subject_id
int64 | _id
int64 | note_id
string | note_type
string | note_subtype
string | text
string | diagnosis_codes
list | diagnosis_code_type
string | diagnosis_code_spans
list | procedure_codes
list | procedure_code_type
string | procedure_code_spans
list | Discharge Disposition:
int64 | Brief Hospital Course:
int64 | Discharge Diagnosis:
int64 | Major Surgical or Invasive Procedure:
int64 | Discharge Condition:
int64 | Past Medical History:
int64 | History of Present Illness:
int64 | Social History:
int64 | Physical Exam:
int64 | Pertinent Results:
int64 | Discharge Instructions:
int64 | Medications on Admission:
int64 | Followup Instructions:
int64 | Family History:
int64 | Discharge Medications:
int64 | DISCHARGE DIAGNOSES:
int64 | PAST MEDICAL HISTORY:
int64 | DISCHARGE MEDICATIONS:
int64 | [**Hospital 93**] MEDICAL CONDITION:
int64 | DISCHARGE DIAGNOSIS:
int64 | MEDICATIONS ON DISCHARGE:
int64 | MEDICATIONS ON ADMISSION:
int64 | Cranial Nerves:
int64 | HOSPITAL COURSE:
int64 | FINAL DIAGNOSIS:
int64 | CARE RECOMMENDATIONS:
int64 | DISCHARGE INSTRUCTIONS:
int64 | PAST SURGICAL HISTORY:
int64 | DISCHARGE LABS:
int64 | Discharge Labs:
int64 | What to report to office:
int64 | Secondary Diagnosis:
int64 | ADMISSION MEDICATIONS:
int64 | DISCHARGE INSTRUCTIONS/FOLLOWUP:
int64 | Review of systems:
int64 | CARE AND RECOMMENDATIONS:
int64 | On Discharge:
int64 | Neurologic examination:
int64 | Discharge labs:
int64 | Secondary Diagnoses:
int64 | On discharge:
int64 | [**Last Name (NamePattern4) 2138**]p Instructions:
int64 | HOSPITAL COURSE BY SYSTEM:
int64 | HOSPITAL COURSE BY SYSTEMS:
int64 | MEDICATIONS AT HOME:
int64 | MEDICATIONS ON TRANSFER:
int64 | Secondary diagnoses:
int64 | Secondary diagnosis:
int64 | TRANSITIONAL ISSUES:
int64 | PATIENT/TEST INFORMATION:
int64 | IMMUNIZATIONS RECOMMENDED:
int64 | -Cranial Nerves:
int64 | Transitional Issues:
int64 | Incision Care:
int64 | Past Surgical History:
int64 | Discharge Exam:
int64 | DISCHARGE EXAM:
int64 | Labs on Discharge:
int64 | REGIONAL LEFT VENTRICULAR WALL MOTION:
int64 | PHYSICAL EXAM:
int64 | Medication changes:
int64 | Physical Therapy:
int64 | Treatments Frequency:
int64 | SECONDARY DIAGNOSES:
int64 | 2. CARDIAC HISTORY:
int64 | HOME MEDICATIONS:
int64 | Chief Complaint:
int64 | FINAL DIAGNOSES:
int64 | DISCHARGE PHYSICAL EXAM:
int64 | ACID FAST CULTURE (Preliminary):
int64 | Wound Care:
int64 | Blood Culture, Routine (Preliminary):
int64 | Discharge exam:
int64 | Neurologic Examination:
int64 | Discharge Physical Exam:
int64 | ACTIVE ISSUES:
int64 | CLINICAL IMPLICATIONS:
int64 | FUNGAL CULTURE (Preliminary):
int64 | FOLLOW UP:
int64 | PREOPERATIVE MEDICATIONS:
int64 | RESPIRATORY CULTURE (Preliminary):
int64 | SUMMARY OF HOSPITAL COURSE:
int64 | Labs on discharge:
int64 | MEDICATIONS PRIOR TO ADMISSION:
int64 | HOSPITAL COURSE BY ISSUE/SYSTEM:
int64 | SECONDARY DIAGNOSIS:
int64 | FOLLOW-UP APPOINTMENTS:
int64 | Cardiac Enzymes:
int64 | OUTPATIENT MEDICATIONS:
int64 | Review of Systems:
int64 | ADMISSION DIAGNOSES:
int64 | MEDICATION CHANGES:
int64 | Blood Culture, Routine (Pending):
int64 | TECHNICAL FACTORS:
int64 | PHYSICAL EXAMINATION:
int64 | [**Last Name (NamePattern4) 4125**]ospital Course:
int64 | ADMISSION DIAGNOSIS:
int64 | Physical Exam on Discharge:
int64 | At discharge:
int64 | RECOMMENDED IMMUNIZATIONS:
int64 | ON DISCHARGE:
int64 | CHRONIC ISSUES:
int64 | Immediately after the operation:
int64 | Transitional issues:
int64 | FOLLOW-UP PLANS:
int64 | Changes to your medications:
int64 | Upon discharge:
int64 | REVIEW OF SYSTEMS:
int64 | CARDIAC ENZYMES:
int64 | Cardiac enzymes:
int64 | Medication Changes:
int64 | [**Location (un) **] Diagnosis:
int64 | ACID FAST CULTURE (Pending):
int64 | Discharge PE:
int64 | General Discharge Instructions:
int64 | INDICATIONS FOR CATHETERIZATION:
int64 | WHEN TO CALL YOUR SURGEON:
int64 | Neurological Exam:
int64 | Exam on Discharge:
int64 | CHIEF COMPLAINT:
int64 | REASON FOR THIS EXAMINATION:
int64 | Relevant Imaging:
int64 | Active Issues:
int64 | [**Location (un) **] Condition:
int64 | RECOMMENDATIONS AFTER DISCHARGE:
int64 | [**Hospital1 **] Disposition:
int64 | TRANSITIONAL CARE ISSUES:
int64 | [**Hospital1 **] Medications:
int64 | [**Location (un) **] Instructions:
int64 | WOUND CULTURE (Preliminary):
int64 | DISCHARGE FOLLOWUP:
int64 | LABS ON DISCHARGE:
int64 | POST CPB:
int64 | URINE CULTURE (Preliminary):
int64 | Review of sytems:
int64 | Labs at discharge:
int64 | Immunizations recommended:
int64 | AEROBIC BOTTLE (Pending):
int64 | -Rehabilitation/ Physical Therapy:
int64 | FOLLOW UP APPOINTMENTS:
int64 | Mental Status:
int64 | Admission labs:
int64 | HOSPITAL COURSE BY PROBLEM:
int64 | [**Hospital 5**] MEDICAL CONDITION:
int64 | PHYSICAL EXAM UPON DISCHARGE:
int64 | WOUND CARE:
int64 | ANAEROBIC BOTTLE (Pending):
int64 | CURRENT MEDICATIONS:
int64 | FOLLOW-UP APPOINTMENT:
int64 | FINAL DISCHARGE DIAGNOSES:
int64 | TRANSFER MEDICATIONS:
int64 | Upon Discharge:
int64 | HISTORY OF PRESENT ILLNESS:
int64 | CRANIAL NERVES:
int64 | CT head:
int64 | Exam on discharge:
int64 | CT Head:
int64 | [**Location (un) **] PHYSICIAN:
int64 | Admission Labs:
int64 | secondary diagnosis:
int64 | Head CT:
int64 | MRA OF THE HEAD:
int64 | INACTIVE ISSUES:
int64 | ADMISSION LABS:
int64 | PROBLEM LIST:
int64 | PRIMARY DIAGNOSIS:
int64 | OTHER PERTINENT LABS:
int64 | PROBLEMS DURING HOSPITAL STAY:
int64 | Medication Instructions:
int64 | IRON AND VITAMIN D SUPPLEMENTATION:
int64 | On admission:
int64 | ANAEROBIC CULTURE (Preliminary):
int64 | MENTAL STATUS:
int64 | ADMITTING DIAGNOSIS:
int64 | TRANSITIONS OF CARE:
int64 | Pertinent Labs:
int64 | 3. OTHER PAST MEDICAL HISTORY:
int64 | # Transitional issues:
int64 | [**Hospital1 **] Diagnosis:
int64 | Chronic Issues:
int64 | FOLLOW-UP INSTRUCTIONS:
int64 | CARE AND RECOMMENDATIONS AT DISCHARGE:
int64 | HOSPITAL COURSE: By systems:
int64 | NEUROLOGIC EXAMINATION:
int64 | Treatment Frequency:
int64 | Neurologic Exam:
int64 | DISCHARGE PLAN:
int64 | Active Diagnoses:
int64 | Medications on transfer:
int64 | Past medical history:
int64 | SOCIAL HISTORY:
int64 | CONDITION ON DISCHARGE:
int64 | FLUID CULTURE (Preliminary):
int64 | Meds on transfer:
int64 | Exam upon discharge:
int64 | Other labs:
int64 | Discharge physical exam:
int64 | [**Hospital1 **] Instructions:
int64 | Imaging Studies:
int64 | Post CPB:
int64 |
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99,231
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Discharge summary
|
Report
|
Admission Date: [**2150-1-10**] Discharge Date: [**2150-1-18**]
Date of Birth: [**2097-6-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Cellcept / Zosyn
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
52 year old female with ESRD on HD with recent admission for VRE
bacteremia, admitted to MICU for sepsis evaluation, transferred
to the floor, readmitted to MICU for afib with RVR, then
transferred to the floor once hemodynamically stable. She
initially presented with fever to 101 after HD on [**1-10**] treated
with 650mg of Tylenol at rehab, rechecked at 101.3, and noted
have some chills by the nurse. She was subsquently sent to the
ED.
.
The patient reports feeling well overall the days prior to
admission. She denies any N/V, cough, shortness of breath, sore
throat, rhinnorhea, or abdominal pain. She reports a good
appetite. She does complain that the rehab was not dosing her
antibiotics appropriately and was only giving her Linezolid once
daily until she corrected them a few days ago.
.
Of note, the patient was recently admitted on [**3-11**] for VRE
Bacteremia and was treated with Linezolid for a planned 4 week
course; she subsequently had her HD lined removed, underwent a
line holiday and then a new line was placed. Also of note, she
has been on Dapsone for PCP prophylaxis as well as Gancyclovir
for CMV viremia.
.
On arrival to the ED, her vitals were: T 99.8 BP 93/60 HR 120
RR22 98%RA. Labs were done which showed WBC 4 with 8% bandemia,
Lactate 4.8. CXR was negative, U/A not done as pt is anuric.
Blood cultures were drawn. EKG showed sinus tachycardia with
flattening laterally. She was given 2L IVF and Vanc/Imipenem for
empiric coverage of an unclear source given her history. A CVL
was offered but the patient refused so an EJ was placed.
.
In the MICU, the patient was started on daptomycin, imipenem
switched to meropenem and vanc continued. Her hypotension
resolved with IVF. She remained afebrile with stable vital
signs.
.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, cough, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- VRE Bacteremia, treated Linezolid
- ESRD due to SLE, s/p cadaveric renal transplant [**8-/2147**]
complicated by FSGS and transplant failure [**7-/2149**], now on HD
- SLE, followed by Dr.[**Last Name (STitle) **] in Rheumatology
- Hypotension (started on midodrine [**11-5**])
- Septic shock [**10/2149**]
- CMV viremia [**10/2149**]
- Acute uncomplicated diverticulitis [**10/2149**]
- hx of C. Diff [**10/2149**]
- Paroxysmal atrial fibrillation
- NSVT
- hx of Hypertension
- Hyperthyroidism
- s/p bilateral knee surgeries and R ACL repair
Social History:
Single, currently at [**Hospital 671**] rehab. Denies tobacco, ETOH, and
drugs.
Family History:
Mother and brother both with diabetes and [**Name (NI) 2091**], both deceased.
Physical Exam:
Vitals - T: 97.7 BP: 125/69 HR: 81 RR: 26 02 sat: 100% RA
GENERAL: Ill appearing female, in NAD
HEENT: O/P Clear, MMM
NECK: No LAD, left tunneled HD line in place, no erythema or
tenderness over area
CARDIAC: RRR, nl S1S3, no m/r/g
LUNG: Clear bilaterally, mild scatered wheezing
ABDOMEN: Soft, NT, ND, +BS
EXT: No clubbing, edema, warm and well pefused, 2+ DP/PT pulses
bilatearlly
NEURO: Alert and oriented x3
Pertinent Results:
==================
ADMISSION LABS
==================
[**2150-1-10**] 07:40PM
WBC-4.0 RBC-2.84* Hgb-7.8* Hct-25.1* MCV-88 MCH-27.4 MCHC-31.0
RDW-18.3* Plt Ct-92*
Neuts-52 Bands-8* Lymphs-30 Monos-8 Eos-0 Baso-0 Atyps-2*
Metas-0 Myelos-0
Hypochr-3+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL
Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
Plt Smr-LOW Plt Ct-92*
Glucose-170* UreaN-10 Creat-3.0*# Na-137 K-4.3 Cl-97 HCO3-24
AnGap-20
CK(CPK)-13*
Calcium-7.6* Phos-1.8*# Mg-1.3*
Glucose-164* Lactate-4.8* Na-137 K-4.2 Cl-96* calHCO3-27
UPRIGHT AP VIEW OF THE CHEST: Left-sided dual-lumen central
venous catheter tip terminates within the mid SVC. The cardiac
silhouette is normal in size. The mediastinal and hilar
contours are within normal limits. The lungs are clear without
focal consolidation. Pulmonary vascularity is normal. No pleural
effusion or pneumothorax is present. The osseous structures are
unremarkable. IMPRESSION: No acute cardiopulmonary abnormality.
==============
EKGs
==============
Cardiology Report ECG Study Date of [**2150-1-10**] 7:14:44 PM
Sinus tachycardia with baseline artifact. Non-specific
anterolateral
ST-T wave changes. Compared to the previous tracing of [**2149-12-27**]
ventricular
premature beats are not seen on the current tracing. Otherwise,
no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
112 138 86 334/425 59 3 144
.
Cardiology Report ECG Study Date of [**2150-1-11**] 1:11:50 AM
Sinus rhythm. Short P-R interval. ST-T wave abnormalities. Since
the previous tracing of [**2150-1-10**] ST-T wave abnormalities are less
prominent at a slower rate.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 148 88 386/435 65 -16 70
.
Cardiology Report ECG Study Date of [**2150-1-12**] 3:16:38 PM
Sinus rhythm. Since the previous tracing baseline artifact is
different. There is probably no significant change in previously
noted findings.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 140 90 414/457 59 -12 62
.
Cardiology Report ECG Study Date of [**2150-1-13**] 5:18:08 AM
Probable atrial fibrillation with rapid ventricular response.
Since the
previous tracing of [**2150-1-12**] atrial fibrillation is new. There is
a single wide complex beat, probably ventricular, which is also
new.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
145 0 84 318/466 0 -10 -142
.
Cardiology Report ECG Study Date of [**2150-1-13**] 8:19:24 AM
Sinus rhythm. Since the previous tracing earlier on [**2150-1-13**],
atrial
fibrillation is no longer present. There is marked Q-T interval
prolongation and there are inferolateral T wave inversions.
Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 160 88 448/472 63 -3 -114
.
Cardiology Report ECG Study Date of [**2150-1-15**] 9:37:40 AM
Sinus tachycardia. Diffuse ST-T wave changes. Cannot rule out
myocardial
ischemia. Compared to the previous tracing of [**2150-1-13**] QTc
interval prolongation has improved. Otherwise, previously
described multiple abnormalities are present.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 148 86 362/433 6 -12 -173
.
Cardiology Report ECG Study Date of [**2150-1-15**] 20:21:24 PM
*After 9 beats of NSVT*
Sinus rythm with PACs. Extensive ST-T changes may be due to
myocardial ischemia. T wave inversion in I, II, aVF, V2-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 118 86 412/450 -17 1 -128
.
Cardiology Report ECG Study Date of [**2150-1-16**] 9:30:44 AM
*At the time, patient was nauseous*
Sinus rythm. Possible LVH. Extensive ST-T changes may be due to
hypertrophy and/or ischemia. T wave inversion in I, II, and aVF;
biphasic T wave in V2, T wave inversion in V3-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
121 160 84 334/[**Medical Record Number 99130**] -154
.
Cardiology Report ECG Study Date of [**2150-1-16**] 17:07:36 PM
*At rest, asymptomatic*
Sinus rythm. Extensive ST-T changes may be due to hypertrophy
and/or ischemia. T wave inversion in I, II, and aVF; biphasic T
wave in V2, T wave inversion in V3-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 152 80 414/449 21 -19 -169
.
Cardiology Report ECG Study Date of [**2150-1-17**] 16:22:36 PM
*During dialysis, asymptomatic*
Possible ectopic atrial rythm. Left ventricular hypertrophy.
Extensive ST-T changes may be due to ventricular hypertrophy. T
wave inversion in I, II, aVF, V2-V6. In V2 T wave inversions are
deep and symmetric.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
98 126 82 380/446 -35 -6 -161
.
Cardiology Report ECG Study Date of [**2150-1-17**] 17:34:12 PM
*Post dialysis, back to floor, asymptomatic*
Sinus rythm. Left ventricular hypertrophy. Extensive ST-T
changes probably due to ventricular hypertrophy. T wave
inversion in I, II, aVF, upright in V2, inverted in V3-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 144 88 398/457 24 -17 -169.
.
Cardiology Report ECG Study Date of [**2150-1-17**] 9:54:46 AM
*Nauseous*
Sinus tachycardia. Left ventricular hypertrophy. Extensive ST-T
changes probably due to hypertrophy and/or ischemia. T wave
inversion in I, II, aVF, upright in V2, inverted in V3-V6.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
106 146 84 424/424 1 -18 -162
.
==================
DISCHARGE LABS
==================
[**2150-1-18**] 06:00AM BLOOD WBC-2.1* RBC-2.50* Hgb-7.1* Hct-23.2*
MCV-93 MCH-28.4 MCHC-30.6* RDW-21.4* Plt Ct-147*
[**2150-1-18**] 06:00AM BLOOD Plt Ct-147*
[**2150-1-18**] 06:00AM BLOOD PT-21.2* PTT-24.9 INR(PT)-2.0*
[**2150-1-18**] 06:00AM BLOOD Glucose-75 UreaN-8 Creat-2.5*# Na-143
K-3.3 Cl-103 HCO3-35* AnGap-8
[**2150-1-18**] 06:00AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.3*
==================
CARDIAC ENZYMES
==================
[**2150-1-10**] 11:24PM BLOOD CK(CPK)-13*
[**2150-1-11**] 05:41AM BLOOD LD(LDH)-443* CK(CPK)-17* TotBili-0.4
DirBili-0.1 IndBili-0.3
[**2150-1-13**] 11:37AM BLOOD CK(CPK)-15*
[**2150-1-13**] 05:23PM BLOOD CK(CPK)-10*
[**2150-1-16**] 03:30AM BLOOD CK(CPK)-47
[**2150-1-16**] 06:40AM BLOOD CK(CPK)-50
[**2150-1-16**] 03:50PM BLOOD CK(CPK)-56
[**2150-1-10**] 11:24PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2150-1-11**] 05:41AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2150-1-13**] 11:37AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2150-1-13**] 05:23PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2150-1-16**] 03:30AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2150-1-16**] 06:40AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2150-1-16**] 03:50PM BLOOD CK-MB-NotDone cTropnT-0.04*
Brief Hospital Course:
52 year old female with ESRD on HD, recent VRE bacteremia, CMV
Viremia, SLE presented with fever and hypotension, developed
Afib with RVR as well as labile t wave inversion, now
hemodynamically stable.
# EARLY SEPSIS: Patient presented with fevers, hyotension,
tachycardia and a lactate of 4.8. In addition, her WBC was 4.0
but with an 8% bandemia. She has had a number of infections
recently in the setting of immunosuppression. The differential
was broad including line infection (new HD line placed on [**12-31**]),
pneumonia (CXR without obvious infiltrate), CMV Viremia (viral
load [**12-29**] negative), UTI, C. Diff (recent infection [**11-5**] but
without any symptoms to suggest this). Patients BP/HR improved
after administration of 2L IVF, and broad coverage with
Meropenem (GN coverage) plus Daptomycin (GP coverage) as well as
PO Vanc, given bandemia. BCx, C.Diff cx, and CMV viral load were
also obtained and were negative. However, after speaking with
ID valganciclovir was restarted. During hospitalization,
antibiotics were narrowed to daptomycin. Patient will need to
complete 4 week course of Daptomycin for VRE bacteremia in
setting of known thrombus that is possibly seeded. She will
receive Daptomycin when she receives HD. The renal team has
arranged for her to get the medication at HD. The last dose will
be on [**2150-1-26**].
.
# T Wave Inversions: Patient's T waves were upright at the time
of admission. She then developed inverted T waves in V3-V6, I,
II, aVF, and intermittently/biphasic in V2 (see attached EKGs
copied from [**Hospital1 18**]), with repeated negative cardiac enzymes. Then
she developed more deeply inverted T waves in V2 that were deep
and symmetrical during HD on [**1-17**] that then turned upright. It
was not clear that the T wave inversions were rate related.
Cardiology was [**Month/Year (2) 4221**]. The ddx included: ischemia,
Takotsubo's, or a cerebral processes, however rapid resolution
of the T waves made the later two less likely. She denied chest
discomfort though she occasionally had nausea. She did not have
any neurological symptoms. Patient has no LVH on prior ECHOs to
invoke repolarization changes. Recommend performing persantine
study to r/o ischemia as an outpatient, not initiated as an
inpatient given difficulty to instigate intervention in this
setting with recent bacteremia and RUE thrombus. In the mean
time, patient is medically managed for coronary artery disease;
she is on aspirin and small dose of beta-blocker. Simvastatin
was added during this admission.
.
# Tachycardia: In addition to atrial fibrillation which is
currently controlled, she had multiple episodes of regular
tachycardia. EKG revealed sinus tach. In terms of the
etiologies of sinus tachycardia, she had evidence of volume
depletion, especially after HD, which likely led to low systolic
blood pressures in the 90s and sinus tachycardia. Sinus
tachycardia invariably improved/resolved after gentle IVF
(250cc-500cc NS). She also experienced nausea during some
episodes of tachycardia, raising the question whether the
tachycardia is due to discomfort. However, after treatment with
zofran and resolution of nausea, her heart rate remained in the
120s, which argues against that theory.
.
# Low Blood Pressure: Patient's baseline systolic blood pressure
is 100s to 110s, though was noted to occasionally be in the 90s,
which responded to small IVF boluses (250-300cc). It was thought
to be secondary to volume shifts and possibly be exacerbated by
autonomic instability. She should continue on Midodrine 10mg
TID.
.
# ESRD on HD s/p failed transplant: Patient was continued on HD
and maintained on Prednisone.
.
# Venous thrombus: Patient was noted to have a complete
thrombosis of the left AV [**Month/Year (2) **], left cephalic vein and left
subclavian vein, and partial thrombosis of left brachiocephalic
vein with extension to SVC on her previous admission. She was
unable to receive a PICC on that side [**12-30**] this thrombus (and not
on the right [**12-30**] presence of fistula). She was maintained on
warfarin with goal [**12-31**] and should continue anticoagulation until
resolution of the thrombus or indefinitely.
.
# CMV viremia: Patient has been treated with valganciclovir.
This was briefly stopped out of concern for myelosuppression but
subsequently restarted per ID. Plan is for her to f/u with
outpatient ID with Dr. [**First Name (STitle) **] on [**2150-1-21**] regarding need to
continue this treatment.
.
# Atrial fibrillation with RVR: On [**1-13**] patient was transferred
to MICU for afib with RVR and hypotension. She was treated with
digoxin load and PRN PO metoprolol. She will continue on digoxin
0.125mg 3/week and metoprolol 12.5 [**Hospital1 **] as an outpatient, with
holding parameters for SBP<95 or HR<55.
.
# Nausea: Patient had repeated bouts of nausea accompanied by
tachycardia in the 120-140 and hypotension that resolved with
ondansetron. This appears to occur after HD and may be related
to volume depletion. She also often gets nausea after eating.
Patient repeatedly denied SOB or chest discomfort. Repeated
cardiac enzymes were negative.
.
# Anticoagulation: Patient should continue on coumadin with goal
INR [**12-31**].
.
# Code status: Full Code
Medications on Admission:
Aspirin 325 mg daily
Pantoprazole 40 mg daily
Prednisone 5 mg Tablet daily
Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,TH).
Midodrine 10mg TID
Linezolid 600 mg [**Hospital1 **] until [**1-19**]
Oxycodone 5 mg q6 prn
Injection q dialysis.
Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous QACHS.
Warfarin 2.5 mg daily
Dapsone 100 mg daily
Zofran 4 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
Atovaquone 1500 daily
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO Q TUES, THURS,
SAT ().
8. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO WED, SAT
().
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 1230**]y (450)
mg Intravenous at dialysis: The last dose on [**2150-1-26**].
11. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
12. Insulin Regular Human 100 unit/mL Cartridge Sig: sliding
scale Injection QACHS.
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
goal INR [**12-31**].
14. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Epoetin Alfa 2,000 unit/mL Solution Sig: at dialysis
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
Primary diagnoses:
Fever
Atrial fibrillation
VRE bacteremia on treatment
.
Secondary diagnoses:
ESRD on HD
SLE
LUE venous thrombus
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
It was a pleasure to be involved in your care, Ms. [**Known lastname 6357**].
You were admitted to [**Hospital1 69**]
because of fever and hypotension. You were then found to have a
type of arrhythmia called "atrial fibrillation with rapid
ventricular response". You were in the medical ICU twice during
this admission. For your fever, we did not find any source of
infection, and your antibiotics was changed from linezolid to
datpomycin because your blood counts went down on linezolid.
You will receive daptomycin on the days of your dialysis, and
you will finish it on [**2150-1-26**]. You were treated for
atrial fibrillation with two medications, digoxin and
metoprolol.
Please note that your medications have been changed:
Please continue daptomycin until [**2150-1-26**]
We have added digoxin
We have added metoprolol
We also added simvastatin
Please continue to take coumadin
Please continue to take valganciclovir until when you are seen
in the infectious disease clinic next week ([**2150-1-21**])
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2150-1-21**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2150-1-30**] 1:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2150-6-18**] 10:00
|
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Discharge summary
|
Report
|
Admission Date: [**2173-8-3**] Discharge Date: [**2173-8-8**]
Date of Birth: [**2114-1-5**] Sex: M
Service: MEDICINE
Allergies:
clindamycin HCl
Attending:[**First Name3 (LF) 23497**]
Chief Complaint:
Weakness and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59M w/pmhx CHF (last EF 55-60%), afib, elevated LFTs, chronic LE
wounds (recent admission for cellulitis on [**6-14**]), hx of PE and
atrial thrombus, presented to clinic today for F/U. Pt had hx of
multiple missed appointments and F/U labs were drawn today.
Reported losing ~20lbs within the past month. Pt appeared
euvolemic and had extensive chronic LE ulcerations (pt was seen
in vascular clinic immediately prior to general medicine
appointment and was started on Keflex).
Referred to ED due to hyponatremia/[**Last Name (un) **] found on labs.
On presentation to the emergency Department the patient reports
that he has had occasional exertional shortness of breath,
reports no symptoms at rest. He denies chest pain at any point.
He reports that due to neuropathy he hasn't felt any pain in his
leg ulcers but notices that they are significantly more
erythematous and draining more fluid. Additionally he reports
that he has not taken any of his A. fib medications for several
days.
In the ED his initial vitals were 98.4 130 90/52 18 100. An EKG
showed afib @ 115, NA, lateral minimal stdep likely demand
related. no STE. He recieved 1L NS and was restarted on his
metorolol and diltiazem. His digoxin was held.
Past Medical History:
CARDIAC HISTORY:
- Afib - noted first during admission [**1-/2171**]; initial TEE CV
aborted due to left atrial thrombus; s/p DCCV [**2171-4-11**].
- Systolic CHF/nonischemic dilated cardiomyopathy - thought due
to tachymyopathy. Recent EF 40% ([**3-/2171**])
- PFO (noted on TEE)
- HTN
Other Past History:
- Pulmonary embolus (noted on CT [**1-/2171**])
- Anxiety
- S/p hernia repair, pt describes complicated course of what
sounds like dehiscence and redo x2 with mesh placement, last in
12/[**2168**].
- Seasonal allergies
Social History:
He is single and lives alone. He worked as a painter at [**Hospital1 **]
[**Location (un) 620**], still out of work. He is a lifetime nonsmoker and
denies illicit drug use. he does drink approximately [**12-28**] bottle
of wine about 3 times weekly and "a few beers" from time to time
with friends.
Family History:
Father: h/o CVA
Mother: h/o heart disease, arrythmia and had a pacer. Deceased
82yo.
Physical Exam:
ADMIT EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, 2+ pulses, no clubbing, s/p DP amutation of left
great toe, venous stasis dermatitis with possible super
infection bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM:
VS: 99.7 112/62 100 18 96% RA
Gen: awake, alert, resting comfortably in chair, NAD
HEENT: sclera anicteric, MMM
CV: RRR
Lungs: CTAB, no wheezes/rales/rhonchi
Abd: bowel sounds present, soft, NT, ND
Ext: bilateral pedal edema, venous stasis changes, legs wrapped
in ACE bandages
Pertinent Results:
IMAGING:
CXR [**2173-8-3**] -
FINDINGS AND IMPRESSION: The lungs are clear. No pleural
effusion, pulmonary
edema or pneumothorax is present. Mild cardiomegaly is
unchanged.
MICRO/PATH:
[**2173-8-3**] BLOOD CULTURES X 2 - no growth to date after 5 days.
ADMIT LABS:
[**2173-8-2**] 04:15PM BLOOD WBC-15.1* RBC-3.29* Hgb-10.5* Hct-30.6*
MCV-93 MCH-31.9 MCHC-34.2 RDW-15.6* Plt Ct-289
[**2173-8-2**] 04:15PM BLOOD Neuts-93* Bands-0 Lymphs-5* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-8-2**] 04:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2173-8-2**] 12:30PM BLOOD PT-15.7* INR(PT)-1.5*
[**2173-8-2**] 04:15PM BLOOD UreaN-60* Creat-3.4*# Na-120* K-4.6
Cl-80* HCO3-24 AnGap-21*
[**2173-8-2**] 04:15PM BLOOD Glucose-102*
[**2173-8-2**] 04:15PM BLOOD ALT-33 AST-36 CK(CPK)-46* AlkPhos-162*
TotBili-0.9
[**2173-8-2**] 04:15PM BLOOD Albumin-3.6 Calcium-9.1 Cholest-141
RELEVANT LABS:
[**2173-8-3**] 12:25AM BLOOD WBC-12.7* RBC-3.08* Hgb-10.0* Hct-28.8*
MCV-94 MCH-32.5* MCHC-34.7 RDW-15.8* Plt Ct-272
[**2173-8-3**] 05:13AM BLOOD WBC-10.7 RBC-2.99* Hgb-10.0* Hct-28.1*
MCV-94 MCH-33.3* MCHC-35.5* RDW-15.7* Plt Ct-224
[**2173-8-3**] 12:25AM BLOOD Neuts-82.3* Lymphs-10.2* Monos-6.3
Eos-0.9 Baso-0.3
[**2173-8-3**] 05:13AM BLOOD Plt Ct-224
[**2173-8-3**] 12:25AM BLOOD Glucose-104* UreaN-58* Creat-3.0* Na-118*
K-4.6 Cl-85* HCO3-20* AnGap-18
[**2173-8-3**] 05:13AM BLOOD Glucose-91 UreaN-55* Creat-2.5* Na-119*
K-4.5 Cl-86* HCO3-24 AnGap-14
[**2173-8-3**] 07:00AM BLOOD Glucose-132* UreaN-58* Creat-2.8* Na-120*
K-4.0 Cl-85* HCO3-22 AnGap-17
[**2173-8-3**] 02:00PM BLOOD Glucose-131* UreaN-55* Creat-2.3* Na-124*
K-4.1 Cl-89* HCO3-23 AnGap-16
[**2173-8-3**] 07:53PM BLOOD Glucose-136* UreaN-52* Creat-2.0* Na-123*
K-5.6* Cl-91* HCO3-22 AnGap-16
[**2173-8-3**] 12:25AM BLOOD ALT-33 AST-35 LD(LDH)-333* AlkPhos-163*
TotBili-0.8
[**2173-8-3**] 05:13AM BLOOD ALT-29 AST-32 LD(LDH)-283* AlkPhos-146*
TotBili-0.9
[**2173-8-3**] 02:00PM BLOOD ALT-25 AST-25 LD(LDH)-265* AlkPhos-137*
TotBili-0.7
[**2173-8-3**] 12:25AM BLOOD proBNP-1588*
[**2173-8-3**] 02:00PM BLOOD proBNP-1666*
[**2173-8-3**] 12:25AM BLOOD ALT-33 AST-35 LD(LDH)-333* AlkPhos-163*
TotBili-0.8
[**2173-8-3**] 05:13AM BLOOD ALT-29 AST-32 LD(LDH)-283* AlkPhos-146*
TotBili-0.9
[**2173-8-3**] 02:00PM BLOOD ALT-25 AST-25 LD(LDH)-265* AlkPhos-137*
TotBili-0.7
[**2173-8-3**] 12:25AM BLOOD proBNP-1588*
[**2173-8-3**] 02:00PM BLOOD proBNP-1666*
[**2173-8-3**] 07:00AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.5*
[**2173-8-3**] 02:00PM BLOOD Albumin-3.2* Calcium-8.0* Phos-3.6 Mg-2.6
[**2173-8-3**] 07:53PM BLOOD Calcium-8.0* Phos-3.6 Mg-2.5
DISCHARGE LABS:
[**2173-8-8**] 06:10AM BLOOD WBC-10.0 RBC-2.65* Hgb-8.4* Hct-25.6*
MCV-97 MCH-31.9 MCHC-33.0 RDW-15.2 Plt Ct-252
[**2173-8-8**] 06:10AM BLOOD Glucose-99 UreaN-16 Creat-0.9 Na-134
K-4.2 Cl-97 HCO3-27 AnGap-14
[**2173-8-8**] 06:10AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.6
[**2173-8-8**] 06:10AM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.4*
Brief Hospital Course:
59 year old male with a past medical history of systolic
congestive heart failure (last EF 55-60%), atrial fibrillation
on coumadin, transaminitis secondary to cirrhosis, chronic lower
extremity stasis dermatitis (recent admission for cellulitis on
[**2173-6-14**]), history of pulmonary embolus and atrial thrombus who
presented from clinic with with a significant hyponatremia,
elevated lactate, and acute kidney injury.
#. HYPONATREMIA: Etiology was likely hypovolemic hyponatremia in
the setting of over-aggressive diuretic use and decreased
dietary intake of sodium. Patient had started dieting, eating
less salt and drinking more water. He presented with
hypotension and tachycardia. Patient also presented with acute
kidney injury, elevated lactate, fractional excretion of sodium
less than 1, low urine sodium, and elevated creatinine and BUN
all suggesting hypovolemic hyponatremia as the etiology. While
in the MICU his sodium was corrected with normal saline and his
urine and serum sodium trended. Once his sodium was trending
upward he was transferred to the medicine floor. His torsemide
was held and then restarted on [**8-7**] on an every other day dosing
schedule, and he should follow up with his PCP for repeat lab
testing.
# HYPOTENSION / TACHYCARDIA - Though initially concerned for
SIRS/sepsis because of leukocytosis on admission, and possible
source of infection being cellulitis from chronic venous stasis
ulcers. CXR, UA, blood cultures were all negative for signs of
infection. He did not have fever of systemic signs of
infection. Initially he met systemic inflammatory response
syndrome criteria with a possible source. He was started on
vancomycin and unasyn empirically. On re-evaluation he remained
afebrile with no constitutional symptoms concerning for sepsis.
His vancomycin and unysin was discontinued and keflex was kept
on per his vascular physicians prescription. Hypotension was
likely a result of extracellular volume depletion in the setting
of overdiuresis and salt restriction as above, with a reactive
tachycardia. Metoprolol, digoxin, and diltiazem were held for
hypotension but restarted as his pressures tolerated them. He
was monitored on telemetry and was not shown to have any atrial
fibrillation with RVR. However, he had asymptomatic sinus
tachycardia to the 130-160s during physical therapy. This was
likely because his home medications were held, and his
tachycardia improved upon restarting digoxin, metoprolol, and
diltiazem at his home doses. Torsemide was restarted on an
every other day dosing schedule.
#. ATRIAL FIBRILLATION: Chronic issue. On coumadin, metoprolol,
diltizem, and digoxin at home. In the MICU, he became mildly
hypotensive (sbp in 90s, not requiring pressors) so his
metoprolol and diltiazem were reduced in dose. Upon trasnfer to
floor, blood pressure was stable after resuming home meidcations
and metoprolol was uptitrates in setting of tachycardia,
particularly with exertion with PT. He should follow up with his
PCP regarding titration of his rate control. His INR was
subtherapeutic, so his warfarin was increased to 6mg. Digoxin
was continued and level was not toxic.
#. Acute kidney injury: Likely prerenal and related to
hypoperfusion in the setting of hypotension. creatinine improved
with holding torsemide and administration of IVF. His creatine
and BUN were trended and his creatine trended downward with IV
fluids.
#. STASIS DERMATITIS WITH POSSIBLE SUPER IMPOSED CELLULITIS:
While in the MICU he did not spike a fever or appear overtly
septic by exam or review of systems. His leukocytosis
normalized. The decision was made to leave him on his outpatient
dose of keflex however pending follow-up with his vascular
physician.
#. CIRRHOSIS: This is a diagnosis that is currently undergoing
outpatient workup. He did not appear hypervolemic and this was
not likely related to the etiology of his hyponatremia. He
denies alcohol abuse and is reportedly planning on undergoing a
liver biopsy to further characterize his liver disease. His
liver function was monitored while in the MICU and remained
stable, and no further management of his possible cirrhosis was
performed.
TRANSITIONAL ISSUES:
-Vascular, renal, and hepatic follow-up.
-Should f/u with PCP regarding torsemide dosing which was
decreased to every other day. He should be evaluated for less
aggressive diuresis if has bump in creatinine.
-He should follow up with his PCP and cardiology regarding
titration of his metoprolol and diltiazem for rate control.
-Warfarin increased to 6mg at discharge as his INR was 1.4
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Month/Year (2) 581**].
1. Warfarin 2 mg PO DAILY16
2. Torsemide 50 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
6. Diltiazem Extended-Release 180 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Cephalexin 500 mg PO Q6H
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
2. Digoxin 0.125 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
5. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
6. Torsemide 20 mg PO EVERY OTHER DAY
please hold for SBP <100
RX *Demadex 20 mg 1 tablet(s) by mouth every other day Disp #*15
Tablet Refills:*0
7. Warfarin 6 mg PO DAILY16
8. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Diltiazem Extended-Release 180 mg PO DAILY
10. Outpatient Lab Work
Please check INR [**2173-8-9**] and send results to [**Company 191**] [**Hospital 3052**]. Phone [**Telephone/Fax (1) 2173**].
Discharge Disposition:
Home With Service
Facility:
Allcare VNA
Discharge Diagnosis:
Primary: Hyponatremia, acute kidney injury
Secondary: Atrial fibrillation, chronic systolic congestive
heart failure
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:
Dear Mr. [**Known lastname 10840**],
You were treated at [**Hospital1 18**] for low sodium and decreased kidney
function. Your low sodium and decreased kidney function were
likely caused by a combination of not eating and drinking as
much as you used to, as well as your torsemide diuretic. As we
gave you fluid and discontinued your torsemide, your sodium
level improved. Please restart your torsemide, but at a lower
dose. Take 20 mg every other day until you see your
cardiologist and primary care doctor. You should take your next
dose on Monday [**2173-8-9**].
Your kidney function also improved with IV fluids, and is now
normal.
Please have your INR checked on Tuesday [**2173-8-10**]. You may need
adjustment in your coumadin dose. For now, you should take 6 mg
per day as your INR is low.
Please keep the appointments listed below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2173-8-13**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2173-9-13**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20205**], MD [**Telephone/Fax (1) 20206**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2173-8-18**] at 1:30 PM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] in the [**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Notes: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Completed by:[**2173-8-8**]
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[
[]
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96,381
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39335
|
Discharge summary
|
Report
|
Admission Date: [**2120-1-11**] Discharge Date: [**2120-1-14**]
Date of Birth: [**2054-4-29**] Sex: F
Service: NEUROSURGERY
Allergies:
Keflex / Azithromycin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
She experienced difficulty seeing her left side. She also had
vertigo, seeing colored lights in periphery of her visual field.
She experienced headaches at the left occipital region, and it
woke her at night. She had nausea, dry heaves, and decreased
dexerity with impaired ability to open pill bottle with her left
hand. She also had tinnitus in her right ear.
Major Surgical or Invasive Procedure:
[**2120-1-11**] Suboccipital craniotomy for tumor resection
History of Present Illness:
[**First Name9 (NamePattern2) 86978**] [**Known lastname 86979**] is a 65-year-old right-handed woman, with
history
of non-small cell lung cancer. Her neurological problem began in
the summer of [**2119**] when she experienced difficulty seeing her
left side. She also had
vertigo, seeing colored lights in periphery of her visual field.
She experienced headaches at the left occipital region, and it
woke her at night. She had nausea, dry heaves, and decreased
dexerity with impaired ability to open pill bottle with her left
hand. She also had tinnitus in her right ear. She initially
blamed the symptoms on her diabetes but an MRI of the brain
showed a left occipital brain mass with surrounding edema. She
was started on dexamethasone 4 mg 3 times daily and her headache
disappeared. She was referred to the BTC for evalaution and was
seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
Past Medical History:
Past Medical History: She has a history of type II diabetes
(diagnosed 2 years ago), hypertension, coronary artery disease,
and COPD. She does not have hypercholesterolemia.
Past Surgical History: She had CABG x 1 on [**2118-7-2**],
hysterectomy for fibroids, cholecystectomy, carpal tunnel
surgeries in both hands, and bladder distension surgery.
Social History:
She works in retail sales. She smoked 1.5 packs
of cigarettes per day for 30 years; she stopped smoking since
[**2102**]. She does not drink alcohol or use illicit drugs.
Family History:
She is adopted and she does not know the
biological or medical histories of her parents or siblings. She
has 1 daughter and 3 sons; they are all healthy.
Physical Exam:
PRE OP EXAM:
Temperature is 97.8 F. Her blood pressure
is 142/60. Heart rate is 60. Respiratory rate is 16. Her skin
has full turgor. HEENT examination is unremarkable. Neck is
supple and there is no bruit or lymphadenopathy. Cardiac
examination reveals regular rate and rhythms. Her lungs are
clear. Her abdomen is soft with good bowel sounds. Her
extremities do not show clubbing, cyanosis, or edema.
Neurological Examination: Her Karnofsky Performance Score is
90.
She is awake, alert, and oriented times 3. There is no
right-left confusion or finger agnosia. Calculation is intact.
Her language is fluent with good comprehension, naming, and
repetition. Her recent recall is good. Cranial Nerve
Examination: Her pupils are equal and reactive to light, 4 mm
to
2 mm bilaterally. Extraocular movements are full. Visual
fields
are full to confrontation. Funduscopic examination reveals
sharp
disks margins bilaterally. Her face is symmetric. Facial
sensation is intact bilaterally. Her hearing is intact
bilaterally. Her tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: She does not have a drift. Her muscle
strengths are [**6-7**] at all muscle groups. Her muscle tone is
normal. Her reflexes are 2- and symmetric bilaterally. Her
ankle jerks are 2-. Her toes are down going. Sensory
examination is intact to touch and proprioception. Coordination
examination does not reveal dysmetria. Her gait is normal. She
can do tandem gait. She does not have a Romberg.
Exam on the day of discharge: [**2120-1-14**] neurologically intact, no
field cut apprieciated on exam. patient is independently
ambulating in the halls, alert, oriented to person, place and
time. strength is full, sensation is full. no pronator drift
noted. occipital incision clean dry and intact sutures closing
the wound. perrl, pupils 5-3mm bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2120-1-11**] 08:38PM WBC-12.6* RBC-4.61 HGB-12.2 HCT-38.2 MCV-83
MCH-26.4* MCHC-31.9 RDW-18.5*
[**2120-1-11**] 08:38PM GLUCOSE-187* UREA N-33* CREAT-1.0 SODIUM-133
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-24 ANION GAP-19
[**2120-1-11**] 08:38PM CALCIUM-7.9* PHOSPHATE-5.1* MAGNESIUM-1.8
dISCHARGE LABS: na 140, GLUCOSE 120, wbc 12.5, PLATLETS 266, hgb
12.4, HCT 39.3, pt 10.1, ptt 19.7, inr .8
IMAGING:
CT Head [**1-11**]: Interval occipital mass resection with
pneumocephalus, but no hemorrhage or midline shift
MR HEAD W/ CONTRAST Study Date of [**2120-1-11**] 6:47 AM
[**Last Name (LF) **],[**First Name3 (LF) **] M. OPT [**2120-1-11**] 6:47 AM
MR HEAD W/ CONTRAST Clip # [**Clip Number (Radiology) 86980**]
Final Report
INDICATION: Left occipital mass.
COMPARISON: [**2119-12-29**] MRI brain from [**Hospital3 3583**] and
scanned into our
PACS system for review.
FINDINGS: The right occipital lobe mass is similar in size to
the [**2119-11-28**] MRI, measuring today 24 x 27 x 26 mm (AP x ML x
SI). The mass has a thick rind of enhancement and a T1
hypointense center.
The adjacent edema has decreased slightly, with slight interval
expansion of the occipital [**Doctor Last Name 534**] and atrium of the left lateral
ventricle and better
definition of adjacent sulci. No new lesions are seen. Major
intracranial
vessels are patent.
IMPRESSION: Left occipital lobe mass, necrotic-appearing. This
can represent a metastasis from the patient's lung cancer or a
primary neoplasm. There has been slight interval decrease in the
adjacent vasogenic edema and slight interval decrease in mass
effect. Study for surgical planning.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2120-1-13**]
5:40 PM
[**Last Name (LF) **],[**First Name3 (LF) **] M. NSURG FA11 [**2120-1-13**] 5:40 PM
MR HEAD W & W/O CONTRAST PRELIMINARY RADIOLOGY REPORT 1.
Post-surgical changes in the left occipital surgical resection
cavity, with small areas of linear nodular enhancement within,
which may relate to post-surgical changes/residual tumor or a
combination of both.
2. Areas of decreased diffusion in the periphery of the left
occipital lobe posteriorly and medially, may relate to acute
infarction. Consider followup to assess interval change.
Persistent surrounding vasogenic edema and partial effacement of
the atrium of the left lateral ventricle and the left occipital
[**Doctor Last Name 534**]. Other details as above.
Brief Hospital Course:
Patient presented electively for suboccipital craniotomy for
resection of tumor on [**2120-1-11**]. It was an uncomplicated
procedure, and she was admitted to the ICU for Q1 neurochecks
and Dexamethasone. She had no issues overnight and her pain was
well controlled.
On [**2120-1-12**], the morning of POD #1 she felt well and she had no
acute issues. SHe was transferred out of the ICU to the floor.
She experienced a severe headache and her pain medications were
changed with good post operative pain relief. On exam the
patient ws stable with right field cut noted. A decadron taper
was written.
On [**1-13**], the patient ws seen by physical therapy. She was
noted to ambulate independently but had higher level balance
issues requiring home physical therapy. The patient had her post
operative MRI of the brain which was reviwed by Dr [**Last Name (STitle) **] and
consistent with expected post operative change.
On [**2120-1-14**], the patient was tolerating a regular diet,
ambulating in the halls independently. The patient had not had a
post operative bowel movement but was passing flatus and has
baseline constipation. On exam, a visual field cut was no
apprieciated and the patients strength and sensation was full.
Pupils were equal and reactive bilaterally. The surgical
incision was clean dry and intact. The patient was instructed
to begin her Metformin on [**1-15**] hours after her last MRI of
the Brain. She was also instructed to resume her home dosing of
Humalog insulin. The patient will follow up in Brain [**Hospital 341**]
Clinic and with Opthomology. The patient's husband was at her
bedside and the patient was looking forward to her discharge
home.
Medications on Admission:
Metformin (held [**3-7**] contrast ). paroxetine, decadron, albuterol,
ativan, protonix, albuterol, asa 81mg
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
Disp:*60 Tablet(s)* Refills:*1*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
Wheezing, SOB.
5. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 1 days: start [**2120-1-14**].
Disp:*4 Tablet(s)* Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety: hold for lethargy.
Disp:*30 Tablet(s)* Refills:*0*
9. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*2*
10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every 4-6 hours as needed for pain: do not exceed
4 grams tylenol in 24 hours.
Disp:*50 Tablet(s)* Refills:*0*
11. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 12H
(Every 12 Hours): start this dose [**2120-1-15**].
Disp:*40 Tablet(s)* Refills:*1*
12. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for muscle spasm for 2 weeks: hold for lethargy-
do not drive while on this medication.
Disp:*20 Tablet(s)* Refills:*0*
13. humalog
please resume your home dose of humalog per your primary care
physician. [**Name10 (NameIs) 357**] continue to check finger sticks 4 times a day
and prior to bed as directed by your primary care physician.
Discharge Disposition:
Home With Service
Facility:
VNA [**Hospital3 **] inc
Discharge Diagnosis:
occipital mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
You may resume Aspirin one week following your surgery
Please restart your home dose of Metformin on [**2120-1-15**]
(48 hours after your MRI that was performedin the hospital)
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**8-12**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**1-29**] at 9:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain
You may resume Aspirin one week following your surgery
Please restart your home dose of Metformin on [**2120-1-15**] (48 hours
after your MRI that was performed in the hospital which was
performed at 6pm [**1-13**])
You will need formal visual field testing performed
with Opthomology before you will be able to drive. This should
be performed in the next 6 weeks. The office number to call for
an appointment is Office Phone:([**Telephone/Fax (1) 5120**],Office Fax:([**Telephone/Fax (1) 22009**]
Office Location:E/TCC-5, [**Location (un) 86**], [**Numeric Identifier 718**]
You may resume your home dose of humalog insulin as
prescribed by your primary care physician.
Completed by:[**2120-1-14**]
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icd9pcs
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90,427
| 141,751
|
22980
|
Discharge summary
|
Report
|
Admission Date: [**2130-1-21**] Discharge Date: [**2130-1-25**]
Date of Birth: [**2083-8-19**] Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Petechial rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 59319**] is a 46F with a history of mild asthma, obesity,
hypertension and chronic lower back pain who presents with a
petechial rash to body (starting on right hand, also noticed
spread to forehead) and tongue since yesterday. She also had
some bloody mucous with blowing her nose, but no gross
epistaxis. She went to her PCP's office this morning, where she
was seen in urgent care by [**Name8 (MD) **] NP; bloodwork there was notable
for platelets of zero and ESR of 36. She was therefore referred
into [**Hospital1 18**] for further evaluation.
She reports use of hydrocodone x 1 dose for musculoskeletal pain
about a week prior to presentation. Otherwise, she denies any
recent medication changes or over-the-counter/herbal
medications, including no other pain medications or antibiotics.
(There is a prescription for ophthalmic erythromycin ointment in
[**Hospital1 **] records from the end of [**Month (only) 404**], but patient
states she never filled this prescription as it was not needed.)
In the ED, initial VS were: T 99.3, HR 63, BP 143/90, RR 16, O2
sat 100% on RA. Hematology was contact[**Name (NI) **] and recommended 100 mg
PO prednisone and 1 unit platelets. While in the ED, patient
developed a headache and was sent for head CT to rule out bleed
(negative preliminarily for bleed). Hematology recommended
frequent neuro checks overnight given the hemorrhagic bullae in
the mouth (sometimes associated with intracranial bleed), which
is the reason for ICU admission. Vitals on transfer were T98.7,
HR 62, RR 16, BP 123/76, 98% on RA.
.
On arrival to the MICU, she reports that her headache has
resolved. She feels dehydrated due to nothing to drink since
11AM, and also hungry. Otherwise, no complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Has felt fatigue recently, but she has attributed this to
stress over her divorce. Denies sinus tenderness, rhinorrhea or
congestion though endorses sore throat for about 2 weeks which
she has attributed to "allergies." Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
- Morbid obesity
- Asthma (not on medication)
- Essential hypertension
- Chronic lower back pain following fall in [**2117**] (fell from a
fire escape that gave way; had two herniated disks, sacral
fracture, abdominal hematoma which required "panniculectomy" to
treat; chronic bursitis in hip and chronic pain are
consequences, though not on pain medication)
- History of abnormal LFTs (currently WNL)
- Impaired fasting glucose
- Rapid weight loss followed by weight re-gain a few years ago
- Domestic abuse by ex-husband
- [**Name (NI) **] apnea requiring CPAP
- "Arrhythmia" for which she takes atenolol (? PVCs per Atrius
records, unable to locate Holter study from [**2126**])
- "Water weight" problems (no known heart problems)
- Peripheral neuropathy in feet/hands of unclear etiology (has
been told related to swelling, B12 deficiency, carpal tunnel in
hands)
- PTSD related to her fall as well as to history of abuse by her
husband and other instances of high stress (son sick as a child)
Surgical history:
- Panniculectomy x 2
- Lipectomy (complicated by infection requiring two subsequent
procedures)
- C-sections x 2
Social History:
Currently lives with 7-year old daughter and periodically hosts
[**Name (NI) **] exchange students. 20-year old son lives with her part-time.
She has been engaged in an expensive and drawn out custody
battle with her ex-husband for the past two and a half years,
whom she says has been physically abusive toward her and has
also threatened to kill her. Currently, she is in a
"quasi-relationship" with a male partner, with whom she is
sexually active by oral/anal sex (no vagnial sex). Significant
social stress related to interactions with her ex-husband.
- Tobacco: Never-smoker
- Alcohol: None
- Illicits: None
Family History:
Father with diabetes and hypertension; mother with hypertension
and reduced EF, paternal grandfather and great uncles with CAD.
Brother has [**Name (NI) 13808**] (carrier for hemochromatosis) and has had
bleeding/coagulopathy. No known FH of autoimmune disease or ITP.
Physical Exam:
On admission:
General: Alert, oriented, no acute distress. Periodically
tearful during interview.
Skin: Scattered petechiae over face, arms, legs, upper torso.
Ecchymoses on right arm at site of forearm BP cuff.
HEENT: Sclera anicteric, no conjunctival hemorrhage, MMM, EOMI,
PERRL. Hemorrhagic bullae on top center of tongue, under tongue,
left buccal mucosa.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, distant S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft/obese, non-tender, non-distended, bowel sounds
present, no clear organomegaly but difficult to palpate given
body habitus
GU: no foley
Ext: warm, well perfused, minimal LE edema but significant
adipose tissue on lower extremities
Neuro: No focal deficits appreciated; patient upset due to
stress/PTSD and unable to cooperate with full exam at this time
Pertinent Results:
Labs at [**Hospital1 **] [**2130-1-21**]:
- Antistreptolysin O titer (pending at time of admission)
- Smear from [**Hospital1 **] notable for zero platelets seen
- Chem-7, liver panel all WNL (except for glucose 111)
- Coags WNL
- CBC 6.5/13.8/41/0, normal differential
- ESR 36
Labs on admission to [**Hospital1 18**]:
[**2130-1-21**] 01:20PM GLUCOSE-89 UREA N-13 CREAT-0.8 SODIUM-142
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-24 ANION GAP-20
[**2130-1-21**] 01:20PM ALT(SGPT)-29 AST(SGOT)-28 LD(LDH)-255* ALK
PHOS-56 TOT BILI-0.4
[**2130-1-21**] 01:20PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.6
MAGNESIUM-1.8
[**2130-1-21**] 01:20PM WBC-7.3 RBC-4.57 HGB-14.4 HCT-40.1 MCV-88
MCH-31.4 MCHC-35.9* RDW-13.0
[**2130-1-21**] 01:20PM NEUTS-58.4 LYMPHS-33.3 MONOS-4.8 EOS-2.1
BASOS-1.4
[**2130-1-21**] 01:20PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2130-1-21**] 01:20PM PLT COUNT-5*
[**2130-1-21**] 01:20PM PT-11.6 PTT-31.6 INR(PT)-1.1
Microbiology:
- EBV IgM
- EBV IgG
- HIV 1&2 antibody:
Imaging:
CT HEAD W/O CONTRAST [**2130-1-21**]: No evidence of acute intracranial
process. No definite evidence of intracranial hemorrhage.
Brief Hospital Course:
46 yo F with morbid obesity and hypertension who presented with
petechial rash, found to have platelets of 0. Assumed to be ITP
and started on steroids.
ACTIVE ISSUES:
# THROMBOCYTOPENIA: Platelet count on admission was markedly
abnormal at 5, which explains the patient's petechial rash. She
is not known to have any chronic condition associated with low
platelets and has no history of similar symptoms. Differential
is broad and includes ITP, TTP, and pregnancy-related,
drug-induced, and viral causes (no history to support
genetic/congenital conditions). Serum hCG is negative which
rules out gestational cause. She had not used medications
(heparin, sulfonamides) commonly known to cause drug-induced
thrombocytopenia. Smear was negative for schistocytes, making
TTP unlikely. HCV, H pylori, EBV and HIV serologies were sent
and returned negative for acute infection. Given the absence of
other suggestive cause, the most likely etiology for the
patient's presentation was felt to be ITP. She was evaluated by
the hematology service, who recommended treatment with high-dose
prednisone (initial dose of 100 mg PO daily was increased to 150
mg PO daily given patient's body weight of ~375lbs and desire to
avoid use of IVIg, which could be dangerous in this patient if
used according to weight-based dosing guidelines). Given oral
lesions which are associated with intracranial hemorrhage, she
was admitted to the MICU for close monitoring overnight. A head
CT was done and read as negative for acute bleed. She received a
partial platelet transfusion on admission (stopped due to
development of hives as below). Further platelet transfusions
were not required. Platelet count trended up to 68 on
discharge. She was discharged on prednisone 150mg daily with
followup with heme.
# ALLERGIC REACTION: Patient began receiving a platelet
transfusion on arrival to ICU. About 10 minutes into the
transfusion, she developed hives on face, a "heavy" sensation in
her chest and subjective SOB (had normal RR, no wheezing, no
desaturation, no evidence of angioedema or stridor). The
transfusion was discontinued, and she received 50 mg of IV
diphenhydramine and 20 mg of IV famotidine. She became very
emotional (crying) and stated that this response reminded her of
a scary experience with her son's breathing when he was young
and that it had triggered her PTSD. After approximately 20-30
minutes hives began to resolve, and resolution was cmoplete by
one hour. She never developed objective evidence of respiratory
compromise. Emotional response was aided by one dose of IV
lorazepam, supportive listening by staff, and speaking with her
family on the phone.
# PTSD/ANXIETY/SOCIAL STRESS: Patient was very tearful when she
developed hives. She reported flashbacks to when her son was ill
at [**Hospital3 1810**] years ago. She also was very concerned
about her on-going custody battle with her ex-husband and his
potential to use her hospitalization to claim custody of their
7-year old daughter. She received one dose of IV lorazepam
overnight on the night of admission, and was seen by social work
consult the following day. Required PO ativan as needed.
INACTIVE ISSUES:
# HYPERTENSION: The patient was generally normotensive with SBPs
ranging ~115-140 off of medication. Her home antihypertensives
were held on admission at the recommendation of hematology
(though chlorthalidone, lisinopril and atenolol have not been
commonly associated with thrombocytopenia, there have been case
reports of low platelets with chlorthalidone and captopril),
with a plan to restart one medication at a time once platelets
become stable.
# "ARRHYTHMIA": Patient reported a history of "arrhythmia" on
admission which she states is the reason she uses the atenolol.
The "arrhythmia" seems most likely due to palpitations from PVCs
based on limited documentation in [**Hospital1 **] primary care
and cardiology notes. She was monitored on telemetry in the ICU
and other than sinus bradycardia to the 50s with sleep, no
arrhythmias were noted. She remained asymptomatic.
# OSA: Patient reported using CPAP at home but did not know her
settings. She was seen by the respiratory therapist who selected
settings that resulted in good-quality sleep in-house per
patient report. She required continuous O2 monitoring per
hospital protocol, although she eventually requestd it be
removed.
Medications on Admission:
- Atenolol 25 mg PO daily
- Chlorthalidone 25 mg PO daily
- Lisinopril 20 mg PO daily
- Cholecalciferol, Vitamin D3 2,000 unit PO daily (when
remembers)
- Vitamin B12 PO daily (when remembers)
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. calcium carbonate 400 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*0*
6. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
7. prednisone 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Immune Thrombocytopenic Purpura
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 59319**],
You were admitted to [**Hospital1 18**] with low platelets that were thought
to be due to a condition called Immune Thrombocytopenic Purpura.
You were given steroids which have increased your platelet
numbers. You will need to continue these steroids until the
hematologist asks you to taper them.
Medication Changes
Please START prednisone 150mg daily (until tapered by your
doctor)
Please START bactrim 1 DS tab daily for pneumonia prophylaxis
Please START famotidine 20mg daily for ulcer prophylaxis
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Location (un) 2274**] [**Location 1268**], Internal Medicine
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1701**]
Appt: [**2-3**] at 10:40am
Name: [**Last Name (LF) 349**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: [**Location (un) 2274**] [**Location (un) **], Oncology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
Appt: [**1-30**] at 3:30pm
|
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"309.81",
"300.00",
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"327.23",
"287.31"
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icd9cm
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[] |
icd9pcs
|
[
[
[]
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] | 7
| 155
| 0
| 7
| 1
| 0
| 0
| 0
| 0
| 1,234
| 0
| 0
| 586
| 272
| 0
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| 196
| 0
| 0
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| 0
| 0
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| 17
| 0
| 0
| 2,997
| 0
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| 0
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| 1,752
| 0
| 0
| 0
| 0
| 0
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| 0
| 0
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| 1,198
| 0
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94,125
| 187,893
|
30125
|
Discharge summary
|
Report
|
Admission Date: [**2188-7-16**] Discharge Date: [**2188-8-21**]
Date of Birth: [**2114-9-29**] Sex: F
Service: SURGERY
Allergies:
Pravachol / Lisinopril
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic Head Mass
Major Surgical or Invasive Procedure:
1. Classical Whipple resection.
2. Open cholecystectomy.
3. Incisional hernia repair (separate procedure).
.
4. Percutaneous tracheostomy placement
.
PICC
Dobhoff Feeding tube
History of Present Illness:
This is a 73 year old female with pancreatic head mass, which is
newly identified incidentally. She came alone to the clinic
today after having seen Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from our oncology
group just yesterday.
Basically, she was getting a workup for dysphasia. She was
asymptomatic otherwise. The workup led ultimately to
identification of a mass in the head of the pancreas. She has
had no weight loss and no steatorrhea. She has no evidence of
diabetes. She had an ultrasound-guided biopsy performed by
endoscopic ultrasound technique and this has shown cells
suspicious for adenocarcinoma.
Her only GI procedures of late has been the endoscopic
ultrasound performed on the [**2188-7-4**] and this showed biopsy
proven adenocarcinoma. She has not been jaundiced and she has
not required stenting.
Past Medical History:
PMH: HTN, hlipid, tics&polyps, breast ca [**2158**] s/p L mast,
osteopenia, panc cyst, esophagitis, hypothyroidism, colitis s/p
partial colectomy, arthritis, urin incont
PSH: L mast, hysterect, herniorrhaphy w mesh infxn and removal,
partial colectomy.
Social History:
Retired Teacher
Lives alone
Physical Exam:
98.7/98.7 57 96/47 19 93% on trach mask 50%
f.s. 117-181
Gen: NAD, comfortable
HEENT: PERRL, NCAT
Heart: sinus, no murmur
Chest: crackles bilat, symmetric bs
Abd: soft, NTND, JP in place
ext: min. edema, 2+ pulses throughout
Pertinent Results:
[**2188-7-16**] 07:06PM BLOOD WBC-9.9 RBC-3.67* Hgb-10.6* Hct-30.5*
MCV-83 MCH-29.0 MCHC-34.9 RDW-14.5 Plt Ct-234
[**2188-7-27**] 03:24AM BLOOD WBC-12.4* RBC-3.22* Hgb-9.2* Hct-26.5*
MCV-82 MCH-28.5 MCHC-34.6 RDW-14.0 Plt Ct-374
[**2188-8-21**] 04:25AM BLOOD WBC-12.7* RBC-3.14* Hgb-8.7* Hct-26.6*
MCV-85 MCH-27.5 MCHC-32.6 RDW-15.7* Plt Ct-376
[**2188-8-19**] 06:42AM BLOOD Glucose-125* UreaN-25* Creat-0.8 Na-139
K-3.8 Cl-98 HCO3-31 AnGap-14
[**2188-8-1**] 03:48PM BLOOD ALT-38 AST-34 LD(LDH)-181 CK(CPK)-29
AlkPhos-163* Amylase-19 TotBili-0.4
[**2188-8-1**] 03:48PM BLOOD Lipase-25
[**2188-8-13**] 05:29AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2188-8-19**] 06:42AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.1
.
Micro:
Date 6 Specimen Tests Ordered By
All [**2188-7-20**] [**2188-7-21**] [**2188-7-23**] [**2188-7-28**] [**2188-7-31**]
[**2188-8-3**] [**2188-8-6**] [**2188-8-8**] [**2188-8-11**] [**2188-8-12**]
[**2188-8-19**] [**2188-8-20**] All BLOOD CULTURE BRONCHOALVEOLAR LAVAGE
CATHETER TIP-IV MRSA SCREEN PERITONEAL FLUID SPUTUM STOOL SWAB
URINE All INPATIENT
[**2188-8-20**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2188-8-19**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY {PSEUDOMONAS AERUGINOSA}; ANAEROBIC
CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY INPATIENT
[**2188-8-12**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2188-8-11**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {GRAM NEGATIVE ROD(S)}; FUNGAL CULTURE-PRELIMINARY
INPATIENT
[**2188-8-11**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2188-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-8**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}; FUNGAL
CULTURE-PRELIMINARY INPATIENT
[**2188-8-8**] URINE URINE CULTURE-FINAL INPATIENT
[**2188-8-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA} INPATIENT
[**2188-8-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-8-3**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA}
INPATIENT
[**2188-8-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2188-7-31**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2188-7-31**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
[**2188-7-28**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
{ENTEROCOCCUS SP.} INPATIENT
[**2188-7-23**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {ESCHERICHIA COLI, STAPH AUREUS COAG +}; ANAEROBIC
CULTURE-FINAL INPATIENT
[**2188-7-21**] URINE URINE CULTURE-FINAL INPATIENT
[**2188-7-21**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2188-7-21**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
INPATIENT
[**2188-7-21**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2188-7-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +} INPATIENT
[**2188-7-20**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
.
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos
[**2188-8-19**] 03:14AM [**Numeric Identifier 71804**]* 13* 92* 8* 0 Import Result
ASCITES CHEMISTRY Glucose Amylase
[**2188-8-19**] 12:16PM [**Numeric Identifier 71805**] Import Result
[**2188-8-19**] 03:14AM 207 Import Result
[**2188-7-21**] 11:00AM [**Numeric Identifier **] Import Result
OTHER BODY FLUID CHEMISTRY Amylase
[**2188-8-1**] 10:46AM 1652 Import Result
.
SPECIMEN SUBMITTED: fs pancreatic neck margin, gall bladder,
Jejunum, whipple specimen.
Procedure date Tissue received Report Date Diagnosed
by
[**2188-7-16**] [**2188-7-16**] [**2188-7-21**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl
DIAGNOSIS:
I. Gallbladder (A-B):
1. Chronic cholecystitis, mild.
2. Cholelithiasis, cholesterol-type.
II. Jejunum (C-D):
Within normal limits.
III. Pancreatic neck margin (E):
1. Tiny focus of pancreatic intraepithelial neoplasm, low grade
(PanIN I).
2. No invasive carcinoma.
IV. Whipple (F-AR):
1. Adenocarcinoma of the pancreas, see synoptic report.
2. Multiple foci of pancreatic intraepithelial neoplasm, low
grade (PanIN I-II), including the uncinate area.
3. Segments of stomach, duodenum, and bile duct; No tumor.
Pancreas (Exocrine): Resection Synopsis
MACROSCOPIC
Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy.
Tumor Site: Pancreatic head.
Tumor Size
Greatest dimension: 2.0 cm. Additional dimensions: 2.0
cm.
Other organs/Tissues Received: Gallbladder, Jejunum.
MICROSCOPIC
Histologic Type: Ductal adenocarcinoma.
Histologic Grade: G2: Moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric artery.
Regional Lymph Nodes: pN1a: Metastasis in single regional
lymph node (see comment).
Lymph Nodes
Number examined: 31.
Number involved: 2.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Margins uninvolved by invasive carcinoma:
Distance from closest margin: 1.7 cm. Specified
margin: Pancreatic neck.
Venous/Lymphatic vessel invasion: Absent.
Perineural invasion: Present.
Additional Pathologic Findings: Pancreatic intraepithelial
neoplasia -- highest grade: PanIN: 2.
Comments: The tumor extends focally into the peripancreatic
adipose tissue. One of the lymph nodes involved with tumor is
due to contiguous spread.
Clinical: Pancreatic cancer.
.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2188-7-18**] 1:38 PM
IMPRESSION:
1. Negative examination for pulmonary embolism.
2. Bibasilar consolidations, probably corresponding to
atelectasis, but
infection/aspiration cannot be excluded. Suggest followup.
Minimal pleural
effusion.
3. Endotracheal tube end impinges lateral anterior wall of the
trachea.
Suggest reposition.
4. Coronary calcifications.
5. Enlarged heart size, especially left ventricle.
6. Unchanged appearance of the liver hypodense lesion, likely
cyst.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-7-20**] 4:46
AM
Final Report
REASON FOR EXAM: Intubated patient, post-Whipple.
Comparison is made with prior study performed the day earlier.
There have
been no interval changes. ET tube is in standard position. Right
IJ catheter
tip is in the SVC. Small bilateral pleural effusions, greater in
the left
side with associated atelectasis and atelectasis in the right
upper lobe are
unchanged as does cardiomegaly and prominent pulmonary arteries.
There is no
CHF or new lung abnormalities. NG tube tip is out of view below
the
diaphragm.
.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
IMPRESSION: Suboptimal image quality. LVH with preserved
regional and global function. The RV is not well seen but may be
dilated with depressed systolic function. Mild pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of [**2187-7-6**],
the right ventricle appears to be dilated with depressed
function on the current study. Mild pulmonary artery systolic
hypertension is now seen. The other findings are similar.
.
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2188-7-22**]
11:50 AM
IMPRESSION:
1. Patient is status post classic Whipple procedure. There is a
hypodense
area adjacent to the pancreaticojejunostomy that cannot be
evaluated well
without oral contrast. The hypodense area appears to be a
jejunal loop;
however, hematoma or postoperative collection cannot be
excluded.
2. Multiple hypodense liver lesions in both lobes of the liver,
one in
segment II appears to be new. Attention will be paid to these
areas on future
studies.
3. Small bilateral pleural effusions with increased dependent
atelectasis
versus infiltrate in the right lower lobe. Minimal atelectasis
in the left
base.
4. Status post abdominal hernia repair.
5. Large bladder calculus.
6. Diverticulosis without evidence of diverticulitis.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-7-27**] 4:27
AM
Provisional Findings Impression: DJRX SUN [**2188-7-27**] 11:49 AM
Bilateral perihilar densities suspicious for pneumonia.
IMPRESSION: Focal areas of increased density bilaterally
suspicious for
pneumonia. A little interval change
.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2188-7-28**]
12:16 PM
IMPRESSION:
1. No acute intracranial pathology identified.
2. Sinus disease as described above, likely related to chronic
inflammatory
process and/or patient's intubated status; however, correlation
should be made
for any findings to suggest acute sinusitis/mastoiditis.
3. S/P left occipital craniotomy- please provide reason for this
procedure.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-7-30**] 2:59
AM
FINDINGS: The tracheostomy tube remains in place, but appears to
contact the right lateral tracheal wall. Nasogastric tube is
still in place. The right internal jugular line ends in the SVC.
Allowing for difference in positions, there is no significant
change in the degree of cardiomegaly, bilateral pleural
effusions, or pulmonary vascular congestion.
.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2188-8-1**] 10:21 PM
IMPRESSION:
1. No pulmonary embolus or acute aortic abnormality.
2. Bilateral pleural effusions, right greater than left, with
fluid tracking
into the fissures, which could be loculated. Associated
compressive
atelectasis demonstrates enhancement, and is not likely to
represent pneumonic
consolidation.
3. Support lines in place.
4. Extensive vascular calcification.
5. Cardiomegaly.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-8-6**] 4:36
AM
IMPRESSION: AP chest compared to [**7-31**]:
Mild pulmonary edema has worsened since [**8-5**]. Large heart
and
generally large and tortuous thoracic aorta are chronic. No
pneumothorax or
pleural effusion. Right subclavian line barely central should be
re-evaluated
by film it is not rotated. Esophageal tube or probe ends in the
upper
stomach, as before.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2188-8-14**] 4:47
AM
Of note, the patient is markedly rotated. Tracheostomy tube and
right PICC
are in standard positions. NG tube tip is out of view below the
diaphragm.
Bibasilar consolidations consistent with aspiration or pneumonia
are stable.
Opacity in the right upper lobe is more conspicuous in this
examination
could be due to aspiration.
.
Radiology Report VIDEO OROPHARYNGEAL SWALLOW Study Date of
[**2188-8-19**] 9:47 AM
IMPRESSION: Mild oropharyngeal dysphagia characterized by mildly
reduced
bolus control with thin liquids, and mildly reduced laryngeal
elevation and laryngeal valve closure, resulting in episodes of
penetration during swallow of thin liquids.
.
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2188-8-20**]
10:13 AM
IMPRESSION:
1. Resolving postoperative stranding status post Whipple
procedure. Soft
tissue attenuation conglomeration in the pancreaticojejunostomy
bed is
not as well evaluated on the current study but is not
significantly
changed and likely represents loops of jejunum.
2. Three hypodense liver lesions no fully characterized.
Attention should be
paid to these areas on followup studies.
3. Peribronchovascular ground glass opacities may represent
infection,
inflammation and less likely edema.
4. Enlarged pulmonary artery suggesting underlying pulmonary
arterial
hypertension.
5. Dense coronary artery calcificiations.
Brief Hospital Course:
This is a 73 year old female with a pancreatic head mass who
went to the OR on [**2188-7-16**] for:
1. Classical Whipple resection.
2. Open cholecystectomy.
3. Incisional hernia repair (separate procedure).
During the case there was some concern about her oxygenation
particularly in the early portion of the operation where she
required 100% oxygen saturation in order
to maintain a appropriate saturation rate level. There is no
evidence of any pneumothorax, and she had a bronchoscopy in the
case which was nonrevealing.
On POD 2, she desaturated on floor and was transferred to the
ICU and reintubated for acute respiratory distress/failure. She
remained in the ICU for 3 weeks. The following summarizes
significant events:
[**7-18**]: CTA neg for PE , increased PEEP, EKG, cardiac enzymes were
negative.
[**7-19**]: continue vent
[**7-21**]: vanc and zosyn lasix d/ced and then restarted TTE EF 60%
RV dilated, fever, inc insulin in TPN
[**7-22**]: ct abd - small fluid collection (not drainable), wean fio2
[**7-23**]: decr lopressor, JP cx, wean vent, tighten SSI, cont TPN,
incr insulin to 50, vulvar lesion clean (recent partial
vulvectomy [**2188-7-8**])
[**7-24**]: Decrease PEEP, Insulin 65 with TPN [**7-25**]: wound care
consult, added NPH 40/40 [**7-26**]: consult gyn for vulvar lesion
[**7-27**]:wean propofol
[**7-28**]: head ct negative, continue tpn,
[**7-29**]: trach,
[**7-30**]-nasoenteric feeding tube placed by radiology
[**7-31**]: picc placed, CVL removed; increased secretions from trach
(02 sat stable)
[**8-1**]:d/c vanco/cirpo;acute hypotensive episode x 1 with
spontaneous return, CTA PE - negative, BL atelectasis with R>L
effusions, secretions reduced from previous but present; Echo -
nl ef, no gross abnormalities; Cards consulted - no changes;
increased Fi02 to 60% for improved oxygenation; acetazolamide
started
[**8-2**]: 2 units PRBC, desat after 1 unit, improved after lasix
[**8-3**]: destat episode, mucous plugging. Lasix gtt increased for
fluid volume overload and pulmonary hypertension
[**8-4**]: up in chair, good sat, lasix 2/hr
[**8-5**]: up in chair, secretions still tend to be substantial, lasix
gtt increased to make the patient negative
[**8-6**]: replaced dobhoff, clonidine patch and PO, versed prn,
increased lasix gtt
[**8-7**]: Recurrent episodes of desaturation, likely secondary to
mucous plugging. Increased Fi02, Aggressive suctioning. Pt also
with episode of vomiting when given large volume KCL down
dobhoff. Feeds held, then restarted. Pt with vagal episode with
vomiting.
[**8-9**]: Dobhoff removed and patient fighting placement, IVF
started while tube feeds off, copious secretions, lasix gtt
increased, diamox frequency increased, albumin level f/u in AM
[**8-10**]: Dobhoff placed. Lasix gtt decreased
[**8-11**]: cont diuresis, stopped diamox, started metalozone, fluc
started
[**8-13**]: Tube feeds restarted p MN, NGt was placed for
decompression/evacuation, no asystolic events
[**8-14**]: Pt had FS 57, NPH decreased to 25, 25. Pt self d/c aline
[**8-15**]: passed S/S eval, [**Hospital 71806**] rehab screening, diamox
[**8-20**] CT: resolving stranding, soft tissue atten in
pancreaticojej bed not well-evaluated, but no signif. change,
likely represents loops of jejunum. 3 hypodense LVR lesions not
fully characterized. Peribronchovascular ground glass opacities
may represent infection, inflammation and less likely edema.
.
CARDIOVASCULAR: Due to Bradycardia and pauses, her nodal
blocking agents were held. These were restarted without incident
once back on the floor.
PULMONARY: trach and passe muir valve in place.
GI / ABD: abdomen soft, and nontender. JP drain on the right
side has sequentially been backed out. There is now an ostomy
appliance in place. The last JP Amylase was [**Numeric Identifier 71805**].
NUTRITION: TF at goal 50cc/hr. Tolerating some PO's. See recs
below.
RENAL: lasix gtt, diamox stopped. Fluid status now stable.
HEMATOLOGY:stable
ENDOCRINE: RISS
ID:inhaled tobramycin, and fluc have been completed. Zosyn to
continue for 2 weeks due to PSEUDOMONAS AERUGINOSA from the JP
drain.
LINES/TUBES/DRAINS: Trach, picc line rt antecub,
WOUNDS:none
.
Pathology:
Primary Tumor: pT3: Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric
artery. 2/31 nodes positive. Margins uninvolved by invasive
carcinoma:
No PVI, +perineural invasion.
.
Micro:
[**8-20**] C dif: Negative x2
[**8-19**] Peritoneal: Pseudomonas - Resistant to Cipro
[**8-12**] C dif: negative
[**8-11**] BAL: GNRs
[**8-8**] Spcx: pseudomonas - R cipro
[**8-8**] Ucx: neg
[**8-6**] Spcx: pseudomonas - R cipro
[**8-3**] Ucx: pseudomonas - R cipro
[**7-23**] JPcx: E.coli - R gent; MRSA
.
