New Test Results
Unresponsive trip to the ER
Acute Heart Failure with Lung infection
The Heart Attack
Heart Burn
Spin Lumbar complications.
Syncopy episode, BP 45/20
Vanderbilt Clinical Trial
Open heart Surgery
Pacemaker
First Syncope episode
info unavailable
Emergency C Section
information coming soon
5-5-2023
Lab Results
Creatine Kinase, Total: 15L
Ideal range: 29-143 u/L
** Low Creatine Kinase Levels are Linked to Fainting. The more creatine kinase a person has within the normal range, the better their heart and muscles can function. In a study of 442 people, people with low creatine kinase levels were 73% more likely to faint.
Creatine kinase is an enzyme that is found in various tissues throughout the body, including skeletal muscle, heart muscle, and the brain. When Creatine levels remain high, it's a profound indicator of degeneration, chronic and acute. Western medicine options include exercise, creatine supplements, and physical therapy.
Eastern medicine options: Healthy diet, eat red meat daily (this is contradictory to our heart disease diagnosis.) increase daily intake of dairy, like milk and cheese. Consume as much eggs as possible along with tofu, Brazilian nuts, which beans and quinoa. Absolutely no Alcohol.
C-Reactive Protein: 16.9H
Ideal Range: <8.0 mg/L
** C-reactive protein (CRP) is a protein produced by the liver in response to inflammation in the body. It is a marker of acute inflammation and is often measured in blood tests to diagnose and monitor various conditions. A high CRP level indicates the presence of inflammation in the body, but it is important to understand what that means and what could be causing it.
High levels of CRP, it's time for a lifestyle change to reduce inflammation in your body. This includes eating a healthy diet and getting regular exercise.
Medication may be necessary to reduce the inflammation and lower CRP levels. Nonsteroidal anti-inflammatory drugs, corticosteroids, and disease-modifying antirheumatic drugs are common western medicine style treatments for inflammation. The eastern medical approach is, Eat an anti-inflammatory diet. Cut out the carbs and eat natural, organic and unprocessed foods. Avoid cheap refined vegetable oils like cottonseed, safflower and corn oil and avoid hydrogenated fats altogether. Anti-inflammatory foods include most-nuts, avocados, garlic and onions, olive oil, fatty fish, berries and even red wine, coffee, tea and most certainly dark chocolate.
High CRP level indicates the presence of inflammation in the body, but it is not a diagnosis on its own. If you have elevated CRP levels, you must determine the underlying cause and lower the inflammation. This is the only way to reduce your risk of complications. The longer they stay high the more at risk you are to major issues.
Treatment Plan: Exercise, Sleep, De-stress with Yoga, massage and acupuncture. Take multi-vitamins, Magnesium is a must, Vitamin D, Vitamin C in abundance, Fish Oil, Curcumin, and Omega-7.
HCA FL Sarasota Doc Hosp (COCDT)
Discharge Summary
REPORT#:0411-0379 REPORT STATUS: Signed
DATE:04/11/23 TIME: 1711
PATIENT: BEYER,ELIZABETH UNIT #: D000567468
ACCOUNT#: D20307933 ROOM/BED: D.519-1
DOB: 03/30/75 AGE: 48 SEX: F ATTEND: Gutierrez,James D DO
ADM DT: 04/10/23 AUTHOR: Khan,Sana DO
REP SRV DT: 04/11/23 REP SRV TM: 1711
* ALL edits or amendments must be made on the electronic/computer document *
General Information
Discharge date: 04/11/23
Discharge diagnosis:
Syncope
Likely polypharmacy and orthostasis
pt has had recurrent syncope episodes in the past 2/2 autonomic dysfunction
and orthostasis
Sick sinus syndrome status post permanent pacemaker
Metabolic encephalopathy, resolved
Polypharmacy
Nonischemic cardiomyopathy EF 55% from 10-15%
Multiple system atrophy
Autonomic dysfunction on outpatient medication therapy
Chronic peripheral neuropathy
Gastroparesis
History of takotsubo
History of atrial septal defect status post repair
Hospital course:
Patient is a 48-year-old female with past medical history of multiple system
atrophy, nonischemic cardiomyopathy, chronic peripheral neuropathy, sick sinus
syndrome status post permanent pacemaker who present to the hospital after
syncopal episode. In the emergency room CT brain was negative. Chest x-ray
negative for acute pathology. Blood work within normal limits. TSH within
normal limits. Urinalysis negative for urinary tract infection. Patient
admitted to internal medicine for further evaluation. Patient reports she
recently has been taking Klonopin 4 mg, baclofen 10mg and gabapentin 900mg all
together at night. She has autonomic dysfunction and is on midodrine. Her
telemetry overnight showed a paced sinus bradycardia in 45. Her pacemaker is
set to 45. Her pacemaker was interrogated and settings were changed to 60 beats
per minute. Patient improved with IV fluids. It was discussed at length at
patient is taking too much Klonopin. She needs to space out her medications and
try to be weaned off of her Klonopin. Patient reports her primary care provider
is working on weaning her off. Patient was seen by Cardiology and cleared for
discharge after pacemaker settings were changed. Patient clinically improved.
On day of discharge vitals and labs are stable. Patient to be discharged home
and is to follow-up with cardiology. Further details available in patient's
medical chart.
