Other specified mononeuropathies Hypothyroidism unspecified Anxiety disorder unspecified Other specified diseases of gallbladder Other specified cardiac arrhythmias Gastro-esophageal reflux disease without esophagitis Presence of other specified functional implants Somatization disorder
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Penicillins / Topamax / Reglan
 
Attending: ___.
 
Chief Complaint:
============================
HMED Admission H&P
============================

CC: Back pain
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of 
debilitating pudendal neuralgia who was admitted in ___ and 
___ with worsening back pain, who presented to the ED 
today with subacutely worsening back pain. She had an 
intrathecal ziconotide pump for placed in ___ in ___ 
and had presented to ___ in ___ with worsened back pain at 
the site of the pump as well as urinary retention. Cord 
compression was ruled out at that time and her ziconotide was 
stopped (this was suspected as the cause of her urinary 
retention), and she was also started on prednisone for her pain 
which was attributed to inflammation around the site of her pump 
catheter where it passes by the L2 spinous process.  She has 
also been managed on multiple chronic narcotics and other agents 
for her pain. During the prior admission she was seen by 
neurology, neurosurgery, and pain service. 

She reports that initially the steroids were extremely helpful 
at controlling her pain but that she has been completing a slow 
taper. The plan had been tapering to 15 mg in ___ and 10 mg 
in ___, but in recent weeks she has had worsening control 
of her pain, similar to its prior location and quality. The pain 
is most severe over the lumbar incision site and is severe to 
the point of limiting basic daily function - has been using 
commode d/t difficulty ambulating ___ pain. She is followed 
closely by her PCP, who increased the steroids back to 40 mg 
daily and attempted a rapid taper with 4 days of 40mg, 4 days of 
30, and 4 days of 20. She noted some slight improvement with the 
increase to 40 mg but subsequently returned to severe pain when 
this was reduced to 30 and then 20. She also notes that she no 
longer sees the doctor in ___ who placed her pump. She reports 
that her PCP obtained an MRI in recent days, although she is 
unsure what the results showed. Her PCP recommended presenting 
to the ED given her worsening pain control. She denies any 
urinary retention, changes in bowel patterns, weakness, or 
numbness. 

Review of systems:  
Const: no fevers, chills
HEENT: + HA x 2 weeks, bilateral, constant non-pulsating "not 
migraine"
CV: + intermittent palpitations, no CP
Pulm: + occasional dyspnea associated with palpitations, 
otherwise no dyspnea or cough
GI: +RUQ pain for past week intermittently, no n/v, no changes 
in PO intake, no changes in BMs
GU: no retention or urinary changes
MSK: no new myalgias/arthralgias except as per HPI
Neuro: no new focal weakness or numbness
Derm: no new rashes
Hem: no new bleeding/bruising
Endo: no hot/cold intolerance
Psych: no recent mood changes

 
Past Medical History:
HYPOTHYROIDISM  
ARRHYTHMIA  
PUDENDAL IMPINGEMENT SYNDROME s/p INTRATHECAL PUMP PLACEMENT
SOMATIZATION DISORDER

 
Social History:
___
Family History:
No cardiac or cancer history in either parent. Mother and sister 
with depression. 
 
Physical Exam:
Admission Physical Exam:
Vital signs: 98 120/72 68 18 99% RA
gen: pt in NAD, lying in bed
HEENT: nc/at, sclera anicteric, conjunctiva noninjected, PER, 
EOMI, MMMs
CV: RRR no m/r/g
Pulm: CTAB No c/r/w
Abd/GI: S NT ND BS+, no masses/HSM palpated (except pump)
Back: tenderness over lumbar incision site
Extr: wwp, distal pulses intact, no edema
GU: no Foley
Neuro: alert and interactive, strength, sensation, CNs grossly 
intact, reflexes brisk throughout all 4 extremities
Skin: no rashes on limited skin exam
Psych/MS: normal range of affect

Discharge PE:
VS: 98.0 132 / 84 86 18 100 RA  
Gen: NAD, occasionally tearful, resting on her side
HEENT: EOMI, PERRLA, MMM
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Back: pump site c/d/I, no erythema or swelling, diffuse lower
back tenderness to even light palpation of skin
Neuro: CN II-XII intact, ___ strength throughout
Skin: warm, dry no rashes
 