Consults:
[**8-15**] Cards: AF, WBC downtrending. d/c nodal blocking agents;
atropine at bedside, pacer pads; if continues to have pauses > 5
secs, would consider placing temp pacing wire. Once transferred
to the floor, she was no longer having pauses and meds were
restarted.
.
Video Swallow:
1. PO intake of thin liquids and regular solids.
2. Pills may be given whole with puree.
3. Aspiration Precautions:
A. Use straws while drinking thin liquids.
B. If drinking by cup, use a chin tuck.
C. Use intermittent cough to help clear any penetration.
D. No mixed consistencies (i.e. cereal, hearty soups).
4. PMV must be in place for all POs.
5. Continue supervision to assist with feeding and monitor
swallow safety.
Medications on Admission:
Alendronate 35 Qwk, atenolol 25', fenofibrate 200', fexofenadine
180', levothyroxine 150mcg', nifedipine 90', valsartan 320', ASA
81', percs, tylenol, B12, Ca +D, naproxen, VitE
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q12H (every 12 hours).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: One (1)
Inhalation [**Hospital1 **] (2 times a day).
4. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
8. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
12. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
13. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
14. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) Subcutaneous twice a day.
16. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection four times a day.
17. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 2 weeks: 2
weeks.
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Adenocarcinoma of the pancreas
Post-op Acute Respiratory Failure / Hypoxia
Post-op Blood Loss Anemia
Post-op Fluid Volume Overload / Pulmonary Hypertension
Post-op Bradycardia / Cardiac Pauses
Post-op Mild oropharyngeal dysphagia
Post-op Pneumonia
Post-op Atelectasis
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* Monitor your incision for signs of infection (redness,
drainage).
* Continue with drain care
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2188-9-12**] at
8:30am.
Completed by:[**2188-8-21**]
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42184
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Discharge summary
|
Report
|
Admission Date: [**2179-8-16**] Discharge Date: [**2179-8-20**]
Service: MEDICINE
Allergies:
morphine
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
dizziness and vomitting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
OUTPATIENT CARDIOLOGIST: [**Last Name (LF) 1270**], [**Name8 (MD) **] MD
.
PCP:
.
CHIEF COMPLAINT: Dizziness and vomiting
.
.
HISTORY OF PRESENTING ILLNESS:
Pt is a [**Age over 90 **] y/o female with history of ?bradycardia, LE swelling,
CKD, HTN, HL, hypothyroidism, RA who was transferred to [**Hospital1 18**]
for pacemaker placement s/p symptomatic bradycardia. Per OSH
(Good Sumaritan) records, she was in usual state of health until
this evenning when she developed acute onset dizziness while
washing her dishes when she fell and EMS was caled. No LOS or
headache. On route developed chest pain radiating to her back
and got aaspirin 325 and nitro once. In the ambulance she was
noted to be diaphoretic, pale, nausea with vomiting and
dizzzines. The initial EKG showed junctional bradycardia in
40s. A subsequent 12 lead EKG demonstrated aflutter with 5:1
conduction with rates between 49 and 52. In the ED Code STEMI
was activated given STE in I and aVL and patient determined to
be medically managed and NOT taken to cath lab. She was sent
for CT chest to r/o aortic dissection and after put on heparin
drip, asa, nitro drip, morphine, and continued on her home dose
of lasix, hydrochlorothiazide, and home benazepril was changed
to lisinopril (unknown dose).
Her exam at OSH was notable for BP systolic 160s both upper
extremities, bradycardia, crackles in left base, 2+ pitting
edema in LE bilaterally, and skin tear on left elbow with
brusing and echhymoses. Labs WBC 11.3, hct 38.5, plt 225,000,
INR 0.9 PTT 30. Na 137 K3.7, Cl94, bicarb 29, AG 14. BUN/Cr
71/2.2. glu 250 and Ca 9.6. Cl 73, peak MB 14, peak TropI
1.55.
EKG with Aflutter 5:1 conduction block. 1mm STE in I, 2mmSTE in
aVL with reciprocal ST depressions in II, II, avF, V5 and V6.
Also "new LBBB". CXR with enlarged cardiac silhouette. CT
Chest showed cardiac enlargement with small pericardial
effusion, large hiatal hernia, small right pleural effusion.
ECHO showed EF 60-65%, normal systolic function, right atrium
mildly dilated, trace AR, no AS, Pulmonary HTN present with RVSP
67
On arrival to CCU the patient appeared well and was conversant,
alert and oriented x3. She did describe some chest pain on her
lower right sternum which only was present during moving. The
pain was felt to be internal and non-radiating. She denied
nausea, dizziness, shortness of breath, but did endorse a cough
which is new.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
?CHF
Bradycardia- had been evaluated by cardiologist who recommended
no intervention as patient was asymptomatic. Unclear if history
3. OTHER PAST MEDICAL HISTORY:
CKD
ANEMIA
GERD
Rheumatoid arthritis
MEDICATIONS:
hydrochlorothiazide - in OMR, not on OSH records
25 mg tablet
0.5 (One half) Tablet(s) by mouth once a day [**2179-4-9**]
isosorbide mononitrate [Imdur]
60 mg tablet extended release 24 hr
1 Tablet(s) by mouth once a day
levothyroxine [Synthroid]
25 mcg tablet
1 Tablet(s) by mouth once a day [**2179-2-12**]
nitroglycerin [Nitrostat]
0.3 mg tablet, sublingual
1 Tablet(s) sublingually 5 minutes [**2178-12-11**]
pantoprazole [Protonix]
40 mg tablet,delayed release (DR/EC)
simvastatin [Zocor]
20 mg tablet
1 Tablet(s) by mouth once a day
Benzapril 40 mg daily
Lasix 20 mg daily
Prednisone 5 mg daily
ALLERGIES: Morphine years ago, does not remember her reaction
Social History:
SOCIAL HISTORY
Lives in [**Hospital3 **] home, lately increased dependence on
ambulatory aid. 1 son [**Name (NI) **] [**Name (NI) **] involved in her care
-Former smoker, [**3-28**] ppd 45 years, quit in [**2144**]
-No etoh or illicits
Family History:
FAMILY HISTORY:
Mother and father died in 80s, father from CAD, sister cancer,
mother unknown
Physical Exam:
PHYSICAL EXAMINATION:
VS: T=97.6 BP=143/61 HR= 45 3rd degree AV block RR=20 O2 sat=99%
GENERAL: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 9 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Slow rate, normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: Crackles auscultated in left lower lobe
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: [**1-25**]+ edema bilateral lower extremities, R>L.
Ecchymosis on L elbow
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Pertinent Results:
11:16p
140 98 56 144 AGap=15
3.9 31 1.6
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
estGFR: 30/36 (click for details)
CK: 165 MB: 10 MBI: 6.1 Trop-T: 0.52
Comments: CK(CPK): New Reference Interval As Of [**2177-1-27**];Upper
Limit (97.5th %Ile) Varies With Ancestry And Gender
(Male/Female);Whites 322/201 Blacks 801/414 Asians 641/313
cTropnT: Reported To And Read Back By
cTropnT: J.Brady @ 0054 [**2179-8-17**]
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 9.1 Mg: 2.1 P: 3.0
94
12.6 12.3 201
34.5
PT: 10.8 PTT: 42.4 INR: 1.0
EKG:
-In house: Rate 40, 3rd degree AV block, Axis 80, No ST changes
seen on this EKG.
-OSH- STE in Leads aVL and I with reciprocal changes in v5 and
v6. Ventricular escape takes over in 09:56:36 PM EKG.
.
2D-ECHOCARDIOGRAM:
EF 60-65%, normal systolic function, right atrium mildly
dilated, trace AR, no AS, Pulmonary HTN present with RVSP 67
[**2179-8-16**] 11:16PM GLUCOSE-144* UREA N-56* CREAT-1.6* SODIUM-140
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-31 ANION GAP-15
[**2179-8-16**] 11:16PM estGFR-Using this
[**2179-8-16**] 11:16PM CK(CPK)-165
[**2179-8-16**] 11:16PM CALCIUM-9.1 PHOSPHATE-3.0 MAGNESIUM-2.1
[**2179-8-16**] 11:16PM WBC-12.6* RBC-3.69* HGB-12.3 HCT-34.5* MCV-94
MCH-33.3* MCHC-35.6* RDW-13.4
[**2179-8-16**] 11:16PM PLT COUNT-201
[**2179-8-16**] 11:16PM PT-10.8 PTT-42.4* INR(PT)-1.0
Brief Hospital Course:
ASSESSMENT AND PLAN
This is a [**Age over 90 **] y/o female with PMHx of HTN, HL, questionable
history of bradycardia and CHF, also with CKD who presented to
[**Hospital3 **] hospital with near syncope found to be in 3rd degree
heart block/Aflutter with evidence of lateral STEMI .
She was transferred here for consideration of pacemaker
placement.
ACUTE ISSUES
# Afib with Junctional escape/complete heart block: Per son and
attending, this had happened in the past and pt had not been
symptomatic. ECG changes indicated likely completed STEMI that
could be contributing to bradycardia vs acute on chronic
process. Patient felt dizzy when walking with physical therapy.
At this point in time it was decided to not place a pacemaker.
# Completed STEMI: Trop peak was 1.5 at the outside hospital.
She was treated with heparin for 2 days as ACS treatment. She
was also given aspirin and plavix. Her beta blocker wa held
because of slow heart rate. She was not brought to cath lab
because it was believed this was a completed MI. On [**8-18**] her
CKMB was down to 4 and trop down to .32.
# Right arm hematoma: Patientn came home with a right arm
hematoma. She did not recall how she got this though it is
possible it was related to when she fell before coming in.
During hospital stay the hematoma got larger and we consulted
vascular and hand surgery for their input. They could obtain an
ulnar pulse on doppler and recommended the patient be monitored
and there was no need to do any surgery at this time. We did
further imaging which showed a brachial artery dissection with
no fractures in any of the bones in her arm. We gave her
tramadol and tylenol for pain while she was uncomfortable.
#Vertigo: On [**8-20**] patient started feeling vertigo. She described
a dizziness like the room is spinning sensation. She said it was
worse when turning her head. We felt this was either Meuniere's
vs benign position veritgo vs a small stroke involving the
brainstem. We started her on meclizine on day of discharge and
ordered a soft collar to prevent neck movements.
# HTN: Her SBPs were in the 160s-170s. We stopped her home hctz
and started amlodipine. She was also on captopril which was
changed to her home benazepril at discharge. Her goal SBP Is
140.
CHRONIC ISSUES.
# Hypothryoidism: TSH nl. We continued home levothyroxine
# HLD: stable We continued home simvastatin
# GERD/Hiatal hernia
-Pantoprazole 40 mg daily
#HL
-Simvastatin 20 mg daily
TRANSITIONAL ISSUES
#veritgo: patietn should follow up with PCP
#[**Name10 (NameIs) **] hematoma showed be followed up with vascular surgery if
does not resolve.
#hypertension: we started amlodipine during hosptial stay and
discontinued her home thiazide. Her SBPs were in the 140's.
#Bradycardia with heart block: should be followed up with
outpatient cardiologist in terms of if patient will need a
pacemaker in the future.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Furosemide 20 mg PO ONCE Duration: 1 Doses
2. Hydrochlorothiazide 25 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN angina
9. benazepril *NF* 40 mg Oral daily
Discharge Medications:
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Nitroglycerin SL 0.3 mg SL PRN angina
3. Pantoprazole 40 mg PO Q24H
4. PredniSONE 5 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Acetaminophen 650 mg PO TID
7. Amlodipine 5 mg PO DAILY
Hold for SBP < 100
8. Aspirin 325 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Docusate Sodium 100 mg PO BID:PRN constipation
hold for loose stools
11. Heparin 5000 UNIT SC TID
D/C once pt is mobile
12. Meclizine 12.5 mg PO TID
13. Senna 1 TAB PO BID:PRN constipation
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. benazepril *NF* 40 mg ORAL DAILY
Hold SBP < 100
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Completed STEMI
Acute on chronic diastolic congestive Heart failure
Acute on chronic kidney function
Atrial Fibrillation with complete heart block
Vertigo
Hypertension
Right arm hematoma
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 had a fall before you arrived here and your heart rate was
found to be very slow. You had a heart attack before you came
and you have been started on medicines to help your heart
recover. Your heart rate has been slow for a long time so a
pacemaker was not placed. You had some fluid overload and was
given diuretics to remove the fluid. A large bruise developed
over your upper and lower right arm and you were seen by a
vascular surgeon, a rheumatologist and a plastic surgeon. They
have all agreed that it is resolving on it's own. Please be sure
to keep it elevated. You have new dizziness that may have been
caused by a very small stroke. You are now on aspirin and plavix
for your heart that may also help to prevent further strokes.
Your vertigo should go away as you recover.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: FRIDAY [**2179-9-24**] at 11:00 AM
With: [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], MD [**0-0-**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**]
Campus: OFF CAMPUS Best Parking: On Street Parking
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
|
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91,103
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25511
|
Discharge summary
|
Report
|
Admission Date: [**2120-11-26**] Discharge Date: [**2120-12-3**]
Date of Birth: [**2090-10-22**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreatitis, ETOH overdose, severe acidosis, ETOH hepatitis,
substance abuse, UGIB
Major Surgical or Invasive Procedure:
[**2120-11-26**]: Intubation, CVL and axillary [**Last Name (un) **] monitor placment
[**2120-12-2**]: UGI:
History of Present Illness:
30F w active EtOH abuse and alcoholic hepatitis p/w altered
mental status and report of hematemesis. Of note, HPI is per
report/documentation as pt intubated/sedated at time of
consultation. Pt has hx EtOH abuse/binge drinking w multiple
EtOH related admits/ED visits for withdraw, escalating in
frequency in recent months. Presents today in setting of
reported 2.5 day EtOH abstention with altered mental status,
nausea and vomiting. Intubated on arrival for
confusion/hematemesis and inability to protect airway. Reported
episodes of hematemesis at this time though quality/quantity of
blood in emesis unclear. Started on pressors w massive
resuscitation for hypotension/ tachycardia. Laboratories
reflected dehydration, known EtOH hepatitis and lipase 100
suggestive of acute pancreatitis. CT scan showed severe
pancreatitis and GB with edematous wall filled w sludge vs
blood.
Surgery consult obtained for pancreatitis, UGIB.
Past Medical History:
EtOH abuse with several inpatient detox stays
Social History:
The patient is originally from [**Location (un) 11177**], [**State 4565**]. She is
currently on dental student on a leave of absence. She reports a
history of binge drinking, typically [**3-26**] "strong" drinks at a
time. She reports a history of multiple inpateint detox stays
without success. She denies tobacco or IVDU
Family History:
Maternal grandfather with alcoholism
Maternal uncle with drug problem
Paternal aunt with alcoholism
Physical Exam:
At time of admission:
P/E:
Levo: 0.12, Protonix: 8; Versed: 18
VS: T: 97.0 P: 134 BP: 110/57 RR: 20 O2sat: 100
CMV 0.5; 20x500; 5
GEN: WD, WN F intubated/sedated
HEENT: NCAT, PERRLA, anicteric
CV: RRR; tachy
PULM: CTA B/L w no W/R/R, intubated
ABD: firmly distended, unable to assess tenderness [**1-24**] sedation
EXT: WWP, no CCE, 2+ B/L radial/DP/PT
NEURO: moves all 4 extremities; sedated
On Discharge:
VS:
GEN; Pleasant with NAD
CV: RRR
Lungs: Diminished breath sounds bilateraly on bases
Abd: NT/ND, soft
Extr: Warm, no c/c/e
Neuro: AAO x 3, Cranial nerves II-XII grossly intact
Pertinent Results:
Labs at time of admission:
15.7>-14.8/48.1-<393
N:86.4 L:11.2 M:1.2 E:0.7 Bas:0.5
PT: 11.0 PTT: 31.8 INR: 1.0
150 91 13
-------------< 93 AGap=58
4.7 6 2.8 ∆
ALT: 230 AP: 180 Tbili: 1.2
AST: 485 Lip: 100
Serum EtOH 255
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
8AM:
pH 6.93 pCO2 33 pO2 124 HCO3 8 BaseXS -26
Type:Art; Intubated; FiO2%:50; Rate:/16; TV:500;
Mode:Assist/Control
Lactate:12.0
[**12-2**]:
7.4>----<125
36.1
142 101 5 aGap=11
-------------<118
3.3 33 1.0
Ca: 9.2 Mg: 1.3 P: 2.0
ALT: 51 AP: 78 Tbili: 0.8
AST: 62 LDH: 430
[**Doctor First Name **]: 146 Lip: 206
IMAGING:
CT A/P [**11-26**]: Noncontrast CT due to elevated creatinine, limiting
assessment. Peripancreatic inflammation, c/w pancreatitis.
Cannot assess parenchymal enhancement or vascular complications.
But no obvious large pseudocyst or abscess. Diffusely fatty
liver. Gallbladder with diffuse mural thickening and distended
with hyperdense material. No free air. Free fluid in pelvis.
[**12-3**] CXR:
As compared to the previous radiograph, all monitoring and
support
devices have been removed. There are persistent opacities at
both lung bases, right more than left, that are exaggerated by
relatively [**Name2 (NI) 15410**] breast tissue.
The changes could reflect minimal fluid overload or layering
pleural
effusions. No circumscribed focal parenchymal opacity suggesting
pneumonia.
No cardiomegaly. No lung nodules or masses.
[**12-3**] EGD:
Impression:
1. Erythema in the stomach body compatible with gastritis
(biopsy)
2. Mucosa suggestive of Barrett's esophagus (biopsy)
Brief Hospital Course:
[**11-26**]- Admitted to the TSICU after a reported 2.5 day EtOH
abstention ( ETOH level 255) with altered mental status, nausea
and vomiting. Intubated on arrival for confusion/hematemesis and
inability to protect airway. Reported episodes of hematemesis
prior to arrival prompted Protonix and Octreotide drips. IN the
Ed patient was started on Levophed w 12L resuscitation for
hypotension/ tachycardia in the ED. She was admitted to the ICU
with suspected EtOH hepatitis, acute pancreatitis with lipase
100, severe acidosis with lactate 22, ph 6.9. Sh was
hypernatremic to 150 qith acute renal failure Cr 2.3. Liver
function tests significant for ALT: 230 AP: 180 Tbili: 1.2 Alb:
AST: 485 Serum ASA, Acetaminophen, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
CT scan showed severe pancreatitis and GB with edematous wall
filled w sludge vs blood. In the ICU an Axillary line and [**Last Name (un) 18821**]
monitor were placed, as well as a central line in the R IJ. A
Bicarb drip for PH 6.9 that was later stopped in the pm.
Thiamine and folate where repleted. Toxicology , general
surgery and Gi were consulted. Bladder pressure were checked for
evidence of compartment syndrome. With aggressive management she
improved overnight. Cardiac ECHO showed no evidence of
infarction.
[**11-27**]: By the am her ventilator was weaned to [**4-25**]. Fentanyl dc'd
and she was started on 3mg IV Ativan for intermittent agitation
and question of withdrawal. She had Elevated BPs 150-160's
overnight. Also started clonidine patch.
[**11-28**]: She was changed to Precedex gtt. IR attempt to make
Dobbhoff post pyloric unsuccessful so tube remained as NG.
[**11-29**] Extubated. A&Ox3. She was advanced to a regular diet.
Overnight pt with hallucinations (Visual/auditory) and she was
agitated requiring Valium. CIWA protocol was initiated. She was
also noted to have a drop in her platelets to the 69s, Her HSQ
was discontinued and HITT panel sent.
[**11-30**]: Patient was transferred to floor; psych and social work
c/s ordered to help facilitate substance abuse counseling.
Patient's abdominal pain slowly resolving.
[**12-1**]: After psychiatry and SW recommended 30 day substance
abuse rehab upon dc. GI consult recomended inpatient endoscopy
to evaluate the source of patient's reported UGIB. Recheck of
platelets showed recovery to 125 without intervention.
[**12-2**]: Upper Endoscopy. HITT pending. In the am pt complained of
mild SOB prompting a CXR.
[**12-3**]: CXR was negative for PNA. EGD demonstrated erythema in
the stomach body compatible with gastritis and mucosa suggestive
of Barrett's esophagus, biopsy were taken. Patient's diet was
advanced to regular and she was discharge home in stable
condition. Her PCP was [**Name (NI) 653**] prior discharge, and message
was left explaining patient's needs for prompt follow up with
PCP.
Medications on Admission:
[**Last Name (un) 1724**]: folic acid 1', thiamine 100', fluoxetine 10', MVI,
naltrexone 50'
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. naltrexone 50 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks: Please do not drink alcohol while taking this
medication.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. EtOH induced pancreatitis
2. Alcohol abuse
3. Alcohol withdrawal
4. Metabolic acidosis
5. Upper gastrointestinal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Please call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2998**] if you have any
questions.
.
Please follow up with [**Doctor Last Name 634**], PA (PCP) in 1 week after
discharge
.
Call [**Telephone/Fax (1) 13545**] in one week for the biopsy (EGD) results
Completed by:[**2120-12-3**]
|
[
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"571.1",
"276.51",
"577.0",
"458.9",
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[
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icd9pcs
|
[
[
[
5976,
5984
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],
[
[
6917,
6944
]
]
] | 7
| 2,883
| 0
| 110
| 1
| 0
| 0
| 0
| 0
| 1,641
| 0
| 0
| 299
| 103
| 0
| 0
| 0
| 365
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| 0
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92,170
| 105,063
|
457465
|
Physician
|
Physician Resident Progress Note
|
TITLE:
Chief Complaint: hyponatremia, altered MS
24 Hour Events:
-Family mtg: D/c home with hospice, full code.
-Renal: Cont fluid restrict
-Abx changed to cefpodoxime for dispo as MRSA screen negative and
pseudomonas unlikely
[**Hospital 7395**] hospice bed
Allergies:
Coumadin (Oral) (Warfarin Sodium)
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin - [**2189-3-30**] 11:12 PM
Piperacillin/Tazobactam (Zosyn) - [**2189-4-1**] 08:00 AM
Vancomycin - [**2189-4-1**] 08:32 AM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-4-2**] 06:51 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 37.1
C (98.8
Tcurrent: 37.1
C (98.8
HR: 119 (93 - 119) bpm
BP: 91/44(55) {74/40(51) - 97/57(63)} mmHg
RR: 35 (15 - 35) insp/min
SpO2: 94%
Heart rhythm: AF (Atrial Fibrillation)
Total In:
1,291 mL
64 mL
PO:
150 mL
TF:
IVF:
1,141 mL
64 mL
Blood products:
Total out:
712 mL
115 mL
Urine:
712 mL
115 mL
NG:
Stool:
Drains:
Balance:
579 mL
-51 mL
Respiratory support
O2 Delivery Device: None
SpO2: 94%
ABG: ////
Physical Examination
Gen:
Neck:
CV:
Lungs:
[**Last Name (un) 61**]:
Extre:
Neuro:
Labs / Radiology
458 K/uL
9.3 g/dL
50 mg/dL
0.8 mg/dL
16 mEq/L
4.3 mEq/L
21 mg/dL
98 mEq/L
127 mEq/L
28.2 %
25.5 K/uL
[image002.jpg]
[**2189-3-30**] 12:31 AM
[**2189-3-30**] 05:30 AM
[**2189-3-31**] 04:47 AM
[**2189-3-31**] 08:14 AM
[**2189-4-1**] 05:31 AM
WBC
22.3
21.2
25.5
Hct
28.3
27.3
28.2
Plt
446
490
458
Cr
0.7
0.7
0.7
0.8
Glucose
60
69
44
49
50
Other labs: PT / PTT / INR:15.3/33.4/1.4, ALT / AST:35/96, Alk Phos / T
Bili:496/1.5, Lactic Acid:4.0 mmol/L, Albumin:2.1 g/dL, LDH:765 IU/L,
Ca++:7.6 mg/dL, Mg++:1.9 mg/dL, PO4:3.5 mg/dL
Assessment and Plan
71 yo man with history of metastatic pancreatic cancer was admitted
with dyspnea, new ascites, and profound hyponatremia.
# Hyponatremia: Likely etiology of altered mental status. Has improved
with hypertonic saline and restriction of free water intake. Underlying
mild SIADH and hyponatremia was likely exacerbated by excessive free
water intake at home given recent admission for
dehydration.
-fluid restrict to 1L
-would avoid add
l IV fluids per Renal, could consider lasix
-appreciate renal recommendations
# Hypotension: DDx intravascular hypovolemia (given tachycardia) versus
new baseline w/ chronic disease
-holding IV fluids for now due to concern of worsening hyponatremia
# Dyspnea, ?pneumonia on CT: Infiltrate on CXR being treated as HAP.
Also with small bilateral effusions, ddx parapneumonic v. malignancy.
[**Month (only) 51**] also have hypoventilation related to increased ascites.
-vanco and Zosyn stopped yesterday; will continue cefpodoxime for 8-day
course (today is d4/8)
# Bandemia: Likely [**12-29**] pneumonia, stable to mildly improved. No other
localizing sx. Blood cultures negative. Respiratory viral screen, MRSA
swab both negative. Urine legionella and urine culture negative. Still
awaiting stool sample for c. diff
-continue cefpodoxime for pna, 8-day course
-f/u cultures
-awaiting stool for C. diff
# Guaiac positive stools: Patient was found to have guiac positive
stools, likely related to metastatic pancreatic cancer. In light of
guiac positive stools, will hold off on any anticoagulation at this
time.
-hematocrit stable, will continue to follow
# Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis. Unclear if this
represents a spontaneous thrombosis or is related to tumor invasion.
Patient is certainly a poor candidate for anticoagulation given his
poor PO intake, multiple comorbidities, and reported allergy to
coumadin.
-continue to monitor
# Fluid overload: [**Month (only) 51**] be [**12-29**] increased metastatic disease, low albumin.
[**Month (only) 51**] have some diastolic dysfunction not assessed on prior echo. [**Month (only) 51**]
also have third-spacing [**12-29**] hyponatremia. Nephrotic syndrome unlikely
given U/A. ? of new ascites which is likely related to metastatic
disease.
-high protein diet, could consider lasix per renal recs
# Metastatic pancreatic cancer: Evidence of progression on CT
abdomen/pelvis. He declined palliative chemo and/or radiation therapy.
Goals of care meeting [**4-1**] addressed home hospice, which patient would
like to try.
ICU Care
Nutrition: High protein, pureed/nectar-thick
Glycemic Control:
Lines:
18 Gauge - [**2189-3-30**] 12:54 AM
20 Gauge - [**2189-4-1**] 12:00 AM
Prophylaxis:
DVT: pneumoboots
Stress ulcer: eating
VAP:
Comments:
Communication:
Code status: FULL code (per patient and family mtg on [**4-1**]
Disposition: Home w/ hospice
|
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91,572
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Discharge summary
|
Report
|
Admission Date: [**2171-6-4**] Discharge Date: [**2171-6-18**]
Date of Birth: [**2091-8-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Abdomnal pain
Major Surgical or Invasive Procedure:
ERCP with placement of a plastic stent ([**2171-6-4**])
PICC line placement ([**2171-6-6**])
Percutaenous cholecystostomy drain ([**2171-6-7**])
Drainage of liver abscess by interventional radiology ([**2171-6-13**])
History of Present Illness:
Mr. [**Known lastname **] is a 79yoM with a history of HTN, HLD, and previous
bladder neoplasm who developed acute RUQ pain two days ago. It
occurred suddenly, has been constant, dull, and nonradiating in
nature. He has been anorexic but denies nausea or vomiting. He
notes subjective fevers. He had confusion per his wife. His
urine has been cola-colored, but denies changes in his stool.
Has not noticed yellowing of skin. No previous history of
biliary or hepatic disease. Denies previous gall stones. He saw
his PCP, [**Name10 (NameIs) 1023**] referred him to the [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **]. There he was
febrile to 103.8F with systolic blood pressures in the upper 80s
which responded well to fluid resuscitations. He had a RUQ US
showing acute cholecystitis with a CBD diameter of 5mm. A CT
showed pneumobilia with scattered hepatic densities concerning
for abscesses.
He was transferred to [**Hospital1 18**], initial VS were T99.4 BP83/42 HR80
RR18 Sat97RA. His lactate was elevated to 4.4, he received 2L
NC. His initial labs showed transaminitis of AST/ALT 198/167,
Tbili 4.9 Dbili 4.0, AP 34, Lipase 86. Surgery was consulted for
suspicion of cholangitis. He received zosyn, and was admitted to
[**Hospital Unit Name 153**] briefly before undergoing ERCP, which revealed only sludge
in the gallbladder without note of stone. A stent was placed,
and he received tetracycline/clindamycin for suspected
claustridium given his pneumobilia. He was transferred back to
the [**Hospital Unit Name 153**] in stable condition.
On arrival back to the [**Hospital Unit Name 153**], his initial VS were T95.6 P82
BP118/39 RR14 Sat94%RA. He has mild RUQ pain but he is
comfortable and has no acute complain. On ROS, denies chest
pain, shortness of breath, N/V/D, no palps, myalgias,
arthralgieas, dysuria, hematuria.
Past Medical History:
PMH:
- HTN
- hyperlipidemia
- ? bladder neoplasm
PSH:
- TURP
- ? resection of tumor from the bladder
Social History:
Lives with wife, retired, smoked a pack a day for about 40
years, quit several years ago
Family History:
No family history of biliary or hepatic disease, gallstones,
pancreatitis
Physical Exam:
on admission:
gen: NAD, pleasant, jaundiced sclera, flushed in the face,
uncomfortable in pain
VS: 99.4 80 83/42 16 97% Nasal Cannula
CV: RRR
pulm: CTA b/l
abdomen: mildly softly distended, + BS, tender in the RUQ
tolight palpation, also tender in RLQ to deeper palpation
extremities: no LE edema, no cyanosis
Pertinent Results:
ERCP ([**2171-6-4**])
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized. The course and caliber of the
structures are normal with no evidence of extrinsic compression.
There was a filling defect in the middle third of the common
bile duct. This could represent stone fragment or debris. The
intrahepatics appeared normal, but the cholangiogram was limited
due to a small amount of contrast injection due to the patient's
sepsis from cholangitis. Successful placement of a plastic
biliary stent for decompression. Otherwise normal ercp to third
part of the duodenum
CT ABDOMEN ([**2171-6-4**])
1. Air within a mildly distended gallbladder with associated
pericholecystic stranding is compatible with acute
cholecystitis, with likely involvement of a gas-forming
organism.
2. Pneumobilia and ill-defined hypodensities in the left lobe of
the liver are concerning for infection with developing hepatic
abscesses, likely secondary to ascending cholangitis.
3. Calcifications in the region of the distal common bile duct
could be within the lumen of the duct, although could also be
within the pancreatic head. Further evaluation could be
performed with MRCP, if clinically indicated.
4. Right adrenal nodule, not fully characterized.
5. Well-defined hypodense liver lesions are likely simple cysts,
as described above.
DISCHARGE LABS ([**2171-6-17**])
WBC-7.0 RBC-3.55* Hgb-11.1* Hct-33.4* MCV-94 MCH-31.2 MCHC-33.2
RDW-13.4 Plt Ct-362
Glucose-107* UreaN-8 Creat-1.0 Na-141 K-3.7 Cl-104 HCO3-26
AnGap-15
BLOOD ALT-63* AST-51* LD(LDH)-248 AlkPhos-52 TotBili-0.6
BLOOD CULTURE ([**2171-6-4**]): pansensitive
BLOOD CULTURE ([**2171-6-10**])
GRAM POSITIVE ROD(S).
CONSISTENT WITH CLOSTRIDIUM OR
BACILLUS SPECIES.
BILE CULTURE ([**2171-6-7**])
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN/SULBACTAM-- <=2 S 8 S
CEFAZOLIN------------- <=4 S 16 I
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2171-6-11**]):
CLOSTRIDIUM PERFRINGENS. SPARSE GROWTH.
Brief Hospital Course:
1. SIRS/sepsis with:
- cholangitis
- septicemia (GNR and anaerobic bacteremia)
- liver abscess
Initially presented to an OSH with signs and symptoms suggestive
of cholangitis (RUQ pain, fever and hypotension; labs and
ultrasound indicative of biliary obstruction). He was taken for
ERCP on [**6-4**] which revealed gallbaldder sludge and a filling
defect in the middle third of CBD without stone presence or
extrinsic compression; a stent was placed.
Surgery recommended PTC drain to decompress the gallbladder
which was done on [**6-7**]. Blood cultures returned with klebsiella
and clostridium species. After initially treating broadly,
antibiotics were narrowed. Unfortunately, the patient worsened
with RUQ ultrasound and MRCP showed worsening perihepatic
abscesses; repeat blood culture returned positive for bacillus.
After drainage of the largest liver abscess by interventional
radiology and use of vancomycin (for empiric enterococcus),
pip-tazo, and fluconazole (for empiric fungal coverage) he once
again improved.
At the time of discharge, plan included;
- antibiotics (vancomycin and ertepenem) until
cholecystectomy
- cholecystectomy in [**4-3**] weeks
- once cholecystectomy performed, both the gallbladder
drain and plastic stent can be removed
2. CHF, acute diastolic, resolved. After volume repletion was
grossly overloaded requiring diuresis.
3. Acute renal failure. Improved with supportive care.
Medications on Admission:
- HCTZ 25 mg PO qd
- cetirizine 10 mg PO qd
- citalopram 20 mg PO qd
Discharge Medications:
1. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. ertapenem 1 gram Recon Soln Sig: One (1) gram Injection once
a day for 4 weeks.
Disp:*qs mg* Refills:*0*
5. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 4 weeks.
Disp:*[**Numeric Identifier **] mg* Refills:*0*
6. Outpatient Lab Work
[**2171-6-24**] - result to Dr. [**Last Name (STitle) 9461**] (fax [**Telephone/Fax (1) 17715**])
Vancomycin trough
LFTs
CBC with diff
Chem 7
7. Outpatient Lab Work
[**2171-7-2**] - result to Dr. [**Last Name (STitle) 9461**] (fax [**Telephone/Fax (1) 17715**])
Vancomycin trough
LFTs
CBC with diff
Chem 7
8. Outpatient Lab Work
[**2171-7-8**] - result to Dr. [**Last Name (STitle) 9461**] (fax [**Telephone/Fax (1) 17715**])
Vancomycin trough
LFTs
CBC with diff
Chem 7
9. Outpatient Lab Work
[**2171-7-15**] - result to Dr. [**Last Name (STitle) 9461**] (fax [**Telephone/Fax (1) 17715**])
Vancomycin trough
LFTs
CBC with diff
Chem 7
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Location (un) 5871**]/[**Location (un) 6159**]
Discharge Diagnosis:
acute cholecystitis, choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fevers, confusion and cholangitis.
An ERCP on [**6-4**] revealed gallbaldder sludge and a filling defect
in the middle third of CBD without stone. To help reduce the
pressure in the gallbladder, a stent was placed followed by a
drain. You also required drainage of a liver abscess by
interventional radiology.
As a result of these multiple infections, you will require:
1. Treatment with antibiotics (ertapenem and vancomycin) with
coordination and duration directed by the infectious diseases
team
2. Removal of your gallbladder (cholecystectomy). Dr. [**Last Name (STitle) 853**] will
coordinate timing of this with you.
Once the gallbladder has been removed, the current gallbladder
drain and stent can be removed.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2171-6-25**] at 4:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2171-6-27**] at 3:10 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ENDO SUITES
When: TUESDAY [**2171-7-2**] at 12:00 PM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2171-7-2**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
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91,910
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4998
|
Discharge summary
|
Report
|
Admission Date: [**2136-8-3**] Discharge Date: [**2136-8-9**]
Date of Birth: [**2064-2-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin Preparations
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left lower lobe mass
Major Surgical or Invasive Procedure:
[**2136-8-3**] Left thoracotomy and left lower lobectomy with en bloc
chest wall resection and reconstruction with a 2-mm [**Doctor Last Name 4726**]-Tex
mesh, mediastinal lymph node dissection, intercostal muscle flap
buttress.
History of Present Illness:
Mr. [**Known lastname 20692**] is a 72 year old male with a 10 cm LLL NSCLC
confirmed by EBUS with negative work up for nodal and distant
metastatic disease. Preoperative evaluation for resection of
mass revealed borderline PFT's. He [**Known lastname 1834**] VQ scan on [**2136-7-19**]
with evidence of sufficient residual lung volume to tolerate LLL
resection. Patient [**Month/Day/Year 1834**] preop cardiac evaluation today with
MIBI and was found to have new onset atrial fibrillation with
RVR 120's. Cardiologists
recommended no additional work up since patient was without
angina or other symptoms of ischemia. Echo revealed normal
systolic function with mild MR.
Past Medical History:
- Cardiac stenting 12 years ago without recent stress test
- 2 lumbar disk surgeries
- Cholecystectomy [**45**] years ago
- Neuropathy
- Right thyroid nodule
Social History:
Cigarettes: quit 15 yrs ago, 20 pk yr hx
ETOH: 1 glass wine/night
Family History:
Sister had cervical CA in 80s, otherwise no family cancer hx.
Both mother and father died in 70's from DM complications:
amputations and DM.
Physical Exam:
Vital signs: T- HR- BP- RR- O2 Sat-
General: Well appearing, breathing comfortably
HEENT: Moist mucous membranes, no nasal flaring
CV: Irregular, Nl S1, S2
Resp: Right lung with breath sounds throughout, left lung -no
breath sounds at midchest downward, occasional wheezes
Abdomen: Soft, nontender, nondistended
Ext: Mild pedal edema (at baseline), no cyanosis, or sking
breakdown
Neuro: No gross abnormalities
Psych: A&Ox3, appropriate
Pertinent Results:
[**2136-8-8**]
CBC: WBC-11.4 Hgb-10.7 Hct-32.8 Plt Ct-347
Chemistry: Na-137 K-4.1 Cl-102 HCO3-26 UreaN-16 Creat-0.7
Glucose-105
CXR [**2136-8-9**]:
Status post left lower lobectomy with according pleural and
chest wall changes, as well as overall volume loss of the left
hemithorax. There is
no visualization of an apical pneumothorax.
Brief Hospital Course:
Mr. [**Known lastname 20692**] [**Last Name (Titles) 1834**] a left lower lobectomy with en bloc 4 rib
resection, chest wall reconstruction with a 2-mm [**Doctor Last Name 4726**]-Tex mesh,
mediastinal lymph node dissection, and intercostal muscle flap
buttress on [**2136-8-3**] without complications. He was extubated
without difficulty in the OR and was admitted to the ICU for
management of atrial fibrillation with sick sinus syndrome. The
rest of Mr. [**Known lastname 20693**] hospital course is described below by
system:
1. Respiratory:
Postoperatively, Mr. [**Known lastname 20692**] was kept on 4L of oxygen by nasal
cannula with O2 sats >95% and was breathing comfortably with
pain control by bupivicaine epidural and dilaudid PCA. Chest
tube had minimal serosanginous ouput with no leak detected. On
POD#2, patient had an episode of desaturation to high 80s on
100% O2. CXR showed complete collapse of left lung. Bronchoscopy
was performed with removal of copious clear mucus plugs from
left mainstem and LUL bronchi. Patient was placed on BIPAP
overnight for improved ventilation. AM CXR on POD#3 showed
re-expansion of lung and patient was started on nebulizer
treatments, with improvement in dyspnea, cough production, and
oxygen saturation. Chest tube was removed on POD#4 without
evidence of pneumothorax on post-pull CXR. Oxygen was gradually
weaned to 2L and patient was transferred to the floor on POD#5.
With chest PT and continued nebs, oxygen was weaned completely
by POD#5 during rest and exertion. Patient was discharged home
on POD#6 with O2 sats >98% on room air and arrangements for VNA
and nebulizer treatments at home.
2. Cardiac:
Mr. [**Known lastname 20693**] newly diagnosed afib was present throughout his
postoperative period. He was started on IV lopressor and
transitioned to po lopressor with dose titrated to keep rate
less than 120. He did not experience any ischemic symptoms
throughout this period. He was started on coumadin on POD#6, as
per his cardiologist, with plans to follow up with his PCP for
coumadin dosing.
3. Endocrine:
Mr. [**Known lastname 20693**] blood glucose was 150-200 in the PACU after
surgery. He was kept on a sliding scale during his hospital
stay. He will follow up with his PCP regarding diabetes work up.
4. Heme/Onc:
Pathology reports are pending on Mr. [**Known lastname 20693**] resected lung
mass. EBL from surgery was 1 liter and patient's hct post-op
trended down to 25.2 from preop of 30. He was transfused 2U
PRBCs with appropriate increase in HCT and Hct on day of
discharge was 32.8.
5. ID: No issues.
6. Renal: No issues, Cr less than 1 throughout stay, 0.7 on
discharge.
7. GI/FEN: No issues, tolerated regular diet with normal bowel
functions.
Medications on Admission:
Hydrocodone 5 mg + acetaminophen 500 mg prn
Discharge Medications:
1. Nebulizers Kit Sig: One (1) Miscellaneous every [**3-13**]
hours.Disp:*1 * Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain. Disp:*20 Tablet(s)* Refills:*1*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
Disp:*1 * Refills:*2*
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).Disp:*1 * Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left lower lobe lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you develop fevers
greater than 101.5, chills, nightsweats, shortness of breath,
unmanageable pulmonary secretions, uncontrolled pain or if left
chest incision develops redness, drainage or opens.
Walk 10-15 minutes 3-5 times a day. Start slow and increase.
Do not drive while on narcotics for pain. Take stool softeners
while on narcotics to prevent constipation.
Use nebulizer treatments every 6 hours (albuterol and
ipratropium) until you can cough easily without them. Do daily
breathing exercises (deep breath in, hold for 3 sec, breath out)
to keep your lungs expanded.
Followup Instructions:
Followup appointments:
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2136-8-21**] 1:00 [**Hospital Ward Name 23**] 9 [**Hospital Ward Name **]. Get a chest xray
30 minutes before this appointment on the [**Location (un) **] radiology
department of the [**Hospital Ward Name **].
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2136-8-21**]
11:45 [**Hospital Ward Name 23**] 9 [**Hospital Ward Name **]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2136-8-23**] 8:30
Completed by:[**2136-8-14**]
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[
1432,
1459
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],
[
[
2894,
2912
]
],
[
[
2919,
2937
]
],
[
[
6133,
6159
]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[
4989,
4993
]
]
] | 59
| 2,733
| 0
| 231
| 1
| 0
| 0
| 0
| 0
| 339
| 0
| 0
| 645
| 144
| 0
| 0
| 0
| 708
| 0
| 31
| 0
| 46
| 0
| 0
| 0
| 0
| 650
| 0
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| 0
| 0
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| 0
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| 0
| 0
| 673
| 0
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| 113
| 0
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|
92,473
| 143,547
|
33908
|
Discharge summary
|
Report
|
Admission Date: [**2161-12-22**] Discharge Date: [**2161-12-31**]
Date of Birth: [**2119-9-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Right hepatic duct stricture.
Major Surgical or Invasive Procedure:
[**2161-12-25**] right lobectomy for common hepatic stricture
History of Present Illness:
42M with remote h/o lap chole previously p/w [**Month/Day/Year 5283**] pain, s/p ERCP
[**11-18**] showing R hepatic biliary stricture, thougt to be
postsurgical; s/p PTC external biliary drain into R anterior
biliary duct [**11-19**], PTC repositioned [**11-30**]. Bile cultures grew
out sparse Lactobacillus. Discharged from hospital [**12-3**] on 21 d
course of Augmentin. Returned [**12-10**] with diarrhea, [**Month/Year (2) 5283**] abd pain,
nausea, po intolerance with 7 pound wt loss
Past Medical History:
Bile duct stricture
depression and anxiety.
ERCP [**2161-11-18**] showing R hepatic biliary stricture
PTC external biliary drain into R anterior biliary duct
[**2161-11-19**], PTC repositioned [**2161-11-30**]
chronic back pain s/p fall down stairs 1 yr prior
PSH: lap chole [**2145**], L4-5/L5-S1 fusion [**10-5**]
[**2161-12-22**] R hepatic lobectomy with cholangiogram for R duct
biliary stricture, benign
Social History:
The patient's relatives are from [**Name (NI) 11660**]
islands. He lives in RI. He is not currently working. He does
smoke cigarettes
one pack per day for 13 years. He does not consume alcohol. He
is married. His wife has suffered from Lupus for many years and
recently completed a lengthy chemotherapy course. He and his
wife have been financially stressed. Has been staying with his
daughter in [**Name (NI) 1474**], MA
Family History:
Family history is significant for cancer and diabetes in his
mother and father as well. There is no family history of spinal
disorders.
Pertinent Results:
[**2161-12-22**] 04:58PM BLOOD WBC-15.6*# RBC-3.85* Hgb-12.2* Hct-35.3*
MCV-92 MCH-31.7 MCHC-34.5 RDW-13.5 Plt Ct-391
[**2161-12-23**] 03:38AM BLOOD WBC-12.9* RBC-3.72* Hgb-11.7* Hct-35.1*
MCV-95 MCH-31.5 MCHC-33.3 RDW-13.3 Plt Ct-291
[**2161-12-25**] 04:11AM BLOOD WBC-8.8 RBC-2.84* Hgb-9.2* Hct-27.1*
MCV-95 MCH-32.5* MCHC-34.1 RDW-13.4 Plt Ct-190
[**2161-12-28**] 05:30AM BLOOD WBC-4.6 RBC-2.49* Hgb-8.0* Hct-22.9*
MCV-92 MCH-32.1* MCHC-34.9 RDW-13.5 Plt Ct-307
[**2161-12-30**] 06:53AM BLOOD WBC-4.6 RBC-2.53* Hgb-8.1* Hct-24.2*
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.8 Plt Ct-363
[**2161-12-30**] 06:53AM BLOOD Glucose-105 UreaN-6 Creat-0.6 Na-142
K-3.8 Cl-105 HCO3-32 AnGap-9
Brief Hospital Course:
On [**2161-12-22**] he underwent right hepatic lobectomy with
cholangiogram for right hepatic duct stricture. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see operative report for details. Postop,
he was sent to the SICU given excessive pain management needs.
APS followed him. He was treated with vanco and zosyn for 24
hours then remained afebrile until pod 2 when he had a temp of
101.2. This was attributed to atelectasis. He was encouraged to
use the incentive spirometer and was assisted oob. Temperature
decreased. He was transferred out of the SICU on [**12-26**].
Bile was noted in his JP. On [**12-28**], JP fluid bilirubin was 3.1.
LFTs improved with the exception of the alk phos which which
increase slightly from 96 to 123. His complaint posopt op was
pain control. Initially postop, this was controlled with an
epidural that was ineffective. The epidural meds were then split
with a dilaudid pca and a bupivicaine epidural that was later
discontinued on pod 3. Oxycontin was then added at 45mb [**Hospital1 **] and
prn oxycodone. This was ineffective in controlling his pain.
Oxycontin was switched to MS contin 90mg [**Hospital1 **] with oxycodone
breakthru. PCA was discontinued. He required supplemental break
thru iv dilaudid for [**Hospital1 5283**] pain.
On [**12-29**], an abdominal CT was done to evaluate his pain. This
showed a small-to-moderate amount of fluid about the liver and
at the resection bed with free air presumed to be post-surgical.
His diet was advanced slowly and tolerated. He was drinking [**3-1**]
Ensures per day.He was ambulatory and vital signs remained
stable. Of note, his hct slowly trended down from 35.3 on pod 0
to 22.9 on pod 6. This stablized at 24 on pod 7 and 8.
Incision was clean, dry and intact without redness. JP drainage
averaged 200cc of bile tinged fluid. He was discharged with the
JP and was instructed to record volume of outputs. He was
declared safe for discharge home with a st. cane by PT.
Pathology was as follows: I. Right hepatic duct (A-B):
1. Chronic inflammation with focal glandular regeneration and
fibrosis.
2. No tumor.
II. Liver, right lobe (C-J):
1. Area of chronic inflammation with bile duct epithelial
regeneration and marked fibrosis.
2. No tumor.
3. Moderate steatosis and mild portal mononuclear cell
inflammation, without intracellular hyalin.
Clinical: Bile duct stricture, pain.
Gross: The specimen is received fresh from the O.R. in two
parts, both labeled with "[**Known lastname 16651**], [**Known firstname **]" and the medical
record number.
Part 1 is additionally labeled "right hepatic duct." It consists
of one piece of brown soft tissue measuring 1.0 x 0.8 x 0.7 cm.
A lumen is identified within the specimen. The specimen is
bisected and frozen for intraoperative frozen section diagnosis.
Frozen section diagnosis by Dr. [**Last Name (STitle) **] reads: "Right hepatic duct:
Bile duct with edema, mild chronic and acute inflammation, and
focal epithelial hyperplasia with mild atypia. No definitive
carcinoma seen, final diagnosis pending permanent sections." The
specimen is entirely submitted as follows: A = frozen section
remnant, B = remaining tissue.
Part 2 is additionally labeled "liver, right lobe." It consists
of a right lobe of liver weighing 772 grams and measuring 18 x
12.2 x 6 cm. The anterior and superior and posterior surface of
this right liver lobe is smooth and peritoneal with a rough area
measuring 1 x 1 cm near the lateral edge which is consistent
with cautery. There is a rough surface on the medial edge of the
specimen which measures 14 x 7 cm and has cautery marks. There
are associated staples throughout this rough edge and there are
no discernable structures. A portion of this area is inked in
black at the potential margin. The specimen is serially
sectioned medially to laterally at 5 mm intervals to reveal a
surpentuous white area which contains a tubular structure. This
area measures 4.5 x 3 cm and is firm. The specimen is
represented as follows; C-D = shaved inked margin, E-I =
representation of white firm area inferior to superior, J =
normal liver parenchyma.
Medications on Admission:
tylenol, colace, valium 1 [**Hospital1 **], nicotine patch, paxil 30', senna,
MS Contin 30mg q 12 hours, oxycodone 2-3 tabs q 4 hours prn
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO q8H PRN as
needed for pain.
6. Morphine 30 mg Tablet Sustained Release Sig: Three (3) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*42 Tablet Sustained Release(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Diazepam 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours)
as needed for anxiety.
Disp:*20 Tablet(s)* Refills:*0*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary stricture
acute and chronic pain
Discharge Condition:
Good
Discharge Instructions:
1. Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if fever,
chills, nausea, vomiting, worsening abdominal pain, jaundice
(yellowing of whites of eyes or skin)or diarrhea/constipation
2. No driving while taking pain medication
3. No heavy lifting for four weeks
4. You may shower, but no baths.
5. Empty and record volume of fluid from drain.
Followup Instructions:
Please call Dr.[**Name (NI) 670**] office to schedule a follow-up
appointment.
Please also follow up with your primary care doctor.
Completed by:[**2162-1-1**]
|
[
"576.2",
"311",
"300.00",
"338.29",
"V45.4",
"305.1",
"518.0"
] |
icd9cm
|
[
[
[
275,
303
],
[
2757,
2785
],
[
8021,
8037
]
],
[
[
971,
980
]
],
[
[
986,
992
]
],
[
[
1161,
1177
],
[
8049,
8060
]
],
[
[
1239,
1255
]
],
[
[
1496,
1511
]
],
[
[
3137,
3147
]
]
] |
[
"50.3"
] |
icd9pcs
|
[
[
[
362,
405
]
]
] | 7
| 4,179
| 0
| 65
| 8
| 0
| 0
| 0
| 0
| 678
| 0
| 0
| 163
| 140
| 0
| 0
| 0
| 929
| 0
| 46
| 0
| 140
| 0
| 0
| 0
| 0
| 372
| 0
| 0
| 0
| 0
| 0
| 0
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| 0
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| 493
| 0
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| 413
| 425
| 0
| 0
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| 0
| 0
| 0
| 0
| 0
|
96,443
| 103,219
|
15250
|
Discharge summary
|
Report
|
Admission Date: [**2109-12-20**] Discharge Date: [**2110-1-5**]
Date of Birth: [**2045-2-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Quinine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2109-12-20**] Right posterolateral thoracotomy, replacement of the
proximal descending thoracic aortic aneurysm using a 26mm
Vascutek Dacron interposition tube graft
[**2109-12-20**] Diagnostic bronchoscopy pre-aortic reconstruction and
bronchoscopy with toilet aspiration of secretions post aortic
reconstruction
[**2109-12-23**] Right Bronchial Y-stent placement
[**2109-12-23**] Flexible bronchoscopy and Therapeutic aspiration of
secretions
[**2109-12-27**] Flexible bronchoscopy through endotracheal tube,
Therapeutic aspiration of secretions, Bronchoalveolar lavage of
the right middle lobe
History of Present Illness:
64 y/o female with complex past medical history (see below) who
has had intermittent bouts of dyspnea on exertion and hoarseness
(along with wheezing and dysphagia) over the past several years.
Underwent coronary artery bypass graft x 1 with respiratory
function continuing to decline. Further work-up revealed right
sided arch with aberrant takeoff of left subclavian and dilated
aorta. Also noted to have right mainstem bronchus compression.
Has already underwent 2 surgical procedures with vascular
surgery (Dr. [**Last Name (STitle) **] and now presents for surgical
replacement of her descending aorta.
Past Medical History:
Descending thoracic aortic aneurysm with aberrant left
subclavian artery and Kumeral's diverticulum with aortic sling
compressing the right main stem bronchus, s/p Left Carotid to
Subclavian bypass [**7-7**], s/p Amplatzer plugging of Aberrant left
subclavian [**9-6**], Coronary artery bypass graft x 1 (LIMA to LAD),
Connective tissue disorder with features of Lupus, Sjogren's and
raynaud syndrome, Stroke, Interstitial lung disease,
Hypothyroidism, Gastroesophageal Reflux disease, Right kidney
cyst, s/p cholecystectomy, s/p carcinoid tumor removal during
colonoscopy, s/p right lung resection?wedge
Social History:
She is a retired administrative assistant. She quit smoking 15
years ago and has wine daily with dinner. She is currently
living with her husband.
Family History:
She has a noncontributory family history.
Physical Exam:
At Discharge:Expired
Pertinent Results:
[**12-20**] Echo: PREBYPASS: 1. The left atrium is mildly dilated. 2.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal. 4. The descending thoracic aorta is moderately dilated.
The patient has a known right sided arch. 5. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. 6. The mitral valve
appears structurally normal with trivial mitral regurgitation.
7. There is no pericardial effusion. 8. Dr. [**Last Name (STitle) 914**] was notified
in person of the results during the surgical procedure.
POSTBYPASS: Patient is on an phenylephrine infusion and is in
sinus rhythm 1. Biventricular function is preserved. 2.
Descending thoracic graft not clearly appreciated. 3. Other
findings are unchanged.
[**Known lastname 44356**],[**Known firstname 3049**] [**Age over 90 44357**] F 64 [**2045-2-20**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2109-12-31**]
8:43 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2109-12-31**] SCHED
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # [**Clip Number (Radiology) 44358**]
Reason: elevated lft's, not tolerating tube feeds, elevated INR
not
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman s/p right sided descending aorta repair
REASON FOR THIS EXAMINATION:
elevated lft's, not tolerating tube feeds, elevated INR not
on coumadin. Please
do chest and abdominal CT WITH PO contrast
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: AJy TUE [**2109-12-31**] 6:33 PM
PFI:
1. The feeding tube appears to be coiled within the stomach and
is not
post-pyloric. Remainder of the supporting and monitoring lines
and tubes
appear in adequate position.
2. Bilateral lower lobe focal consolidation with air
bronchograms consistent
with pneumonia. Aspiration should be considered given location.
Further
interstitial and ground-glass opacities likely reflect a
combination of
atelectasis and fluid overload.
3. Ascites and diffuse anasarca suggest fluid overload.
4. Borderline fatty infiltration of the liver, but no biliary
dilatation or
mass lesions to explain patient's liver function test
abnormalities.
5. Status post repair of descending thoracic aortic aneurysm,
without
evidence for immediate complication.
Final Report
HISTORY: 64-year-old female, status post repair of descending
thoracic aortic
aneurysm. Referred for evaluation of persistent fever, elevated
LFTs and INR,
and poor tolerance of tube feedings.
COMPARISON: CT of the chest dated [**2109-5-10**].
TECHNIQUE: MDCT axial imaging of the chest and abdomen was
performed
following the administration of oral but not IV contrast.
Sagittal and
coronal reformatted images were reviewed.
CT CHEST: An endotracheal tube terminates approximately 2.5 cm
from the
carina. Tracheal Y-stent is seen with branches extending into
the right and
left main stem bronchi. Two right-sided central venous lines,
one subclavian
and one internal jugular, terminate in the distal SVC. There is
an NG tube
terminating in the stomach. A Dobbhoff-type feeding tube is also
seen
extending into the stomach and is coiled extensively, not
extending post-
pylorically. A right-sided chest tube courses along the
posterior margin of
the lung and terminates adjacent to the superior mediastinum.
Right-sided aortic arch is again noted. Patient is status post
repair of
descending thoracic aortic aneurysm, with graft anastomoses seen
at the level
of the arch and inferiorly. The graft appears to extend
approximately 10 cm
in the craniocaudal direction, and has a diameter of 2.9 cm at
the level of
the carina. There is no significant mediastinal hematoma. The
heart and
pulmonary vessels appear unremarkable. Coronary vascular
calcifications are
appreciated.
There are diffuse reticular and ground-glass opacities in both
lungs, left
greater than right, and more pronounced at the lung bases, where
there are
also areas of focal consolidation and air bronchograms
appreciated. The
crowding of vessels and bronchi suggests a component of
atelectasis, and
generalized anasarca indicates that a degree of fluid overload
is also likely
involved. However, an underlying pneumonia cannot be excluded;
dependent
location would suggest aspiration as possible etiology. There is
no
significant pleural effusion on the right. Pleural effusion on
the left is
small.
There is no mediastinal lymphadenopathy appreciated. There is no
axillary or
supraclavicular lymphadenopathy.
CT ABDOMEN: Oral contrast is seen in the stomach only.
Evaluation of intra-
abdominal organs is limited in lack of IV contrast. There is
moderate amount
of ascites present. The liver is of somewhat low attenuation,
suggesting
fatty infiltration. Liver is otherwise unremarkable without
focal lesions or
intra-/extra-hepatic biliary dilatation. Patient is status post
cholecystectomy. The pancreas, spleen, and adrenal glands appear
normal. The
left kidney is unremarkable. There is a large 5 x 6 cm cystic
structure
arising from the superior pole of the right kidney and has the
density of
simple fluid and is likely a simple cyst. This is unchanged
compared to [**Month (only) 547**]
of [**2109**]. There is no soft tissue stranding or significant
lymphadenopathy
present. There is no free air. Vascular calcifications are seen
without
aneurysmal dilatation.
IMPRESSION:
1. The feeding tube is coiled in the stomach. The remainder of
the
supportive and monitoring devices appear in adequate position.
2. Status post repair of descending thoracic aortic aneurysm,
with no
evidence for immediate post-surgical complication.
3. Diffuse interstitial and ground glass opacities in the lungs,
left
greater than right, with focal consolidations at the bilateral
bases. While
atelectasis and fluid overload are present, underlying pneumonia
cannot be
excluded. The location suggests aspiration as possible etiology.
4. Mild ascites and soft tissue anasarca suggests fluid
overload.
5. Stable large right renal cyst.
6. Borderline fatty infiltration of the liver, without evidence
for focal
liver lesions, biliary dilatation, or masses. Patient is status
post
cholecystectomy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: WED [**2110-1-1**] 10:03 AM
Imaging Lab
[**Known lastname 44356**],[**Known firstname 3049**] [**Age over 90 44357**] F 64 [**2045-2-20**]
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
Study Date of [**2109-12-29**] 4:57 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2109-12-29**] SCHED
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL Clip #
[**Clip Number (Radiology) 44359**]
Reason: evaluate flow, increased LFT ? obstruction
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with s/p descending aorta replacement
REASON FOR THIS EXAMINATION:
evaluate flow, increased LFT ? obstruction
Wet Read: KYg SUN [**2109-12-29**] 7:13 PM
limited exam. no e/o bil dil. patent hepatic vasculature.
Final Report
CLINICAL HISTORY: 64-year-old female with lupus, status post
descending aorta
surgery, with increased LFTs. Evaluate for obstruction.
COMPARISON: None.
ABDOMINAL ULTRASOUND: Limited exam as indwelling chest tubes
limits acoustic
windows. The liver is somewhat heterogeneous in appearance. No
focal hepatic
lesion is identified. There is no intra- or extra-hepatic
biliary dilatation.
The common duct measures 5 mm. There is no ascites.
DOPPLER ULTRASOUND: With the exception of the left portal vein,
which could
not be interrogated, the main/right portal veins and hepatic
veins are patent
with appropriate waveforms. The main, right and left hepatic
arteries show
normal flow.
IMPRESSION:
1. Limited exam as patient with indwelling chest tubes which
limits acoustic
windows. No focal hepatic lesion or evidence of biliary
dilatation.
2. Patent hepatic vasculature. The left portal vein was not
interrogated.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: MON [**2109-12-30**] 10:40 AM
Imaging Lab
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit and on [**12-20**] was brought to the
operating room where she underwent a right posterolateral
thoracotomy, replacement of the proximal descending thoracic
aortic aneurysm using a 26-mm Vascutek Dacron interposition tube
graft and bronchoscopy. Please see operative report for complete
surgical details. Post-surgery bronchoscopy revealed right
mainstem bronchus to still be collapsed. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. On post-op day one she was weaned from sedation,
awoke neurologically intact and extubated. Pulmonary medicine
was consulted for stent placement on post-op day two.
Post-operatively she required several blood transfusions d/t
anemia. Lumbar drain was removed on post-o p day two. Also on
this day she had episode of atrial fibrillation and was treated
appropriately. She continued to have bouts of atrial
fibrillation during post-op course. On post-op day three she was
brought to the operating room where she underwent Y-stent
placement by interventional pulmonology. Later this day she
required a bronchoscopy which found significant mucus retention
and mucus plug in the lumen of the Y-stent. And had successful
therapeutic aspiration. Later on this day she was again weaned
from sedation and extubated. Aggressive pulmonary therapy/toilet
were performed but she continued to require several
bronchoscopies and increasing oxygen requirements over next
several days. Overnight on post-op day six Mrs. [**Known lastname **] was
progressively getting more dyspneic and was in respiratory
distress the morning of post-op day seven, requiring intubation
and mechanical ventilation. Respiratory distress and hypoxia
seemed to be from developing pneumonia (Chest x-rays were
consistent with pneumonia and acute lung failure with ground
glass opacities) and acute respiratory distress syndrome. Blood
cultures taken on post-op day seven were positive for
Enterobacter Aerogenes and COAG negative Staphylococcus.
Bronchoalveolar Lavage and Urine cultures were positive as well
and she was started on broad-spectrum antibiotics until final
sensitivities were performed. Also on this day she had
increasing metabolic acidosis and hypotension (d/t septic shock)
and required multiple pressor support. She received similar
medical care over the next several days (including multiple
pressors and antibiotics) and infectious disease was consulted
on post-op day 11.
The patient remained intubated and her condition worsened with
the family asking that the patient be made comfort measures
only. The patient was extubated and expired shortly thereafter.
Medications on Admission:
Atenolol 12.5mg qd, Lipitor 10mg qd, Restasis, Plaquenil 400mg
qd, Synthroid 100mcg qd, Protonix 80mg qd, Effexor 75mg qd,
Zolpidem 10mg qd, Spiriva, Advair, Albuterol
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Descending thoracic aortic aneurysm with aberrant left
subclavian artery and Kumeral's diverticulum with aortic sling
compressing the right main stem bronchus s/p Right
posterolateral thoracotomy, replacement of the proximal
descending thoracic aortic aneurysm [**12-20**] and Right Bronchial
Y-stent placement [**12-23**]
Post-op Pneumonia
Post-op Sepsis
Post-op Acute Respiratory Distress Syndrome
Post-op Atrial Fibrillation
Post-op Anemia
PMH: s/p Left Carotid to Subclavian bypass [**7-7**], s/p Amplatzer
plugging of Aberrant left subclavian [**9-6**], Coronary Artery
Disease s/p Coronary artery bypass graft x 1 (LIMA to LAD),
Connective tissue disorder with features of Lupus, Sjogren's and
raynaud syndrome, Stroke, Interstitial lung disease,
Hypothyroidism, Gastroesophageal Reflux disease, Right kidney
cyst, s/p cholecystectomy, s/p carcinoid tumor removal during
colonoscopy, s/p right lung resection?wedge
Acute lung injury and respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2110-1-28**]
|
[
"V45.81",
"244.9",
"530.81",
"V15.82",
"441.2",
"747.69",
"997.39",
"995.91",
"518.82",
"429.4",
"285.1"
] |
icd9cm
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] |
[] |
icd9pcs
|
[
[
[]
]
] | 10
| 2,675
| 0
| 602
| 10
| 0
| 0
| 0
| 0
| 1,415
| 0
| 0
| 39
| 44
| 0
| 0
| 0
| 18
| 57
| 965
| 0
| 170
| 0
| 0
| 0
| 0
| 10
| 0
| 0
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| 0
| 0
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| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 1
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 11
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 22
| 1,331
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 610
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 607
| 149
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
97,037
| 129,694
|
12490
|
Discharge summary
|
Report
|
Admission Date: [**2117-3-6**] Discharge Date: [**2117-3-12**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 14820**]
Chief Complaint:
Tachycardia at rehabilitation facility, hypotension.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is an 84 year old male with PVD and recent admission for
right axillobifemoral artery bypass grafting c/b wide complex
tachycardia, systolic CHF, COPD, nonfunctional ICD; admit with
hypotension following treatment for "SVT" and concern of sepsis.
Patient was recently admitted [**2117-2-12**] - [**2117-3-5**] for gangrenous
lower extremities; workup included angiography with eventual
revascularization (axillobifemoral grafting). Course complicated
by wide complex tachycardia (SVT with aberrancy vs. Vtach)
following central line change requiring amio drip, eventually
discharged on PO amiodarone.
Patient noted at rehab to have "SVT" with HR 140s at 7:30 AM.
ECG performed and thought to be SVT by rehab (review actually
concerning for VT). Given 10 mg IV lopressor and 25 mg IV
diltiazem total. SBP 83 with HR 138 at rehab. Maintained SBPs in
80s-90s with HRs in 120s-130s throughout [**Hospital1 **] course; per
page one at least 90 minutes in this rhythm. Does note mild
dyspnea during this time, but otherwise reports being
asymptomatic (though poor historian). Denies CP, palps, cough,
abdominal pain, diarrhea, fever, bleeding, HA, dizziness,
lightheadedness, lower extremity pain, change in baseline edema
(denies edema).
In the [**Hospital1 18**] ED, vitals T 97.9, HR 80, 91/55, R18, 94% 3L. SBP
range 81-92. Started NRB for sats in high 80s on 5L. Labs
notable for WBCs 22K with abnormal diff (though has this at
baseline), BNP 33K, troponin 0.09, lactate 2-> 0.8, ABG
7.48/35/156 on NRB. UA negative. CXR with pulm edema and
worsened effusions, otherwise unremarkable. Guaiac negative. Got
vanc/?levoflox (per verbal report only) for concern for sepsis.
1 L NS given. Vascular consulted, felt surgical wounds healing
well without evidence of infection.
Past Medical History:
- chronic systolic heart failure with EF 20%; s/p ICD placement
but currently nonfunctional [**12-21**] wire fracture
- CAD with history of large anterior MI in past
- History of Vtach and Vfib in past, managed by ICD
- Left hip fx s/p repair
- PVD, s/p recent axillobifemoral bypass
- carotid stenosis s/p bilat CEAs
- COPD
- macular degeneration
- GERD
- PUD s/p surgical repair in past
- anemia
Social History:
Previously lived with son, widower of 2 years, now in rehab.
Smoked [**11-20**] ppd up through recent hospital admission. Non-alcohol
beer in the day and whiskey x 3 at night prior to rehab stay.
Family History:
No family history of early CAD or early sudden cardiac death.
Physical Exam:
On admission:
General: Alert elderly male, no respiratory distress.
HEENT: PERRL, EOMI, MMM.
Neck: Prominent carotid pulsations, JVD appears to be only ~3
ASA, no adenopathy. Bilat carotid bruits.
Heart: very diminished heart sounds, no murmurs appreciated.
Lungs: Diminished throughout with further decrease at bases,
rare wheeze and basilar crackles.
Abdomen: + BS, soft, NT, mildly distended but tympanic
throughout.
Extrem/Skin: Warm. 2+ pitting edema of bilat UEs, LEs, and
sacrum. LLE severely affected by vascular ulcerations/eschars
(particularly L lateral leg with minimal surrounding erythema
except most proximal portion of ulceration with increased
erythema concerning for ?cellulitis. No drainage. Bilat heel
ulcers (likely pressure ulcers). R axillary and bilateral groin
incisions C/D/I with intact staples. Dopplerable DP/PT.
Back: ~5x5cm sacral decub with central eschar.
Neuro: II-XII intact. Strength 5/5 bilateral UE and RLE; LLE
with weak (3 to 4-/5) dorsiflexion. Oriented to place and [**Month (only) 547**]
[**2115**].
Pertinent Results:
Labs on admission:
[**2117-3-5**] 06:40AM BLOOD WBC-18.0* RBC-3.34* Hgb-10.6* Hct-31.6*
MCV-95 MCH-31.6 MCHC-33.4 RDW-18.8* Plt Ct-287
[**2117-3-5**] 06:40AM BLOOD Neuts-60 Bands-3 Lymphs-8* Monos-15*
Eos-6* Baso-0 Atyps-0 Metas-1* Myelos-5* Promyel-2*
[**2117-3-6**] 11:55AM BLOOD PT-14.7* PTT-28.9 INR(PT)-1.3*
[**2117-3-5**] 06:40AM BLOOD Glucose-87 UreaN-24* Creat-1.4* Na-139
K-3.9 Cl-105 HCO3-26 AnGap-12
[**2117-3-6**] 11:55AM BLOOD ALT-14 AST-34 LD(LDH)-553* CK(CPK)-98
AlkPhos-86 TotBili-0.6
[**2117-3-6**] 11:55AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 38760**]*
[**2117-3-5**] 06:40AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.3
[**2117-3-6**] 11:55AM BLOOD Digoxin-1.2
.
CXR [**3-6**]
AP UPRIGHT CHEST: A left pacer/AICD with leads overlying the
right atrium and ventricle is stable. Mild cardiomegaly
persists. Moderate left and small right pleural effusions are
noted. There is diffuse hazy bilateral reticular opacity with
[**Last Name (un) 16765**] A and B lines. There is no focal consolidation or
pneumothorax.
IMPRESSION: Moderate CHF.
.
CXR [**3-9**]
In comparison with the study of [**3-7**], there is increasing
prominence of the cardiac silhouette with evidence of pulmonary
edema and bilateral pleural effusions. The change in heart size
raises the possibility of underlying pericardial effusion.
Pacemaker leads remain in place. Retrocardiac opacification most
likely is consistent with atelectasis, though supervening
pneumonia cannot be
unequivocally excluded.
Brief Hospital Course:
This is an 84 year old male with history of PVD status-post
recent axillobifemoral grafting with course complicated by wide
complex tachycardia; now admitted to MICU after getting multiple
nodal agents for VT at rehab.
# Ventricular tachycardia:
The patient has had previous Ventricular Tachycardia (VT). On
this admission, he presented with a wide complex VT which is
different from his previous VT. Cardiology followed the patient
at arrival to MICU. The reason for recurrence of VT is unclear:
new ischemia, stretch from volume overload, or possibly further
disruption of pacer leads leading to more irritation of
ventricle. The patient did have an episode of asymptomatic
ventricular tachycardia on night of admission that spontaneously
aborted. He also received amiodarone 150 mg IV at time of that
ventricular tachycardic episode. He had a repeat episode of VT
on [**3-9**] in the morning. He was given amiodarone 150 mg IV x 1,
Lidocaine 75 mg IV x 2. EP converted to sinus rhythm via
patient??????s AICD. He was started on Mexiletine 150 mg [**Hospital1 **] with
plans to titrate this medication per Cardiology. He had another
episode of VT on the morning of [**3-10**] which converted with
another bolus of amiodarone 150 mg IV. He did not have any
further episodes of VT since then.
He was continued on oral amiodarone 400 mg twice daily, his
electrolytes (magnesium and potassium) were repleted
aggressively.
According to Cardiology, he is not a candidate for lead
replacement, and should be medically managed. This is also in
line with the patient and his family's wishes to avoid
aggressive care. (The patient is DNR/DNI, and moving towards
comfort care, although not at officially comfort care only). TTE
on [**3-9**] showed slightly increased EF (25-30%), slightly
decreased left ventricular cavity size and slightly worse mitral
regurg. Amiodarone dosing should be adjusted as follows:
Amiodarone 400 mg twice a day for one more week (through [**3-18**]), then 200 mg twice a day for two weeks ([**3-19**] through
[**4-1**]), then 200 mg once a day indefinitely.
.
# Hypotension:
Possible causes include sepsis / vasodilatory (given
leukocytosis and questionable appearance of gangrenous ulcers),
cardiogenic (ACS or poor forward flow from CHF; less likely
pericardial effusion), most likely med related (multiple
nodal/negative inotropic agents for tachycardia). Lactate was
not elevated. Vancomycin was discontinued after 48 hours with
continued negative culture data; he remained afebrile. His ACEI
and alpha blockers were held; he was continued on low dose beta
block given arrhythmia as BPs tolerate. Pt remained 110s-130s
systolic since transfer out of MICU on [**3-10**].
.
# Hypoxia:
He was on a non-rebreather (NRB) in the ED but easily
transitioned to nasal cannula (NC) in ICU. This was likely
volume overload related. He also has a history of COPD. He was
satting 99-100% on RA, although he did have increased wheezing
and dyspnea over the night of admission without relief with
nebs. He was given solumedrol 125 mg IV with improvement.
Steroids and nebulizers were discontinued and goal even to
negative fluid balance was maintained with PRN IV Lasix. Lasix
was held since [**3-10**] due to mild elevation of creatinine. Pt
maintained O2 sats in mid-upper 90s on RA-2L via NC.
.
# Congestive heart failure, systolic dysfunction, acute on
chronic:
The patient had elevated BNP and pulmonary edema on chest x-ray.
His beta-blocker dose was increased over the night of admission
and continued as pressures tolerated. His ACEI was held for
hypotension. His I/Os were also targeted for a net diuresis with
PRN Lasix. Again, lasix was held since [**3-10**] and remained net
even since then. Pt remained stable from respiratory
perspective. Consider restarting lasix (was on 20 mg PO Qday) in
[**12-22**] weeks.
.
# Lung Nodules/Spiculated Mass: on CT [**2117-3-2**] from prior
admission. At that time it was felt to be infectious process but
it needs to be followed for resolution.
- Repeat CT in 3 months vs pulmonary consult as outpatient
.
# Leukocytosis:
Vancomycin was discontinued on [**3-9**]. The patient has no normal
recorded WBC count in recent history. Thoughts are Infection vs.
hematopatholgy, and it is felt the patient should consider
outpatient hematology workup for possible myelodysplasia. No LAD
on exam.
.
# PVD with recent revascularization:
Vascular surgery followed patient. No acute events. Qday
dressing changes on left leg (cover with dry guaze, then wrap
with kerlix)
.
# Sacral decubitus:
Wound care was consulted and directed care. Pt was turned every
2-3 hours.
.
Medications on Admission:
Aspirin 81 mg DAILY
Digoxin 125 mcg MONDAY, WEDNESDAY, FRIDAY
Ferrous Sulfate 325 mg DAILY
Camphor-Menthol TID as needed.
Simvastatin 20 mg DAILY
Omeprazole 20 mg DAILY
Lisinopril 2.5 mg DAILY
Tamsulosin 0.4 mg HS
Amiodarone 200 mg DAILY
Metoprolol 12.5 mg [**Hospital1 **]
Thiamine HCl 100 mg DAILY
Multivitamin DAILY
Ipratropium neb Q6H
Albuterol Sulfate Nebulization Q6H and Q2H as needed for
wheezing.
Oxycodone-Acetaminophen 5-325 mg [**11-20**] Q4H as needed
Lasix 20 mg once a day.
Collagenase 250 unit/g Ointment DAILY
Miconazole Nitrate 2 % TID as needed.
Heparin SC 5000 units [**Hospital1 **]
colace 100 mg [**Hospital1 **] prn
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day) as needed for constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical
DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4-Q6 ().
12. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
13. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: through [**3-18**], then 200mg [**Hospital1 **] for two
weeks, then 200 mg Qday indefinitely.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Wide complex tachycardia
Chronic systolic heart failure
Acute on chronic renal failure
PVD w/ cellulitis/dry gangrene LLE
Decubiti (scaral area, both buttocks and both hip areas)
Discharge Condition:
Stable.
Discharge Instructions:
You were brought to the hospital for evaluation of a fast heart
rhythm that was noticed at the rehab. We were able to control it
with medications. You expressed the wish to shift the overall
goal of care away from aggressive measures. Our
electrophysiologists (cardiologists that specialize in heart
rhythm) agreed with the plan, and again recommended against
fixing the fractured defibrillator leads.
.
Changes were made to your medication regimen. Most notably, you
will take amiodarone 400 mg twice a day for one more week
(through [**3-18**], then 200 mg twice a day for two weeks ([**3-19**] through [**4-1**]), then 200 mg once a day indefinitely.
.
Please call your doctor if you experience any symptoms
concerning to you. They will be able to triage and will tell you
whether you need an evaluation in the emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2117-4-27**] 8:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2117-4-27**] 9:00
Vascular surgery: Dr. [**Last Name (STitle) 38759**] Wednesday, [**3-17**] at 10:15 am.
([**Telephone/Fax (1) 4852**] (Please call to confirm appointment. You will
also get staples removed then)
Completed by:[**2117-3-12**]
|
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"707.03",
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"585.9"
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[] |
icd9pcs
|
[
[
[]
]
] | 87
| 4,623
| 0
| 8
| 11
| 0
| 0
| 0
| 0
| 6
| 0
| 0
| 492
| 64
| 0
| 0
| 0
| 1,329
| 0
| 182
| 0
| 641
| 0
| 0
| 0
| 0
| 832
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 1
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 56
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 1,777
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 1,474
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 400
| 198
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
97,765
| 118,349
|
39728
|
Discharge summary
|
Report
|
Admission Date: [**2173-10-4**] Discharge Date: [**2173-10-16**]
Date of Birth: [**2109-5-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hydrothorax
Major Surgical or Invasive Procedure:
TIPS Placement (Failed x2)
History of Present Illness:
[**Known firstname 85376**] [**Known lastname 174**] is a 64 year old male with alcoholic cirrhosis c/b
portal hypertension, ascites, and varices who presented as a
transfer from [**Hospital1 **] for TIPS evaluation. Of note, he has
Guillain-[**Location (un) **] syndrome and is currently wheelchair bound due to
lower extremity weakness.
.
He was diagnosed with cirrhosis in [**4-/2173**] and was unaware of his
liver disease prior to then. Per patient report, he has had
paracentesis about twice monthly since then with volumes of [**7-16**]
L. He reports failing diuretic therapy due to symptomatic
hypotension. He also reports that he has had endoscopy showing
mild varices and denies ever having upper or lower GI bleeding.
.
Per the patient, he has needed recurrent paracentesis over the
past few months despite being on Furosemide and Spironolactone.
His hepatologist suggested a TIPS procedure to relieve the
recurrent ascites and hepatic hydrothorax which he has had over
the past year. The patient states that he initially went to
[**Hospital1 **] to have the TIPS procedure done, but later requested a
transfer since he wanted one of the [**Hospital1 18**] IR physicians to do
the procedure.
