED]. She is noted to have tolerated the procedure well, and only has mild residual tenderness surrounding the central incision site. She reports acute onset of chest pain in the morning 2 days ago, with gradual progression to [MASKED] severity when presenting to the ED. Pain was located in the midsternal region and radiated up towards clavicles. Pain worse with inspiration and lying flat, and improves with leaning forwards. Also has mild-mod dysp, no pain while swallowing. She denies fevers, chills, nausea, vomiting, abdominal pain, diarrhea, or dysuria. She endorses cough sx, feeling light-headed recently, nocturia over months, and bilateral knee arthritis. Her grandchildren have recently been sick with GI illness. In the ED, initial VS: Tmax in ED 101.4 HR 99 107 128/80 16 100% RA Exam notable for: rub on cardiac auscultation, surgical site from whole c/d/I. Cardiology and Surgery were consulted. While in ED Pt given: Acetaminophen 1000 mg Morphine Sulfate 4 mg Ondansetron 4 mg Ibuprofen 600 mg Colchicine .6 mg amLODIPine 10 mg FLUoxetine 40 mg IVF NS Colchicine .6 mg On the floor, pt endorses improvement in chest pain symptoms s/p beginning treatment. She denies feeling faint. Denies fever, chills, abdominal pain, nausea, vomiting, diarrhea, dysuria. Complete ROS obtained and is otherwise negative. Past Medical History: PAST MEDICAL HISTORY: -obesity -seasonal allergies -gastroesophageal reflux disease -fibroid uterus -hypertension -anxiety -depression -asthma -obstructive sleep anemia -Fe deficiency anemia Past Surgical History: -tubal ligation -breast lumpectomy -s/p fibroid embolization -s/p laparascopic cholecystectomy Social History: [MASKED] Family History: Mother with DM and breast CA, living in [MASKED] Father, deceased [MASKED], patient does not know much about her biological father. Has 6 sisters, 3 brothers. Only one sister in the [MASKED] with her, living in [MASKED]. Has one sister with fibroids, who lives in [MASKED]. Physical Exam: ADMISSION PHYSICAL EXAM: ============================== Weight 135.81 kg VITALS: Temp 99.3 PO BP 110 / 79 HR 98 RR 18 SAT 94 RA GENERAL: AOx3, NAD, obese. 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. NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No rubs/gallops. No JVD. +friction rub. LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema, no sign of atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. SKIN: Abdominal incision sites x3 c/d/I with mild tenderness. NEUROLOGIC: CN2-12 intact. [MASKED] strength througout. Normal sensation. DISCHARGE PHYSICAL EXAM: ============================== VITALS: 98.7PO, 124/87, 92, 30, 95% Ra GENERAL: AOx3, NAD, obese. HEENT: PERRL, EOMI, sclera anicteric, MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No rubs/gallops. No JVD. +friction rub. LUNGS: decreased breath sounds throughout but otherwise clear to auscultation bilaterally. ABDOMEN: Normal bowels sounds, non distended, non-tender to palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: hypopigmented patches consistent with vitiligo on the face, Abdominal incision sites x3 c/d/I. NEUROLOGIC: CN2-12 grossly intact, no focal deficits. Pertinent Results: ADMISSION LABS: ======================= [MASKED] 09:57PM BLOOD WBC-18.2* RBC-4.34 Hgb-11.3 Hct-33.7* MCV-78* MCH-26.0 MCHC-33.5 RDW-14.4 RDWSD-40.5 Plt [MASKED] [MASKED] 09:57PM BLOOD Neuts-75.2* Lymphs-8.9* Monos-14.9* Eos-0.1* Baso-0.1 Im [MASKED] AbsNeut-13.68* AbsLymp-1.62 AbsMono-2.71* AbsEos-0.01* AbsBaso-0.01 [MASKED] 09:57PM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-2+* Macrocy-NORMAL Microcy-1+* Polychr-NORMAL Target-2+* [MASKED] 11:48PM BLOOD [MASKED] PTT-25.5 [MASKED] [MASKED] 09:57PM BLOOD Glucose-120* UreaN-12 Creat-0.9 Na-139 K-3.7 Cl-95* HCO3-28 AnGap-16 [MASKED] 09:57PM BLOOD ALT-20 AST-28 AlkPhos-53 TotBili-1.3 [MASKED] 09:57PM BLOOD Lipase-13 [MASKED] 09:57PM BLOOD cTropnT-0.04* [MASKED] 09:57PM BLOOD Albumin-3.6 [MASKED] 09:57PM BLOOD CRP-258.6* [MASKED] 10:45PM BLOOD Lactate-1.1 [MASKED] 06:30AM URINE Color-Yellow Appear-Clear Sp [MASKED] [MASKED] 06:30AM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-8* pH-6.5 Leuks-MOD* [MASKED] 06:30AM URINE RBC-1 WBC-5 Bacteri-FEW* Yeast-NONE Epi-1 PERTINENT LABS: ======================= [MASKED] 09:57PM BLOOD CRP-258.6* [MASKED] 