Med Rec
Med Rec
Discharge meds:
Stop taking the following medications:
Metoprolol Succinate ER (TOPROL XL) 25 MG TAB.SR.24H
12.5 MILLIGRAM ORAL DAILY
Continue taking these medications:
Baclofen (LioresaL) 20 MG TAB
20 MILLIGRAM ORAL EVERY 6 HOURS AS NEEDED as needed for MUSCLE SPASMS
clonazePAM (KlonoPIN) 1 MG TAB
2 MILLIGRAM ORAL AT BEDTIME as needed for ANXIETY
Gabapentin (Neurontin) 300 MG CAP
900 MILLIGRAM ORAL TWICE A DAY
Midodrine (Proamatine) 10 MG TAB
10 MILLIGRAM ORAL THREE TIMES DAILY WITH MEALS
Esomeprazole Magnesium (NexIUM) 20 MG CAP.EC
FLUoxetine (PROzac) 40 MG CAP
40 MILLIGRAM ORAL DAILY
pyRIDostigmine (Mestinon) 60 MG TAB
60 MILLIGRAM ORAL DAILY
Comments:
TAKE 1 TABLET BY MOUTH ONCE DAILY; #90 - SIG Obtained From DrFirst
Objective
VS/I O
Last Documented:
Result Date Time
Pulse Ox 98 04/11 1707
B/P 101/63 04/11 1707
B/P Mean 76.0 04/11 1707
Temp 98.6 04/11 1707
Pulse 60 04/11 1707
Resp 16 04/11 1707
O2 Delivery Room air 04/11 0403
24 hour I O ending at 0700:
04/11 0700 04/10 1900
Intake Total 120
Output Total 550
Balance -430
Intake, Oral 120
Output, Urine 550
Patient 105 lb 101 lb
Weight
Weight Bed scale Bed scale
Measurement
Method
PATIENT WEIGHT:
Weight (lb): 104
Weight (oz): 11.51
Weight (kg): 47.500
Results
Findings/Data:
Laboratory Tests:
04/11 04/11 04/10 04/10 04/10
0440 0440 2348 1810 1807
Chemistry
Sodium (136 - 145 MMOL/L) 138
Potassium (3.6 - 5.0 MMOL/L) 4.1
Chloride (101 - 109 MMOL/L) 105
Carbon Dioxide (22 - 31 MMOL/L) 27
Anion Gap (4 - 15 MMOL/L) 11
BUN (7 - 21 MG/DL) 10
Creatinine (0.7 - 1.5 MG/DL) 0.71
Estimated GFR (>60.0 ml/min) > 60
BUN/Creatinine Ratio (9.0 - 25.0) 14
Glucose (70 - 110 MG/DL) 93
Calcium (8.6 - 10.6 MG/DL) 9.2
Ammonia (11 - 35 UMOL/L) < 10 L
Troponin I High Sens (<51 ng/L) 5
TSH (0.36 - 3.74 uIU/ML) 2.30
Urines
Urine pH (5.0 - 8.0) 6.0
04/10
1807
Toxicology
Urine Opiates Screen (NEGATIVE) NEGATIVE
Ur Methadone (NEGATIVE) NEGATIVE
Urine Barbiturates (NEGATIVE) NEGATIVE
Ur Phencyclidine (PCP) (NEGATIVE) NEGATIVE
U Amphetamin/Meth Scrn (NEGATIVE) NEGATIVE
U Benzodiazepines Scrn (NEGATIVE) NEGATIVE
Urine Cocaine (NEGATIVE) NEGATIVE
U Cannabinoids Screen (NEGATIVE) POSITIVE H
Urines
Urine Color (YELLOW) Yellow
Urine Clarity (CLEAR) Clear
Urine pH (5.0 - 8.0) 6.0
Ur Specific Gravity (1.001 - 1.030) 1.015
Urine Protein (NEGATIVE mg/dL) NEGATIVE
Urine Ketones (NEGATIVE mg/dL) NEGATIVE
Urine Blood (NEGATIVE) NEGATIVE
Urine Nitrate (NEGATIVE) NEGATIVE
Urine Bilirubin (NEGATIVE) Negative
Urine Urobilinogen (0.2 E.U./dL) 0.2
Ur Leukocyte Esterase (NEGATIVE) NEGATIVE
Urine Glucose (NEGATIVE mg/dL) NEGATIVE
Radiology data:
Recent Impressions:
RADIOLOG - CHEST, 1 VIEW 04/10 1740
*** Report Impression - Status: SIGNED Entered: 04/10/2023 1901
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Impression By: RAZAL - ALI RAZA, M.D.
CAT SCAN - CT BRAIN W/O CONTRAST 04/10 1845
*** Report Impression - Status: SIGNED Entered: 04/10/2023 2001
IMPRESSION:
No acute intracranial findings.
Impression By: RAZAL - ALI RAZA, M.D.
Results: labs reviewed, vital signs reviewed, current med profile rev'd
Free Text Obj Notes
Free Text Obj Notes:
Per hospitalist progress note dated same day
Treatments Procedures
Imaging:
Recent Impressions:
RADIOLOG - CHEST, 1 VIEW 04/10 1740
*** Report Impression - Status: SIGNED Entered: 04/10/2023 1901
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Impression By: RAZAL - ALI RAZA, M.D.
CAT SCAN - CT BRAIN W/O CONTRAST 04/10 1845
*** Report Impression - Status: SIGNED Entered: 04/10/2023 2001
IMPRESSION:
No acute intracranial findings.
Impression By: RAZAL - ALI RAZA, M.D.
Discharge Instructions
PCP
PCP:
PCP: Duggin,Kelly Akin MD
)( Discharge to: Home/Self Care
Discharge Instructions
Additional Discharge Routines: PCP Follow-Up, Consultant Follow-Up
)( Diet: Resume Home Diet/Feeds
)( Activity: As Tolerated
)( Notify PCP of these S/S: Shortness of breath, Temp. 101 or greater
Prescriptions: none
Discharge management: greater than 30 mins, face to face encounter
Follow-up Appointments
PCP follow up:
PCP:
Duggin,Kelly Akin MD
Phone: 941-782-2800
PCP follow up timeframe: In 6 days
Special instructions:
f/u polypharmacy, pt taking too much klonapin
Consulting provider 1:
Provider 1:
Omar,Sabry MD
Specialty: CARDIOLOGYINTERVENTIONAL
Phone: 941-837-2922
Consult follow up timeframe: In 6 days
Special instructions:
f/u SSS s/p PPM, nonischemic cardiomyopathy
Quality: Discharge
Advanced Care Plan 65 or Older
Discussed with: patient
Current Medications
Current medication review:
I attest that the foregoing medication list in the medical record is true,
accurate, and complete to the best of my knowledge.