.
Per the transfer summary he was admitted to [**Hospital3 **] on
[**2173-9-18**] for increasing ascites and hypotension. The transfer
summary is confusing but it appears as if there was a concern
for SBP. He was given an albumin infusion which was later
discontinued due to pleural effusion. He was then seen by
Pulmonary who noted his cirrhosis, ascites, and a large pleural
effusion. They decided to observe him, and offered thoracentesis
for to help with dyspnea. The patient declined thoracentesis.
According to the patient, he received [**4-12**] large volume
paracentesis taps ranging from 8-9 L a tap. He states that
during his hospitalization his diuretic therapy was stopped
because he was hypotensive and required albumin infusions.
.
ROS was otherwise essentially negative. The patient denied
recent fevers, night sweats, chills, hematemesis, coffee-ground
emesis, nausea, vomiting, melena, hematochezia. He does have
significant lower extremity weakness due to his ongoing
Guillain-[**Location (un) **] syndrome.
.
Past Medical History:
Guillain-[**Location (un) **] Syndrome
Alcoholic Cirrhosis
Portal Hypertension
Postural Hypotension
Anemia
Anxiety
Gait disorder
Social History:
He previously worked as a dentist. He is married and his wife
is supportive.
# Smoking: Quit over 15 years ago
# Alcohol: Stopped drinking over 10 years ago
# Drugs: No recreational drug use
Family History:
Noncontributory
Physical Exam:
VS: T 97.4(96.9-97.4), BP 106/65(100-115/58-71), HR 81(77-88)
....RR 22(20-22), SpO2 96(96-100) on RA
Gen: NAD. Alert and oriented x3. Mood and affect appropriate.
Pleasant and cooperative. Resting in bed.
HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
CV: RRR. Normal S1, S2. No M/R/G appreciated.
Chest: Respiration unlabored. Decreased breath sounds on right.
No wheezes, rhonchi, or rales.
Abd: BS present. Soft, NT, ND. Ascites present but not tense.
Ext: WWP, no cyanosis or clubbing. No LE edema. Digital cap
refill <2 sec. Distal pulses radial 2+, DP 2+, PT 2+.
Neuro: CN II-XII grossly intact. LE strength hip flexion [**4-12**],
knee flexion and extension [**4-12**], dorsiflexion and plantarflexion
[**3-12**]. UE strength intact.
Pertinent Results:
Labs on Admission:
[**2173-10-5**] 12:50AM BLOOD WBC-2.4* RBC-3.10* Hgb-10.3* Hct-30.4*
MCV-98 MCH-33.2* MCHC-33.8 RDW-14.6 Plt Ct-136*
[**2173-10-5**] 12:50AM BLOOD PT-16.2* PTT-28.7 INR(PT)-1.4*
[**2173-10-5**] 12:50AM BLOOD Glucose-107* UreaN-22* Creat-0.9 Na-136
K-5.2* Cl-103 HCO3-29 AnGap-9
[**2173-10-5**] 12:50AM BLOOD ALT-15 AST-22 AlkPhos-82 TotBili-1.2
[**2173-10-5**] 12:50AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.4 Mg-2.3
.
Thoracentesis:
[**2173-10-6**] 11:48AM PLEURAL WBC-23* RBC-428* Polys-11* Lymphs-51*
Monos-10* Meso-4* Macro-24*
[**2173-10-6**] 11:48AM PLEURAL TotProt-2.3 LD(LDH)-68 Albumin-1.6
.
Other Relevant Labs:
[**2173-10-6**] 05:25AM BLOOD VitB12-761 Folate-18.9
[**2173-10-5**] 05:35PM BLOOD calTIBC-114* Ferritn-558* TRF-88*
[**2173-10-5**] 05:35PM BLOOD Iron-35*
.
[**2173-10-14**] 05:05AM BLOOD Triglyc-63 HDL-25 CHOL/HD-3.0 LDLcalc-37
[**2173-10-5**] 06:10AM BLOOD TSH-7.8*
[**2173-10-5**] 06:10AM BLOOD Cortsol-8.3
.
[**2173-10-14**] 05:05AM BLOOD HAV Ab-POSITIVE
[**2173-10-5**] 05:35PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
[**2173-10-5**] 05:35PM BLOOD HCV Ab-NEGATIVE
[**2173-10-5**] 05:35PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2173-10-5**] 05:35PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2173-10-14**] 05:05AM BLOOD CEA-4.2* PSA-0.4 AFP-1.5
[**2173-10-5**] 05:35PM BLOOD IgG-898 IgA-422* IgM-33*
.
.
[**2173-10-5**] 17:35
Test Result Reference
Range/Units
ALPHA-1-ANTITRYPSIN QN 177 83-199 mg/dL
.
.
[**2173-10-5**] 17:35
Test Result Reference
Range/Units
CERULOPLASMIN 18 18-36 mg/dL
.
.
[**2173-10-6**] 11:48 am PLEURAL FLUID
GRAM STAIN (Final [**2173-10-6**]):
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 (Final [**2173-10-9**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2173-10-12**]): NO GROWTH.
ACID FAST SMEAR (Final [**2173-10-7**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
.
[**2173-10-14**] 5:05 am Blood (Toxo)
TOXOPLASMA IgG ANTIBODY (Final [**2173-10-15**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML.
.
[**2173-10-14**] 5:05 am SEROLOGY/BLOOD
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2173-10-15**]): POSITIVE BY EIA.
A positive IgG result generally indicates past exposure and/or
immunity.
.
[**2173-10-14**] 5:05 am SEROLOGY/BLOOD
Rubella IgG/IgM Antibody (Final [**2173-10-14**]):
NEGATIVE by Latex Agglutination.
A negative result generally indicates lack of immunity.
.
[**2173-10-5**] 5:35 pm Blood (EBV)
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2173-10-7**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2173-10-7**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2173-10-7**]): NEGATIVE <1:10
BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
.
[**2173-10-5**] 5:35 pm Blood (CMV AB)
CMV IgG ANTIBODY (Final [**2173-10-8**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA. < 4 AU/ML.
.
[**2173-10-5**] 5:35 pm SEROLOGY/BLOOD CONSENT RECEIVED.
RAPID PLASMA REAGIN TEST (Final [**2173-10-6**]): NONREACTIVE.
.
.
TTE (Complete) Done [**2173-10-5**] at 3:50:26 PM
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). There is no left ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
.
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2173-10-5**] 10:22 AM
FINDINGS: The liver is nodular and shrunken in appearance but no
solid liver lesion is identified. A simple cyst is seen at the
dome of the right lobe measuring 1.0 cm and a simple cyst is
seen at the dome of the left lobe also measuring 1.0 cm.
No biliary dilatation is seen and the common duct measures 0.4
cm. Several shadowing gallstones are seen within the lumen of
the gallbladder. The pancreas and midline structures are
obscured from view by overlying bowel. The spleen is enlarged
measuring 19.7 cm. No hydronephrosis is seen. The right kidney
measures 9.4 cm and the left kidney measures 10.8 cm. A moderate
amount of ascites is seen within the abdomen. A large right
pleural effusion is identified.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were obtained. The main, right and left portal veins are patent
with hepatopetal flow. Appropriate flow is seen in the IVC, the
hepatic veins, and the hepatic arteries.
IMPRESSION:
1. Nodular shrunken liver with two small simple cysts but no
solid liver lesion identified.
2. Large right pleural effusion and ascites.
3. Splenomegaly.
4. Cholelithiasis.
.
.
CHEST (PA & LAT) Study Date of [**2173-10-5**] 2:52 PM
FINDINGS: A large right pleural effusion causes collapse of the
right lung. The left lung and cardiac size are normal.
IMPRESSION: Extensive right pleural effusion with associated
right pulmonary collapse.
.
.
CHEST (PORTABLE AP) Study Date of [**2173-10-6**] 11:58 AM
FINDINGS: In comparison with the study of [**10-5**], there has been
removal of a substantial amount of fluid from the right
hemithorax. However, a large amount of pleural fluid remains.
The left lung is clear and there is no evidence of pneumothorax.
.
.
Cytology Report PLEURAL FLUID Procedure Date of [**2173-10-6**]
REPORT APPROVED DATE: [**2173-10-8**]
SPECIMEN RECEIVED: [**2173-10-7**] [**-1/3452**] PLEURAL FLUID
SPECIMEN DESCRIPTION: Received 2000ml cloudy yellow fluid.
Prepared 1 ThinPrep slide.
DIAGNOSIS: Pleural Fluid:
NEGATIVE FOR MALIGNANT CELLS.
Macrophages, mesothelial cells, and inflammatory cells.
.
.
Radiology Report TIPS Study Date of [**2173-10-8**] 8:26 AM
PROCEDURE:
1. Abdominal paracentesis.
2. Right pleural thoracocentesis.
3. Hepatic venography via right internal jugular vein approach.
4. Unsuccessful transhepatic cannulation of the portal vein.
HISTORY: 64-year-old man with cirrhosis and intractable ascites,
requires TIPS for control of ascites and recurrent right-sided
hydrothorax.
ANESTHESIA: General anesthesia was provided by the
anesthesiology service. In addition, 1% lidocaine was
administered to the skin around the internal jugular vein
puncture, thoracocentesis and paracentesis site.
RADIOLOGIST: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4401**], Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12166**] performed the procedure. Dr. [**Last Name (STitle) 12166**], the
attending radiologist, was present throughout the procedure.
PROCEDURE: Informed consent was obtained outlining the risks and
benefits of the procedure involved. Following this, the patient
was brought to the angiography suite where general anesthesia
was induced. The right neck and right-sided chest and upper
abdomen were prepped and draped in the usual sterile fashion. A
preprocedure huddle and timeout were performed as per [**Hospital1 18**]
protocol. Ultrasound of the right side demonstrates a large
right-sided pleural effusion and a large volume of ascites.
Under ultrasound guidance, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11097**] centesis needle was positioned
within the peritoneal space and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire advanced under
fluoroscopic guidance. A 5 French OmniFlush catheter was then
advanced over the wire and attached to a suction drainage
device. Again under ultrasound guidance and following
administration of 1% lidocaine, a 7 French all purpose drainage
catheter was advanced into the right pleural space and again
attached to a underwater seal on suction drainage. Both drainage
catheters were secured.
Attention was then turned to access the right internal jugular
vein. 1% lidocaine was administered to the skin overlying the
internal jugular vein and under direct ultrasound guidance, a
micropuncture needle advanced into the right internal jugular
vein. A 4.5 French micropuncture sheath was advanced over an 018
nitinol wire. The 018 wire and inner dilator were removed and an
035 [**Last Name (un) 7648**] wire advanced into the IVC. The micropuncture sheath
was removed and the venotomy site dilated with an 8 French
dilator. The sheath was then advanced to the level of the origin
of the hepatic veins and a 035 Glidewire advanced into the right
hepatic vein. The sheath was advanced over the wire to lie in
the mid portion of the right hepatic vein. Pressure gradients
were obtained at this time. Following this, a 5 French 035
occlusive balloon was advanced into the distal right hepatic
vein branch and CO2 portography was performed to evaluate the
position of the right and left main portal vein. AP and lateral
projections were obtained. Following this, the Roshida needle
was used to attempt to access the portal vein from the right
hepatic vein approach. Despite multiple needle passes in
multiple orientations, it was not possible to enter the portal
vein and advance a wire. In addition, an attempt was made to by
the portal vein via a right flank percutaneous transhepatic
approach. Again despite multiple wire passes, we were unable to
sufficiently opacify the portal vein. Following a total
procedure time of 6 hours and a fluoroscopic time of 80 minutes,
a decision was made to abort the procedure. The internal jugular
vein access sheath was removed and manual pressure was applied
for 10 minutes, ensuring good hemostasis. The peritoneal
drainage catheter was removed over a wire and a sterile dressing
applied. A 7 French right pleural drain was left in situ to
continue pleural drainage and lung expansion. The catheter was
attached to an underwater seal. The referring clinician, Dr.
[**Last Name (STitle) **], was contact[**Name (NI) **] at the time of procedure. There were no
early complications and the patient was extubated in the
angiography suite and transferred to the anesthesia care unit.
FINDINGS: Ultrasound demonstrated large volume right-sided
pleural effusion and ascites. There was uncomplicated placement
of right pleural and right peritoneal drainage catheter. Portal
venography demonstrated a markedly narrowed right hepatic vein.
In addition, CO2 portography demonstrated a small right portal
vein branch. Given the overall anatomy and severe background
ascites added to the difficulty in accessing the portal vein
transhepatically.
CONCLUSION: Successful right-sided thoracocentesis and abdominal
paracentesis. Hepatic venography and pressure measurements. The
right atrial pressure was measured at 8 mmHg. The hepatic wedge
pressure was measured at 20 mmHg. The staff radiologist, Dr.
[**Last Name (STitle) 12166**], has reviewed the report.
.
.
CT PELVIS W/O CONTRAST Study Date of [**2173-10-12**] 1:03 PM
HISTORY: Alcoholic cirrhosis with known portal hypertension,
status post attempted TIPS procedure x2, most recent complicated
by hepatic venous arterial fistula and subsequent embolization.
Evaluate for subcapsular or retroperitoneal bleed.
COMPARISON: Outside CT [**2173-9-22**], as well as angiogram
images from [**2173-10-11**].
CT ABDOMEN WITHOUT CONTRAST
Limited evaluation of the included lung bases displays
normal-appearing left lung. The right lung displays significant
interval decrease in size to a now slightly high-attenuation
small-to-moderate pleural effusion with persistent adjacent
compressive atelectasis involving portions of the right lower
lobe as well as the small locule of air noted posterior to the
sternum and a small anterior pneumothorax present.
Unenhanced images of the abdomen display no large
retroperitoneal or subcapsular hematoma. There has been interval
decrease in the amount of ascites when compared to the prior
outside imaging; however, the fluid is now more mixed density
with Hounsfield values measuring 20-30, suggestive of a mixture
of underlying ascites hemorrhage likely related to some oozing
after capsular puncture on TIPS attempt. Contrast is noted
within the gallbladder and there is streak artifact from the
indwelling coils and Amplatz occluder devices in the right
hepatic artery. Distal to these devices, the hepatic parenchyma
displays abnormal low attenuation, which may suggest underlying
infarction given the poor flow noted on the post-embolization
angiogram images to this region. Some residual air is noted
within the liver parenchyma likely related to a recent
procedure. Multiple small hypoattenuating lesions in the liver
are again seen, likely hepatic cysts and there is unchanged
configuration to known underlying cirrhosis with sequelae of
portal hypertension including splenomegaly, massive
esophageal/paraesophageal varices, and intra-abdominal
collateral vessels. Limited unenhanced evaluation of the
remaining solid organs within the abdomen including the pancreas
and adrenal glands are normal. Kidneys displays persistent
corticomedullary differentiation involving the kidneys
suggestive of underlying renal dysfunction from prior contrast
administration one day prior. There are some prominent
air-filled loops of small and large bowel with the small bowel
measuring up to 3.4 cm, which may suggest some mild underlying
ileus with no findings of obstruction. Scattered mesenteric and
retroperitoneal lymph nodes are better appreciated on prior
contrast-enhanced CT.
CT OF THE PELVIS WITHOUT INTRAVENOUS OR ORAL CONTRAST:
Significant interval decrease in amount of free fluid within the
pelvis is identified, although the fluid is noted to be slightly
higher in attenuation as compared to the prior outside exam with
Hounsfield value of approximately 20. A large fecal ball is
noted within the rectal vault, with the intrapelvic bowel
appearing otherwise unremarkable. Contrast is noted within the
bladder from prior procedure.
BONE WINDOWS: No malignant-appearing osseous lesions are
identified.
IMPRESSION:
1. No significant retroperitoneal or subcapsular hematoma
identified. While the amount of intra-abdominal/pelvic ascites
has significantly decreased from prior [**2173-9-22**] exam
the fluid is of slightly higher density suggesting that it is a
mixture of underlying ascites and blood likely related to oozing
from capsular puncture during TIPS attempt.
2. Abnormal appearance to the inferior right hepatic lobe
parenchyma distal to site of known embolization. This may
reflect underlying parenchyma infarction.
3. Persistent corticomedullary differentiation of the kidneys
with contrast within the collecting systems. This suggests
underlying contrast-induced nephropathy/ATN and should be
correlated with serial creatinine values.
4. Interval decrease in size to now moderate right pleural
effusion which is also of slightly higher density than before
and may have a component of blood within it. A very small
anterior right pneumothorax is also noted, not unexpected given
the recent pleural catheter removal.
.
.
Brief Hospital Course:
The patient is a 64 year old male with alcoholic cirrhosis c/b
portal hypertension, ascites, and varices who presented as a
transfer from OSH for TIPS evaluation. He has had two failed
TIPS placement attempts with hepatic artery puncture on the
second attempt.
.
# TIPS Placement Attempts: He was sent from OSH for TIPS
evaluation and placement. CXR, echocardiogram, and duplex US of
liver were completed and no contraindication to the procedure
was identified on this imaging. Viral and autoimmune hepatitis
assays were negative. Imaging from the OSH was uploaded and
reviewed by IR. TIPS placement was attempted on [**2173-10-8**], but
the shunt could not be passed through his liver tissue. He had
a second attempt on [**2173-10-11**], which was also not successful. The
hepatic artery was punctured during the procedure and repaired
without blood loss or significant hemodynamic instability. He
had a brief stay in the MICU and returned to the floor. His
transaminases were significantly elevated after the second
procedure, but were trending down rapidly at the time of
discharge. Per IR, further TIPS placement attempts would be
technically possible, but will be deferred until a later time.
.
# Creatinine Elevation: His Cr increased to 1.3 after his second
TIPS attempt. CT scan on [**2173-10-12**] showed findings concerning for
contrast-induced nephropathy/ATN. His Cr remained stable at 1.3
for the last three days. A prerenal etiology may also have been
contributing given his limited PO intake and recent fluid
losses. He will likely need aggressive hydration and
Acetylcysteine with any future contrast loads.
.
# Pain Control: He has significant pain from immobility due to
[**Last Name (un) 4584**]-[**Location (un) **] Syndrome, which was made worse by chest tube
placement during his first TIPS attempt. He was much more
comfortable after the chest tube was removed. He was started on
Oxycodone 5 mg PO with close monitoring. He did not show any
signs of hepatic encephalopathy or sedation. He was switched to
Q6H PRN dosing on [**2173-10-13**], which worked well for the patient.
.
# Hydrothorax: He has a history of recurrent hepatic
hydrothorax. His CXR on admission showed a large pleural
effusion / hydrothorax with complete whiteout of the right
hemithorax. He was asymptomatic and maintaining good oxygen
saturation. He had thoracentesis with removal of 2 L of fluid.
He tolerated the procedure well, with only some mild coughing.
The fluid was transudative based on Light's criteria, with no
evidence of infection. During his TIPS procedure on [**2173-10-8**], he
had 3.5 L of fluid drained and a chest tube was placed. The
chest tube drained large amounts of fluid over the days
following its placement. The chest tube was removed at the time
of his repeat TIPS attempt on [**2173-10-11**]. Patient has oxygen
saturation 98% on room air at time of discharge.
.
# Ascites: His outpatient hepatologist was contact[**Name (NI) **] for more
information regarding his prior diuresis, recurrent ascites, and
hydrothorax. He was previously taking Furosemide and
Spironolactone, but developed hypotension with use of the
diuretics and continued to have significant hydrothorax and
recurrent ascites requiring large volume paracentesis. During
his stay at [**Hospital1 18**], he was kept on a low sodium diet and fluid
restriction of 1500 ml. Strict I/Os and daily weights were
monitored. He did not require additional paracentesis after 4 L
of fluid were removed during his first TIPS attempt.
.
# Alcholic Cirrhosis: The indications for TIPS include recurrent
ascites, hepatic hydrothorax, or variceal bleeding. His MELD
score on admission was 11, so TIPS was not contraindicated. He
denied any prior episodes of hepatic encephalopathy or GI
bleeding. He was continued on a regimen of Lactulose and
Rifaximin. His Rifaximin dosing was changed to 400 mg TID so
that he could take smaller pills. MELD labs were checked daily
and his score remained stable around 11, but acutely increased
to 15 after his second TIPS attempt.
.
# Nutrition: On admission he appeared cachectic and chronically
ill, reporting a significant weight loss over the last few
months. His PO intake was poor during his admission. Nutrition
consult felt that he would clearly benefit from additional
nutrition through tube feeds. A Dobhoff tube was placed on
[**2173-10-15**] and tube feeds were initiated. Nutrition recommended
Nutren 2.0 at 70 ml/hr. Continued PO intake was encouraged and
he was provided Ensure and Beneprotein supplements with each
meal.
.
# Hypotension: He has a history of symptomatic hypotension. His
TSH was mildly elevated at 7.8 and his morning cortisol was 8.3,
which is WNL but on the low side. He will need followup of his
TSH as an outpatient. Further workup of his cortisol level is
probably not necessary at this time. He remained
hemodynamically stable with SBP in the 90s to 100s after
admission mild diuretic treatments, paracentesis, and
thoracentesis. Diuretic treatment was discontinued pending
TIPS. He was given Albumin (5%) 25 g on several occasions for
volume repletion.
.
# [**Last Name (un) 4584**]-[**Location (un) **] Syndrome: He had an episode of GBS in [**2169**] which
resolved and a second episode which started several months ago.
He is currently wheelchair bound due to LE weakness. He was
seen by PT and was able to stand with a walker but not ambulate.
He will require additional PT after discharge.
.
# Anemia: He has a slightly macrocytic anemia with a hematocrit
stable around 30. His WBC count and platelets are also low,
suggesting a component of marrow suppression. Iron studies show
an moderately elevated ferritin, low TIBC, and low serum iron
consistent with chronic inflammation. His B12 and folate levels
were normal. His hematocrit was monitored closely, and he
showed no signs of GI bleeding.
.
# DVT Prophylaxis: Provided with Heparin 5000 units SC TID.
.
# MICU Course [**2173-4-8**]:
Patient was admitted to the MICU after puncture of hepatic
artery during TIPS procedure for hemodynamic monitoring. Patient
remained stable and serial hematocrits were stable. A CT scan
was completed showing: No significant hematoma, with decreased
ascites, with some blood mixed in (likely oozing from the TIPS
procedure attempts). It also demonstrated possible kidney damage
secondary to contrast nephropathy so patient's creatinine needs
to be monitored clinically. Patient was transferred back to the
floor after 24 hour monitoring.
.
# Followup:
-- Appointment scheduled in 2 weeks with Dr [**Name (NI) **] to begin
transplant evaluation process
-- Pending results: CA [**82**]-9 and Vitamin D assays
Medications on Admission:
Home Medications:
Heparin 5,000 units daily
Lactinex 1 packet [**Hospital1 **]
Lactulose 30 ml TID
Lorazepam 1 mg QHS
Lorazepam PRN
Colace 100 mg [**Hospital1 **]
Senna
Lactobacillus
MVI daily
.
Discharge Medications:
Morphine Sulfate 2 mg Q6H PRN
Heparin SC 5,000 units [**Hospital1 **]
Lactulose 30 ml TID
Rifaxamin 400 mg [**Hospital1 **]
Nasal Spray 1 spray each nostril TID
Lorazepam 2 mg Q6H PRN
Lorazepam 1 mg QHS
Colace 100 mg [**Hospital1 **]
Senna 2 tabs QHS
Lactobacillus 1 mg PO BID
MVI daily
.
Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to [**3-11**] bowel movements per day.
2. rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Hold for sedation, RR<12, or signs of
encephalopathy.
8. Tube feeds
Nutren 2.0 Full strength;
Starting rate:10 ml/hr; Advance rate by 10 ml Q4H;
Goal rate:70 ml/hr;
Flush with 50 ml water Q6H
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
Alcoholic cirrhosis complicated by ascites
Right hepatohydrothorax
Ascites
Secondary:
Guillain-[**Location (un) **] Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2173-10-4**] to have an evaluation for a TIPS procedure. Two
attempts were made and unsuccessful. You also had a chest tube
placed temporarily for fluid in your right lungs; this was
removed several days prior to your discharge. During this
hospitalization we discussed undergoing evaluation for a liver
transplant; many tests were done in the hospital, and the workup
will continue on an outpatient basis. You are scheduled to see
Dr. [**Name (NI) **], a liver specialist, for this and further
management of your liver disease.
A feeding tube was also placed to aid with your nutrition.
During the hospitalization you also worked with physical
therapy; improvement in your strength was noted.
Your medication regimen has changed. Please review the
medication list closely.
Followup Instructions:
Please be sure to keep the following appointment with the liver
center.
Department: TRANSPLANT
When: FRIDAY [**2173-10-29**] at 8:40 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT SOCIAL WORK
When: FRIDAY [**2173-10-29**] at 10:00 AM [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please also schedule an appointment to see your primary care
doctor within 1-2 weeks of discharge from the rehabilitation
facility.
During this hospital course you were noted to have a slightly
elevated TSH, which is a marker of thyroid function. This
should be rechecked as an outpatient, particularly after you
start feeling better. Please discuss this with your primary
care doctor.
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14318
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Discharge summary
|
Report
|
Admission Date: [**2122-6-13**] Discharge Date: [**2122-6-23**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
ruptured AAA
Major Surgical or Invasive Procedure:
[**2122-6-13**]:
Endovascular stent graft exclusion of ruptured abdominal aortic
aneurysm with a [**Doctor Last Name 4726**] 31 x 14-1/2 x 130 main body endo prosthesis
and right [**Doctor Last Name 4726**] 20 x 9.5 iliac limb and [**Doctor Last Name 4726**] 14-1/2 x 7 left
iliac extension limb
[**2122-6-22**]:
[**Company 1543**] Permanent Pacemaker generator exchange [**2122-6-22**]
History of Present Illness:
The patient is a [**Age over 90 **] year old woman with a history of CAD s/p
pacemaker placement, atrial fibrillation, and known AAA who
presented to an OSH today with abdominal and back pain, and was
scanned demonstrating an 8.4 X 7.5 cm AAA with evidence of leak.
She was therefore transferred to [**Hospital1 18**]
urgently for vascular surgery evaluation.
Past Medical History:
PMH:
HTN
hypothyroidism
s/p pacemaker
Atrial fibrillation
CHF
h/o MRSA cellulitis in legs
history of falls
PSH:
s/p cholecystectomy
s/p L CEA
Social History:
lives alone with daughter nearby
Family History:
NC
Physical Exam:
On Admission:
PE:
HR 61 BP 170/75 94% RA
NAD, awake/alert, responsive; poor historian
RRR
lungs clear
abdomen soft, moderately distended, pulsatile mass with deep
palpation
bilateral lower extremities warm, no ulceration
Pulses:
R femoral palpable, R DP palpable
L femoral palpable, L DP palpable
\
On Discharge:
VSS Afebrile
WDWN in NAD
Lungs - cta bilat
Card - RRR, paced at 60, strong PMI felt in the distal,external
thoracic cavity, due to pts habitus can feel PMI in the extreme
LUQ of the abd
Abd- soft +bs, no m/t/o
Ext- warm and dry, Fem/DP/PT pulses all palpable bilat
Pertinent Results:
[**2122-6-13**] 11:31 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2122-6-16**]**
MRSA SCREEN (Final [**2122-6-16**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2122-6-16**] 12:17 am BLOOD CULTURE Source: Line-arterial.
**FINAL REPORT [**2122-6-22**]**
Blood Culture, Routine (Final [**2122-6-22**]): NO GROWTH.
[**2122-6-16**] 12:17 am BLOOD CULTURE 2ND.
**FINAL REPORT [**2122-6-22**]**
Blood Culture, Routine (Final [**2122-6-22**]): NO GROWTH.
[**2122-6-16**] 12:17 am URINE Source: Catheter.
**FINAL REPORT [**2122-6-18**]**
URINE CULTURE (Final [**2122-6-18**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2122-6-14**]
1:12 PM
IMPRESSION:
Extremely limited examination due to lack of intravenous
contrast.
1. Cardiomegaly. Small bibasal effusions and pulmonary
ground-glass
opacities. The lung findings may represent infection, fluid
overload or ARDS.
2. AAA with an aortofemoral bypass graft in situ. The
appearances are
suggestive of an endoleak as described above.
3. Extensive atherosclerosis in the vasculature of the abdomen
and pelvis
including the coronary arteries.
4. Striated appearance of both kidneys, most marked on the
right. The
appearances may represent acute tubular necrosis from prior
contrast
administration.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2122-6-16**] 10:34 AM
Reason: PE PROTOCOL. Please eval for PE.
IMPRESSION:
1. Unchanged multifocal bilateral ground-glass opacities
consistent with
multifocal pneumonia.
2. Compared to [**2122-6-14**] increase of now large bilateral
simple pleural
effusion and partial atelectasis of the superior segments of the
lower lobes
bilaterally.
3. Unchanged ascending aorta and aortic arch dilatation with
focal aortic
arch aneurysm.
4. Unchanged cardiomegaly without significant pulmonary edema.
5. A central line ends in the distal left brachiocephalic vein.
UNILAT UP EXT VEINS US RIGHT Study Date of [**2122-6-18**] 1:36 PM
Reason: r/o dvt in rue
Occlusive thrombus involving the right cephalic vein. No DVT in
the right upper extremity.
[**2122-6-19**] 4:13 PM
UNILAT LOWER EXT VEINS RIGHT
Reason: CALF PAIN, PLEASE EVAL FOR DVT
IMPRESSION: No evidence of DVT in right lower extremity.
[**2122-6-23**] 03:56AM BLOOD WBC-8.8 RBC-3.09* Hgb-10.6* Hct-31.9*
MCV-103* MCH-34.3* MCHC-33.2 RDW-18.6* Plt Ct-249
[**2122-6-23**] 03:56AM BLOOD Glucose-81 UreaN-31* Creat-1.3* Na-137
K-3.2* Cl-95* HCO3-33* AnGap-12
[**2122-6-23**] 03:56AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
[**2122-6-16**] 12:17AM URINE RBC-[**3-13**]* WBC-21-50* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2122-6-22**] 05:46AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-FEW
Epi-0-2
[**2122-6-16**] 12:17AM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2122-6-22**] 05:46AM URINE Blood-MOD Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2122-6-16**] 12:17AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2122-6-22**] 05:46AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016
Brief Hospital Course:
Patient was admitted from an OSH with leaking AAA seen on OSH
imaging. She was emergently taken to the angio suite and her
images were uploaded and reviewed. She underwent:
1. Ultrasound-guided puncture of bilateral common femoral
arteries.
2. Bilateral introduction of catheter into aorta.
3. Abdominal aortogram and selective iliac arteriogram.
4. Endovascular stent graft exclusion of ruptured abdominal
aortic aneurysm with a [**Doctor Last Name 4726**] 31 x 14-1/2 x 130 main body
endo prosthesis and right [**Doctor Last Name 4726**] 20 x 9.5 iliac limb and
[**Doctor Last Name 4726**] 14-1/2 x 7 left iliac extension limb.
5. Perclose closure of bilateral common femoral
arteriotomies.
6. Left common femoral endarterectomy with vein patch
angioplasty.
The patient tolerated the procedure well. Of note, she was not
intubated for the procedure given her age and co-morbidities.
Neuro: no active issues, patient is alert and interactive
Cardiopulmonary: Post-operatively she was closely monitored in
the CVICU. Initally her PPM was pacing her appropriately,
however, overnight she had an episode of asystole, lasting less
than 30 seconds. Compression were started, and the pt almost
immediately began pacing appropriately again. These episodes
recurred a few more times the evening of POD 0 and
electrophysiology was urgently consulted. The EP fellow
interrogated the device and found the RV lead to be dislodged.
He adjusted the settings, and the pacer functioned properly. He
recommended repleting electrolytes and discontinuing digoxin as
well. These interventions resolved her arrythmias. On [**6-16**]
the patient went into atrial fibrillation with rapid ventricular
response and required IV lopressor and then a diltiazem drip for
rate control. EP and cardiology were asked to advise on
treatment. Soltalol 80mg [**Hospital1 **] and diltiazem 30mg qid were
started and the diltiazem gtt weaned off. The pt returned to a
paced sinus rhythm within 24hrs of the atrial fibrillation and
had no further episodes throughout her stay. Anticoagulation
was initally recommended, however given the pts age and
comorbidities it was decided that heparin/coumadin benefit would
not outway the risk, and thus asprin 325mg was initiated. On the
morning of [**6-16**] the patient began to c/o SOB, required increased
O2 and was hypoxemic on her ABG. There was concern for CHF
exacerbation as well as PE. She urgently underwent CTA which
ruled out pulmonary embolism. The CT did reveal pulmonary edema
and bilateral pleural effusions. Interventional pulmonology was
consulted and felt these effusions were not large enough to
drain. There was some concern the pt may have developed
pneumonia as well given her previous emesis and immobility. The
patient was put on broad spectrum antibiotic coverage and put on
a fluid restriction and aggressively diuresed with lasix over
the next several days with close monitoring and repletion of her
electrolytes. The diureses significantly improved her symptoms
and her O2 requirements were subsequently minimal. On [**6-22**] she
was thought to be quite stable from a medical and surgical
standpoint and EP took her to the procedure lab where they
exchanged her PPM for a new device. She tolerated the procedure
well and her.
GI/Nutrition: The patient vomitted twice on POD 0 during chest
compressions, after which an NG tube placed. The tube was
removed a few days later when her bowel function returned.
Speech and swallow was consulted to evaluate for aspiration risk
prior to advancing the patients diet. On preliminary
examination she passed her swallow evaluation and she was
started on a ground puree diet which was later advanced to
regular diet with thin liquids which she tolerated well.
GU: patient was found to have a UTI on Urinalysis and she was
started on antibiotics. The culture grew moderate amt of
pseudomonas and she was started on cirpo. Her foley was
exchanged. It was not removed as she was being aggressively
diuresed and her I/O's required close monitoring. A second UA/Cx
was sent on [**6-22**] and was negative with no bacterial growth. At
the time of discharge her foley was removed and she was voiding
without difficulty.
ID: Post-operatively patient received 3 days of kefzol for
perioperative coverage. Given her UTI, she was started on
ciprofloxacin on [**2122-6-16**], but this was switched to ceftriaxone
and doxyclycline given concern for PNA after episodes of
vomitting and consolidation seen on CXR and CT.
Heme: patient received SQH throughout her stay for dvt
prophylaxis. There was concern for a DVT in her RUE and RLE
during her stay, however both were ruled out. She did work with
physical therapy but given her deconditioned state only
ambulated minimally. She is discharged on SQH to continue at
rehabilitation facility until she is ambulating at her baseline
state.
Medications on Admission:
potassium 20 meq daily
lasix 40 mg po qd
digoxin .125 mg daily
cardizem ER 240 mg po qd
ASA 81 mg po qd
miralax
clonidine 0.1 mg po bid
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): until pt fully
ambulatory and low risk for dvt.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb INH Inhalation Q6H (every 6 hours)
as needed for wheezing.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb inh
Inhalation Q6H (every 6 hours) as needed for SOB.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: when
on lasix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]
Discharge Diagnosis:
8.4 X 7.5cm ruptured AAA
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:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
except for the following changes: we have stopped your digoxin
and diltiazem and you are now on sotalol. You should take
aspirin [**Street Address(2) 42488**] of your previous 81mg.
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go to rehab:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-11**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? Do not shower x 1 week, you may have sponge baths. After 1
week you may shoewer, but no soaking tubs
?????? Your right chest/shoulder dressing covering the incision from
the pacemaker exchange should stay on for three days, it may be
removed on thursday [**6-25**]. The groin and leg incisions may be
left uncovered, unless you have small amounts of drainage from
the wound, then place a dry dressing or band aid over the area
that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Keep your f/u appointment to be seen for post procedure check
and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2122-6-30**]
1:00
(pacemaker follow up and wound check)
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-7-16**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2122-7-16**] 12:00
(vascular surgery f/u, imaging of aorta and see surgeon)
Completed by:[**2122-6-23**]
|
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| 0
| 0
| 0
| 0
| 0
| 288
| 0
| 145
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 146
| 36
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
95,705
| 180,095
|
52515
|
Discharge summary
|
Report
|
Admission Date: [**2137-3-29**] Discharge Date: [**2137-4-1**]
Date of Birth: [**2061-2-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline Analogues / Atrovent / Chlorhexidine
/ Cephalosporins
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Palpitations/tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 yo M with history of AML, MDS, and prostate cancer who
presents to [**Hospital1 18**] ED with palpitations after he had been sent
home from [**Hospital1 3242**] outpatient clinic after assessment for dyspnea and
fevers. According to patient's wife, the patient had been
cleared to go home from [**Hospital1 3242**] outpatient clinic after a CXR was
unrevealing, though the patient was only home for a coupld of
hours prior to feeling acutely unwell and EMS was called. EMS
noted HR of 190 and pushed diltiazem with little change in HR.
.
At presentation to the ED, patient was noted to have HR of 150
and EKG consistent with atrial flutter and was started on an
amiodarone bolus and infusion. Patient was given morphine for
dyspnea per home regimen. Vitals prior to transfer to the MICU
were: T 100.8, HR 134, BP 98/56, RR 36, O2Sat 97% 3L NC.
.
Upon arrival to the floor the patient's wife and daughter
indicated that patient would want to be DNR/DNI and would be
discerning about performing any invasive procedures. Within 30
minutes of arriving to the MICU, patient spontaneously converted
to sinus rhythm and HR dropped from 150s to 80s.
Past Medical History:
Past Oncologic History:
# AML status post induction with 7 and 3 on [**2134-12-5**].
Consolidation treatment initiated on ALFA low dose 7+3
chemotherapy regimen on [**2135-4-4**], s/p 3 cycles. Currently
off azecitadine.
#MDS diagnosed in [**9-1**] s/p 2x decitabine then treated with
Neulasta and Nplate, started on azacytidine in [**2136-11-24**]
#Prostate Cancer - diagnosed in [**2121**] ([**Doctor Last Name **] 2+5) at which
time he received bracytherapy and was subsequently followed
expectantly by Dr. [**Last Name (STitle) **]; he's experienced a PSA only relapse
.
Other Past Medical History:
#2V CAD s/p BMS to ramus [**2-28**]
#HTN
#Hyperlipidemia
#AAA s/p endovascular repair in [**9-1**]
#s/p appendectomy
#emphysema
#s/p basal cell ca excision
Social History:
Lives in [**Location **] with wife. 3 kids. Former VP Gillete for 32
yrs, retired in [**2128**]. Smoked 68 yrs 2ppd. Quit smoking
[**Holiday 1451**] in [**2135**]. Drinks 1 [**Doctor Last Name 6654**] a day.
Family History:
Father died of lung cancer at age 44. Mother died of an MI.
Physical Exam:
ADMISSION EXAM:
.
GEN: Somnolent, appears comfortable, though high respiratory
rate
[**Doctor Last Name 4459**]: Corrective lenses, PERRL, oral mucosa dry
NECK: Supple, no [**Doctor First Name **], no JVP elevation
PULM: Anteriorly coarse breath sounds with inspiratory squeaks
and mild exp wheezing
CARD: Tachycardic, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND
EXT: 1+ BLE pitting edema
SKIN: no rashes
NEURO: somnolent, though easy to awake and is oriented x 3 when
awake
.
DISCHARGE EXAM:
.
VS: T: 96.98.9 BP: 144/74 (100s-140s/50s-70s) HR: 87
(80s-100s) RR: 18 O2: 94% 2L
GEN: AOx3, interactive, NAD
[**Doctor First Name 4459**]: MMM. Neck supple.
Cards: RRR, S1/S2 normal, no murmurs/gallops/rubs.
Pulm: Scattered crackles
Abd: Soft, NT/ND, no rebound/guarding
Extremities: WWP, 1+ pitting LE edema bilaterally.
Pertinent Results:
ADMISSION LABS:
.
[**2137-3-29**] 09:25AM GRAN CT-60*
[**2137-3-29**] 09:25AM PLT SMR-RARE PLT COUNT-10*#
[**2137-3-29**] 09:25AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
[**2137-3-29**] 09:25AM NEUTS-1* BANDS-0 LYMPHS-24 MONOS-48* EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0 BLASTS-24* NUC RBCS-1*
[**2137-3-29**] 09:25AM WBC-6.0# RBC-3.02* HGB-9.0* HCT-26.4* MCV-88
MCH-29.9 MCHC-34.1 RDW-14.4
[**2137-3-29**] 09:25AM ALBUMIN-3.5 CALCIUM-8.4 PHOSPHATE-3.6
MAGNESIUM-2.0
[**2137-3-29**] 09:25AM ALT(SGPT)-12 AST(SGOT)-42* LD(LDH)-1287* ALK
PHOS-96 TOT BILI-0.6
[**2137-3-29**] 09:25AM UREA N-26* CREAT-0.8 SODIUM-138 POTASSIUM-4.1
CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2137-3-29**] 10:50AM URINE RBC-3* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2137-3-29**] 10:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2137-3-29**] 10:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2137-3-29**] 01:05PM PLT COUNT-22*#
[**2137-3-29**] 03:30PM PLT COUNT-35*#
[**2137-3-29**] 09:55PM PT-13.4 PTT-29.8 INR(PT)-1.1
[**2137-3-29**] 09:55PM PLT SMR-VERY LOW PLT COUNT-30*
[**2137-3-29**] 09:55PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
BURR-1+ BITE-OCCASIONAL
[**2137-3-29**] 09:55PM NEUTS-1* BANDS-0 LYMPHS-4* MONOS-66* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-29* NUC RBCS-2*
[**2137-3-29**] 09:55PM WBC-7.3 RBC-2.93* HGB-9.2* HCT-24.5* MCV-84
MCH-31.3 MCHC-37.5* RDW-14.6
[**2137-3-29**] 09:55PM LACTATE-1.5
[**2137-3-29**] 09:55PM TSH-1.5
[**2137-3-29**] 09:55PM cTropnT-0.01
[**2137-3-29**] 09:55PM GLUCOSE-106* UREA N-23* CREAT-0.9 SODIUM-137
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
.
DISCHARGE LABS:
.
[**2137-4-1**] 06:20AM BLOOD WBC-7.3 RBC-2.67* Hgb-7.9* Hct-23.5*
MCV-88 MCH-29.5 MCHC-33.6 RDW-14.3 Plt Ct-28*#
[**2137-4-1**] 06:20AM BLOOD Neuts-0 Bands-0 Lymphs-9* Monos-34* Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Promyel-1* Blasts-56* NRBC-1*
Other-0
.
STUDIES:
.
CXR [**2137-3-29**]:
In comparison to study performed earlier the same day, lung
volumes are
decreased. This may account for increased bibasilar opacitites,
though new
consolidation should also be considered. Right apical opacity is
likely
unchanged, though is now partially obscured by overlying soft
tissue artifact. Left peripherally inserted central catheter
reaches the mid SVC. Hilar and cardiomediastinal contours are
unchanged. There is no large effusion or pneumothorax. There is
no free air in the upper abdomen.
IMPRESSION: Persistent right apical opacity with apparent new
bibasilar
opacities, which may in part reflect atelectasis in conjunction
with low lung volumes. Repeat PA and lateral radiographs with
better inspiration would be helpful for further evaluation.
.
CXR [**2137-3-31**]:
Heart size remains normal. Pulmonary vascularity is also within
normal limits. Lung volumes are increased compared to the recent
radiograph, and recently described new bibasilar opacities have
nearly resolved with only minimal linear atelectasis remaining.
Poorly defined right apical opacity has slightly decreased in
size since prior studies and is likely due to slowly resolving
infection based on appearance on [**2137-3-2**] chest CT. Small
pleural effusions are present bilaterally.
IMPRESSION:
1. Near resolution of bibasilar opacities which were likely due
to
atelectasis.
2. Right apical opacity, likely due to slowly resolving
infection. Continued radiographic followup of this region may be
helpful to document complete resolution.
Brief Hospital Course:
#. Atrial fibrillation with RVR:
Patient presented to ED primarily because of new palpitations at
home which was proven to be atrial fibrillation with RVR as well
as one documented episode of atrial flutter. Patient converted
to sinus rhythm soon after admission to MICU overnight. The
patient was switched to oral amiodarone after having converted
to sinus. He tolerated the PO well and was called out to the
floor and was transfered to the [**Hospital Ward Name **] under the care of
the oncology/[**Hospital Ward Name 3242**] service. Pt was not not discharged on amio
given that he converted prior to receiving his 1st dose and we
thought the benefits did not outweight the drawbacks given his
baseline pulmonary disease and overall decreased life
expectancy.
.
#. Anemia:
Pt has long term anemia with frequent outpatient transfusions
related to MDS. The patient was ordered for HCT daily with
transfusion threshold of HCT < 21. The patient had a stable
hematocrit and did not require any transfusions while in the
ICU, but did receive 2U of PRBC for a Hct of 23.5 on the day of
discharge.
.
#. Febrile neutropenia with pneumonia:
Patient with ANC of 60 at presentation and spiked a fever to
100.8 in the ED and pneumonia on CXR. Patient with reported
end-stage MDS and AML and will be difficult for him to mount a
response to any infection. He was given neupogen recently as a
trial to attempt to affect change in his refractory neutropenia.
The patient was covered with broad antibiotics with Vancomycin,
Meropenem. This was continued as the patient was called out to
the oncology floor. Upon discharge he was sent home on
linezolid and levofloxacin with the course to be determined by
his outpatient oncologist.
.
#. MDS, AML:
Patient and family aware of overall poor prognosis and have
expressed their wish for patient to be DNR/DNI. Counts were
trended, and he remained anemic, neutropenic, and
thrombocytopenic as above. He received a total of 2U PRBC and
3U of platelets.
Medications on Admission:
1) Albuterol sulfate 90 mcg HFA Inhaler Q4H:PRN dyspnea/wheezing
2) Dexamethasone 4 mg in the morning and 2 mg at noon
3) Fluticasone-salmeterol 250 mcg-50 mcg [**Hospital1 **]
4) Lorazepam 0.5-1 mg PO QHS:PRN insomnia
5) Morphine 15-30 mg Q4H:PRNs hortness of breath or wheezing
6) Omeprazole 40 mg DAILY
7) Tiotropium bromide 18 mcg
8) Voriconazole 400 mg [**Hospital1 **]
9) Zolpidem 12.5 mg QHS
10) Multivitamin
Discharge Medications:
1. voriconazole 200 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
2. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): Please follow up with your oncologist to determine when
to stop this medication.
Disp:*60 Tablet(s)* Refills:*0*
3. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day:
Please follow up with your oncologist to determine when to stop
this medication.
Disp:*30 Tablet(s)* Refills:*0*
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Inhalation twice a day.
6. multivitamin Capsule Sig: One (1) Capsule PO once a day.
7. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
8. morphine 15 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for shortness of breath or wheezing.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
11. zolpidem 12.5 mg Tablet,Ext Release Multiphase Sig: One (1)
Tablet,Ext Release Multiphase PO at bedtime.
12. dexamethasone 2 mg Tablet Sig: 1-2 Tablets PO twice a day:
[**11-25**] Tablet(s) by mouth As directed Take 2 tablets in the
morning, and 1 tablet at 12pm .
13. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO twice
daily at 8am, 12pm: [**Month (only) 116**] skip second dose if desired.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Atrial flutter
Pneumonia
Secondary Diagnosis:
Acute Myelogenous Leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for palpitations, and were
found to be in a rapid heart rhythm called atrial flutter. You
received medications for the rapid heart rhyrhm and your heart
rate converted back to normal. You had no further symptoms
other than shortness of breath, and you received a dose of
medication called Lasix to remove fluid from your lungs.
Your chest xray from admission showed a possible pneumonia, and
a repeat chest xray in the hospital was more consistent with
residual findings from a resolving pneumonia you had previously
rather than a new pneumonia. However, due to your frequent
neutropenia and pneumonia infections, it was felt best to
re-start you on antibiotics until follow-up with your primary
outpatient oncologist.
You were also given a transfusion of platelets and red blood
cells while in the hospital to increase your blood counts.
The following changes were made to your home medications:
- Linezolid was re-STARTED.
- Levofloxacin was re-STARTED.
Please follow up with your oncologist about when to stop taking
these medications.
Followup Instructions:
Department: [**Hospital 3242**] CHAIRS & ROOMS
When: WEDNESDAY [**2137-4-3**] at 12:30 PM
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2137-4-3**] at 12:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2137-4-3**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
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[] |
icd9pcs
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[
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91,123
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49512
|
Discharge summary
|
Report
|
Admission Date: [**2125-11-26**] Discharge Date: [**2125-12-7**]
Date of Birth: [**2065-1-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
A 60 year old male with PMH HTN, COPD, and Alcoholism presented
to the [**Hospital1 18**] ED with dyspnea and cough and was admitted to the
ICU for hypoxia.
History obtained primairly from ExWife who is at bedside. She
reports that for the past month, the patient has been having
worseing dyspnea on exertion. Two days prior to admission, she
reports that he had increasing sputum production and dyspnea, he
was somnolent and spent >16 hours sleeping each day. On the day
of admission, she noted confusion, though he usually speaks with
her in English, he began only speaking in Hindi which she does
not speak.
In the ED initial vitals were 98.7, 107, 125/68, 40 and 70 on
RA, he was triggered for hypoxia. Initial labs were remarkable
for HCT 44.0, WBC 9.7 PMN 76%, INR 1.4, Cr 1.1, Lactate 2.6, BNP
3272. Chest xray showed BL (L>R) pleural effusions and pulmonary
edema. According to the report, exam was remarkable for
abdomiinal distention however ultrasound examination failed to
identify ascitic fluid collection.
Initial ABG showed 7.31/69/76/36 on 15L (unclear O2 delivery) he
was placed on BiPAP with 50% FiO2 repeat ABG showed
7.33/65/74/36.He was given Albuterol and ipratropium nebulizer
treatements, 500mg Azithromycin, Ceftriaxone 1g IV, and
Methylprednisolone 125mg IV x1.
ABG shortly prior to transfer showed 7.39/55/58/35. Vitals on
transfer BP157/72 RR24 SaO293% on BiPAP PEEP of 8
On arrival to the ICU, initial vitals were BP 127/70 HR:80 RR:19
90% on a 50% ventimask. He was agitated, pulling at lines and
his foley and demanding to get out of bed. He stated that his
last alcoholic drink was 2 days ago which his ExWife confirmed.
Review of systems:
(+) Per HPI
(-) Denies changes in sputum color. Denies fever. Denies chest
pain, chest pressure. Unable to perform further ROS due to
agitation.
Past Medical History:
Alcoholism since [**33**]'s, Denies withdrawl history, denies history
of seizures
COPD
Hypertension
Social History:
- Tobacco: 120-160 pack years (3-4 packs daily x 40 years)
currently smoking 3 packs daily.
- Alcohol: currently drinking 2 bottles of wine + large mixed
drink daily
Family History:
Mother: [**Name (NI) 2481**] Coronary artery disease
Father: Leukemia
Physical Exam:
Admission Exam:
Vitals: T:96.9 BP:127/70 P:80 R:19 O2:92 30% 10/2 BiPAP
General: Overewight male. Agitated, oriented to
person/place/year speaking in [**12-31**] word sentences
HEENT: Sclera anicteric fair dentition
Neck: full supple, JVP not elevated, no LAD
Lungs: Poor air movement, right sided wheezes, decreased breath
sounds on the left base.
CV: Distant Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: Distended, soft, non-tender, bowel sounds normoactive,
unable to assess shifting dullness
GU: Foley in place
Ext: Non pitting edema to mid calf BL, warm, hyperpigmentation
of anterior shin BL consistent with peripheral vascular disease
Discharge Exam:
Physical Exam:
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT
NECK - no JVD appreciated
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c trace edema
NEURO - awake, A&Ox3, moving all extremities
Pertinent Results:
Admission Labs:
[**2125-11-26**] 01:05AM BLOOD WBC-9.7 RBC-4.31* Hgb-14.0 Hct-44.0
MCV-102* MCH-32.4* MCHC-31.8 RDW-15.3 Plt Ct-233
[**2125-11-26**] 01:05AM BLOOD Neuts-76* Bands-0 Lymphs-15* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-8*
[**2125-11-26**] 01:05AM BLOOD Plt Ct-233
[**2125-11-26**] 01:05AM BLOOD PT-15.2* PTT-28.3 INR(PT)-1.3*
[**2125-11-26**] 01:05AM BLOOD Glucose-96 UreaN-11 Creat-1.1 Na-140
K-4.6 Cl-100 HCO3-32 AnGap-13
[**2125-11-26**] 01:05AM BLOOD ALT-24 AST-55* CK(CPK)-58 AlkPhos-176*
TotBili-0.7
[**2125-11-26**] 01:05AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-2372*
[**2125-11-26**] 01:05AM BLOOD Albumin-2.9*
[**2125-11-26**] 01:05AM BLOOD TSH-3.5
[**2125-11-26**] 01:05AM BLOOD Free T4-1.0
[**2125-11-26**] 01:18AM BLOOD Lactate-2.6*
[**2125-11-26**] 09:00PM BLOOD freeCa-1.13
Notable studies:
ECHO [**2125-11-26**]:
Poor image quality. The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Regional left
ventricular wall motion is normal. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with normal free wall contractility. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. The
aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are not well seen. No mitral regurgitation is seen.
Tricuspid regurgitation is present but cannot be quantified. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
prominent fat pad.
CXR [**2125-11-26**]:
IMPRESSION:
1. Bibasilar consolidation, left greater than right, and
moderate left
pleural effusion, may represent infection in the appropriate
clinical setting.
2. Moderate cardiomegaly and/or pericardial effusion. Mild
pulmonary edema.
LE Ultrasound [**2125-11-26**]:
IMPRESSION:
No left or right lower extremity DVT.
RUQ Ultrasound [**2125-11-27**]:
The liver is echogenic and shows some irregularity of outline
more suggestive of cirrhosis than fatty liver, though either
could be the cause. Portal blood flow is towards the liver. No
focal defects are seen within the liver. The gallbladder is free
of stones. The liver itself is enlarged. Both right and left
kidneys are normal. Spleen could not be identified suggesting
that it is not enlarged. Pancreas and aorta are hidden by
overlying bowel gas. There is no ascites.
IMPRESSION: Abnormal liver more consistent with cirrhosis than
fatty infiltrate. No ascites.
Discharge Labs:
[**2125-12-6**] 07:00AM BLOOD WBC-9.2 RBC-4.38* Hgb-14.0 Hct-43.6
MCV-100* MCH-32.0 MCHC-32.1 RDW-14.7 Plt Ct-194
[**2125-12-6**] 07:00AM BLOOD Glucose-104* UreaN-13 Creat-0.9 Na-141
K-3.4 Cl-94* HCO3-38* AnGap-12
[**2125-12-5**] 06:45AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8
Studies pending at Discharge:
None
Brief Hospital Course:
Mr. [**Known lastname 103584**] is a 60 y/o male with a history of hypertension,
chronic obstructive pulmonary disease, probable alcoholic
cirrhosis, and alcohol abuse/dependence admitted with pneumonia
and hypoxemic respiratory failure. Hospital course was notable
for alcohol withdrawal, encephalopathy, and acute diastolic
heart failure.
#Hypoxemic respiratory failure/Pneumonia/Severe exacerbation of
chronic obstructive pulmonary disease:
Chest X-ray was consistent with left lower lobe pneumonia and
patient was requiried ICU admission and intubation. He was also
given steroids for exacerbation of COPD and was able to be
extubated. He completed his antibiotic course of Ceftriaxone and
azithromycin during his hospitalization and was discharged off
supplemental oxygen. He was also started on maintenance
Tiotropium and inhaled fluticasone on discharge.
#Acute diastolic heart failure:
Patient was felt to be volume overloaded on admission and was
diuresed with improvement in pulmonary edema and oxygen
requirement. Since he has had poor PCP follow up in the past and
was felt to have heart failure exacerbation due to infection,
which was treated prior to discharge, he was not discharged on
diuretics. Echocardiogram showed mild symmetric LVH, preserved
LVEF, and mild RV dilation.
#Alcohol withdrawal/encephalopathy/Cirrhosis:
Patient became delirious and agitated following extubation and
this was felt to be due to alcohol withdrawal and benzodiazepine
withdrawal. He was treated with Haldol and tapering doses of
benzodiazepines and his mental status returned to [**Location 213**] prior
to discharge. Although he had imaging consistent with cirrhosis,
he was not felt to have hepatic encephalopathy. Abdominal
ultrasound showed probable cirrhosis but no ascites. He was
counseled on importance of abstaining from alcohol and was given
folate and thiamine. He was maintained on CIWA protocol while on
the medical floor.
# Transitional issues:
Patient was discharged with PCP follow up of COPD, probable
cirrhosis, diastolic heart failure, and alcohol abuse.
Medications on Admission:
Symbicort 80/4.5 prescribed but not using
Vitamin D (Dose unknown)
Vitamin B12 (Dose unknown)
Folate (Dose unknown)
Calcium (Dose unknown)
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 Cap(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing: please have pharmacist teach you how to use
this.
Disp:*1 * Refills:*0*
6. Calcium 500 + D Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Community Acquired Pneumonia
COPD exacerbation
Acute on Chronic Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 103584**],
You were admitted to the hospital for shortness of breath and
cough and you were found to have pneumonia. You were admitted to
the intensive care unit and a breathing tube was placed. You
were treated with antibiotics and your symptoms improved. You
were transferred to the medicine floor and continued to improve.
During your hospital stay, you underwent an ultrasound of your
liver which shows liver disease. It is very important that you
stop drinking alcohol, as this can further damage your liver and
make you very sick. It is also important that you quit smoking,
as this can increase your risk for developing pneumonia. You
primary care doctor can help you with this.
It is very important you follow up with your primary care doctor
regarding your multiple medical conditions. Please go to your
scheduled appointments. You need to have your primary care
doctor set up home physical therapy services.
Please check your weights each morning and if you notice greater
than 3 pound weight gain, please call your primary care doctor
immediately, as this can represent worsening heart failure.
The following changes were made to your medications:
- Please START tiotropium inhaler daily -- this is to help with
your lungs because you have emphysema
- Please STOP Symbicort
- Please START fluticasone inhaler -- this is also for your
lungs
- Please START thiamine vitamins
Please be sure to schedule a followup appointment with your
primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 807**].
Dr. [**First Name (STitle) 807**] may set you up with a liver specialist, a lung
specialist, and a heart specialist.
1.) You likely have Emphysema from smoking so much, so you will
need to start the inhalers, as listed below. You will also need
to have pulmonary function tests when you are feeling back to
normal.
Please try to cut back as much as possible on your smoking to
make it easier to quit.
2.) You were also found to have diastolic heart failure, which
means that you can build up fluid easily in your lungs and legs
if you eat extra salt. Please try to avoid salt as much as
possible in your diet. Please also weigh yourself every morning
before breakfast, as we discussed. If you are gaining more than
3 lbs, it is likely fluid weight, so you should call Dr. [**Name (NI) 30283**] office, and he may need to start you on a medication
called furosemide so that you can urinate out the extra fluid.
3.) You were also found to have cirrhosis of the liver, likely
because of the alcohol you have been drinking over the years.
Please try to stop drinking alcohol, as this can cause further
harm to your liver. You will need to follow with a liver
specialist.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital **] MEDICAL PHYSICIANS, P.C.
Address: [**University/College 808**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 823**]
**Please contact your Primary Care Physician for [**Name Initial (PRE) **] follow up
appointment from your hospital stay. It is recommended you
follow up with Dr [**First Name (STitle) 807**] within 1 week for a FULL PHYSICAL.**
**Also please speak with your PCP about the need to follow up
with a Liver specialist, Heart specialist, Lung specialist**
Completed by:[**2125-12-9**]
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Discharge summary
|
Report
|
Admission Date: [**2157-12-16**] Discharge Date: [**2157-12-21**]
Date of Birth: [**2102-10-7**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2157-12-18**]
1. Open treatment fracture-dislocation, thoracic spine.
2. Bilateral laminotomy T9, T10, T11.
3. Posterolateral fusion T9-T10, T10-T11.
4. Posterolateral instrumentation T9, T10, T11.
5. Application of iliac crest bone graft for fusion
augmentation.
6. Application of local autograft for fusion augmentation.
7. Application of allograft for fusion augmentation.
History of Present Illness:
HPI: 55 yo F who fell backwards off of a [**Location (un) 453**] balcony onto
a
concrete slab. Pt was leaning backwards on a rail at a
restaurant
when the rail gave way and she fell approximately 7 feet onto a
concrete slab. Pt recalls the entirety of the event and denies
LOC. She does recall striking the back of her head on the
concrete. She describes immediate pain in the middle of her back
after the fall and was unable to stand because of it. She denies
any numbness or tingling in her extremities and denies any
incontinence following her fall. Pt was taken to an OSH where
she
was found to have multiple posterior rib fxs (6th-8th on L, 9th
on R), a T10 compression fx w/ impringement on the thecal sac.
Pt
was subsequently transfered to the [**Hospital1 18**] for further evlauation
and Spine surgery consultation.
On presentation to the [**Name (NI) **], pt was stable and complaining of
severe pain throughout her mid back. While in the trauma bay her
O2 saturation decreased to high 80s on NC and a nonrebreather
was
required. At that point she was tachypnic into the 30s. She was
admitted to the TSICU for close observation, respiratory
support,
and pain control. Ortho Spine was consulted for further
evaluation of her spinal fractures
Past Medical History:
Past Medical History: anxiety - gerd
Social History:
Social History: Denies Alcohol and Smoking
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2157-12-16**]
Temp:afeb HR:100 BP:131/83 Resp:36 O(2)Sat:99 Normal
Constitutional: Immob
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent; no deficits
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2157-12-16**]: Cat scan of spine:
IMPRESSION:
1. Burst fracture of T10 vertebral body, with outward
displacement of
multiple fracture fragments with associated laminar fractures on
both sides of the posterior arch of T10. Bone along the
posterior margin of T10 vertebral body is displaced into the
spinal canal.
2. Compression of the superior endplate of the T7 vertebral body
with intact posterior arch point.
3. Transverse fractures of left T7, 8, 9, 10 and 11.
4. Fractures of the left 5th, 6th and 7th ribs and right 9th
posterior ribs.
5. Developing atelectasis in bilateral lungs as well as possible
bilateral
pleural effusions
[**2157-12-15**]: Cat scan of abdomen and pelvis:
IMPRESSION:
1. Bilateral dependent pleural effusion with some hyperdensity
within the
pleural effusion which may represent a component of hemothorax.
2. Adjacent compressive atelectasis.
3. Bilateral rib fractures as detailed above.
4. Fractures of the left 7, 8, 9, 10,11 transverse processes.
5. Burst fracture of T10 vertebral body with posterior arch
involvement and
retropulsion of the components of the fracture fragment into the
vertebral
canal.
6. Fracture of the anterior superior endplate of T7 with no
obvious arch
involvement
[**2157-12-15**]: Chest x-ray:
PORTABLE AP CHEST RADIOGRAPH: In the interim since the most
recent chest
radiograph there is increased inflation of the left lung.
Bilateral pleural effusions are still noted, left greater than
right. Rib fractures are better visualized on the adjacent chest
CT. Cardiac silhouette is top normal.
[**2157-12-16**]: MR thoracic spine:
IMPRESSION:
1. Worst fracture of T10 vertebra with retropulsion and likely
disruption of the anterior and posterior longitudinal ligaments
with retropulsion causing mild spinal stenosis.
2. Moderate compression of T7 vertebra with probable disruption
of the
posterior longitudinal ligament and mild retropulsion in the mid
portion in contact with the anterior aspect of the spinal cord.
3. Disc herniation at T3-4 level indenting the anterior aspect
of the spinal cord with subtle increased signal in the T4
vertebra, likely due to mild compression injury. Alternatively,
the increased signal in the T4 vertebra could be due to
degenerative change.
4. No evidence of high-grade spinal cord compression or
intrinsic spinal cord signal abnormalities
[**2157-12-17**]: cat scan of the head:
IMPRESSION: No acute intracranial process
[**2157-12-17**]: Chest x-ray:
FINDINGS: In comparison with the study of [**12-16**], there is some
increased
opacification at the right base consistent with atelectasis and
fluid in the pleural space. Retrocardiac atelectasis is again
seen. The multiple rib fractures are better visualized on the CT
scan. Top normal or slightly
enlarged cardiac silhouette is again noted. No definite
pulmonary vascular congestion
[**2157-12-18**]: T-spine:
FINDINGS AND IMPRESSION: AP and lateral intraoperative images
of the
thoracolumbar spine. At approximately T10, a compression
fracture is noted. Status post posterior spinal fusion from
approximately T9-T11. .
[**2157-12-16**] 01:15AM WBC-9.5 RBC-3.67* HGB-11.4* HCT-33.8* MCV-92
MCH-30.9 MCHC-33.6 RDW-12.9
[**2157-12-16**] 01:15AM NEUTS-86.9* LYMPHS-9.3* MONOS-3.2 EOS-0.1
BASOS-0.5
[**2157-12-16**] 01:15AM PLT COUNT-257
[**2157-12-16**] 01:15AM PT-12.4 PTT-21.4* INR(PT)-1.0
[**2157-12-16**] 01:15AM GLUCOSE-119* UREA N-18 CREAT-0.7 SODIUM-137
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
Brief Hospital Course:
55 year old female who presented to the Acute Care Service
after a fall from a porch landing on her back. Initially, she
was seen at an outside hospital where she was reported to have
multiple rib fractures and a thoracic compression fracture.
Upon admission to the Acute Care Service, she was evaluated by
Ortho-spine who recommended TLSO brace. She had blood work done
and further imaging of her back, chest, and head.
She had an episode of oxygen desaturation upon admission, and
for this reason was admitted to the Trauma Intensive Care unit
for neuro-checks, pulmonary toilet and pain management. She was
placed on log-roll precautions until she was fitted for her TLSO
brace.
She was taken to the Operating room on [**12-18**] where she had a
T10 posterior corpectomy and a T9-T11 fusion. During her
operative procedure, she did receive blood for a liter blood
loss. She was extubated in the recovery room.
Her post-operative course has been stable. She is afebrile and
her vital signs are stable. She is tolerating a regular diet.
She has been out of bed with the TLSO brace. Her pain is
controlled with oxycodone. She was evaluated by Physical Therapy
Service and rehab was recommended with the hopes of improving
her mobility and returning home.
After an uneventful post op course she was discharged to rehab
on [**2157-12-21**] and will follow up with Dr. [**Last Name (STitle) 1007**] in 2 weeks.
Medications on Admission:
Medications: Omeprazole
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
5. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours) as needed for itching/insomnia.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain: as needed.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-15**]
Tablets PO Q6H (every 6 hours) as needed for pain.
10. insulin regular human 100 unit/mL Solution Sig: [**2-23**] units
Injection four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
S/P Fall
1. posterior L 6-8th rib fx
2. posterior R 7-9th rib fx
3. severely comminuted compression fx T10
4. compression fx T7
5. L transverse fx T7-11
6. acute blood loss anemai
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair, pt has TLSO brace when out of bed
Discharge Instructions:
You are being discharged after you were admitted for a fall in
which you sustained back and rib fractures. You were taken to
the operating room for a laminectomy and fusion. You are now
preparing for discharge with the following instructions:
Your injury caused posterior right and left rib fractures
which can cause severe pain and subsequently cause you to take
shallow breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus )
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1007**] in 2 weeks. You can schedule
this appointment by calling #[**Telephone/Fax (1) 1228**].
Please follow up with the Acute Care Service in 2 weeks, you can
schedule this appointment by calling #[**Telephone/Fax (1) 600**]
Completed by:[**2157-12-21**]
|
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| 30
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
92,170
| 105,063
|
456728
|
Physician
|
Physician Resident Progress Note
|
TITLE:
Chief Complaint:
24 Hour Events:
- Continued on vanc/zosyn
- Nasal swab done
Allergies:
Coumadin (Oral) (Warfarin Sodium)
Nausea/Vomiting
Last dose of Antibiotics:
Piperacillin - [**2189-3-30**] 02:00 AM
Vancomycin - [**2189-3-30**] 03:00 AM
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2189-3-30**] 07:05 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.8
C (98.3
Tcurrent: 36.8
C (98.3
HR: 79 (75 - 89) bpm
BP: 90/52(62) {90/41(53) - 105/72(78)} mmHg
RR: 15 (14 - 19) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Total In:
811 mL
PO:
TF:
IVF:
811 mL
Blood products:
Total out:
0 mL
260 mL
Urine:
260 mL
NG:
Stool:
Drains:
Balance:
0 mL
551 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 99%
ABG: ///19/
Physical Examination
Gen: Somnolent male difficult to arouse from sleep but in NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: Anterior breath sounds notable for rales at right base and
diminished breath sounds at left base.
ABD: Soft, nl BS, mildly distended, unable to appreciate fluid wave
EXT: 2+ pitting LE edema extending to lower back and 1+ of upper
extremities b/l. 2+ DP pulses BL
SKIN: No lesions
NEURO: Arousable but not oriented. PERRL, unable to elicit rest of
neuro exam as pt not too obtunded
PSYCH: Listens and responds to questions appropriately, pleasant
Labs / Radiology
446 K/uL
9.5 g/dL
69 mg/dL
0.7 mg/dL
19 mEq/L
5.2 mEq/L
21 mg/dL
84 mEq/L
113 mEq/L
28.3 %
22.3 K/uL
[image002.jpg]
[**2189-3-30**] 12:31 AM
[**2189-3-30**] 05:30 AM
WBC
22.3
Hct
28.3
Plt
446
Cr
0.7
0.7
Glucose
60
69
Other labs: PT / PTT / INR:15.3/33.4/1.4, ALT / AST:35/96, Alk Phos / T
Bili:496/1.5, Lactic Acid:4.2 mmol/L, Albumin:2.1 g/dL, LDH:765 IU/L,
Ca++:7.3 mg/dL, Mg++:1.7 mg/dL, PO4:3.6 mg/dL
Assessment and Plan
ASSESSMENT / PLAN:
71yo male with history of metastatic pancreatic cancer was admitted
with dyspnea, new ascites, and profound hyponatremia to 103.
.
1. Dyspnea
Etiology of his dyspnea is likely multifactorial. Differential
diagnosis includes pneumonia, aspiration, hypoventilation related to
increased ascites, and effusion. Regarding pneumonia, CXR infiltrate
and leukocytosis are suggestive. Regarding hypoventilation, patient may
have increased sensation of dyspnea related to his ascites. Regarding
effusion, patient has evidence of effusion on CXR. Etiology of his
effusion could be secondary to pneumonia or malignancy.
- treat for hospital acquired pneumonia with vancomycin and zosyn
- consider IR-guided paracentesis for evaluation of paracentesis
- consider IR guided thoracentesis for evaluation of his pleural
effusion if his symptoms do not improve with antibiotics
.
2. Hyponatremia
Patient has profound hyponatremia. Patient appears total body
overloaded on exam, although he is likely intravascularly depleted.
This appears likely given his concentrated urine, although it is
somewhat surprising that his creatinine is normal. His hyponatremia is
likely related to an increased ADH related to intravascular volume
depletion. An additional possibility includes SIADH secondary to a
pulmonary process. Given his altered mental status and sodium values,
he likely has symptomatic hyponatremia. Will likely need aggressive
repletion of sodium with increase in sodium concentration of
1-2mEq/hour for the first 3-4 hours and then can slow down to
.5-1mEq/hour after that.
- start hypertonic saline at 150mL/hour x 3 hours and check sodium and
make appropriate adjustments after that
- add on urine and serum osm
.
3. Leukocytosis
Etiology of his leukocytosis is unclear. Differential diagnosis
includes most likely infection, with pneumonia being his most likely
source.
- follow-up blood cultures
- send urine cultures
- follow-up final read of CXR
- send sputum gram stain and culture
- continue vancomycin and zosyn for treatment of presumed hospital
acquired pneumonia
.
4. Guaiac positive stools
Patient was found to have guiac positive stools, likely related to his
history of GI cancer and it is unclear if he has any GI tract
involvement of his cancer. In light of guiac positive stools, will hold
off on any anticoagulation at this time.
.
5. Metastatic Pancreatic Cancer
Patient has known metastatic pancreatic cancer. He has been offered
palliative chemotherapy and radiation treatment, which he has refused.
He has also had palliative care evaluation which has not been pursued.
Patient's CT scan demonstrates progression of his disease with new
ascites, likely related to his increased burden of hepatic mets.
- will let patient's primary oncologist know that patient is
hospitalized
- palliative care consult
6. Ascites
Patient has developed new ascites which is likely related to his
increased metastatic disease. IR guided paracentesis may improve his
subjective symptoms of dyspnea, although this will likely recur quickly
given his metastatic disease.
- consider IR guided paracentesis pending improvement in sodium
7. Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis. Unclear if this
represents a spontaneous thrombosis or is related to tumor invasion.
Patient is certainly a poor candidate for anticoagulation given his
poor PO intake, multiple comorbidities, and reported allergy to
coumadin.
- appreciate GI input
- continue to monitor
ICU Care
Nutrition:
Comments: NPO for now
Glycemic Control:
Lines:
18 Gauge - [**2189-3-30**] 12:54 AM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
|
[
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icd9cm
|
[
[
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[] |
icd9pcs
|
[
[
[]
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95,517
| 119,923
|
42346
|
Discharge summary
|
Report
|
Admission Date: [**2196-10-13**] Discharge Date: [**2196-10-21**]
Date of Birth: [**2145-4-30**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
worst headache of life
Major Surgical or Invasive Procedure:
[**2196-10-14**]: DIAGNOSTIC CEREBRAL ANGIOGRAM
[**2196-10-20**]: DIAGNOSTIC CEREBRAL ANGIOGRAM
History of Present Illness:
51 y/o female who presents a history of being at the gym today
around 5pm doing weighted hip lifts when she developed a sudden
onset severe headache and nausea. She was unable to rise from
the
floor, EMS was called, she was transported to [**First Name8 (NamePattern2) 745**] [**Last Name (NamePattern1) **]
Hospital and subsequently transferred here after a head CT
revealed SAH.
She received aprox. 9mg of Morphine and several anti-emetics
prior to transfer and was re medicated for nausea in our ER.
Past Medical History:
None
Social History:
Denies Tobacco, ETOH socially, Married, Lives at home with
husband and two kids.
Family History:
NC
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 2 GCS E: 3 V:5 Motor 6
O: T: 97.6 BP:126 /69 HR: 84 R15 O2Sats 100
Gen: WD/WN, comfortable, NAD.
HEENT: NCNT
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT,
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Lethargic but alert, presents complete history,
cooperative with exam
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength intact and symmetric, decrease
sensation
right cheek.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-21**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2196-10-13**]
1. Stable bilateral supratentorial subarachnoid blood as well as
stable
hemorrhage in the 4th ventricle, and in the prepontine,
premedullary and right lateral medullary cisterns.
2. No evidence of cerebral aneurysm or AVM, or vertebral or
other cervical
arterial dissection.
3. 1.1 cm and a 1 cm bilateral hypodense thyroid lesions. If not
previously done elsewhere, ultrasound is suggested if clinically
warranted.
Cerebral Angiogram [**2196-10-14**]:
Negative for aneurysm
MRI/A C-spine [**2196-10-15**]:
No evidence of arteriovenous fistula or malformation seen in the
cervical region. No abnormal signal seen within the spinal cord.
Mild
degenerative changes. No abnormal enhancement.
Brief Hospital Course:
51 y/o F s/p WHOL after working out at the gym. She was taken to
OSH where head CT revealed a perimesincephalic SAH. She was
transferred to [**Hospital1 18**] for further neurosurgical evaluation. Once
at the [**Hospital1 **], patient had a CTA of the head that showed no
aneurysm. Patient remained neurologically intact. On [**10-14**],
repeat head CT showed stable SAH with no hydrocephalus. She was
taken to for a cerebral angiogram for confirmation and was
negative for aneurysm or other vascular anomalies.
On [**10-15**] a MRI/A of the cervical spine was performed to rule out
a vascular anomaly and was negative. Patient remained in the
ICU.
On [**10-17**] A CTA of the head was performed to r/o vasospasm which
was negative. She was subsequently transferred to the SD unit.
She did well on the floor, but mostly had difficulties with
lower back pain which ultimately responded to a combination of
NSAIDs and valium. Her headaches were controlled with fioricet-
and similar agents.
Following a repeat angiogram on [**10-20**] which was normal, she
was discharged to home the next day with instructions to follow
up in one month with Dr. [**First Name (STitle) **]. A referral was placed for the
patient to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in clinic.
Medications on Admission:
None
Discharge Medications:
1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every six (6) hours as needed for Headache.
Disp:*40 Tablet(s)* Refills:*0*
2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain/spasm.
Disp:*40 Tablet(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*1*
5. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
SUBARACHNOID HEAMORRHAGE
HEADACHE
THYROID LESION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during this
hospitalization. You were admitted to the Neurosurgery Service
of the [**Hospital1 69**] for an evaluation of
your headache which was associated with a "subarachnoid
hemorrhage", which is a collection of blood just outside the
brain that can be very serious and dangerous. You received
multiple procedures to search for an "aneurysm", which is an
outpouching of a blood vessel that can be prone to easy rupture.
- Your restrictions are that you should not work x 4 weeks
- do not lift > 15 lbs
- you may exercise as tolerated
- It is important that you take your medications as prescribed
below.
- Please do not hesitate to contact us if you experience further
symptoms or have questions.
- Please follow up with your PCP as well as Dr. [**First Name (STitle) **] from the
Neurosurgery Department.
Medications:
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
PLEASE FOLLOW-UP WITH DR [**First Name (STitle) **] IN 1 month. PLEASE CALL
[**Telephone/Fax (1) 4296**] TO MAKE THIS APPOINTMENT.
PLEASE FOLLOW-UP WITH YOUR PCP REGARDING THE THYROID LESION
NOTED ON IMAGING. [PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 10505**]]
Completed by:[**2196-10-21**]
|
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icd9cm
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icd9pcs
|
[
[
[
349,
377
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] | 7
| 1,305
| 0
| 99
| 1
| 0
| 0
| 0
| 0
| 739
| 0
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| 330
| 5
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| 678
| 0
| 52
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99,274
| 131,735
|
2047
|
Discharge summary
|
Report
|
Admission Date: [**2151-11-9**] Discharge Date: [**2151-11-13**]
Date of Birth: [**2069-3-22**] Sex: M
Service: SURGERY
Allergies:
Moexipril
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
splenic artery pseudoaneurysms
Major Surgical or Invasive Procedure:
splenectomy [**2151-11-11**]
History of Present Illness:
82M who sustained left-sided rib fractures, left hemorrhagic
pleural effusion and a splenic laceration with surrounding
hematoma one month ago after falling from a chair. Follow-up
outpatient ultrasound approximately one month after the injury
ultrasound which detected three splenic artery aneurysms. Thus
he
was taken to the interventional suite with angiography today.
The
procedure was uneventful but they were unable to embolize either
of the three aneurysms due to aberrant anatomy. During the
procedure, pt HR dropped to 30s with advancement of guidewire
and with breath holding. There was concern for rupture of
pseudoaneurysm (per ACS). Pt went to PACU and became bradycardic
to 30s when sheath was removed. SBP dropped to 70s. 1 amp
Atropine was given and 1.5L of fluid was given. He has been HD
stable.
Patient was former athlete and used to run track. He walks at a
fast pace on his treadmil 30 min every day. He denies having CP
(had CP with previous MI), diaphoresis with any activity or
during bradycardic events.
