OfNote


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Drugs causing mineral deficiencies: ref
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Remodulin, that helped keep blood pathways open in the lungs, though it is delivered by injection or a pump. They developed Tyvaso, which is inhaled; and finally, Orenitram, a pill.
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Abdominal pain work up - CTAP, LFT, lactic acid, lipase, abdominal x-ray all normal.
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Nausea vomiting and diarrhea – resolved was likely 2/2 viral gastroenteritis, no known recent antibiotics, CT AP nonacute, afebrile, WBC normal, supportive treatment for now.
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Hama - Narendra's wife
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Medications contributing to insomnia:
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Brilinta can be replaced with (Effient) prasugrel or (Plavix) clopidogrel if SEs are intolerable.
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- 10 worst medications for your kidneys:
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- PCSK-9 inhibitor
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Max simvastatin dose w/ a CCB is 10 mg.
- includes Amlo and Verap
- He also may have had a virus that contributed to CK > 330,000.
Tekulve
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PO Zyvox is the substitute for IV Vanc in a patient with MRSA PNA (pulm reccs 14 days IV Vancomycin)
- PO Zyvox is also indicated if there is a vancomycin allergy.
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Investigate relation between Prozac and pancytopenia 0000514137
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http://www.the-hospitalist.org/category/clinical/
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Remember email templates and the EPIC App.
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Patient admitted with UTI and Alt. MS. On admission Per lab BUN 49, Creat 2.7, GFR 18. Treatment includes: 1L NS bolus and IV fluids at 200 ml/hr. 

If possible, please clarify in progress notes and d/c summary the stage of CKD:
- Acute renal failure with CKD (please specify the stage 1-5)
- CKD Stage I GFR > 90 ( mild )
- CKD Stage II GFR 60-89 ( mild )
- CKD Stage III GFR 30-59 ( moderate) 
- CKD Stage IV GFR 15-29 ( severe) 
- CKD Stage V; ESRD GFR < 15
- Unable to determine 
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MD,
1. FYI: Trimethoprim decreases urinary excretion of potassium. Up to 6% of patients on TMP/SMX develop hyperkalemia...and the risk is higher when it's added to other meds that raise potassium...ACEIs, ARBs, aldosterone antagonists, potassium supplements, etc. Hospitalizations due to hyperkalemia increase by 7-fold or more when seniors take TMP/SMX with an ACEI, ARB, or spironolactone. Patient is currently ordered TMP/SMX + Spironolactone. Admission K = 5.8 yesterday. 
2. Would you be interested in changing Rocephin and Bactrim to Carbapenem until cx data results?
Thanks,
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DX Serotonin Syndrome - elevated CK, hyperreflexia, nucynta, Prozac, trazodone
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People on fibrates should have their CK checked because vibrates can increase their CK.
Triamterene and HCTZ increase K.
Combine Catapres and clonidine and you are likely to see bradycardia.
- what are the mechanisms of the foregoing ?
-------------- Pulmonary Consults
The TriHealth Pulmonary Medicine Group (Drs. Eisentrout, Halvonik, Sheatt, Thorpe, and Malik) have sent written notification resigning their privileges at Mercy Anderson effective October 1 in order to concentrate on their practice at Bethesda North.   From this point forward, all new pulmonary critical care consults should be called to the in-house group affiliated with Sound Physicians (Drs. Parker, Mostafa, et al).  The pager number is 513-329-0512(unchanged).  
 
Tomorrow, the attending physician on any remaining patients followed by TriHealth Pulmonary Medicine will determine if continued pulmonary consultation is required and re-consult the in-house group if needed. 
 