Pertinent Results:
CBC: 6.0>12.6<227
BMP: ___
UA wnl

MRI lumbar spine w/o contrast ___:
Impression
There has been interval placement of hardware since the prior 
exam as further discussed above.  This results in extensive 
artifact including regions of signal loss and distortion of the 
anatomy. Allowing for this limitation, there is persistent 
changes of mild lumbar spondylosis but no definitive limiting 
central canal or foraminal stenosis at any level in the lumbar 
spine.  
Extrahepatic biliary ductal dilation.

MRI thoracic spine w/o contrast ___:
Impression
Mild chronic T6 and T9 compression fracture deformities.  No 
limiting central canal or foraminal stenosis at any level in the 
thoracic spine.
Extrahepatic biliary duct dilation to 7.5 mm.

RUQ ___: 
 
IMPRESSION:  
Unremarkable abdominal ultrasound.  No evidence of biliary tree 
dilation.  
Normal CBD. 

 
Brief Hospital Course:
___ year old woman with pudendal neuralgia status post 
intrathecal pump catheter placement in ___ treated with 
ziconotide infusion complicated by urinary retention (pump 
currently not in use) presenting with worsening of chronic back 
pain.

#Pudendal neuralgia with severe subacute on chronic pain: 
No significant change in character of pain, no fevers, chills, 
weakness, numbness, incontinence, retention or other concerning 
findings.  MRI T/L spine on ___ showing no concerning findings, 
no evidence of infection or significant spinal stenosis.  
Chronic pain service was consulted.  She reports she had 
significant benefit from her intrathecal pump prior to 
developing side effect of urinary retention and having it 
stopped, she is interested in trialing another medication 
through the pump.  On discharge in ___ she was counselled to 
find a physician to manage the pump but has not done so, 
recommended that she work on seeing an outpatient doctor who can 
manage her Prometra intrathecal pump, given name and office 
information of a local physician who is certified to manage the 
Prometra pump.  Concern that there is significant anxiety and/or 
possible somatization disorder contributing to symptoms.  
     - Started Lidoderm patch, recommend following up with Dr. 
___ to manage her intrathecal pump.
     - Home ___
     - continuing home medication regimen, which is as follows:
     - methadone 5 tid prn
     - percocet 10 tid prn
     - pregabalin 150 AM 300 HS
     - Exalgo 16 mg daily (in hospital placed on hydromorphone 4 
mg PO q6H as Exalgo non-formulary)
     - tizanidine 2 tid prn
     - ativan 1 q4h prn
     - duloxetine 120
     - elmiron (will use home med) and miralax for constipation
     - topical lidocaine PRN
     - increasing prednisone to 40 mg daily with taper of 10 mg 
daily.
     - Recommend that she establish care with a psychiatrist and 
therapist to help manage her anxiety and psychiatric disorders 
which are likely contributing significantly to her symptoms. 

#Abdominal pain
#Biliary ductal dilation on MRI
She denies any current abdominal pain, n/v, pruritus, jaundice.  
LFTs normal and RUQ unremarkable without ductal dilation.

#History of supraventricular arrhythmia
-cont verapimil 120

#HA:
History of migraine headaches.
 - Continue home PRN Imitrex

#Other home meds:
 - cont albuterol PRN for wheezing 
 - cont abilify 5 for mood
 - cont buspar 15 TID for anxiety
 - cont synthroid ___ for hypothyroidis
 - cont PRN zofran for nausea
 - cont PRN trazodone for insomnia
 - cont home ranitidine and substitute omeprazole for protonix
for GERD

# FEN: regular diet  
# Prophylaxis: Subcutaneous heparin  
# Access: peripherals  
# Communication: Patient  
# Code: Full (discussed with patient)  
# ___: home with home ___