Past Medical History:
CAD s/p quadruple CABG in [**2137**]
HTN
HLD
Anemia of chronic disease
Chronic kidney disease stage II
Osteoarthritis, right knee
R neck shingles, treated with acyclovir [**2151-4-25**]
Left inguinal hernia repair [**2150-9-25**]
Cataracts bilaterally s/p extraction at [**Hospital1 2177**] [**2149**]
Social History:
Quit smoking in [**2109**], previously smoked half ppd for 20 years.
Minimal EtOH socially. No illicit drugs. Retired [**Company 2318**]
consultant, now working in [**Location (un) 86**] Public Schools 9th grade.
Family History:
No history of syncope, cardiovascular disease, stroke, seizures.
Mother had HTN, died in 80s from GI blood loss,
?diverticulosis. Father died in 50s from cancer. Had 4
sisters, they died from childbirth, COPD, cancer.
Physical Exam:
Vitals: 97 105 126/82 22 97 3L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist. No scalp
lacerations or hematomas. PERRL, EOMI.
Cspine: no TTP, full AROM without pain
CV: sinus bradycardia. Well healed sternotomy incision
PULM: Clear to auscultation b/l, No W/R/R.
ABD: Soft, non-tender, nondistended, no guarding. No masses
palpated, incision CDI, JP drains x 2 SS output
Groin: no hematoma at previous
Ext: No LE edema, LE warm and well perfused
Pertinent Results:
Laboratory:
2.8 >------< 162
30.6
Cr: 1.2
[**2151-11-9**] WBC-4.5 Hct-35.4 Plt Ct-170
[**2151-11-9**] WBC-2.8* Hct-30.6* Plt Ct-162
[**2151-11-10**] WBC-5.6# Hct-28.5* Plt Ct-162
[**2151-11-10**] WBC-5.0 Hct-29.2* Plt Ct-161
[**2151-11-10**] WBC-5.0 Hct-29.2* Plt Ct-161
[**2151-11-12**] WBC-11.7 Hct-28.6* Plt Ct-122*
[**2151-11-13**] WBC-13.7* Hct-27.2* Plt Ct-156
Brief Hospital Course:
Mr. [**Known lastname 11172**] was admitted to the TSICU from the angiography suite.
He remained hemodynamically stable overnight. Serial hematocrits
were checked and remained stable. Cardiology consult obtained.
Their suspicion was that he was hypovolemic in the setting of
beta blockade, contributing to bradycardia and intermittent
hypotension. He tolerated a regular diet and was transferred to
the floor.
Once stabalized it was decided that he have a splenectomy given
the high risk of a rebleed. He did so on HD 3 and tolerated the
procedure well. Post splenectomy he has tolerated a regular
diet, is ambulating, and his pain is controlled with PO pain
medications. He will be discharged to home today and follow up
in clinic in [**7-4**] day's time. He will receive post plenectomy
vaccines prior to discharge.
Medications on Admission:
amlodipine 10mg', atenolol 25mg', HCTZ 25mg',
losartan 100mg', lovastatin 40mg', sildenafil 25mg', ASA 81mg'
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
Disp:*50 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*1*
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 2 weeks.
Disp:*40 Tablet(s)* Refills:*0*
7. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
splenic artery pseudoaneurysms
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after failed embolization of
multiple splenic artery aneuryms. You had your spleen removed
this admission and have done well since the operation. You are
now ready to be discharged home. Please return to the hospital
if you develop chest pain, shortness of breath, abdominal pain,
or if you increased or bloody output from the drains. The drains
will stay in until your follow up appointment at which time they
will be removed. Please follow up as instructed below.
Followup Instructions:
Please follow up in [**Hospital 2536**] clinic in [**7-4**] days. Please call for a
follow up appointment. The number to call is [**Telephone/Fax (1) 11173**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2151-11-13**]
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40208
|
Discharge summary
|
Report
|
Admission Date: [**2144-1-24**] Discharge Date: [**2144-1-27**]
Date of Birth: [**2079-12-25**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vicodin
Attending:[**First Name3 (LF) 65686**]
Chief Complaint:
s/p seizure
Major Surgical or Invasive Procedure:
Extubation [**2144-1-25**]
History of Present Illness:
64M h/o brain mass undergoing cyber knife last Tx last teusday,
followed by [**First Name5 (NamePattern1) 1151**] [**Last Name (NamePattern1) 6570**] (neuro-onc), no h/o sz but on keppra
after first cyberknife and stopped 2-3d ago, was also tapering
decadron, pt found by wife this morning with jerking movements
of arms, unresponsive. Prior to this he had been having coughing
fit and wife found him slumped on the couch with rhythmic
jerking of hands but did not respond to voice but could squeeze
his hands. He had not been having any fevers. Spontaneously
resolved after several minutes, when EMS arrived pt was
post-ictal with GCS 3. Intubated for airway protection at
Southern [**Hospital **] medical center because he was still unresponsive but
had stopped convulsing, got tylenol suppository there. got
decadron, keppra, ativan, propofol for sedation. Head CT was
obtained at OSH which was unchanged from scan [**10-31**] when mass
initially discovered. He was transferred to [**Hospital1 **] ED for continuity
of care.
.
Seen by Neuro in ED, reviewed CT head from OSH. Has not been
getting chemo but anemic and thrombocytopenic. His primary
neuro-oncologist was paged and suggested that LP may be
necessary if he appears to be infected clinically. Dr. [**Last Name (STitle) 6570**]
will follow in house instead of neuro consult team. He
recommended: Keppra 1g IV BID 1:1 w/ PO as well as decadron 4mg
Q6hrs. ED was not comfortable w/ doing LP given mass effect
(though recommended by his neuro-oncologist) and
thrombocytopenia to 64 (guideline is 80). He was not given
empiric Abx because he was afebrile, no leukocytosis and had a
good reason for sz other than meningitis.
.
VS prior to transfer: 87, 102/63, 100% 550 18, PEEP 50% FiO2.
.
Past Medical History:
# Mestatastic clear cell renal CA s/p R nephrectomy 3 yrs ago
# Prostate CA s/p prostatectomy
# HTN
# DM
# HL
# Anxiety
# GERD
# Gout
Social History:
Married. Lives with his wife. [**Name (NI) **] is a retired insurance [**Doctor Last Name 360**].
He never smoked. No alcohol since [**2140**]. No drugs.
Family History:
He has two daughtres and one son, all healthy. His father died
at age 49 after returning from WWII, cause unclear. His mother
died at age 85. He has no siblings.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
PHYSICAL EXAM ON DISCHARGE:
Vital signs: Tc 98.2 Tmax 99.1 BP 118/74 (118-146/70-82) HR 63
(63-70) O2 sat 100% RA FS 208-279
GEN: AOx3, NAD
HEENT: PERRL. MMM. No LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB, no wheezes/crackles
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+. Contracture of right
hand (chronic for 10 years)
Skin: no rashes or bruising
Neuro: A & O x 3, slow to speak, CNs II-XII intact. 5/5 strength
in U/L extremities.
Pertinent Results:
LABS ON ADMISSION:
[**2144-1-24**] 01:00PM BLOOD WBC-6.4 RBC-3.43* Hgb-11.4* Hct-31.1*
MCV-91 MCH-33.3* MCHC-36.7* RDW-15.7* Plt Ct-65*
[**2144-1-24**] 01:00PM BLOOD PT-12.9 PTT-21.7* INR(PT)-1.1
[**2144-1-24**] 01:00PM BLOOD Fibrino-481*
[**2144-1-24**] 01:00PM BLOOD Ret Aut-4.0*
[**2144-1-24**] 11:48PM BLOOD Glucose-260* UreaN-31* Creat-1.5* Na-138
K-4.2 Cl-104 HCO3-22 AnGap-16
[**2144-1-24**] 01:00PM BLOOD ALT-37 AST-23 LD(LDH)-377* AlkPhos-72
TotBili-0.9
[**2144-1-24**] 11:48PM BLOOD Calcium-7.8* Phos-4.2 Mg-1.3*
[**2144-1-24**] 01:00PM BLOOD Hapto-234*
[**2144-1-24**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2144-1-24**] 01:19PM BLOOD Type-MIX pO2-209* pCO2-36 pH-7.46*
calTCO2-26 Base XS-2 Comment-GREEN TOP
[**2144-1-24**] 01:19PM BLOOD Glucose-179* Lactate-1.0 Na-138 K-4.4
Cl-102
LABS ON DISCHARGE:
[**2144-1-27**] 07:20AM BLOOD WBC-7.6 RBC-3.86* Hgb-12.1* Hct-35.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-15.1 Plt Ct-108*
[**2144-1-27**] 07:20AM BLOOD Glucose-203* UreaN-34* Creat-1.3* Na-137
K-4.5 Cl-100 HCO3-28 AnGap-14
[**2144-1-27**] 07:20AM BLOOD TotProt-5.9* Calcium-9.3 Phos-3.7 Mg-1.5*
[**2144-1-27**] 07:20AM BLOOD PEP-HYPOGAMMAG IgG-356* IgA-93 IgM-63
IFE-TRACE MONO
[**2144-1-26**] 01:58PM URINE U-PEP-NO PROTEIN
[**2144-1-26**] 01:58PM URINE Hours-RANDOM TotProt-12
Portable CXR [**2144-1-24**]:
1. ET tube terminates 5 cm from the carina without evidence of
pneumothorax.
2. There is prominence of hilar and mediastinal silhouette and
pulmonary
vasculature, which may be reflective of increased pulmonary
vascular pressure.
3. Retrocardiac opacity, likely atelectasis or aspiration;
however,
superimposed infection cannot be entirely excluded.
CXR (PA & LAT) [**2144-1-26**]:
IMPRESSION: PA and lateral chest reviewed in the absence of
prior chest
radiographs:
The lateral view shows a wedge-shaped area of opacity in one of
the lower
lungs, could be a composite shadow of anterior spinal
osteophytes and large lower lung vessels. Two other regions of
abnormality are the suggestion of 11-mm wide right upper lobe
nodule at the level of the first anterior interspace and
fullness in the right lower paratracheal mediastinum, which
could be adenopathy or fat. All these issues would be resolved
with routine chest CT.
Heart is top normal size, there is no pulmonary edema or pleural
effusion.
Brief Hospital Course:
64 yo M w/ renal cell CA to the brain p/w new onset seizure.
.
#. S/p seizure: Pt presented with new onset seizure at home. Pt
had mass lesion in brain and had been recently taken off seizure
prophylaxis. He had been on a dexamethasone taper and had had
his last dose of keppra on [**2144-1-21**]. He initially presented to an
OSH where he was intubated for airway protection. Head CT at
OSH was largely unchanged per neurology team. Lumbar puncture
was not performed as he was afebrile with no leukocytosis and
because he had thrombocytopenia (plts 60s). Clinical suspicion
for infectious etiology for seizure was quite low. He was
placed back on keppra and dexamethasone and extubated on [**2144-1-25**]
with no complications. He did not have further seizures in the
hospital. He was discharged with follow-up with his primary
neuro-oncologist.
.
#. Renal cell carcinoma: Pt with renal cell carcinoma metastatic
to brain. He was diagnosed with renal cell carcinoma in [**6-/2141**]
and was s/p right nephrectomy [**8-/2141**] with recently diagnosed
left frontal brain mass. He was s/p first cyberknife treatment
[**2144-1-14**]. Pt had chronic mild right hemiparesis, anomia, and
dysphasia but no new neurologic deficits. He had recently
completed keppra course and had been on dexamethasone taper
prior to presenting with new onset seizure. He had intermittent
headaches controlled with oxycodone. He will follow up with his
primary oncologist as outpatient.
.
#. ?Aspiration: CXR on admission showed retrocardiac opacity,
likely atelectasis vs. aspiration but could not rule out PNA. Pt
had low grade temp 100.2 upon arrival to [**Hospital1 18**] ED but was
afebrile with no leukocytosis throughout remainder of hospital
course. Clinical suspicion for PNA was quite low and he was not
started on antibiotics. Repeat cxr showed an opacity that was
read as possible composite shadow of osteophytes and lung
vessels; two other regions of fullness were interpreted as
adenopathy or fat. Pt also reportedly had difficulty swallowing
at ICU and was put on thickened liquid diet. He underwent a
speech and swallow assessment and was deemed safe for thin
liquids and regular consistency solids.
#. Normocytic Anemia: Pt with normocytic anemia, Hct 30-35
during hospital admission. Given anemia in conjunction with
thrombocytopenia, SPEP and UPEP were sent to rule out multiple
myeloma. SPEP showed low levels of IgG but was otherwise
unremarkable. Hct remained stable and pt had no evidence of
bleeding.
.
#. CKD: Cr baseline was 1.7. Cr was 1.3-1.5 during admission.
.
#. Thrombocytopenia: Pt presented with thrombocytopenia, plt
count in 60s. He was given 1 unit platelets upon admission to
ICU. Platelet count had slowly been downtrending since
[**2143-11-21**]. Peripheral smear was examined per ICU and did not
show schistocytes to suggest TTP. Thrombocytopenia may have
been [**12-25**] dexamethasone. He was started on folic acid and plt
count rose to 108 by time of discharge.
.
#. DMII: Pt had been on glyburide at home and was maintained on
HISS while in the hospital. He had rare hyperglycemia to 400s
while on dexamethasone which improved by time of discharge. He
was discharged back on home dose of glyburide.
Medications on Admission:
ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet -
1
Tablet(s) by mouth DAILY (Daily)
DEXAMETHASONE - (Prescribed by Other Provider; Dose adjustment
-
no new Rx) - 2 mg Tablet - 2 Tablet(s) by mouth once a day
GLYBURIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth twice a day
LEVETIRACETAM [KEPPRA] - 500 mg Tablet - One Tablet(s) by mouth
twice a day starting [**2144-1-12**] stopped [**2144-1-21**]
LISINOPRIL - (Prescribed by Other Provider) - Dosage uncertain
LORAZEPAM - 0.5 mg Tablet - [**11-24**] Tablet(s) by mouth 30 minutes
prior to your CyberKnife treatment
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours as needed for pain
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO qam.
Disp:*90 Tablet(s)* Refills:*0*
5. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO at bedtime
for 3 days: Take in addition to dexamethasone 4mg in the morning
through [**2144-1-29**].
Disp:*3 Tablet(s)* Refills:*0*
6. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain: [**Street Address(1) 87025**], DRINK ALCOHOL, OR OPERATE HEAVY
MACHINERY WITH THIS MEDICATION.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Seizure
Secondary:
Renal cell carcinoma with metastases to brain
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you in the hospital. You were
admitted with a new seizure. This was likely caused by your
brain mass. You were re-started on a medication to prevent
seizures and steroids to reduce swelling in the brain. You
should follow-up with your primary oncologist to discuss further
management of your renal cancer.
You were also evaluated with a speech and swallow assessment
given your difficulties swallowing. You were assessed to be
safe when swallowing. If you have further difficulties with
swallowing, please contact the speech and swallow clinic.
The following changes were made to your medications:
1) Keppra 1000mg twice a day to prevent seizures
2) Dexamethasone 4mg in the morning and 2mg at night for three
days until [**2144-1-29**], then take dexamethasone 4mg daily ONLY
starting on [**2144-1-30**]
Followup Instructions:
You have the following appointments scheduled for you:
Department: RADIOLOGY
When: MONDAY [**2144-2-10**] at 12:35 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2144-2-10**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2144-2-2**]
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icd9pcs
|
[
[
[]
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] | 7
| 3,253
| 0
| 30
| 1
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| 0
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| 6
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| 165
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|
99,081
| 147,170
|
45408
|
Discharge summary
|
Report
|
Admission Date: [**2140-5-2**] Discharge Date: [**2140-5-6**]
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Complex left cystic adnexal mass, bilateral cystic adnexal
masses, and left colon cancer.
Major Surgical or Invasive Procedure:
Laparoscopic left colectomy
Laparoscopic bilateral salpingo-oophorectomy
History of Present Illness:
A [**Age over 90 **]-year-old woman who presented with symptoms of obstruction
who was found to have descending colon cancer as well as ovarian
cyst. The risks and benefits including but not limited to
infection, bleeding, leak, the need for more procedures, hernia,
pneumonia, death and heart attack were discussed. The patient
consented and agreed.
Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Postural dizziness
Social History:
Patient lives alone independently, daughter lives in [**Name (NI) 760**]
and son in [**Name (NI) 8447**]. Daughter-in-law lives close by and
frequently visits the patient. She is very active and frequently
does yard work on her own.
Physical Exam:
General: Appears well, ambulating the floor independently,
toelrating a regular diet, +flatus, appropriate amount of pain.
VS: Tmac: 99.0 Tcurrent: 97.7 HR: 59 BP: 129/71 RR:16 SaO2:98
RA'
General: A&Ox3
Cardiac: RRR
Lungs: CTA bil
Abdominal: soft, nontender, nondistended, no rebound/gaurding
Wound: CD&I, all laparoscopic sites covered with staples
Pertinent Results:
[**2140-5-4**] 05:30AM BLOOD WBC-12.4* RBC-2.97* Hgb-9.5* Hct-29.4*
MCV-99* MCH-32.1* MCHC-32.5 RDW-14.6 Plt Ct-216
[**2140-5-3**] 04:06AM BLOOD WBC-14.6*# RBC-2.86* Hgb-9.3* Hct-27.7*
MCV-97 MCH-32.5* MCHC-33.5 RDW-14.5 Plt Ct-228
[**2140-5-2**] 10:06PM BLOOD Hct-27.6*
[**2140-5-2**] 09:25AM BLOOD WBC-9.2# RBC-3.38* Hgb-11.2* Hct-32.7*
MCV-97 MCH-33.1* MCHC-34.1 RDW-14.3 Plt Ct-307
[**2140-5-3**] 04:06AM BLOOD Plt Ct-228
[**2140-5-2**] 09:25AM BLOOD Plt Ct-307
[**2140-5-2**] 09:25AM BLOOD PT-12.4 PTT-22.9 INR(PT)-1.0
[**2140-5-4**] 05:30AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-136
K-3.8 Cl-103 HCO3-25 AnGap-12
[**2140-5-3**] 04:06AM BLOOD Glucose-132* UreaN-11 Creat-0.6 Na-140
K-4.4 Cl-107 HCO3-23 AnGap-14
[**2140-5-2**] 10:06PM BLOOD Na-140 K-3.3 Cl-104
[**2140-5-2**] 09:25AM BLOOD Glucose-104* UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-102 HCO3-30 AnGap-12
[**2140-5-4**] 05:30AM BLOOD Phos-2.5*# Mg-2.1
[**2140-5-3**] 04:06AM BLOOD Calcium-7.7* Phos-4.3 Mg-2.2
[**2140-5-2**] 10:06PM BLOOD Mg-2.2
[**2140-5-2**] 09:25AM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.7# Mg-2.7*
Brief Hospital Course:
[**Hospital Unit Name 13533**]:
[**Age over 90 **] yo F was admitted to the [**Hospital Unit Name 25503**] 0 s/p laparoscopic left
colectomy and b/l salpingooothecectomy complicated by
subcutaneous emphysema. subcutaneous emphysema thought to be
likely secondary to intraoperative CO2 insulfation . On transfer
she had hypercarbic respiratory failure. Her respiratory
acidosis improved with change of ventilator settings and
respiratory alkalosis was induced; vent settings were changed
again to correct this. Sedation was weaned overnight and patient
was extubated in the morning. Patient was made DNR/DNI in
discussion with her daughter. [**Name (NI) **] from now on will be
determined by general surgery and gyn/oncology. The patient was
extubated on post-operative day one. She was transferred to the
inpatient floor after extubation.
.
PENDING ON TRANSFER: Blood cultures
The patient was transferred to the inpatient unit from the [**Hospital Unit Name 153**]
in stable condition. She progressed well without any acute
event. [**2140-5-4**] she was started on a clear liquid diet which she
tolerated well and her Foley catheter was removed. She was able
to void spontaneously. The subcutaneous emphysema from the
operating room continued to steadily improve. The patient was
cleared by physical therapy to be discharged home with services.
The patient has a supportive family and this discharge plan was
realistic. The patient continued to ambulate independently and
on [**2140-5-5**] passed flatus and tolerated a regular diet. The
patient was discharged home on post-operative day four in stable
condition.
Medications on Admission:
Nicardipine 20 daily
Enteric coated aspirin 325 daily
Valsartan 320 daily
Atorvastatin 10 daily
Metoprolol XL 50 daily
MVI
Stool softener QID
Discharge Medications:
1. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. nicardipine 20 mg Capsule Sig: One (1) Capsule PO once a day.
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 7 days: do not take more than 4000mg of tylenol
daily, do not drink alcohol while taking tylenol.
Disp:*42 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain for 5 days: Please call the office if you
feel the need to take this medication. Do not drink alcohol or
drive a car while taking this medciation.
Disp:*10 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Miralax 17 gram Powder in Packet Sig: One (1) packet PO
every other day as needed for constipation: Please take if
constipated.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Complex left cystic adnexal mass,
bilateral cystic adnexal masses, and left colon cancer.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a Left laparoscopic
colectomy and bilateral salpingo-oophrectomy for surgical
management of your adnexal masses and left colon cancer. You
have recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact you
[**Name2 (NI) 19605**] these results they will contact you before this time.
You have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next 2-3 days. After anesthesia it is not
uncommon for patient??????s to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are explected however, if you notice that you are passing bright
red blood with bowel movments or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. Please follow the bowel regimen prescribed for you, you
have been prescribed the medication miralax which is a powder
that you may take every other day as needed for constipation. If
you notice that you are developing loose stools you make take
away one bowel medication at a time. If you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonges loose stool, or
constipation.
You have [**3-11**] laparoscopic surgical incisions on your abdomen
which are closed with internal surtures and staples. These are
healing well however it is important that you monitor these
areas for signs and symptoms of infection including: increasing
redness of the incision lines, white/gree/yellow/malodorous
drainage, increased pain at the incision, increased warmth of
the skin at the incision, or swelling of the area. Please call
the office if you develop any of these symptoms or a fever.
Youmay go to the emergency room if your symptoms are severe. You
may shower, pat the incisions dry with a towel do not rub. The
small incisions may be left open to the air. Your staples will
be removed at your post-operative appointment with Dr. [**Last Name (STitle) **].
Please no baths or swimming for 6 weeks after surgery unless
told otherwise by Dr. [**Last Name (STitle) **].
You may continue to take tylenol for pain. Please do not take
more than 4000mg of tylenol [**Last Name (LF) **], [**First Name3 (LF) **] not drink alcohol while
taking tylenol. You will be given a small amount of the
medication oxycodone for pain, please take only as needed as you
have not taken this medication in the hospital. You should take
a half tablet only if needed. If you find thta you are having
abdominal pain requiring you to use pain medications please call
Dr.[**Name (NI) 10065**] office. Do not drink a car or drink alcohol if
taking narcotic pain medicaitons.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr.
[**Last Name (STitle) **].
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. FOr a short time you will have visiting nurses check
on you at home. Good luck!
Followup Instructions:
Please call the colorectal surgery office at [**Telephone/Fax (1) 160**] to
make an appointment for your first post-operative check with Dr.
[**Last Name (STitle) **] 3 weeks after your discharge from the hospital.
Please call and make an appointment with your primary care
provider to have you staples removed in 7 days.
Completed by:[**2140-5-6**]
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90,441
| 157,639
|
54552
|
Discharge summary
|
Report
|
Admission Date: [**2193-1-18**] Discharge Date: [**2193-1-21**]
Date of Birth: [**2127-3-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
elective admit for craniotomy
Major Surgical or Invasive Procedure:
[**2193-1-18**]: right craniotomy for resection of tumor
History of Present Illness:
65M who is on Plavix and ASA with a hx of a triple bypass 21
years ago who reports a sudden onset of headache accompanied by
nausea on [**2192-12-9**]. Work up revealed a right parietal mass
measuring 4 x 6 x 4 cm with rim contrast enhancement. Cardiology
eval reveals a poor surgical candidate and requested an cardiac
cath prior ro surgical consideration. The patient was cleared
for
neurosurgical intervention. The patient had initially opted to
undergo a stereotactic biopsy of the lesion. He now wishes to
have a discussion with regards to the relative merits of
craniotomy versus stereotactic biopsy.
Since last seen in clinic, the patient has no new complaints.
Past Medical History:
- HTN
- HL
- CAD s/p CABG, currently a plan for elective cardiac
catheterization for unstable angina
- BPH
Social History:
quit smoking several yrs ago, Rx heavy smoker
Ex alcoholic, No drugs, Lives with family, owns a restaurant.
Family History:
NC
Physical Exam:
On the day of admission: On examination, the patient is awake,
alert, and approriate. VFF.EOMI. FS. T/U midline. Hearing + SS
symmetric. MA4E with good
strength. No drift. Normal gait
On the day of discharge:
non-focal except left hemi-anopsia which is improving compared
to immediate post op
Pertinent Results:
[**2193-1-18**] 02:36PM GLUCOSE-406*
[**2193-1-18**] 12:33PM GLUCOSE-360* UREA N-28* CREAT-1.1 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
[**2193-1-18**] 12:33PM estGFR-Using this
[**2193-1-18**] 12:33PM CALCIUM-8.4 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2193-1-18**] 12:33PM WBC-5.5 RBC-3.82* HGB-11.6* HCT-33.4* MCV-87
MCH-30.5 MCHC-34.9 RDW-13.6
[**2193-1-18**] 12:33PM PLT COUNT-160
[**2193-1-18**] 12:33PM PT-12.1 PTT-18.4* INR(PT)-1.0
[**2193-1-18**] 10:46AM TYPE-ART TIDAL VOL-830 O2-25 PO2-127*
PCO2-30* PH-7.49* TOTAL CO2-23 BASE XS-1 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2193-1-18**] 10:46AM GLUCOSE-270* LACTATE-3.9* NA+-133* K+-4.3
CL--97*
[**2193-1-18**] 10:46AM HGB-12.1* calcHCT-36 O2 SAT-97
[**2193-1-18**] 10:46AM freeCa-1.11*
[**2193-1-18**] 09:17AM TYPE-ART RATES-10/ TIDAL VOL-700 O2-30
PO2-121* PCO2-37 PH-7.43 TOTAL CO2-25 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2193-1-18**] 09:17AM GLUCOSE-255* LACTATE-2.3* NA+-130* K+-3.7
CL--96*
[**2193-1-18**] 09:17AM HGB-11.2* calcHCT-34 O2 SAT-97
[**2193-1-18**] 09:17AM freeCa-1.08*
Tissue: RIGHT PARIETAL MASS, Study Date of [**2193-1-18**]
MR HEAD W/ CONTRAST Study Date of [**2193-1-18**] 5:50 AM ******
CT HEAD W/O CONTRAST of [**2193-1-18**]
IMPRESSION: Expected postoperative appearance of the brain
status post recent resection of right parietal hemorrhagic
lesion.
MRI Brain [**2193-1-19**]
IMPRESSION:
1. Postoperative changes in the right parietooccipital region
with blood
products and pneumocephalus. Small areas of residual enhancement
seen
posterior to the surgical cavity.
2. New right posterior cerebral artery infarct.
3. Findings were communicated to neurosurgery at the time of
interpretation of this study on [**2193-1-19**].
Brief Hospital Course:
This is a 65year old male who is on Plavix and ASA with a hx of
a triple bypass 21
years ago who reports a sudden onset of headache accompanied by
nausea on [**2192-12-9**]. Work up revealed a right parietal mass
measuring 4 x 6 x 4 cm with rim contrast enhancement. Cardiology
eval reveals a poor surgical candidate and requested an cardiac
cath prior to surgical consideration. This was worked up
outpatient and then the patient was cleared for neurosurgical
intervention.
The patient was electively admitted on [**2193-1-18**] for a right sided
craniotomy for resection of tumor. The patient was transfused
with platelets intraop as he was on aspirin at home. The
patient was extubated post operatively and recovered in the
surgical intensive unit. He was placed on decardon 4mg every 6
hours. A physical therapy consult was ordered for the patient.
A post operative head CT was consistent with stable post
operative changes.
On [**1-19**] the patient was neurologically well except for a left
hemi-anopsia. He was out of bed to the chair and tolerating a PO
diet. A post operative MRI was consistent with small residual
enhancement. He remained on an insulin drip with difficult to
control blood sugars.
On [**1-20**] the patient was again stable and was able to be weaned
off of the insulin gtt. decadron was tapered.
On [**1-21**] the patient was seen by physical therapy and cleared for
discharge home with services. He was restarted on aspirin and a
[**Last Name (un) **] Diabetes consult was requested for assistance with blood
sugar management and discharge planning. Insulin and PO
medication adjustments were made and the patient was cleared for
discharge to home with services.
Medications on Admission:
.
Discharge Medications:
.
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-16**]
Tablets PO Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
13. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
14. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
15. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO taper for 2
days: 2mg Q6hrs on [**1-21**].
1mg Q6hrs on [**1-22**] then discontinue.
Disp:*7 Tablet(s)* Refills:*0*
16. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
17. insulin lispro 100 unit/mL Solution Sig: One (1) as directed
Subcutaneous QAC.
Disp:*1 as directed* Refills:*2*
18. insulin safety needles (disp) 29 x [**12-16**] Needle Sig: One (1)
syringe Miscellaneous QAC.
Disp:*90 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
right parietal mass
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:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You were on Aspirin, prior to your injury, and this was
restarted on [**2193-1-21**]. You were also on plavix prior to your
surgery. This should NOT be restarted until after it is
discussed at your follow up appointment.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit. DO NOT drive until you are
cleared.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Your sutures are dissolvable and do not need to be removed.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2193-1-28**]
@ 9:30 AM. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
?????? Please call for a follow up appointment at [**Last Name (un) **] in 2
weeks with Dr. [**Last Name (STitle) 15279**] or first available attending. You should
also make an appointment with the diabetes educator at [**Last Name (un) **]
for the same date
for insulin teaching. These appointments can be made by calling
[**Telephone/Fax (1) 2378**].
?????? You should follow up with your PCP [**Name Initial (PRE) 176**] 7 days of
discharge.
Completed by:[**2193-1-22**]
|
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| 0
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| 0
| 0
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| 0
| 0
| 0
| 109
| 112
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
|
96,456
| 192,435
|
51224
|
Discharge summary
|
Report
|
Admission Date: [**2119-12-17**] Discharge Date: [**2119-12-27**]
Date of Birth: [**2050-1-3**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin / Erythromycin Base
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
internal jugular line placement
History of Present Illness:
Ms. [**Known lastname 1007**] is a 69 year-old woman with a history of asthma, CAD,
CHF (EF 10%), IDDM, CKD, discharged 1 week ago after an
admission for cellulitis and hypercarbic respiratory failure,
who now presents hypotension and acute on chronic kidney injury.
.
She was recently admitted [**12-1**] - [**12-11**]. She had acute on chronic
cellulitis and completed a 10 day course of vancomycin. She also
had hypercarbic respiratory failure requiring intubation. She
was treated for a COPD exacerbation as well as volume overload
and was extubated after two days. She was called out of the ICU.
On the medical floor, she was agressively diuresed. Her heart
failure regimen was also optimized in consultation with
cardiology. In particular, metoprolol was increased from Toprol
XL 100 mg qday to metoprolol tartrate 150 mg [**Hospital1 **]. Lisinopril 2.5
mg was started. She remained mildly hypoxic and was discharged
to home on [**1-29**] L O2, having refused rehab. Her previous dose of
torsemide 100 mg daily was resumed on discharge. Creatinine was
1.5 on the day of discharge.
.
After arrival at home, Ms. [**Known lastname 1007**] was living with her husband who
noted her to be mostly immobile, unwilling to eat, and taking
her medications unreliably. A visiting nurse noted that she was
unable to care for herself and so was admitted to rehab from
home on [**12-14**]. At the time her initial BP was low 70s but
quicklky rose into the 80s and then 90s. Diuretics were held.
Despite holding torsemide for two days, the patient remained
hypotensive. Today, sge was noted to be more lethargic and BP
70s so she was referred to [**Hospital1 18**].
.
Upon arrival to ED, initial VS: 96.6 58 103/42 18 99% 6L NC. FS
WNL. She was very confused. Blood pressure then fell into the
70s systolic. She was given vancomycin 1 g,
piperacillin-tazobactam 4.5 g, and 4 L NS. IJ was placed and
levophed started (initially at .03, titrated up to .12 prior to
transfer). She was not more hypoxic than baseline (99% on 2L).
EKG was similar to prior. Labs were notable for a troponin
elevated to .45 and creatinine 2.4. CXR did not demonstrate
volume overload or infiltrate. Her mental status improved after
the initiation of pressors. Cardiology was consulted with regard
to the elevated troponin. They thought an ischemic event was
unlikely and will follow. She was sent for CT head and torso
prior to transfer to the ICU. However, she refused the torso
portion of this exam. She was transferred to the ICU.
.
Upon arrival to the MICU, the patient complains of low back pain
that is chronic for her. She also has leg pain when moved. She
denies chest pain, cough, palpitations, abdominal pain, nausea,
diarrhea, dysuria.
Past Medical History:
1. Asthma
2. CAD s/p CABG [**2112**]
3. Congestive heart failure with EF 10-15% on TTE [**11/2119**]
4. Atrial fibrillation on coumadin
5. DM - insulin dependent, c/b DM retinopathy
6. Morbid obesity
7. stage III chronic kidney disease
8. Vitamin D deficiency
9. chronic peripheral edema
10. h/o blood in stool
11. hypercholesterolemia
12. lower extremity cellulitis
Social History:
Lives independently with husband. Denies alcohol, drugs and
smoking.
Family History:
Cancer, hypertension, substance abuse, heart disorder, adult
onset diabetes.
Physical Exam:
Vitals: BP 125/38 (on norepi .04), HR 86, RR 20, O2 95% on 4L NC
General: obese female, lying in bed with eyes closed, no
apparent distress.
HEENT: no apparent lesions in OP
Neck: obese, difficult to assess JVD
Lungs: distant breath sounds, faint crackles at bases barely
audible
Heart: regular, no murmurs appreciated, sternal defect with
palpable heart tones
Abdomen: Obese, soft, nondistended, positive bowel sounds
Ext: 2+ bilateral partially pitting edema. Bilateral lower legs
with woody changes, areas of denuded skin, minimal serous
drainage, appear much improved compared to prior admission
Neuro: oriented to self and year, not place. Moving all
extremities
Pertinent Results:
Admission labs:
[**2119-12-17**] 01:00PM GLUCOSE-114* UREA N-111* CREAT-2.4*
SODIUM-129* POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-30 ANION GAP-13
[**2119-12-17**] 01:00PM WBC-7.5 RBC-3.79* HGB-10.7* HCT-34.0* MCV-90
MCH-28.3 MCHC-31.6 RDW-16.7*
[**2119-12-17**] 01:00PM NEUTS-76.1* LYMPHS-15.1* MONOS-5.8 EOS-2.4
BASOS-0.6
Brief Hospital Course:
Assessment and Plan: Ms. [**Known lastname 1007**] is a 69 year-old woman with
ischemic cardiomyopathy and EF 10-15% who presents with
hypotension.
.
# Hypotension: Given [**Last Name (un) **], hyponatremia, hypotension, and good
response to 4 L IVF in the ED, this may have been simply related
to volume depletion and an aggressive heart failure regimen.
However, diuretics have recently been held and it is notable
that her bicarb and her Hct are actually both lower than
discharge on admission labs. CVP on admission was 18. Sepsis
was also on the differential, but patient afebrile, WBC not
elevated, CXR clear, UA not impressive, so she was not initially
covered with antibiotics. However, the following morning her
WBC was elevated so vancomycin and zosyn were started.
Norepinephrine was weaned to low doses and continued to maintain
MAP >60. Patient was transferred to the floor off pressors and
was normotensive for the remainder of her stay. Her home
hypertension medications were held except for
hydrochlorothiazide which was restarted prior to discharge.
.
# Shortness of breath: Patient with increased work of breathing
on the second hospital day. This was attributed in part CHF
exacerbation. She intermittently became drowsy. ABGs showed
hypoxia and hypercarbia. Bipap was used, but patient was poorly
tolerant of this and consistently took it off when she woke up.
She was also diuresed, with improvement in shortness of breath.
She was initially maintained on torsemide 20 mg daily with IV
lasix 40 mg prn volume overload. After necessitating IV lasix
due to tachypnea, torsemide was increased to 30 mg daily.
Oxygen and IV morphine prn were continued as needed for comfort
although patient did not require IV morphine. She remained
stable on 1-3L NC with no respiratory distress during her
hospital stay.
.
# Acute on chronic kidney injury: Baseline creatinine per
records obtained at last hospitalization ~1.5, which was what it
was on discharge a week ago. 2.5 on this admission. Given
concominant mild hyponatremia, hypotension, this may be simply
due to volume depletion. Creatinine fell with IVF in the ED.
Urine electrolytes showed a prerenal etiology. Labs were
discontinued on the floor per patient request. She continued to
have good urine output throughout the rest of her hospital stay.
.
# Elevated troponin: Troponin .45. Recently, .08 in the setting
of not quite so bad renal function. It does seem likely that she
has had some cardiac ischemia, probably in the setting of poor
coronary perfusion secondary to systemic hypotension. This was
trended and fell appropriately.
.
# Hyponatremia: likely secondary to volume depletion. Improved
after IVF resuscitation. Labs discontinued on floor after
discussion with patient.
.
# CHF: EF 10%: Metoprolol, ACEI, torsemide held in the setting
of hypotension but were restarted at lower-than-home-doses. She
will be discharged on lower doses of these medications as she
has been stable during hospital stay.
.
# Atrial fibrillation: Rate controlled and anticoagulated on
admission. Was subtherapeutic INR after having warfarin held at
rehab for several days (for INR 5 on [**12-15**]). Warfarin was
restarted at a lower dose and she was started on a heparin drip
while warfarin subtherapeutic. INR was then found to be
supratherapeutic and warfarin was held. Risks and benefits of
anticoagulation were discussed with patient and she decided that
she did not want to continue anticoagulation. Warfarin was thus
stopped and will not be continued at discharge. No evidence of
bleeding or clots on exam. Will continue metoprolol for rate
control as described above.
.
#End of life: Palliative care consult was obtained per PCP
[**Name Initial (PRE) **]. Patient was confirmed DNR/DNI and also did not wish to
be transferred to the MICU or undergo NIPPV should she
decompensate. She will be discharged to hospice
.
# DM: Home dose of glargine 15 units qam was initially
continued, with humalog sliding scale. Glargine was decreased
to 5 units daily on the floor. Blood sugars were well
controlled on this regimen.
.
Medications on Admission:
-insulin glargine 15 units qhs
-humalog sliding scale
-warfarin 1.5 mg daily (but held on [**12-15**] and decreased to .5 mg
[**12-16**], not given [**12-17**])
-metoprolol tartrate 150 mg [**Hospital1 **]
-torsemide 100 mg daily
-simvastatin 40 mg qhs
-cholecalciferol 1000 IU daily
-ipratropium-albuterol nebs prn
-calcium carbonate 500 mg daily
-ASA 81 mg daily
-docusate 100 mg [**Hospital1 **]
-senna 8.6 mg [**Hospital1 **]
-acetaminophen 650 mg tid prn
-oxycodone 1.25 - 2.5 mg prn dressing changes
-lisinopril 2.5 mg daily
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ipratropium bromide 0.02 % Solution Sig: One (1) spray
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) spray Inhalation Q6H (every 6 hours)
as needed for shortness of breath or wheezing.
8. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Five (5)
units Subcutaneous once a day.
Disp:*30 ml* Refills:*2*
9. Humalog Subcutaneous
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for pain.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO at bedtime.
14. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
15. torsemide 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
16. needle (disp) Needle Sig: One (1) Miscellaneous once a
day.
Disp:*30 needles* Refills:*2*
17. lancets Misc Sig: One (1) Miscellaneous once a day.
Disp:*30 lancets* Refills:*2*
18. One Touch Basic System Kit Sig: One (1) Miscellaneous
once a day.
Disp:*1 kit* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
hypotension, responsive to fluids
acute renal failure, likely pre-renal
UTI
diabetes
CHF
Afib
chronic pain
respiratory failure, resolved,
CAD s/p CABG
Chronic lower extremity venous stasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mrs. [**Known lastname 1007**],
It was a pleasure participating in your health care. You were
admitted to [**Hospital1 **] for hypotension
and acute renal failure for which you were admitted to the
intensive care unit where you were given fluids. In the
intensive care unit, you were treated with pressors and diuresis
as well as antibiotics. The decision was made to transition to
hospice care and to stop anticoagulation with warfarin.
Please make the following changes to your medications:
STOP WARFARIN
DECREASE Torsemide to 30 mg daily
INCREASE Lisinopril to 5 mg daily
DECREASE Metoprolol to 25 mg twice a day
DECREASE Glargine to 5 units daily
START Oxycodone 2.5 mg every 3 hours as needed for pain
Followup Instructions:
Please follow-up with a physician as desired
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
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20660
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Discharge summary
|
Report
|
Admission Date: [**2161-5-16**] Discharge Date: [**2161-5-23**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
respiratory failure and septic shock
Major Surgical or Invasive Procedure:
central venous catheter placement
History of Present Illness:
88 y/o Russian male with Alzheimer's dementia, remote latent TB
treated w/rifampin and pyrazadine in [**2153**], AF on coumadin, HTN
sent in from [**Hospital 100**] Rehab for dyspnea, fever, and hypoxia. On
the day prior to presentation ([**2161-5-15**]) he was noted to be tired
and weak, and he fell. He has not complained of respiratory
symtpoms. Overnight at 0100 he dropped to below 90% and placed
on 2LNC. He had respiratory distress, was given nebulizer and
tylenol without improvement. Later, his O2 sat dropped to 70 on
2L, and he was switched to NRB with 15L, then 96%. Temp was
99.6, given albuterol, but respirations increased to 37. Two
other people were ruled out for flu on the floor. Urine
legionella is pending.
.
In the ED, initial VS - 101, 125 (AF), 148/70, 32, 94% 15L NRB.
Exam notable for tachypnea, 94% on NRB, diffuse rhonchi. Labs
notable for lactate 5.8, Cr 1.1, bicarb 19, wbc 10.3 (29%
bands), INR 2.2. Bcx pending. CXR showing right sided pneumonia.
EKG showing ST 125, LAD, first degree AV delay, no ischemic
changes. Patient was given vancomycin, zosyn, combivent x 3,
tylenol. Only received 1L IVF. His vitals on transfer - 96 on
10L, RR 27, and his access was 1 PIV.
.
On the unit, he was tachypneic, but appeared comfortable and
denied any symptoms. He had a few episodes of relative
hypotension to the 80s-90s systolic. His oxygenation improved to
low-mid 90s on 5L. His lactate rose to 9. He was given 2L of LR
and his lactate trended down to 6. A second IV was placed and he
was started on vancomycin, cefepime, and levofloxacin.
Past Medical History:
- COPD (unclear history, always a nonsmoker)
- HTN (active)
- AF on coumadin (active)
- colon cancer [**2152**] (inactive)
- dementia (AO x 1 at baseline)
- history of TB, found to have 10mm PPD in [**2153**], had a negative
CXR so treated in [**2153**] for 9 months for latent TB. CXR repeat in
[**2156**] looked increased density at the bases
- BPH (active)
- GERD (active)
Social History:
lives at [**Hospital 100**] Rehab
Family History:
No family history of TB.
Physical Exam:
On Admission:
GEN: pleasantly demented, AOx2 (knew he was in a hospital)
comfortable but tachypneic, NAD, pulling at lines
HEENT: PERRL, anicteric, MMM, no jvd,
RESP: Right basilar rales and reduced breath sounds, otherwise
clear. No wheezes.
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx2. [**4-7**] symmetric strength throughout upper and lower
extremities. No pronator drift., downgoing toes,
1+DTR's-patellar and biceps.
.
On Discharge:
GEN: alert, comfortable, no increased work of breathing
HEENT: sclera anicteric. MMM
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: limited by cooperation. bibasilar rales
Abd: +BS, soft, NT, ND
GU: + foley
Extremities: warm, +SCDs
Neuro/Psych: face symmetric, moves all extremites
Pertinent Results:
Admission:
[**2161-5-16**] 06:00AM BLOOD WBC-10.3 RBC-5.53 Hgb-14.2 Hct-43.4
MCV-79* MCH-25.6* MCHC-32.6 RDW-14.8 Plt Ct-177
[**2161-5-16**] 06:00AM BLOOD Neuts-62 Bands-29* Lymphs-5* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0
[**2161-5-16**] 06:00AM BLOOD PT-23.7* PTT-36.7* INR(PT)-2.2*
[**2161-5-16**] 06:00AM BLOOD Glucose-172* UreaN-27* Creat-1.1 Na-140
K-5.0 Cl-104 HCO3-19* AnGap-22*
[**2161-5-16**] 06:00AM BLOOD cTropnT-0.01 proBNP-1255*
[**2161-5-17**] 04:25AM BLOOD Calcium-7.6* Phos-1.8* Mg-1.4*
.
Discharge:
[**2161-5-23**] 06:00AM BLOOD WBC-11.4* RBC-4.95 Hgb-12.4* Hct-38.5*
MCV-78* MCH-25.1* MCHC-32.3 RDW-15.5 Plt Ct-367
[**2161-5-23**] 06:00AM BLOOD PT-30.3* PTT-34.4 INR(PT)-3.0*
[**2161-5-23**] 06:00AM BLOOD Glucose-112* UreaN-21* Creat-1.2 Na-146*
K-3.5 Cl-105 HCO3-27 AnGap-18
[**2161-5-23**] 06:00AM BLOOD Calcium-8.8 Phos-2.3* Mg-2.3
.
[**2161-5-17**] 10:08 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2161-5-17**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
SINGLY IN PAIRS.
RESPIRATORY CULTURE (Final [**2161-5-19**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
.
[**2161-5-19**] 1:55 pm BLOOD CULTURE Source: Line-Rt CVL.
Blood Culture, Routine (Preliminary): ENTEROCOCCUS
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ R
LEVOFLOXACIN---------- R
VANCOMYCIN------------ R
Anaerobic Bottle Gram Stain (Final [**2161-5-20**]):
GRAM POSITIVE COCCI IN CHAINS.
.
[**2161-5-20**] 3:07 pm CATHETER TIP-IV Source: Rt IJ.
**FINAL REPORT [**2161-5-22**]**
WOUND CULTURE (Final [**2161-5-22**]): No significant growth.
.
5 sets of blood cultures pending, all no growth to date
Brief Hospital Course:
88 year-old Russian-speaking M with Dementia, suspected COPD,
AFib on Coumadin, HTN who presented with dyspnea, hypoxia, and
fever, s/p MICU course for treatment of respiratory failure and
septic shock likely secondary to healthcare-associate pneumonia,
transferred to the Medicine floor for continued management,
which was complicated by delerium and subsequent uretheral
injury from self-discontinuation of foley placement. Also found
to have VRE bacteremia for which he was started on 14 days of
Linezolid.
.
# Acute respiratory distress/Healthcare Associated Pneumonia:
Presentation with dyspnea, fever, bandemia, hypoxia, and CXR
findings all consistent with acute pneumonia. Given his
residence at [**Hospital 100**] Rehab, he was started on Vancomycin,
Cefepime, and Levofloxacin. TB felt unlikely given the rapid
acuity of symptoms and lack of other more subacute
constitutional symptoms. Moreover, patient had documented
adequate treatment of latent TB (with negative CXR) in [**2153**].
Additional processes, such as pulmonary embolism, seemed
unlikely given his therapeutic INR. Patient was treated with
Bipap and appeared to improve, but on hospital day #2, he was
tachypneic to the 30s, somnolent and working very hard to breath
so he was intubated and placed on ARDS net ventilation. Once
stable he was 12L positive and diuresis with IV Lasix was
initiated. He responded well to Lasix 20mg IV and was extubated
on [**5-19**] without complication. Diuresis was continued until his
volume status was optimized. An echocardiogram showed normal
systolic function. He completed a 7 day course of broad
antibiotics.
.
# Severe sepsis: Patient presented with pneumosepsis and
elevated lactate up to 9. His lactate trended down to 2 after
6L IVF in the ED. His pressures maintained MAP >60 until the
patient was intubated when he became hypotensive. A central
line was placed and he was started on Levophed. He was given
bolus fluids for CVP <10 and weaned off pressors. He was put on
Vanc/Levo/Cef for presumed HAP. He did have BCx positive for
GPCs after resolution of sepsis, which were ultimately speciated
to VRE (Vancomycin Resistant Enterococcus). His central venous
catheter was removed. He was started on a 14 days course of PO
Linezolid 600 mg twice daily, which should continue until
[**2161-6-3**]. Surveillence blood cultures have shown no growth to
date. These are still pending and should be followed up on.
.
# Delerium: Likely secondary to toxic/metabolic encephalopathy
from infection in a patient with underlying dementia. We
attempted to minimize unecessary lines and tubes, provide
frequent orientation, and avoid aggravating
medications/sedatives.
.
# Atrial fibrillation: Rate controlled without medications. On
Coumadin for anticoagulation. His INR was elevated at 3 (likely
secondary to antibiotics and poor nutrition), so Coumadin has
been held at discharge. His INR should be monitored and Coumadin
re-started once necessary.
.
# BPH/Urinary Obstruction: Tamsulosin held on admission during
severe sepsis, but re-started upon transfer to the floor. The
patient self-discontinued his foley and had subsequent traumatic
injury resulting in blood clots that would cause painful
obstruction. A foley was placed and will need to remain until he
is healed and a voiding trial can be attempted. Frequent
irrigation should be provided to prevent blood clots.
.
# [**Last Name (un) **]: Mild, but eGFR of 40 on admission with elevated BUN.
Creatinine improved from 1.1 to 0.8 after IVF resuscitation in
the MICU, but increased after diuresis. 1.2 at discharge, which
should be monitored in the future.
.
# Suspected COPD: Patient continued on nebulizer treatement.
.
# Microcytic Anemia: Remained relatively stable throughout the
admission. He required no blood products.
Medications on Admission:
- warfarin 3 mg daily
- aspirin 325 mg daily
- flomax 0.4 mg daily
- senna 17.2mg PO HS
- trazodone 12.5mg PO HS
- albuterol nebs 0.083%
- tylenol 650mg PO PRN pain
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for Pain.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for shortness of breath, wheezing.
7. linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 11 days: last day [**2161-6-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
health-care associated pneumonia
bacteremia
toxic/metabolic encephalopathy
urinary obstruction
.
dementia
anemia
atrial fibrillation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 55195**],
You were initially admitted to the intensive care unit (ICU) for
treatment of your difficulty breathing, which was likely
secondary to a pneumonia. You were given medications and you
improved. You were also found to have a bacteria in your blood,
for which you will continue to take an antibiotic for after
discharge.
.
Your INR was elevated from the antibiotics you are receiving.
Today the level was 3. We are holding your Coumadin (3 mg
daily), but this will need to be re-started once the level
falls.
.
Additionally, when you were confused you pulled out your foley,
which caused an injury and subsequent blood clots. You will be
discharged with the foley, which will be removed once you heal.
.
-Please START Linezolid 600 mg by mouth twice daily for a total
of 14 days (last day [**2161-6-3**])
-Please HOLD Coumadin for now until labwork shows INR falls
below 2.5
Followup Instructions:
A physician at your facility will be taking care of your needs.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
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icd9pcs
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[
[
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94,828
| 116,543
|
44453
|
Discharge summary
|
Report
|
Admission Date: [**2112-10-10**] Discharge Date: [**2112-10-16**]
Date of Birth: [**2041-10-20**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Ace Inhibitors
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
N/V/D
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old man with h/o CAD, dilated
ischemic cardiomyopathy (EF 10%), aflutter on Dabigatran, BiV
ICD, DM, HTN, HLD, CKD, R 4th toe amputation with debridement in
[**2112-6-3**], s/p 6 weeks of Vanc/Ctx for osteomyelitis, who
presents with N/V/D x4 days.
Patient has been having nausea, vomiting, and diarrhea for the
past 4 days. Diarrhea is watery stool, nonbloody. No recent
travel or sick contacts. [**Name (NI) **] abdominal pain. +subjective fevers
and chills. Of note, patient finished 6 week course of Vanc/Ctx
for R foot osteomyelitis on [**2112-9-11**].
In the ED, initial VS were stable. Patient was given Dilaudid
for chronic LE pain, 250cc NS, and Zofran. RUQ U/S with sludge,
negative [**Doctor Last Name 515**], no wall edema. Labs notable for lactate 2.7,
anion gap 19, Cr 2.2, HCO3 9. pH was 7.21 on VBG. Patient has
been relatively hypotensive, SBP 90s. On the Medicine floor, the
patient was treated with IVF boluses (1.5L) and started on
broad-spectrum antibiotics for concern for sepsis. Patient was
altered in the AM, but became more alert in the afternoon. He
was refusing VS and lab draws at times. Lactate and anion gap
improved initially, but then worsened in the early evening.
Given concern for worsening labs, patient was transferred to the
ICU for closer monitoring.
In the ICU, the patient is currently not complaining of nausea,
vomiting, or abdominal pain. He has had no episodes of diarrhea
today. He is c/o L knee pain, new from a few weeks ago.
Past Medical History:
1. CAD, multiple MIs, CABG ([**2101**]) ([**2101**]): SVG-PL, SVG-Diagonal
and LIMA-LAD. He had a PTCA only of the mid Cx with an Apex OTW
2.25x15 mm
2. Dilated ischemic cardiomyopathy with LVEF of 10%.
3. Atrial flutter, status post cardioversion [**2110-11-28**].
4. BiV ICD pacemaker.
5. Diabetes.
6. Dyslipidemia.
7. Hypertension.
8. Stage III chronic kidney disease secondary to hypertension
and diabetes.
9. Retinopathy, neuropathy, and nephropathy from diabetes.
10. Left hip fracture with attempted surgery, which resulted in
a cardiac arrest.
11. History of substance abuse.
12. History of pancreatitis.
13. GERD.
14. Colonic polyps.
15. [**6-6**] Right fourth toe amputation.
16. [**5-/2111**] ORIF left hip with persistent nonunion of his
subtrochanteric femur fracture
17. Left eye vitrectomy
18. [**2112-7-1**]: RLE Balloon angioplasty of tibioperoneal trunk,
Balloon angioplasty of the anterior tibialis artery.
19. [**2112-7-5**]: Debridement of wound down through subcutaneous
tissue and including bone with placement of vacuum-assisted
closure dressing.
20. R foot osteomyelitis, s/p 6 weeks Vanc/Ctx, finished
[**2112-9-11**]
Social History:
- Previously employed as cab driver, now retired. Lives at home
with his wife.
- Tobacco history: 40-50 pack year history, quit 15 years ago
- ETOH: heavy use until [**2090**]
- Illicit drugs: previous heroin/cocaine use
Family History:
Mother and father died in 70's-80s of cancer. Denies any family
history of cardiac disease. No family history of early MI.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.8 BP: 92/55 P: 87 R: 20 O2: 98% RA
General: Alert, orientedx2, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild ttp in RLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: cool to touch, palpable/dopplerable distal pulses, no
edema, R 4th toe amputated with dry gauze overlying ulcer, L
knee with effusion, no warmth/erythema, mild tenderness
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS:
[**2112-10-10**] 04:30AM BLOOD WBC-12.8*# RBC-3.88*# Hgb-9.3*#
Hct-30.2*# MCV-78* MCH-24.0*# MCHC-30.9* RDW-16.0* Plt Ct-256
[**2112-10-10**] 04:30AM BLOOD Neuts-91.3* Lymphs-4.5* Monos-3.4 Eos-0.6
Baso-0.2
[**2112-10-10**] 09:36AM BLOOD PT-21.5* PTT-40.6* INR(PT)-2.0*
[**2112-10-11**] 03:04PM BLOOD Fibrino-556*#
[**2112-10-11**] 03:04PM BLOOD ESR-35*
[**2112-10-10**] 04:30AM BLOOD Glucose-156* UreaN-47* Creat-2.2*#
Na-132* K-4.4 Cl-104 HCO3-9* AnGap-23*
[**2112-10-10**] 04:40AM BLOOD ALT-32 AST-37 AlkPhos-330* TotBili-1.4
[**2112-10-10**] 04:40AM BLOOD Lipase-17
[**2112-10-10**] 09:36AM BLOOD CK-MB-4
[**2112-10-10**] 09:36AM BLOOD Calcium-8.7 Phos-4.4# Mg-2.0
[**2112-10-11**] 05:59AM BLOOD CRP-161.1*
[**2112-10-10**] 06:00PM BLOOD Digoxin-1.0
[**2112-10-10**] 08:08AM BLOOD pO2-62* pCO2-38 pH-7.21* calTCO2-16* Base
XS--12 Comment-GREENTOP
[**2112-10-10**] 04:41AM BLOOD Lactate-2.7*
[**2112-10-10**] 06:07PM BLOOD O2 Sat-68
[**2112-10-10**] 11:50AM BLOOD freeCa-1.13
URINE:
[**2112-10-10**] 10:45PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2112-10-10**] 10:45PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2112-10-10**] 10:45PM URINE RBC-36* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
[**2112-10-10**] 10:45PM URINE WBC Clm-FEW
[**2112-10-10**] 10:45PM URINE Hours-RANDOM UreaN-92 Creat-124 Na-91
K-25 Cl-63
[**2112-10-10**] 10:45PM URINE Osmolal-312
MICRO:
[**2112-10-10**] BCx: MRSA
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2112-10-10**] UCx: negative
STUDIES:
[**2112-10-10**] ECHO:
Left ventricular hypertrophy with cavity dilatation and severe
global biventricular hypokinesis c/w diffuse process
(multivessel CAD, toxin, metabolic, etc.) Severe pulmlonary
artery hypertension. Tricuspid regurgitation. Mild-moderate
mitral regurgitation.
Compared with the prior study (images reviewed) of [**2110-12-1**],
global and regional left ventricular systolic function is now
more depressed. The severity of tricuspid regurgitation is
slightly increased.
[**2112-10-10**] RUQ U/S:
1. Nondistended gallbladder filled with sludge, negative
son[**Name (NI) 493**] [**Name2 (NI) 515**] sign, and minimal gallbladder wall edema
and pericholecystic fluid. Findings likely due to chronic liver
disease.
2. Mild perihepatic ascites and small left pleural effusion.
3. Normal common bile duct diameter measuring 3 mm.
4. Homogeneous echogenicity of the liver without focal lesion.
[**2112-10-11**] L Knee XR:
1. Incompletely seen intramedullary rod with distal interlocking
screw, with ossification surrounding the head of the screw and
distal lateral femur. No signs of orthopedic hardware loosening.
2. No definite acute fracture or dislocation.
3. Extensive vascular calcified atherosclerotic disease at the
left knee soft tissues.
4. Trace knee joint effusion
[**2112-10-12**] CXR:
Left pectoral CCD with defibrillator leads leading to the right
ventricle and other two leads each terminating into the right
atrium and left ventricle are unchanged in position. Patient is
status post median sternotomy and has intact sternal sutures.
Moderate-to-large cardiomegaly and mediastinal and hilar
contours are stable. Bilateral lung volumes remain low with mild
improvement in the pulmonary edema. No pleural effusion. No
discrete opacities concerning for pneumonia.
Brief Hospital Course:
Mr. [**Known lastname **] is a 70 year old man with h/o CAD, sCHF (EF <20%),
DM, HTN, CKD, s/p R 4th toe amputation and recent Abx, who was
admitted with N/V/D x 4days. He was transferred from the medical
floor to the ICU for sepsis, found to have MRSA bacteremia.
Likely source is from his R foot, where he recently had a toe
amputation and osteomyelitis. Despite treatment with
broad-spectrum antibiotics (Linezolid and Zosyn), the patient
declined rapidly and had multi-system organ failure. The patient
and family declined further invasive lines and treatments. The
family and medical team decided to make the patient comfort
measures only on [**2112-10-13**]. The patient was transitioned to
inpatient hospice on the medical floor. He expired on [**2112-10-16**].
Medications on Admission:
ASA 81mg PO daily
Atorvastatin 40mg PO qhs
Dabigatran 150mg PO BID
Digoxin 0.125mg PO daily
Metoprolol XL 50mg PO daily
Imdur 30mg PO daily
NTG 0.4mg SL q5min prn
Valsartan 80mg PO daily
Spironolactone 25mg PO daily
Torsemide 60mg PO daily
Gabapentin 100mg PO TID
Oxycontin 10mg PO BID
Percocet 2tabs PO q4-6h prn
Oxycodone 5mg PO BID prn
Lorazepam 0.5mg PO q6h prn
Trazodone 25mg PO BID
NPH
Humalog
Ascorbic acid 250mg PO BID
Colace 100mg PO BID
Ferrous sulfate 325mg PO BID
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
MRSA sepsis
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2112-10-18**]
|
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[] |
icd9pcs
|
[
[
[]
]
] | 10
| 772
| 0
| 8
| 10
| 0
| 0
| 0
| 0
| 1
| 0
| 0
| 40
| 125
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| 0
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| 14
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| 478
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| 0
| 0
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| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 666
| 0
| 0
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| 0
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| 0
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| 0
| 0
| 0
| 0
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| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 8
| 0
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| 0
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| 0
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| 0
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| 0
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| 1,520
| 0
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| 0
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| 3,650
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| 1,146
| 224
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
|
94,953
| 196,881
|
39833
|
Discharge summary
|
Report
|
Admission Date: [**2160-3-3**] Discharge Date: [**2160-3-4**]
Date of Birth: [**2107-1-29**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
L PICA aneurysm
Major Surgical or Invasive Procedure:
[**2160-3-3**]: Cerebral angiogram with coiling of the L PICA aneurysm
History of Present Illness:
53F elective admission for coiling of the L PICA aneurysm
Past Medical History:
carpal tunnel syndrome, COPD, tonsillectomy, and adenoidectomy,
right thumb pulley,
bunionectomy of the right foot.
Physical Exam:
Pre-procedure:
Nonfocal exam
Post-procedure:
Nonfocal exam
Brief Hospital Course:
53F elective admission for PICA aneurysm coiling. Post-angio she
was monitored in the ICU and extubated. Overnight she remained
stable. On [**3-4**] her foley was removed and she ambulated
independently. She was discharged home on [**3-4**].
Medications on Admission:
-albuterol sulfate 90 mcg 1-2 Puffs Inhalation UP TO 7 TIMES A
DAY
-fluticasone-salmeterol 500-50 mcg/dose Disk One (1) Disk with
Device Inhalation [**Hospital1 **] (2 times a day).
-sertraline 100mg PO DAILY (Daily).
-tiotropium bromide 18 mcg Capsule, w/Inhalation Device One (1)
Cap Inhalation DAILY (Daily).
-alprazolam 0.50 mg PO TID (3 times a day) as needed for
anxiety.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain .
Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation UP TO 7 TIMES A DAY ().
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) as needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
L PICA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with coiling
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 4 weeks, you do not need
imaging at that time. Please call [**Telephone/Fax (1) 4296**] to make this
appointment.
Completed by:[**2160-3-4**]
|
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490049
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Physician
|
Physician Resident Admission Note
|
TITLE:
Chief Complaint: Abdominal pain, continued bloody diarrhea
HPI:
Ms [**Known lastname 8339**] is a 47 yo female with pmh of Hep C with presumbed cirrhosis
and history of grade I esophageal varices, ETOH abuse, with a recent
admissions for C.diff colitis and continued abdominal pain and bloody
diarrhea admitted to the [**Hospital Unit Name 1**] due to concern for a GI bleed, also seen
to have air in her biliary tree on CT. The patient states she has had
two months of constant, diffuse abdominal pain which she describes as
an achy, bloaty feeling. Currently she states the pain is sharp over
her RUQ, but achy everywhere else. The pain gets up to [**8-10**]. The pain
occasionally goes to her back. Nothing makes it better. Was having
black stools previously, but has not had a bowel movement in two days.
She thought over the past few days her dark stool had been improving.
Admits to associated nausea, subjective fevers/chills; denies vomiting
in the last couple of months. Due to her pain she states she's had
decreased po intake. Also has generalized weakness and DOE which has
been worsening slowly. Admits to subjective fevers, chills,
palpitations, and night sweats for a week. No sick contacts. Denies
CP.
.
Notably she has been admitted with concern for GI bleed multiple times
in the past 4 months. She was admitted in [**5-9**] with an upper GI
bleed. At that time she underwent an EGD which showed 3 cords of
nonbleeding grade I esophageal varices. She was transfused, her Hct
remained stable and she was discharged on a PPI to follow up with the
liver clinic. She was seen in the liver clinic on [**6-12**] and was started
on nadolol. On her follow up visit on [**7-24**] her Hct was found to be
decreased to 24 from 35 in [**Month (only) 807**]. At that time she also reported BRBPR
as well as recent melena and was admitted. She received PRBC on
admission and then had a stable Hct without active bleeding. She
underwent an EGD on [**7-27**] which again showed varies and additionally an
esophagitis as well as portal hypertensive gastropathy and Gastric
antral vascular ectasia.
.
She was then hospitalized from [**8-4**] to [**8-7**] with abdominal pain. A CT
abd/pelvis showed pancolitis and she was found to be C. diff positive.
She was discharged on po flagyl. Per OMR documentation she did not
finish the course of flagyl and was hospitalized at [**Hospital1 3633**] in mid [**Month (only) **]
for continued abdominal pain and dark stools. She was again admitted
to [**Hospital1 19**] from [**8-22**] to [**8-29**] with persistent abdominal pain and bloody
stools. She was transfused initially and then her Hct remained stable,
although she continued to have dark stools. She was discharged on po
vanco. She was scheduled to follow up with GI for a repeat endoscopy
on [**9-1**], but missed the appointment.
.
In the ED, initial vs were: T 98.6 HR 100 BP 101/58 RR 20 Sat 96% on
RA. She was found to have a Hct of 18.1. Patient was given 40 mg IV
pantoprazole. She underwent an abd/pelvis CT which showed interval
improvement in her colitis, however there was concern for small amount
of air in her biliary tree. She also had an NG lavage which showed a
few small clots, but the fluid was otherwise clear w/ bile tinge.
.
On arrival to the [**Hospital Unit Name 1**] she states her abdominal pain is currently
[**6-9**]. She denies recent bowel movement.
Patient admitted from: [**Hospital1 19**] ER
History obtained from [**Hospital 15**] Medical records
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
(per recent discharge summary)
1. Methadone 40 mg po daily
2. Senna 8.6 mg 1-2 Tablets PO BID:prn constipation.
3. Bisacodyl 5 mg tab, 2 prn constipation.
4. Pantoprazole 40 mg po bid
5. Docusate Sodium 100 mg po bid
6. Lactulose 10 gram/15 mL Syrup 30 ML PO Q6H prn constipation.
7. Sucralfate 1 gram Tablet PO four times a day.
8. Thiamine HCl 100 mg po daily
9. Folic Acid 1 mg po daily
10. Alum-Mag Hydroxide-Simeth 200-200-20 mg Tablet 1 PO four times a
day as needed for constipation.
11. Tramadol 50 mg Tablet 1 Tablet PO twice a day.
12. Vancomycin 125 mg PO Q6H for 9 days (starting from [**2186-8-29**]).
Patient states she has only been taking methadone, omeprazole, and
motrin prn.
Past medical history:
Family history:
Social History:
1. History of Cholecystitis s/p Cholecystotomy tube at [**Hospital1 3633**] - 4 years
ago
2. History of ampullary stenosis s/p sphincterotomy and ERCP in [**8-4**]
3. Depression
4. Raynaud's
5. Polysubstance Abuse- Past history of IV drug use with heroin and
cocaine (none in many years). Continues to drink alcohol, up to one
pint of vodka daily, less recently. Continues to smoke tobacco - [**12-2**]
PPD
6. Hepatitis C Infection
7. Presumed Cirrhosis c/b grade 1 esophageal varices (EGD [**7-9**])
8. Chronic Anemia
9. Chronic Abdominal Pain
10. Lumbar Stenosis
11. Lumbar Disk Herniation
12. History of an upper GI Bleed
13. History of C.diff colitis in [**10-4**]
14. History of facial cellulitis in [**5-6**]
15. History of alcoholic pancreatitis
16. s/p sexual assault in [**2180**] while hospitalized at a
psychiatric institution
Denies a family history of GI disease or GI bleeding.
Occupation: Not currently working.
Drugs: Had previous used IV drugs but states she hasn't done so for at
least 15 years.
Tobacco: . Smokes [**4-6**] cig/day (has smoked for 30 years, but recent cut
back).
Alcohol: Was drinking 1 pint of vodka per day up until 4 weeks ago when
she cut back for her health. Drank 4 drinks the day prior to admission
and a couple the day of admission. Denies a history of withdrawal.
Other: She lives with a roomate in [**Location (un) 590**].
Review of systems:
(+) Admits to a frontal HA for the last week.
(-) Denies recent weight loss or gain. Denies sinus tenderness,
rhinorrhea or congestion. Denied cough. No dysuria. Denied arthralgias.
Flowsheet Data as of [**2186-9-6**] 08:12 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since 12 AM
Tmax: 36.9
C (98.5
Tcurrent: 36.9
C (98.5
HR: 84 (84 - 95) bpm
BP: 109/65(76) {96/60(68) - 109/71(78)} mmHg
RR: 13 (13 - 17) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
Height: 67 Inch
Total In:
375 mL
PO:
TF:
IVF:
Blood products:
375 mL
Total out:
0 mL
950 mL
Urine:
950 mL
NG:
Stool:
Drains:
Balance:
0 mL
-575 mL
Respiratory
SpO2: 97%
Physical Examination
General: Middle-aged woman, alert, appropriate, in no acute distress.
Smells somewhat alcholic.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD to the madible, no LAD
Lungs: Breathing comfortably. Inspiratory crackles at the bases
bilaterally, otherwise clear.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, bowel sounds present, fluid wave present. Tenderness
to palpation throughout, worse in the center of her abdomen, but upon
percussion jumps when the RUQ is percussed. No rebound or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema.
No asterixis present.
Skin: a few spider angioma over her chest
Labs / Radiology
[image002.jpg]
Labs:
Na 133 K 3.8 Cl 100 Bicarb 24 BUN 14 Cr 0.5 Glu 84
ALT 16 AST 57 AP 105 T bili 0.6 Lipase 47 Albumin 3.4
.
WBC 5.7 Hct 18.1 Plt 313
Hct baseline in mid to high 20's
N 71.1% L 21.5% M 6.5% E 0.4%
.
Peripheral smear: Hypochr: 3+ Anisocy: 1+ Poiklo: 1+ Macrocy:
OCCASIONAL Microcy: OCCASIONAL Polychr: OCCASIONAL Schisto: OCCASIONAL
Plt-Est: Normal
.
Micro: None
.
Images:
Abd/pelvis CT: Prelim
Interval improvement in colitis, now w/moderate fecal loading.
Cirrhotic liver with trace ascites. No acute abnormalities. No focal
collection or abscess. Additionally, was called with concern for a
small amount of air in her biliary tree.
Assessment and Plan
47 yo female with pmh of Hep C with presumbed cirrhosis and history of
grade I esophageal varices, ETOH abuse, with a recent admissions for
C.diff colitis and continued abdominal pain and bloody diarrhea
admitted to the [**Hospital Unit Name 1**] due to concern for a GI bleed, also seen to have
air in her biliary tree on CT.
# Pneumobilia: The patient does have a history of ERCP in [**2180**],
however it is unclear that an ERCP 5 years ago could leave persistent
air in her biliary tree. The partial focality of her abdominal pain in
the RUQ makes a biliary source of her pain concerning.
- Appreciate surgery consult. Will f/u recs.
- F/u abdominal US results to look for evidence of cholelithiasis and
to assess the patency of the portal vein.
# Acute blood loss anemia/GI bleed: Most likely due to an upper source
given that she has had melena. Unlikely to be secondary to varices as
she would have a much brisker bleed and hemeatemesis. She received 1
unit PRBC in the ED.
- Will transfuse another two units of PRBC and check a post-transfusion
Hct.
- Appreciate GI consult, plan for EGD in the am.
- Pantoprazole 40 mg IV bid.
- Active type and screen.
- Adequate access - will need a CVL as she has very difficult access.
# Abdominal pain: She has had persistent abdominal pain for multiple
weeks and previous hospitalizations and workup has been unrevealing.
Differential includes SBP, gastritis, esophagitis, biliary source,
diverticulitis (less likely given its characteristics).
- Diagnostic paracentesis to rule out SBP.
- Workup of pneumobilia/gallbladder source of pain as above.
- EGD in the am.
- Prn morphine for pain control.
# Hep C Cirrhosis: Patient is followed at the liver center. Has known
portal gastropathy and grade I esophageal varices.
# Alcohol abuse: Patient continued to drink alcohol and has the smell
of alcohol on her currently.
- folate, thiamine, MVI
- CIWA q4h with ativan prn for CIWA > 10
- SW consult
ICU Care
Nutrition: NPO, IVF prn
Glycemic Control:
Lines:
18 Gauge - [**2186-9-6**] 05:33 PM
Prophylaxis:
DVT: Boots
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition: ICU
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98,959
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38497
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Discharge summary
|
Report
|
Admission Date: [**2141-12-31**] Discharge Date: [**2142-1-9**]
Date of Birth: [**2065-5-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, transfer for STEMI
Major Surgical or Invasive Procedure:
[**2142-1-1**] Cardiac Cath
[**2142-1-4**] Coronary artery bypass grafting x4, with the left
internal mammary artery to the left anterior descending artery
and reversed saphenous vein grafts to the posterior descending
artery and first and second diagonal arteries.
History of Present Illness:
76 year old male who presented to OSH for ED with sudden onset
of [**9-19**] chest pressure, similar to prior chest pain. Attempted
to fall asleep however could not and so called EMS who brought
him to [**Hospital3 **]. At OSH, EKG revealed ST elevations in
anterior leads. Pt was started heparin gtt and transferred to
[**Hospital1 18**] emergently for further evaluation. Code STEMI was called
after EKG showed ~2mm ST elevations in V3-V4. Labs were
significant for mild troponin of 0.09. He was found to have two
vessel disease and he is now being referred to cardiac surgery
for revascularization.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
2 stents at [**Hospital1 3278**] in [**2129**] (not on plavix because of CVA)
Atrial fibrillation not on Coumadin because of CVA
MCA stroke with hemorrhagic conversion s/p craniectomy in [**2132**]
at Southshore
B12 deficiency
BPH
s/p craniectomy in [**2132**]
Social History:
Race:Caucasian
Last Dental Exam:>1 year ago
Lives with:wife, Wheelchair bound. Wife is primary caretaker
Contact: [**Name (NI) 18380**] (wife) Phone #[**Telephone/Fax (1) 85652**]
Occupation:retired business man
Cigarettes: Smoked no [] yes [x] Hx:quit 20 years ago, has a
greater than 20 pack year history of smoking
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-16**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
No premature coronary artery disease- Father had an MI at age 70
Physical Exam:
Pulse:97 Resp:26 O2 sat:96/2L
B/P 109/66
Height:65" Weight:83kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x] Contracted left knee
Neuro: Grossly intact []
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Discharge Exam:
VS: T: 97.6 HR: 65-100 SR BP: 105-125/60-70 Sats: 96% RA
General: 76 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,.S2 no murmur
Resp: diminished breath sounds bilateral with fine crackles
right 1/4 up, no wheezes
GI: obese, bowel sounds positive, abdomen soft
Extr: warm no edema
Incision: sternal and left lower extremity clean, dry margins
well approximated with no erythema
Skin: ecchymosis right hip, Left papula rash left upper, lower
and groin region.
Neuro: awake, alert, oriented to person, place and time. Mild
left facial droop
Strengths R 3-3/4, Left 0-/4 (old CVA)
Pertinent Results:
[**2142-1-1**] Cardiac Cath: 1. Selective coronary angiography in this
right dominant system demonstrated two vessel CAD. The LMCA was
patent. The LAD had diffuse plaquing throughout and tapers to
90% beyond the patent proximal to mid LAD stent and the D2
takeoff. The D2 is diffusely diseased with 40% at ostium and 50%
proximally. The D1 is a substantive bifricating vessel with 70%
ostial stenosis (partially jailed by the LAD stent). The LCx had
mild plaquing throughout. The proximal OM1 and mid OM2 (both
small vessels) have focal 70% stenosis with normal flow. The RCA
was subselectively engaged due to ostial stent and
calcifications. The ostial stent was patent with instent
restenosis (mild, nonflow-limiting). Serial focal stenosis (1st
65-70%) just beyond the acute marginal takeoff and second (90%)
about 2 cm downstream. The PL has 70-80% ostially but overall
this is a small diffusely diseased vessel. The R-PDA is patent.
2. Limited resting hemodynamics revealed moderately elevated
systemic arterial systolic pressures with an SBP of 150 mmHg. 3.
Abdominal aortography was performed using a pigtail catheter via
power injection and showed diffuse plaquing in the infra-renal
aorta, possible moderate L renal artery stenosis, calcific right
common iliac artery stenosis (difficulty passing the wire
through the common iliac into the aorta).
.
[**2142-1-3**] Carotid U/S: Right ICA <40% stenosis. Left ICA no
stenosis.
.
[**2142-1-4**] Echo: Pre-CPB: The patient is in A.Fib. No spontaneous
echo contrast is seen in the left atrial appendage. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
right ventricular cavity is mildly dilated with mild global free
wall hypokinesis. The ascending aorta is mildly dilated. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is moderate aortic valve stenosis (valve area 1.0-1.2cm2). In
the face of more modest peak and mean gradients across the
valve, a discussion led to the decision to not replace it. Dr.
[**Last Name (STitle) 4901**] offered his opinion also. Trace aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion. Post-CPB: The patient is on an AV-Pacer, though there
is no atrial response. No inotropes. Preserved biventricular
systolic fxn. 1+MR, trace AI. Aorta intact.
.
[**2142-1-9**] WBC-10.4 RBC-3.14* Hgb-9.3* Hct-27.7* MCV-89 MCH-29.6
MCHC-33.5 RDW-13.9 Plt Ct-308
[**2141-12-31**] WBC-11.5* RBC-4.95 Hgb-14.6 Hct-43.0 MCV-87 MCH-29.6
MCHC-34.0 RDW-13.0 Plt Ct-205
[**2142-1-9**] Glucose-136* UreaN-23* Creat-1.0 Na-140 K-4.5 Cl-103
HCO3-32
[**2141-12-31**] Glucose-172* UreaN-21* Creat-0.9 Na-141 K-4.4 Cl-106
HCO3-22
[**2142-1-3**] ALT-27 AST-29 LD(LDH)-260* AlkPhos-61 TotBili-0.4
Micro:
[**2142-1-3**] URINE CULTURE (Final [**2142-1-4**]): <10,000
organisms/ml.
MRSA SCREEN NASAL SWAB. MRSA SCREEN (Final [**2142-1-6**]): No MRSA
isolated
PICC line [**2141-1-7**]:
Right jugular line has been removed. Tip of the new right PIC
line is in the right atrium. It should be withdrawn 3.5 cm to
position it low in the SVC.
Mild pulmonary edema has developed, most readily appreciated in
the right
lower lung. Severe cardiomegaly is longstanding, but mediastinal
and hilar
vascular engorgements have worsened. There is greater
consolidation at the
left lung base, presumably atelectasis though pneumonia is not
excluded, and an increase in small-to-moderate left pleural
effusion. There is no
pneumothorax.
CXR: [**2142-1-6**] There is a questionable tiny left pneumothorax.
The pulmonary edema has almost resolved. There are persistent
low lung volumes with bibasilar atelectasis. Cardiomediastinal
silhouette is unchanged. Right IJ catheter remains low in the
right atrium and can be withdrawn 3-4 cm for more standard
position. If any there are small bilateral pleural effusions.