Dr. Mike Halvonik has been a member of the Anderson Hospital medical staff since March 1989.  Deb Halvonik served a valuable volunteer in the medical staff office for five years, winning “volunteer of the year” in 2013.  We truly appreciate the long history of service  Dr. Halvonik and his colleagues have provided to the patients and staff of this hospital.
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Does lisinopril cause hyponatremia?
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Tachycardia - use Lopressor 2.5 IV X1 or X2 PRN w/o a drop in BP
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467021-10022015 Add clindamycin to cover gas producing organisms - in a pt w/ poss nec fascitis.
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309681 - bicarb contributes to diarrhea in a pt w/ CKD on HD
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chronic macrocytic anemia
- HbB 6.9, transfusing 2U PRBC
- baseline Hb ~ 10
- vit b12, folate, TSH all normal. LFTs unremarkable.
- etiol bone marrow suppression 2/2 alcoholism, nursing notes blood in stool
- retic count noted and is low as would be expected in bone marrow suppression
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0000299964
Stress test was personally reviewed. I did not appreciate any apical infarct
as was reported. Will obtain an echocardiogram to assess apical wall
motion. Considering that his ejection fraction is low, we will switch him
from Lopressor to Toprol XL. He is not on ACE inhibitor due to chronic
kidney disease and a solitary kidney, which was removed for renal cell
carcinoma. We will add Isordil and continue hydralazine for the left
ventricular dysfunction based on the VAL-HeFT trial. He will follow-up with
cardiology at the VA Hospital.
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What is Revatio ? for secondary pulmonary htn ? 0000478875
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-- Management of acute stroke on admission.
- CT Head W/O: Mass or ischemia in the left cerebellar hemisphere
- MRI brain w w/o: Acute ischemia within the left cerebellum 15:22
-- Based upon criteria provided in UTD Ms Luersman is not a candidate for alteplase for the following reasons:
- minor and isolated neurological signs
- platelet count < 100,000
- current AC use (Warfarin) with INR > 1.7

- BP Goals in acute ischemic stroke as per UTD
-- acute phase - BP is not to be lowered unless > 220/120 in patients who are not candidates for reperfusion therapy.
-- after 8-24 hours oral medicines can be used to taper toward normals
-- UTD Topic 3837, Version 25.0
-- Discussed with nursing by phone 16:48
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------------- Drugs to substitute in patients with renal insufficiency (ex cr 2.2)

stop atenolol, start metoprolol 2/2 CKD - investigate this

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Interesting BP regimen for a hypertensive F smoker working at a mini-mart:
- norvasc
- coreg
- lisinopril
- minoxidil 
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Stroke Exam

General: Awake and alert
Cardiovascular: s1, s2, rrr, no murmurs, no carotid bruits
Lungs: +wheezes, rhonchi b/l

NIH Stroke Scale

Interval: Baseline
Time: 2:21 PM
Person Administering Scale: Julian Macedo

1a Level of consciousness: 0=alert; keenly responsive 
1b. LOC questions:
1c. LOC commands: 0=Performs both tasks correctly 
2. Best Gaze: 0=normal 
3. Visual: 0=No visual loss 
4. Facial Palsy: 0=Normal symmetric movement 
5a. Motor left arm: 0=No drift, limb holds 90 (or 45) degrees for full 10 seconds 
5b. Motor right arm: 0=No drift, limb holds 90 (or 45) degrees for full 10 seconds 
6a. motor left leg: 0=No drift, limb holds 90 (or 45) degrees for full 10 seconds 
6b Motor right leg: 0=No drift, limb holds 90 (or 45) degrees for full 10 seconds 
7. Limb Ataxia: 0=Absent 
8. Sensory: 0=Normal; no sensory loss 
9. Best Language: 0=No aphasia, normal 
10. Dysarthria: 0=Normal 
11. Extinction and Inattention: 0=No abnormality 
Total:  

Detailed Neuro Exam: 
Mental Status: Awake, alert and oriented to person, place, date and situation. Tracks, Regards and regards examiner. No gaze preference. Follows commands in face and x4 extremities; normal language.

Cranial Nerves: 
2, 3: Visual fields are full to confrontation, Pupils: 4->2 b/l 
3, 4, 6: EOMI intact, no nystagmus
5: Facial sensation intact bilaterally
7: No facial assymetry
9, 10: Fluctuating slured speech, + cough, gag not tested
Motor/Sensory: Moves all extremties equally. No evidence of pronator drift in UEs. Collapsing weakness of RUE, coachable to maintain RUE without limitation

Psych: Endorses significant stress, with daily substance use (THC) as coping mechanism, unsure if that is contributing to today's presentation

------------- TIA and CP - low risk order sets.