BMI Screening > 25 or < 18.5
Patient's BMI:
Current BMI: 18.6
BMI status/follow-up: nml BMI,no counsel needed
Tobacco Use/Counseling
Tobacco use/counseling: non tobacco user, no counseling needed
HTN Screening/Follow-up
Last documented vitals:
Last Documented:
Result Date Time
Pulse Ox 98 04/11 1707
B/P 101/63 04/11 1707
B/P Mean 76.0 04/11 1707
Temp 98.6 04/11 1707
Pulse 60 04/11 1707
Resp 16 04/11 1707
O2 Delivery Room air 04/11 0403
B/P assess/follow-up: normal B/P, no f/u req
Blood pressure ranges/guide:
Screening for Hypertension and follow up measure #317
Blood pressure parameters
Normal B/P SBP /= 140 DBP >/= 90
Electronically Signed by Khan,Sana DO on 04/11/23 at 1715
RPT#:0411-0379
***END OF REPORT***
HCA FL Sarasota Doc Hosp (COCDT)
Discharge Summary
REPORT#:0311-0153 REPORT STATUS: Signed
DATE:03/11/23 TIME: 1216
PATIENT: BEYER,ELIZABETH UNIT #: D000567468
ACCOUNT#: D20237336 ROOM/BED: D.425-1
DOB: 03/30/75 AGE: 47 SEX: F ATTEND: Rayasa,Devon R DO
ADM DT: 03/05/23 AUTHOR: Rayasa,Devon R DO
REP SRV DT: 03/11/23 REP SRV TM: 1216
* ALL edits or amendments must be made on the electronic/computer document *
General Information
Date of admission:
Observation Start Date:
Date of admission: 03/05/23
Discharge date: 03/11/23
Discharge diagnosis:
as below
Hospital course:
Patient is a 47-year-old female with a history of nonischemic cardiomyopathy,
multiple system atrophy, sick sinus syndrome status post ppm, and autonomic
dysfunction that presented to the hospital with respiratory failure. The
patient is currently intubated and sedated, HPI was obtained from the patient's
husband at bedside. He reports the patient developed confusion and decreased
responsiveness over the past several days. He is suspecting that the patient
accidentally took too much gabapentin on Friday and Saturday. He does note that
the patient was drinking and eating soup and a flat position, coughing after her
meal. In the emergency department she was found to be in acute respiratory
failure and intubated, she was transferred to Doctors Hospital ICU. She is
currently on pressor support. She is intubated and sedated.
Patient was initially treated aggressively in the ICU setting given concern of
septic shock with aspiration pneumonia present on arrival. Patient was
escalated to Merrem and tolerated this medical therapy without side effects.
Patient did have improvement in condition was able to be extubated and
eventually weaned off of oxygen therapy altogether. She continued to tolerate
medical therapies. 2D echocardiogram was done during admission this revealed a
resolution of previous nonischemic cardiomyopathy thought to be related to a
viral infection -- LVEF 55%. Patient's blood pressure was monitored and treated
with Levophed initially and patient was restarted on her home midodrine was able
to wean off of Levophed with aggressive IVF resuscitation. Patient continued to
improve and was stepped down to medical-surgical floor where she continued to
improve. Patient did work with physical therapy and occupational therapy team
during admission who noted that patient was ambulatory and tolerating PT/OT. It
was recommended to consider home health care for this patient for PT/OT and this
was discussed with patient in the presence of her husband on final day of
admission. Patient prefers to follow-up with her primary care physician in
regards to setting up home health care. Additionally addressed during admission
was patient history of recent hallucinations that was present on arrival. She
she was offered a psychiatrist consultation in this regard given multiple
medications with concern of polypharmacy. Patient declined inpatient
psychiatric evaluation and plans to follow-up with her primary care physician
for further medication management. Given significant improvement in condition,
patient was ultimately discharged home in improved/stable condition with her
husband and family.
Free Text General Notes
Free Text General Notes:
ASSESSMENTS
1. Acute hypoxic respiratory failure requiring mechanical ventilation. now
extubated
2. Suspected aspiration pneumonitis occasioning admission
3. Septic Shock POA. confirmed/treated/resolved. Cardiogenic shock ruled out (
LVEF 55%)
4. Acute kidney injury, resolved.
5. Prior Takotsubo nonischemic cardiomyopathy. resolved.
6. Sick sinus syndrome status post pacemaker
7. Multiple system atrophy
8. Atrial septal defect status post repair
9. Ileus, resolved.
10. Autonomic dysfunction on outpatient midodrine therapy
11. Colonic distension with concern of obstruction. Obstruction ruled out.
Possible Ogilvie syndrome
12. Acute toxic encephalopathy POA, resolved. suspect related to polypharmacy
and complicated by Septic Shock and Hypoxia.
13. Chronic peropheral neuropathy
Plan:
* Pulm/CCT signed off as patient has been transferred to med/surg floor.
* GI team recommends lactulose solution BID which has been ordered.
* Gastrograffin enema reveals no obvious colonic obstruction. patient has active
bowel sounds
* monitor blood pressures. continue midodrine therapy. patient has history of
orthostasis so maintain fall precautions
* Will continue broad-spectrum antibiotic therapy. Monitor BCX. Viral studies
NGTD -- transition to augmentin for dc.
* Restarted appropriate home meds. avoid medications that could induce
hypotension (Hold parameters in place)
* 2D Echo reveals stability of LVEF to 55%
* continue SQH for DVT PPx
* ST eval and treat -- dysphagia diet. continue to reassess for least
restrictive diet
* Decreased appetite. dietician consult placed
Patient offered referral for HHC -- patient declined and prefers to follow up
with her PCP for such needs.
d/w patient and husband at bedside
OK for discharge.