The sternal wires are aligned.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 47059**] was transferred from
outside hospital with an ST-elevation myocardial infarction. He
underwent a cardiac cath on [**1-1**] which revealed severe three
vessel coronary artery disease. He then underwent appropriate
surgical work-up while awaiting Plavix to wash-out. On [**1-4**] he
was brought to the operating room where he underwent a coronary
artery bypass graft x 4. Please see operative note for surgical
details. Following surgery he was transferred to the CIVCU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one he was started on beta-blockers and diuretics
and diuresed towards his pre-op weight. On post-op day two he
was transferred to the telemetry floor for further care. Chest
tubes and epicardial pacing wires were removed per protocol. On
post-op day three he had episode of rapid atrial fibrillation
IV/PO amiodarone was started. He converted to sinus rhythm
(pre-op history of AF but not on Coumadin d/t hemorrhagic
stroke). A Non-heparin PICC line was placed for IV access. His
Foley was removed and a condom cath was placed for incontinence.
He was bladder scanned for 300. He continued to make good
progress while working with physical therapy. On post-op day 5
he was discharged to rehab with the appropriate medications and
follow-up appointments.
Medications on Admission:
Medications at home:
metoprolol tartarte 50mg [**Hospital1 **]
lisinopril 10mg daily
simvastatin 20mg daily
tamsulosin 0.4mg daily
escitalopram 20mg daily
finasteride 4mg
senna-docunsate 1 tab TID
NPH/Novolin 10 units SC daily
NPH 15 units SC at dinner
ascorbic acid 500mg daily
folic acid-vit b2-vit b6-vit b 1 tab [**Hospital1 **]
ergocalciferol 1000 units daily
trazodone 50mg daily
aspirin 81mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours).
11. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation Q6H (every 6 hours).
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
14. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 7 days
then 400 mg daily x 7 days then 200 mg daily.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash: apply to rash.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for PAIN/TEMP.
18. PICC Line
Non-Heparin: FLUSH with 10 mL of Normal Saline
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Diabetes
Dyslipidemia
Hypertension
2 stents at [**Hospital1 3278**] in [**2129**] (not on plavix because of CVA)
atrial fibrillation not on Coumadin because of CVA
MCA stroke with hemorrhagic conversion s/p craniectomy in [**2132**]
at
Southshore
B12 deficiency
BPH
s/p craniectomy in [**2132**]
Discharge Condition:
Alert and oriented with Left Hemi-paresis
Ambulating with Max assist
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2142-2-8**] at 1:15PM in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) 10357**] [**Hospital Unit Name **]
Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**] [**2142-1-22**] 12:00
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2142-1-9**]
|
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"600.00",
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icd9cm
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11295
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[
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icd9pcs
|
[
[
[
383,
494
]
],
[
[
500,
603
]
]
] | 73
| 1,431
| 0
| 268
| 231
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| 4,009
| 0
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| 546
| 68
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| 1,757
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| 386
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| 672
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| 0
|
94,213
| 168,974
|
35962
|
Discharge summary
|
Report
|
Admission Date: [**2151-1-5**] Discharge Date: [**2151-1-21**]
Date of Birth: [**2073-9-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted with abdominal distention and pain.
Major Surgical or Invasive Procedure:
Status Post Proximal jejunum resection and anastomosis of
deodunum to jejunum and sigmoid colectomy w/ end colostomy.
History of Present Illness:
77M, NH resident and wheelchair bound having onstipation,
increasing ab distension and mild pain for the past 2-3 days.
Afebrile, mild problems breathing, no CP/d/n/v. Never had
symptoms like this before. At [**Hospital1 **] had AXR shows
significant
distension c/w sigmoid volvulus. Intubated for respiratory
protection do to tachypnea and low O2 sats for the transfer.
Past Medical History:
bipolar & schizophrenia (newer diagnoses), BPH, urnary
retention, neuromuscular disorder - wheelchair and NH bound
Social History:
Patient is wheelchair bound and lives in nursing home. Daughter
([**Doctor First Name **]) involved with care.
Family History:
Not applicable.
Physical Exam:
PE 98.2 100 121/76 18 100% ventilator (50% FIO2 PEEP 5)
intubated, sedated
decreased bs b/l
RRR
soft distended, tympanitic
no c/c/e
guiac neg
Pertinent Results:
[**2151-1-5**] 12:00AM BLOOD WBC-24.3* RBC-4.23* Hgb-12.9* Hct-37.2*
MCV-88 MCH-30.5 MCHC-34.7 RDW-12.9 Plt Ct-491*
[**2151-1-8**] 03:09AM BLOOD WBC-14.5* RBC-2.95* Hgb-8.9* Hct-26.4*
MCV-89 MCH-30.2 MCHC-33.7 RDW-13.1 Plt Ct-292
[**2151-1-18**] 08:16AM BLOOD WBC-8.8 RBC-3.20* Hgb-9.8* Hct-28.0*
MCV-87 MCH-30.5 MCHC-34.9 RDW-13.7 Plt Ct-315
Brief Hospital Course:
77yo M, NH resident presented [**1-5**] with 1 day history of
abdominal pain and distension with 1 episode diarrhea day prior.
Seen at OSH where XRays showed distended loops of bowel and
likely sigmoid colon volvulus. Tx with hydration. Became
tachypneic with RR 50 and hypoxic and was intubated. Transfer to
[**Hospital1 18**]. Sigmoid volvulus confirmed, and pt with leukocytosis of
24.3 with left shift, lactate of 4.8, and urinanalysis
consistent with UTI. To MICU. Decompression by GI but not
sustained. Question of mass found on barium enema. Pt extubated
and wish to have surgery. To OR [**1-6**] and is now s/p prox
jejunum resection and anastomosis of deod to jejunum and sigmoid
colectomy w/ end colostomy.
Postoperative course complicated by several days of ileus
requiring nasogastric tube and TPN. Currently patient on regular
diet with oral reglan. Ostomy is actively draining.
Patient will follow up with Dr. [**Last Name (STitle) **] in 2 weeks. He will be
discharged to nursing home/rehab today.
Medications on Admission:
flomax, mvi, colace, zcor, risperdal, senna
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection twice a day.
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis: Gastric volvulus with mass of colon.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**10-21**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2151-2-5**] 3:15
Completed by:[**2151-1-20**]
|
[
"V46.3",
"296.80",
"295.90",
"600.01",
"788.20",
"560.2"
] |
icd9cm
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[
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],
[
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[] |
icd9pcs
|
[
[
[]
]
] | 78
| 1,018
| 0
| 122
| 10
| 0
| 0
| 0
| 0
| 345
| 0
| 0
| 181
| 18
| 0
| 0
| 0
| 499
| 0
| 1
| 0
| 46
| 0
| 0
| 0
| 0
| 932
| 0
| 0
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| 0
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| 0
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| 0
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| 0
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| 0
| 0
| 0
| 0
| 0
| 0
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| 0
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| 0
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| 0
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 55
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
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| 0
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| 0
| 0
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| 0
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| 0
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| 335
| 0
| 0
| 0
| 0
| 0
| 0
| 373
| 0
| 0
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| 0
| 0
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| 0
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| 0
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| 118
| 113
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| 0
| 0
| 0
|
94,987
| 193,169
|
731719
|
Physician
|
Physician Admission Note - MICU
|
Chief Complaint: hypoxia, back pain
HPI:
55 y/o F with hx of recent L5/S1 laminectomy who presented on [**4-23**] with
worsening SOB and found to have multiple PEs. Was in the MICU from
[**4-23**] until the night of [**4-29**]. See the initial admission note and last
night's transfer note for details of her presentation and hospital
stay.
.
In short, she was admitted and started on a heparin gtt which was
difficult to titrate to a therapeutic range. She remained hypoxic with
O2 sats in the high 80s to low 90s while on high flow mask and nasal
canula. Over the course of her stay, she became therapeutic on the
heparin and was started on coumadin on [**4-26**] after being therapeutic for
24 hours. She was weaned from the high flow face mask to a venti mask
and then nasal canula overnight. She was otherwise normotensive with
mild tachycardia to high 100s throughout her hospitalization. She had
pain control with IV morphine and then PO oxycodone/oxycontin for her
post-surgical pain.
.
On transfer to the floor last night, she triggered for a SBP in the
80s. She had just received all her pain medications, and her BP
quickly normalized after a fluid bolus. Then she triggered again this
morning for marked nursing concern with increased upper and lower back
and "lung" pain. She had desatted to the high 80s on her nasal canula
and was placed back on a venti mask. Her oxygenation saturations
improved to mid 90s after being placed back on the mask.
.
During evaluation, she was tachypneic and uncomfortable, complaining of
middle upper back pain and pain with deep breaths. She was afebrile,
her BP was 110/80, P 98. She was 92% on venti-face mask. She had
already received her morning pain meds and was not comfortable. She
was given IV morphine and ativan. She had a CT torso to evaluate lung
parenchyema and for RP bleed. Her hct was stable today at 29 and had a
therapeutic INR. Her herparin was stopped.
.
She was transferred to the MICU for nursing concern about her hypoxia.
Patient admitted from: [**Hospital1 5**] [**Hospital1 **]
History obtained from [**Hospital 19**] Medical records
Allergies:
Ambien (Oral) (Zolpidem Tartrate)
Headache;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Past medical history:
Family history:
Social History:
(Per prior admission note)
Past Medical History:
Obesity
Gastric Bypass
s/p anterior L4-S1 fusion
.
Medications:
Oxycodone 5 mg [**2-8**] Tablet(s) every 4 hours, as needed
Docusate Sodium 100 mg Tab Twice Daily
Tizanidine 4 mg Tab Daily, at bedtime
Quetiapine 50 mg Tab Daily, at bedtime
Cyanocobalamin 50 mcg Tab Daily
Multivitamin Tab Daily
Clonazepam 0.5 mg Tab Daily, at bedtime
Venlafaxine ER 225 mg 24 hr Tab Daily
Doxidan (bisacodyl) 5 mg Tab Oral 2 Tablet Once Daily, as needed
OxyContin 20 mg 12 hr Tab every 12 hours
.
Transfer MEDS:
see OMR
.
Allergies:
Ambien
no hx of blood clots; otherwise non-contributory
Occupation:
Drugs:
Tobacco:
Alcohol:
Other: Lives with husband, runs food service supplying mixes for
breads/brownies/etc to chain stores. Denies tobacco, etoh or illicits.
Having a difficult time with coping about her diagnosis. Also has a
son who was recently incarcerated.
Review of systems:
Constitutional: Fatigue
Ear, Nose, Throat: Dry mouth
Cardiovascular: Chest pain, Palpitations
Respiratory: Dyspnea, Tachypnea, Wheeze
Gastrointestinal: Abdominal pain, Constipation
Genitourinary: Foley
Musculoskeletal: Myalgias
Heme / Lymph: Anemia
Neurologic: Headache
Psychiatric / Sleep: Agitated, depressed
Pain: [**8-13**] Severe
Pain location: upper and lower back
Flowsheet Data as of [**2172-4-30**] 03:21 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance
24 hours
Since [**74**] AM
Tmax: 37.2
C (99
Tcurrent: 36.7
C (98
HR: 93 (69 - 97) bpm
BP: 144/71(89) {119/59(73) - 154/88(102)} mmHg
RR: 29 (14 - 29) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 89.3 kg (admission): 91.6 kg
Height: 64 Inch
Total In:
1,175 mL
PO:
500 mL
TF:
IVF:
675 mL
Blood products:
Total out:
1,340 mL
0 mL
Urine:
1,340 mL
NG:
Stool:
Drains:
Balance:
-165 mL
0 mL
Respiratory
O2 Delivery Device: Nasal cannula
SpO2: 95%
Physical Examination
General Appearance: Well nourished, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,
No(t) Crackles : , Bronchial: at bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Not assessed
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
Labs / Radiology
433 K/uL
9.1 g/dL
87 mg/dL
0.6 mg/dL
6 mg/dL
28 mEq/L
103 mEq/L
3.3 mEq/L
141 mEq/L
28.7 %
6.5 K/uL
[image002.jpg]
[**2168-2-8**]
2:33 A3/18/[**2172**] 02:37 PM
[**2168-2-12**]
10:20 P3/18/[**2172**] 05:48 PM
[**2168-2-13**]
1:20 P3/19/[**2172**] 03:24 AM
[**2168-2-14**]
11:50 P3/20/[**2172**] 02:53 AM
[**2168-2-15**]
1:20 A3/21/[**2172**] 01:47 AM
[**2168-2-16**]
7:20 P3/22/[**2172**] 04:12 AM
1//11/006
1:23 P3/23/[**2172**] 05:27 AM
[**2168-3-10**]
1:20 P3/23/[**2172**] 12:11 PM
[**2168-3-10**]
11:20 P3/24/[**2172**] 02:17 AM
[**2168-3-10**]
4:20 P
WBC
8.8
10.0
8.1
7.7
6.6
6.5
Hct
27.8
26.7
26.9
26.3
26.7
28.7
Plt
398
392
372
[**Telephone/Fax (3) 12186**]
Cr
0.7
0.6
0.6
0.6
0.7
0.6
0.6
TC02
24
Glucose
109
99
103
102
137
100
99
87
Other labs: PT / PTT / INR:23.3/111.3/2.2, Ca++:8.2 mg/dL, Mg++:1.9
mg/dL, PO4:4.2 mg/dL
Imaging: [**4-23**] CTA (OSH, uploaded):
Large left main pulmonary artery PE extending to segmental arteries
involving all lobes of the left lung, as well as a right upper lobe
apical segmental artery PE, and an occlusive embolus in the right lower
lobe pulmonary artery.
.
[**4-23**] TTE:
The left atrium is mildly dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal (LVEF
>55%). The right ventricular cavity is dilated with mild global free
wall hypokinesis. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated and mildly hypokinetic right ventricle. Normal
global and regional left ventricular systolic dysfunction. Moderate
functional tricuspid regurgitation. Moderate pulmonary hypertension.
.
[**4-23**] LENIs: Subacute, non-occlusive DVT within the right distal femoral
vein, inferior to the bifurcation.
.
[**4-23**] CXR:
ABDOMEN, SUPINE PORTABLE FRONTAL VIEW: The lateral aspect of the left
lung is not included on this study. Lung volumes are low. Linear
opacity of the right lung base corresponds to atelectasis on CT. The
imaged portion of the left lung is clear. The heart is accentuated by
low lung volumes. There is no evidence of pulmonary edema. Medial right
apical density corresponds to an azygos fissure on CT.
IMPRESSION: No acute cardiopulmonary abnormality.
Please refer to CT for imaging of bilateral pulmonary emboli.
.
[**4-30**] CXR:
.
[**4-30**] CT Torso: (per dictation)
Large central pulmonary emboli extending into all segments which has
slightly increased in extent, more on the Right. No evidence of pulm
artery enlargement or R heart strain. Small L and trace R pleural
effusion. LUL infiltrate consistent with a pneumonia. Bowel is
without free air or obstruction. No evidence of bleed. No
abnormalities of other organs. Has post operative seroma. Spinal
hardware appears intact.
Microbiology: mrsa screen negative
ECG: NSR, no signs of ischemia
Assessment and Plan
DEPRESSION
ACTIVITY INTOLERANCE
PULMONARY EMBOLISM (PE), ACUTE
ASSESSMENT AND PLAN:
55 y/o F with hx of obesity, s/p gastric bypass, s/p L5/S1 laminectomy
who presented with large bilateral PEs. Was called out of MICU
yesterday and returning for continued hypoxia and worsening pain.
.
# Pulmonary emboli: were diffuse, never hemodynamically unstable. On
CT today, she continues to have extensive clot burden. Is requiring
fask mask oxygen and has been slow to wean. Desats on the floor,
likely from exertion and movement. Will be transferred back to unit
for continued respiratory monitoring.
- continue coumadin; can continue to hold heparin
- wean O2 as tolerated
- nebs PRN wheezing, SOB
.
# LUL infiltrate: concerning for pneumonia. [**Month (only) 8**] have contributed to
her desaturations on the floor. Is not febrile and no leukocytosis,
but may be early.
- vanco/cefepime for HAP coverage
- repeat CXR tomorrow
.
# Back pain: unclear etiology, no bleeding seen on CT scan today.
Likely is post-operative pain and/or pain from lying in bed all day.
Could also have pleuretic pain from PEs and new pneumonia.
- pain control with home PO meds
- can use morphine IV PRN if needed
.
# S/p laminectomy: Midline incision healing well, pt still having pain
in abdomen, low back. Ortho is following along.
- will continue home pain control regimen of oxycontin, oxycodone and
tizanidine; morphine PRN as above
- ortho requesting AP & lateral L-spine x-rays prior to d/c
- follow up ortho recs if any
.
# Anemia: hct is within her recent baseline after surgery. Will
continue cyanocobalamin and multivitamin. No active evidence of
bleeding. No bleed seen on CT
- monitor hct daily
.
# Anxiety: Will continue venlafaxine, clonazepam, quetiapine. Social
work has seen patient. Continues to be anxious and crying. Supportive
care as needed.
.
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: on coumadin, bowel regimen, pain control as above
# Access: peripherals; consider PICC for abx and blood draws
# Communication: Patient, family
# Code: Full (discussed with patient); HCP husband [**Name (NI) 938**] [**Name (NI) 3033**]
# Disposition: ICU for now, consider calling out when stable on nasal
canula
.
.
[**First Name8 (NamePattern2) 4452**] [**Last Name (NamePattern1) 4399**], MD
PGY 2
pager [**Numeric Identifier 11908**]
ICU Care
Nutrition:
Glycemic Control:
Lines:
Prophylaxis:
DVT: Boots(Systemic anticoagulation: Coumadin)
Stress ulcer:
VAP:
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
------ Protected Section ------
I saw and examined the patient, and was physically present with the ICU
resident for the key portions of the services provided. I agree with
the note above, including the assessment and plan. To that I would add
the following:
Mrs. [**Known lastname 3033**] is well-known to the MICU service, having presented last
week with extensive bilateral PEs. She was called out yesterday to the
floor but returns to us with ongoing hypoxemia and new pleuritic chest
pain on L. Pt has been therapeutic on her Coumading CTA today shoes
ongoing extensive bilateral PEs as well as scattered groung glass
infiltrates, which are most prominent in the LUL. There is also a
component best viewed on chest/abdomen windows that appears to be
pleural-based in the LUL and a new L-sided effusion. I suspect that
her pleuritic CP is due to distal inflammation/pleuritis as a late
consequence of her PEs but we will also treat her for hospital-acquired
PNA. Her oxygenation is stable at the moment.
[**Name2 (NI) **] is critically ill. Time spent 35 minutes.
------ Protected Section Addendum Entered By:[**Name (NI) 1776**] [**Name8 (MD) **], MD
on:[**2172-4-30**] 18:18 ------
|
[
"415.19",
"724.5"
] |
icd9cm
|
[
[
[
11441,
11456
]
],
[
[
12129,
12138
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] | 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 1
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
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| 0
| 0
| 0
| 0
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| 0
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| 0
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| 0
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| 0
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| 0
| 0
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| 0
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| 0
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| 0
| 0
| 5,154
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 2,378
| 0
| 0
| 0
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| 0
| 0
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| 0
| 0
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| 0
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| 0
| 0
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| 0
| 0
| 0
| 0
| 0
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| 0
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| 0
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| 0
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 941
| 31
| 0
| 0
| 0
| 0
| 6,539
| 0
| 0
| 0
| 0
|
99,231
| 168,976
|
46681
|
Discharge summary
|
Report
|
Admission Date: [**2149-8-3**] Discharge Date: [**2149-8-26**]
Date of Birth: [**2097-6-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Cellcept
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
52 yo F with SLE s/p renal tx 2 years ago presents with b/l LBP,
atraumatic. Started acutely this AM while watching television.
Also c/o abdominal fullness but no frank pain. No
F/C/N/V/CP/SOB. Had been feeling her usual self until this AM.
.
In the ED, VS: T98.4 BP 120/100 HR 86 100%RA. Labs were notable
for K 6.8, BUN/cr 121/14.7. EKG showed mild peak Ts in lead V2.
She received 2g calcium gluconate, 10U insulin, kayexalate and
2L NS. She was given 4mg morphine for pain. CT abd/pelvis showed
perinephric fat stranding. She was given levo flagyl for empiric
abx coverage. While in the ED, she was seen by renal and
transplant surgery with concern for acute rejection. She was
started on high dose IV steroids and transferred to the MICU for
further management.
.
Upon arrival stat labs were drawn, notable for increasing K to
7.4 with no changes on EKG from prior. Patient had stat LUE U/S
which demonstrated patent fistula. She was started on dialysis.
Past Medical History:
S/P renal transplant
SLE followed by Dr.[**Last Name (STitle) **] in Rheumatology.
Hypertension.
History of hyperthyroidism.
PSH:LUE AVF
History of bilateral knee surgeries and ACL repair on the
right knee.
Social History:
Single, lives alone, but has family in the area
Denied smoking/etoh
Family History:
NC
Physical Exam:
VS: HR 75 BP 185/85 97% RA
GEN: African American female in NAD
HEENT: EOMI, PERRL
NECK: Supple
CHEST: CTABL, no w/r/r
CV: RRR, S1S2
ABD: Soft/NT/ND
EXT: LUE: fistula with bruit and palpable thrill
SKIN: NO rashes
NEURO: AAOx3, no focal deficits
Pertinent Results:
[**2149-8-3**] 01:30PM BLOOD WBC-3.9* RBC-3.20* Hgb-8.1* Hct-27.0*
MCV-84 MCH-25.2* MCHC-29.9* RDW-16.8* Plt Ct-107*
[**2149-8-10**] 06:10AM BLOOD WBC-2.9* RBC-2.98* Hgb-7.7* Hct-25.1*
MCV-84 MCH-25.9* MCHC-30.8* RDW-17.9* Plt Ct-83*
[**2149-8-14**] 05:10AM BLOOD WBC-3.9* RBC-2.52* Hgb-6.7* Hct-21.6*
MCV-86 MCH-26.5* MCHC-30.9* RDW-17.5* Plt Ct-75*
[**2149-8-20**] 06:44AM BLOOD WBC-10.2# RBC-3.11* Hgb-8.4* Hct-27.9*
MCV-90 MCH-27.0 MCHC-30.1* RDW-17.4* Plt Ct-160
[**2149-8-22**] 06:13AM BLOOD WBC-12.4* RBC-3.61* Hgb-9.6* Hct-32.0*
MCV-89 MCH-26.5* MCHC-29.9* RDW-16.6* Plt Ct-244
[**2149-8-22**] 06:13AM BLOOD Neuts-73* Bands-2 Lymphs-20 Monos-3 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-2*
[**2149-8-13**] 05:00AM BLOOD Neuts-86* Bands-0 Lymphs-11* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2149-8-16**] 10:12AM BLOOD PT-13.1 PTT-30.8 INR(PT)-1.1
[**2149-8-16**] 06:00AM BLOOD QG6PD-10.0
[**2149-8-14**] 05:10AM BLOOD Ret Aut-3.0
[**2149-8-16**] 06:00AM BLOOD Ret Aut-2.2
[**2149-8-5**] 09:54PM BLOOD ACA IgG-5.6 ACA IgM-7.4
[**2149-8-5**] 09:54PM BLOOD Lupus-NEG
[**2149-8-3**] 01:30PM BLOOD Glucose-141* UreaN-121* Creat-14.7*#
Na-141 K-6.7* Cl-113* HCO3-11* AnGap-24*
[**2149-8-3**] 08:22PM BLOOD Glucose-153* UreaN-113* Creat-13.5*#
Na-139 K-7.6* Cl-115* HCO3-10* AnGap-22*
[**2149-8-3**] 10:47PM BLOOD Glucose-171* UreaN-117* Creat-13.3*
Na-141 K-7.2* Cl-115* HCO3-10* AnGap-23*
[**2149-8-4**] 03:32AM BLOOD Glucose-196* UreaN-73* Creat-9.1*# Na-141
K-4.2 Cl-105 HCO3-24 AnGap-16
[**2149-8-6**] 03:39AM BLOOD Glucose-179* UreaN-73* Creat-9.1*# Na-141
K-4.4 Cl-101 HCO3-26 AnGap-18
[**2149-8-7**] 05:00AM BLOOD Glucose-130* UreaN-94* Creat-10.6*#
Na-141 K-4.3 Cl-100 HCO3-25 AnGap-20
[**2149-8-11**] 04:56AM BLOOD Glucose-109* UreaN-58* Creat-7.0*# Na-144
K-3.9 Cl-104 HCO3-29 AnGap-15
[**2149-8-14**] 05:10AM BLOOD Glucose-93 UreaN-42* Creat-5.4* Na-146*
K-3.5 Cl-108 HCO3-27 AnGap-15
[**2149-8-16**] 10:12AM BLOOD Glucose-103 UreaN-61* Creat-6.3* Na-144
K-3.9 Cl-107 HCO3-24 AnGap-17
[**2149-8-19**] 05:31AM BLOOD Glucose-96 UreaN-83* Creat-6.4* Na-141
K-4.4 Cl-105 HCO3-21* AnGap-19
[**2149-8-21**] 05:15AM BLOOD Glucose-158* UreaN-102* Creat-7.6* Na-137
K-5.3* Cl-103 HCO3-24 AnGap-15
[**2149-8-22**] 06:13AM BLOOD Glucose-103 UreaN-64* Creat-5.8*# Na-139
K-5.2* Cl-100 HCO3-27 AnGap-17
[**2149-8-23**] 05:16AM BLOOD Glucose-120* UreaN-72* Creat-6.7* Na-136
K-5.3* Cl-99 HCO3-28 AnGap-14
[**2149-8-22**] 06:13AM BLOOD ALT-12 AST-15 AlkPhos-66 TotBili-0.5
[**2149-8-16**] 06:00AM BLOOD ALT-7 AST-14 LD(LDH)-520* AlkPhos-27*
TotBili-0.7
[**2149-8-3**] 01:30PM BLOOD Lipase-114*
[**2149-8-5**] 04:53AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2149-8-5**] 02:36PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2149-8-6**] 03:39AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2149-8-23**] 05:16AM BLOOD Calcium-9.6 Phos-4.6* Mg-2.4
[**2149-8-7**] 05:00AM BLOOD Calcium-6.3* Phos-8.8* Mg-2.6
[**2149-8-7**] 07:45PM BLOOD Calcium-6.8*
[**2149-8-8**] 06:48AM BLOOD Calcium-6.8* Phos-5.3*# Mg-2.0
[**2149-8-8**] 04:41PM BLOOD Calcium-7.2*
[**2149-8-14**] 05:10AM BLOOD VitB12-552 Folate-11.2 Hapto-95
Ferritn-304*
[**2149-8-4**] 03:32AM BLOOD calTIBC-181* Ferritn-925* TRF-139*
[**2149-8-5**] 09:54PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2149-8-5**] 09:54PM BLOOD ANCA-NEGATIVE B
[**2149-8-5**] 09:54PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 dsDNA-NEGATIVE
[**2149-8-5**] 09:54PM BLOOD PEP-NO SPECIFI IgG-1192 IgA-421* IgM-27*
IFE-NO MONOCLO
[**2149-8-5**] 04:53AM BLOOD C3-107 C4-25
[**2149-8-7**] 12:05PM BLOOD HIV Ab-NEGATIVE
[**2149-8-3**] 05:32PM BLOOD tacroFK-13.3
[**2149-8-5**] 09:54PM BLOOD HCV Ab-NEGATIVE
CXR [**2149-8-6**]: IMPRESSION: AP chest compared to [**2149-8-4**]:
.
Right PIC line can be traced only as far as the mid SVC. Left
lower lobe
consolidation, new since [**2149-8-3**], is unchanged since
[**2149-8-4**] could be pneumonia or atelectasis. Small right
pleural effusion and generalized vascular engorgement have
increased. Mild cardiomegaly stable. No pneumothorax.
.
CT A/P [**2149-8-13**]: IMPRESSIONS:
1. Colonic diverticulosis along the descending and sigmoid
colon, with area of pericolonic fat stranding in the left lower
quadrant, compatible with mild uncomplicated diverticulitis. No
free air, free fluid, or fluid collection except for the seroma
in ant [**Last Name (un) 103**] wall.
.
2. Small bilateral pleural effusions are slightly increased
compared to
[**2149-8-3**], with associated adjacent atelectasis in the lung bases.
The study and the report were reviewed by the staff radiologist.
.
AC Fistulogram [**2149-8-15**]: IMPRESSION: Fistulogram demonstrating
dilated, tortuous and widely patent left cephalic venous outflow
from fistula, and no central stenosis or clot. Brisk inflow
across arterial anastomosis implies no stenosis there.
.
CT C/T/L Spine [**2149-8-23**]: IMPRESSION:
Given limitations of the image acquisition and the patient's
inability to
cooperate, there is no evidence for fracture or dislocation.
.
CT Head: [**2149-8-23**]: IMPRESSIONS: Very limited study, particularly
through the skull base due to patient motion. The visualized
brain reevals no definite abnormality. If there remains concern
for acute intracranial pathological process, reimaging would be
recommended when the patient is able to be still for the exam.
.
NOTE AT ATTENDING REVIEW: The hyperdensity noted above likely is
minimal
hyperostosis frontalis interna, with a similar finding noted on
the right
side in an analogous locale.
.
CXR [**2149-8-22**]
IMPRESSION: Increased right basilar opacity which may represent
atelectasis or developing pneumonia. Improved left basilar
atelectasis.
The study and the report were reviewed by the staff radiologist.
.
[**2149-8-25**] 2:13 pm Immunology (CMV) Source: Line-picc.
CMV Viral Load (Pending):
[**2149-8-20**] 6:44 am Immunology (CMV) Source: Line-picc.
**FINAL REPORT [**2149-8-21**]**
CMV Viral Load (Final [**2149-8-21**]):
861 copies/ml.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].
Time Taken Not Noted Log-In Date/Time: [**2149-8-19**] 1:27 pm
URINE Site: NOT SPECIFIED CHEM # 66381R [**8-19**].
**FINAL REPORT [**2149-8-22**]**
URINE CULTURE (Final [**2149-8-22**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ =>32 R
[**2149-8-19**] 12:17 pm BLOOD CULTURE
**FINAL REPORT [**2149-8-25**]**
Blood Culture, Routine (Final [**2149-8-25**]): NO GROWTH.
[**2149-8-3**] 8:19 pm MRSA SCREEN
**FINAL REPORT [**2149-8-6**]**
MRSA SCREEN (Final [**2149-8-6**]): No MRSA isolated.
[**2149-8-17**] 9:47 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2149-8-19**]**
OVA + PARASITES (Final [**2149-8-18**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
FEW RBC'S.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2149-8-18**]):
REPORTED BY PHONE TO G PARSOPAROU @ 3:54A [**2149-8-18**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
VIRAL CULTURE (Final [**2149-8-19**]):
VIRAL CULTURE DISCONTINUED DUE TO PRESENCE OF CLOSTRIDIUM
DIFFICILE
TOXIN.
.
Brief Hospital Course:
A/P: 52yo W with PMH of SLE, renal failure s/p transplant
presents with acute renal failure and likely rejection.
.
# Acute Renal Failure: Mrs. [**Known lastname 6357**] presented to the ED with
hyperkalemia [**12-30**] acute renal failure in her transplant kidney.
Due to faliure of medical management of the hyperkalemia, Mrs.
[**Known lastname 6357**] underwent emergent dialysis via her previous left arm
fistula that remained patent by U/S. Renal transplant
ultrasound was normal except for large subcutaneous fluid
collection that was also noted on CT. On hospital day 1, there
was concern for rejection. She was started on solumedrol 500mg
IV qday for this concern pending biopsy results. Renal biopsy
showed no signs of rejection, but was consistent with rapidly
progressing FSGS. IV solumedrol was decreased from 500 to 100 mg
qday on day 3 then ultimately switched to Prednisone 60 mg qday
on day 5--which was continued throughout admission and continued
on discharge. Studies into the etioogy of the FSGS were
negative -- HIV negative, BK virius negative, ANCA negative,
compliment levels normal, Hepatitis serology negative, [**Doctor First Name **] 1:40,
parvo b19 and HTLV negative. Urine output was monitored as best
as possible, however patient was non-compliant with collection.
UA with no signs of urinary tract infection. On hospital day
3, plasmapheresis was empirically initiated. During her
plasmapheresis courses, calcium levels were noted to be low and
were repleted on an as needed basis. She received 4 sessions of
plasmapheresis, however due to development of fever and signs of
infection on hospital day 10 this was not continued. Urine
Protein/Creatinine ratio was monitored on a daily basis during
the initial part of admission peaking at 30.7 then trending down
to 1.7 after 2 weeks. Throughout admission, hemodialysis was
done on as needed basis with one 9-day period of no
hemodialysis. Patient will continue dialysis as outpatient, as
well as prednisone and tacrolimus. She should follow up with
Transplant nephrology as arranged. Should continue tacrolimus
with goal trough [**5-5**]. Dose was decreased to 4mg [**Hospital1 **] on day of
discharge for elevated trough 9.1. Please contact transplant
nephrology at [**Hospital1 18**] for dose adjustments. Please check tacro
levels on Thursday, [**2149-8-28**], and regularly there after.
She should continue prednisone at 60mg daily for now. She
should remain on GI prophylaxis, Ca/Vit D as ordered. Patient
should be considered for starting dapsone for PCP prophylaxis in
the future rather than atovaquone, but given h/o severe bactrim
allergy did not challenge with dapsone on this hospitalization.
G6PD testing was negative.
-Please send all lab work to Dr. [**Last Name (STitle) **] at [**Hospital1 18**]-
.
# Hemodialysis: Patient to receive T/Th/Sa dialysis as
outpatient. At dialysis, she should receive epogen. In
addition, she should have PTH, Vitamin D and Iron studies drawn
at dialysis. She should continue cinacalcet as outpatient and
vitamin D as follows (50,000 units weekly x 8 weeks, followed by
1000 units daily thereafter until replete.). Patient has a slot
at [**Hospital4 117**] [**Hospital5 **] [**Hospital6 **] after she leaves rehab.
.
# C. difficile infection - On day 10 of admission, patient was
noted to be febrile. Patient was also complaining of LLQ
abdominal pain, but no other associated symptoms. At this time
patient was started empirically on cefepime and flagyl for
suspected diverticulitis given findings of sigmoid colon wall
thickening on CT Abdomen and pelvis. Blood and urine cultures
were drawn and negative. UA negative for UTI. CXR had no
interval change of right basalar atelectasis and patient was
asymptommatic. Patient continued to have fevers and vancomycin
added on hospital day 12. Additionally valgancyclovir and
atovoqoune were added at this time for prophylaxis while on high
dose steroids. Patient continued to be febrile and complained
of diarrhea, ID consult felt symptoms were most consistent for
C. Difficile (had recieved one dose of ceftazadime on
admission). Adenovirus PCT, Toxo serology and stool O&P were
negative. Stool was positive for C. Diff and po vancomycin
started. Cefepime, flagyl and vancomycin were discontinued.
Patient had 2 more fevers over the first 48 hours of PO
vancomycin treatment then was afebrile. Of note, diarrhea
work-up was positive for CMV viral load in blood possibly
consistent with CMV colitis (see below). Patient should complete
a 14 day course of PO vancomycin to end on [**2149-9-2**].
.
# CMV viremia - patient had detectable CMV viral load during
diarrheal work-up. At the time of detection, patient had been
on valgancyclovir prophylaxis for 4 days. Initially, it was
felt to be viremia w/o end organ involvement, however due to
continued diarrhea on PO vancomycin for C. difficile infection,
treatment was changed from valgancyclovir to gancyclovir for
treatment of possible CMV disease. She should be continued on
IV ganciclovir for treatment of CMV viremia until she has 2
negative CMV viral loads separated by one week. (viral load
[**8-20**] 861, repeat viral load [**8-25**] pending).
.
# Hyperkalemia: Mrs. [**Known lastname 6357**] was diagnosed with elevated
potassium on admission to the ED. She had mild peaked T waves
in V2. In the ED, she received 2 rounds of calcium, insulin and
was transferred to the ICU where medical management for
hyperkalemia was more effective, but she still required emergent
dialysis. After a short course of emergent dialysis there was
improvement in her electrolytes. Potassium was monitored closely
throughout her admission while she underwent intermittant
hemodialysis.
.
# Atrial fibrillation: Mrs. [**Known lastname 6357**] went into atrial
fibrillation with RVR on the evening of [**8-4**] after dialysis.
She had no prior history. Had some chest pain during episode and
was ruled out. The atrial fibrillation was converted with
metoprolol then Diltiazem IV and she had no further episodes on
telemetry. She was continued on metoprolol for rate control and
hypertension. Hydralazine was discontinued. Echo showed a
mildly dilated left atrium and LVEH > 55%. TSH was WNL. After
one week, telemetry was discontinued.
.
# Hypertension: Mrs. [**Known lastname 6357**] was not previously on
anti-hypertensives prior to admission. On admission, she was
noted to be hypertensive and started on hydralazine and
amlodipine. After her episode of atrial fibrillation, she was
also on hydralazine. Hydralazine ws discontinued after 2 days
with good blood pressure control on metoprolol and amlodipine.
Blood pressure was monitored and stable throughout her hospital
course with some episodes of hypotension during dialysis.
Amlodipine was changed to be dosed after dialysis and metoprolol
reduced to 12.5mg [**Hospital1 **]. At discharge, amlodipine was
discontinued due to its tendency to cause lower extremity edema,
and b/c hypotension had limited her HD sessions. Metoprolol
should be continued and titrated up as needed for hypertension.
.
# SLE: stable; on prednisone for FSGS.
.
# Anemia - continued iron supplement, epogen with HD as above,
transfusions as needed.
.
# Access: PICC line in place. AV fistula functional for now,
but had difficulty during hospital stay.
.
# Diabetes: presented during hospital stay while on treatment
with high dose steroids. Was covered with glargine qhs, and
humalog sliding scale with meals.
Medications on Admission:
Tacro 12mg [**Hospital1 **]
epo
iron
Vitamin D
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: not to exceed 4g tylenol per
day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for for dry skin.
6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
9. Insulin Glargine 100 unit/mL Cartridge Sig: Two (2) units
Subcutaneous at bedtime.
10. Insulin Lispro 100 unit/mL Cartridge Sig: as per sliding
scale as per sliding scale Subcutaneous qACHS.
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
12. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week for 8 weeks.
13. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
15. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: to end on [**2149-9-2**].
16. Ganciclovir 120 mg IV Q24H Start: In am
Give after HD on dialysis days
17. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
18. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO every
twelve (12) hours. Capsule(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) **]
Discharge Diagnosis:
Focal Segmental Glomerulosclerosis
Acute Renal Failure
End Stage Renal Disease
C. Diff Colitis
CMV Viremia
Discharge Condition:
Stable, AOx3, appropriate.
Discharge Instructions:
You were admitted to the hospital for evaluation of kidney
failure. You had a biopsy of your kidney that showed a reaction
known as FSGS or focal segmental glomerulosclerosis. This was
treated with high doses of steroids, and plasmapheresis. You
had some mild improvement in your kidney function but required
dialysis to replace your kidneys. You will need to continue on
dialysis until your kidney function improves. During your
hospital stay you also developed an infectious diarrhea known as
C. Diff. This diarrhea is treated with oral antibiotics such as
vancomycin. You were also treated for CMV infection which
occurs in patients on high doses of immunosuppression such as
yourself. Please continue to take all medications on discharge.
.
Please return to the hospital should you experience any fevers,
chills, night sweats, worsening diarrhea, or other symptoms
concerning to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-9-1**] 1:30
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-9-22**] 1:20
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
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Discharge summary
|
Report
|
Admission Date: [**2118-7-28**] Discharge Date: [**2118-8-11**]
Date of Birth: [**2040-2-5**] Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. [**Known lastname 78131**] is a 78M with stageIV NSCLC on palliative Tarceva
who presents from his nursing facility with fevers x2d as high
as 103.6F. Per paperwork from rehab, he was given levofloxacin
500mg.
.
Of note, he was recently admitted to the OMED service, having
presented with fevers and discharged on [**7-14**] on cefpodoxime and
azithromycin for suspected pneumonia.
.
In the ED, initial vs were T98 P 73 BP 86/51 RR 22 98% on . He
was given vancomycin, cefepime, flagyl, acetaminophen, zofran,
and started on peripheral dopamine. Awake and mentating, making
small amounts of dark urine. CT abdomen done for h/o 1day of
diarrhea, noncontrast showed ?of colitis. Got 5L of saline. BP
remains 70's systolic on 15mcg dopamine and levophed.
.
On the floor, he denies any complaints - though initially
reported some abdominal pain to the RN. Review of systems
otherwise negative, though unclear if patient's history is
reliable.
Past Medical History:
Past Medical History:
1. Hypertension
2. Atrial Fibrillation
3. COPD
4. h/o bilateral hernia repair
5. aspiration
.
Oncologic History: (Per OMR note [**2118-6-15**] by Dr. [**Last Name (STitle) **]
1. Stage IIB nonsmall cell lung cancer (adenocarcinoma) s/p
surgical resection and adjuvant chemotherapy.
2. FDG avid left lower [**Last Name (STitle) 3630**] lung nodule with non-malignant
biopsy in [**2117-2-13**].
3. Stage IV nonsmall cell lung cancer (bone and lung
recurrence)diagnosed in [**2118-4-15**].
TREATMENT:
1. Status post right thoracotomy with right lower lobectomy,
mediastinal lymph node sampling in [**2117-4-13**].
2. Status post 4 cycles of carboplatin 5AUC and pemetrexed
500mg/m2 every 21 days of a 3 week cycle today. Started in
[**2117-6-29**] and last dose was given [**2117-8-31**].
3. Status post 3000 cGy of radiotherapy to left hip lesion
completed in [**2118-5-10**].
4. Started erlotinib 150 mg/day in [**2118-5-24**].
5. h/o mets to sacral spine s/p radiation, on narcotics for pain
control
Social History:
70+ year h/o smoking. Currently at rehab facility.
Family History:
Unknown cause of death of mother or father. The patient does
have siblings that are alive. No recurrent cancers in the
family.
Physical Exam:
On [**Hospital Unit Name 153**] admission:
Vitals 96.3 102 101/58 21 100% on 4L
General Chronically ill appearing man, appears anxious
HEENT Sclera anicteric, dry MMM
Neck supple
Pulm Lungs with few bibasilar rales L>R
CV Tachycardiac regular S1 S1 no m/r/g
Abd Soft +bowel sounds tender to palpation throughout without
rigidity or guarding
Extrem Warm tr bilateral edema palpable distal pulses
Neuro Awake and interactive, oriented to hospital in [**Location (un) 86**],
does not know date
Derm No rash or jaundice
Lines/tubes/drains Foley with yellow urine, RIJ
Pertinent Results:
On admission [**2118-7-28**]:
WBC-10.9 RBC-3.71* Hgb-10.3* Hct-32.1* MCV-87 MCH-27.8 MCHC-32.2
RDW-17.1* Plt Ct-410
Neuts-55 Bands-27* Lymphs-6* Monos-10 Eos-0 Baso-0 Atyps-0
Metas-2* Myelos-0
PT-17.9* PTT-33.4 INR(PT)-1.6*
Glucose-143* UreaN-35* Creat-1.6* Na-130* K-4.1 Cl-94* HCO3-26
AnGap-14
ALT-17 AST-34 AlkPhos-60 TotBili-0.7
Albumin-2.6* Calcium-7.6* Phos-3.7 Mg-2.0
[**7-29**] FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA
[**7-28**] EKG: Probable sinus rhythm with low amplitude P waves
(visible in lead V1) versus ectopic atrial rhythm. Right
bundle-branch block. Left anterior fascicular block. Q-T
interval prolongation. Compared to the previous tracing of
[**2118-7-7**] P waves are less apparent. Q-T interval is more
prolonged.
[**7-28**] CXR: 1. Stable post-surgical changes in the right lung from
prior right lower lobectomy and upper [**Month/Year (2) 3630**] wedge resection due
to known non-small cell lung cancer.
2. Hazy opacity in the left lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] reflect atelectasis.
[**7-28**] CT Abd/pelvis:
1. Bibasilar lung consolidations, worse when compared to prior
exam.
Differential diagnosis includes infectious etiologies as well as
a slow
growing lesion such as bronchoalveolar carcinoma. Clinical
correlation is
recommended.
2. No evidence of small bowel obstruction. Colon appears
relatively
featureless with air-fluid levels and possibly pericolonic fat
stranding
versus third spacing. These findings may suggest a colitis.
3. Extensive vascular calcifications.
4. Large prostate.
5. S1 vertebral body fracture with buckling of the superior
cortex, worse
when compared to prior exam.
[**7-30**] Left LENI:
IMPRESSION: No left lower extremity DVT.
[**7-31**] KUB:
FINDINGS:
Small bowel loops containing air are seen without distension.
There is a
paucity of air in the left lower quadrant which might be due to
liquid stool within the descending colon. No free air is seen on
the right lateral decubitus film. The visualized osseous
structures are unremarkable. The right lung base is not well
seen with the dome of the diaghragm being pushed superiorly.
This correlates with the right lower [**Month/Year (2) 3630**] atelactasis on the
corresponding CT.
IMPRESSION: No distended loops of bowel seen.
Brief Hospital Course:
Mr. [**Known lastname 78131**] is a 78M with stage IV NSLC who presents with
fevers from his rehab facility.
.
* Hypotension: Patient presented with hypotension concerning for
sepsis. He was briefly on levophed and was taken off of
pressors when SBP 100s-110s. His hypotension was probably due
to hypovolemia from diuresis but severe hypotension in setting
of developing sepsis was also considered. Lactate down to 1.0
from 1.3 on admission with SVO2 73.
On the floors, his SBP's ranged in the 130's to 140's and he was
restarted on his home doses of LASIX WAS HELD FOR THE SEVERAL
DAYS PRIOR TO DISCHARGE BECAUSE HE WAS AUTODIURESING. HE NEEDS
TO BE RE-EVALUATED REGULARLY FOR WHETHER LASIX NEEDS TO BE
RESTARTED. HE WILL LIKELY NEED HIS LASIX RESTARTED AT SOME POINT
AT REHAB. His pressures remained stable throughout
hospitalization.
.
* Fever: Patient's fever likely caused by C diff as patient is
toxin positive, although aspiration pneumonia was also
considered a possibility given evidence of dysphagia on prior
video swallow. His underlying pulmonary malignancy predisposes
him to a post-obstructive pneumonia. However the absence of
cough or hypoxia made a pulmonary etiology less compelling.
Blood and urine cultures are negative. His C difficile colitis
was originally treated with PO vancomycin and IV flagyl. Prior
to discharge, as diarrhea began to resolve, he was switched to
PO flagyl alone, to be continued for a two week course (until
[**2118-8-12**]).
.
* L leg swelling and pain: Patient had lower extremity pain
edema greater on left than right after receiving fluid
resuscitation in the ICU. LENI showed no evidence of DVT. He
was diuresed with lasix until his fluid output was negative. He
was autodiuresing on discharge so his lasix was held. His fluid
status should be reassessed daily to determine if he needs to be
restarted on lasix.
* Hyponatremia: Patient's hyponatremia resolved after
intravenous fluids, which supports hypovolemia as cause on
admission. Review of OMR shows Na's running ~130. At last
discharge, thought to have a component of SIADH.
* Acute renal failure: Patient had creatinine elevated to 1.4
and FeNa was 0.1 on admission. Creatinine has improved to
0.7-0.8 (his baseline). His acute renal failure has resolved and
was likely pre-renal as it improved with IVF.
* Anemia: His hematocrit is down from admission but suspect
this was secondary to hemoconcentration. His anemia is
consistent with baseline.
* NSCLC: Advanced disease, on palliative chemotherapy. Social
work and palliative care were consulted throughout this
hospitalization and discussed goals of care with the family.
Erlotinib will be restarted on [**2118-8-19**] and should be taked every
other day. He will follow up with Dr. [**Last Name (STitle) **].
* Atrial fibrillation: His sotalol was restarted now that his
hypotension resolved.
# Nutrition ?????? Patient has aspiration risks and is unable to
swallow pills easily. He was evaluated by nutrition and kept on
a pureed diet with TID ensure. He also had an elevated INR
despite not being on anticoagulation which possibly could be due
to malnutrition. INR improved after administration of one dose
of vitamin K.
# Oral thrush: Patient failed nystatin swish and swallow. He was
loaded with 400mg fluconazole and should continue 200mg daily
until [**2118-8-25**].
#Pain control: Patient was maintained on methadone and diluadid
PRN during hospitalization. His methadone should be tapered and
pain reassessed daily while in rehab.
Medications on Admission:
At rehab:
Erlotinib 100mg daily
Simvastatin 10mg daily
Lasix 20mg daily
Sotalol 80mg [**Hospital1 **]
Nifedipine 30mg daily
Methadone 15mg tid
Folate
Lidoderm patch
[**Name (NI) **], [**Name (NI) 78132**], MOM, dulcolax, lactulose, senna, guiafenesin,
colace, tylenol all prn
Zofran prn
Neurontin 300mg q12h
Heparin 5000 units SQ TID
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: One (1)
injection Injection TID (3 times a day).
2. Metronidazole 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every
8 hours): continue util [**2118-8-12**].
3. Neurontin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO every twelve
(12) hours.
4. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day) as needed for constipation: once diarrhea subsides,
please start taking as standing dose [**Hospital1 **].
5. Methadone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
6. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: no more than 4g in 24 hours.
8. Sotalol 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
10. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
11. Nifedipine 30 mg Tablet Sustained Release [**Hospital1 **]: One (1)
Tablet Sustained Release PO DAILY (Daily).
12. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
13. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO
DAILY (Daily).
14. Oral Wound Care Products Gel in Packet [**Hospital1 **]: One (1) ML
Mucous membrane TID (3 times a day) as needed.
15. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for fungal rash-groin.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
18. Dilaudid 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every four (4)
hours as needed for pain.
19. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a day as
needed for constipation: Please start taking after diarrhea has
resolved.
20. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
[**Last Name (STitle) **]: One (1) dose PO once a day as needed for constipation:
Please use as needed after diarrhea has resolved.
21. Dulcolax 10 mg Suppository [**Last Name (STitle) **]: One (1) Rectal once a day
as needed for constipation: Please start using as needed after
diarrhea has resolved.
22. Zofran 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8)
hours as needed for nausea.
23. Ambien 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
24. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours): continue until [**2118-8-25**].
25. Erlotinib 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QOD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 4444**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Clostridium difficil colitis
2. Dehydration
3. Hyponatremia
4. Hypotension
SECONDARY DIAGNOSIS:
1. Non Small Cell Lung Cancer
Discharge Condition:
Stable, afebrile [**2-16**] BM's per day.
Discharge Instructions:
You were admitted to the hospital on [**2118-7-28**] with fevers
secondary to clostridium dificile colitis (an infection in your
colon). You are being treated with an antibiotic called flagyl.
You need to continue this antibiotics until [**2118-8-12**].
You should STOP taking lasix (water pill). Your body has been
eliminating excess fluid well without the lasix. Your doctors
[**Name5 (PTitle) **] [**Name5 (PTitle) 4656**] your fluid status at rehab and decide whether or
not you need lasix in future.
You can continue to take methadone with dilaudid as needed for
breakthrough pain. Your doctors at rehab [**Name5 (PTitle) **] taper your
methadone as needed. Never drive while taking these medications
or perform any activities requiring a fast reaction time. Never
drink alcohol with these medications. Once your diarrhea stops,
you should start taking colace and senna daily to prevent
constipation, which is a common side effect of narcotics.
You also had thrush in your mouth. Continue to take fluconazole
200mg daily until [**2118-8-25**].
You should restart your erlotinib on [**2118-8-19**] and take it every
other day.
Use miconazole for the fungal rash in your groin. Apply it four
times a day.
Please return to the emergency room if you have worsening
diarrhea >10 BM per day, bloody/black stools, fever>100.4, chest
pain, shortness of breath, or any other symptoms concerning to
you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-17**] weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
Completed by:[**2118-8-11**]
|
[
"401.9",
"427.31",
"496",
"305.1",
"276.52",
"995.29",
"782.3",
"584.9",
"285.9",
"162.8",
"263.9",
"112.0",
"008.45",
"276.51",
"276.1",
"458.9"
] |
icd9cm
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1330
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[
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[
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[
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[
[
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[
[
12510,
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[
12805,
12832
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[
[
12542,
12552
]
],
[
[
12557,
12568
]
],
[
[
12573,
12583
]
]
] |
[
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[
275,
296
]
],
[
[
5621,
5646
]
]
] | 75
| 3,526
| 0
| 25
| 45
| 0
| 0
| 0
| 0
| 2,283
| 0
| 0
| 217
| 130
| 0
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| 3,025
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| 1
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| 0
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| 33
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|
92,473
| 143,547
|
545680
|
Nutrition
|
Clinical Nutrition Note
|
Potential for nutrition risk. Patient being monitored. Current
intervention if any, listed below:
Comments:
42M w/remote h/o lap chole c/b common hepatic biliary stricture c/b PTC
external biliary drain into R anterior biliary duct [**11-19**] and R
lobectomy [**12-22**].
Pt on regular diet, tol well.
If po
s decline, pls c/s for recs on nutrition support.
Pge w/ questions/concerns #[**Numeric Identifier 526**]
15:24
|
[
"V45.72"
] |
icd9cm
|
[
[
[
130,
142
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] | 0
| 0
| 0
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| 0
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|
89,758
| 110,353
|
41982
|
Discharge summary
|
Report
|
Admission Date: [**2122-10-31**] Discharge Date: [**2122-11-2**]
Date of Birth: [**2061-9-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
-Central Venous Line Placement
-Dialysis Line Placement
History of Present Illness:
61M transferred from [**Hospital3 26615**] hospital with CAD s/p 3V CABG
and AVR @ [**Hospital3 2358**] [**4-/2121**] (90% distal left main extending to
LAD and ostium of LCX with 80% mid-RCA) for NSTEMI, s/p DDD
pacer implant for intermittent complete heart block @ [**Hospital1 3343**] [**9-/2122**] transferred from OSH for evaluation and
management of VT with HD instability requiring shocks x 1. He
was admitted to OSH after being started back on metoprolol which
caused him symptoms of light-headedness, lethargy, and mental
slowing (which he had previously experienced leading him to stop
taking metoprolol and lisinopril). He stopped the medication
himself and began to feel better but became extremely SOB when
walking up stairs and ended up lying on the floor due to his
inability to catch his breath which prompted him to call 911 and
present to OSH. He was assessed has possibly having ACS and
underwent ROMI with trops <0.03 -> 0.16 -> 0.12, negative MB's
throughout and EKG with pacer rhythm and 100% capture. He was
started on ASA 325, given lovenox 1mg/kg SQ.
.
Then rapid response was called at 3am today at OSH for VT with
HR to 280 with pt found to be diaphoretic and dyspneic but then
uresponsive for 5 seconds. VT self-teriminated after 2 minutes
and pt started on amiodarone drip @ 3:30AM, crit found to be 26
(stable from admission)and rec'd 1u pRBCs and trop drawn and
found to be 0.14. Later went into monomorphic VT with rate in
the 250's @ 11:45AM, shocked x 1 with return to paced rate of 88
and was apparently neurologically intact and AOx3 following. He
was transferred to the ICU and transferred to [**Hospital1 18**] for further
evaluation and treatment.
.
On the floor he describes shaking chills occasionally over the
past 3 weeks after having his pacemaker placed although he
denies frank fevers. He also denies pain, redness, or drainage
from the site of his pacemaker. He also describes having a cough
over the past week but states it is non-productive.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools.
.
Cardiac review of systems is notable for dyspnea on exertion,
negative for paroxysmal nocturnal dyspnea, negative for
orthopnea, ankle edema, palpitations.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes type 2 +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY:
- CABG: Per report, CABG with AVR in [**4-/2121**] (90% distal left
main extending to LAD and ostium of LCX with 80% mid-RCA)
- PERCUTANEOUS CORONARY INTERVENTIONS: C. Cath [**9-/2122**] with
clean grafts per report at [**Hospital1 1774**]
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
HTN
HLD
DM2
R total hip replacement
Social History:
Married, works as carpenter. Denies drugs, alcohol, smoking.
Family History:
father with CAD, brother with carotid vascular disease, paternal
grandfather with CAD
Physical Exam:
ADMISSION EXAM:
VS: 100.9 98 127/62 14 98% on 2L
GENERAL: NAD, sleeping comfortably in bed
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP not appreciated
CHEST: pacemaker pocket-no erythema, no discharge, no tenderness
to palpation
CARDIAC: RRR, normal S1, S2, + mechanical click, no
murmurs/rubs/gallops appreciated
LUNGS: anterior lung fields clear to auscultation, patient
refused to sit up for posterior lung exam
ABDOMEN: soft, nontender, nondistended, +BS
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+
PT 2+
Neuro: CN 2-12 grossly intact, normal strength and sensation
throughout
Pertinent Results:
ADMISSION LABS:
[**2122-10-31**] 05:56PM GLUCOSE-142* UREA N-11 CREAT-0.8 SODIUM-133
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-25 ANION GAP-13
[**2122-10-31**] 05:56PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2122-10-31**] 05:56PM WBC-15.0* RBC-3.35* HGB-9.8* HCT-28.1* MCV-84
MCH-29.3 MCHC-35.0 RDW-14.1
[**2122-10-31**] 05:56PM NEUTS-90.7* LYMPHS-5.0* MONOS-3.9 EOS-0.2
BASOS-0.1
[**2122-10-31**] 05:56PM PLT COUNT-429
[**2122-10-31**] 05:56PM PT-29.0* PTT-45.8* INR(PT)-2.8*
[**2122-10-31**] 05:56PM CRP-143.7*
[**2122-10-31**] 05:56PM SED RATE-62*
.
MICRO:
4/4 bottles positive for coagulase negative staph
.
ECHO [**2122-11-2**]
No atrial septal defect is seen by 2D or color Doppler. Two
pacemaker leads are seen entering the right atrium from the SVC,
without definite associated vegetations. Overall left
ventricular systolic function is normal (LVEF>55%). There are
simple atheroma in the descending thoracic aorta. A mechanical
aortic valve prosthesis is present. The anterior attachment of
the prosthesis is normal. The posterior half of the prosthesis
appears hypermobile/partial dehiscence extending nearly [**12-14**] way
around the prosthesis (clip [**Clip Number (Radiology) **]). An echolucent space is seen
posteriorly with systolic flow into this space which is then
contiguous with the right atrium with continus flow (aorta to
right atrial fistula). There are mobile echodensities (clip [**Clip Number (Radiology) **],
84) seen at the posterior attachment site of the prosthesis c/w
tissue, sutures and/or vegetations. No aortic regurgitation is
seen through this area. There is trivial valvular aortic
regurgitation (normal for this prosthesis). The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen.
IMPRESSION: Partially posterior aortic valve prosthesis
dehiscence with flow from the aorta into the right atrium.
Vegetations vs. suture vs. tissue in the area.Moderate to severe
tricuspid regurgitation.
.
RUQ US [**2122-11-2**]
IMPRESSION:
1. Mildly coarsened hepatic echotexture. No frank biliary
dilatation.
2. A few peripheral echogenic foci in the liver likely represent
small portal branches; however, portal venous gas cannot be
entirely excluded. If there is clinical concern for ischemic
bowel, further assessment should be performed with CT.
3. Diffuse gallbladder wall thickening.
4. Splenomegaly to 15 cm.
.
KUB [**2122-11-1**]
FINDINGS: Two supine and one left lateral decubitus image show
no evidence of free air. There are air-filled loops of
nondilated small bowel. There is air and stool seen within the
colon extending into the sigmoid and rectum. There is no
evidence of obstruction or ileus. Patient is status post a total
left hip arthroplasty with no evidence of loosening. There are
degenerative changes of L4 and L5 in the right hip. The bases of
the lungs are clear. Sternotomy wires and pacemaker wires are
seen within the chest.
IMPRESSION: No evidence of obstruction or ileus.
.
KUB [**2122-11-2**]
FINDINGS: Three supine frontal images of the abdomen show newly
dilated loops of small bowel measuring up to 3.4 cm in the left
upper quadrant. Given history of recent arrest, the dilation may
be secondary to ischemia. Could also consider the possibility of
an early or partial small-bowel obstruction. There is no obvious
free air, although exam is somewhat limited due to supine
positioning. There has been interval placement of a femoral line
on the right groin. A catheter overlies the left upper quadrant,
and is likely external to the patient. Again noted is dense
calcification of the aorta and iliac vessels. A left total hip
arthroplasty is unchanged.
IMPRESSION:
Interval increasing dilation of air-filled loops of small bowel
loops raises concern for ischemia.
Brief Hospital Course:
Mr. [**Known lastname 91160**] is a 61M transferred from [**Hospital3 26615**] hospital with
CAD s/p 3V CABG and AVR in [**2120**], NSTEMI, s/p DDD pacer implant
for intermittent complete heart block in [**9-/2122**] transferred
from OSH for evaluation and management of VT with HD instability
requiring defibrillation.
.
# Septic shock/endocarditis with aortic valve dehiscence: The
patient underwent pacemaker placement [**2122-10-2**]. He was febrile
on admission with elevated wbc count and described weeks of
shaking chills. Blood cultures grew coag negative staph and he
was started on Vancomycin. His blood pressure decreased to the
SBPs in the 80-90s. He was started on cefepime in addition to
vancomycin. A TEE showed aortic valve dehiscence with flow from
the aorta to the right atrium and possible vegetations. He later
went into PEA briefly then his pulse returned but because of
hypotension and poor O2 saturation he was intubated and put on
pressors. His blood pressure continued to fall and he was
requiring 4 pressors and large volumes of IVF. A dialysis
catheter was placed to try to remove some volume and manage his
potassium. However, after this was placed his BP would not
tolerate dialysis. Shortly after he went into asystole and
passed away.
.
# VT/rhythm: In [**Month (only) 359**] he had a syncopal event thought to be
related to heart block so a pacemaker was placed. He was
transferred to [**Hospital1 18**] from an OSH after he had pulseless VT
requiring defibrillation. He was not in VT when he arrived at
[**Hospital1 18**]. He was planned to have an EP procedure and prior to the
procedure he was started on atenolol to prevent VT. However,
before he could undergo any procedure he developed septic shock
and aortic valve dehiscence and then expired as above.
.
Medications on Admission:
HOME MEDICATIONS:
ASA 81 mg daily
metformin 1000 mg qam
Vitamin D 1000 u daily
Coumadin
simvastatin 80 mg
lisinopril 10 mg daily (stopped taking)
metoprolol 50 mg daily (stopped taking)
.
Medications on transfer:
atenolol 25 mg daily
ASA 325 daily
atorvastatin 40 mg daily
NG
heparin drip
ISS
bisacodyl
docusate
milk of magnesia
Simethacone
guafenesin
acetaminophen
metformin 1000 mg
amiodarone infusion
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic Shock
Presumed Endocarditis
Mechanical Disruption of aortic valve
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"250.00",
"272.4",
"401.9",
"V43.64",
"414.00",
"V45.81",
"412",
"V45.01",
"038.9",
"E878.1",
"427.1",
"V58.66",
"V58.61",
"785.52",
"424.90",
"996.02"
] |
icd9cm
|
[
[
[
2853,
2867
]
],
[
[
2872,
2883
]
],
[
[
2888,
2899
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[
[
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3242
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[
[
8253,
8255
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[
[
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8267
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[
[
8292,
8297
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[
[
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8320
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[
[
8484,
8495
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[
[
8515,
8537
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],
[
[
9431,
9432
]
],
[
[
10002,
10016
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[
[
10063,
10070
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[
[
10475,
10486
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],
[
[
10497,
10508
]
],
[
[
10510,
10546
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] | 10
| 1,799
| 0
| 59
| 7
| 0
| 0
| 0
| 0
| 1
| 0
| 0
| 8
| 88
| 0
| 0
| 0
| 11
| 0
| 76
| 0
| 1
| 0
| 0
| 0
| 0
| 6
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 792
| 0
| 0
| 0
| 0
| 255
| 171
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 10
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 2,370
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 3,869
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 38
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 193
| 76
| 64
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
94,872
| 123,622
|
49198
|
Discharge summary
|
Report
|
Admission Date: [**2110-8-11**] Discharge Date: [**2110-8-22**]
Date of Birth: [**2029-1-28**] Sex: M
Service: MEDICINE
Allergies:
Heparin,Porcine
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
leg swelling
Major Surgical or Invasive Procedure:
Persantine MIBI exam
History of Present Illness:
81 y/o M with hx of COPD, CAD, AAA, and BPH presents today after
a recent admission for PNA with new swelling and discoloration
of his bilateral feet. He was found to be newly hyponatremic to
a Na of 117 in the ED and therefore admitted to the MICU.
.
He was discharged last Wednesday (5 days prior to admission), he
was discharged to home after being diagnosed with a pneumonia.
During his admission, he had worsening renal failure and
evaluated with a renal ultrasound that did not show hydro. His
respiratory status returned to baseline. He was discharged home
on augmentin. His Na had already started to drift downward
during the admission and was 129 on discharge. He also had mild
diarrhea during his admission.
.
After going home, he was mostly in bed due to profound weakness.
His family was watching his legs and noted the little bit of
swelling and new blue color. They called his PCP today who
suggested ED evaluation. He otherwise has no complaints. He
has generalized weakness and intermittent periods of shortness
of breath. Per the daughter, he has been not eating, but trying
to drink a lot. He is afraid to sleep because he is scared of
death.
.
In the ED, initial vitals were T 97.8, P 80, BP 147/74, R 24 and
99% on 3L (his home O2 level). He remained stable with some
hypertension to SBPs in the 170s. He had a CXR that showed mild
fluid overlad. He had a CT abd that showed no aortic aneurysm
leak. Vascular was consulted and worried that his foot
discoloration was related to embolic events and heparin was
started with a bolus. The patient was guiac negative in the ED.
Past Medical History:
- COPD
- CAD
- HTN
- AAA s/p repair
- CRF (recent baseline ~2.7, ?atheroembolic)
- BPH
Social History:
- Quit smoking 30y ago (~50 pack years)
- Lives with his wife who has [**Name (NI) 2481**] dementia; caregiving
has become increasingly stressful.
Family History:
non-contributory
Physical Exam:
General Appearance: Thin, Anxious
.
Eyes / Conjunctiva: PERRL, Pupils dilated
.
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
soft systolic murmur
.
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
.
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bases, Diminished: at bilateral bases)
.
Abdominal: Soft, Non-tender, Bowel sounds present
.
Extremities: pads of toes and plantar surface of foot is
purplish, but warm, with petechiaie on the dorsum of the feet
.
Musculoskeletal: Muscle wasting
.
Skin: Cool
.
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
On admission:
[**2110-8-11**] 04:09PM PLT COUNT-173
[**2110-8-11**] 04:09PM NEUTS-67.0 LYMPHS-23.1 MONOS-8.1 EOS-1.3
BASOS-0.6
[**2110-8-11**] 04:09PM WBC-5.2 RBC-4.20* HGB-12.0* HCT-37.5* MCV-89
MCH-28.6 MCHC-32.0 RDW-15.6*
[**2110-8-11**] 04:09PM OSMOLAL-260*
[**2110-8-11**] 04:09PM CALCIUM-10.3 PHOSPHATE-3.9 MAGNESIUM-1.9
[**2110-8-11**] 04:09PM proBNP-GREATER TH
[**2110-8-11**] 04:09PM cTropnT-0.09*
[**2110-8-11**] 04:09PM estGFR-Using this
[**2110-8-11**] 04:09PM GLUCOSE-110* UREA N-36* CREAT-2.5*
SODIUM-117* POTASSIUM-5.4* CHLORIDE-84* TOTAL CO2-22 ANION
GAP-16
[**2110-8-11**] 04:32PM HGB-12.9* calcHCT-39
[**2110-8-11**] 04:32PM LACTATE-1.9 NA+-119* K+-5.2
[**2110-8-11**] 04:32PM COMMENTS-GREEN TOP
During hospitalization/On discharge:
[**2110-8-18**] 07:05AM BLOOD WBC-5.3 RBC-3.79* Hgb-11.5* Hct-34.2*
MCV-90 MCH-30.4 MCHC-33.7 RDW-15.9* Plt Ct-54*
[**2110-8-20**] 06:50AM BLOOD WBC-6.4 RBC-4.05* Hgb-12.3* Hct-36.0*
MCV-89 MCH-30.4 MCHC-34.2 RDW-15.4 Plt Ct-80*
[**2110-8-20**] 06:50AM BLOOD Glucose-102* UreaN-46* Creat-2.6* Na-134
K-4.1 Cl-92* HCO3-27 AnGap-19
[**2110-8-14**] 05:30AM BLOOD ALT-768* AST-348* AlkPhos-91 TotBili-0.7
[**2110-8-20**] 06:50AM BLOOD ALT-132* AST-45* CK(CPK)-PND AlkPhos-61
TotBili-0.7
[**2110-8-20**] 06:50AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.4 Mg-2.1
[**2110-8-21**] 07:05AM BLOOD ALT-19 AST-33
[**2110-8-16**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES- Optical
density 0.692
.
[**2110-8-22**] 07:35AM BLOOD PT-55.2* PTT-85.7* INR(PT)-6.2*
[**2110-8-22**] 07:35AM BLOOD WBC-5.3 RBC-3.76* Hgb-11.4* Hct-33.7*
MCV-90 MCH-30.2 MCHC-33.7 RDW-15.0 Plt Ct-118*
[**2110-8-22**] 07:35AM BLOOD Glucose-104* UreaN-40* Creat-2.3* Na-135
K-4.0 Cl-96 HCO3-28 AnGap-15
[**2110-8-22**] 07:35AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.1
.
Studies:
[**2110-8-12**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed with inferior/inferolateral akinesis with hypokinesis
elsewhere (LVEF= 35%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**2-8**]+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2104-10-2**], left ventricular function is now
depressed.
.
[**2110-8-17**] CXR read:
Portable chest radiograph is compared to multiple prior
examinations. Since the prior study, there is mild improvement
in the right lower lobe with decreased right pleural effusion
and atelectasis. Left lung is relatively clear.
Cardiomediastinal silhouette is unremarkable. There is no
congestive failure.
.
[**2110-8-12**] echo:
INTERPRETATION: This 81 y/o man with a h/o CAD, CHF, COPD and
renal
failure s/p AAA repair was referred for evaluation of chest
pain. The
patient was infused with 0.142mg/kg/min of Persantine over 4
minutes. No
chest, neck, back or arm discomfort was reported by the patient
throughout the procedure. The EKG is uninterpretable for
ischemia in the
presence of a LBBB. The rhythm was sinus with rare isolated APDs
and
VPDs. Hemodynamic response to infusion was appropriate.
Post-infusion
during the IV injection of 125mg of Aminophylline, the patient
reported
dizziness with a palp blood pressure of 88/-mmHg. Patient was
immediately placed in the Trendelenburg position with a BP of
106/palp
and relief of dizziness.
IMPRESSION: No anginal type symptoms with uninterpretable EKG
changes.
Nuclear report sent separately.
.
CARDIAC PERFUSION PERSANTINE [**2110-8-19**]:
INTERPRETATION:
The image quality is adequate but limited due to activity
adjacent to the
heart.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a fixed, moderate
reduction in photon counts involving the mid and basal inferior
and inferolateral walls.
Gated images reveal hypokinesis of the mid and basal inferior
and inferolateral walls. There is septal akinesis with normal
thickening, consistent with LBBB.
The remaining segments are mildly hypokinetic.
The calculated left ventricular ejection fraction is 30% with an
EDV of 78 ml.
IMPRESSION:
1. Fixed, medium-sized, moderate severity perfusion defect
involving the PDA territory.
2. Normal left ventricular cavity size. Severe systolic
dysfunction with
hypokinesis of the mid and basal inferior and inferolateral
walls. The
remaining segments are mildly hypokinetic.
Compared with the study of [**2104-10-6**], myocardial perfusion
appears similar.
Left ventricular systolic dysfunction has deteriorated.
.
STRESS TEST:
INTERPRETATION: This 81 y/o man with a h/o CAD, CHF, COPD and
renal
failure s/p AAA repair was referred for evaluation of chest
pain. The
patient was infused with 0.142mg/kg/min of Persantine over 4
minutes. No
chest, neck, back or arm discomfort was reported by the patient
throughout the procedure. The EKG is uninterpretable for
ischemia in the
presence of a LBBB. The rhythm was sinus with rare isolated APDs
and
VPDs. Hemodynamic response to infusion was appropriate.
Post-infusion
during the IV injection of 125mg of Aminophylline, the patient
reported
dizziness with a palp blood pressure of 88/-mmHg. Patient was
immediately placed in the Trendelenburg position with a BP of
106/palp
and relief of dizziness.
IMPRESSION: No anginal type symptoms with uninterpretable EKG
changes.
Nuclear report sent separately.
Brief Hospital Course:
81 y/o M with hx of COPD, CAD, AAA, and BPH presents today after
a recent admission for pneumonia with new swelling and
discoloration of his bilateral feet. The patient was also found
to be severely hyponatremic.
.
# HIT: Pt's platelets dropped from admission levels of 173,000
([**2110-8-11**]) to 54,000 ([**2110-8-18**]). Suspicion for HIT was high and
Heparin PF4 antibody was sent and was positive with an optical
density of 0.692. Anything greater than 0.4 is considered a
positive result, however, strong positivity occurs when the
optical density is larger than 1. In consideration with the
patient's clinical history a high clinical suspicion for HIT and
the positive test results, Heme felt comfortable with this
diagnosis. Pt stopped all heparin products, was started on
argatroban 0.5 mcg/kg/min IV DRIP on [**2110-8-18**] and then began
being bridge to warfarin with a starting dose of 3mg daily on
[**2110-8-19**]. Last INR before discharge was 6.3 with a goal INR of
[**5-13**] for combined therapy. The pt must be overlapped for a 5 days
bridge with INRS [**5-13**] on argatroban and coumadin (argatroban
elevated your INR which is why the INR goal must be so high
while overlapped). We are decreasing his warfarin dose to 2.5 mg
daily on [**2110-8-22**]. After the 5 day bridge is complete the pt's
INR goal is [**3-12**]. He will follow up with hematology as an
outpatient. PLTS must be 150 prior to stopping argatroban.
.
# Hyponatremia: The patient was found to be hyponatremic upon
admission. At that point the patient's volume status was unclear
as he had signs of hyper- and hypovolemia. The patient was
intravascularly volume depleted at the level of the kidney: his
FENa was 0.14% (<1), and the urine lytes demonstrated a very
elevated osm, very low Na, high spec [**Last Name (un) **]. The patient was also
thought to be in heart failure given risk factors of CAD and
CKD, bilateral lower leg edema, elevated BNP to >70,000,
crackles on physical exam, and pleural effusions. Yet, the
patient's urine electrolytes suggested hypovolemia, especially
in the setting of recent decreased PO intake, diarrhea, flat
JVP, and dry MM. The patient's cachexia and recent failure to
thrive since his last hospital admission were consistent with
both a hypo or hyper volemic state. The patient was given a
small normal saline bolus overnight observe whether his sodium
improved. As neither his sodium or respiratory status changed,
hyponatremia secondary to heart failure became more probable as
hyponatremia and resp status worsened. The patient was given
20mg of IV lasix in the morning and afternoon of [**8-12**] with good
urine output. Afternoon electrolytes revealed a modest increase
in Na from 117 to 119. On [**8-13**], pt was given a total of 80 mg IV
Lasix that day with a TBB of -1.9L. His Na that day increased to
125. He was put on standing Lasix 20 mg IV TID on [**8-14**] before
being called out to the floor, at which point his Na had further
increased to 127. Na continued to slowly climb as pt was
diuresed on the floor over the next few days. No symptoms [**3-11**] to
hyponatermia were ever witnessed during admission. On date of
discharge pt [**Name (NI) **] was 135. Patient had symptomatic ORTHOSTATIC
HYPOTENSION WITH SYMPTOMS on the night of [**2110-8-20**] and persisted
up until date of discharge. Lasix were held since the first
episode but will need to be restarted when pt no longer
orthostatic at a dose of 40mg [**Hospital1 **].
.
# Bilateral Feet Discoloration/Edema: The patient's pedal
discoloration was of unclear initial etiology; the main concern
was for atheroemboli given significant aortic calcification on
CT and CKD likely [**3-11**] atheroembolic insults. Due to a concern
for microemboli from the patient's underlying AAA, a abd CT scan
was done in the emergency department and showed stable AAA
without leakage. His ekg showed LBBB and 1st degree AVB,
unchanged from the previous admission. Vascular [**Doctor First Name **] was
consulted and recommended a heparin drip, with a rate adjusted
for PTT, and a CT chest to assess for aortic arch thrombus,
which was negative. The Heparin drip was d'ced on [**8-15**] per
vascular surgery when they decided that foot was improved. pt
was placed on sub q heparin. Feet appearance were closely
monitored on the floor by the medicine teams since they had
improved while on heparin, even though the improvement was
attributed to proper treatment of the new onset systolic heart
failure.
.
# Decompensated heart failure: The patient had clinical signs of
heart failure on admission although the patient's last echo in
[**2104**] was normal. Repeat echo on [**8-12**] revealed an EF of 35% and
hypokinesis that had not previously been present. Cardiac
enzymes were negative and pt did not have EKG changes consistent
with ACS. The patient was started on Lasix diuresis with good
urine output, a daily TBB goal of at least -1L, and slow
restoration of his serum sodium. Heart failure meds were held
until pt reaches dry weight. Patient was continued on ASA and
restarted on home atenolol on [**8-12**]. Statin was also started. Pt
was found to have large bilateral pulmonary effusions on CXR and
chest CT which correlated with physical exam findings. These
were deemed [**3-11**] to his decomponsated heart failure. Despite what
had been initially reported, it was later learned that the
patient was not chronically on home oxygen, but had merely been
on it for the last week after discharge from another hospital
after being treated with a PNA. As a result, the goal for the
patient's heart failure treatment was to get his respiratory
status to the point where he no longer needed supplemental O2.
LASIX WAS HELD THE 2 DAYS PRIOR TO DISCHARGE DUE TO ORTHOSTASIS
AS ABOVE but he will require lasix when no longer orthostatic
and titrate up to 40mg [**Hospital1 **]. Pt had repear Persantine MIBI to
evaluate patency of the coronary vessels. Result from the
stress test showed Fixed, medium-sized, moderate severity
perfusion defect involving the PDA territory, which is similar
to [**2104**] findings. Also severe changes in systolic function was
seen, which correlates with ECHO findings and presentation of
symptoms. HIS BETA-BLOCKER WAS HELD DUE TO ORTHOSTASIS BUT
SHOULD BE RESTARTED at 12.5mg [**Hospital1 **].
.
# Insomnia/Anxiety: The patient had not been sleeping at home
because, according to his daughter, he was scared of dying in
his sleep since his latest discharge from the hospital. The
patient was written for trazodone 25 mg prn. Social Work was
involved in organizing day-care for his progressively demented
wife as pt was unable to continue to be her sole care-giver and
has had significant stress with this in the past few months,
according to his daughters. Sleeping in the hospital helped him
feel much better.
.
# COPD: Moderate-severe emphysema on chest CT. Stable, patient
now on his home O2 requirement of 3L; remote smoking history is
likely cause of his COPD. The patient was put on nebulizer
treatment as needed. On [**8-13**] he started coughing more, probably
due to increased mobilization of secretions with his increasing
strength and fluid shifts. Started chest PT on [**8-14**]. Despite what
had been initially reported, it was later learned that the
patient was not chronically on home oxygen, but had merely been
on it for the last week after discharge from another hospital
after being treated with a PNA.