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH BID 
2. ARIPiprazole 5 mg PO DAILY 
3. BusPIRone 15 mg PO TID 
4. DULoxetine 120 mg PO DAILY 
5. Levothyroxine Sodium 125 mcg PO DAILY 
6. LORazepam 1 mg PO Q4H:PRN anxiety 
7. Methadone 5 mg PO TID 
8. Ondansetron 4 mg PO Q8H:PRN nausea 
9. Polyethylene Glycol 17 g PO DAILY 
10. Pregabalin ___ mg PO DAILY 
11. Ranitidine 300 mg PO QHS 
12. Tizanidine 2 mg PO TID 
13. TraZODone 100 mg PO QHS:PRN insomnia 
14. Verapamil SR 120 mg PO Q24H 
15. Elmiron (pentosan polysulfate sodium) 100 mg oral TID 
16. Exalgo ER (HYDROmorphone) 16 mg oral DAILY 
17. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR 
18. NexIUM (esomeprazole magnesium) 40 mg oral DAILY 
19. Sumatriptan Succinate 6 mg SC ONCE:PRN HA 
20. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain 
21. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO TID 
22. Linzess (linaclotide) 290 mcg oral DAILY 
23. PredniSONE 20 mg PO DAILY 

 
Discharge Medications:
1.  Lidocaine 5% Patch 1 PTCH TD QAM 
RX *lidocaine 5 % Apply one patch to lower back Daily Disp #*30 
Patch Refills:*0 
2.  PredniSONE 40 mg PO DAILY 
40 mg daily x 1 week, 30 mg daily x 1 week, 20 mg PO daily x 1 
week then 10 mg PO daily x 1 week. 
Tapered dose - DOWN 
RX *prednisone 10 mg As directed tablet(s) by mouth Daily Disp 
#*70 Tablet Refills:*0 
3.  Albuterol 0.083% Neb Soln 1 NEB IH BID  
4.  ARIPiprazole 5 mg PO DAILY  
5.  BusPIRone 15 mg PO TID  
6.  DULoxetine 120 mg PO DAILY  
7.  Elmiron (pentosan polysulfate sodium) 100 mg oral TID  
8.  Exalgo ER (HYDROmorphone) 16 mg oral DAILY  
9.  Levothyroxine Sodium 125 mcg PO DAILY  
10.  Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR  
11.  Linzess (linaclotide) 290 mcg oral DAILY  
12.  LORazepam 1 mg PO Q4H:PRN anxiety  
13.  Methadone 5 mg PO TID  
14.  NexIUM (esomeprazole magnesium) 40 mg oral DAILY  
15.  Ondansetron 4 mg PO Q8H:PRN nausea  
16.  OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO TID  
17.  Polyethylene Glycol 17 g PO DAILY  
18.  Pregabalin ___ mg PO DAILY  
19.  Ranitidine 300 mg PO QHS  
20.  Sumatriptan Succinate 6 mg SC ONCE:PRN HA  
21.  Tizanidine 2 mg PO TID  
22.  TraZODone 100 mg PO QHS:PRN insomnia  
23.  Verapamil SR 120 mg PO Q24H  
24.  Voltaren (diclofenac sodium) 1 % topical QID:PRN pain  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Acute on chronic back pain
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).
 
Discharge Instructions:
You were admitted with worsening of your chronic back pain.  You 
had a recent MRI of your spine which did not show any 
significant abnormalities.  You were seen by the chronic pain 
service, you were started on a lidocaine patch.  We recommend 
that you follow-up with a pain physician who specializes in your 
Prometra pump.  
 
Followup Instructions:
___

{'Back pain': ['Acute on chronic back pain'], 'Urinary retention': [], 'Const': [], 'HA': ['Migraine headaches'], 'Intermittent palpitations': ['Supraventricular arrhythmia'], 'RUQ pain': ['Other specified diseases of gallbladder'], 'Biliary ductal dilation': ['Other specified diseases of gallbladder'], 'Anxiety': ['Anxiety disorder'], 'Somatization disorder': ['Somatization disorder'], 'Pudendal neuralgia': ['Other specified mononeuropathies'], 'Hypothyroidism': ['Hypothyroidism'], 'Gastro-esophageal reflux disease': ['Gastro-esophageal reflux disease without esophagitis'], 'Presence of other specified functional implants': ['Presence of other specified functional implants']}