Med Rec
Med Rec
Discharge meds:
Continue taking these medications:
Baclofen (LioresaL) 20 MG TAB
40 MILLIGRAM ORAL TWICE A DAY
clonazePAM (KlonoPIN) 1 MG TAB
2 MILLIGRAM ORAL AT BEDTIME
Gabapentin (Neurontin) 300 MG CAP
900 MILLIGRAM ORAL TWICE A DAY
Midodrine (Proamatine) 10 MG TAB
10 MILLIGRAM ORAL THREE TIMES DAILY WITH MEALS
Esomeprazole Magnesium (NexIUM) 20 MG CAP.EC
FLUoxetine (PROzac) 40 MG CAP
40 MILLIGRAM ORAL DAILY
Start taking the following new medications:
Amoxicillin/K Clav (Augmentin) 875 MG-125 MG TAB
875 MILLIGRAM ORAL TWICE A DAY
Qty = 20
No Refills
Objective
VS/I O
Last Documented:
Result Date Time
Pulse Ox 98 03/11 0741
B/P 98/66 03/11 0741
B/P Mean 76.2 03/11 0741
Temp 98.4 03/11 0741
Pulse 107 03/11 0741
Resp 16 03/10 2000
FiO2 21 03/10 0837
O2 Delivery Room air 03/10 0837
O2 Flow Rate 2 03/07 0428
24 hour I O ending at 0700:
03/11 0700 03/10 1900
Intake Total 700 545.00
Output Total
Balance 700 545.00
Intake, IV 485.00
Intake, Oral 700 60
Number 1 1
Bowel
Movements
Number Voids 4 5
PATIENT WEIGHT:
Weight (lb): 102
Weight (oz): 11.77
Weight (kg): 46.600
Results
Findings/Data:
Laboratory Tests:
03/11
0825
Chemistry
Sodium (136 - 145 MMOL/L) 139
Potassium (3.6 - 5.0 MMOL/L) 4.1
Chloride (101 - 109 MMOL/L) 101
Carbon Dioxide (22 - 31 MMOL/L) 23
Anion Gap (4 - 15 MMOL/L) 19 H
BUN (7 - 21 MG/DL) 4 L
Creatinine (0.7 - 1.5 MG/DL) 0.58 L
Estimated GFR (>60.0 ml/min) > 60
BUN/Creatinine Ratio (9.0 - 25.0) 7 L
Glucose (70 - 110 MG/DL) 79
Calcium (8.6 - 10.6 MG/DL) 9.5
Magnesium (1.5 - 2.4 MG/DL) 1.9
Hematology
WBC (4.0 - 10.5 10 3/uL) 4.6
RBC (3.93 - 5.22 10 6/uL) 3.89 L
Hgb (11.2 - 15.7 g/dL) 11.0 L
Hct (34.1 - 44.9 %) 33.7 L
MCV (79.4 - 94.8 fl) 86.6
MCH (25.6 - 32.2 pg) 28.3
MCHC (32.2 - 35.5 %) 32.6
RDW (11.7 - 14.4 %) 13.4
Plt Count (150 - 450 10 3/uL) 252
MPV (9.4 - 12.3 fl) 10.9
Results: labs reviewed, vital signs reviewed, vital signs stable
Free Text Obj Notes
Free Text Obj Notes:
General appearance: alert, awake, pleasant white female patient lying in bed.
Currently alert and oriented x3 No acute distress. Conversant and cooperative
with exam. Tolerating room air
Cardiovascular: regular rate rhythm, normal heart sounds. There is
reproducible chest wall tenderness over the left chest wall. No murmurs, rubs
or gallops appreciated on this examination.
Respiratory: clear to auscultation, symmetric expansion
Abdomen/GI: active bowel sounds in 4 quadrants, abdomen remains soft, no
guarding, no rebound. There remains no tenderness appreciated on this
examination
Extremities: moves all, no peripheral edema
Skin: Dry, intact. No gross abnormalities noted on brief peripheral exam.
Psychiatry: appropriate mood/affect
Discharge Instructions
PCP
PCP:
PCP: DUGGIN,KELLY AKIN MD
)( Discharge to: Home/Self Care
Discharge Instructions
Additional Discharge Routines: PCP Follow-Up
)( Diet: Regular
)( Activity: As Tolerated, Appropriate for Age
)( Additional instructions:
Follow-ups with your inpatient and outpatient physicians are listed in the
follow-up
appointment section.
Please take your medications as directed above in the
medication reconciliation and monitor for signs of allergies or adverse
reactions to your medications as discussed. Please see your primary care
physician for medication refills. If you do not have a
primary care physician it is highly advisable that you
establish care with one as soon as possible for ongoing medical follow up.
Please return to the local emergency room if your symptoms
worsen.
Please contact your PCP if you have any questions or
concerns.
Prescriptions: e-prescribe
Discharge management: greater than 30 mins, face to face encounter
Time spent:
Time spent on patient care (minutes): 45
>50% spent on counseling/coordination of care: yes
Follow-up Appointments
PCP follow up:
PCP:
DUGGIN,KELLY AKIN MD
PCP follow up timeframe: In 3 days
Quality: Discharge
Current Medications
Current medication review:
I attest that the foregoing medication list in the medical record is true,
accurate, and complete to the best of my knowledge.
Electronically Signed by Rayasa,Devon R DO on 03/11/23 at 1246
RPT#:0311-0153
***END OF REPORT***
HCA FL Sarasota Doc Hosp (COCDT)
Discharge Summary
REPORT#:0113-0158 REPORT STATUS: Signed
DATE:01/13/23 TIME: 1117
PATIENT: BEYER,ELIZABETH UNIT #: D000567468
ACCOUNT#: D20119491 ROOM/BED: D.504-1
DOB: 03/30/75 AGE: 47 SEX: F ATTEND: Threatte,Ann Louise DO
ADM DT: 01/02/23 AUTHOR: Lazaro,Eduardo MD
REP SRV DT: 01/13/23 REP SRV TM: 1117
* ALL edits or amendments must be made on the electronic/computer document *
Procedure peformed
DATE:1/03/2023
PROCEDURE:INSERTION OF ENDOTRACHEAL AIRWAY INTO TRACHEA, VIA OPENING
PROCEDURE:RESPIRATORY VENTILATION, LESS THAN 24 CONSECUTIVE HOURS
PROCEDURE:INSERTION OF INFUSION DEV INTO SUP VENA CAVA, PERC APPROACH
PROCEDURE:INSERTION OF INFUSION DEVICE INTO UP ART, PERC APPROACH
Your provider determines your visit diagnosis using your symptoms, signs, and results from tests such as lab tests or radiology. As your provider continues to investigate your condition, you may see the visit diagnosis change due to new information. If you have questions about the visit diagnosis, please contact your provider.