.
# H/o diarrhea: The patient's diarrhea was likely secondary to
recent antibiotic therapy. The diarrhea was not concerning for c
diff as the patient did not have a leukocytosis. No diarrhea in
house.
.
# H/o pneumonia: The patient was recently treated during last
admission for pneumonia. The patient was currently stable on his
home O2 (started after the recent discharge) and cxr on
admission was without obvious infiltrate. Antibiotics were not
intiated. It is possible that the pt never had pneumonia on his
last admission (afebrile, no leukocytosis, no positive cultures)
and that he was actually discharged in heart failure after his
last hospitalization.
.
# CKD: The patient's creatinine appears to be at baseline, at
most slightly elevated from last discharge. Urine lytes suggest
pre-renal state. Likely to improve with treatment of heart
failure. Monitored Cr and urine output with Lasix diuresis.
.
# AAA: Stable per CT scan
.
# BPH: Stable with hematuria likely from traumatic foley
placement.
.
Medications on Admission:
MVI 1 tab [**Hospital1 **]
Simvastatin 20 mg daily
ASA 81 mg daily
Ranitidine 150 mg qHS
Fluticasone 50 mcg nasal spray [**Hospital1 **]
Omega-3 Fatty Acid Cap [**Hospital1 **]
Os-Cal 500+D tabs [**Hospital1 **]
Augmentin 500-125 mg q12 hrs until [**8-9**]
SLNG PRN for chest pain
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomina.
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
6. Argatroban 100 mg/mL Solution Sig: as per algortihm
Intravenous INFUSION (continuous infusion).
7. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-8**] Sprays Nasal
QID (4 times a day) as needed for dryness and bleeding.
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Orthostatic
HE IS ORTHOSTATIC AND SYMPTOMATIC DO NOT GIVE IVF DUE TO SEVERE
CHF WOULD HAVE PT DRINK. Follow orthostatics daily.
11. Labs
Folly daily INRs goal must be [**5-13**] for INR overlap for 5 days
(today [**8-22**] was first day of therapeutic INR) given also on
argatroban. Follow CBC every other day to see that it remains
stable. Pt currently guaiac +.
12. Argatroban
See attached sheet on how to dose
13. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: MUST CALL PCP if
you use this.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Congestive heart failure
Heparin induced thrombocytopenia
Discharge Condition:
Pt is currently stable, A&Ox3 and not able to ambulate without
PT help.
HE IS ORTHOSTATIC AND SYMPTOMATIC DO NOT GIVE IVF DUE TO SEVERE
CHF WOULD HAVE PT DRINK
[**Name (NI) **] is no longer fluid overloaded and his low sodium has since
resolved.
Discharge Instructions:
Mr. [**Known lastname **] you are being discharged to an extended care facility.
You have had a long complicated hospital course and there have
been some new diagnosis since you came to the hospital. You
came here with a very low sodium level which is now normal, but
we also notice that you had a lot of extra fluid in your body.
We did some tests and they showed that your heart is not working
as well as it used to. You are in heart failure, but are now
doing much better than when you came into the hospital. You
were given lasix to help get the extra fluid off your lungs and
you no longer require oxygen. We had to stop the lasix 2 days
ago because you were orthostatic (dropping your blood pressure
when you sat up and stood up). YOu are still orthostatic and we
are encouraging you to drink fluids. We cannot give you IV
fluids due to your heart failure (not pumping blood out of the
heart effectively). You will need to restart lasix at some
point at rehab once you are no longer orthostatic. Also we
started you on a new blood pressure medication which is good for
your heart called metoprolol. We had to stop the metoprolol
because you are orthostatic but this will be restarted at some
point at rehab. We have made a follow up appointment with a
heart failure doctor for you.
In addition, like most patients that come into the hospital, we
gave you heparin to lower the risk of you getting blood clots.
You reacted to this heparin in a way that you platelets became
very low. This reaction is not common. We stopped the heparin,
and started you on argatroban another medication to help prevent
clots. As your platelet numbers began to rise, we began to
convert you over to warfarin which is an anticlotting medication
you can take by mouth. You will need to take this for a while
and will be advised when to stop by your new outpatient
hematologist doctor.
When we send you to the extended care facility we will continue
you on some of your old medications and also add some new ones.
Here is a list below of all your medications, Old and New:
Meds that will be continued:
MVI 1 tab [**Hospital1 **]
Simvastatin 20mg Daily
Ranitidine 150mg Daily
Omega-3 Fatty Acid cap [**Hospital1 **] (If pt can swallow it)
Os-Cal 500+D tabs [**Hospital1 **]
nitroglycerin 0.3 sl daily prn chest pain you must call your
doctor if you use this
Medications that are new:
Argatroban 0.5 mcg/kg/min IV DRIP INFUSION (until properly
switched to warfarin)
Guaifenesin [**6-16**] mL PO/NG Q6H:PRN
Warfarin 2.5 mg PO/NG DAILY
Nasal Spray for dry nose
Aspirin 325mg Daily
Followup Instructions:
Department: VASCULAR SURGERY
When: FRIDAY [**2110-8-29**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2110-9-8**] at 3:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2110-9-12**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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92,531
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39530
|
Discharge summary
|
Report
|
Admission Date: [**2171-7-10**] Discharge Date: [**2171-7-18**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 86897**]
Chief Complaint:
lower extremity erythema, hypotension, fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. [**Known lastname **] is an 88yoM with a history of AML (s/p 10 cycles
azacitadine), bladder cancer s/p transurethral resection, atrial
fibrillation, chronic left lower extremity osteomyelitis from a
shrapnel injury in WWII, and possible venous thromboembolism who
was referred to the ED by his rehab center for increasing
erythema of the left lower extremity.
.
He has a very longstanding history of left lower extremity osteo
with a chronic wound draining purulent discharge ever since he
sustained a shrapnel injury in [**Country 6171**] in a WWII explosion. He
denies any significant change in this condition recently, but
his wife notes increasing swelling and erythema of the extremity
over the past few days. He had been rehabbing from an early-[**Month (only) 116**]
hospitalization for multifocal pneumonia for which he received a
course of CTX/Azithro, and was referred to the ED this morning
when he became febrile to 104.
.
In the ED, initial vs were: 99.2 83 115/59 18 92% RA. He was
noted to be hypotensive to the 80s-90s, and received 2 L of NS
with stabilization of pressures to the low 90s. LLE tib-fib
films showed chronic osteomyelitis without subcutaneous gas, and
a CXR showed stable bilateral effusions from earlier this month.
He received 2g cefepime and 1g vancomycin. He had an elevated
lactate to 3.5 that corrected with fluids to 2.0. Blood cultures
drawn prior to antibiotics. Given his hypotension, he was
admitted to the [**Hospital Unit Name 153**] for possible sepsis.
.
Upon transfer to the ICU, his initial vitals were T98.1 BP94/54
P58 RR17 Sat94/4LNC. He is comfortable and in no acute
distress. He denies any increased pain or fevers recently. He
has intermittent shortness of breath, and notes that he
sometimes is on oxygen at the nursing home. He has been a
resident there for about 2 weeks, and is rehabbing from a recent
pneumonia. He has no coughing or sputum production, however. Of
note, he is in the midst of a azacitidine cycle for his AML,
which was diagnosed in [**2170**]. He saw his oncologist yesterday,
who's note details a pressure of 94/64.
.
On review of systems, he denies confusion, weakness, fevers,
chills, sore throat, coughing, chest pain, abdominal pain,
nausea, vomiting, diarrhea, bloody stools, black stools,
dysuria, hematuria, myalgias, arthralgias.
Past Medical History:
-Bladder Ca dxed [**2170-8-9**] s/p transurethral surgery (care by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 63724**] with [**Hospital1 **] in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**]).
-AML diagnosed (care by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] at [**Location (un) **]) [**8-/2170**],
[**9-/2170**] started azacytidine, now s/p 10 cycles, most recent dose
[**2171-6-3**].
-atrial fibrillation, rate controlled on fundaparinux
-HTN
-Chronic left lower ext ulcer with osteomyelitis and cellulitis
s/p shrapnel injury in WWII
- Barrett's esophagus
- Low back pain
- Venous thromboembolism?
Social History:
Lives with wife. Professor emeritus in neuroscience at [**University/College **]
Med and [**Hospital 1191**] hospital. Denies smoking. Seven drinks per week.
No ilicits.
Family History:
Denies history of malignancy.
Non-contributory
Physical Exam:
Vitals: T98.1 BP94/54 P58 RR17 Sat94/4LNC
General: alert and oriented x3, NAD
HEENT: Sclera anicteric, very dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at the bases, R>L, otherwise clear to
auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM at the
second RICS without radiation, second SEM at the apex with
radiation to the axilla.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: The left lower extremity has a 3cmx1cm open wound with
purulent necrotic discharge at the level of the tibial
tuberosity. The entire distal extremity is warm, erythematous
with 2+ pitting edema that is tender to touch. No other portals
of entry noted. Pulses 2+. Unaffected extremity is warm and
well purfused.
NEURO: CNII-XII intact bilaterally, strength 5/5 throughout, no
sensory limitations to soft touch.
Labs: see below
Pertinent Results:
Labs upon admission:
[**2171-7-10**] 11:40AM BLOOD WBC-3.2* RBC-2.97* Hgb-10.0* Hct-29.5*
MCV-100*# MCH-33.6* MCHC-33.8 RDW-26.3* Plt Ct-174#
[**2171-7-10**] 11:40AM BLOOD Neuts-46* Bands-2 Lymphs-27 Monos-12*
Eos-2 Baso-0 Atyps-2* Metas-6* Myelos-3*
[**2171-7-10**] 11:40AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
[**2171-7-10**] 11:40AM BLOOD Glucose-127* UreaN-31* Creat-1.4* Na-142
K-4.5 Cl-106 HCO3-25 AnGap-16
[**2171-7-10**] 11:49AM BLOOD Lactate-3.5*
[**2171-7-10**] 02:30PM BLOOD Lactate-2.0
[**2171-7-10**] 11:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2171-7-10**] 11:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Labs upon discharge:
***********
Microbiology
[**2171-7-10**]: 1/2 bottles of blood culture: Staph coag negative,
sensitivities pending
[**2171-7-11**]: blood culture: no growth to date (preliminary)
[**2171-7-12**]: Feces negative for C.difficile toxin A & B by EIA.
Imaging:
Tib/fib X-ray [**2171-7-10**]: FINDINGS: In comparison with the study of
[**9-13**], there is little overall change. Areas of sclerosis and
lucency with periosteal reaction is consistent with chronic
osteomyelitis. Deformity of the adjacent fibula is seen with
substantial resorption at its proximal aspect. No definite
evidence of gas within soft tissues.
CXR [**2171-7-10**]: IMPRESSION: Little change except possibly for some
small increase in left effusion.
Brief Hospital Course:
Dr. [**Known lastname **] is an 88yoM with AML, h/o bladder cancer, chronic LLE
osteomyelitis, HTN, Afib who presented with lower extremity
cellulitis and septic hypotension.
# LEFT LOWER EXTREMITY CELLULITIS: Likely port of entry was
non-healing chronic ulcer in left lower extremity. He was
treated with intravenous vancomycin and cefepime starting [**2171-7-10**]
and will continue until follow up appointment with infectious
disease on [**2171-8-1**]. At that point it will be determined if IV
antibiotics can be stopped and whether oral suppressive
antibiotics need to be started. His erythema and edema improved
over the course of his stay. PICC line was placed [**2171-7-17**] and
can be removed once IV antibiotics are finished. Once IV
antibiotics are finished, he will start on oral suppressive
antibiotics for chronic osteomyelitis. Note 1/2 blood cultures
grew Staph coag negative (sensitive to oxacillin and
tetracycline), presumed to be a contaminant rather than actual
bacteremia. Echocardiogram was deferred due to lack of
suspicion for endocarditis and MRI leg was not pursued due to
clinical improvement on antibiotics and patient resistance to
surgical debridement. His chronic non-healing ulcer/chronic
osteomyelitis of his left lower extremity is stable in size and
without exudate. Note weekly labs should be checked including
CBC with diff, chem 7, vanco trough and LFTs and faxed to
infectious disease. Additionally, vanco trough will need to be
checked on [**2171-7-20**], goal trough is 15-20.
# HYPOTENSION: Initial systolic blood pressure 80-90's prompted
ICU admission, he received intravenous fluids and improved. His
furosemide was restarted on [**2171-7-10**], however his
antihypertensives were held. Note recent blood pressures prior
to admission have been low, so there is a question of whether
SBP 90-100 is his baseline.
# HYPOXIA: Resolved spontaneously, suspected atelectasis and
mild pulmonary edema. No pneumonia was seen on CXR. Lasix was
resumed [**2171-7-13**] once blood pressure was deemed stable.
# ACUTE RENAL FAILURE: Pre-renal secondary to infection and
hypotension, resolved with intravenous fluids.
# AML: Azacytidine was held during admission, but may be
resumed as an outpatient by Dr. [**First Name (STitle) 2405**]. His hematocrit was 24
for several days of admission. We gave 1 unit PRBC on [**2171-7-17**]
and another 1 unit PRBC on [**2171-7-18**]. He was mildly neutropenic on
the day of discharge (ANC 961), but he was afebrile. His CBC
and ANC should be monitored daily for 3 days upon discharge.
His other medical problems were managed with his home
medications without complications. He was FULL CODE for this
admission.
Medications on Admission:
from recent d/c summary and rehab list
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily).
9. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Four
Hundred (400) mg PO BID (2 times a day).
10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
11. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day) as needed for constipation.
12. Ocuvite Oral
13. Multivitamin
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
8. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
BID (2 times a day).
9. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
10. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
three times a day as needed for constipation.
11. Ocuvite Tablet Sig: One (1) Tablet PO once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Outpatient Lab Work
Please check vancomycin trough on Saturday [**2171-7-20**] Please fax
results to [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **] Infectious Disease at [**Telephone/Fax (1) 1419**].
Please check labs weekly CBC with differential, chem 7, LFTS and
vancomycin trough, while on intravenous antibiotics. Please fax
results to [**First Name8 (NamePattern2) 47034**] [**Last Name (NamePattern1) **] Infectious disease at FAX [**Telephone/Fax (1) 1419**]
14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): please continue until
appointment with ID on [**2171-8-1**].
15. cefepime 2 gram Recon Soln Sig: One (1) Intravenous q24H:
please continue until appointment with ID on [**2171-8-1**].
16. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
19. Outpatient Lab Work
Please check daily CBC with differential for 3 days to monitor
his hematocrit, white blood cell count, and absolute neutrophil
count. Please fax results to [**Last Name (un) **] [**Doctor Last Name 2405**] [**Telephone/Fax (1) 6808**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]
Discharge Diagnosis:
Left lower extremity cellulitis
Septic shock
Acute renal failure
Chronic left lower extremity osteomyelitis
Acute myelogenous leukemia
Anemia
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because of swelling and redness in your
left lower leg which was diagnosed as cellulitis (infection of
the soft tissues). You had low blood pressure which responded
to intravenous fluids. You were placed on intravenous
antibiotics and improved. You will continue to take intravenous
antibiotics until your follow up infectious disease appointment
on [**2171-8-1**] at which time it will be determined whether you will
need more antibiotics. Please elevate your leg daily to
decrease the swelling.
We made the following changes to your medications:
- START vancomycin 1 gram every 24 hours until ID appointment on
[**2171-8-1**]
- START cefepime 2grams every 24 hours until ID appointment on
[**2171-8-1**]
- START oxycontin 10mg twice daily for pain
- START sarna lotion as needed for itching
It was a pleasure caring for you. We wish you a speedy
recovery.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) 2405**]
[**7-29**] at 2:00pm
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
Fax: [**Telephone/Fax (1) 6808**]
Department: INFECTIOUS DISEASE
When: THURSDAY [**2171-8-1**] at 2:50 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 86898**]
Completed by:[**2171-7-18**]
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Discharge summary
|
Report
|
Admission Date: [**2149-11-23**] Discharge Date: [**2149-12-8**]
Date of Birth: [**2097-6-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Cellcept / Zosyn
Attending:[**First Name3 (LF) 6734**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Tunneled Hemodialysis Line Placement
History of Present Illness:
This is a 52 yo female with ESRD on HD, s/p failed renal
transplant, who was discharged 1.5 wks ago for septic shock
thought due to CMV viremia and diverticulitis, who presented
yesterday to [**Hospital1 18**] with a fever to 104.
To summarize her recent history, she was admitted [**Date range (1) 99101**]/[**2148**]
with ARF leading to her graft failure, found to also have CMV
viremia and C. diff colitis. She was discharged on IV
ganciclovir until 2 negative CMV VLs, and transitioned to oral
valganciclovir secondary ppx to continue for 3 mos from her
admission. How this was discontinued is unclear: possibly on
[**10-10**] due to neutropenia, and outside records note negative CMV
VL on [**10-18**]. She was also at [**Hospital 3278**] Medical Center from
[**Date range (1) 23929**] septic shock due to pseudomonas bacteremia,
completing a course of ?zosyn on [**10-27**].
On [**10-27**] pt began having fevers. A CMV viral load was rechecked
(970) and repeat VL of 4059 on [**11-2**]. It is unclear when
ganciclovir was restarted, but by [**11-2**], she was on ganciclovir
with HD dosing. She became hypotensive on [**11-6**] with mild
abdominal pain, sent to [**Hospital1 18**] and admitted to MICU on
norepinephrine. She was treated with stress-dose steroids,
empiric PO vancomycin, IV vancomycin, IV zosyn and IV
gancyclovir. CT abd/pelvis showed uncomplicated sigmoid
diverticulitis. All other culture data and infectious workup
(including c. diff toxin negative x 3) was unrevealing as to
another source of infection. She was started on midodrine for
persistent hypotension to 70-80s systolic. Also was
progressively pancytopenic, though to be from pip-tazo. She was
discharged on PO cipro and flagyl for diverticulitis, 10 mg
daily prednisone, with her tacrolimus decreased to 2mg [**Hospital1 **]. Also
discharged on IV ganciclovir, planning to switch to oral after 2
negative VLs, although stopped at some point in rehab.
While in rehab, BPs had remained normotensive. Yesterday am, she
awoke nauseated and febrile, with a temp of 104.0. Blood
cultures (2 sets) were sent from rehab. Also c/o LLQ pain. In
the ED, her Tmax was 102, with BP 142/82. CT abd showed
diverticulitis similar to prior. UA was positive. CXR improved
from prior. Was given vanco/zosyn/flagyl and admitted.
On arrival to HD today, she was tachycardic to 130s, apparently
sinus rhythm. HD was stopped after 1 hour due to progressive
tachycardia to the 160s, with fever to 103.2, despite running
her volume even. After stopping HD, she became hypotensive to
SBP 60s, with preserved mental status. After 1L IVF, her BP
improved to 86/44 with HR 107. Temp improved to 100.3 after
acetaminophen. Currently c/o nausea and fatigue, no resting abd
pain but 10/10 L sided abd pain with palpation. Also c/o fevers,
no chills or sweats. Has some diarrhea that pt notes as chronic
and unchanged. Makes small amt urine and confirms dysuria,
frequency, urgency. Denies vomiting, CP, SOB, cough, sputum,
wheezing, HA, vision changes, confusion.
Past Medical History:
- ESRD due to SLE, s/p cadaveric renal transplant [**8-/2147**]
complicated by FSGS and transplant failure [**7-/2149**], now on HD
- SLE, followed by Dr.[**Last Name (STitle) **] in Rheumatology
- Hypotension (started on midodrine [**11-5**])
- Septic shock [**10/2149**]
- CMV viremia [**10/2149**]
- Acute uncomplicated diverticulitis [**10/2149**]
- hx of C. Diff
- Paroxysmal atrial fibrillation
- NSVT
- hx of Hypertension
- Hyperthyroidism
- s/p bilateral knee surgeries and R ACL repair
Social History:
Single, currently at [**Hospital 671**] rehab. Denies tobacco, ETOH, and
drugs.
Family History:
Mother and brother both with diabetes and [**Name (NI) 2091**], both deceased.
Physical Exam:
Vitals: T 101.2 BP 105/49 HR 113 RR 18 O2sat 98RA
GENERAL: NAD, AAOx3, appropriate, comfortable
HEENT: NCAT, EOMI, aniceteric sclerae, MMM
NECK: No JVD
CARDIAC: RRR, no m/r/g
LUNG: CTAB
ABDOMEN: NABS. Soft, ND, exquisitely TTP with in LUQ/LLQ with +
rebound and grimacing, pain with bed movement, no significant
guarding, graft palpable in RLQ without TTP
EXT: Warm and dry, 2+ DP pulses, AVF in LUE. No edema.
Pertinent Results:
Hematology:
[**2149-11-23**] 12:40PM BLOOD WBC-2.4* RBC-3.37* Hgb-9.5* Hct-32.6*
MCV-97 MCH-28.3 MCHC-29.2* RDW-17.1* Plt Ct-97*
[**2149-11-25**] 09:00AM BLOOD WBC-4.1 RBC-3.70* Hgb-10.3* Hct-35.4*
MCV-96 MCH-27.8 MCHC-29.0* RDW-17.0* Plt Ct-144*
[**2149-11-23**] 12:40PM BLOOD Neuts-51 Bands-20* Lymphs-12* Monos-13*
Eos-2 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2149-11-25**] 09:00AM BLOOD Neuts-67 Bands-2 Lymphs-20 Monos-8 Eos-0
Baso-0 Atyps-1* Metas-1* Myelos-1*
[**2149-11-23**] 12:40PM BLOOD Plt Smr-VERY LOW Plt Ct-97*
[**2149-11-24**] 12:12PM BLOOD PT-15.1* PTT-29.8 INR(PT)-1.3*
[**2149-11-25**] 09:00AM BLOOD Plt Smr-LOW Plt Ct-144*
Chemistries:
[**2149-11-23**] 12:40PM BLOOD Glucose-96 UreaN-24* Creat-5.9*# Na-147*
K-4.2 Cl-108 HCO3-27 AnGap-16
[**2149-11-25**] 09:00AM BLOOD Glucose-130* UreaN-30* Creat-5.1* Na-143
K-4.0 Cl-106 HCO3-26 AnGap-15
[**2149-11-23**] 12:40PM BLOOD ALT-15 AST-12 AlkPhos-57 TotBili-0.3
[**2149-11-24**] 12:45PM BLOOD Calcium-7.4* Phos-2.7 Mg-1.7
[**2149-11-24**] 07:30AM BLOOD Vanco-19.5
[**2149-11-23**] 12:47PM BLOOD Lactate-1.0
Imaging:
CT Abdomen and Pelvis [**2149-11-23**]:
1. Extensive diverticulosis with diverticulitis of the sigmoid
colon and
distal descending colon, similar in extent when compared to the
most recent study of [**2149-11-7**]. No evidence of
perforation or abscess formation.
2. Mild enhancement of the transplanted kidney in the right
lower quadrant, which is similar in appearance to the prior
study. No evidence of perinephric fluid collection or abscess.
3. Persistently dilated pancreatic duct may be related to
ampullary stenosis or IPMN. As noted previously, if not already
performed, consultation with the Pancreas Center may assist in
evaluation.
CXR [**2149-11-24**]:
Since interval examination from [**2149-11-11**], there has been
improvement in left lower lobe atelectasis and removal of a
central venous catheter. The lungs are clear with no signs of
pneumonia or congestive heart failure. No pleural effusions or
pneumothorax. The cardiomediastinal silhouette is stable in
size.
Microbiology:
Blood cultures [**2149-11-23**], [**2149-11-24**] - pending
Urine culture [**2149-11-23**] - 10,000-100,000 Klebsiella
Clostridium Difficle [**2149-11-23**] - positive
CMV Viral Load [**2149-11-24**] - negative
Discharge Labs:
Hematology:
BLOOD WBC-2.7* RBC-2.85* Hgb-7.7* Hct-26.9* MCV-94 MCH-27.1
MCHC-28.7* RDW-17.3* Plt Ct-182
Neuts-41* Bands-8* Lymphs-37 Monos-11 Eos-0 Baso-2 Atyps-1*
Metas-0 Myelos-0
BLOOD PT-11.9 PTT-25.3 INR(PT)-1.0
BLOOD Glucose-89 UreaN-17 Creat-4.2* Na-145 K-3.7 Cl-105 HCO3-32
AnGap-12
Brief Hospital Course:
52 yo female with ESRD on HD, recent admission for septic shock
from diverticulitis vs CMV, here with fever and hypotension.
Hypotension/Fevers: Patient presented with evidence of septic
physiology with fevers and hypotension, along with abdominal
pain and diarrhea. Cultures revealed negative blood cultures,
urine culture positive for klebsiella 10-100,000 colonies and
positive clostridium difficle. She had a CT of the abdomen
which revealed diverticulitis. CXR did not show evidence of
pneumonia. She was initially started on broad spectrum
antibiotics with vancomycin and cefepime and this was
transitioned to PO vancomycin and tigacycline for coverage of
clostridium difficle as well as IV Gancyclovir given her history
of CMV viremia. Her hypotension resolved with 1 liter of normal
saline. She also received stress dose steroids given her
history of long term steroid use. She was transitioned to the
floor. Cortisol stim test was performed which was negative.
Her hypotension was responsive to fluid boluses. She was
continued on midodrine. On the floor she was found to have a
positive c diff toxin. She was started on vancomycin taper with
resolution of her abdominal pain and diarrhea. Fevers abated.
She was covered with valgancyclovir for CMV prophylaxis and
atovaquone for PCP [**Name Initial (PRE) 1102**]. Towards the end of her
hospitalization, her fevers reappeared without accompanying
hypotension. Pan culture revealed no organism repeatedly. Her
left arm at the fistula site was painful and ultrasound revealed
extensive clot burden. Transplant surgery did not feel
immediate correction was required; a tunneled line was placed
for HD. PICC line was removed and cultures were negative. Her
fevers were felt secondary to clot burden. She was discharged
on empiric vancomycin to be given with each HD treatment for a
total of four weeks. She was discharged on vancomycin taper for
c difficile and prophylaxis as mentioned above in addition to
the vancomycin with dialysis.
Pancytopenia: Patient has a history of pancytopenia of unclear
cause. Differential diagnosis considered includes drug reaction
from zosyn, CMV viremia versus lupus related. Her blood counts
were stable from recent admission and were trended. CMV viral
load was negative.
Renal transplant: Complicated by graft FSGS and ESRD on HD. She
received stress dose steroids as above in the setting of sepsis.
She was followed by the renal consult and transplant services.
She was continued on tacrolimus 1 mg [**Hospital1 **] (decreased from 2 mg
[**Hospital1 **]) and atovaquone for prophylaxis. She received hemodialysis
treatments three times a week as per her home schedule. Given
her clotted fistula towards the end of her hospitalization, a
tunneled HD line was placed as mentioned above. Transplant
surgery will see her in outpatient follow up for consideration
of placement of new fistula on the right arm. Her tacrolimus
was discontinued at time of discharge given that she does not
require tacrolimus any longer secondary to graft failure.
Hyperglycemia: Attributed to corticosteroid therapy. She was
treated with a humalog sliding scale.
Paroxysmal atrial fibrillation: In sinus rhythm on discharge 10
days ago and currently. Not on warfarin. She was continued on
aspirin.
.
Dispo - Discharged to rehab following resolution of abdominal
pain, diarrhea, fever work up, and tunneled line placement.
Medications on Admission:
HOME MEDICATIONS: (from d/c summary dated [**2149-11-14**])
- Atovaquone 1500mg (10ml) PO daily
- Aspirin 325mg PO daily
- Pantoprazole 40mg PO Q24hrs
- B Complex-Vitamin C-Folic Acid 1mg capsule PO daily
- Midodrine 10mg PO TID
- Ciprofloxacin 500mg PO Q24hrs - ended [**11-16**]
- Flagyl 500mg PO Q8hrs - ended [**11-16**]
- Tacrolimus 2mg PO Q12hrs
- Ganciclovir 110mg IV QHD
- Heparin 5000units SQ TID
- Insulin glargine 2units SQ QHS
- Insulin NPH 4units SQ QAM
- Insulin Humalog sliding scale
- Prednisone 10mg PO daily
- Zofran 4mg IV Q8hrs PRN nausea
- Epogen 15000units QHD
- Bisacodyl 5-10mg PO daily PRN constipation
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): To be administered during dialysis and
dosed according to the [**Hospital1 18**] Epoetin Alfa P&T Guidelines. .
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO as below:
One (1) Capsule PO every twenty-four(24) hours: Starting [**12-8**], take 125 mg daily for one week ([**12-8**]- [**12-14**]) (b) then take
125 mg every other day for one week ([**Date range (1) **]) (c) then take
125 mg every third day for two weeks ([**Date range (1) 97009**]/10).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a
day: One (1) Tablet PO 2X/WEEK (TU,TH).
10. insulin
glargine 2 U SQ qhs
NPH 4 U SQ qAM
11. Vancomycin 1000 mg IV HD PROTOCOL
please check trough prior to each dose
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
1. Clostridium difficile colitis
2. Fistula Repair
3. Chronic Kidney Disease
Discharge Condition:
Stable for discharge. On room air, ambulating with assistance.
Resolved diarrhea and abdominal pain, intermittent continued low
grade fevers.
Discharge Instructions:
Dear Ms [**Known lastname 6357**],
It was a pleasure caring for you while you were in the hospital.
You were first admitted to the hospital because of pain in your
abdomen that was caused by Clostridium difficile. Because of
this infection, you developed pain in your abdomen, fevers, and
your blood pressure was low. During dialysis, your blood
pressure fell even further. To treat you, we started you on
antibiotics for the infection and your pain and fevers improved.
You will need to continue to take these antibiotics for several
more weeks. The course of antibiotics is described below.
.
During your hospital stay, your fistula on your left arm also
stopped working. Because you needed dialysis, we placed a new
line (called a tunneled line) that will allow us to continue
dialysis. The transplant surgeons want to create a new fistula
for you to use, and you have a follow up appointment set up with
them as an outpatient to arrange this. We also decided to
continue you on antibiotics to be given during dialysis to treat
the possibility of infection in the area of the fistula.
.
The medication changes we made during this hospitalization were:
1. We started you on oral vancomycin. You should continue to
take this with the following regimen:
(a) take 125 mg daily by mouth for one week ([**2149-12-8**] - [**2149-12-14**])
(b) then take 125 mg every other day for one week ([**2149-12-15**] -
[**2149-12-21**])
(c) then take 125 mg every third day for two weeks ([**2149-12-22**] -
[**2150-1-4**])
2. You can take 5 mg of the prednisone every day instead of 10
mg.
3. You will be receiving vancomycin intravenously with
hemodialysis until [**2150-1-1**] to complete a 4 week course.
4. You should take vangancyclovir 450 mg twice a week with
dialysis.
5. You can take oxycodone 5 mg as needed every 6 hours for pain.
6. You should stop taking gancyclovir IV.
7. You should stop taking tacrolimus.
.
Please keep the follow up appointments scheduled for you below.
Followup Instructions:
1) You have an appointment with a transplant infectious disease
doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], on [**12-23**] at 930 AM. Please call
[**Telephone/Fax (1) 673**] if you have any other questions.
2) You have an appointment with your kidney doctor, Dr. [**First Name (STitle) **]
[**Name (STitle) **] on [**2149-12-18**] at 9:40 AM. If you have any questions,
his phone number is [**Telephone/Fax (1) 673**].
.
3) You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from
transplant surgery at 1:40 PM on [**2149-12-25**]. If you
have any questions regarding this appointment, please call
[**Telephone/Fax (1) 673**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**]
|
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"585.6",
"242.90",
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|
[
[
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92,252
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|
42419
|
Discharge summary
|
Report
|
Admission Date: [**2141-4-10**] Discharge Date: [**2141-4-17**]
Date of Birth: [**2067-3-5**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Feldene / epinephrine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
T11-L2 fusion on [**4-10**] and T3-L5 fusion [**4-11**] for kyphosis,
spondylosis and compression fracture
History of Present Illness:
Ms. [**Known lastname **] has a long history of a kyphoscoliosis. She is
electing to proceed with surgical intervention.
Past Medical History:
HTN, HLD, depression, L footdrop, chronic LBP, left frozen
shoulder, left foot drop, bilateral lower extremity neuropathy,
reflux, constipation, depression
Social History:
Denies tobacco
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
RLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
diminished at quads and Achilles
LLE- foot drop; reflexes diminished at quads and Achilles
Pertinent Results:
[**2141-4-14**] 05:14AM BLOOD WBC-13.2* RBC-3.03* Hgb-9.0* Hct-27.8*
MCV-92 MCH-29.6 MCHC-32.3 RDW-14.3 Plt Ct-181
[**2141-4-13**] 03:30PM BLOOD WBC-13.9* RBC-2.58* Hgb-7.9* Hct-24.0*
MCV-93 MCH-30.5 MCHC-32.8 RDW-13.5 Plt Ct-183
[**2141-4-13**] 04:20AM BLOOD WBC-18.4* RBC-3.10* Hgb-9.4* Hct-30.4*
MCV-98 MCH-30.3 MCHC-30.9* RDW-13.7 Plt Ct-169
[**2141-4-12**] 12:42AM BLOOD WBC-14.6* RBC-2.99* Hgb-9.3* Hct-28.2*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.3 Plt Ct-174
[**2141-4-14**] 05:14AM BLOOD Glucose-103* UreaN-9 Creat-0.5 Na-134
K-3.9 Cl-102 HCO3-24 AnGap-12
[**2141-4-12**] 03:19PM BLOOD Glucose-113* UreaN-12 Creat-0.5 Na-132*
K-4.0 Cl-103 HCO3-22 AnGap-11
[**2141-4-11**] 02:36PM BLOOD Glucose-171* UreaN-14 Creat-0.6 Na-128*
K-4.4 Cl-98 HCO3-23 AnGap-11
[**2141-4-14**] 05:14AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.9
[**2141-4-12**] 12:42AM BLOOD Calcium-7.3* Phos-2.5* Mg-2.5
[**2141-4-10**] 03:56PM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2141-4-10**] and taken to the Operating Room for T11-L2 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T3-L5 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the SICU in
stable condition. Postoperative HCT was low and she was
transfused PRBCs. A bupivicaine epidural pain catheter placed at
the time of the posterior surgery remained in place until postop
day one.
POD#2 the chest tube was removed and an x-ray showed no signs of
a pneumothorax. She was kept NPO until bowel function returned
then diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#2 from the second procedure. She was
fitted with a TLSO brace for ambulation. Physical therapy was
consulted for mobilization OOB to ambulate. Hospital course was
otherwise unremarkable. On the day of discharge the patient was
afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
vicodin PRN, atacand 32', HCTZ 25', arthrotec 75-200 1-2 tabs
daily, cymbalta 60', nexium 40', gabapentin 1000''', vitamin D
[**2128**] units', vitamin B, MVI, lovasa 2 tabs QHS, crestor 5 QHS,
oxybutynin SR 20 QHS, tylenol PRN, claritin 5', fortical nasal
spray, miralax, senna
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
6. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. gabapentin Oral
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
10. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
12. loratadine 10 mg Tablet Sig: 0.5 Tablet PO daily () for 4
days.
13. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) Nasal daily () for 4 days.
14. insulin regular human 100 unit/mL Solution Sig: One (1)
syringe Injection ASDIR (AS DIRECTED).
15. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Kyphoscoliosis
Acute post-op blood loss anemia
Post-op delerium
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2141-4-17**]
|
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[
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| 939
| 0
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|
90,604
| 145,942
|
40967
|
Discharge summary
|
Report
|
Admission Date: [**2149-7-16**] Discharge Date: [**2149-7-22**]
Date of Birth: [**2070-5-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Flagyl
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Hypotension, atrial fibrillation with rapid ventricular
response, acute kidney injury
Major Surgical or Invasive Procedure:
TEE (Transesophageal Echocardiogram) with DC cardioversion
[**2149-7-18**]
History of Present Illness:
Ms. [**Known lastname 7594**] is a 79 y/o female with rheumatic heart disease s/p
porcine MVR (bioprosthetic mitral valve, on coumadin), moderate
aortic insufficiency, atrial fibrillation with rapid ventricular
response which has been poorly controlled during recent
hospitalization (was recently chemically cardioverted into NSR),
and recent treatment for enterococcal bacteremia and
endocarditis for 4 weeks at the end of [**Month (only) 116**] to the early part of
this month, who initially presented to [**Hospital3 7569**] for ?
dehydration vs. orthostatic hypotension. She reports that she
"almost passed out" and was "dizzy" at times. She reports "loss
of balance" and "inability to get up." During admission, she was
treated with IVF and fludrocortisone for the hypotension. She
had CT abdomen and pelvis for mild abdominal pain. She was felt
to have ? diverticulitis for which she was started on flagyl. On
her labs, she was noted to be in acute renal failure. The [**Last Name (un) **]
was felt to be in part due to gentamycin, and this was
discontinued. They continued the IV vancomycin. She was
discharged home.
She presented on [**7-13**] for a generalized rash over her body,
swollen lips, and some lesions in her mouth felt to be due to
the recently started flagyl. The rash was felt to be c/w
erythema multiform per dermatology. There was no airway
compromise, but she did report some difficulty swallowing. She
was kept on IV steroids, which was changed to oral prednisone on
date of transfer. Rash and erythema improved per dermatology
team. Reportedly, her SBP was in the 80s, and she was
resuscitated with IVF. HR was in the 130s-140s on arrival to
OSH.
She also had acute renal failure on admission to the OSH. She
was continued on mIVF. Cr on presentation to [**Location (un) **] was 1.8 and
improved to 1.5 on transfer. Her atrial fibrillation is
reportedly poorly controlled, and she remains on IV amiodarone,
now transitioned to oral amiodarone, along with metoprolol and
diltiazem gtt. Initial plan was for electrical cardioversion,
but daughter requested transfer to a tertiary medical center for
this.
Additionally, the patient had an episode of pulmonary edema on
evening prior to transfer. She reported that it was "hard to
breathe." This was suspected to be from poorly controlled heart
rate and perhaps mIVF. CXR showed bilateral pulmonary vascular
congestion. She diuresed well with 40 mg IV lasix (-1800 cc
since then). She was initially on 6L NC. She reports cough, but
no productive sputum. HR reportedly increasing to 138 bpm at
times.
Review of systems:
(+) Per HPI. Reports 20 lb weight loss since [**Month (only) 958**].
(-) Denies fever, chills, night sweats. Denies sinus tenderness,
rhinorrhea or congestion. Denies productive cough, shortness of
breath. Denies chest pain, chest pressure, palpitations, or
weakness. Denies vomiting, diarrhea, constipation, abdominal
pain, or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias.
Past Medical History:
- rheumatic heart disease s/p porcine MVR at [**Hospital2 **] [**Hospital3 6783**]
- moderate AI
- atrial fibrillation, until recently had been chemically
cardioverted to NSR.
- enterococcus endocarditis treated with almost 1 month of
Vanc/Gent (PCN allergic), which was stopped 3 days early
- breast cancer s/p mastectomy
Social History:
intermittently at rehab and was only at home for 2 weeks prior
to ICU stay at [**Location (un) **]. Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is HCP. Phone
[**Telephone/Fax (1) 89391**].
- [**Name2 (NI) 1139**]: denies
- Alcohol: rare
- Illicits: denies
Family History:
dad with [**Name (NI) 4278**]. 5 brothers had cancer as well. No
significant CAD.
Physical Exam:
MICU admission:
Vitals: T: 97.7 BP: 136/83 P: 95 R: 18 O2: 95% 4L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, unable to visualize posterior
oropharynx due to dry and cracked lips
Neck: supple, JVP not elevated, no LAD
Lungs: crackles anteriorly and at bases, no wheezing
appreciated, no accessory muscle use
CV: tachycardic, irregular rhythm, mechanical valve click, ?
grade II diastolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Skin: diffuse erythematous, non-blanching rash over the trunk,
upper and lower extremities, no bullae
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
VS: T= 97.3-99.5, BP=151-183/80-91, HR=53-59, RR=18, O2sat=99%
on RA
Weight: 47.7kg(S)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Lips cracked and dry. Numerous lesions on tongue.
NECK: Thin
CARDIAC: RRR, normal S1, S2.
LUNGS: CTAB. Respirations were unlabored, no accessory muscle
use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pedal edema.
SKIN: Diffuse erythematous, non-blanching maculopapular rash
over the trunk, upper and lower extremities. No bullae. No
[**Last Name (un) **] lesions, osler nodes, or spliter hemmorhages.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Admission labs:
[**2149-7-16**] 06:51PM BLOOD WBC-20.1* RBC-3.88* Hgb-12.5 Hct-35.6*
MCV-92 MCH-32.1* MCHC-35.1* RDW-15.1 Plt Ct-385
[**2149-7-16**] 06:51PM BLOOD Neuts-93* Bands-1 Lymphs-2* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-16**] 06:51PM BLOOD PT-36.7* PTT-35.5* INR(PT)-3.7*
[**2149-7-16**] 06:51PM BLOOD Glucose-161* UreaN-29* Creat-1.6* Na-133
K-3.5 Cl-99 HCO3-20* AnGap-18
[**2149-7-16**] 06:51PM BLOOD ALT-20 AST-18 LD(LDH)-374* AlkPhos-69
TotBili-0.6
[**2149-7-16**] 06:51PM BLOOD Albumin-3.5 Calcium-7.5* Phos-1.9*
Mg-1.5* Iron-48
[**2149-7-16**] 06:51PM BLOOD calTIBC-182* Ferritn-685* TRF-140*
[**2149-7-16**] 06:51PM BLOOD TSH-1.7
.
OSH ([**Location (un) **]) results per phone: INR's [**Month (only) 116**]: 26- 2.0; 23-2.5;
19-5.2; 16-3.9; 12-1.8; 9-1.8; 6-1.9; 4-2.5; 2-3.5; [**5-15**]-1.8.
.
LABS AT DISCHARGE:
[**2149-7-22**] 06:45AM BLOOD WBC-8.7 RBC-3.73* Hgb-11.8* Hct-34.2*
MCV-92 MCH-31.7 MCHC-34.5 RDW-15.3 Plt Ct-345
[**2149-7-22**] 06:45AM BLOOD PT-34.7* INR(PT)-3.5*
[**2149-7-22**] 06:45AM BLOOD Glucose-95 UreaN-25* Creat-1.2* Na-131*
K-3.8 Cl-99 HCO3-21* AnGap-15
[**2149-7-22**] 06:45AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.1
[**2149-7-16**] 06:51PM BLOOD calTIBC-182* Ferritn-685* TRF-140*
[**2149-7-16**] 06:51PM BLOOD TSH-1.7
.
OTHER RELEVANT STUDIES:
.
Images: CXR at OSH - no acute cardiopulmonary process
.
CXR [**2149-7-16**]: Heart size is enlarged with left ventricular
configuration. Mediastinal silhouette is unremarkable. There are
multifocal opacities noted, with some perihilar and upper lung
redistribution as well as both basal involvement. There are also
bilateral pleural effusions, right more than left. There is no
pneumothorax. The findings are worrisome for a combination of
pulmonary edema given the perihilar and upper lobar distribution
as well as multifocal infection giving relatively focal and
patchy character of the finding. Correlation with prior imaging
as well as assessment after diuresis is recommended. Surgical
clips are projecting over the right axilla and no right breast
identified, suggesting that the patient can be after right
mastectomy, please correlate with clinical history.
.
CXR [**2149-7-20**]: CHEST, PA AND LATERAL: The heart is somewhat
enlarged. There is no evidence of failure. The lung fields are
clear. The costophrenic angles are sharp. There has been a
marked improvement in the overall appearances since the prior
chest x-ray of [**7-17**]. IMPRESSION: Mild cardiomegaly, otherwise
normal chest.
.
TTE [**2149-7-17**]: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm. The right ventricular free
wall thickness is normal. The right ventricular cavity is
dilated with depressed free wall contractility. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild to
moderate ([**1-19**]+) aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The prosthetic mitral valve
leaflets are mildly thickened. The transmitral gradient is
normal for this prosthesis. No mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. IMPRESSION: Suboptimal image quality. No
definite vegetations seen
.
TEE ([**2149-7-18**]): The left atrium is dilated. Moderate to severe
spontaneous echo contrast but no thrombus is seen in the body of
the left atrium and left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No
spontaneous echo contrast or thrombus is seen in the right
atrium or right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. LV systolic function appears
depressed. Right ventricular chamber size is normal with global
free wall hypokinesis. There are simple atheroma in the aortic
arch and descending thoracic aorta. The aortic valve leaflets
(3) are mildly thickened. Trace aortic regurgitation is seen. A
well-seated bioprosthetic mitral valve prosthesis is present.
The mitral prosthesis appears well seated, with normal leaflet
motion and transvalvular gradients. Trivial mitral regurgitation
is seen. The tricuspid valve leaflets are moderately thickened.
The estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion. IMPRESSION: Prominent
spontaneous echo contrast but no thrombus in the body of the
left atrium and left atrial appendage. Well seated, normal
functioning mitral valve bioprosthesis. Depressed biventriular
systolic function. Aortic regurgitation.
Patient is at high risk for developing intracardiac thrombus
post cardioversion.
.
EKG [**2149-7-16**]: atrial fibrillation at 99, mild right axis
deviation, normal intervals, no pathologic Q waves, non-specific
ST changes precordially
.
URINE CULTURE (Final [**2149-7-19**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
.
SENSITIVITIES: MIC expressed in MCG/ML
______________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
[**2149-7-16**] 6:51 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2149-7-22**]**
Blood Culture, Routine (Final [**2149-7-22**]): NO GROWTH.
[**2149-7-16**] 8:45 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2149-7-22**]**
Blood Culture, Routine (Final [**2149-7-22**]): NO GROWTH.
Brief Hospital Course:
Ms. [**Known lastname 7594**] is a 79 y/o female with rheumatic heart disease s/p
porcine MVR, moderate AI and atrial fibrillation. In [**Month (only) 116**] she was
treated for enterococcus endocarditis with Vancomycin and
Gentamicin which were discontinued due to ARF, and was later
admitted to [**Location (un) **] for metronidazole induced
bronchoconstriction, rash, and hypotension as well as [**Last Name (un) **] and
afib with RVR. She was transferred to [**Hospital1 18**] for management of
afib with rvr for which she underwent successful DC
cardioversion.
.
ACTIVE ISSUES:
.
# Afib with RVR: The precipitant of her afib was unclear, but
may have been related to her volume status or recent infection.
She was on amiodarone, metoprolol, and diltiazem, and was
difficult to rate control. She was successfully DC cardioverted
on [**2149-7-18**] after a TTE and TEE were negative for thrombus.
After the cardioversion the diltiazem drip was able to be
discontinued and she was discharged on metoprolol succinate 50mg
daily and amiodarone 200mg daily. She was anticoagulated with
heparin for the cardioversion and was then switched to her
previous home dose of warfarin 2mg daily. She was
supratherapeutic at this dose with an INR at discharge of 3.5.
Warfarin was held on [**7-21**] and [**7-22**]. The increased response to
warfarin is likely due to poor PO intake as well as increase in
amiodarone dosage. She will require INR checks daily while in
rehab until a new stable regimen can be ascertained. She should
be re-started on warfarin at 1mg daily after her INR is less
than 3.0. Goal INR [**2-20**]. Patient should follow-up with
cardiologist Dr. [**Last Name (STitle) 11493**] in 2 weeks.
.
# Diffuse rash with oral lesions: This was felt to be erythema
multiforme due to metronidazole per [**Location (un) **] dermatology consult.
It is improving on steroids. Prednisone was tapered as follows:
60 mg x 3 days, 40 mg x 2 days, 20 mg x 2 days, 10 mg x 2 days,
then stop. On discharge ([**2149-7-22**]) she was given the 1st day of
20mg. For pruritus, triamcinolone, sarna, and atarax were
continued. The patient continues to have oral lesions,
predominantly on the tongue that cause pain with eating. She was
given a maalox/benadryl/lidocaine mouthwash QID and a
dexamethasone swish and spit TID which provided some symptomatic
relief. The patient was advised to follow up within 1 week with
Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **] who saw her at [**Location (un) **].
.
# Acute kidney injury: Pt has an unclear baseline, though per
records had recent [**Last Name (un) **] secondary to gent toxicity. Cr on
presentation to [**Location (un) **] was 1.8 and improved to 1.5 on transfer,
and was 1.2 at the time of discharge from [**Hospital1 18**]. [**Month (only) 116**] have been
pre-renal component, as she improved with normalization of
volume status and cardiac output. Urine studies were all normal
(urine sediment, urine electrolytes, smear for eosinophils).
Renal function should be monitored in outpatient setting.
.
# Leukocytosis: The WBC decreased from 20.1 on admission to 8.7
on discharge. The patient remained afebrile and there was no
evidence of infection on chest x-ray, blood culture, TTE, TEE,
or U/A. The etiology was likely steroids vs. stress response.
Urine cultures were positive for Pseudomonas sensitive to
ciprofloxacin however the UA was negative for LE and nitrites
and she was asymptomatic so no treatment was indicated at this
time. However if she becomes symptomatic antibiotic
sensitivities are included in this report above.
.
# Hypertension: After cardioversion the patient maintained blood
pressures consistently over 140/90 and therefore she was started
on losartan 50mg [**Hospital1 **] and amlodipine 5mg daily. Also on
metoprolol succnate 50mg daily. Based on the home medication
list that we have, she was not previously taking any
anti-hypertensives. Her worsening hypertension may be explained
by treatment with steroids or alternatively because her cardiac
output improved after cardioversion. Her blood pressure may
normalize as steroids are tapered therefore she may need
adjustment to her anti-hypertensive regimen. She should have BP
checked daily and she was advised to follow-up with her
cardiologist Dr. [**Last Name (STitle) 11493**] in 2 weeks.
.
# Acute on Chronic Diastolic Heart Failure: The patient had an
episode of pulmonary edema on evening prior to transfer to [**Hospital1 18**]
and was on 6L NC. CXR at that time showed bilateral pulmonary
vascular congestion. TTE here shows low-normal EF of 50%.
Patient with history of diastolic dysfunction, and episode of
afib with RVR likely contributed to acute dCHF exacerbation.
She diuresed well with IV lasix. CXR prior to discharge showed
no pulmonary edema and she did not have any clinical evidence of
heart failure. She did not require any diuretics at the time of
discharge. Was discharged on metoprolol and losartan. Will
follow-up with cardioolgy.
.
# Recent enterococcus endocarditis: Per review of OSH records,
the patient originally presented to [**Location (un) **] in may of this year
with 1 month of weakness and fatigue, and was found to have
enterococcus bacteremia. She was treated with almost 1 month of
Vanc/Gent (PCN allergic). This was stopped 3 days prior to the
planned course, as she developed ARF. All subsequent blood
cultures at the OSH and [**Hospital1 18**] were negative. She did exhibit any
stigmata of endocarditis during her admission and TTE and TEE
were negative.
.
# Rheumatic heart disease s/p porcine MVR: Her goal INR is
2.0-3.0. Her INR was 3.5 at the time of discharge. She should be
restarted on warfarin 1mg daily once INR <3.
.
INACTIVE ISSUES:
.
# ? diverticulitis: AT [**Hospital1 18**] her abdominal exam was benign. No
intervention was instituted at this time, particularly given her
side effect to flagyl.
.
# Hypothyroidism: Her synthroid was continued, and her TSH was
wnl.
.
# ? Hx of Depression: The patient was taking sertraline 50mg
daily at home. This was discontinued at the outside hospital and
it was not reinstituted after transfer to [**Hospital1 18**]. I was not able
to find the rationale for discontinuing the medication in the
records we have. The patient reports that she had been started
on it several months ago and therefore it does not appear that
it was related to the patient's rash. Regardless, she does not
currently meet criteria for major depressive disorder and the
patient states that she would prefer to not take it. However,
there is no contra-indication to her resuming another
anti-depressant in the future.
.
# Nutrition: Patient has limited PO intake secondary to pain
from oral lesions (in setting of erythema multiforme),
particularly with very hot and very cold foods as well as spicy
foods. She was able to tolerate ensure/boost pudding. Can
continue on dexamethasone swish and spit and
maalox/diphenhydramine/lidocaine mouthwash as needed for oral
pain
.
LABS PENDING AT THE TIME OF DISCHARGE: None
.
TRANSITIONAL ISSUES:
-Please monitor INR daily and restart warfarin at 1mg daily when
INR <3. Please trend INR and adjust warfarin dose accordingly
(goal [**2-20**]).
-Please monitor BP and adjust antihypertensive regimen
accordingly. Losartan increased from 50mg daily to 50mg [**Hospital1 **] on
[**2149-7-22**].
-Please monitor electrolytes and renal function at least twice
weekly, as patient has recently been started on new blood
pressure medications and is recovering from acute kidney injury.
-Patient will need PCP, [**Name10 (NameIs) 2086**], and dermatology follow-up.
It is important that she see dermatology within the next [**1-19**]
weeks for follow-up of erythema multiforme.
-PT at rehab
-Please monitor nutrition, and continue Boost milkshakes and
Ensure pudding supplements (or equivalent) with meals until
patient's oral intake improves. Patient may continue to use
dexamethasone swish and spit and
maalox/diphenhydramine/lidocaine mouthwash as needed for oral
pain.
.
-Code status: Full
-Contact: Daughter [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is HCP, home phone
[**Telephone/Fax (1) 89391**].
Medications on Admission:
Medications at home:
-patient unsure, and states that these have frequently changed
going from home to rehab
.
Medications on transfer:
-synthroid 88 mcg daily
-Kdur 20 meq daily
-amiodarone 200 mg daily (on IV amiodarone until this AM)
-triamcinolone ointment [**Hospital1 **]
-prednisone 60 mg daily (plan for 60 mg x 3 days, 40 mg x 2
days, 20 mg x 2 days, 10 mg x 2 days, then stop)
-nystatin 5 mL swish and swallow qid x 5 days
-colace 100 mg [**Hospital1 **]
-lopressor 25 mg q6 per cardiology
-IV diltiazem gtt
Discharge Medications:
1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. triamcinolone acetonide 0.025 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): apply to affected areas. Talk to
your dermatologist about when to stop. .
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pruritis.
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Disp:*2 * Refills:*2*
10. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: Take 2 pills (20mg total) on [**2149-7-23**]. Take 1 pill (10mg) on
[**2149-7-24**] 1 and 1 pill on [**2149-7-25**], and then stop .
Disp:*4 Tablet(s)* Refills:*0*
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. Magic Mouthwash
Maalox/Diphenhydramine/Lidocaine 15-30 mL PO QID:PRN mouth pain
16. Warfarin
To be restarted at 1mg daily when INR <3
17. dexamethasone 0.5 mg/5 mL Solution Sig: Five (5) ML PO TID
(3 times a day) as needed for mouth/tongue pain: swish and spit.
18. losartan 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
life care of [**Hospital3 **]
Discharge Diagnosis:
Primary diagnoses:
Atrial fibrillation with rapid ventricular response
Acute kidney injury
Erythema multiforme
Acute on chronic diastolic heart failure
Hypertension
Secondary Diagnoses:
Rheumatic heart disease s/p porcine mitral valve replacement
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 7594**], it was a pleasure taking care of you while you
were at [**Hospital1 18**]. You were transferred to [**Hospital1 18**] for management of
atrial fibrillation. You underwent a successful procedure
(cardioversion) which restored your normal rhythm. You were
also continued on a medication (amiodarone) that will help
prevent atrial fibrillation in the future.
You had fluid that backed up into your lungs while you were in
the abnormal heart rhythm, and the fluid back-up improved while
you were here.
We also continued medications for your rash. Our dermatologists
here recommended adding a topical steroid swish and spit
solution to help control the pain from the lesions in your
mouth. You should also follow-up with dermatology at [**Location (un) **]
Dermatology.
The following medication changes were made:
STOP TAKING:
1. Metronidazole (Flagyl)
2. Sertraline (Zoloft)
3. Potassium
4. Milk of magnesia
DOSE CHANGES:
1. Amiodarone increased from 100mg every other day to 200mg
daily
NEW MEDICATIONS:
1. Metoprolol Succinate 50mg Daily (for blood pressure and
control of heart rate)
2. Losartan 50mg Twice Daily (for blood pressure)
3. Amlodipine 5mg Daily (for blood pressure)
4. Prednisone: Take 2 pills (20mg) on [**2149-7-23**]. Take 1 pill (10mg)
on [**2149-7-24**] and 1 pill (10mg) on [**2149-7-25**]. (for rash)
5. Hydroxyzine 25 mg every 6 hours as needed for itching
6. Triamcinolone Acetonide 0.025% Ointment. Apply twice daily to
affected areas. Talk your dermatologist about when to stop using
this.
7. Sarna Lotion (camphor-menthol 0.5-0.5 %) apply every 6 hours
as need for itching.
8. "Magic Mouthwash" (Maalox/Diphenhydramine/Lidocaine) 15-30 mL
every 6 hours as needed for mouth pain
9. Dexamethasone Oral Solution (0.1mg/1mL) use 1 tsp to swish
and spit up to three times a day as needed for mouth/tongue pain
10. Senna as needed for constipation
Please continue to take all other medications as you were
previously prescribed.
Remember to let all of your doctors know that [**Name5 (PTitle) **] are allergic
to Flagyl (metronidazole).
Followup Instructions:
Name: [**Last Name (LF) 11493**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**] MD
Address: [**Apartment Address(1) 28703**], [**Location (un) **],[**Numeric Identifier 28704**]
Phone: [**Telephone/Fax (1) 11650**]
***We were unable to schedule a follow up appointment with Dr.
[**Last Name (STitle) 11493**]. The office is closed until [**7-28**]. Please contact them
at that time to schedule a follow up to your hospital stay. You
will need an appointment within 2 weeks of your discharge.***
Name: HELD,[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] DERMATOLOGY
Address: 190 [**Location (un) **], RD. [**Apartment Address(1) 89392**], [**Location (un) **],[**Numeric Identifier 28704**]
Phone: [**Telephone/Fax (1) 89393**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within
1 week. You will be called with the appointment. If you have not
heard from the office within 2 days or have any questions,
please call the number above.
After you are discharged from rehab, you will need to follow-up
with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 63998**]. Please call
[**Telephone/Fax (1) 25685**] to schedule an appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
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],
[
[
15382,
15393
]
],
[
[
16122,
16161
]
],
[
[
17687,
17701
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] | 57
| 569
| 0
| 78
| 1
| 0
| 0
| 0
| 0
| 1
| 0
| 0
| 1,445
| 85
| 0
| 0
| 0
| 1,920
| 0
| 167
| 0
| 1
| 0
| 0
| 0
| 0
| 2,107
| 0
| 0
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| 0
| 0
| 0
| 0
| 0
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| 0
| 0
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| 0
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| 91
| 0
| 0
| 0
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| 0
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 723
| 0
| 0
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| 79
| 0
| 0
| 0
| 0
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| 0
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| 0
| 0
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| 0
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| 0
| 616
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| 1,126
| 0
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| 0
| 426
| 0
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 88
| 0
| 0
| 5,151
| 0
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| 0
| 0
| 0
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| 0
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| 5,265
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| 2,583
| 0
| 0
| 0
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| 0
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| 0
| 0
| 1,302
| 814
| 0
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| 113
| 0
| 0
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| 0
| 0
| 0
| 0
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| 0
| 0
| 0
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| 0
| 385
| 326
| 289
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| 0
| 0
| 0
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|
92,790
| 128,026
|
35051
|
Discharge summary
|
Report
|
Admission Date: [**2120-1-10**] Discharge Date: [**2120-1-13**]
Date of Birth: [**2100-8-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Macrodantin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
elective Chiari Malformation
Major Surgical or Invasive Procedure:
craniectomy
History of Present Illness:
The patient came into the hospital for an elective craniectomy
for a Chiari malformation.
Past Medical History:
headaches
Social History:
lives with parents
Family History:
non-contributory
Physical Exam:
Oriented x 3. The patient is full strength in all 4 extremites.
Her sensation in her face and extremities is intact. She does
have some numbness around the back portion of her head.
Pertinent Results:
CT Head [**2120-1-10**]:
FINDINGS: Resection changes at the posterior atlas and inferior
occipital bone at the level of the foramen magnum are noted
without evidence of hemorrhage. There is a large amount of
pneumocephalus which layers along the frontal and temporal lobes
as well as the near the site of occipital resection and brain
stem. There is no evidence of hydrocephalus or shift of normally
midline structures. There is no evidence of infarction. The
cerebellar tonsils are again noted to lie below the level of
the foramen magnum.
IMPRESSION: Post-craniectomy changes include a large amount of
pneumocephalus. There is no evidence of hemorrhage or shift of
normally
midline structures.
Brief Hospital Course:
The patient went to the OR for an elective craniectomy and the
procedure went well with no complications. She was transferred
to the ICU overnight. The patient had a significant amount of
nausea and vomiting for many hours. She also had a significant
amount of pain the first night. After changing her antiemetic
regimen and increasing her pain medication she improved. By the
afternoon of post-op day#1 she was able to be transferred to the
floor. The patient continued to improve and started taking in
liquids on post-op day#2. She was voiding on her own and walked
with PT. The patient was safe to be discharged and went home
with her parents on post-op day#3.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for Pain: No driving while on narcotics.
Disp:*60 Tablet(s)* Refills:*0*
4. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as
needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Chiari Malformation
Discharge Condition:
neurologically stable
Discharge Instructions:
?????? You must wear your hard collar until you come back to the
office for follow up. You may remove it briefly for showering.
No baths until your sutures are removed.
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to the office in [**8-10**] days(from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 3 months.
?????? You will need a CT scan of the brain without contrast.
Completed by:[**2120-1-16**]
|
[
"787.01",
"348.4"
] |
icd9cm
|
[
[
[
1667,
1685
]
],
[
[
2783,
2801
]
]
] |
[
"02.92"
] |
icd9pcs
|
[
[
[
304,
314
]
]
] | 7
| 666
| 0
| 15
| 25
| 0
| 0
| 0
| 0
| 700
| 0
| 0
| 620
| 19
| 0
| 0
| 0
| 567
| 0
| 23
| 0
| 0
| 0
| 0
| 0
| 0
| 1,579
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 184
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 31
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 92
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
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| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 12
| 21
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
99,944
| 185,654
|
38672
|
Discharge summary
|
Report
|
Admission Date: [**2161-2-16**] Discharge Date: [**2161-2-21**]
Service: MEDICINE
Allergies:
Demerol / Morphine / Hydrocodone / Codeine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
S/p Fall
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
85 yo F with HTN, polymyalgia rheumatica, transferred from [**Hospital1 18**]
[**Location (un) 620**] for cardiac catheterization. The patient was in her
usual state of health until Wednesday [**2-11**], when she developed
black diarrhea, occuring 5 times daily. The patient attributes
the black color to her iron supplements. Along with diarrhea,
the patient also experienced 2 episodes of vomiting (clear, no
blood or coffee grounds). The patient also had fever to as high
as 100.6 on Friday [**2-13**] and Saturday [**2-14**].
On Sunday [**2-15**], the patient became lightheaded when getting up
from the toilet and fell, hitting her head and right elbow. She
presented to [**Hospital1 18**] [**Location (un) 620**], where head and c-spine CT were
negative. She developed chest pain after admission, relieved
with metoprolol and nitroglycerin. She received 1 unit of RBCs
for Hct 27, and became short of breath. She was given 40mg IV
lasix and diuresed 500cc. She ruled in for MI with third set of
troponins peaking at 0.26. She was transferred to [**Hospital1 18**] for
cardiac catheterization on 100% non-rebreather and a heparin
gtt. Of note, pt was guaiac positive on admission.
On arrival to [**Hospital1 18**], the patient was taken to the cardiac
catherization lab, where she was found to have severe 3-vessel
disease and an elevated LVEDP (see below for details). She was
transferred to the CCU on a non-rebreather for further
management. In the CCU, the patient was weaned to a
non-rebreather. She reported that her breathing was improved and
had no other complaints.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, cough,
hemoptysis, or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. She denies
sore throat, sinus congestion, dysuria. She denies weakness,
tingling, or numbness. All of the other review of systems were
negative.
Cardiac review of systems is notable for chest pain and
lightheadedness as above and two pillow orthopnea. No syncope.
The patient reports a recent decrease in exercise tolerance from
100 feet on a flat surface to 50 feet on a flat surface.
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Diastolic CHF
Chronic Kidney Disease (Baseline 1.5-1.7)
Right BBB
MRSA in nares
Atrial Fibrillation
Gout
Cellulitus
Polymyalgia Rheumatica
Diverticulosis
Depression and Anxiety
S/p cholecystecomty/appendectomy
S/p tonsillectomy
S/p surgery for anal fissure
Social History:
Retired. Worked as secretary. Lives alone at [**Location (un) 582**].
-Tobacco history: quit 40 yrs ago; smoked 1 ppd x 30 years
-ETOH: denies
-Illicit drugs: denies
Family History:
Father with stroke at 68. Mother with MI at 65. Two brothers
with HTN. Had 4 children (one died).
Physical Exam:
(Per Admitting Resident)
VS: T=97.5 BP=129/54 HR=69 RR=18 O2 sat=96%/6L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTA anteriorly (could
not sit up due to recent cath).
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs
[**2161-2-16**] 05:30PM BLOOD WBC-13.7* RBC-3.60* Hgb-9.7* Hct-29.4*
MCV-82 MCH-27.0 MCHC-33.0 RDW-14.9 Plt Ct-311
[**2161-2-16**] 05:30PM BLOOD Neuts-92.2* Lymphs-5.4* Monos-2.1 Eos-0.3
Baso-0
[**2161-2-16**] 11:01PM BLOOD PT-12.0 PTT-26.0 INR(PT)-1.0
[**2161-2-16**] 11:01PM BLOOD Glucose-174* UreaN-31* Creat-1.5* Na-141
K-3.3 Cl-105 HCO3-22 AnGap-17
[**2161-2-16**] 11:01PM BLOOD CK(CPK)-110
[**2161-2-16**] 11:01PM BLOOD CK-MB-3 cTropnT-0.14*
[**2161-2-16**] 11:01PM BLOOD Calcium-8.6 Phos-4.3 Mg-1.9
[**2161-2-16**] 05:33PM BLOOD Type-ART O2 Flow-15 pO2-75* pCO2-34*
pH-7.46* calTCO2-25 Base XS-0 Intubat-NOT INTUBA
Discharge Labs
[**2161-2-21**] 05:42AM BLOOD WBC-14.9* RBC-3.43* Hgb-9.8* Hct-29.3*
MCV-86 MCH-28.4 MCHC-33.2 RDW-15.2 Plt Ct-360
[**2161-2-21**] 05:42AM BLOOD PT-12.1 PTT-25.7 INR(PT)-1.0
[**2161-2-21**] 05:42AM BLOOD Glucose-103* UreaN-36* Creat-1.4* Na-139
K-4.2 Cl-98 HCO3-32 AnGap-13
[**2161-2-21**] 05:42AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.1
[**2161-2-18**] 04:05AM BLOOD %HbA1c-6.1* eAG-128*
CXR ([**2161-2-18**]) - The size of the cardiac silhouette is at the
upper range of normal, there is no evidence for overt pulmonary
edema. In the right upper lobe as well as in the entire left
lung, the interstitial markings are increased, there are patchy
areas of opacities, that are ill-defined and distributed in a
mainly peribronchial pattern. In addition, a small left basilar
atelectasis and a small left pleural effusion is seen. Overall,
the morphology and distribution of the changes suggests
multifocal pneumonia rather than pulmonary edema. No evidence of
right basal changes, no evidence of right-sided pleural
effusion.
CXR ([**2161-2-20**]) - In comparison with study of [**2-18**], there has been
placement of left subclavian PICC line extends to the mid
portion of the SVC. There has been some decrease in the
bilateral patchy areas of opacification, most likely consistent
with improving pneumonia.
Cardiac Cath ([**2161-2-16**]) -
1. Coronary angiography in this right dominant system
demonstrated severe three vessel CAD. The LCx was the least
stenosed and there was no obvious single culprit stenosis. The
LMCA had distal calcification with a hazy 30% stenosis. The LAD
was heavily calcified with diffuse disease throughout with
serial 60% stenoses just before a major D4 with a distal 85%
stenosis and an 80% apical stenosis. There was a high D1,
functionally a large septal branch which was patent. A large D2
and D4 were also patent. The LCx was tortuous proximally with
slow flow and mild diffuse disease in the AV groove LCx. OM
branch had a proximal 50% stenosis with a tortuous upper pole
and mild diffuse disease in the lower pole. The distal AV groove
LCx supplied collaterals to the distal RCA system. The RCA was
heavily calcified with a 40% ostial stenosis without pressure
dampening. There was proximal diffuse disease up to 75% and
distal diffuse disease before the RPDA up to 45%. There was
moderate diffuse disease throughout the RPDA with severe diffuse
disease in the distal AV groove RCA supplying the RPLs with slow
flow (? severe disease vs. competitive flow from collaterals).
Septal collaterals from the LAD fill the RPDA.
2. Limited resting hemodynamics revealed mildly elevated RA
pressure
with a mean RAP of 9 mmHg. There was severely elevated left
sided filling pressures with an LVEDP of 29 mmHg. There was
moderate systemic arterial systolic hypertension with an SBP of
160 mmHg. No cardiac index could be calculated as unable to
float PWP catheter beyond RA.
3. Modest hypoxemia (O2 sat 93% on 15L NRB mask) improved to 96%
with the addition of 2L via nasal cannula arguing against
significant shunt physiology.
FINAL DIAGNOSIS:
1. Severe three vessel CAD.
2. Severe left ventricular diastolic dysfunction.
Brief Hospital Course:
85 yo F with HTN, Afib, dCHF, CKD, h/o guaiac-positive stools,
transferred from [**Hospital1 **] [**Location (un) 620**] for cardiac catheterization in the
setting of elevated cardiac enzymes, new focal wall motion
abnormalities, and worsened MR. [**Name13 (STitle) **] to have extensive 3-vessel
disease.
# Coronary Artery Disease: Pt noted to have a troponin leak at
an OSH, with peak of 0.26. Was transferred to [**Hospital1 18**] for cardiac
catheterization, which revealed three-vessel disease. Given
this, pt is a poor candidate for PCI. After much discussion, pt
decided that she would not want cardiac surgery. [**Hospital 49578**]
medical management was pursued. During her hospitalization, she
experienced episodes of chest discomfort, particularly at night.
She did not exhibit any ECG changes during these episodes. Her
metoprolol was uptitrated, and she was started on a long-acting
nitrate for further antianginal activity. By the time of
discharge, she had been free of chest pain for several days.
# Acute on Chronic Diastolic HF / Worsened Ritral Regurgitation:
Echo at OSH showing new focal wall motion abnormalities and
worsened MR, likely of ischemic etiology. On presentation, she
was thought to be hypervolemic. Metoprolol and amlodipine were
tirated for optimum BP control / afterload reduction. The option
of mitral valvular surgery was addressed, but the patient was
not interested in cardiac surgery. She was diuresed with bolus
IV lasix, which was converted to PO lasix prior to discharge.
# Pneumonia: CXR performed on [**2161-2-18**] was suspicious for
multifocal pneumonia. Pt was initially started on broad-spectrum
coverage with vancomycin, cefepime, levofloxacin. She was noted
to spike a fever on the night of [**2161-2-18**]; however, she remained
afebrile after that. She did also have a leukocytosis throughout
her hospitalization, which was improving at the time of
discharge. On [**2161-2-20**], her antibiotics were narrowed to
levofloxacin, as she had no positive cultures and appeared
improved clinically. Of note, at the time of discharge, she did
continue to have an oxygen requirement, which was likely
multifactorial in etiology (see below).
# GI Bleeding: The patient was noted to have guaiac positive
stools during her hospitalization. She did have one episode of a
hematocrit drop, for which she received a unit of PRBCs. Her
hematocrit remained stable after that. She also complained of
some episodes of dysphagia, with food getting "stuck" in her
throat. She states that this has been occuring for some time.
She was seen by GI for both of these issues. Further evaluation
with a barium swallow was recommended as an outpatient. Further
work-up of her GI bleeding should also be pursued as an
outpatient. Of note, in the setting of this GI bleeding, her
aspirin dose was decreased and her PPI dose was increased. Her
iron was also discontinued.
# Oxygen Requirment: Likely multifactorial in the setting of the
patient's pneumonia and severe MR. Treatment as above.
# Positive Blood Cx: One blood cx positive for GPR's. Likely a
contaminant. Speciation pending and not further cultures
positive at the time of d/c.
# Pre-Diabets: Pt was noted to have elevated blood sugars in the
CCU. A1C was 6.1, consistent with pre-diabetic state. This
should be further followed as an outpatient.
# Chronic Kidney Disease: Baseline creatinine 1.5 to 1.7. The
patient remained at her baseline throughout the hospitalization.
ACE inhibitors was held in the setting of her kidney disease.
# Diarrhea: Pt presented with some recent diarrhea in the
setting of recent fever and chills. Stool cultures were sent,
including C.diff, and were negative. Her diarrhea improved.
# Vitamin D Repletion: Pt's previous vitamin D regimen was not
entirely clear. She is being discharged on 1000 units of Vitamin
D3 daily. This may be adjusted as an outpatient if more
significant vitamin supplementation is desired.
# Polymyalgia Rheumatica: Continued on home prednisone dose.
# Anxiety/Depression: Continued on nortriptyline and zyprexa at
home dose.
Medications on Admission:
Ativan 0.5 mg daily PRN
Tylenol 650 mg Q4H PRN
Prochlorperidzine 10 mg Q6H PRN
Lidoderm 5% patch apply to left hip for 12 hours on 12 hours off
Norvasc 5 mg daily
Prilosec 20 mg daily
Nortriptyline 10 mg daily
Metoprolol ER 100 mg daily
Vitamin D 50,000 units weekly for 4 weeks, then monthy
prednisone 10 mg daily
Drisdol once a month
ferrous sulfate 325 mg [**Hospital1 **]
Tylenol 1000 mg PO BID
Calcium carbonate 500 mg TID
acidophilus 1 capsule [**Hospital1 **]
Zyprexa 5 mg daily
Trazodone 12.5 mg PO QHS
Senna 1 tab [**Hospital1 **]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea .
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day: to right hip, 12 hrs on, 12 hrs
off.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: total
dose = 225mg/day.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: total
dose = 225mg/day.
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
13. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
14. Acidophilus Capsule Sig: One (1) Capsule PO twice a day.
15. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime)
as needed for insomnia.
17. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual x3 as needed for CP : Up to three doses
separated by 5 min. If not resolved after three, call physician.
19. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days: Start [**2-22**] am.
20. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for reflux.
21. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
22. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
23. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Primary:
Acute on chronic diastolic heart failure
Pneumonia
Coronary artery disease
Secondary:
Chronic kidney disease
Guaiac positive stool
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance
Discharge Instructions:
You were admitted to [**Hospital1 18**] for a heart catheterization to
evaluate for coronary disease. We found disease in all 3 blood
vessels as well as a leaky mitral valve. You declined to have
heart surgery to repair these problems. We removed extra fluid
with medications called diuretics and treated you for a
pneumonia.
Please take all medications as prescribed. We have made the
following medication changes:
STOPPED:
Lorazepam (Ativan)
Ferrous sulfate (iron)
CHANGED:
Increased metoprolol succinate to 225mg daily
Vitamin D to 1000 units daily
STARTED:
Atorvastatin for cholesterol
Levofloxacin for 4 days (antibiotic for pneumonia)
Isosorbide mononitrate for chest pain
Aspirin for blood thinning
Furosemide to prevent fluid buildup
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with the physician at your nursing facility.
Please call [**Telephone/Fax (1) 62**] on Monday to set up a follow up
appointment for 2-3 weeks with one of our cardiologists.
|
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Discharge summary
|
Report
|
Admission Date: [**2115-12-16**] Discharge Date: [**2116-1-3**]
Date of Birth: [**2066-7-18**] Sex: M
Service: MEDICINE
Allergies:
Epzicom / Sustiva / Norvir
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Thoracentesis
Mechanical Intubation
History of Present Illness:
Found today by the maintence staff at his rehab with SOB,
tachypnea and found to have a O2 sat of 60%. He was brought in
by EMS and was 88% on a non-rebreather.
.
In the emergency department initial VS were T: 100. HR 115, BP
140/91, RR:34, 88% on on-rebreather. He was transitioned to
BiPAP 16/6 and sats improved to 95-98%. CXR showed b/l pleural
effusions and likely consolidation on the left. He was covered
with Vancomycin/Zosyn/Bactrim. He was also given 40mg IV lasix.
His labs were significant for 17.2 (84.6%poly, no bands) with
repeat 18.0, plts 105 (baseline 20-60's), lactate 3.1. Potassium
5.4. LFT showed ALT 62, AST 143 (in [**10-11**] ALT40/AST66), TBili
3.6, INR 2.1. He had a negative UA. ABG was performed and was
7.40/47/93/30 on BiPAP, however he was becoming more agitated
and not tolerating the BiPAP mask. He has a DNR/DNI order, but
after discussion with the ED staff he reversed his code status
to full and was intubated. He was given etomidate/ succinate.
He was sedated with versed and fentanyl. Vent settings were
Tv:550, PEEP:5, RR:16, FiO2:100% with sats in 92%.
Past Medical History:
-- HIV diagnosed [**2106**], (CD4 count 198 [**7-/2115**])
-- History of Hepatitis C, diagnosed [**2099**] and treated
unsucessfully with interferon at that time
-- Right sided retinal detachment and subsequent R-sided
blindness
-- h/o Temporal lobe epilepsy
-- h/o PCP [**Name Initial (PRE) 11091**] [**2113**]
Social History:
Tobacco - Smokes [**2-2**] pack/day x33 years
EtOH - Denies
Drugs - IVDU (Heroin) 20 years ago, cocaine until 2 years ago,
occasional marijuana use.
He is single with no children. He is currently living [**Hospital1 **]
Lights. Estranged from all family and does not want any of them
contact[**Name (NI) **]. His life partner is apparently incarcerated for a
long-term sentence.
Family History:
His mother with [**Name (NI) 933**] disease, Rheumatoid Arthritis.
Grandmother with ovarian cancer.
Physical Exam:
ADMISSION:
Vent setting: Tv:550, PEEP:5, RR:16, FiO2:100% with sats in 92%.