09:57PM BLOOD cTropnT-0.04* [MASKED] 06:10AM BLOOD cTropnT-0.04* [MASKED] 02:37PM BLOOD cTropnT-0.03* MICROBIOLOGY: ======================= [MASKED] [MASKED] 10:32 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Pending): [MASKED] [MASKED] 10:15 pm URINE URINE CULTURE (Pending): [MASKED] [MASKED] 12:15 am BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 5:18 pm URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [MASKED] [MASKED] 10:45 pm BLOOD CULTURE Blood Culture, Routine (Pending): [MASKED] [MASKED] 3:55 am URINE **FINAL REPORT [MASKED] URINE CULTURE (Final [MASKED]: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING: ======================= [MASKED]: CXR: Bilateral low lung volumes. Mild bilateral pulmonary vascular congestion. Left retrocardiac opacity likely represents atelectasis. Probable bilateral small pleural effusions. No pneumothorax. The cardiac and mediastinal silhouettes are unchanged. [MASKED] Echo: The left atrial volume index is normal. The estimated right atrial pressure is [MASKED] mmHg. Mild symmetric left ventricular hypertrophy with normal cavity size, and regional/global systolic function (biplane LVEF = 68 %). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Very small inferolateral pericardial effusion. Mild pulmonary artery systolic hypertension. DISCHARGE LABS: ======================= [MASKED] 05:40AM BLOOD WBC-7.6 RBC-3.46* Hgb-9.0* Hct-27.2* MCV-79* MCH-26.0 MCHC-33.1 RDW-14.5 RDWSD-41.4 Plt [MASKED] [MASKED] 05:40AM BLOOD Glucose-79 UreaN-15 Creat-0.8 Na-142 K-3.7 Cl-102 HCO3-29 AnGap-11 [MASKED] 05:40AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1 OTHER BODY FLUID VIRAL, MOLECULAR FluAPCR FluBPCR [MASKED] 13:30 NEGATIVE NEGATIVE Source: Nasopharyngeal swab [MASKED] 22:32 NEGATIVE NEGATIVE Source: Nasopharyngeal swab [MASKED] 23:35 NEGATIVE NEGATIVE Brief Hospital Course: [MASKED] year old [MASKED] woman with history of hypertension, obstructive sleep apnea, GERD, and recent laparascopic cholecystectomy ([MASKED]) who presented with acute onset chest pain consistent with pericarditis. She was discharged on ibuprofen and colchicine for 3 months, per cardiology. ACUTE ISSUES: ======================= # Pericarditis: Pt presented with acute onset chest pain with history, exam and EKG consistent pericarditis, likely secondary to viral illness given cough and fever. Flu negative x3, CXR without evidence of pneumonia, UA without evidence of infection. Troponin peaked at 0.04. TTE [MASKED] showed minimal inferolateral effusion, with no significant valvular abnormalities or focal wall motion abnormalities and ejection fraction 68%. She remained hemodynamically stable and was discharged on ibuprofen and Colchicine for 3 month course for likely viral pericarditis. #Microcytic Anemia Likely secondary to iron deficiency, given she has history of this and only intermittently takes her iron supplementation due to constipation. #Recent cholecystectomy: Cholecystectomy on [MASKED] done laparoscopically with well healing wounds. LFTs unremarkable. She was seen by surgery while in house without concern for infection. CHRONIC ISSUES: ======================= # Obstructive Sleep Apnea: Pt has APAP at home however does not use it due to comfort issues. # Depression: Continued home Fluoxetine. # HTN: Continued home Amlodipine. # GERD: Continued home Zantac 150 mg BID. # Seasonal Allergies: Continued home Loratadine and fluticasone nasal spray. TRANSITIONAL ISSUES: ====================== Discharge hemoglobin/hematocrit: 9.0 / 27.2 [] Patient was discharged on colchicine with plan for three month course [Day 1: [MASKED] and ibuprofen as needed. [] Patient needs PCP follow up in [MASKED] weeks. [] Please obtain follow up EKG in [MASKED] weeks. [] Please monitor anemia and encourage adherence to ion supplementation. [] Please follow up on pending lab studies: Respiratory viral culture, Respiratory viral antigen screening, urine culture, blood cultures. #CODE: Full Code, presumed. #CONTACT: Next of Kin: [MASKED] Relationship: BROTHER Phone: [MASKED] [x]>30 minutes spent on discharge planning and care coordination Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. FLUoxetine 40 mg PO DAILY 3. Loratadine 10 mg PO DAILY 4. Ranitidine 150 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Ibuprofen 800 mg PO Q8H:PRN AS DIR 8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 9. Docusate Sodium 100 mg PO BID:PRN constipation 10. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Colchicine 0.6 mg PO BID Duration: 3 Months RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*172 Tablet Refills:*0 2. Ibuprofen 600 mg PO Q8H RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 4. amLODIPine 10 mg PO DAILY 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Ferrous Sulfate 325 mg PO DAILY 7. FLUoxetine 40 mg PO DAILY 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Loratadine 10 mg PO DAILY 10. Ranitidine 150 mg PO BID 11. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Pericarditis Secondary Diagnoses: Microcytic Anemia Obstructive Sleep Apnea Seasonal Allergies Depression Hypertension GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [MASKED], WHY WAS I ADMITTED? You were admitted to the hospital because you had chest pain. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -You were diagnosed with a condition called pericarditis, which is caused by inflammation of the lining around your heart. - You had an echo (an ultrasound of your heart) which showed your heart is pumping normally and your heart valves are normal. - The cardiologists (heart specialists) evaluated you and recommended medicines called ibuprofen and colchicine to treat your pericarditis. - The surgeons saw you. They felt you were recovering well from your gallbladder surgery earlier this week. WHAT SHOULD I DO WHEN I GO HOME? -Continue to take all home medications as prescribed. -Follow up with your primary care doctor within [MASKED] weeks. -Please return to the emergency room if you develop worsening chest pain, or any other symptoms of concern. It was a pleasure caring for you, and we wish you all the best. Sincerely, Your [MASKED] team Followup Instructions: [MASKED] | [
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"I10",
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"I301: Infective pericarditis",
"Z6843: Body mass index [BMI] 50.0-59.9, adult",
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"D509: Iron deficiency anemia, unspecified",
"J302: Other seasonal allergic rhinitis",
"G4733: Obstructive sleep apnea (adult) (pediatric)",
"F329: ... | [
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15,315,015 | 27,569,778 | [" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Dat(...TRUNCATED) | "Allergies: Bactrim / Iodinated Contrast Media - IV Dye / erythromycin base / Cipro / Flexeril / azi(...TRUNCATED) | [
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"E1165",
"F17210",
"I10",
"E785",
"K219",
"Z86718"
] | [] |
14,993,494 | 25,076,564 | [" \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___(...TRUNCATED) | "Allergies: Tetracycline / Daypro / Tramadol / Hydrocodone / bee venom protein (honey bee) / hydroco(...TRUNCATED) | ["A419","J189","J9621","I5032","I2720","M0510","J8489","I480","D638","Z66","Z9981","E8339","D509","G(...TRUNCATED) | ["A419: Sepsis, unspecified organism","J189: Pneumonia, unspecified organism","J9621: Acute and chro(...TRUNCATED) | [
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"Z66",
"D509",
"G8929",
"F329"
] | [] |
10,821,939 | 28,879,056 | [" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Da(...TRUNCATED) | "Allergies: No Known Allergies / Adverse Drug Reactions Chief Complaint: Dyspnea Major Surgical or I(...TRUNCATED) | ["I110","I5021","N179","R64","I4892","Z681","E785","K219","E039","I482","Z7901","Z87891","I2720","J4(...TRUNCATED) | ["I110: Hypertensive heart disease with heart failure","I5021: Acute systolic (congestive) heart fai(...TRUNCATED) | [
"I110",
"N179",
"E785",
"K219",
"E039",
"Z7901",
"Z87891"
] | [] |
12,385,857 | 29,372,911 | [" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date:(...TRUNCATED) | "Allergies: morphine Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None Hist(...TRUNCATED) | ["E1143","E1121","I69354","F1120","I2510","I252","Z85118","Z7902","D509","E1140","E11319","H548","Z7(...TRUNCATED) | ["E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy","E1121: Type 2 diabetes (...TRUNCATED) | [
"I2510",
"I252",
"Z7902",
"D509",
"Z794"
] | [] |
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