VISIT DIAGNOSIS
Acute respiratory failure with hypoxia 1/13/2023
Myocardial infarction type 2 1/13/2023
Myocarditis due to infectious agent 1/13/2023
Acute on chronic systolic heart failure 1/13/2023
Acute and subacute hepatic failure without coma 1/13/2023
Acute renal failure due to tubular necrosis 1/13/2023
Lactic acidemia 1/13/2023
Encephalopathy, unspecified 1/13/2023
Dilated cardiomyopathy 1/13/2023
Takotsubo cardiomyopathy 1/13/2023
Rhabdomyolysis 1/13/2023
Hypokalemia 1/13/2023
Depressive disorder 1/13/2023
Anxiety disorder, unspecified 1/13/2023
Familial dysautonomia 1/13/2023
Other hypotension 1/13/2023
Noninfective gastroenteritis and colitis, unspecified 1/13/2023
Other constipation 1/13/2023
Cholecystitis, unspecified 1/13/2023
Other long term (current) drug therapy 1/13/2023
Long term (current) use of aspirin 1/13/2023
Recurrent falls 1/13/2023
Cardiac pacemaker in situ 1/13/2023
Dependence on wheelchair1/13/2023
General Information
Free Text A P:
Assessment
Influenza a
Possible cholecystitis
Acute systolic heart failure, EF 10-15%
* Myocarditis versus stress cardiomyopathy
Transaminitis, likely shock liver, improving
Severe Constipation - improved
NSTEMI type 2 likely secondary to demand ischemia
Rhabdomyolysis, resolving
Encephalopathy secondary to above
Anxiety
Depression
Multiple system atrophy
Sick sinus syndrome status post Dual chamber Medtronic Pacemaker
Prolonged QT
History of autonomic dysfunction
History of ASD status post repair
Acute hypoxic respiratory failure, resolved
Acute renal failure secondary to ATN, resolved
Plan
* Continue to monitor stool output. Fleet enemas p.r.n.. Bisacodyl suppository
p.r.n..
* Patient completed a course of Tamiflu for influenza A.
* Cardiology notes reviewed. Possible takotsubo verses myocarditis.
* Continue current medications. Monitor QTc
* Await neurology records, further recs per neurology
* Continue PT/OT/ST
* Labs in a.m.
* Patient will need rehabilitation efforts. Case management working on
authorization.
Diet: Tube feeds
DVT ppx: Lovenox
Code Status: Full code
Dispo: Awaiting a rehab authorization.
Date of admission:
Observation Start Date:
Date of admission: 01/02/23
Discharge date: 01/13/23
Admission diagnosis:
Influenza a
Possible cholecystitis
Acute systolic heart failure, EF 10-15%
Myocarditis versus stress cardiomyopathy
Transaminitis, likely shock liver, improving
Severe Constipation - improved
NSTEMI type 2 likely secondary to demand ischemia
Rhabdomyolysis, resolving
Encephalopathy secondary to above
Anxiety
Depression
Multiple system atrophy
Sick sinus syndrome status post Dual chamber Medtronic Pacemaker
Prolonged QT
History of autonomic dysfunction
History of ASD status post repair
Acute hypoxic respiratory failure, resolved
Acute renal failure secondary to ATN, resolved
Discharge diagnosis:
Influenza a
Possible cholecystitis
Acute systolic heart failure, EF 10-15%
Myocarditis versus stress cardiomyopathy
Transaminitis, likely shock liver, improving
Severe Constipation - improved
NSTEMI type 2 likely secondary to demand ischemia
Rhabdomyolysis, resolving
Encephalopathy secondary to above
Anxiety
Depression
Multiple system atrophy
Sick sinus syndrome status post Dual chamber Medtronic Pacemaker
Prolonged QT
History of autonomic dysfunction
History of ASD status post repair
Acute hypoxic respiratory failure, resolved
Acute renal failure secondary to ATN, resolved
Hospital course:
47-year-old female with a history of multiple comorbidities presents to Doctors
Hospital Sarasota secondary to hypotension. In the emergency room CT of the
brain was negative for acute pathology. CT C-spine negative for acute pathology
as well. CT L-spine negative. CT abdomen pelvis showed inflammation of the
gallbladder and periportal system. There was also mild colitis noted. CT of
the chest showed patchy alveolitis. Patient became confused in the emergency
room. She was treated during hospitalization for acute hypoxic respiratory
failure bilateral pulmonary infiltrates and influenza A positive. She did
complete a course of Tamiflu and ceftriaxone during hospitalization. She was
also found to be in acute systolic heart failure with an ejection fraction
initially at 10% with global hypokinesis felt more likely to be stress related
then ischemic in nature. Patient had multiple echocardiograms performed and her
ejection fraction improved during hospitalization. The systolic heart failure
is likely secondary to influenza myocarditis versus reverse Takotsubo's.
Patient will be discharged home with physical therapy. Please obtain medical
records for further information.
Med Rec
Discharge meds:
Stop taking the following medications:
FLUoxetine (PROzac) 60 MG TAB
60 MILLIGRAM ORAL DAILY
DOXYCYCLINE HYCLATE (PERIOSTAT) 20 MG TAB
20 MILLIGRAM ORAL TWICE A DAY
OMEPRAZOLE (PriLOSEC) 20 MG CAP.DR
20 MILLIGRAM ORAL DAILY
Continue taking these medications:
Aspirin EC (Ecotrin) 81 MG TAB.DR
81 MILLIGRAM ORAL DAILY
Baclofen (LioresaL) 20 MG TAB
20 MILLIGRAM ORAL TWICE A DAY
clonazePAM ODT (KlonoPIN WAFER) 2 MG TAB.RAPDIS
2 MILLIGRAM ORAL AT BEDTIME
GABAPENTIN (NEURONTIN) 300 MG CAP
300 MILLIGRAM ORAL TWICE A DAY
Midodrine (Proamatine) 10 MG TAB
10 MILLIGRAM ORAL THREE TIMES DAILY WITH MEALS
Pyridostigmine (Mestinon) 60 MG TAB
60 MILLIGRAM ORAL DAILY
Objective
VS/I O
Last Documented:
Result Date Time
Pulse Ox 100 01/13 0802
B/P 100/63 01/13 0802
B/P Mean 75.3 01/13 0802
Temp 98.2 01/13 0802
Pulse 65 01/13 0802
Resp 17 01/13 0802
O2 Delivery Room air 01/13 0351
O2 Flow Rate 0 01/06 1939
FiO2 21 01/06 0920
24 hour I O ending at 0700:
01/13 0700 01/12 1900
Intake Total
Output Total
Balance
Number Voids 1
Patient 39.5 kg
Weight
Weight Bed scale
Measurement
Method
PATIENT WEIGHT:
Weight (lb): 87
Weight (oz): 1.32
Weight (kg): 39.500
Free Text Obj Notes
Free Text Obj Notes:
General appearance: alert, awake
ENT: moist mucosal membranes, normal nose, normal pharynx
Neck: non-tender, no JVD, no lymphadenopathy, no masses or swelling
Cardiovascular: normal capillary refill, regular rate rhythm, normal heart
sounds, no murmur
Respiratory: Hypoxia, decreased breath sounds bilateral bases, no distress, no
tenderness, aerating well, symmetric expansion
Abdomen/GI: Decreased bowel sounds, tense, left periumbilical tenderness,
moderate distension
Extremities: moves all, decreased strength in bilateral upper and lower
extremities, no calf tenderness
Musculoskeletal: normal inspection, no CVA tenderness, no paraspinal tenderness,
ROM b/l UE and LE grossly intact
Skin: dry, intact, no gross abnormalities
Neurology: AOx3, normal speech, no motor defecit, CN II-XII grossly intact
Psychiatry: normal affect, normal judgment/insight, normal mood
Discharge Instructions
PCP
PCP:
PCP: DUGGIN,KELLY AKIN MD
)( Discharge to: Home/Self Care
Discharge Instructions
Additional Discharge Routines: PCP Follow-Up, Consultant Follow-Up
)( Diet: dysphagia diet
)( Activity: As Tolerated
Discharge management: greater than 30 mins
Time spent:
Time spent on patient care (minutes): 35
Follow-up Appointments
PCP follow up:
PCP:
UNKNOWN
PCP follow up timeframe: In 3 days
Consulting provider 1:
Provider 1:
Aranibar,Richard MD
Consult follow up timeframe: In 5 days
Consulting provider 2:
Provider 2:
Milford,Brett M DO
Follow up timeframe: In 5 days
Quality: Discharge
Current Medications
Current medication review:
I attest that the foregoing medication list in the medical record is true,
accurate, and complete to the best of my knowledge.