TIA - symptoms resolving
- TIA order set
- IP consult to neuorology - thank you
- neuro checks
- lipid panel
- daily CBC, BMP
- PT/INR NL
- CT Head - no evidence of acute hemorrhage
- MRI brain w/wo contrast
- 2D echo
- asa daily

Chest Pain
- Chest Pain order set
- serial troponins, trop#1 <0.01
- BNP 595
- EKG NL w/ possible NL variant LVH - BP stage 1 HTN
- CXR Non-acute
- AM repeat EKG
- asa daily
- VS per routine
- daily weights, I/O
- cont pulse ox
- lipid panel

Stage 1 HTN
- start lisinopril 5mg

Acute Renal Insufficiency - was NL 12/14
- GFR 38, Cr 1.4
- recheck AM BMP

Hyperglycemia
- BGL 182
- A1c *** order this


Carb Control Diet pending A1c
Lovenox
Full COde

PT/OT: PRN

DISPO: CP R/O, TIA workup, ARI work up like 2 days then home.

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Leukocytosis DDX:
- corticosteroids
- dilantin (expect a rash as well as this would be a drug rxn)

Colonic wall thickening DDX:
- CDIFF
- shiga toxin producing E. Coli in the setting of TTP / HUS

Renal failure is associated with:
- hyponatremia
- hyperkalemia
- acidosis

Another great Nephrology Note: 950231
Acute Kidney Injury:  Present on admission / KDIGO stage II / non-oliguric  
- Data:  + rash, vanc = 20, UA with U Na < 20, 0-2 RBCs, and 0-2 WBCs.  Foley placed
- Etiology:  Acute Interstitial Nephritis is a concern given his rash, however, this is less likely considering the bland UA and pronounced renal failure.  With hypotension, low U Na, and edema it would seems this is more of early ATN due to sepsis.  

Hyponatremia: Hypervolemic / chronic / asymptomatic -  Due to AKI with impaired free water excretion.  This has been a chronic issue.  One problem is that he does drink a lot of free water.  U Na is consistently low so poor renal blood flow is contributing but I do think he has SIADH from pain.  

Lab findings in dx of SIADH:
Euvolemic hyponatremia <134 mEq/L, and POsm <275 mOsm/kg OR ( POsm - Serum [Urea]mmol/l < 280 mOsm/kg )
Urine osmolality >100mOsm/kg of water during hypotonicity.
Urine sodium concentration >40 mEq/L with normal dietary salt intake.


Hypomagnesemia:  Nutritional / getting supplement 

Acidosis:  Due to AKI with impaired net acid excretion.  The anion gap is normal

Edema:  Chronic problem, largely due to CCB and immobility.  Now could have leaky capillaries due to sepsis and loss of the glycocalyx 

Anemia:  No report of GI bleed, plts are ok but falling.  

Hypotension:  Septic shock, concern for PNA.  WBC = 51

Rash:  Would seem to be allergic / no pyuria 
Plan:
•Gentle hypertonic fluids for resuscitation with HCO3 to avoid dilutional acidosis  
•May need pressors given his volume status
•Supportive care and treatment of sepsis, he is non-oliguric so hopefully he will plateau and recover.  Will monitor Vanc levels
•Follow labs  
•Agree with Mg replacement 

Cardizem - avoid in a pt w/ unk LVEF as it is a negative inotrope. 558998

Prolonged QT can be 2/2 Namenda, Aricept and narcotics. 140269

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Diagnose AKI:
Urinary indices - FENa <1%, Ucr/Pcr >50/1 - suggest volume deficit, likely pre-renal
- likely 2/2 intravascular volume deficit
- this is based on his h/o thirst & bump in Cr with added diuretics
- no frank nephrotoxins noted
- admit BP 75/45 
- this could be an early or establishing ATN as well from the hypotension
- consider HD versus CRRT if volume status or renal status worsens clinically.
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ID PE of infected hip:
- No clubbing, cyanosis, or peripheral edema.
- There is erythema over and adjacent to the healed right hip incision, there is no fluctuance, the soft tissues are somewhat edematous, but not particularly indurated and only mildly tender. The erythema is a blanching, macular erythema.
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Pulmonology Example Note:
Sepsis
Aspiration pneumonia
Urinary tract infection
Hypovolemia
Cerebral palsyAspiration /Dysphagia

- O2 to keep Pox > 88%
- BIPAP for Tv~300 - assist w/ expansion and atelectasis 
- Airway clearance: percussion if not able to use IS / flutter.
- Dulera, ICS for  bronchitis/mobilize secretions/airway edema 
- IVF LR
- Levophed for goal MAP > 65 for sepsis
- sMerrem / vancomycin, follow cx.
- Toradol - pain, tylenol -fever 
- DVT prophylaxis lovenox

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