GEN: intubated and sedated
HEENT: left pupil 3mm and right pupil 2, reactive to light,
sclera anicteric
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2
PULM: coarse breath sounds L>R, belly breathing
ABD: Soft, distended, slight fluid wave, +BS
EXT: No C/C/E
NEURO: cranial nerves grossly intact except for pupils, Plantar
reflex downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
DISCHARGE:
VS: 97.2, BP: 100/70, P: 82, RR: 18, 97% on RA
GEN: Chronically ill appearing, cachextic AAOx person, year,
hospital, city
CV: enlarged, laterally displaced PM; reg rate rhythm, no m/r/g
PULM: decreased BS over right side to mid lung, dull to
percussion over right lower lung, no wheezes, rales, rhonchi
over left lung
ABD: BS+, soft, ND, NT, palpable HSM, minimal ascites
EXT: thin, no edema, 2+ DP/ PT pulses., +asterixis
Pertinent Results:
Hematology:
[**2116-1-2**] 05:43AM BLOOD WBC-9.7 RBC-3.97* Hgb-12.4* Hct-37.7*
MCV-95 MCH-31.3 MCHC-32.9 RDW-20.3* Plt Ct-61*
[**2115-12-16**] 10:42AM BLOOD WBC-18.0* RBC-4.32* Hgb-12.8* Hct-38.4*
MCV-89 MCH-29.7 MCHC-33.4 RDW-19.0* Plt Ct-90*
[**2115-12-16**] 10:00AM BLOOD WBC-17.2*# RBC-4.78 Hgb-14.4 Hct-43.5
MCV-91 MCH-30.2 MCHC-33.1 RDW-19.1* Plt Ct-105*#
[**2115-12-26**] 03:09AM BLOOD Neuts-79.9* Lymphs-14.4* Monos-4.3
Eos-1.0 Baso-0.5
[**2115-12-16**] 10:00AM BLOOD Neuts-84.6* Lymphs-9.4* Monos-4.4 Eos-0.7
Baso-0.8
[**2116-1-2**] 05:43AM BLOOD PT-20.4* INR(PT)-1.9*
[**2115-12-16**] 10:42AM BLOOD PT-21.9* PTT-34.4 INR(PT)-2.1*
[**2115-12-16**] 10:42AM BLOOD WBC-18.0* Lymph-10* Abs [**Last Name (un) **]-1800 CD3%-57
Abs CD3-1032 CD4%-15 Abs CD4-262* CD8%-40 Abs CD8-720*
CD4/CD8-0.4*
Chemistries:
[**2116-1-2**] 05:43AM BLOOD Glucose-85 UreaN-29* Creat-1.2 Na-136
K-4.6 Cl-103 HCO3-27 AnGap-11
[**2115-12-17**] 02:44AM BLOOD Glucose-137* UreaN-28* Creat-0.9 Na-131*
K-4.8 Cl-98 HCO3-28 AnGap-10
[**2115-12-16**] 08:14PM BLOOD Glucose-123* UreaN-24* Creat-0.9 Na-131*
K-4.6 Cl-98 HCO3-30 AnGap-8
[**2115-12-16**] 10:42AM BLOOD Glucose-96 UreaN-21* Creat-0.8 Na-135
K-5.4* Cl-99 HCO3-25 AnGap-16
[**2115-12-16**] 10:00AM BLOOD Glucose-85 UreaN-22* Creat-0.9 Na-132*
K-7.3* Cl-99 HCO3-19* AnGap-21*
[**2116-1-2**] 05:43AM BLOOD ALT-129* AST-107* LD(LDH)-320*
AlkPhos-144* TotBili-3.6*
[**2116-1-1**] 05:37AM BLOOD ALT-140* AST-106* LD(LDH)-332*
AlkPhos-136* TotBili-3.7*
[**2115-12-31**] 02:59PM BLOOD ALT-155* AST-120* LD(LDH)-321*
AlkPhos-143* TotBili-3.3*
[**2115-12-26**] 03:09AM BLOOD ALT-220* AST-342* LD(LDH)-355*
AlkPhos-121 TotBili-3.6*
[**2115-12-16**] 10:42AM BLOOD ALT-62* AST-143* LD(LDH)-531*
AlkPhos-172* TotBili-3.6*
[**2116-1-2**] 05:43AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0
[**2115-12-16**] 08:14PM BLOOD Calcium-8.7 Phos-2.4* Mg-2.2
[**2116-1-1**] 05:37AM BLOOD AFP-9.0*
IMAGING:
CXR: [**2115-12-31**]:
IMPRESSION: An AP chest compared to [**12-25**]:
Large right pleural effusion has decreased and mediastinum has
returned to the midline. Right lower lobe is presumably
collapsed. Left lung grossly clear. No left pleural effusion.
No pneumothorax. No free subdiaphragmatic gas.
CXR: [**2115-12-25**]:
SINGLE AP VIEW OF THE CHEST: An endotracheal tube tip terminates
5 cm from
the carina. A left PICC terminates within the cavoatrial
junction. An NG
tube is partially imaged. Diffuse hazy opacification of the
right hemithorax is compatible with a large layering right
pleural effusion, which is slightly denser compared to prior
study, suggestive of an interval increase in size compared to
the prior study. Aside from left retrocardiac atelectasis, the
left lung is clear.
IMPRESSION: Large right layering pleural effusion, slightly
larger compared to the prior study.
CT HEAD [**2115-12-28**]:
FINDINGS: There is no intracranial hemorrhage, mass effect,
edema, or shift of normally midline structures. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. Ventricles and sulci are
prominent for age. Suprasellar and basilar cisterns appear
patent. Paranasal sinuses and mastoid air cells are well
aerated, within limitation of motion. Vascular calcification is
present in the cavernous carotid arteries. A scleral band is
seen around the right globe. Soft tissues are within normal
limits.
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
NOTE ON ATTENDING REVIEW:
on the prior MR [**Name13 (STitle) 430**] dated [**2115-12-23**], there were FLAIR
hyperintense foci in the left temporal lobe invovling the cortex
and adjacent white amtter . These are possibly seen on the
present CT study as hypodense areas and are
inadequately assessed. Consider MR [**Name13 (STitle) 430**] if clinically indicated
to assess the extent and anture (infarct vs encephalitis).
Prominent ventricles and sulci related to volume loss.
[**2115-12-27**]: RUQ US:
FINDINGS: The liver echotexture is slightly coarsened. In
segment V of the
liver, there is a heterogeneous and overall hypoechoic lesion
measuring 1.9 x 1.8 cm. This lesion was seen on the prior CT
from [**2115-12-24**] and is
concerning for hepatocellular carcinoma. Additional hypoechoic
areas are seen at the dome of the liver in a subdiaphragmatic
distribution and are likely artifact. The portal vein is patent
and shows normal hepatopetal flow. There is no evidence of
intra- or extra-hepatic biliary duct dilatation. The common bile
duct is normal in caliber, measuring 2 mm. The gallbladder wall
is diffusely thickened, likely secondary to the patient's
underlying liver disease. The remainder of the gallbladder is
normal in appearance and no gallstones are identified.
The pancreatic tail is not well visualized secondary to
overlying bowel gas. The visualized portions of the pancreas
are unremarkable. A small amount of perihepatic ascites is
present. A large right pleural effusion is seen.
IMPRESSION:
1. Segment V liver lesion as previously seen on the CT from
[**2115-12-24**] that is concerning for HCC.
2. Additional hypoechoic foci in a subdiaphragmatic distribution
along the
dome of the liver felt likely artifactual, but suggest attention
to these
regions on next contrast-enhanced scan.
3. Large right pleural effusion.
4. Small amount of perihepatic ascites.
[**2115-12-23**] MR HEAD:
FINDINGS:
There is an area of increased FLAIR/T2 signal within the left
temporal white matter and also involving the adjacent cortex (
se 4, im [**9-11**], 13), with no associated enhancement or mass
effect or decreased diffusion. Thsi may relate to encephalitis,
inflammatory, infectious etiology/demeylinating
disease/associated with seizure. Small scattered FLAIR
hyperintense foci int hecerebral white matter are liekly
non-specific.
There is symmetric prominence of the ventricles, cisterns and
sulci. There is no other evidence of mass, infarct or
hemorrhage. There is no pathologic intracranial enhancement.
Major intracranial flow voids are preserved.
The examination is otherwise significant for small amount of
fluid/mucosal
thickening in the mastoid tips, fluid layering in the pharynx,
minimal
maxillary sinus mucosal thickening and abnormal shape of the
right globe
likely status post scleral banding.
IMPRESSION:
1. Area of increased FLAIR/T2 signal within the left temporal
white matter
and adjacent cortex could represent an area of evolving
encephalitis,
inflammatory, infectious or demyelinating process or related to
seizure.
Correlation with CSF for Herpes, etc and continued follow up can
be
considered.
2. Symmetric prominence of the ventricles, cisterns and sulci
for age,
compatible with volume loss
Brief Hospital Course:
A/P: This is a 49 yo male with PMH of HCV cirrhosis, HIV/AIDS
(CD4 count 262 [**2115-12-16**]) who presented with hypoxic respiratory
failure was admitted to the MICU with a course that was
complicated by persistent fevers, difficulty extubating and
rapidly re-accumulating pleural effusion.
MICU COURSE:
He was inbuted in the ED and transferred to the MICU. He was
placed on vancomycin, zosyn, cipro and continued on bactrim for
PCP [**Name Initial (PRE) 31304**]. Mini-BAL was negative for pneumocystis, AFB.
Bactrim was changed to prophylatic dose for PCP. [**Name10 (NameIs) **] had
persistent right sided effusion which was thought [**3-5**] hepatic
pneumothorax. Thoracentesis was done and pleural fluid was
negative for culture, malignancy. Patient had question of
pneumonia and was treated with zosyn for 10 days. Patient was
difficult to wean from the ventilator as his effusions rapidly
accumulate. He was extubated on [**12-25**]. His course was also
complicated by encephalopathic picture. MRI brain showed
question of encephalitis. He was treated with acyclovir until
the LP viral cultures came back negative. He was also followed
by hepatology as he had increasingly elevated LFTs and MR
abdomen is concerning for HCC. He was transferred to the
medicine floor on [**2115-12-26**].
MEDICINE FLOOR COURSE:
# Respiratory: Patient had persistent fevers since admission
without an identified infectious etiology. He was treated with
10 days of zosyn for presumed pneumonia. He was very difficult
to wean off the ventilator. This was thought to be secondary to
rapidily accumulating pleural effusions secondary hepatic
hydrothorax. Patient is not a good candidate for TIPS procedure
given his significant comorbidities. He was given oxygen
supplementation and treated with albuterol nebulization.
# HCV Cirrhosis: Patient has ascites and hepatic
hydropneumothorax. Diminished functional capacity of liver was
further evidenced by coagulopathy (INR 1.9-2.0). TIPS and
pleurodesis were not recommended per hepatology in the setting
of this other comorbidities. For the same reason, patient would
be a poor liver transplant surgery. He was treated with
spironolactone and lasix for diuresis. He was given lactulose
for hepatic encephalopathy.
#Altered Mental Status: hepatic encephalopathy is most likely
etiology though AIDS dementia, delirum may have also
contributed. His mental status waxed and waned. He was often not
oriented to place or time. His hepatic encephalopathy was
treated with lactulose. He was oriented to person, hospital,
year and city on discharge.
# Liver Nodule: very suspicious for HCC though AFP not elevated.
Patient has follow-up with hepatology.
# HIV/AIDS: On HAART. Last CD4 was 262 on [**2115-12-16**]. VL
undetectable. Patient meets AIDS criteria with prior CD4<200
(114 [**8-/2114**]) and previous infection with pneumocystis. HIV was
likely contributing to altered mental status and HCV cirrhosis
progression. He was treated with Raltegravir 400 mg PO BID,
Maraviroc 600 mg PO BID, Etravirine 200 mg PO BID (doubled per
ID recs). He was continued on bactrim for PCP [**Name Initial (PRE) 1102**].
Medications on Admission:
ETRAVIRINE [INTELENCE] - 100mg [**Hospital1 **]
RALTEGRAVIR [ISENTRESS] 400mg [**Hospital1 **]
MARAVIROC [SELZENTRY] - 600mg [**Hospital1 **]
Bactrim SS 1 tab daily
Lasix 40mg [**Hospital1 **]
Spironolactone 100mg daily
Lactulose 30ml [**Hospital1 **]
amitryptyline 50mg qhs
ranitidine 150mg daily
Multivitamin
Dilaudid 2mg [**Hospital1 **] prn
Celexa 40mg daily
Neurontin 300mg TID
Nystatin 10,000U swish and swallow
Tylenol prn
Marinol 10mg qachs
MS Contin 30mg TID
Tums
Diphenydramine 25mg prn
Alubterol
simetheicone 80mg prn
artificial tears
compazine 10mg prn
maalox
dulcolax
Klonopin 0.5mg TID prn
Discharge Medications:
1. maraviroc 300 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
5. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
7. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
9. multivitamin Capsule Sig: One (1) Capsule PO once a day.
10. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Marinol 10 mg Capsule Sig: One (1) Capsule PO QACHS.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for wheeze.
13. simethicone 80 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for gas pain.
14. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
15. Artificial Tears Drops Sig: One (1) drop Ophthalmic
twice a day as needed for dry eyes.
16. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
17. Maalox RS 600 mg (1.5 gram) Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day as needed for heartburn.
18. nystatin 100,000 unit/mL Suspension Sig: One (1) cap PO
twice a day as needed for thrush.
19. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
20. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
every eight (8) hours as needed for itching.
21. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
Harbour Lights
Discharge Diagnosis:
Primary: Pneumonia, hepatic hydrothrorax
Secondary: HCV Cirrhosis, HIV/AIDS
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. You
were intubated with a breathing tube to help you breath and you
were in the intensive care unit for 10 days. You were treated
with antibiotics for pneumonia. You also have a large amount of
fluid around your lungs. This was treated with drainage and with
diuretics. Your shortness improved by the time of discharge.
The following changes were made to your medications:
-INCREASED Lactulose from 30 ml twice a day to 30 ml three times
a day
-INCREASED Etravirine (Intelence) 100 mg twice a day to 200 mg
twice a day
-STOPPED: Dilaudid, Neurontin, MS Contin, Tylenol
Followup Instructions:
Name: PA [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10564**] (works with [**Last Name (LF) **],[**First Name3 (LF) **] C.)
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appt: [**1-8**] at 1pm
Department: LIVER CENTER
When: FRIDAY [**2116-1-10**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
|
[
"518.81",
"070.44",
"369.66",
"305.1",
"571.5",
"511.89",
"572.8",
"042",
"486"
] |
icd9cm
|
[
[
[
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53276
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Discharge summary
|
Report
|
Admission Date: [**2178-8-3**] Discharge Date: [**2178-8-26**]
Date of Birth: [**2100-9-20**] Sex: M
Service: MEDICINE
Allergies:
Dilantin Kapseal / Sulfa (Sulfonamide Antibiotics) / Tegretol /
Fentanyl / Thiopental / Succinylcholine / Vecuronium Bromide
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Weight gain
Major Surgical or Invasive Procedure:
PICC line placement
Milrinone infusion
admission to the cardiac intensive care unit
right heart catheterization
History of Present Illness:
Mr. [**Known lastname 109642**] is 77M with h/o systolic and diastolic CHF, a-fib,
cardiac amyloidosis, and multiple myeloma transferred from
[**Hospital1 **] initially for volume overload and need for lasix
drip and chemotherapy.
The patient was recently discharged from [**Hospital1 18**] on [**2178-6-5**], at
which time RV biopsy demonstrated cardiac amyloidosis, as well
as a bone marrow biopsy with e/o multiple myeloma. ECHO showed
e/o new systolic heart failure on top of preexisting diastolic
heart failure and is s/p cardiac catheterization with e/o 50%
left main disease, 50% LAD stenosis.
Since discharge, the patient reports weight gain, as well as
DOE. He denies orthopnea, PND, palpitations, syncope or
presyncope. He waited until he was seen by Dr. [**Last Name (STitle) **] on [**2178-7-22**]
where he was noted to have elevated JVD and 3+ LE edema. Lasix
was switched to torsemide 40mg [**Hospital1 **] with continued spironolactone
50mg daily.
When he initially presented to [**Hospital1 **], the patient was
noted to have change in mental status that was attributed to
uremia, [**Last Name (un) **], and medication side effect from torsemide. He also
had a bandemia of 9% and was initially treated for a potential
UTI. His CXR showed recurrent right pleural effusion. He was
treated for acute on chronic systolic and diastolic heart
failure with IV lasix but of note this was limited by his BP's.
Weight prior to discharge from [**Location (un) 620**] 105kg.
While on the [**Hospital1 1516**] service, the patient was being diuresed on
Lasix drip 30 mg/hour, with diuresis limited by increasing
creatinine. After discussion with Dr. [**First Name (STitle) 437**], it was thought that
the patient could benefit from milronone drip in the setting of
having a Swan placed to measure his wedge and his CO. The
patient also has an element of systolic failure, which could
also be improved with milronone.
On transfer to the floor, the patient reports feeling well.
Past Medical History:
Afib on coumadin
Diastolic heart failure (EF 60-65%)
OSA
Gout
GERD with Barrett's esophagus
Hiatal hernia
Elevated PSA
Erectile dysfunction
s/p cholecystectomy ([**2172**])
s/p right hip replacement ([**2170**])
s/p tailers bunion, fascia release, prosthesis (left foot)
([**2169**])
s/p deviated septum repair ([**2168**])
s/p tailers bunion removal ([**2166**])
s/p multiple laminectomies ([**2164**], [**2151**], [**2148**])
s/p tendon repair right arm ([**2145**])
s/p hemorrhoidectomy ([**2126**])
s/p pilonidal cyst removal ([**2120**])
s/p appendectomy ([**2116**])
s/p bone removal left foot ([**2114**])
s/p tonsillectomy ([**2106**])
Social History:
The patient is married and worked in the import business and
worked for the navy in the shipyards. He never smoked.
Family History:
Positive for hay fever.
Physical Exam:
ADMISSION EXAM:
VS - 97.9 117/63 72 18 98% on RA 105.7kg
GENERAL - chronically ill appearing male in NAD, comfortable,
slightly short of breath while speaking
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVP at 12, no carotid bruits
LUNGS - bibasilar crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 3+ pitting LE edema to upper thighs, 2+
peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-13**] throughout
DISCHARGE EXAM:
24hr I/O: 1236/1620
87.6 ->88 ->89.1
General: Well NAD,pleasant, well appearing, elderly gentleman in
NAD, laying comfortably in bed
HEENT: EOMI, PERRLA, no cerivcal lymphadenopathy, 12cm JVP
LUNGS: Fine Crackles at right base, no wheezing, rhonchi
HEART - PMI non-displaced, RRR, II/VI systolic murmur at apex,
nl S1-S2,
ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ pitting edema to calves, 2+ peripheral pulses
(radials, DPs), PICC Line in right arm w/o errythema or
tenderness.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-13**] throughout
Pertinent Results:
ADMISSION LABS:
[**2178-8-3**] 11:39PM BLOOD WBC-10.8 RBC-3.43* Hgb-11.1* Hct-35.0*
MCV-102* MCH-32.3* MCHC-31.6 RDW-15.7* Plt Ct-194
[**2178-8-3**] 11:39PM BLOOD Neuts-80.9* Lymphs-8.5* Monos-9.1 Eos-1.0
Baso-0.5
[**2178-8-3**] 11:39PM BLOOD PT-25.4* PTT-37.9* INR(PT)-2.4*
[**2178-8-3**] 11:39PM BLOOD Glucose-119* UreaN-50* Creat-1.6* Na-138
K-4.3 Cl-98 HCO3-30 AnGap-14
[**2178-8-5**] 04:20PM BLOOD CK(CPK)-31*
[**2178-8-5**] 04:20PM BLOOD CK-MB-4 cTropnT-0.14*
[**2178-8-3**] 11:39PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.4
TRANSFER LABS:
[**2178-8-7**] 03:45PM BLOOD PT-27.2* INR(PT)-2.6*
[**2178-8-7**] 03:10PM BLOOD Glucose-100 UreaN-81* Creat-2.3* Na-135
K-4.0 Cl-91* HCO3-31 AnGap-17
[**2178-8-7**] 03:10PM BLOOD Calcium-8.9 Phos-4.8* Mg-2.6
[**2178-8-6**] 11:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2178-8-6**] 11:19AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
[**2178-8-6**] 11:19AM URINE Hours-RANDOM Creat-37 Na-74 K-38 Cl-88
DISCHARGE LABS:
[**2178-8-26**] 04:26AM BLOOD WBC-15.9* RBC-3.02* Hgb-9.2* Hct-28.3*
MCV-94 MCH-30.4 MCHC-32.4 RDW-16.1* Plt Ct-233
[**2178-8-25**] 05:32AM BLOOD PT-22.4* PTT-36.2 INR(PT)-2.1*
[**2178-8-26**] 04:26AM BLOOD Glucose-118* UreaN-66* Creat-1.7* Na-131*
K-4.6 Cl-93* HCO3-29 AnGap-14
[**2178-8-15**] 06:40AM BLOOD ALT-22 AST-22 AlkPhos-93 TotBili-0.9
[**2178-8-26**] 04:26AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
Blood Culture, Routine (Final [**2178-8-26**]): NO GROWTH.
URINE CULTURE (Final [**2178-8-21**]): NO GROWTH.
KAPPA/LAMDA:
Test Result Reference
Range/Units
FREE KAPPA, SERUM 20.0 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 2.7 L 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 7.41 H 0.26-1.65
Cardiac Cath Report [**8-19**]: Elevated right- and left-sided filling
pressures, moderate pulmonary arterial hypertension in the
setting of left-sided heart failure, large V waves suggestive of
moderate to severe mitral regurgitation. Normal cardiac output
and index.
EKG [**2178-8-25**]
Atrial fibrillation. Right bundle-branch block. Left axis
deviation. Left
anterior fascicular block. Old inferior myocardial infarction.
Compared to
the previous tracing of [**2178-8-22**] no significant changes are
noted.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 0 148 440/457 0 -70 107
CXR [**2178-8-20**]: As compared to the previous radiograph, the patient
has received a Swan-Ganz catheter. The catheter needs to be
pulled back given that the tip is projecting over distal parts
of the right pulmonary artery. An opacity that pre-existed at
the bases of the right upper lobe is no longer visible. However,
the lung volumes have decreased and a small pleural effusion is
unchanged at the right lung base. Unchanged moderate
cardiomegaly. The right PICC line is constant in position.
RENAL ULTRASOUND:
1. No hydronephrosis. Simple bilateral renal cysts.
2. Right pleural effusion and trace of ascites seen in the
right upper
quadrant.
3. Arterial and venous flow is documented within each of the
kidneys,
however, further Doppler analysis cannot be performed as the
patient is unable to hold his breath.
Social Work:
Family has met w/ palliative team and wife expresses that the
conversation is "premature". Pt and wife have not signed DNR and
still solidifying long-term plans. Pt, wife and [**Name2 (NI) **] are aware of
life expectancy ([**7-21**] mos) and reiterated to SW and physician
that Pt is going to optimize highest level of care and the
priority is to be at home.
Pt and family met w/ infusion home care co. as an option for
next
steps. Physician communicated to pt/family that PT will be
consulted on recommendations for home vs rehab.
Family and Pt are continuing to explore all options and continue
to look into rehab's that can manage current medications however
family has reiterated that going home is their first preference.
Assessment: Family and Pt is experiencing difficult adjustment
to
illness and next steps on the best approach for Pt. SW provided
empathic listening, guidance on resources that are available,
and
encouraged Pt and family to continue to utilize clinicians to
help make an informed decision on where Pt should transition to
next.
Brief Hospital Course:
Mr. [**Known lastname 109642**] is 77M with history of atrial fibrillation on
coumadin, systolic and diastolic heart failure, cardiac
amylodosis, and multiple myeloma who initially presented from
OSH with weight gain and need aggressive IV diuresis, requiring
CCU admission for initiation of milrinone drip.
.
# Acute on chronic systolic and diastolic heart failure: Patient
with baseline restrictive disease secondary to his cardiac
amyloid. Also with systolic CHF first seen [**5-21**] with RV free
wall hypokinesis. He presented with diffuse peripheral edema,
worsening abdominal distention and JVP elevated to 12 cm,
consistent with right sided failure. He also presented with
right pleural effusion that represented transudate [**3-12**] CHF. He
was initially diuresed with lasix drip and metolazone with good
effect, but was stopped after increasing creatinine. He was
then transferred to the ICU for diuresis with milrinone for
inotropic effect and pulomary vasodilation allowing right sided
unloading. His right heart pressures were monitored by swan-ganz
cath with PA pressure 50 to 40s and wedge pressures of 28 to 19
after administartion of milrinone. He diuresed well in the CCU,
was transfered to the floor, but after weaning milrinone, he
required reinitiation of milrinone in the CCU due to drop off in
energy level, urine output an reaccumulation of fluid. He
tolerated reinstitution of milrinone infusion well and was
transferred to the floor. He was also continued spironolactone
and torsemide after period of autodiuresis from [**Last Name (un) **] ended. Over
the course of the hospitalization he lost about 40lbs. His
discharge weight was roughly equivalent to his dry weight at
89.1 kg (196 lbs). He was counseled on the importance of daily
weights and CHF management. He will follow up with Dr. [**Last Name (STitle) **]
in cardiology clinic.
.
[**Last Name (un) **]: Pt developed [**Last Name (un) **] in the setting of aggressive diuresis.
Nephrology was consulted and felt this was likely ATN vs
pre-renal due to hypoperfusion. It was unlikely a sequelae of
MM or amyloid as no protein was found in the urine. After
discontinuing Lasix gtt, he autodiuresed. Upon discharge, his
Creatinine returned to his baseline of 1.7.
.
Community Acquired Pneumonia: Pt developed cough and
leukocytosis with CXR findings of right upper lobe infiltrate.
He was treated with Ciprofloxacin and then Levofloxacin caused
him to have a supratherapeutic INR above 5. For the remainder
of 10 day abx course, his coumadin was held.
.
# Cardiac amyloidosis with restrictive myopathy: The patient has
history of cardiac amyloidosis confirmed on RV biopsy, and has
resulting restrictive heart disease, with subsequent R sided
dilation and R sided heart failure as above.
.
# Multiple Myeloma: During his last admission, patient was found
to have a monoclonal kappa band and severe hypogammaglobulinemia
on SPEP/UPEP. He underwent bone marrow biopsy which showed 40%
plasma cells. Abdominal fat pad biopsy both performed [**5-28**],
revealed no amyloid but RV cardiac biopsy was positive for
amyloid. He also continued dexamentasone/velcade treatment
while inpatient. Cycle4 Day8 Velcade administration on [**8-25**].
Will continue treatment with Dr. [**Last Name (STitle) 109643**].
.
# Coronaries: The patient has history of 3VD s/p NSTEMI during
his last admission. Cath from that admission with e/o 50% left
main disease, 50% LAD stenosis. It was decided that the patient
was too high risk for CABG, as well as PCI given his amyloidosis
and was discharge on medical management of his CAD. He was
continued on atorvastatin 80 mg daily, ASA 162 mg daily,
metoprolol 12.5 mg [**Hospital1 **].
.
# Afib: Stable. CHADS score of 2 (age and CHF). He was
continued on coumadin for goal INR of 2.0-2.5 given for
increased risk of bleeding with amyloid. During the hospital
course, he reached a supratherapeutic INR ~5 after
fluoroquinolones were addded. His coumadin was held for a few
days and restarted to maintain appropriate anticoagulation. He
will continue INR checks and Coumadin management through Dr. [**Name (NI) 109644**] office.
.
# BPH: stable, continued doxazosin
.
# GERD/Barrett's/hiatal hernia: stable, continued omeprazole,
home tums
.
# DEPRESSION/sleep: stable, continued amitriptyline, zolpidem.
.
# GOUT: stable, continued allopurinol, colchine, tramadol prn
.
TRANSITIONAL ISSUES:
-Cycle4 Day8 Velcade administration on [**8-25**]. will f/u with Dr.
[**Last Name (STitle) 3759**]
[**Name (STitle) **] monitored by Dr. [**Last Name (STitle) 3759**]
[**Name (STitle) 30412**] not amenable to palliative care now
-patient is a full code
-?depression versus adjustment reaction with depression
-Discharge and dry weight 89.1 kg (196 lbs).
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR OSH records.
1. Atenolol 12.5 mg PO DAILY
2. Aspirin 162 mg PO DAILY
3. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral qAM
4. Multivitamins 1 TAB PO DAILY
5. Torsemide 40 mg PO BID
6. Omeprazole 20 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Amitriptyline 30 mg PO HS
9. Doxazosin 4 mg PO HS
10. Zolpidem Tartrate 5-10 mg PO HS
11. Allopurinol 100 mg PO QHS
12. Colchicine 0.6 mg PO HS
13. Guaifenesin Dose is Unknown PO Frequency is Unknown
14. Warfarin 5 mg PO DAILY16
15. TraMADOL (Ultram) 50 mg PO QID pain
16. Nitroglycerin SL 0.3 mg SL PRN CP
17. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn indigestion
Discharge Medications:
1. Hospital Bed
2. Milrinone 0.26 mcg/kg/min IV INFUSION
RX *milrinone in D5W 20 mg/100 mL (200 mcg/mL) 0.26 mcg/kg/min
continuous infusion Disp #*1 Mutually Defined Refills:*12
3. Amitriptyline 30 mg PO HS
4. Aspirin 162 mg PO DAILY
5. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn indigestion
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*3
9. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
10. Warfarin 4 mg PO DAILY16
RX *warfarin 2 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
11. Zolpidem Tartrate 10 mg PO HS:PRN sleep
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *Milk of Magnesia 400 mg/5 mL 30 mL(s) by mouth every 6 hours
Disp #*1 Bottle Refills:*3
13. Sarna Lotion 1 Appl TP DAILY:PRN itchy
RX *Sarna Anti-Itch 0.5 %-0.5 % apply to itchy skin daily Disp
#*1 Bottle Refills:*3
14. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet
Refills:*3
15. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 80 mg 1-2 tablets by mouth four times a day Disp
#*120 Tablet Refills:*3
16. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral qAM
17. Nitroglycerin SL 0.3 mg SL PRN CP
18. Allopurinol 100 mg PO QHS
19. Outpatient Lab Work
INR check on [**8-28**] with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 109645**] at
[**Telephone/Fax (1) 21962**]. ICD-9 427.31
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY
-acute on chronic systolic heart failure
-amyloidosis with restrictive myopathy
-multiple myeloma
-community acquired pneumonia
-Hyponatremia
-acute kidney injury
-atrial fibrillation
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:
It was a pleasure caring for you while you were at [**Hospital1 18**]. You
were admitted for treatment of your congestive heart failure.
Our testing suggested this was a result of the effects on your
heart from your multiple myeloma. You were started on a
medication called milrinone that helped your heart pump better
and given medications to help you urinate off all the excess
fluid. Your weight was decreased by about 40 pounds. We tried
to stop the milrinone infusion, but your clinical picture
worsened without this medication and it was determined that you
will need it chronically infusing from now on. Home services to
assist with this have been set up for you. You also continued
to recieve therapy for your multiple myeloma while and inpatient
and will continue to see Dr. [**Last Name (STitle) 109645**] as an outpatient.
You were discharged on diuretics (torsemide) in order to keep
your weight down. Your discharge weight was 89.1 kg (196 lbs),
you should call Dr.[**Name (NI) 10159**] office at [**Telephone/Fax (1) 9832**] if you
notice your daily weight goes up by more than 3 lbs in a day or
if you notice worsening swelling in your legs, shortness of
breath while walking or any other symptoms that concern you.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2178-9-1**] at 2:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2178-9-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2178-9-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2178-8-30**]
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94,452
| 126,300
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48367
|
Discharge summary
|
Report
|
Admission Date: [**2139-7-7**] Discharge Date: [**2139-7-16**]
Date of Birth: [**2058-11-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22864**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
PICC line placed on [**2139-7-13**]
History of Present Illness:
80 year old female with a history of multiple sclerosis,
alzheimer's disease, hypertension who presents from a nursing
home with one day of back pain. Per staff at her nursing home
she was in her usual state of health until the day prior to
presentation when she began to complain of back pain. She was
unable to clarify further. Her temperature was 100.4 with blood
pressure 162/82. She received vicodin and tylenol without
improvement. At baseline she is alert, oriented but does not
ambulate. She is able to eat by herself but is incontinent of
urine and stools. She was transferred to [**Hospital3 **] for further
management.
.
In the ED, initial vs were: T: 98.0 P: 90 BP: 104/69 R: 16 O2
sat: 92% on RA. She became tachycardic to the 140s (sinus
tachycardia) with stable blood pressures and spiked a fever to
101.5. Her antibiotics were broadened to vancomycin and cefepime
and she had a CT of the chest with contrast which was not timed
appropriately and did not show a large pulmonary embolism but
could not rule out a small pulmonary embolism. She also received
2 mg morphine, tylenol, ciprofloxacin 500 mg x 1, morphine 2 mg
IV x 1 and haldol 2.5 mg IV x 1. She received 2 liters of IV
with improvement in her heart rate to the high 100s. She was
admitted to the ICU for further management.
.
On the floor, she is unable to clarify further. She says that
she has been having back pain for 2-3 days. The pain is in her
bilateral back. It is worse with movement. It was not associated
with any trauma that she recalls. She denies fevers, chills,
lightheadedness, dizziness, chest pain, difficulty breathing,
nausea, vomiting, abdominal pain, diarrhea, constipation,
dysuria, hematuria, leg pain or swelling.
Past Medical History:
Multiple sclerosis
Coronary Artery Disease
Hypertension
Hyperlipidemia
Osteoporosis
Hypothyroidism
Depression
Chronic sinusitis and allergic rhinitis.
Endometriosis, status post laparoscopy.
Dysfunctional uterine bleeding
Social History:
Currently coming from nursing home. No current smoking, alcohol
or illict drug use. Very remote smoking history (less than 3
pack years). Used to work in a cardiology office.
Family History:
Coronary artery disease in brother. Possible MS in a deceased
sister.
Physical Exam:
Vitals: T: 99.8 BP: 109/68 P: 89 R: 16 O2: 95% on RA
General: Alert, oriented to person and hospital, not [**Hospital1 18**], date
or year, speech slurred (noted in previous neurologic exams)
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender in epigastric region and right upper
quadrant, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: foley draining [**Location (un) 2452**] urine (received pyridium in ER)
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, excoriations throughout
Back: Pain in paraspinal region bilaterally, no flank pain
Neurologic: CN II-XII tested and intact, strength 5/5
throughout, sensation intact across all dermatomes, reflexes 2+
and symmetric, unable to assess gait
Pertinent Results:
[**2139-7-7**] 01:35PM BLOOD WBC-12.2*# RBC-4.03* Hgb-11.9* Hct-37.1
MCV-92 MCH-29.6 MCHC-32.2 RDW-13.8 Plt Ct-338
[**2139-7-7**] 01:35PM BLOOD Neuts-80.9* Lymphs-12.4* Monos-5.4
Eos-1.0 Baso-0.3
[**2139-7-7**] 01:35PM BLOOD Glucose-118* UreaN-22* Creat-1.0 Na-140
K-3.6 Cl-101 HCO3-29 AnGap-14
[**2139-7-8**] 04:08AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.8
[**2139-7-7**] 01:35PM BLOOD ALT-13 AST-15 AlkPhos-90 TotBili-0.4
[**2139-7-7**] 04:15PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.026
[**2139-7-7**] 04:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2139-7-7**] 04:15PM URINE RBC-3* WBC-21-50* Bacteri-MANY Yeast-NONE
Epi-4
.
Micro
[**2139-7-7**] Aerobic Bottle Gram Stain (Final [**2139-7-8**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2139-7-8**]):
GRAM POSITIVE COCCI IN CLUSTERS.
LAST POSITIVE BLOOD CULTURE ON [**7-9**]:
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 101883**],
[**2139-7-7**].
Anaerobic Bottle Gram Stain:
GRAM POSITIVE COCCI IN CLUSTERS
MRSA SCREEN: No MRSA isolated
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
[**2139-7-8**] Urine culture: ESCHERICHIA COLI. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
URINE CULTURE ON [**2139-7-11**]: NO GROWTH.
.
[**2139-7-7**] ECG: Probable sinus tachycardia versus regular SVT at
148, borderline left axis, borderline prolonged QTc at 470, no
St segment elevation or depression, compared with prior dated
[**2138-2-25**] the rate is faster.
.
[**2139-7-7**] CXR: No evidence of pneumonia.
.
[**2139-7-7**] CTA chest: Equivocal subsegmental pulmonary embolism in
a right upper lobe branch (3:38, 402b:54) may reflect volume
averaging artifact. no large PE. bibasilar atelectesis. no acute
aortic pathology.
ABD XRAY ON [**2139-7-14**]: Mild distension of the stomach is once
again noted in this study. Dilated loops of small bowel are
noted. Multiple air- fluid levels are noted on left lateral
decubitus. Colon is noted to be filled with air throughout the
colon. Overall findings are consistent with ileus.
IMPRESSION: Dilated loops of small bowel with air noted
throughout colon
consistent with ileus. Gastric distension is once again noted in
this study.
ABD US ON [**2139-7-13**]: There is no focal liver lesion identified.
There is no biliary dilatation and the common duct measures .6
cm. The portal vein is patent with hepatopetal flow. Multiple
shadowing gallstones are seen in the gallbladder which is not
overly distended. There is no gallbladder wall thickening and no
pericholecystic fluid is seen. The visualized portion of the
pancreas is unremarkable, however, the pancreas is partially
obscured by overlying bowel. The spleen is unremarkable and
measures 9.3 cm. Both right and left kidneys show no
hydronephrosis. The right kidney measures 9.0 cm and the left
kidney measures 8.8 cm. No AAA is identified on limited views of
the aorta.
IMPRESSION: 1) Cholelithiasis with no sign of cholecystitis.
Brief Hospital Course:
This is a 80 yo female with history of MS, alzheimers,
hypertension who presents from a nursing home with one day of
back pain, fever and confusion who was found to have MSSA
bacterimia and developed an ileus and transaminitis.
.
#BACTERIMIA/BACK PAIN: Given patients history of acute onset,
change in mental status, fever and elevated WBCs this was
concerning for sepsis/infection paraspinal abcess,
osteomyelitis. Given history of osteoporosis, compression
fracture was also in the differential but preliminarily no
evidence on CT chest. MRI T&L done on [**2139-7-9**] which showed no
acute processes. She was given broad spectrum antibiotics
including: ciprofloxacin and ceftaxine were given x1, Vanco IV
x 2 days until her blood culture results were available. She was
foud to have MSSA so she was started on Nafcillin 2 gm IV Q4
hrs, from [**7-10**]->[**7-13**]. Nafcillin was stopped due to increased in
LFTs, RUQ abdominal pain, nausea and vomiting. She was started
on Cefazolin 2 gm IV Q 8hrs. Patient's condition had overall
improved, her confusion resolved on the second day of admission
although she has Alzheimers at baseline. She states to always
have a baseline backpain, but it was much improved from
admission. Pt was also found to have a UTI + E.Coli which she
was treated for a total of 3 days, urine culture was repeated on
[**7-11**] which was negative.
Patient also has been followed by infectious diseases who gave
antibiotic recommendations. She had a PICC line placed on
[**2139-7-13**] which she had removed after the first day, she stated
that if was ictching and she pulled it out. She had another PICC
replaced on her Right AC which was working well prior to
discharge.
.
# Nausea and vomiting: pt complained of nausea and vomited a
small amount of greenish fluid on [**2138-7-12**] and [**7-13**]. she also had
tenderness on her right upper quad. Abdominal US showed
cholelithiasis without cholecystitis. Since Naficillin can cause
some liver toxicity, the medication was discontinued.
Transaminitis started to trend down. However, on [**2139-7-14**]
patient's abdomen looked distended, tympanic, and she continued
to complaint of RUQ abdominal pain. She had increased liquid BMs
for the prior 2 days which were attributed to motility agents
she had received. Given that she was in numerous antibiotics,
stool was sent for C-Diff and place her on prophylactic Flagyl
500mg PO. We also did a KUB which showed an ileus. This was most
likely related to an functional ileus, since she was on
narcotics, laying in bed with decreased mobility, and no BM for
a 4-5 days prior to receiving motility agents. She was made NPO
for 1 day. On physical exam her abdomen on the following day was
soft, continued to be mildly distended, but less tender. + BS x
4 quads and she had two BMs. We advanced her diet. She has been
tolerating her diet well with no N/v and no complain of
abdominal pain.
Her C-diff culture was negative and her Flagyl was D/c on
[**2139-7-16**].
#TRANSMIANITIS: As noted above she had sl. increase in AST, ALT
and Alk phos with nausea and vomiting for 2 days and RUQ
tenderness. This was thought to be related to the Nafcillin.
Once Nafcillin was D/c'd and labs started to trend down. She was
also found to have increase in Lipase of 79 and amylase of 113
on [**7-16**] . This was believed to be caused by mild pancreatitis
also related to prior treatment administration of Nafcillin. She
will have continue monitoring of LFTs, including lipase and
amylase weekly. She was doing well at discharge, tolerating her
regular diet with no complains of N/V or abdominal pain.
.
#UTI: Urine culture Positive for E.Coli > 100,000 colonies,
rresistant to cipro and ampicillin. Sensitive to the
cefalosporins, zozyn, tobramycin, Bactrim, and Nitrofurantoin.
Received 3 days of Bactrim. D/c on [**7-11**]. Repeat UA on [**7-11**].
Urine culture on [**7-11**] shows no growth.
.
#Tachycardia: Patient has been sinus tachycardic for most of her
admission. EKG remained unchanged, she was placed on tele for
the first few day of admission where she remained on sinus tachy
in rates ranging from 90s to low 100s, asymptomatic. This could
be due to mild hyperthyroidism, TSH low 0.08 and on
levothryroxine. Patient also given extra fluid bolus which she
responded well, so could also be due to dehydration. Patient
stable at time of discharge. Follow TSH and T4 as outpaint
encourage PO fluids.
.
# 2nd degree right buttock ulcer: Patient with small 2x1 cm in
diameter excoriation on right buttock. The wound care nurse
assessed and treated the wound. The wound has overall improved,
now there is only very small wound healing well less than .5cm
in diameter at the time of discharge with dressing over it.
.
#Coronary Artery Disease: No changes on EKG.
- continue aspirin 81 mg daily
.
At discharge: Patient is alert and oriented times place and
time. She respond appropriately to questions, and conversing.
Very pleasant. She moves in bed with minimal assist. She is
incontinent of urine and stool which is her baseline. She is
stable and medically clear to go back to her extended care
facility.
Medications on Admission:
Cymbalta 30 mg daily
Folic Acid 1 mg daily
Loratadine 10 mg daily
Multivitamin
Thiamine 100mg daily
Simvastatin 40 mg dialy
Vicodin 5-500 [**Hospital1 **] and Q4H:PRN
Namenda 10 mg [**Hospital1 **]
Lorazepam 0.5 mg Q6H:PRN
Prochlorperazine 10 mg Q6H:PRN
Tylenol 650 mg PRN
Milk of Magnesia 400 mg daily:PRN
Bisacodyl 10 mg PR daily:PRN
Fleets enema PRN
Senna PRN
Calcium 500 mg TId
Detrol 4 mg QHS
Aricept 10 mg QHS
Levothyroxine 125 mcg daily
Colace
Aspirin 325 mg daily
Vitamin D 50,000 q month
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q 6HRS: PRN as
needed for anxiety.
8. Donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain: ON FOR 12 HRS AND OFF FOR 12 HRS.
10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain: PLEASE DO NOT EXCEED 2GM PER
DAY .
13. Cefazolin in Normal Saline 2 gram/100 mL Solution Sig: Two
(2) gram Intravenous every eight (8) hours for 22 days: MSSA
bacterimia. PLEASE STOP ON [**2139-7-30**].
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous once a day as needed for line flush: PICC, heparin
dependent: Flush with 10mL Normal Saline followed by 2 mL of
Heparin daily and PRN per lumen.
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by 2
mL Heparin daily and PRN per lumen.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation: Please hold for loose stool.
17. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day:
PLEASE HOLD FOR LOOSE BM.
18. Compazine 10 mg Tablet Sig: One (1) Tablet PO Q 6HRS: PRN.
19. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. Calcium 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
21. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
22. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
month.
23. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
Q Day PRN as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care
Discharge Diagnosis:
Primary:
Bacteremia
Urinary tract infection
ileus
Secondary:
Alzheimers
dementia
Multiple sclerosis
HTN
depression
Discharge Condition:
Stable, confusion and pain improved. Afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] for severe back pain and confusion.
When you came into the emergency room your temperature was 101.5
F and your heart rate was fast. We found that you have an
urinary tract infection and an infection in your blood. We have
been giving you antibiotics and your symptoms of back pain and
confusion have improved.
You had Infectious Diseases consult and you will need to be in
IV antibiotics for a total of 4 to 6 weeks. You also had a PICC
line placed for the IV antibiotics.
You also developed nausea, vomiting, and pain in the right side
of your abdomen. You had a xray of your abdomen which showed
that you had a blockage in your intestine. You didn't eat for
one day and we changed some of your medications which helped you
started to feel better.
We have made the following medication changes:
-Started on Cefazolin 2 gm IV every 8 hours
You should have blood draws every week and you should follow the
appointments as noted below.
If you develop any chest pain, shortness of breath, fever
(temperature greater than 101.3 F), chills, palpitations,
confusion or for increase pain in your abdomen or in your back,
or for any other concerns you should call your doctor or come
the emergency room.
Followup Instructions:
PROVIDER: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 1420**], infectious diseases doctor,
on [**2139-8-6**] at 9:OO AM. Location: [**Hospital Unit Name **] at [**Doctor First Name **], across from [**Hospital1 **] Emergency room. Phone:
[**Telephone/Fax (1) 457**]
BLOOD DRAW: Please have CBC, Chem 7 (Na, K, Cl, HCO2, BUN,
Creat, gluc), LFTs (ALT,AST,T.bili, Alk phos), drawn weekly
while on antibiotics and have results faxed to Dr.
[**Name (NI) 1420**] at [**Telephone/Fax (1) 1419**] (Phone # [**Telephone/Fax (1) 457**]).
|
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icd9pcs
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[
[
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99,255
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31115
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Discharge summary
|
Report
|
Admission Date: [**2152-1-18**] Discharge Date: [**2152-1-29**]
Date of Birth: [**2071-8-8**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Superior mesenteric artery stenosis, NSTEMI
Major Surgical or Invasive Procedure:
1. Ultrasound-guided puncture of left brachial artery.
2. Introduction of catheter into aorta.
3. Abdominal aortogram.
4. Selective first order catheterization of celiac artery.
5. Celiac artery angiogram.
6. Selective first order catheterization of the superior
mesenteric artery.
7. Superior mesenteric arteriogram.
8. Primary stenting of superior mesenteric artery.
9. Pressure measurement across the superior mesenteric
artery.
10. percutaneous coronary intervention x 3 with placement of
drug-eluting stents
11. hemodialysis
History of Present Illness:
80 year old male with MMP including DMII, hyperlipedemia, CRF,
COPD who presented with intestinal angina and was admitted by
vascular surgery for possible stenting. As per the patient his
abdominal symptoms occurred only when he was at dialysis about
[**3-1**] of the way through. Patient was also having symptoms of
abdominal cramping. Both of these sytmpoms were felt to be
related to poor abdominal blood floor. Paitent was admitted to
vascular surgery and underwent routine angiogram on [**2152-1-18**] with
stent placement to SMA. Patient appparently in the PACU had very
difficult to control pain requiring multiple nitroglycerins with
some relief. Patient ruled in with NSTEMI with troponins
peaking to 0.89 and CK- MB to 34. Cardiology was consulted and
patient underwent cardiac catherization and was found to have
3VD. C-surgery was consulted and pt was deemed not a surgical
candidate for CABG, thus it was decided that pt would undergo
staged PCI. Plan current was for staged PCI to begin on Monday.
On transfer patient denies any current symptoms. Denies current
chest pain, abdominal pain, or shortness of breath. Patient has
severly depressed exercise tolerance. Patient states he can
barely walk a few feet without getting short of breath. Patient
also endorses chest pain with exertion that occurs when patient
walks just a few steps. Patient states this pain improves with
rest. Patient also endorses sleeping sitting up as he feels
uncomfortable if he is lying down flat. Patient states that
sometimes he sleeps upright in a chair because it is more
comfortable. IN addition, patient endorses + PND. Denies current
lower extremity swelling although he states that he previously
has had bilateral lower extremity swelling.
Past Medical History:
CAD
HTN
DMII - insulin dependent
hyperlipedemia
CRF - HD M/W/F
COPD- home O2 2L at night
Carotid stenosis s/p LCEA
CHF, dialstolic
Paget's disease
b/l total knee replacement
removal of neck cyst in [**2080**]
Social History:
Social history is significant for the absence of current tobacco
use. Pt quit smoking 4 years ago. Prior to that patient smoked
[**12-31**] pack of cigarettes from age 6 on = 35 year pack smoking
history. There is no history of alcohol abuse. Patient states he
drinks socially.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - Temp 97.6, P 70, BP 133/72, R 18, 97% on RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate recieving dialysis.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva
non-injfected.
Neck: Difficult to assess JVP given positioning.
CV: RR, normal S1, S2. distant. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. fine crackels at the
bases, no wheezes or rhonchi.
Abd: Soft, NT, ND. No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission labs-
[**2152-1-20**] 07:00AM BLOOD WBC-9.7 RBC-3.29* Hgb-11.1* Hct-31.4*
MCV-96 MCH-33.8* MCHC-35.4* RDW-14.8 Plt Ct-185
[**2152-1-20**] 07:00AM BLOOD PT-14.0* PTT-32.4 INR(PT)-1.2*
[**2152-1-20**] 07:00AM BLOOD Glucose-85 UreaN-43* Creat-7.2*# Na-140
K-4.0 Cl-97 HCO3-30 AnGap-17
[**2152-1-19**] 05:40AM BLOOD WBC-11.9* RBC-3.36* Hgb-11.0* Hct-31.7*
MCV-94 MCH-32.8* MCHC-34.8 RDW-14.7 Plt Ct-177
[**2152-1-20**] 07:00AM BLOOD PT-14.0* PTT-32.4 INR(PT)-1.2*
[**2152-1-19**] 05:40AM BLOOD Glucose-114* UreaN-67* Creat-9.3*# Na-137
K-4.7 Cl-95* HCO3-25 AnGap-22*
[**2152-1-19**] 01:30AM BLOOD CK(CPK)-24*
[**2152-1-19**] 05:40AM BLOOD CK(CPK)-63
[**2152-1-19**] 04:40PM BLOOD CK(CPK)-223*
[**2152-1-19**] 01:30AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2152-1-19**] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2152-1-19**] 04:40PM BLOOD CK-MB-34* MB Indx-15.2* cTropnT-0.89*
[**2152-1-25**] 08:52PM BLOOD CK-MB-20* MB Indx-12.7* cTropnT-2.18*
[**2152-1-21**] 04:10PM BLOOD ALT-10 AST-15 LD(LDH)-145 CK(CPK)-38
AlkPhos-58 TotBili-0.3
[**2152-1-20**] 07:00AM BLOOD Calcium-9.9 Phos-5.1* Mg-1.8
[**2152-1-21**] 04:10PM BLOOD calTIBC-168* VitB12-414 Folate-8.1
Ferritn-1505* TRF-129*
[**2152-1-21**] 04:10PM BLOOD Triglyc-184* HDL-27 CHOL/HD-4.8
LDLcalc-65
[**2152-1-21**] 04:10PM BLOOD %HbA1c-5.8
Discharge labs-
[**2152-1-29**] 07:25AM BLOOD WBC-10.4 RBC-2.98* Hgb-9.6* Hct-28.3*
MCV-95 MCH-32.3* MCHC-34.0 RDW-15.1 Plt Ct-215
[**2152-1-28**] 05:30AM BLOOD PT-15.1* PTT-34.4 INR(PT)-1.3*
[**2152-1-29**] 07:25AM BLOOD Glucose-91 UreaN-35* Creat-6.8*# Na-138
K-4.0 Cl-98 HCO3-30 AnGap-14
[**2152-1-28**] 05:30AM BLOOD CK(CPK)-24*
[**2152-1-29**] 07:25AM BLOOD Calcium-9.7 Phos-4.7*# Mg-1.6
Micro
[**2152-1-28**] 5:37 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT [**2152-1-28**]**
GRAM STAIN (Final [**2152-1-28**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2152-1-27**]):
Feces negative for C.difficile toxin A & B by EIA.
MRSA SCREEN (Final [**2152-1-27**]): No MRSA isolated.
Blood Culture, Routine (Final [**2152-1-27**]): NO GROWTH
====================================
Reports-
Cath [**2152-1-20**]
COMMENTS:
1. Coronary angiography of this right dominant system revealed
three
vessel CAD. The LMCA had mild luminal irregularities. The LAD
was a
tortuous vessel with a 95% calcified mid vessel lesion. The LCx
had a
99% mid vessel lesion. The RCA serial 90% proximal and mid
vessel
lesions.
2. Hemodynamic evaluation revealed severely elevated right and
left
sided filling pressures. The pulmonary arterial systolic
pressure was
severely elevated at 65mm Hg. Mean PCWP was elevated at 31 mm
Hg.
Systemic arterial pressures were elevated at 132 mm Hg. Cardiac
index
was preserved at 3.94 l/min/m2.
3. Left ventriculography revealed no mitral regurgitation.
LVEF was
60% with normal regional wall motion.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severely elevated biventricular filling pressures.
3. Pulmonary arterial systolic hypertension.
=========================================
Cath [**2152-1-25**]
COMMENTS:
1- Successful stenting of the mid LCX with two overlapping
Microdriver
BMSs (2.5x18 and 2.5x8 mm). Final anfiography revealed 0%
residual
stenosis with TIMIn III flow and no dissection or distal emboli.
2- Failed attempt to cross the LAD into the diagonal.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the mid LCX with two overlapping bare
metal
stents.
3. Failed attempt to cross the LAD lesion.
=========================================
Cath [**2152-1-27**]
COMMENTS:
1- Sucecssful rotablation, PTCA and stenting of the proximal-mid
RCA
with two overlapping Driver BMSs (3.5x15 and 3.5x24 mm). Final
angiography revealed 0% residual stenosis and no dissection or
distal
emboli.
2- Partially successful deployment of an 8 French Angioseal
closure
device to the left CFA with limited bleeding that responded to
compression.
3- Vagal reaction requiring Dopamine infusion.
FINAL DIAGNOSIS:
1. Successful rotablation, PTCA and stenting of the proximal-mid
RCA
with two overlapping Driver BMS.
2. partially successful deployment of
an 8 French Angioseal.
3. Vagal reaction secondary to groin compression requiring
Dopamine
infusion.
4. Consider CT scan to r/o retroperitoneal hemorrhage if
dopamine
requirement persists or significant hematocrit drop.
======================================
Cardiology Report ECG Study Date of [**2152-1-20**] 2:37:12 PM
Baseline artifact. Sinus rhythm with borderline P-R interval
prolongation.
predominantly inferolsateral ST segment depressions. Since the
previous tracing of [**2152-1-19**] atrial premature beats are no longer
seen.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 [**Telephone/Fax (3) 73455**]/411 78 76 40
=======================================
Brief Hospital Course:
80 year old male with MMP who presents for vascular procedure
with SMA stenting for mesenteric ischemia, having NSTEMI post
procedure, found to have extensive CAD not amenable to surgery,
now status post staged PCI.
NSTEMI: On [**2152-1-19**], patient had an NSTEMI (ruled in with
troponins positive) and required increasing amounts of
nitroglycerin. Patient had unstable angina though he remained
hemodynamically stable. Patient underwent a cardiac
catheterization with which showed extensive cardiac disease (The
LAD had a 95% calcified mid vessel lesion. The LCx had a 99%
mid vessel lesion. The RCA serial 90% proximal and mid vessel
lesions.) He was evaluated for CABG and thought not to be a
candidate given multiple medical problems including PVD and
Renal failure on HD. Instead, staged PCI was planned and
medical therapy optimized including ASA, clopidogrel, and
heparin gtt until PCIs were completed. Because he had
persistent chest pain and ST depressions v4-v6 despite nitro gtt
after catheterization, he was transferred to the CCU while
awaiting the procedures.
.
On arrival to the ccu he was chest pain free but continued to
have nitermittent symptoms. Nitro drip was titrated to pain
relief. ASA, Plavix, atorvastatin, metoprolol, and lisinopril
were continued. He underwent staged PCI with 2 bare metal
stents to the LCx and then another PCI with two bare metal
stents to the RCA. He will need continued plavix tx for at
least 1 month. Per pt request he will follow up with his
cardiologist by his home.
.
#.ESRD- Patient had a history of ESRD likely [**1-31**] hypertension
and diabetes, on MWF dialysis. On [**1-21**] he became hypotensive
during HD and was only able to have 1 L removed. Because he had
elevated R heart pressures on cath, the plan was made to
undertake ultrafiltration with the plan to remove more fluid and
prevent pulmonary edema. Afte that he had his regular HD, with
good results. He has an appointment to restart his MWF HD after
discharge. Sevalamer was continued; nephrocaps were started.
.
#. Pump - Patient had evidence clinically of heart failure by
history with PND, dyspnea on exertion as well as previous
history of lower extremity edema, although ventrigulograph done
with cath showed normal EF and wall motion. On arrival to the
ccu, patient appeared euvolemic to slightly overloaded. ACEI and
beta blocker were continued.
.
# Diabetes - Patient was not on outpatient medications. Sliding
scale was instituted. Pt was discharged on diabetic diet. He
will f/u with his PCP.
.
# Hyperlipdemia - Patient with history of hyperlipedemia. Lipid
panel showed LDL 65 on 20 mg atorvastatin as an outpatient.
Given NSTEMI, he was changed to atorvastatin 80mg.
.
# Carotid stenosis s/p LCEA: Statin and ASA were continued.
.
# Anemia - Normocytic and hematocrit of 28 in the setting of
chronic renal failure. Iron panel consistent with anemia of
chronic disease. Also with decreased EPO production. Goal Hct
>30 given NSTEMI and angina; no transfusion was required.
# COPD - on 2L NC at night PRN at home, continued while in
patient. Will resume use at home.
He was discharged home with home safety evaluation planned. He
will have PCP and cardiology follow up.
Medications on Admission:
Albuterol 90 1-2 puffs IHH q 6 hours PRN
Albuterol nebs PRN
Ipratropium 0.2 mg/ml 0.02% solution, 1 q 6 PRN
Ipratropium-albuterol [**12-31**] q 6 hours PRN
Metoprolol Tartate 50 mg PO daily
Nitro PRN
Omeprazole 20 mg PO daily
Oxygen 2L at night
Ranitidine 300 mg PO q hs
Sevelamer 2400 mg PO QID
Simvastatin 20 mg PO daily
Temazepam 30 mg PO qhs PRN
Acetominophen 650 mg PO q 6 PRN
Aspirin 81 mg PO daily
Docusate 100 mg PO PRN
MVI
Nut.Tx.Imparied Renal fxn, soy 0.08 gram-1.8 kcal/mL ( 1 by
mouth TID)
Omega 3- fatty acids 1 capsule at bedtime
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min as needed for chest pain.
3. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
6. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed for insomnia.
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, headache, fever.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for sob, wheezing.
13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
16. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
primary:
Non-ST elevation myocaridal infarction
Periphrial vascular disease s/p stenting to Superior mesenteric
artery
secondary:
Chronic renal failure, end stage on hemodialysis
hypertension
Diabetes mellitus, type II
hyperlipedemia
COPD
Chronic heart failure, diastolic
Carotid stenosis s/p LCEA
Paget's disease
Discharge Condition:
stable, free of chest pain
Discharge Instructions:
You came to the hospital for a procedure to open the artery to
your intestine which was done successfully. While in the
hospital you had a heart attack and had 2 procedures to place
stents in the arteries to the heart. You are now on several
medications to help keep the arteries to your heart open. It is
important that you take your plavix and aspirin every day.
Please keep your follow up appointments
Clopidogrel was added.
The following medication changes were made:
Lisinopril was added.
Metoprolol was increased.
Atorvastatin was increased.
Your sevelamer should be taken three times daily with meals.
Nephrocaps have been added.
Please return to the emergency department if you have chest
pain, shortness of breath, high fevers and chills, or other
symptoms that are concerning to you.
Please follow the wound care instructions provided to you for
your groin.
Followup Instructions:
Please resume dialysis on Monday, [**1-31**].
Please also follow up as below:
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26225**] ([**Telephone/Fax (1) 73456**] on Tues.
[**2-8**] at 3pm.
.
Please follow up with your cardiologist Dr. [**First Name (STitle) 1557**] ([**Telephone/Fax (1) 73457**] on Tuesday [**2-15**] at 2:30 pm.
.
Please follow up with Vascular Surgery:
VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-2-10**] 10:45
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2152-2-10**]
11:30
Completed by:[**2152-1-29**]
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Discharge summary
|
Report
|
Admission Date: [**2180-12-2**] Discharge Date: [**2180-12-7**]
Date of Birth: [**2129-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
attempted thoracentesis [**12-3**]
History of Present Illness:
Mr. [**Known lastname 4711**] is a 51yo male with stage IV clear cell renal
carcinoma s/p R laparoscopic nephrostomy on [**2180-9-5**], who
presented with shortness of breath worsening over the last 48
hours. The patient was recently admission for hypercalcemia,
acute renal failure and a large left pleural effusion. A Pleurex
catheter was placed during that admission but was removed prior
to discharge. The patient stated that he was home from rehab for
approximately one week and felt as if he was getting his
strength back. Two days prior to admission the patient stated
that he began to feel short of breath when working with his
physical therapist. He remained home until the next evening when
a friend took him to [**Hospital2 **] [**Hospital3 **] because he felt he could no
longer catch his breath. He was immediately transferred here. He
denied any recent fevers or chills, chest pain or dizziness. He
further denied any nausea, vomiting, constipation or diarrhea.
.
In the ER, VS were T 98.5, BP 125/70, HR 120, but his HR came
down to 90, RR 20 and saturations to 95% after the patient was
placed on 3L of O2 by nasal canula. A CXR was performed that was
concerning for bilateral pleural effusions.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- began to have fatigue, dizziness and flu symptoms in [**Month (only) 404**]
[**2180**]
- on routine visit in [**Month (only) 116**], found to have RUQ mass
- CT abd/pelvis on [**2180-6-24**] showed a large exophytic mass in R
kidney, 9.6 x 9.3 cm, with associated abdominal lymphadenopathy
and pulmonary metastasis
- CT chest showed diffuse pulmonary metastases
- CT guided needle biopsy of the kidney on [**2180-7-17**] showed high
grade carcinoma, favoring renal cell cancer, with necrosis
- enrolled in protocol 04-117: Tumor/DC fusion in patients with
Renal Cell Carcinoma on [**2180-8-16**]
- s/p R laparoscopic radical nephrectomy on [**2180-9-5**]
- path showed clear cell renal cell carcinoma with sarcomatoid
features (60%), [**Last Name (un) 19076**] grade [**5-14**], with extension into
perinephric fat (T3a, N0, M1); margins clear, LVI indeterminate
- post-surgical CT showed rapid disease progression and he was
taken off study on [**2180-10-9**]
- Completed recent two week course of Sutent and is currently
taking two weeks off
.
PAST MEDICAL HISTORY:
# Hypercholesterolemia
# Bilateral shoulder and hand surgery
Social History:
He is divorced, lives and works on [**Hospital3 **] as an electrician.
He quit smoking at age 51, one pack per week x15 years.
Previously drank 1-2 drinks several times per week, but none in
last 1-2 weeks due to feeling ill. No recreational drug use.
Family History:
Negative for kidney, prostate or bladder cancer. Father has CAD,
but is alive and well.
Physical Exam:
At admission:
VS: T 96.4, BP 130/72, HR 104, R 18, sats 95% on 2L
GEN: uncomfortable appearing, laboring to breath but NAD
HEENT: sclera anicteric, dry mucus membranes, no nasal flaring
NECK: no cervical LAD, no JVD
CV: tachycardic, regular rhythm, normal S1, S2, no m/r/g
LUNGS: decreased breath sounds at the bases bilaterally, left
worse than right, dullness to percussion
ABD: S/NT/ND, BS+
EXT: warm, well-perfused, no palpable cords, no TTP
NEURO: CN II-XII grossly intact, moving all extremities,
sensation to light touch in tact
Pertinent Results:
At admission:
[**2180-12-2**] 01:20AM BLOOD WBC-5.5 RBC-4.05* Hgb-12.6* Hct-36.5*
MCV-90 MCH-31.2 MCHC-34.6 RDW-19.6* Plt Ct-248#
[**2180-12-2**] 01:20AM BLOOD Neuts-80* Bands-4 Lymphs-12* Monos-3
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2180-12-2**] 01:20AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0
[**2180-12-2**] 01:20AM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-136
K-4.8 Cl-103 HCO3-24 AnGap-14
[**2180-12-2**] 01:20AM BLOOD Albumin-3.2* Calcium-10.9* Phos-2.6*
Mg-1.8
[**2180-12-3**] 02:06PM BLOOD Type-ART pO2-84* pCO2-46* pH-7.43
calTCO2-32* Base XS-4
[**2180-12-2**] 01:34AM BLOOD Lactate-2.5*
[**2180-12-2**] 01:36AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
On Discharge:
[**2180-12-7**] 05:46AM BLOOD WBC-4.8 RBC-3.26* Hgb-10.2* Hct-29.3*
MCV-90 MCH-31.4 MCHC-34.9 RDW-18.8* Plt Ct-326
[**2180-12-7**] 05:46AM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-131*
K-5.2* Cl-96 HCO3-27 AnGap-13
[**2180-12-7**] 05:46AM BLOOD Calcium-9.9 Phos-2.1* Mg-2.0
Blood cultures 10/23, no growth as of [**12-7**]
CTA chest [**12-2**]
IMPRESSION:
1. Progression of multiple bilateral pulmonary metastatic
lesions.
2. No evidence of pulmonary embolism.
3. Progression of right adrenal, likely metastatic lesion.
[**12-5**] AP CXR - FINDINGS: In comparison with the study of [**12-4**],
there is little overall change in the diffuse bilateral
pulmonary opacifications consistent with multiple pulmonary
metastases apparently complicated by a pulmonary edema or
hemorrhage. Enlargement of the cardiac silhouette persists and
there is mediastinal widening reflecting diffuse adenopathy.
Brief Hospital Course:
Mr. [**Known lastname 4711**] is a 51 year old male with stage IV clear cell
renal carcinoma with known lung mets who presented with
worsening shortness of breath and hypoxia.
# Dyspnea, Hypoxia - Patient initially required 2L O2 to
maintain O2 sats 94%. CTA chest on admission was negative for
PE. By hospital day two he required 4L by nasal canula. A
thoracentesis was attempted, but there was insufficient fluid to
tap. On hospital day 3 he triggered for O2 sat of 86% on 4L
nasal canula and was increased to 6L nasal canula and then
transferred to the ICU for closer monitoring and placed on a
face tent. Chest x-ray demonstrated worsening bilateral patchy
opacities. He was treated with broad spectrum antibiotics for
48 hours (vancomycin, levofloxacin, cefepime, and bactrim),
however, his respiratory status failed to improve and cultures
remained negative so antibiotics were stopped. He did not
tolerate oral bactrim due to nausea. His hypoxia and dyspnea
are most likely secondary to his widespread pulmonary metastatic
disease. He was given morphine and nebs to treat his dyspnea
and guiafenesin with codeine and benzonatate for cough.
#. Metastatic Renal Cell Carcinoma: He recently completed a
cycle of Sutent. The patient was continued on dexamethasone per
his outpatient regimen which was initiated at the time of his
whole brain radiation. It is unclear if he is continuing to
derive benefit from this medication so consideration to stopping
this medication can be given. As he has been on this medication
for almost a month, it will need to be tapered before stopping
completely. He has stage 4 disease with poor prognosis. There
are no further treatment options per the patient's oncologist.
After discussion with his oncologist following transfer to the
ICU the patient changed his code status to DNR/DNI. Palliative
care was consulted and made [**Known lastname 7219**] for symptom
management including dyspnea, nausea, and insomnia. He is being
discharged to inpatient hospice for further symptom management
and due to his high oxygen requirement.
#. Hypercalcemia: Patient was noted to have elevated calcium on
presentation. He was given IVF and lasix and calcium remained
elevated. He was also treated with a dose of pamidronate and
calcitonin.
# Hyperkalemia: The patient had intermittently elevated serum
potassiums that peaked at 5.2. Etiology is unclear but may be
secondary to dexamethasone or tumor burden causing increased
lactate due to increased metabolic demand. There was no
evidence of renal failure or acidemia.
#. Contact: friend and HCP [**Name (NI) **] [**Name (NI) 85654**] [**Telephone/Fax (1) 85655**] or
[**Telephone/Fax (1) 85656**]
Medications on Admission:
MEDICATIONS (per patient):
Dexamethasone 2 mg PO BID
Pantoprazole 40 mg PO daily
Sunitinib 12.5 mg PO daily for two weeks, then two weeks off
Lorazepam 0.5 mg PO daily Q8H
Senna 8.6 mg, 1-2 tabs PO daily as needed
.
ALLERGIES: NKDA
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea or anxiety.
Disp:*60 Tablet(s)* Refills:*0*
4. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
5. morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime) as needed for shortness of
breath.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
6. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath.
9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath.
10. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
eight (8) hours as needed for nausea.
11. morphine in 0.9 % NaCl 2 mg/mL (1 mL) Syringe Sig: 1-4 mg
Intravenous Q2H as needed for shortness of breath or pain.
Disp:*50 mL* Refills:*0*
12. Prochlorperazine 10 mg IV Q6H:PRN nausea
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): If stopped, this medication will need to be tapered
off.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospice
Discharge Diagnosis:
Primary:
Dyspnea and hypoxia
Renal cell carcinoma metastatic to lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Requires 50% face tent to maintain O2 sats > 93%
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of shortness of breath. While you were here, you had
imaging which showed that the cancer in your lungs has
progressed and is likely what is causing your symptoms. There
is no further treatment available for your cancer at this time.
You were seen by the palliative care doctors who made
[**Name5 (PTitle) 7219**] for helping to manage your symptoms.
While you were here some of your medications were changed.
-You were started on morphine and nebulized albuterol and
ipratroprium to help alleviate your shortness of breath.
-You were also given zofran and compazine as needed to treat
your nausea.
-You were given benzonatate and guiafenesin with codeine for
your cough.
-You were given lorazepam as needed for anxiety.
-You were given trazodone as needed for insomnia.
Followup Instructions:
Please follow-up with your primary care doctor,
[**Last Name (LF) **],[**First Name3 (LF) 85657**], as needed ([**Telephone/Fax (1) 85658**])
|
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icd9pcs
|
[
[
[]
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96,218
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|
43313
|
Discharge summary
|
Report
|
Admission Date: [**2189-5-10**] Discharge Date: [**2189-5-19**]
Date of Birth: [**2127-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vicodin / Cidofovir / Lisinopril / Ace Inhibitors / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dypnea
Major Surgical or Invasive Procedure:
[**2189-5-13**] AVR ([**Street Address(2) 6158**]. [**Male First Name (un) 923**] porcine)/ eplacement Ascending aorta
(30 mm Gelweave
left heart catheterization, coronary angiogram [**2189-5-11**]
History of Present Illness:
This 61 year old male is status post orthotopic liver and kidney
transplantation with a well functioning [**Month/Day/Year **] liver and a
marginally functioning [**Month/Day/Year **] kidney. He has chronic
diastolic congestive heart failure secondary to aortic stenosis.
He has a known bicuspid aortic valve and stable ascending aortic
aneurysm. He is followed closely by Dr. [**First Name (STitle) 437**] from the heart
failure service who referred him for aortic valve replacement
surgery.
He reports worsening shortness of breath, increasing fatigue
and lower extremity edema. He denied chest pain, orthopnea and
syncope. He reports symptoms of SOB and chest burning has
increased over the past month.
Past Medical History:
Chronic Diastolic Congestive Heart Failure
Bicuspid Aortic Valve, Severe Aortic Stenosis
Ascending Aortic Aneurysm
Hypertension
Hypercholesterolemia
alcoholiccirrhosis
History of variceal bleeding
end stage renal failure, s/p [**First Name (STitle) **]
Depression
s/p simultaneous liver/kidney [**First Name (STitle) **] on [**2187-10-11**]
s/p L4-5 spinal fusion
s/p Hernia Repair, left
s/p Knee Meniscal Repair
Social History:
Born in [**State **], lived in [**Male First Name (un) 1056**], then Mass for last 30
yrs, worked as school counselor and high school basketball
coach, retired [**6-1**]. Lives with wife, has dog at home. Drank [**1-28**]
drinks/day (martinis, beer) on social basis, last drink [**2187-1-21**]
for wife's birthday. Denies smoking or illicit drug use.
Family History:
Father had CABG in 40's, father and paternal grandmother with
leukemia, uncle with unknown liver problem. [**Name (NI) **] hx pulmonary
disease, diabetes, stroke.
Physical Exam:
admission:
T 98
Pulse:74 Resp:18 O2 sat:98% RA
B/P Right:118/80 Left:
Height: 72inches Weight:213#
General: WDWN male in NAD
Skin: Dry [x] intact [x] - well healed abd scars, right forearm
scar
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] - no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur IV/VI systolic ejection
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema - trace bilaterally
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 1 Left: 1
DP Right: decreased Left: decreased
PT [**Name (NI) 167**]: decreased Left: decreased
Radial Right: 1 Left: 1
Carotid Bruit Right: ? transmitted murmur Left: ?
transmitted murmur
Pertinent Results:
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
A patent foramen ovale is present with left to right flow under
anesthesia
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. There are simple
atheroma in the descending thoracic aorta. The aortic valve is
bicuspid. There is severe aortic valve stenosis (valve area
0.8-1.0cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known firstname **]
[**Known lastname **] before surgical incision.
POST-BYPASS:
Preserved biventricualr systolic function.
Intact thoracic aorta and the tube graft in the ascening aorta
is visualized well with a good contour and no leaks
Aortic bioprosthetic valve is well seated and functioning well
with a residual peak gradient of 28mm of Hg peak and 15mm of Hg
mean.
Mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2189-5-13**] 13:43
[**2189-5-18**] 05:15AM BLOOD WBC-9.4 RBC-3.17* Hgb-9.5* Hct-29.2*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.7* Plt Ct-216
[**2189-5-17**] 05:20AM BLOOD WBC-10.4 RBC-3.08* Hgb-9.4* Hct-28.7*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.0* Plt Ct-197
[**2189-5-18**] 05:15AM BLOOD Glucose-122* UreaN-60* Creat-3.3* Na-134
K-4.5 Cl-101 HCO3-24 AnGap-14
[**2189-5-10**] 04:00PM BLOOD Glucose-133* UreaN-44* Creat-3.2* Na-139
K-5.1 Cl-106 HCO3-23 AnGap-15
[**2189-5-19**] 04:40AM BLOOD PT-12.6 INR(PT)-1.1
[**2189-5-19**] 04:40AM BLOOD Glucose-104* UreaN-56* Creat-3.2* Na-136
K-4.5 Cl-101 HCO3-26 AnGap-14
Brief Hospital Course:
He was admitted on [**5-10**] for pre-op work up and cardiac
catheterization. This did not reveal significant coronary
disease. The liver /renal tranplant team clearance was obtained
for surgery. He underwent surgery with Dr. [**Last Name (STitle) **] on [**5-13**]. He
was transferred to the CVICU in stable condition on titrated
phenylephrine and Propofol drips. He remained stable, weaned
from pressors and the ventilator easily, was extubated and
transferred to the floor. He developed rate controlled atrial
fibrillation and Coumadin was added to the medications.
His pacing wires and CTs were removed per protocols and wound
were clean and healing well. Arrangements were made for
Coumadin management by Dr. [**First Name (STitle) **] and dosing and results were
given to his office. Discharge restrictions, medications and
follow up were explained to him. He remained edematous with
10kilograms of extra fluid aborad. he was discharge to home on
lasix 40mg daily, indefinitely after discussion with his
nephrologist Dr. [**Last Name (STitle) **].
Tacrolimus levels remained therapeutic on the current dose. His
BUN, creatinine and potassium will be checked on [**5-21**] along with
his INR.
Medications on Admission:
Carvedilol 25 mg po BID
Fenofibrate 160 mg daily
Lovaza 1 gram capsulte (2) capsules po BID
Prednisone 5 mg daily
Ranitidine 300 mg daily
Sertraline 50 mg po daily
Bactrim 400-80 mg po daily
Tacrolimus 1 mg capsules (2) capsules [**Hospital1 **]
Calclium Carb-Vit D3 supplement 600-400 1 tab [**Hospital1 **]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Chronic Diastolic Congestive Heart Failure
Bicuspid Aortic Valve with Severe Aortic Stenosis
dilated ascending aorta
Hypertension
Hypercholesterolemia
alcoholic cirrhosis
History of variceal bleeding paracenteses
end stage Renal failure
s/p renal [**Hospital1 **]
s/p liver [**Hospital1 **]
Depression
Discharge Condition:
Alert and oriented x3. nonfocal
Ambulating independently steady gait
Incisional pain managed with oral analgesics
Incisions:
sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] on Thursday, [**2189-6-18**] @ 1:15 pm
([**Telephone/Fax (1) 170**])
Please call to schedule appointments with:
Primary Care: Dr. [**First Name11 (Name Pattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 45859**]) in [**12-27**] weeks
Cardiologist: Dr. [**First Name (STitle) 437**] in [**12-27**] weeks
[**Date Range 1326**] and renal as requested by them
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Coumadin follow up: Indication-atrial fibrillation. Goal 2-2.5.
Next blood draw on Thursday, [**5-21**]. Fax results to Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 45868**].
Completed by:[**2189-5-19**]
|
[
"428.32",
"424.1",
"441.2",
"404.93",
"272.0",
"585.6",
"311",
"V42.0",
"427.31"
] |
icd9cm
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[
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[] |
icd9pcs
|
[
[
[]
]
] | 56
| 1,206
| 0
| 201
| 230
| 0
| 0
| 0
| 0
| 2,195
| 0
| 0
| 673
| 165
| 0
| 0
| 0
| 0
| 0
| 305
| 0
| 312
| 0
| 0
| 0
| 0
| 711
| 0
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| 711
| 0
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| 416
| 353
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| 0
| 0
| 0
| 0
|
99,366
| 136,021
|
42815
|
Discharge summary
|
Report
|
Admission Date: [**2197-3-20**] Discharge Date: [**2197-5-18**]
Date of Birth: [**2123-11-27**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Right cerebellar hemorrhage
Major Surgical or Invasive Procedure:
[**2197-3-21**] Suboccipital crani for evacuation of the Right
cerebellar hemorrhage
[**2197-3-21**] Right frontal EVD placement
History of Present Illness:
This is a 73 year old man with hypertension and vascular disease
transferred from [**Hospital3 417**] Hospital with reported
cerebellar hemorrhage. He reportedly was brought to the OSH
after developing nausea, vomiting, and diaphoresis at his
apartment complex. He arrived complaining of a [**10-25**] headache;
the nursing notes says he was awake and speaking and denied
CP/SOB on arrival. He was markedly hypertensive on arrival -- BP
was recorded initially as 232/132
(VS otherwise unremarkable). CBC and coags were normal (INR 0.9
and no known h/o A/C); BMP was pending. ECG remarkable for
obvious LVH (voltage criteria) and ?RBBB (RSR' in III), with
NSR. He was given Zofran and labetalol, and when his systolics
remained elevated in the 200s, he was started on a nitroprusside
drip. He was taken for NCHCT, which showed a 3cm Right
cerebellar hemorrhage. At some point during this initial
evaluation, he became acutely non-responsive, so he was
intubated (induced with etomodate and succinylcholine, also
fentanyl) and Med-Flighted here to [**Hospital1 18**]. He was continued on
the Nipride gtt en route, and paralyzed for transport using
rocuronium and propofol gtt.
He arrived here around 21:30 with BP 267/131, down to 168/96
with increased nitroprusside gtt rate. He was flaccid
(paralyzed). The ED resident informed me that someone had
commented on "asymmetric pupils" at some point, but the
[**Location (un) **] personell said that his pupils were 2mm and equal the
entire trip (they were this size of smaller, non-reactive, on my
arrival to the ED a few minutes after his arrival).