BMI Screening > 25 or < 18.5
Patient's BMI:
Current BMI: 15.9
BMI status/follow-up: nml BMI,no counsel needed
Tobacco Use/Counseling
Tobacco use/counseling: non tobacco user, no counseling needed
HTN Screening/Follow-up
Last documented vitals:
Last Documented:
Result Date Time
Pulse Ox 100 01/13 0802
B/P 100/63 01/13 0802
B/P Mean 75.3 01/13 0802
Temp 98.2 01/13 0802
Pulse 65 01/13 0802
Resp 17 01/13 0802
O2 Delivery Room air 01/13 0351
O2 Flow Rate 0 01/06 1939
FiO2 21 01/06 0920
B/P assess/follow-up: normal B/P, no f/u req
Blood pressure ranges/guide:
Screening for Hypertension and follow up measure #317
Blood pressure parameters
Normal B/P SBP /= 140 DBP >/= 90
Electronically Signed by Lazaro,Eduardo MD on 01/13/23 at 1125
RPT#:0113-0158
***END OF REPORT***
HCA FL Sarasota Doc North Emer Name: BEYER,ELIZABETH
LAKEWOOD RANCH ED Phys: Biondolillo,Frank C DO
8500 SR 70 E. DOB: 03/30/1975 Age: 47 Sex: F
BRADENTON, FL 34202 Acct: D19997616 Loc: D.EDLR
PHONE #: 941-242-6550 Exam Date: 10/28/2022 Status: REG ER
FAX #: 941-242-6533 Radiology No:
Unit No: D000567468
EXAMS: REASON FOR EXAM?:
001891277 CT L-SPINE W/O CONTRAST Fall x4 days ago
STUDY: CT LUMBAR SPINE WITH AND WITHOUT CONTRAST
REASON FOR EXAM: Female, 47 years old. Fall x4 days ago MIDDLE
BACK PAIN
TECHNIQUE: The patient was scanned in a multi detector CT scanner.
Sagittal and coronal images were reconstructed.
Individualized dose optimization techniques were used for this CT.
COMPARISON: None
___________________________________
FINDINGS:
Normal lumbar lordosis. There is no substantial scoliosis.
Normal vertebrae of the lumbar spine.
L1-2: Normal endplates. Normal disc height and morphology. Normal
bilateral facet joints. Normal central canal and bilateral lateral
recesses. Normal bilateral intervertebral neural foramina.
L2-3: Normal endplates. Normal disc height and morphology. Normal
bilateral facet joints. Normal central canal and bilateral lateral
recesses. Normal bilateral intervertebral neural foramina.
L3-4: Normal endplates. Normal disc height and morphology. Normal
bilateral facet joints. Normal central canal and bilateral lateral
recesses. Normal bilateral intervertebral neural foramina.
L4-5: Normal endplates. Normal disc height and morphology. Normal
bilateral facet joints. Normal central canal and bilateral lateral
recesses. Normal bilateral intervertebral neural foramina.
L5-S1: Normal endplates. Normal disc height and morphology.
Normal bilateral facet joints. Normal central canal and bilateral
lateral recesses. Normal bilateral intervertebral neural foramina.
Normal visualized paraspinous soft tissue structures.
Acute nondisplaced fracture involving the right L1 transverse
process.
___________________________________
IMPRESSION:
PAGE 1 Signed Report (CONTINUED)
HCA FL Sarasota Doc North Emer Name: BEYER,ELIZABETH
LAKEWOOD RANCH ED Phys: Biondolillo,Frank C DO
8500 SR 70 E. DOB: 03/30/1975 Age: 47 Sex: F
BRADENTON, FL 34202 Acct: D19997616 Loc: D.EDLR
PHONE #: 941-242-6550 Exam Date: 10/28/2022 Status: REG ER
FAX #: 941-242-6533 Radiology No:
Unit No: D000567468
EXAMS: REASON FOR EXAM?:
001891277 CT L-SPINE W/O CONTRAST Fall x4 days ago
Acute nondisplaced fracture involving the right L1 transverse
process.
** Electronically Signed by D.O. GREGORY AROV on 10/28/2022 at 1059 **
Reported and signed by: GREGORY AROV, D.O.
