Discharge Summary-Page 1

Transcription

1 Discharge Summary-Page 1 Admission diagnosis: 1. Gastritis. 2. Alcoholic cirrhosis, ascites, grade 1 esophageal varices. 3. Recent left knee arthroplasty. 4. Osteoporosis naqmq : 1. Three chest X-rays were performed on which showed no acute aspiration, no focal consolidation and no interstitial lung diseases. 2. A CT of abdomen pelvis with contrast was performed on, which showed a new onset collecting system dilatation on the right but no clear obstruction can be seen. IPI: in summary, Ms. is a 67-year-old female with a history of alcoholic cirrhosis and ascites, who resented with epigastric pain for two weeks duration. The symptoms started after she stayed in a nursing ome for two weeks, after a left knee arthroplasty, and was given a list of new medications, including Celebrex, SA and Foxamax. Please see the admission H & P on for more details. lospital Course 1. Epigastric pain: The patient was admitted to the floor. History, physical examination, labs and CT abdomen results ruled out GERD, pancretitis, cholecytitis. The most likely cause of her signs and

2 Discharge Summary-Page 2 symptoms is medication triggered gastritis. The patient had already stopped taking all the medication she was given at the nursing home, before she came to our hospital. She was given Maalox, IV morphine, IV PPI, ondensetron to relieve her symptoms. On the day of discharge, her symptoms were cleared and she was back to her baseline. 2. Hypokalemia: The patient was given IV KCL and Mg. 3. Hydronephrosis: Pelvicayceal dilation found on abdominal CT: No clear obstruction was found on the CT with radiology and was instructed to follow up with us next week to ensure that hydronephrosis had resolved. iischarqe Medications: Multivitamain Take once daily Lactulose Take 15mL titrated to 2-3 Bowel Movements daily Boniva 150mg Take once monthly Vitamin 0 50,000 Take once weekly Iron 325mg Take three times weekly Aspirin 325mg Take once daily Percocet 5/325mg Take 1-2 tablets every 3 hours as needed for pain Take with food ; may cause drowsiness Do not take more than 4000mg of Tylenol in 24 hours Each tablet contains 325mg Omeprazole 40mg Take twice daily on an empty stomach lischarge Instructions: The patient was discharged home. She was instructed to follow up with us next week lr the suspected hydronephrosis. She was also instructed to follow up with her PCP for her anemia and to Ike precautions to prevent aspiration when eating. She was given detailed instruction on her medications. She nderstood and accepted the above instructions.

3 History and Physical CC: abdominal pain x 2wks HPI: 67y F with history of alcoholic cirrhosis and ascites presented with epigastric pain for two weeks duration. The patient had a left knee arthroplasty about one month ago and subsequently stayed in a nursing home for two weeks where she was started a list of medications, including Celebrex, ASA and Foxamax. About two

4 weeks on these new medications, she started having burning epigastric pain that is relieved by taking Pepto Bismol or energy drinks that "coat the stomach." The patient left the nursing home in about 2-3 days and stopped taking all the medications that were added to her medicine regimen since then. Patient describes the pain wakes her up at night. She describes feeling nausea but vomited only once, two weeks ago with food she took in. There was no blood in the vomited content. She reports 2-5 dark loose stools per day. The patient also reported lower abdominal intermittent cramping pain that is not worsening or relieving by any factors. The patient has decreased food intake for two weeks. She reports that she always feels thirsty and drinks a lot of water and has increased frequency of urination. She denies dysuria or blood in urine. She hsnt noticed significant abdominal distension recently. She denies the following : weight changes, night sweats, fever, chills, shortness of breath, vision changes, hearing changes, headaches. EGO on this year showed grade I esophageal varices. RSO: as in HPI. Medical history: alcoholic cirrhosis for 8 years ; ascites, osteoporosis. Medications taken at nursing home: lactulose 30ml PO Qam,ergocalciferol 50,000lU PO Qwk; FeS04 325mg PO BID; Senna S 2 tabs PO Qam ; ASA 325mg PO Qday; Celebrex 200mg PO Qam ; Foxama x 70mg PO Qwk. Surgery history: mastectomy 13 years ago due to breast cancer, transflap later; left knee arthroplasty one month ago. Allergies: doxycycline causes diarrhea, Fe and pain medications upset stomach. Personal history:the patient used to drink 3+ glasses of wine per day for about 20 years. Not had drink since 6 years. Vital : temperature 37.1, pulse 71, respiratory rate 16, blood pressure 139/48 mmhg, Sa02 97% on room air. Physical exam : GEN: NAO. HEENT: pupils equal, round, reactive and accommodate to light; icterus sclera ; no lymphadenopathy; all others within normal ranges. Heart: RRR, no gallops, no rubs. Lungs: clear on auscultation bilaterally. Abdomen: epigastric tenderness.bowel sounds positive with no appreciable organomegaly.no significant ascites noted Extremities/skin : no rushes, no edema. Neuro: normal strength and reflex upper extremities bilaterally, normal strength on lower extremities, normal reflex on right side. Left lower extremities is not tested on reflexes due to recent knee arthroplasty. Labs and imagings WBC 5.92, hemoglobin 10.1, hematocrit 30, plallet 182

5 Na+ 135, K+ 2.9, CI-103, C02 27, BUN 8, CrO.54, glucose 101, Ca Alkaline phosphatase 181, AST 55, ALT 39, Total protein 5.5, albumin 2.7, total bilirubin 1.2, lactic acid 1.3 Lipase 273, Troponin I < 0.02 UA: possible stones CXR: no significant changes ECG : normal CT abdomen with contrast: new onset collecting system dilatation on the right with hydroureter to the level of the pelvis. Assessment and plan Patient is a 57y F with history of alcoholic cirrhosis and ascites presented with epigastric pain of two weeks duration. 1. Abdominal pain: differential include gastritis, GERO, pancretitis, cholecytitis. Given the patient's sign and symptoms of epigastric pain that is relieved with Pepto-Bismol and drinks "coating the stomach" plus recent initiated medications in nursing home, her abdominal pain is most likely caused by medication triggered gastritis. Pancretitis and cholecytitis are less likely because her lipase of 273 is not high enough for pancretitis and CT abdomen did not have any findings for cholecystitis or pancreatitis. Her pain pattern is also inconsistent with cholecystitis. Patient will be given IV PPI to reduce stomach acid production, Maalox and IV morphine to relieve her abdominal pain. She will also receive ondensetron to control her nausea. She will be put NPO over night and we will give her IV 05 to keep her hydrated. 2. Hypokalemia: Patient had a recent knee arthoplasty and may had been on antibiotics post surgically. We will send her stool samples for C. diff toxin. We will supplement with IV potassium and magnesium. 3. Ascites: will arrange out patient follow up with GI/liver specialist. No portal thrombosis reported on the CT. need to ascertain if TIPS still working. 4. OVT prophylaxis: SCOs.