CC: DUGGIN,KELLY AKIN MD
Dictated Date/Time: 10/28/2022 (1059)
Technologist: BRENNAN D. BATIEN RT (R)(CT)
Transcribed Date/Time: 10/28/2022 (1059)
Transcriptionist: RAD.VR
Printed Date/Time: 10/28/2022 (1100) BATCH NO: N/A
PAGE 2 Signed Report
HCA FL Sarasota Doc Hosp (COCDT)
Brief Discharge Note w/Med Rec
REPORT#:0520-0381 REPORT STATUS: Signed
DATE:05/20/22 TIME: 1803
PATIENT: BEYER,ELIZABETH UNIT #: D000567468
ACCOUNT#: D19708515 ROOM/BED: D.OP-12
DOB: 03/30/75 AGE: 47 SEX: F ATTEND: Khazanchi,Arun MD
ADM DT: 05/20/22 AUTHOR: Khazanchi,Arun MD
REP SRV DT: 05/20/22 REP SRV TM: 1803
* ALL edits or amendments must be made on the electronic/computer document *
Med Rec
Med Rec
Discharge meds:
Continue taking these medications:
Aspirin EC (Aspirin EC) 81 MG TAB.DR
81 MILLIGRAM ORAL DAILY
Baclofen (LioresaL) 20 MG TAB
20 MILLIGRAM ORAL TWICE A DAY
clonazePAM ODT (KlonoPIN WAFER) 2 MG TAB.RAPDIS
2 MILLIGRAM ORAL AT BEDTIME
FAMOTIDINE (PEPCID) 40 MG TAB
40 MILLIGRAM ORAL DAILY
FLUoxetine (PROzac) 60 MG TAB
60 MILLIGRAM ORAL DAILY
GABAPENTIN (NEURONTIN) 300 MG CAP
300 MILLIGRAM ORAL TWICE A DAY
LINACLOTIDE (LINZESS) 290 MCG CAP
290 MICROGRAM ORAL BEFORE BREAKFAST
Midodrine (Proamatine) 10 MG TAB
10 MILLIGRAM ORAL THREE TIMES DAILY WITH MEALS
Prucalopride (Motegrity) 2 MG TAB
2 MILLIGRAM ORAL DAILY
Pyridostigmine (Mestinon) 60 MG TAB
60 MILLIGRAM ORAL DAILY
METOCLOPRAMIDE (REGLAN) 5 MG TAB
5 MILLIGRAM ORAL DAILY
Brief Discharge Note w/Med Rec
Additional Discharge Routines: None
Attestations
Physician Attestation
Agree w/findings plan:
Agree with the findings and plan as documented by [insert APP name];
* my personal evaluation is
[ ]
Electronically Signed by Khazanchi,Arun MD on 05/20/22 at 1804
RPT#:0520-0381
***END OF REPORT***
(Unprofessional and an emotionally overwhelming visit)
I was taken to Manatee Memorial Monday Feb. 14th in an unresponsive state. My husband said that I was treated well while in the emergency room. I was then moved to room 232. I let my nurse know that I had severe anxiety. She told my sister and I that the neurologist would be by shortly and it looks like I would be going home. The Doctor did stop by and told me he wanted to keep me for observation and testing the next day. He was very thorough and nice. I said that was fine however, I was hoping to go home because the nurse said that It looked like I would be discharged. The night shift then took over. My roommate needed to be checked on often so the door was often left open. I over heard a nurse come out of a room and yell “I will not help that damn oom-pah Loompa again” At this point I realized she is referring to the size of her patient. She continued yelling inappropriate things so the nurse in my room went out of the room to see what was going on. He told her to calm down and not be angry. When he returned I told him that it seems like she was angry. He then closed the door. After treating my roommate, he left the room and let the nurses know that I heard what was said. The response was “who cares”. Later during the shift I heard the nurses say “you go get her, I’m not” and lots of laughter. A nurse that I hadn’t seen before came in and took my blood. When she spoke to me, I recognized the voice and realized it was the nurse that was speaking inappropriate earlier. She blew a vein in my right hand. It appeared to be intentional based on the physical frustration she showed and the roughness in which she treated me. She was aggressive. At this point I was overwhelmed with anxiety. At approximately 10 minutes before shift change my roommate which I believe has Alzheimer’s, her machine began beeping over and over until it made the loud noise and was turned off manually from the nurse station. This continued until almost 8 am. When the nurse that I had from the previous day came in, I let her know how long it has been manually turned off after beeping for long periods of time. She apologized and informed me she would not be treating me, explaining, it was due to restructuring. However, she continued to treat my roommate. I heard her talking at the nurse station, sharing with them how upset she was that I was no longer her patient. The other nurse at the station said “your patient (referring to me) should have kept her mouth shut”. She was clearly referring to a comment I made earlier to the neurologist about being discharged, which is what the nurse told me. I got up to sit in my chair. I heard another nurse ask where I was and that I was not suppose to be out of bed by myself. She was told by another nurse that I had been up and sitting in my chair. The nurse with the foul mouth said “wow that is what Narcan can do for you and laughed” I went to the nurses station and told them I heard what she said and It was unprofessional. I shared with all of them at the nurses station, that I have MSA and I did not appreciate her assuming I was using drugs. After that my family was told my EEG was scheduled for after 3pm. At 8:45 the EEG nurse came in and started to set up for my test. The nurses were openly discussing why my procedure was pushed up. A nurse then said to everyone that I was getting special treatment because I was an unsatisfied patient. The only dissatisfaction I had was due to poor treatment by these same nurses that continued to harass me and make me feel completely uncomfortable. During the EEG I heard the tending neurologist ask what was so special about me that he had to come up there to read my results. Making the statement, they were not done with the procedure and he was leaving. He asked the nurse to read my results herself, told her what to look for and if the results required his attention, let him know. He did come back at 4pm, letting them know I was ok to be discharged. He did not come into my room to discuss any results. During my EEG I heard a group of nurses discussing one of my medications. They wanted to stop the procedure to give me the medicine. They said that the EEG nurse was feisty as hell and would not like it. They proceeded in playing an elimination game to see which one was going to interrupt the EEG. The person that was picked didn’t want to do it and everyone was laughing and telling her good luck. They said loudly that they were not going to deal with the “neuro bully” I felt bad for the Nurse doing my procedure because I know she could hear them as well. I was never given that medicine while at the hospital. I then heard a patient screaming her nurses name over and over. This continued while nurses and staff walked by her door for a while. Her situation was discussed loudly as they didn’t care who heard them. The experience very disturbing. I could not believe a patient was treated so bad. My roommate was then given the wrong medicine and it was lowering her heart rate. Her husband was visibly upset. At this point up until I left around 4pm, only the student nurse came to do my assessments. The nurses continued to openly talk about me. While looking at my chart and test results, it was said to cross whatever T’s they needed to get me the hell out of there. The others said yes she has got to go. There was increased profanity mixed in with the comments that would make anyone cringe. The student nurse came in and asked if I was ready to go home. I said yes and It’s obvious that you all are ready for me to go as well. She immediately turned around, went to the nurses station and repeated what I said while they all laughed. A nurse then said “she need to shut the F up and stop listening to our conversation, she doesn’t know who she is dealing with.” She then started yelling “go home birdie” “go home little birdie - birdie” over and over again, while the others around her laughed. This was so upsetting and emotionally draining. I never said anything negative to them and was as compliant as a patient could be. I was visibly upset the whole day and could not eat. My stomach was upset, I was having panic attacks and physically shaking. The student nurse was uncomfortable with the situation, noticed I was upset and shaking, even asked if I was cold. I did not say anything else because I did not want to draw anymore attention. I felt very uncomfortable and trapped. To this day, I am having ongoing panic attacks, trouble eating and sleeping. I have been in 9 different hospitals in 6 years. I have never seen such unprofessional behavior in a staff in my life. I am still very upset at the thought that other patients have to deal with what I dealt with and if I have to return, what I will be faced with. It is overwhelming to be mocked, spoken ill about, ignored and physically mishandled, especially when you are in the most vulnerable situation like I was when I was admitted. I should have felt safe and cared for. Instead I was harassed, mocked, belittled, mentally and physically abused. It’s unacceptable for a staff to treat patients in this manner. I’m still in shock and fearful to ever return to the Manatee Memorial Hospital.
I'm enough, I believe
Multiple system atrophy (MSA) is an extremely rare neurodegenerative disorder associated with auto immune disease showing effects like tremors, mobility loss, muscle loss, postural instability and dizziness, numbness, slurred speech, loss of balance, bowel instability, urination disorder - the list goes on. All caused by the degeneration of neurons in several parts of the brain including the basal ganglia which helps control movement, learning and emotions, inferior olivary nucleus which controls motor coordination and learning, and cerebellum which is a major feature of the vertebrates and effects your motor control. It is also involved in some cognitive functions such as attention and language as well as emotional control such as regulating fear and pleasure responses.
Most MSA victims experience dysfunction of the autonomic nervous system, which commonly manifests as orthostatic hypotension, impotence, loss of sweating, dry mouth, and urinary retention and incontinence. Paralysis of the vocal cords which causes aspiration, leading cause of death. It is an important and sometimes the initial manifestation of this disorder.
A modified form of the alpha-synuclein protein which regulates synaptic vesicle trafficking and the subsequent neurotransmitter release. This protein is abundant in the brain, while also found in the heart, muscle and other tissues. In the brain, this protein is found mainly in the axon terminal which is the nerve that receives the electrical impulse and is also the area where the impulse is converted to a chemical signal. It transfers information from its neuron into another neuron, though it does not come into physical contact with the other neuron. The release of neurotransmitters relays signals between neurons and is critical for normal brain function. These affected neurons may be the cause of MSA.
MSA often presents with some of the same symptoms as Parkinson's disease. However, those with MSA generally show little response to the dopamine medications used to treat Parkinson's disease.
MSA is different from multiple organ dysfunction syndrome, sometimes referred to as multiple organ failure, and from multiple organ system failures, an often-fatal complication of septic shock and other severe illnesses or injuries. MSA is truly a degenerative disease unlike any other.
** Our biggest hope right now. Mesenchymal Stem Cell Therapy, this may delay the progression of neurological deficits in patients with MSA-cerebellar type. It's a leader on our board right now.
MSA is characterized by the following, which can be present in any combination:
The most common first sign of MSA is the appearance of an "akinetic-rigid syndrome" or slowness of movement resembling and "Vasovagal Syncope" A sudden loss of consciousness which can result in falling and hitting the floor, which may cause fractures or other complications, such as severe head injury found in the majority. Problems with basic balance and urinary symptoms are also very common initial signs of problems: both men and women often experience urgency, frequency, incomplete bladder emptying, or an inability to pass urine. About 25% of MSA patients experience a fall in their first year of disease.
As the disease progresses, one of three groups of symptoms dominates. For Elizabeth it has been Autonomic nervous system dysfunction.
A study in Japan has found a correlation between the deletion of genes in a specific genetic region and the development of MSA. This includes the gene which, in mice and rats, appears to have some function in the nervous system. The study hypothesized that there may be a link between the deletion of the SHC2 and the development of MSA. It's hard to explain, but in simple terms, SHC2 is a protein that in humans is encoded by the SHC2 gene. This is a protein coding gene. If you break a link in the gene, you lose a coding source and MSA can form.
A follow-up study in America was unable to replicate this finding. The authors of the U.S. study concluded that the SHC2 gene deletions show few, if any, cases of well-characterized MSA in the US population. This is in contrast to the Japanese experience reported by Sasaki et al., likely reflecting heterogeneity of the disease in different genetic backgrounds.
That's a bummer for us.
In several recent studies, the effectiveness of treating MSA with stem cell therapy, has been reported. A study confirming that Mesenchymal stem cells can improve the neurological deficits in patients with MSA-C. This is a safe and simple method with fewer complications, according to this study. However, the MSA coalition currently warns against this treatment, for now. We are optimistic options are on the rise. There are non-pharmaceutical studies being conducted with MSA patients to determine if they can measure symptom progression, differentiate MSA from other similar diseases or improve quality of life. The MSA coalition has been on top of it. A group I am following. They offer options and constantly update their information. I find many studies, trials and research that indicate a ton of options on the rise.
Multiple system atrophy can be explained as cell loss and brain healing or a proliferation of astrocytes in damaged areas of the central nervous system. This damage forms a scar. The presence of inclusion bodies known as Papp-Lantos bodies is the hallmark of MSA affecting the movement, balance, and autonomic-control centers of the brain.
The disease probably starts with an oligodendrogliopathy (see video below), also known as a brain lesion or form of tumor. It has been proposed that the α-synuclein inclusions found in Oligodendrocytes result from the pruning and the saturation of diseased nerve fibers.
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