Past Medical History:
1. Hypertension
2. Renal artery stenosis
3. AAA endovascular repair c/b R ext iliac pseudoaneurysm, also
s/p repair [**2195**]
4. Peripheral vascular disease
5. Nephrolithiasis
6. Hyperlipidemia
7. COPD
Social History:
Lives alone, ex wife lives in U.S. but the rest of extended
family resides in [**Country 1684**]. He is primarily arabic speaking, but
understands some English. no tobacco.
Family History:
non-contributory
Physical Exam:
On admission:
Mental Status: Sedated / non-responsive. Does not blink or
track.
Later, as paralytic lifted, he grimaced inconsistently to
noxious
stimulation and spontaneously moved his Right shoulder and both
legs.
-Cranial Nerves: Pupils are equally small (1.5-2mm), round, and
non-reactive to light (?"pontine" pupils). No good view for
fundoscopy (small pupils). No doll's eye response initially.
Eyes
mid-position with no movement. Initially, no corneal response or
response to nasal tickle. Later, bilateral weak eyelash-blink
responses and legs moved to bilateral nasal tickle. Face was
symmetrically lax; when he later furrowed his brow to noxious
stimulation, it elevated symmetrically. Initially, no gag or
cough; later strong cough (tracheal suction) and weak gag
(gentle
ETT-wiggle). Initially, not over-breathing the vent and not
initiating full breaths on CPAP.
-Motor: Initially, flaccid x all extremities and axially. Later,
spontaneous minimal movements of RUE and bilatearl LEs.
At discharge:
awake, alert to self, hospital, month. following all commands.
MAE with full strengths. incision well healed.
Pertinent Results:
Head CT [**2197-3-20**]:
FINDINGS: Centered within the right cerebellum, there is a 5.4 x
3 cm
hyperdense hemorrhage with surrounding edema (previously 2.8 x 3
cm); this
hemorrhage crosses the cerebellar vermis into the left
cerebellar hemisphere. Hyperdense blood is seen within the
fourth ventricle extending up into the third ventricle. The
lateral ventricles and third ventricle are dilated measuring up
to 4.4 cm. Hyperdense blood is seen layering within the
occipital horns bilaterally. There is no significant shift of
normally midline structures. The basal cisterns inferiorly are
obliterated. The posterior fossa is expanded with mass effect on
the brainstem. The cerebellar tonsils are at the level of the
foramen magnum. No acute fracture is seen. The visualized
portions of the paranasal sinuses and mastoid air cells are well
aerated. Retained secretions are noted in the nasopharynx.
IMPRESSION: Large parenchymal hemorrhage centered in the right
cerebellar
hemisphere with intraventricular extension, mass effect, and
hydrocephalus as above, increased since 2 hours prior.
[**3-21**] Head CT
1. Interval occipital craniectomy with increased but residual
hyperdense
blood in the cerebellum and ventricles; evaluation of mass
effect is
suboptimal on this study due to portable technique.
2. Interval placement of a right frontal approach ventricular
catheter with
persistent hydrocephalus.
[**3-24**] CT head
IMPRESSION:
1. Interval significant decrease of the hydrocephalus with
normal size of the lateral ventricles and with the EVD in place.
2. Increase of subarachnoid hemorrhage in the both temporal and
occipital
lobes, likely due to redistribution of the intraventricular
hemorrhage.
3. Compared to the most recent prior study from [**2197-3-21**],
unchanged
amount of hemorrhage in the fourth ventricle and the cerebellar
hemispheres.
CT head [**2197-3-25**]
Overall stable examination without significant hydrocephalus in
the setting of external ventricular drain. Parenchymal
hemorrhage centered in the right cerebellum with extension into
the fourth ventricle and
biparietal/bitemporal subarachnoid hemorrhage, similar to 20
hours prior.
CT head [**2197-3-26**]
1. Interval removal of the right transfrontal ventriculostomy
catheter with hyperdensity along catheter tract, representing
minor parenchymal hemorrhage with trace intraventricular
extension.
2. Otherwise, the appearance is largely unchanged with
biparietal and
bitemporal subarachnoid blood, likely redistributional, related
to the right cerebellar hemispheric hemorrhage with fourth
ventricular extension, status post occipital craniectomy.
CT head [**2197-3-27**]
Unchanged right cerebellar hemorrhage with intraventricular
extension into the fourth ventricle. Unchanged biparietal and
bitemporal
subarachnoid blood. Unchanged minor parenchymal hemorrhage along
the prior
ventriculostomy catheter tract. Unchanged ventricle size. No
evidence of
vascular territorial infarction
LENIS [**2197-3-28**] IMPRESSION: No evidence of deep venous thrombosis
in the lower extremities.
CHest Xray [**3-31**]: PA and lateral radiograph demonstrates
unremarkable mediastinal, hilar and cardiac contours. Lungs are
clear. Previously noted pulmonary edema has resolved. Small
bilateral pleural effusions noted. Left subclavian line tip is
terminating in the mid-to-distal superior vena cava. No
pneumothorax.
Lower Extremity Doppler Ultrasound [**2197-4-4**]:
No evidence of deep vein thrombosis in either right or left
lower extremity.
LENIS [**4-12**]:
No evidence of deep vein thrombosis in either leg.
NCHCT: [**4-13**]: IMPRESSION:
1. Increased prominence of the extra-axial CSF spaces,
particularly evident in the right posterior fossa and right
frontal region. This may be related to volume loss from surgery,
but the patient should be followed for intracranial hypotension
with clinical correlation. Indentation on the right cerebellar
hemisphere from the right posterior fossa extra-axial fluid
collection.
2. Expected evolution of intracranial hemorrhage with decreased
density of
right cerebellar hemispheric hemorrhage, and near complete
resolution of
subarachnoid and ventriculostomy catheter tract hemorrhage.
Brief Hospital Course:
Pt was taken to the OR emergently for suboccipital craniectomy
and evacuation of ICH. Prior to this procedure a R frontal EVD
was placed without difficulty. He did recieve 2 units of
platelets for his use of Plavix. Post operatively he remained
intubated and was taken to the ICU for further care including
SBP control and q1 neurochecks. His EVD was kept at 15cm above
the tragus. On post op exam he was not following commands but
moved everything to noxious. His pupils were equal and reactive.
A head CT on the morning of [**3-21**] showed good evacuation of ICH
and decreased hydrocephalus.
On [**3-22**] he was extubated without difficulty. He was noted to be
awake and alert to self, following commands and moving all
extremities with full strength.
On [**3-24**], The patient experienced respiratory issues overnight
into am. Bipap ventilation was started at 930 am. Teh patient
was given lasix. A CXR was consistent with worseing
consolidation and empiric antibiotic therapy was initiated for
for Ventilatory Aquired Pneumonia. The WBC level was 17.2 from
14.8 on [**3-23**]. The External Ventricular Drain exhibited poor
output of 4cc from 7-9am. The EVD was distally/proximally
flushed and the extrenal ventricular drain decreased to 10 and
left open. ICPs were correlating with patient's activity and
were [**4-30**]. A NCHCT was performed which was consistent with good
placement EVD and no hydrocephalas. Emergent reintubation at
1230pm for poor ventilatory status. A triple lumen placed. and a
Bronchcoscopy was performed at the bedside and a BAL was sent.
On [**3-25**], The patient's exam improved and he was able to follow
some simple commands. The External Ventricular Drain was
discontinued as there was no drainage of CSF from the EVD and
the patient's 4th ventircle was noted to be patent on head CT.
There staples were placed for closure.
On [**3-26**], The patient neurological exam was improved and he was
able to follow commands in all four extremities with full
strength. Eyes were open sponanteously, pupils were equal and
reactive. The patient was electively extubated after diuresis
with lasix. He tolerated extubation well. The steroids were
discontinued as the patient has pneumonia and Cdiff
concurrently.
He was agitated on [**3-27**] and seroquel was increased. In the
evening he did well on Q2 hr neuro checks. He was less agitated.
Staining was noted on his pillowcase and there was a concern for
CSF leak. A clean dressing was applied and scant staining only
was noted. He had no sign of hydrocephalus on [**3-28**]. He was more
oritented and appropriate. Orders to the SDU were done. PT and
SW were consulted.
On [**3-28**], patient was transferred to the Step Down Unit. His EVD
staples were removed. His catheter was removed, but unfortnately
patient was unable to void on his own requiring him to undergo a
straight catheterization.
On [**3-29**] his dressing remained clean and dry without evidence of
leak and the patient continued to improved neurologically. He
worked with PT and was found to be orthostatic. On [**3-30**] he
continued to improve and worked with PT and began being screened
for rehab.
Attempts were made to contact the family in [**Name (NI) 1684**] but three
numbners were disconnected. He had some hypotension on [**4-1**] that
responded to fluid bolus. He was stable on [**4-2**].
On [**4-3**] his abdomen was found to be distended and post void
bladder scan revealed 1000cc remaining in the bladder so a foley
was replaced and the patient was started on Flomasx. His
creatinine bumped on [**4-4**] to 2.1 (baseline elevated > 1.3)
likely due to mild dehydration as his oral intake was poor. He
was given a fluid bolus and placed on low IV maintenence fluids.
His labs were trended. On [**4-6**] his creatinine decreased to 1.8,
and we again attempted to remove his foley.
His sutures were removed on [**4-4**].....He had screening LENIs on
[**4-4**] that were again negative for DVT. He remained stable [**4-4**]-
[**4-11**]. Disposition planning continues.
A stool sample was sent on [**4-11**] which was negative for Cdiff. On
[**4-12**] he remained stable and his creatinine was done to 1.7 from
2.0
[**4-13**] He was seen by OT and c/o dizziness - he vomited x 1 with ?
of some small blood tinged mucus. This was discarded and not
seen by staff. He did vomit again while OOB to chair without
any blood. Labs and CT were ordered after reviewing OMR.
His CT was stable with no changes. quetiapine dosing was
decreased by half.
On [**5-8**] he continued to have nausea and poor PO intact.
Nutrition was consulted and stool was sent for c-diff. nystatin
and second alpha blocker were discontinued.
On [**4-16**] the patient was orthostatic when he got up with PT. He
was given an IVF bolus and standing IVF due to his continued
poor PO intake. He was started on calorie counts.
On [**4-17**] he was neurologically stable. He continued to have
abdominal discomfort despite c-diff negative x3. Stool O+P were
sent, although discomfort is likely just due to history of +
cdiff. Laboratory values were stable.
Throughout his hospital course, he coninued to have episodes of
nausea with occasional vomiting. This responded well to Zofran
and fluid resuscitation. On [**4-19**], he remained stable.
His PO intake remained poor and the psychiatry team was
consulted as it was felt his poor po intake could be a result of
depression. The psychiatry team recommended starting remeron to
help with sleep/wake cycle.
On [**4-25**] a foley catheter d/c trial was once again initiated but
the pt failed to void so it was replaced. The urology team was
consulted since this was the 4th time he failed. They
recommended keeping the foley in place for an additional 6 days
then following up in the urology clinic.
The patient continued to remain stable awaiting his family's
arrival from [**Country 1684**].
On [**4-28**] the patient's ex-wife arrived and worked with PT/OT.
Teaching was initiated on how to care for the patient upon
leaving the hospital. He remained stable on [**5-5**]. He continued
to await disposition to an extended care facility. He had
another repeat LENIs on [**5-13**] which showed no evidence of DVT. A
CT head was obtained on [**5-14**] which showed expected evolution of
intracranial hemorrhages. No acute infarct or hemorrhage. No
evidence of hydrocephalus.
On [**5-16**] the patient failed another voiding trial and the foley
catheter was replaced. On [**5-17**] Urology was re-consulted for
persistent failure to void. They continued to recommend a
urodynamic study as an outpatient. They also recommended
intermittent catheterization, which is preferred over indwelling
foley catheter but this was not possible due to patient's lack
of participation.
On [**5-18**] the patient and his ex-wife worked with PT and OT with
the help of an interpreter and he was cleared for discharge. He
is afebrile, VSS, and neurologically stable. Patient's pain is
well-controlled and the patient is tolerating a good oral diet.
Pt's incision is clean, dry and inctact without evidence of
infection. Patient is ambulating safely over short distances
and has been given a wheelchair for longer distances.
Medications on Admission:
1. Plavix
2. simvastatin
3. amlodipine
4. labetatlol
5. lisinopril
6. Cardura (doxazosin)
7. Percocet
8. Ambien
9. Atrovent
10. Advair
11. Miralax
12. colace
13. vitamin C
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO
DAILY (Daily).
Disp:*1 bottle* Refills:*2*
10. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
inhalation Inhalation once a day.
11. Atrovent HFA 17 mcg/actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation Inhalation q6hr as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Right cerebellar hemorrhage
Intraventricular hemorrhage
Hydrocephalus
Cerebral edema
Confusion
C-Diff
VAP
Respiratory failure requiring intubation
Hypotension
Urinary retention
Nausea
Vomiting
Orthostasis
Malnutrition
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? You may shower
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a Head CT w/o
contrast. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Completed by:[**2197-5-18**]
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47569
|
Discharge summary
|
Report
|
Admission Date: [**2139-11-27**] Discharge Date: [**2139-11-29**]
Service: MEDICINE
Allergies:
Iodine / Codeine / Rose Hips / Zocor / Flecainide / Diamox
Sequels
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Weakness and Melena
Major Surgical or Invasive Procedure:
Eesophagogastroduodenoscopy
History of Present Illness:
Ms. [**Known lastname **] is an 89 year-old woman with a history of atrial
fibrillation on coumadin who presents with a GI bleed. She was
in her usual state of excellent health until yesterday morning
when she woke up feeling weak and unable to do her usual ADLs.
She also noted two black stools, which had never happened to her
before. She had no abdominal pain, nausea, vomitting.
.
In the ED, initial VS: T 99, 79, 143/54, 20, 97% RA
Labs were notable for INR 3.2 and Hct 19.7, down from 35 10 days
ago. She received vitamin K 5 mg IV and pantoprazole 80 mg
followed by 8 mg/h drip. 2 PIV were placed. GI was contact[**Name (NI) **] and
would like to scope in the morning.
VS prior to transfer: 89, 136/54, 20, 98%
Past Medical History:
-paroxysmal atrial fibrillation
-s/p PPM for pauses
-mitral and tricuspid regurgitation
-mild AS and AR
-hyperlipidemia
-chronic kidney disease
-cholelithiasis (asymptomatic
-osteoporosis
-DJD
-hearing loss
-glaucoma
Social History:
She quit smoking 25 years ago. She drinks wine very
occasionally. she lives alone and is independent in her ADLs.
She plans to travel to [**State 108**] for the winter in 3 days as per
her usual routine.
Family History:
Non-Contributory
Physical Exam:
VS: 96.3, 103/85, 500 cc u/o
GEN: pleasant, A&Ox 3, pale
HEENT: MMM, no scleral icterus
RESP: bilateral apical expiratory wheeze
CV: regular, 3/6 systolic murmur
ABD: No echymoses, + BS, no hepatosplenomegaly, non tender to
palpation. No rebound or gaurding
EXT: trace bilateral pitting edema
RECTAL: Skin tag, small amount of black stool in vault
Pertinent Results:
[**2139-11-27**] 03:30PM BLOOD WBC-11.5* RBC-2.37*# Hgb-6.9*# Hct-20.4*#
MCV-86 MCH-29.2 MCHC-34.0 RDW-17.9* Plt Ct-248
[**2139-11-27**] 11:07PM BLOOD Hct-26.5*#
[**2139-11-28**] 03:14AM BLOOD WBC-9.3 RBC-3.01*# Hgb-9.1*# Hct-26.1*
MCV-87 MCH-30.2 MCHC-34.9 RDW-16.7* Plt Ct-210
[**2139-11-28**] 01:44PM BLOOD Hct-26.7*
[**2139-11-28**] 09:00PM BLOOD Hct-27.1*
[**2139-11-29**] 07:25AM BLOOD WBC-9.9 RBC-3.14* Hgb-9.4* Hct-27.6*
MCV-88 MCH-29.8 MCHC-33.9 RDW-16.8* Plt Ct-214
[**2139-11-27**] 03:30PM BLOOD Glucose-106* UreaN-57* Creat-2.0* Na-140
K-4.2 Cl-106 HCO3-24 AnGap-14
[**2139-11-29**] 07:25AM BLOOD Glucose-98 UreaN-28* Creat-1.4* Na-145
K-3.8 Cl-111* HCO3-25 AnGap-13
[**2139-11-27**] 03:30PM BLOOD cTropnT-<0.01
[**11-28**] EGD report
Ulcer in the antrum 1.5 cm raised lesion with central erosion
noted in the antral-body junction. No active bleeding. Bile
noted in duodenum, no blood.
Erythema and petechiae in the fundus compatible with gastritis.
Otherwise normal EGD to second part of the duodenum.
Recommendations: Small non-bleeding ulceration and gastritis
noted in stomach. 1.5 cm raised gastric lesion of unknown
significance potentially from previous ulcer with raised edges
or potential submucosal lesion such as GIST.
Recommend IV BID PPI, test and treat for H-pylori, call out from
ICU. Can resume anticoagulation as needed at discharge. Advance
diet. Recommend repeat endoscopy in 6 weeks to assess
improvement in ulceration and address raised lesion if still
present and or need for EUS.
Brief Hospital Course:
Ms. [**Known lastname **] is a 89 year-old woman with atrial fibrillation on
warfarin who was admitted for an upper gastrointestinal bleed
with an INR of 3.2.
# GI bleed: She was admitted with a hematocrit of 20.4 and an
INR of 3.2. She received 5 mg IV vitamin K in the ED and her INR
fell to 1.4 over the ensuing 12 hours. She also received 2
units of pRBC with an appropriate rise in Hct to 26. After this
she felt subjectively much improved. Her coumadin was held
durring her admission. An upper endoscopy revealed gastritis,
small non-bleeding antral ulcer and 1.5 cm raised gastric
lesion. The gastroenterology service advised twice daily PPI and
a follow-up EGD in 6 weeks. H. pylori IgG was also collected and
was pending at the time of discahrge. She was to follow up with
her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in [**State 108**] early the following week.
.
# Atrial fibrillation: She had paroxysmal atrial fibrillation
and had been anticoagulated with coumadin. She did not require
rate control agents, and her rate remained stable in the
70s-80s. Anticoagulation was held durring her admission. Upon
discharge, it was decided that given her risk of stroke
anticoagulation should not be discontinued altogether. Thus, her
aspirin was stopped and she was restarted
on her anticoagulation at 5 mg on the day of discharge and 2.5
mg daily thereafter with close PCP [**Name9 (PRE) 702**] advised. She was to
get her INR checked 2-3 days following discharge with her PCP in
[**Name9 (PRE) 108**].
.
# Acute Renal Failure: Her acute elevation in serum creatinine
was likely due to relative renal hypoperfusion in the setting of
acute blood loss anemia. Her renal function improved following
blood transfusion to its prior baseline of 1.2-1.4.
.
# Hypothyroidism: Her home dose of levothyroxine 100 mcg daily
was continued.
Medications on Admission:
atorvastatin 20 mg daily
brimonidine .1% gtt one drop OD TID
levothyroxine 100 mcg daily
valsartan 80 mg [**Hospital1 **]
warfarin 2.5 mg MF, 2 mg all other days
ascorbic acid 500 mg daily
ASA 81 mg daily
calcium carbonate-vitamin D3 1250 - 200 mg daily
MVI
omega 3
vitamin E
Social History
Discharge Medications:
1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. valsartan 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Calcium+D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
6. Omega-3 Fish Oil Oral
7. Multiple Vitamins Oral
8. vitamin E Oral
9. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Take two tablets today [**2139-11-29**] and one table daily
thereafter. Please see your PCP to check to INR and adjust your
dose on Tuesday [**2139-12-1**].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Gastrointestinal Bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for black tarry stools, a sign
of upper GI bleeding. You were evaluated and treated by the
medicine service and found to be anemic. You INR was elevated at
3.2, so your coumdin was held. You also received IV vitamin K.
You were transfused 2 units of packed red blood cells for your
anemia and your blood levels remained stable througout the
remainder of your admission. You also underwent an endoscopy,
which show gastritis, a small ulcer and a 1.5cm lesion in your
stomach that will require a follow-up endoscopy in 6 weeks. You
also received a blood test for H. pylori, a bacteria that causes
ulcers; this test is still pending. If this test is positive you
will need appropriate treatment for this infection from your
PCP. [**Name10 (NameIs) **] will be contact[**Name (NI) **] via your cell phone to inform you of
the result of this test.
The following changes were made to your medication:
1. You have been STARTED on Pantoprazole 40mg twice daily for 6
weeks.
2. You have been Re-STARTED on Coumadin, you should take 5mg
today and 2.5mg daily until Tuesday when you should present to
Dr. [**Last Name (STitle) **] for an INR check and adjust the of coumdin dose
accordingly.
3. Your Valsartan has been DECREASED to 40mg [**Hospital1 **], please discuss
this change with your PCP.
4. Your Aspirin has been STOPPED, please discuss this change
with your PCP.
No other changes have been made to your medications.
Please take your medications as prescribed and keep your
outpatient appointments.
Followup Instructions:
You shold follow up with you physcian in [**State 108**] for this bleed
and your atrial fibrillation management. Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 100546**]
You will be contact[**Name (NI) **] about the results of the H. Pylori test to
your cellular phone number: [**Telephone/Fax (1) 100547**].
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icd9pcs
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[
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296,
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3854,
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94,546
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47227
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Discharge summary
|
Report
|
Admission Date: [**2169-7-9**] Discharge Date: [**2169-7-13**]
Date of Birth: [**2108-1-8**] Sex: F
Service: NEUROLOGY
Allergies:
Dilaudid (PF) / Zofran
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
right sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms [**Known lastname **] is a 61 year old LEFT handed female who presents
from an OSH s/p tPA after sudden onset of right sided weakness.
Patients husband states that she was driving to go shopping
however returned home at 2:20 pm on [**7-9**]. He states she was
complaining that the right side of her face felt 'warm and
numb.'
He sat her down and went to call an ambulance because he noticed
her speech became slurred. At that point she became
unresponsive
and would not open her eyes. EMS arrived and she was taken to
an
OSH. No seizure activity was detected. Patient was brought to an
outside hospital where she was found to be hypertensive to the
210s systolically. She also had a negative noncontrast CT. Med
flight was called for transfer to [**Hospital1 18**] ED for further care and
en route patient was started on TPA (Patient was given a bolus
and then started
on a drip on her right based on 70.9 kg) after discussion with
the stroke fellow and patients family.
Past Medical History:
HTN, GERD, diverticulitis, lymphocytic colitis
Social History:
Married, has 1 daughter. Smokes [**1-17**] PPD, [**2-16**] glasses of wine
daily, denies drugs. Works as special needs teacher.
Family History:
mother had stroke in her 60's
Physical Exam:
ADMISSION EXAM:
Temp: 98 HR: 87 BP: 134/87 Resp: 16 O(2)Sat: 99 Normal
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language dysarthric but fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. She did not have her glasses and was unable
to read but could name large letters. Initially was only
following midline commands but later followed appendicular
commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. On visual fields she did not
consistently visualize the right visual field, however
inconsistently reacted to threat on the right.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation decreased on right.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout.
Right arm with significant drift, was able to sustain the left
arm antigravity. Right leg was unable to lift antigravity with
about a 3 at the IP. left leg with significant drift.
-Sensory: decreased senstion to light touch and noxious on the
right leg, arm, and face.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: unable to formally test, but no obvious dysmetric
movements
DISCHARGE EXAM: awake, alert, oriented to person, place and
date. Mild right nasolabial fold flattening, though has
symmetric smile. Has give-way weakness on the right greater than
left. Light touch and proprioception intact throughout.
Pertinent Results:
[**2169-7-9**] 05:10PM BLOOD WBC-6.5 RBC-4.26 Hgb-14.6 Hct-40.3 MCV-95
MCH-34.3* MCHC-36.3* RDW-12.7 Plt Ct-255
[**2169-7-11**] 01:40AM BLOOD Glucose-91 UreaN-8 Creat-0.6 Na-139 K-3.7
Cl-108 HCO3-23 AnGap-12
[**2169-7-10**] 05:23PM BLOOD ALT-20 AST-18 LD(LDH)-202 CK(CPK)-46
AlkPhos-52 TotBili-0.5
[**2169-7-9**] 05:10PM BLOOD cTropnT-<0.01
[**2169-7-10**] 05:23PM BLOOD CK-MB-2 cTropnT-<0.01
[**2169-7-9**] 05:10PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2
[**2169-7-10**] 05:23PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CTA Head and neck:
1. No evidence of an acute intracranial process or evidence of a
flow-limiting stenosis.
2. 12-mm low-density left thyroid nodule with some
calcifications may be
assessed with ultrasound if not performed earlier.
3. Minor soft plaques at the carotid bifurcation.
MR head:
Diffusion images demonstrate no acute infarction. Gradient
images
demonstrate no hemorrhage. There is no intracranial mass or mass
effect. The ventricles and sulcal configuration are age
appropriate. The [**Doctor Last Name 352**]-white matter differentiation is normal.
The brain stem, cerebellum and
craniocervical junction are normal. Mucosal thickening is seen
in the
bilateral ethmoid air cells.
Echo: Suboptimal image quality due to body habitus. No cardiac
source of embolism seen. Left and right ventricular systolic
function are probably normal. No significant valvular
abnormality. Borderline elevation of pulmonary artery systolic
pressures. Negative bubble study.
CT head 24hrs post tPA:
No acute intracranial process.
Brief Hospital Course:
61 year old LEFT handed female presented from OSH s/p tPA after
sudden onset of right facial numbness and generalized weakness.
She had been given tPA on the [**Location (un) **] over to [**Hospital1 18**].
Upon arrival to [**Hospital1 18**] her NIHSS was 9 and was signifant for
inability to follow commands, oriented but slow to respond.
There was an inconsistent right hemianopia, right arm drift and
decreased right sided sensory loss, but all extremities drifted
and could not cooperate with full strength exam. The patient
also complained of a severe throbbing headache. She had been
having increasing throbbing headaches over the past 6 months,
but particularly worse over the past 1-2 weeks, associated with
nausea, seeing red flashing spots, and photophobia.
The patient was admitted to the neuro ICU for post-tPA protocol.
Head CT/CTA: no acute infarct, vascular stenosis. Brain MRI:
normal.
Toxic-metabolic workup including tox screens were negative.
Blood pressure was allowed to autoregulate with goal SBP
140s-180s. There were no arrhythmias on cardiac telemetry.
Patient was ruled out for MI.
The patient was ultimately thought to have a complicated
migraine, with functional overlay. Her headache was controlled
with Ultram, IVF, antiemetics. She actually noted significant
improvement with IV Reglan and IVF. Her neuro exam improved
gradually back to normal except for giveway weakness throughout,
more on R than L. She was started on verapamil for migriane
prophylaxis. Her home HCTZ was D/Ced.
Given her weakness and difficulty walking, patient was
recommended to be discharged to rehabilitation facility.
Patient will be following up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] as
outpatient.
Medications on Admission:
HCTZ 25 mg daily, omeprazole 20 mg daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Complicated Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro deficits: Halting speech and labile mood. Giveway
weakness of R side - downward drift of R arm and does not bear
weight on the R leg when standing.
Discharge Instructions:
You came to the hospital with symptoms of right facial numbness
folllowed by difficulty speaking and episode of fainting. There
was concern for an acute stroke, so you received IV tPA, while
en route to [**Hospital3 **]. While here, you had brain imaging,
including CT of the head and blood vessels and MRI. The imaging
was all normal and there was no evidence of stroke. You were
initially admitted to the ICU after receiving the clot busting
medication, just for monitoring; there was no complications
after receiving the medication. As there was no stroke and you
did have a headache (and recent headache symptoms consistent
with migraines), your symptoms are most likely due to a
complicated migraine. For this reason, you were started on a
medication called Verapamil to help prevent future migraines.
Followup Instructions:
Please ask your PCP for referral to follow-up with the
neurologist who oversaw your care during this admission:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2169-8-28**] 2:30
[**Hospital Ward Name 23**] Building ([**Hospital1 18**]), [**Location (un) **]
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2169-10-30**] 5:15
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge
from rehab.
Completed by:[**2169-7-13**]
|
[
"V45.88",
"401.9",
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icd9cm
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427,
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1440
]
],
[
[
5759,
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[
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[] |
icd9pcs
|
[
[
[]
]
] | 98
| 1,745
| 0
| 7
| 1
| 0
| 0
| 0
| 0
| 1,578
| 0
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| 619
| 32
| 0
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| 24
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| 43
| 0
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99,559
| 146,121
|
44071
|
Discharge summary
|
Report
|
Admission Date: [**2153-6-11**] Discharge Date: [**2153-6-19**]
Service: MEDICINE
Allergies:
Azulfidine / Penicillins / Aspirin / Allopurinol / Dilantin /
Tegretol / Keppra / Trileptal
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Fungal UTI, Infected Renal Calculus, Acute Renal Failure,
Septicemia
Major Surgical or Invasive Procedure:
Percutaneous Nephrostomy Tube
History of Present Illness:
88 year old female transferred from [**Hospital3 **] with
chief complaint of persistent acidosis in spite of more
aggressive treatment of UTI. On [**5-27**] Urine culture grew
Klebsiella pneumonea and E.Coli. She received 10 days
ciprofloxacin PO.
On [**6-8**] they started ceftriaxone IV. On [**6-11**] ordered for
Vancomycin but did not receive (remote [**11/2152**] U/C MRSA). Also
noted to have CO2: 12 (had been 16-20 lately). ABG at HRC
7.31/27/94, HCO2 13.6/total CO2 14.4. She has not had any fever
in past week but continued to have dysuria, malaise and failure
to thrive.
She was recently ([**Date range (1) 32334**]/09) admitted to [**Hospital1 18**] for epistaxis &
vaginal bloody discharge on ASA; now off ASA and no more
epistaxis/?vaginal blood. Also has had ARF at HR responding to
IVF. Vaginal U/S that admit (patient declined vaginal u/S)
showed bilateral renal calculi- largest right 1.2 cm with
prominent renal pelvis and no hydronephrosis.
ED Course: Labs consistent with metabolic acidosis, ARF. She got
IVF and IV Vancomycin. Her urine cultures at that time grew out
yeast.
Past Medical History:
1) Ulcerative colitis, status post colostomy in [**2132**]
2) Hypertension
3) Chronic renal insufficiency (baseline 1.4-2.0)
4) Osteoarthritis
5) History of Seizures, on topiramate
6) Atrial fibrillation, on amiodarone
7) Urge incontinence, on tolterodine
8) Bilateral cataracts
9) History of microscopic hematuria
10) Nephrolithiasis
11) Depression
12) Renal cysts
Social History:
Lives at [**Hospital 100**] Rehab. Smoked 2 packs per week many years ago.
No smoking currently, no etoh, no IVDU.
Daughters: [**Name2 (NI) **] [**Telephone/Fax (3) 94605**]
[**Doctor First Name **] [**Telephone/Fax (1) 94606**], [**Telephone/Fax (1) 94607**]
Family History:
non contributory
Physical Exam:
VSS: 98, 78, 22, 127/72, 96/RA
GEN: appears lethargic, drowsy, although answers appropriately
Pain: 0/0
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: diffuse tenderness, colostomy bag present draining copius
clear fluid
EXT: - CCE
Nephrostomy CDI
Midline CDI
NEURO: lethargic, open eyes to commands, able to communicate,
oriented atleast x2; able to lift all extremities
Pertinent Results:
[**2153-6-19**] 06:25AM BLOOD WBC-10.1 RBC-3.03* Hgb-9.0* Hct-29.4*
MCV-97 MCH-29.7 MCHC-30.6* RDW-15.9* Plt Ct-288
[**2153-6-18**] 09:15AM BLOOD WBC-16.5* RBC-3.11* Hgb-9.5* Hct-29.7*
MCV-95 MCH-30.7 MCHC-32.1 RDW-15.6* Plt Ct-276
[**2153-6-17**] 07:53AM BLOOD WBC-26.3* RBC-2.97* Hgb-9.1* Hct-28.1*
MCV-95 MCH-30.5 MCHC-32.3 RDW-15.8* Plt Ct-269
[**2153-6-16**] 03:50AM BLOOD WBC-29.9* RBC-2.89* Hgb-8.6* Hct-27.1*
MCV-94 MCH-29.9 MCHC-31.8 RDW-16.0* Plt Ct-273
[**2153-6-15**] 05:35PM BLOOD WBC-39.7* RBC-3.08* Hgb-9.5* Hct-29.2*
MCV-95 MCH-31.0 MCHC-32.7 RDW-15.4 Plt Ct-297
[**2153-6-15**] 03:15PM BLOOD WBC-37.5* RBC-3.19* Hgb-9.9* Hct-31.0*
MCV-97 MCH-30.9 MCHC-31.8 RDW-15.8* Plt Ct-287
[**2153-6-15**] 01:20PM BLOOD WBC-41.0*# RBC-3.31* Hgb-10.2* Hct-31.5*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-279
[**2153-6-14**] 06:20AM BLOOD WBC-9.2 RBC-3.54* Hgb-10.7* Hct-33.3*
MCV-94 MCH-30.4 MCHC-32.3 RDW-15.8* Plt Ct-325
[**2153-6-13**] 09:52AM BLOOD WBC-9.4 RBC-3.99* Hgb-12.1 Hct-36.8
MCV-92 MCH-30.3 MCHC-32.9 RDW-16.1* Plt Ct-387
[**2153-6-12**] 06:25AM BLOOD WBC-9.8 RBC-3.33* Hgb-10.4* Hct-31.4*
MCV-95 MCH-31.3 MCHC-33.1 RDW-16.2* Plt Ct-353
[**2153-6-11**] 07:52PM BLOOD WBC-9.9 RBC-3.71* Hgb-11.1* Hct-35.3*
MCV-95 MCH-30.0 MCHC-31.5 RDW-15.7* Plt Ct-443*
[**2153-6-11**] 06:50PM BLOOD WBC-10.9 RBC-3.90*# Hgb-11.8*# Hct-37.4#
MCV-96 MCH-30.3 MCHC-31.6 RDW-15.6* Plt Ct-421
[**2153-6-17**] 07:53AM BLOOD Neuts-90.7* Lymphs-5.7* Monos-2.9 Eos-0.6
Baso-0.1
[**2153-6-16**] 03:50AM BLOOD Neuts-94.1* Lymphs-2.8* Monos-2.9 Eos-0.1
Baso-0
[**2153-6-19**] 06:25AM BLOOD PT-17.2* PTT-41.6* INR(PT)-1.5*
[**2153-6-18**] 09:15AM BLOOD PT-16.8* PTT-44.0* INR(PT)-1.5*
[**2153-6-17**] 07:53AM BLOOD PT-17.9* PTT-44.5* INR(PT)-1.6*
[**2153-6-15**] 05:35PM BLOOD PT-17.5* INR(PT)-1.6*
[**2153-6-19**] 06:25AM BLOOD Glucose-105 UreaN-41* Creat-1.7* Na-137
K-3.6 Cl-102 HCO3-20* AnGap-19
[**2153-6-18**] 09:15AM BLOOD Glucose-88 UreaN-36* Creat-1.7* Na-136
K-3.6 Cl-105 HCO3-19* AnGap-16
[**2153-6-17**] 07:53AM BLOOD Glucose-105 UreaN-33* Creat-1.7* Na-140
K-3.7 Cl-109* HCO3-20* AnGap-15
[**2153-6-16**] 03:50AM BLOOD Glucose-125* UreaN-32* Creat-2.0* Na-139
K-3.1* Cl-107 HCO3-20* AnGap-15
[**2153-6-14**] 06:20AM BLOOD Glucose-107* UreaN-36* Creat-2.5* Na-134
K-4.3 Cl-98 HCO3-23 AnGap-17
[**2153-6-11**] 07:52PM BLOOD Glucose-106* UreaN-37* Creat-3.0* Na-128*
K-4.0 Cl-100 HCO3-11* AnGap-21*
[**2153-6-11**] 06:50PM BLOOD Glucose-112* UreaN-37* Creat-3.2*#
Na-130* K-4.2 Cl-99 HCO3-14* AnGap-21*
[**2153-6-18**] 09:15AM BLOOD ALT-33 AST-34 AlkPhos-116 TotBili-0.4
[**2153-6-15**] 03:15PM BLOOD ALT-34 AST-128* LD(LDH)-454* AlkPhos-89
TotBili-0.5
[**2153-6-14**] 06:20AM BLOOD ALT-17 AST-28 AlkPhos-75 Amylase-91
TotBili-0.2
[**2153-6-14**] 06:20AM BLOOD Lipase-33
[**2153-6-19**] 06:25AM BLOOD Calcium-9.7 Phos-2.5* Mg-2.3
[**2153-6-18**] 09:15AM BLOOD Albumin-2.7* Calcium-9.3 Phos-2.3* Mg-2.4
[**2153-6-12**] 08:45AM BLOOD Vanco-15.5
[**2153-6-15**] 03:54PM BLOOD Type-[**Last Name (un) **] pH-7.52* Comment-GREEN TOP
[**2153-6-15**] 03:54PM BLOOD Lactate-2.9*
[**2153-6-11**] 08:10PM BLOOD Glucose-105 Lactate-2.2* Na-137 K-4.1
Cl-104 calHCO3-11*
[**2153-6-14**] 03:13PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2153-6-13**] 09:51AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2153-6-11**] 08:00PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2153-6-14**] 03:13PM URINE Blood-LG Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2153-6-13**] 09:51AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2153-6-11**] 08:00PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2153-6-14**] 03:13PM URINE RBC-0 WBC->1000* Bacteri-MOD Yeast-NONE
Epi-0
[**2153-6-13**] 09:51AM URINE RBC-42* WBC->1000* Bacteri-NONE
Yeast-NONE Epi-0
[**2153-6-11**] 08:00PM URINE RBC-0 WBC->50 Bacteri-MOD Yeast-NONE
Epi-0
[**2153-6-16**] 10:08 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2153-6-17**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2153-6-17**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
URINE NEPHROSTOMY TUBE (CUP).
**FINAL REPORT [**2153-6-17**]**
GRAM STAIN (Final [**2153-6-16**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
URINE CULTURE (Final [**2153-6-17**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2153-6-15**] 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2153-6-15**] 3:15 pm BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
[**2153-6-15**] 3:48 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2153-6-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2153-6-16**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2153-6-14**] 5:06 pm STOOL CONSISTENCY: WATERY
**FINAL REPORT [**2153-6-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2153-6-15**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
FECAL CULTURE (Final [**2153-6-16**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2153-6-16**]): NO CAMPYLOBACTER
FOUND.
[**2153-6-14**] 3:13 pm URINE Source: Catheter.
**FINAL REPORT [**2153-6-15**]**
URINE CULTURE (Final [**2153-6-15**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2153-6-11**] 7:52 pm BLOOD CULTURE
**FINAL REPORT [**2153-6-17**]**
Blood Culture, Routine (Final [**2153-6-17**]): NO GROWTH.
RENAL U.S. Study Date of [**2153-6-12**] 2:04 PM
IMPRESSION:
1. Bilateral extensive nephrolithiasis, appearing greatest on
the left as
above with evidence of left renal obstruction. No right
hydronephrosis.
2. Suboptimal assessment of the urinary bladder.
CHEST (PORTABLE AP) Study Date of [**2153-6-12**] 5:46 PM
IMPRESSION: No pneumonia or evidence of CHF.
CT PELVIS W/O CONTRAST Study Date of [**2153-6-13**] 3:05 PM
IMPRESSION:
1. Extensive bilateral nephrolithiasis, most severe on the left
with a
staghorn calculus and consequent obstruction, overall similar to
an ultrasound done one day earlier.
2. Marked atherosclerotic calcification.
3. Prominent loops of small bowel and collapsed ileum entering
the ileostomy. Recommend close monitoring of ostomy output for
signs of possible partial small bowel obstruction.
4. Small hepatic hypodensities likely cysts and hyperdensities,
possibly
calcified granulomas.
5. Hyperdense gallbladder material, possibly sludge.
PORTABLE ABDOMEN Study Date of [**2153-6-14**] 8:04 AM
IMPRESSION: Air in loops of small and large bowel without
evidence for ileus or obstruction. There is no free air given
limitation of supine technique.
RENAL SCAN Study Date of [**2153-6-15**]
IMPRESSION: Differential renal function demonstrated with the
left kidney
performing 18% of total renal function and the right performing
82%. There is a large renal pelvis on the right, but there is
prompt washout from the pelvis after administration of lasix.
INTRO CATH TO PELVIS FOR DRAINAGE AND INJ Study Date of [**2153-6-15**]
6:23 PM
IMPRESSION:
1. Large stone in the left renal collecting system.
2. Dilatation of the upper pole calices, containing pus.
3. Uncomplicated ultrasound and fluoroscopically guided left
nephrostomy tube placement.
PORTABLE ABDOMEN Study Date of [**2153-6-16**] 5:11 AM
ABDOMEN, SUPINE AND UPRIGHT: Comparison is made to the two days
earlier.
A left-sided percutaneous nephrostomy tube has been placed since
the prior
study. A nasogastric tube terminates in the stomach, but a
leading sidehole is likely within the distal esophagus.
Advancement of the tube by several centimeters would lead to
more optimal placement. There is moderate persistent distention
of small bowel loops, little changed since both films from the
prior day, and non-specific as to etiology.
Brief Hospital Course:
[**Hospital Unit Name 153**] [**Date range (1) 30784**] - Pt was admitted to the [**Hospital Unit Name 153**] s/p left
percutaneous nephrostomy due to high risk of hemodynamic
instability with active infection and markedly elevated WBC. Pt
was recieved to the unit with stable vitals and no complaints.
she was placed on IV fluids and monitered. There were no
overnight events, electrolytes were replaced and she was
transferred back to the floor with stable vital signs and
improvement in WBC.
# Septicemia, Fungal UTI, Obstructing Renal Calculus,
Leukocytosis
- Cultures of the urine, including from the percutaneous
nephrostomy tube have repeatedly grown yeast, and although never
speciated clinical there was impressive effect from diflucan,
with resolution of her leukocytosis. She had a brief stay in the
ICU, but rapidly improved. Initially in the [**Hospital Unit Name 153**] she was started
on cefepime, vancomycin, mtronidazole and floconazole, but
nothing other than yeast was ever isolated, so other than
diflucan these were stopped.
- Urology was consulted and a percutaneous nephrostomy tube was
inserted. After insertion, the urology team was deciding between
a nephrectomy versus lithotripsy. Both of these would be high
risk in this patient. It was noted that the stone appears
radiolucent on xray, so there is a thought this is a uric acid
stone; the patient was started on bicitra to dissolve the stone.
The plan is 6 weeks of bictra then followup CT, with plan that
if stone is dissolving then continue current therapy, but if
not, then patient will require intervention, likely lithotripsy.
# Acute Renal Failure on CKD Stage III:
- This is likely multifactorial given her obstructing renal
calculus. It improved with the nephrostomy and hydration. At
time of discharge she was at her baseline.
- Given decision of what to do with the stone, a renal scan was
performed as above.
# Metabolic Acidosis: in setting of ARF
- IV hydration with bicarb drip with resolution in ICU
# Hypoxemia: developed mild O2 requirement while on floor (was
also getting IVF). Reports of hypoxia at rehab, this had
resolved by time of discharge and was likely due to septicemia.
# Seizure disorder:
- cont topiramate 50 [**Hospital1 **]
- cont neurontin for now (Neurontin may also be contributing to
her lethargy in the setting of ARF), however this can be
addressed by Dr. [**Last Name (STitle) **] at [**Hospital1 1501**].
# Atrial fibrillation: Continued amiodarone 200, (deemed not a
candidate for coumadin in past, not on ASA given vaginal
bleed/epistaxis). Well controlled.
# Access: Midline
.
#. Code - DNR/DNI (ok to intubate in case of status epilepticus)
.
#. Communication - [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (daughter) is [**Name (NI) 3508**] cell
[**Telephone/Fax (1) **].
Medications on Admission:
Ceftriaxone IV 1 GM daily
Topiramate 50mg [**Hospital1 **]
tylenol
Amiodarone 200mg daily
Remeron 15mg QHS
Artificial Tears
Gabapentin 1600mg TID
Psyllium 1 scoop tid
Cholecalciferol 1000unit daily
Discharge Medications:
1. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO TID (3
times a day).
5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
6. Sodium Citrate-Citric Acid 500-300 mg/5 mL Solution Sig:
Thirty (30) ML PO TID (3 times a day).
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous once a day as needed for line flush.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Fungal UTI
Pyelonephritis
Renal Calculi
Septicemia - Fungal
Leukocytosis
Stage III Chronic Kidney Disease
Epilepsy
Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
You are being discharged with a very large kidney stone in
place, along with a nephrostomy tube in place to drain the urine
around the stone. We are trying to dissolve the stone with a
medication. This medication can affect your electrolytes, so
will need to be closely monitored.
You will need a cat scan in 6 weeks to assess.
You need to eat carefully, as you have a high-risk of aspirating
food into your lung which can cause pneumonia.
You are going on a medication called Fluconazole which is an
antibiotic to treat the infection you had in the kidney. You
must complete the course of this medication.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2153-9-11**] 10:30
CT Scan Pelvis with/without contrast in 6 weeks with results to
urology
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Discharge summary
|
Report
|
Admission Date: [**2191-6-24**] Discharge Date: [**2191-7-1**]
Date of Birth: [**2114-4-1**] Sex: M
Service: SURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreatic mass
Major Surgical or Invasive Procedure:
[**2191-6-24**]:
1. Pylorus-Preserving Pancreaticoduodenectomy
2. Harvest of left internal jugular vein and portal vein
excision with reconstruction
History of Present Illness:
The patient is a very pleasant 77-year-old who had presented in
[**Month (only) 958**] with acute pancreatitis. On imaging studies, he was noted
to have a mass in the head of the pancreas. He subsequently
underwent endoscopic ultrasound with fine-needle aspiration.
Cytology on these aspirates was nondiagnostic. He
subsequently developed obstructive jaundice and on [**Month (only) **], he was
noted to have a biliary stricture. A biliary stent was placed.
He underwent a laparoscopic cholecystectomy with a presumed
diagnosis of gallstone pancreatitis. The subsequent CT scan
images showed complete resolution of pancreas mass. However,
repeat [**Month (only) **] showed persistence of biliary stricture. Brushings
of the biliary stricture are suspicious for adenocarcinoma. The
patient is well known for Dr. [**First Name (STitle) **] and she was followed the
patient along. The patient also had cholecystectomy done with
Dr. [**First Name (STitle) **] in the past. Dr. [**First Name (STitle) **] evaluated the patient for
possible Whipple procedure secondary to highly suspicious
brushing results. During the evaluation all risks, goals and
benefits were discussed with the patient and his family, and
patient was scheduled for elective Whipple on [**2191-6-24**].
Past Medical History:
PMH: HTN, vertigo episodes x2, Giant cell arteritis [**2188**], CAD
PSH: lap CCY [**2191-5-19**]
Social History:
He has an 18-pack-year history of tobacco, but quit 13 years
ago. He drinks alcohol only occasionally. There are no
environmental exposures.
Family History:
Mr. [**Known lastname 92312**] reports a family history of pancreatic cancer. His
sister died of it at age [**Age over 90 **]. There is no other history of
pancreatic disease or GI malignancy.
Physical Exam:
On Discharge:
VS: 98.6, 70, 138/69, 12, 95% RA
GEN: Pleasan with NAD
NECK: Left longitudinal incision open to air with steri strips
and c/d/i
CV: RRR
RESP: CTAB
ABD: Bilateral subcostal incision open to air with staples,
minimal erythema on middle portion of incision. RLQ JP drains x
2 to bulb suction, site c/d/i and covered with drain dressing.
EXTR: Warm, no c/c/e
Pertinent Results:
[**2191-6-29**] 06:20AM BLOOD WBC-6.5 RBC-3.38* Hgb-10.7* Hct-33.0*
MCV-98 MCH-31.5 MCHC-32.3 RDW-14.1 Plt Ct-205#
[**2191-6-29**] 06:20AM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-139
K-4.0 Cl-105 HCO3-29 AnGap-9
[**2191-6-29**] 06:20AM BLOOD ALT-81* AST-82* AlkPhos-91 TotBili-2.7*
[**2191-6-29**] 06:20AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.9
[**2191-6-30**] 09:55AM ASCITES Amylase-10
[**2191-6-30**] 09:55AM ASCITES Amylase-12
[**2191-6-29**] 10:16AM ASCITES TotBili-7.7 Albumin-LESS THAN
[**2191-6-28**] LIVER DOPPLER:
IMPRESSION:
1. Patent main and right portal veins. Flow within the left
portal vein could not be detected. This could be due to
technical factors or slow flow, however a thrombosed LPV cannot
be excluded.
2. Pneumobilia
3. Right pleural effusion.
[**2191-6-29**] ABD CT:
IMPRESSION:
1. Patent main, left and right portal veins; however, some
non-critical
narrowing of the presumed graft.
2. Small non-hemorrhagic pleural effusions with adjacent
compressive
atelectasis.
3. Generalized anasarca.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2191-6-24**] for elective Whipple procedure. On same day, the
patient underwent pylorus-preserving pancreaticoduodenectomy
(Whipple) and portal vein excision with reconstruction, which
went well without complication. The patient was transferred in
ICU after operation for observation. On POD # 1, patient was
extubated and was transferred on the floor NPO with an NG tube,
on IV fluids, with a foley catheter and a JP x 2 drain in place,
and epidural catheter for pain control. The patient was
hemodynamically stable.
Neuro: The patient received Fentanyl/Bupivacaine via epidural
catheter with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Metoprolol was
restarted on POD # 1. On POD # 2, patient was started on Aspirin
325 mg daily per Vascular Surgery, he was discharge home on this
medication as well.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: Post-operatively, the patient was made NPO with IV fluids.
Diet was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary. The patient had two JP
drains placed intraoperatively. On POD # 4, one JP output
increased up to 1 L and patient underwent liver doppler to rule
out portal vein obstruction. The doppler revealed patent main
and right portal veins, but left portal vein was doppler was
limited. The patient's JP # 1 output still high, JP bilirubin
was sent and was elevated (7). On POD # 5, patient underwent
abdominal CT which demonstrated patent main, left and right
portal veins; however, some non-critical narrowing of the
presumed graft. The patient's JP output was started to slow
down. On POD # 6 JP amylase was sent from both drains and was
normal. The patient was discharged home with both JP to continue
monitor their output.
GU: The foley catheter discontinued at midnight of POD#4. The
patient subsequently voided without problem.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound was evaluated
daily and small area of erythema was noticed on the middle part
of the incision on POD # 3. The erythema subsided prior
discharge, and though to be cause by staples.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. No insulin
was needed upon discharge.
Hematology: The patient was transfused with 2 units of pRBC
intraoperatively secondary to blood loss. Post op patient's
complete blood count was examined routinely; no further
transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Diazepam 5mg PRN; Lisinopril 5mg'; Metoprolol tartrate 12.5mg'';
Percocet PRN; ASA 81mg'; Calcium carbonate; Vitamin D3; Centrum
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*5*
8. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO once a day.
9. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Carenet
Discharge Diagnosis:
Locally advanced cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-9**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
.
JP x 2 Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2191-7-11**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please follow up with Dr. [**Last Name (STitle) **] (PCP) in [**3-4**] weeks after
discharge
Completed by:[**2191-7-1**]
|
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41817
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Discharge summary
|
Report
|
Admission Date: [**2158-8-4**] Discharge Date: [**2158-8-11**]
Date of Birth: [**2100-8-8**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Penicillins / Iodine / clindamycin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
S/P STEMI with cardiogenic shock
Major Surgical or Invasive Procedure:
Cardiac catheterization with percutaneous coronary
revascularization of left circumflex artery with drug eluding
stent
PICC placement
History of Present Illness:
Mr. [**Known lastname 13512**] is a 57 year-old man with ESRD on HD who presented
to [**Hospital3 **] on [**2158-8-1**] with an inferior STEMI now s/p
RCA PCI being transfered for further care. Patient was
scheduled to have an outpatient stress test the day prior to
admission, but was unbale to participate in the study and
returned to his nursing home. Later the same evening he
developed acute SOB and was take to [**Hospital3 **] where he
was found to be having an STEMI. Cardiac catheterization
revealed severe three vessel disease with 100% occluded LAD, 90%
LCx lesion and severe RCA disease requiring BMS x3. He required
intubation during cardiac catheterization for respiratory
failure and subsequently required pressor support with
peripheral dopamine for cardiogenic shock. He is now extubated
but continues to require dopamine to maintain a SBP in the
80s-90s.
.
On arrival his vital signs were HR 114 with BP 94/71. He is
breathing comfortably and has no complaints other than hearing
loss. In particular, he denies chest and jaw pain.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension,
PVD
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2158-8-1**] BMS to RCA x 3
3. OTHER PAST MEDICAL HISTORY:
- ESRD [**2-1**] to diabetic nephropathy on HD x7yrs MWF
- Osteomyelitis of the spine with resultant paraplegia
- Hyperparathyroidism
- Left BKA [**2-1**] to gangrene
- Right arm fistula
Social History:
Single Male. Has been on disability in his left BKA. Lives in a
nursing home.
- Tobacco history: Denies
- ETOH: Denies
- Illicit drugs: Denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Significant for diabetes
Physical Exam:
Admission Exam:
GENERAL: Profoundly hard of hearing. NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 9 cm.
CARDIAC: Regular rhythm, soft S1 and S2. No m/r/g appreciated
LUNGS: Pronounced leftward chest deformity of unknown
chronicity. symmetric air movement bilaterally. End expiratory
crackles on exam, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: L BKA, No femoral bruits. right heel ulcer 2x4cm
with scant exudate and exposed bone and fat
PULSES:
Right: Carotid 2+ Femoral 2+ doplerable DP pulse
Left: Carotid 2+ Femoral 2+
Discharge exam:
Pertinent Results:
Admisson Labs:
[**2158-8-4**] 09:16PM WBC-8.3 RBC-3.35* HGB-10.7* HCT-33.4*
MCV-100* MCH-32.0 MCHC-32.2 RDW-14.0
[**2158-8-4**] 09:16PM PLT COUNT-189
[**2158-8-4**] 09:16PM GLUCOSE-404* UREA N-30* CREAT-3.5* SODIUM-136
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-24 ANION GAP-23*
[**2158-8-4**] 09:16PM CALCIUM-7.7* PHOSPHATE-4.8* MAGNESIUM-2.1
[**2158-8-4**] 09:16PM PT-15.0* PTT-30.6 INR(PT)-1.3*
Cardiac Enzymes:
[**2158-8-4**] 09:16PM CK(CPK)-146
[**2158-8-4**] 09:16PM CK-MB-9 cTropnT-13.7*
[**2158-8-5**] 04:50AM BLOOD CK-MB-8 cTropnT-13.99*
Other pertinent labs:
[**2158-8-6**] 12:14PM BLOOD Lactate-2.4*
Studies
Micro:
[**2158-8-5**] 4:50 am BLOOD CULTURE Source: Line-central lumen
cath.
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
OXACILLIN------------- S
Aerobic Bottle Gram Stain (Final [**2158-8-5**]):
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90823**] @ 2232 ON [**8-5**]
-[**Numeric Identifier 28124**].
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2158-8-5**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Imaging:
CXR AP [**2158-8-4**]: Central catheter projects over the lower superior
vena cava. Lung volumes are quite low, making evaluation of the
lungs difficult. There are multiple bilateral rib fractures. I
see no pneumothorax.
TTE [**2158-8-5**]: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Overall left ventricular systolic function is
severely depressed (LVEF= 15-20 %) with global hypokinesis and
distal LV/apical akinesis to dyskinesis. No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is dilated with severe
global free wall hypokinesis. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
R foot X ray: [**2158-8-10**]
Large ulcer extending to the calcaneal tuberosity
posteroinferiorly without gross cortical destruction. If the
ulcer probes the bone this would be highly suspicious for
osteomyelitis.
Brief Hospital Course:
Primary Reason for Hospitalization:
57M w/ HTN, DM, HLD, PVD and ESRD on HD presented to OSH with
inferior STEMI s/p PCI to RCA now transfered for further care.
Active Issues:
# Cardiogenic Shock: Patient required pressor support with
dopamine following PCI at OSH and was transferred to [**Hospital1 18**] at a
dose of 8mg/kg/min. On HD6 patient was successfully weaned from
dopamine and was maintaining a stable blood pressure. He
maintained pressures through dialysis as well. He was restarted
on his home anti-hypertensives prior to discharge.
# CAD: Patient did not have prior history of known CAD, but
recent TTE from [**5-/2158**] revealed anterolateral and apical defects
consistent with CAD. Patient presented on [**8-1**] with RCA infarct
that required BMS x3. Cardiac cath also revealed 90% LCx disease
and completely occluded LAD that was presumed chronic. LV gram
revealed LVEF of 20%. On HD3 patient was taken to the cath lab
and had successful stenting of his left circumflex. He was
continued on plavix and aspirin throughout admission.
# ESRD on HD: Patient receives chronic HD on MWF schedule.
Patient's electrolytes were monitored closely throughout
admission. Patient was dialyzed on his normal schedule and
pressures tolerated this without issue. He refused many of his
medications throughout admission.
#Bacteremia: Patient had one blood culture positive for gram
positive cocci, MSSA. He was treated with IV vancomycin given
penicillin allergy. Patient will be treated for 10 day course,
last day [**2158-8-15**]. A PICC line was placed for IV administration
following discharge. Patient was afebrile and hemodynamically
stable at the time of discharge. He had two days of
surveillance cultures with no growth to date at the time of
discharge.
#Atrial fibrillation: Patient had an episode of atrial
fibrillation during his catheterization. He was given
amiodarone, and spontaneously converted to sinus rhythm. He
again had an episode of atrial fibrillation on HD5 and was
started on an amiodarone drip. He spontaneously converted into
sinus rhythm again, later the same day. He was started on oral
amiodarone with a goal loading dose of 8g. At the time of
discharge, his dose was 300mg po BID. He will continue this for
11 days, ending [**2158-8-21**]. At that time, he should be
transitioned to amiodarone 200mg po daily. Despite CHADS2 score
of 3, patient was felt to be a poor candidate for
anticoagulation given poor medication compliance and fall risk.
Patient was in sinus rhythm and hemodynamically stable at the
time of discharge.
# HTN: Patient was in cardiogenic shock at the time of
admission, therefore his home anti-hypertensives were held.
Since BPs were still lowish at discharge norvasc was
discontinued and valsartan was continued but at a much lower
dose (40mg [**Hospital1 **]).
# HLD: Patient is s/p STEMI. He was changed to 40mg po
atorvastatin daily as he is also on amiodarone, and therefore
was felt to not necessitate 80mg daily.
# Right heel ulcer: Patient had a 2x4 cm ulcer on right heel
consistent with arterial insufficiency. Per report, this has
been followed by vascular surgery as an outpatient. Patient was
evaluated by both vascular surgery and podiatry. Both teams
agreed that the ulcer was not actively infected, and therefore
there was no indication for antibiotics. The ulcer was cleaned
daily with application of Santil ointment. An xray of the heel
was performed showing an ulcer but no cortical destruction. Per
vascular surgery, the patient should have an ABI checked as an
outpatient.
# Bilateral hearing loss: Patient reported acute hearing deficit
coinciding with his myocardial infarction. No obstructive cause
was apparent on otoscopic examination. Hearing loss appeared to
be symmetric. He was not given otoxic drugs. Ischemia in the
setting of cardiogenic shock is also a possiblity. Symptoms were
not consistent with CVA causing hearing loss, as he had no
associated symptoms of nystagmus, nausea or dizziness as would
be expected. Patient's hearing improved spontaneously. He
should have ENT follow-up as an outpatient if he continues to
have further issues.
# Compliance: Patient refused many medications throughout
admission, which made regulation of blood sugar and electrolytes
difficult. He was made aware of the risks involved in refusing
each medication.
Chronic Issues:
# DM: Patient is on oral hypoglycemics and insulin at home.
Patient's blood sugars were controlled throughout admission on a
diabetic diet and insulin sliding scale.
Transitional Issues:
- Patient maintained full code status throughout hospitalization
- Patient will need ABIs performed as outpatient. Dressing
changes daily to heel. Will also need to follow-up with his
vascular surgeon.
- Follow-up with ENT if hearing issues persist
-Follow- up with cardiology in approximately 2 weeks
Medications on Admission:
HOME MEDICATIONS:
- Norvasc 10mg on non-HD days
- Sensipar 120mg daily
- Trazodone 50mg QHS
- Zocor 20mg QPM
- Diovan 160mg [**Hospital1 **]
- DuoNeb Q4H PRN
- Actos 30mg daily
- Glipizide 5mg daily
- PhosLo 3 tabs QAC
- Reglan PRN
- Atarax PRN
.
MEDICATIONS on TRANSFER:
- Acetaminophen 650 Q6H PRN
- Albuterol HFA 4 puff Q2H PRN
- Aspirin 325 daily
- Calcium Acetate 2001mg TIDQAC
- Cinacalcet 120mg QHS
- Plavix 75mg daily
- Colace 100mg [**Hospital1 **]
- Dopamine gtt
- Epoetin 8000 unit IV QHD
- Glipizide 5mg QAM
- Heparin 5000 units SQ
- Hydroxyzine 50mg Q6H PRN
- Lidoderm Patch QD
- Metoclopramide 10mg TIDQAC
- Metoprolol 6.25 Q8H
- Morphine 2mg Q5MIN
- NTG 0.4mg SL
- Zofran 4mg IV Q8H PRN
- Pantoprazole 40mg QD
- Simvastatin 10mg QHS
- Trazodone 50mg QHS
- Valsartan 160mg [**Hospital1 **]
- Insulin Sliding Scale:
201-250:3 units
251-300:5 units
301-350:7 units
351-400:9 units
>400: 11 units
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation q4h PRN SOB, wheezing.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 1X/WEEK ([**Doctor First Name **]):
last dose given [**2158-8-6**], next dose [**2158-8-13**].
Disp:*30 Tablet(s)* Refills:*2*
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for nausea.
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
8. amiodarone 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day) for 11 days: Then change to 200 daily.
Disp:*44 Tablet(s)* Refills:*2*
9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol) for 4 days: ending
[**2158-8-15**].
Disp:*4 units* Refills:*0*
10. Norvasc 10 mg Tablet Sig: One (1) Tablet PO on non-HD days:
hold for SBP<90, HR<60.
11. Sensipar 60 mg Tablet Sig: Two (2) Tablet PO once a day.
12. Diovan 40 mg Tablet Sig: One (1) Tablet PO twice a day: hold
for SBP<90, HR<60.
13. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Colonial Heights Care and Rehabilitation Center - [**Hospital1 487**]
Discharge Diagnosis:
Primary Diagnosis:
1. Cardiogenic shock
2. Left circumflex stenosis
Secondary Diagnosis:
1. Coronary artery disease
2. End stage renal disease
3. Diabetes mellitus type II
4. Peripheral vascular disease
5. Chronic right heel ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 90824**],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**]. You were admitted to our hospital because
following heart your catheterization because you required IV
medications to maintain your blood pressure. During this
hospitalization, a previously noted blockage in your coronary
arteries was stented open. After this, the IV medications were
slowly weaned and your blood pressure was stable off of these
medications at the time of discharge.
You were dialyzed on your normal schedule throughout admission.
In addition, you had an infection in your blood stream. One of
your blood cultures grew a bacteria called Staph Aureus. We
treated this with an IV antibiotic (vancomycin) as you are
allergic to penicillin. You will need to continue this
medication through [**2158-8-15**].
Medication changes:
You were continued on most of your home medications. But you
should STOP the following home medications:
1. Norvasc
The following home medications had their doses changed:
1. Diovan dose decreased from 160mg [**Hospital1 **] to 40 mg [**Hospital1 **]
You were started on the following NEW medications. These
medications are very important. Please be sure to take them
every day as prescribed.
1. Plavix 75 mg by mouth once each day
2. Aspirin 325 mg by mouth once each day
3. Atorvastatin 40mg by mouth once each day
4. Digoxin 0.125mg by mouth once a week, next dose [**2158-8-16**]
5. Amiodarone 300mg by mouth twice each day for 11 days. On
[**2158-8-23**] you will change this does to 200mg by mouth once each
day and continue this indefinitely.
6. Vancomycin IV with dialysis each time dialyzed, ending
[**2158-8-15**]. After you finish this medication your PICC line can be
safely removed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
|
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| 0
| 0
| 0
| 0
| 0
| 0
| 307
| 0
| 0
| 0
| 0
| 0
| 138
| 88
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 35
| 0
| 0
| 4,201
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 1,583
| 0
| 0
| 0
| 0
| 0
| 0
| 150
| 0
| 0
| 0
| 0
| 0
| 53
| 138
| 0
| 0
| 0
| 0
| 0
| 138
| 0
| 0
| 0
| 190
| 0
| 0
| 168
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 638
| 68
| 148
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| 0
| 0
| 0
| 0
| 0
|
95,474
| 188,695
|
5200
|
Discharge summary
|
Report
|
Admission Date: [**2190-6-15**] Discharge Date: [**2190-6-20**]
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
The patient is a [**Age over 90 **] year old female with a history of
Aflutter/AF (on coumadin) s/p AV node ablation and pacemaker,
hypertension, systolic HF, and dementia who presents with
complaints of [**2-23**] days of BRBPR. The patient has a known history
of diverticulosis and internal hemmeroids. While their is no
documentation in our OMR, she may have a history of LGIB She is
maintained on coumadin for reduction of thromboembolic risk in
the setting of AF. She denies any chest pain, shortness of
breath, or lightheadedness. Shes is a poor historian at
baseline, but reports feeling well.
.
In the ED, initial vs were: T 97.5 P 71 BP 161/59 O2 sat 100% on
RA. The patient was noted to have rectal bleeding, and had a BM
w/ a reported 10-15cc of BRB. She was given 10mg of vit K and
protonix, and was admitted to the ICU for further manegment.
Past Medical History:
1. Atrial fibrillation/flutter - on anticoagulation and s/p AVJ
ablation w/ PPM
2. Diastolic / Systolic heart failure - EF of 35% in [**2188**]
Moderate global LV hypokinesis. Relatively preserved apical LV
contraction.
3. Hypertension
Social History:
Lives at [**Hospital3 **] at Scandinavian Center. Was living
alone and caring for sister in hospice until she passed away. No
Smoking or ETOH.
Family History:
Family History: Patient unaware.
Physical Exam:
Vitals: T 97.3 BP 135/56 P 72 R 22 18 SaO2 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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
Rectal (previously documented): No no visible external
hemorrhoids, fissues, or cracks on exam, BRB
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, oriented x 2
Pertinent Results:
Labs on Admission:
[**2190-6-15**] 03:30PM BLOOD WBC-7.3 RBC-3.73* Hgb-11.4* Hct-34.7*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.5* Plt Ct-272
[**2190-6-15**] 03:30PM BLOOD Neuts-75.7* Lymphs-14.7* Monos-5.5
Eos-3.8 Baso-0.3
[**2190-6-15**] 03:30PM BLOOD PT-26.4* PTT-30.1 INR(PT)-2.6*
[**2190-6-15**] 03:30PM BLOOD Glucose-109* UreaN-31* Creat-1.3* Na-136
K-4.7 Cl-100 HCO3-24 AnGap-17
.
HCT trend:
[**2190-6-15**] 03:30PM BLOOD WBC-7.3 RBC-3.73* Hgb-11.4* Hct-34.7*
MCV-93 MCH-30.5 MCHC-32.7 RDW-16.5* Plt Ct-272
[**2190-6-15**] 11:01PM BLOOD Hct-29.8*
[**2190-6-16**] 03:01AM BLOOD WBC-6.1 RBC-3.05* Hgb-9.4* Hct-28.7*
MCV-94 MCH-30.9 MCHC-32.9 RDW-15.9* Plt Ct-220
[**2190-6-16**] 09:15AM BLOOD Hct-29.7*
[**2190-6-16**] 05:16PM BLOOD Hct-29.7*
[**2190-6-17**] 12:45AM BLOOD Hct-28.0*
[**2190-6-17**] 06:35AM BLOOD WBC-6.6 RBC-3.03* Hgb-9.3* Hct-28.7*
MCV-95 MCH-30.6 MCHC-32.3 RDW-16.0* Plt Ct-229
[**2190-6-18**] 06:25AM BLOOD WBC-7.2 RBC-3.09* Hgb-9.4* Hct-28.8*
MCV-93 MCH-30.5 MCHC-32.8 RDW-15.7* Plt Ct-228
[**2190-6-18**] 12:50PM BLOOD Hct-31.6*
[**2190-6-20**] 06:50AM BLOOD WBC-7.9 RBC-3.20* Hgb-9.9* Hct-30.1*
MCV-94 MCH-30.8 MCHC-32.8 RDW-16.1* Plt Ct-225
.
Labs on Discharge:
[**2190-6-20**] 06:50AM BLOOD WBC-7.9 RBC-3.20* Hgb-9.9* Hct-30.1*
MCV-94 MCH-30.8 MCHC-32.8 RDW-16.1* Plt Ct-225
[**2190-6-20**] 06:50AM BLOOD Plt Ct-225
[**2190-6-20**] 06:50AM BLOOD Glucose-102 UreaN-21* Creat-1.1 Na-142
K-4.1 Cl-108 HCO3-27 AnGap-11
.
Imaging:
Permanent pacer in place, moderate cardiomegaly.
Mild-to-moderate chronic failure with interstitial edema, but no
acute pulmonary edema or acute infiltrates.
.
Procedures:
Sigmoidoscopy: Significant amount of old blood. No acute bleed
or active source. Extensive diverticular disease throughout
colon.
.
Prior studies:
Colonoscopy [**2180**]:
Diverticulosis of the distal descending colon and proximal
sigmoid colon
Internal hemorrhoids
Polyp in the sigmoid colon (biopsy)
Brief Hospital Course:
[**Age over 90 **] year old female with a history of AF on coumadin, systolic
HF, diverticulosis, and internal hemorrhoids who presents with
complaints of LGIB.
.
# BRBPR: In the ER patient received 10 mg of vitamin K for an
INR of 2.6. Due to concern of acute bleed patient was admitted
to ICU, but transferred to the general medicine floor when found
to be hemodynamically stable. Sigmoidoscopy demonstrated a
significant amount of old blood, but no acute bleed. Source felt
to be extensive diverticular disease. On admission patient's HCT
dropped 5 points (from 34.7 -> 29.8), however remained stable at
28-30 throughout the remainder of admission and upon discharge.
Patient required no blood transfusions and was hemodynamically
stable throughout her hospital course. On discharge she
continued to have dark, loose, guaiac positive stool which was
felt to be old blood (HCT and hemodynamics stable). Patient is
on coumadin for A Fib and ASA + dipyridamole for TIA - all three
were held throughout admission.
- Continue to hold coumadin, ASA, dipyridamole for 1 week
following discharge. Re-start following 1 week, but patient
needs to follow-up with pcp, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17143**], regarding continuation
of all three anti-coagulents.
- Check HCT twice a week
.
# Atrial fibrillation: status post AVJ ablation w/ PPM. On
coumadin as an outpatient. INR was reversed on admission due to
concern of acute bleed (see above).
- Continue to hold coumadin 1 week following discharge. Re-start
following 1 week, but patient needs to follow-up with pcp, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17143**], regarding continuation of all three anti-coagulents.
.
# Chronic Systolic CHF: Patient currently euvolemic on exam.
B-blocker and diuretics held briefly in setting of acute bleed.
Metoprolol 100 mg TID and diuretics re-started prior to
discharge.
.
# Hx of CVA: Dipyradiole and ASA as outpatient suggest history
of TIA or small vessel disease.
- Continue to hold ASA, dipyridamole for 1 week following
discharge. Re-start following 1 week, but patient needs to
follow-up with pcp, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17143**], regarding continuation of all
three anti-coagulatents.
.
# FEN: Tolerating regular diet prior to discharge.
# Code: DNR/DNI - confirmed with patient.
# Communication: Patient. Only relative (nephew in law) [**Name (NI) **]
[**Name (NI) 21244**] [**Telephone/Fax (1) 21245**], [**Telephone/Fax (1) 21246**].
Discharge to short term rehab for physical therapy needs.
Medications on Admission:
per OMR
1. Dipyridamole 25 mg Tablet TID
2. Metoprolol Tartrate 100 mg TID
3. Aspirin 81 mg Daily
4. Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-22**] PO BID (2 times a
day) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Furosemide 20 mg Daily
7. Spironolactone 12.5 mg daily
8. Coumadin
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
6. Outpatient Lab Work
Check Hematocrit twice weekly
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Lower gastrointesintal bleeding
.
Atrial fibrillation/flutter s/p AV ablation
Congestive heart failure
Hypertension
Discharge Condition:
Fair. Patient is alert and interactive. She has poor short
term memory and cannot remember why she is in the hospital.
Discharge Instructions:
You were admitted for gastrointestinal bleeding. You underwent a
sigmoidoscopy which demonstrated old blood in the
gastrointestinal tract, but there was no active bleeding. You
were monitored in the hospital to ensure stable blood counts and
blood pressure. You are being discharged to a short term rehab
for physical therapy.
.
Please continue taking all medications as you were previously
taking with the following exceptions:
HOLD Coumadin, aspirin, dypridamole for 1 week following
discharge. Re-start and discuss longterm coagulation plan with
primary care doctor.
.
Attend the following appointments:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**]
Specialty: PCP
Date and time: [**2190-7-1**] 1:00pm
Location: [**Apartment Address(1) 21247**] F
Phone number: [**Telephone/Fax (1) 19196**]
.
Please return to the hospital or call your primary care
physician if you have lightheadedness, shortness of breath,
chest pain, or any other concerning symptoms.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16258**]
Specialty: PCP
Date and time: [**2190-7-1**] 1:00pm
Location: [**Apartment Address(1) 21247**] F
Phone number: [**Telephone/Fax (1) 19196**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2190-6-20**]
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icd9pcs
|
[
[
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] | 79
| 2,567
| 0
| 17
| 124
| 0
| 0
| 0
| 0
| 6
| 0
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89,119
| 191,630
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13466
|
Discharge summary
|
Report
|
Admission Date: [**2167-7-7**] Discharge Date: [**2167-7-16**]
Date of Birth: [**2096-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
70 yo M with [**Hospital 7235**] medical problems including ESRD on HD
M/W/F iwth HD line that was changed [**6-11**], diabetes (? not on
insulin per discharge meds from earlier this month), sCHF FE
40%, HTN, HLP, boderline PD who was found to be unresponsive at
HD yesterday with BP 70/40 and fingerstick to fs 41. Recent
admission for pseudomonal urosepsis in [**Month (only) 547**] and c. diff in [**Month (only) 116**].
Also has ? discitis/osteomyelitis but negative bone biopsy in
[**Month (only) **].
At HD, he received an amp of D50 and MS improved to - A/O x3 and
he was brought to [**Location (un) 620**] ED. There, EKG showed with AV pacing
and trop found to be elevated to 0.4 (baseline per ED there is
0.3). Got PR ASA and was sent here for ROMI/NSTEMI.
On arrival to the [**Hospital1 18**] ED last night, pressures remained low,
hypoxic on 3L (unclear baseline O2 requirement). BP's were
90/palp and pt was bradycardic to 38 (though unclear how it's
possible given that pt is paced). Given slightly higher trop,
there was initial concern for NSTEMI. He receive 2L IVF for his
hypotension and cardiology was consulted. They were not
concerned given trop around baseline. Unclear if EKG's were
faxed for them to look at. Overnight, pressures improved with
IVF, no antibiotics or blood cultures were drawn. Fingersticks
continued to be low 40-80 and he was started on D5 gtt at 100
cc/hr. BP's overnight continued to be low and this morning D5
increased to 150cc/hr.
CT torsos (one without contrast and one with contrast) were
obtained to look for source of hypoglycemia and found a
large-moderate intussception and L3/L4 discitis. Surgery was
consulted for intussception and felt comfortable with medical
admission, no emergent surgery given lactate 0.6 this morning at
3am. Radiology read partial obstruction with small amount of
contrast passing through but very edematous bowel and
recommended that surgery address. Additionally, renal masses
concerning for RCC were noted which are old. Per prior
transplant note, nephrology/urology aware, last urology visit
[**2-/2167**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**].
This morning, blood cultures were drawn and CTX/vanco were
ordered (unclear if given) in the [**Name (NI) **].
Vitals prior to transfer to the ICU: 4L nc, sating 99%. BP
114/64. HR 60 paced. Per ED resident. abd exam totally benign.
Past Medical History:
- Diabetes mellitus c/b neuropathy - not on insulin
- End-stage renal disease on hemodialysis on M,W,F
- Hyperlipidemia
- CHF (EF 40%)
- HTN
- CAD s/p cath and AICD
- s/p gastric bypass
- h/o aspiration pneumonia
- hypothyroid
- peripheral vascular disease
- benign prostatic hypertrophy
- h/o bacteremia (Klebs/Serratia/pseudomonas)
- recurrent C. diff
- Zoster
- h/o delirium
- spinal stenosis
- adjustment disorder
- personality disorder
- mitral regurgitation
- h/o hypocalcemia
- h/o bilateral renal mass
Social History:
Retired. Denies alcohol use. Non smoker. Discharged to Newbridge
on the [**Doctor Last Name **] on [**6-16**]. Prior to that lived with wife.
Family History:
Brother with DM.
Physical Exam:
VS:
- General Appearance: Chronically ill appearing
- Eyes / Conjunctiva: PERRL,
- Head, Ears, Nose, Throat: Poor dentition
- Cardiovascular: distant heart sounds, S1, S2, ii/vi systolic
murmur, 1+pitting peripheral edema of upper and lower extremity
- Peripheral Vascular: (Right radial pulse: Present), (Left
radial pulse: Present), (Right DP pulse: Present), (Left DP
pulse: Present)
- Respiratory / Chest: symmetic, unlabored respirations, Breath
Sounds: Crackles : bilaterally at bases
- Abdominal: Soft, Non-tender, non-distended Bowel sounds
present,
- Extremities: pale, ulcer on toe
- Skin: Warm, bangages on forearms with scattered traumatic
skin tears
- Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): person, place.
Pertinent Results:
Admission Labs
[**2167-7-6**] 09:50PM BLOOD WBC-10.4 RBC-3.39* Hgb-10.7* Hct-33.0*
MCV-97 MCH-31.7 MCHC-32.5 RDW-16.2* Plt Ct-314
[**2167-7-6**] 09:50PM BLOOD PT-13.6* PTT->150* INR(PT)-1.2*
[**2167-7-6**] 09:50PM BLOOD ESR-10
[**2167-7-6**] 09:50PM BLOOD Fibrino-349
[**2167-7-6**] 09:50PM BLOOD Glucose-97 UreaN-35* Creat-2.8* Na-136
K-4.4 Cl-104 HCO3-24 AnGap-12
[**2167-7-6**] 09:50PM BLOOD ALT-9 AST-18 CK(CPK)-34* AlkPhos-55
TotBili-0.2
[**2167-7-6**] 09:50PM BLOOD Albumin-2.1* Calcium-7.0* Phos-3.7 Mg-2.0
[**2167-7-6**] 09:50PM BLOOD CRP-5.8*
Cardiac Enzymes:
[**2167-7-6**] 09:50PM BLOOD CK(CPK)-34* CK-MB-5 cTropnT-0.36*
[**2167-7-7**] 06:15AM BLOOD cTropnT-0.34*
[**2167-7-7**] 02:03PM BLOOD CK(CPK)-46* cTropnT-0.31*
Other Labs:
[**2167-7-10**] 02:33PM BLOOD TSH-2.8
[**2167-7-7**] 06:15AM BLOOD Cortsol-17.0
[**2167-7-6**] 09:50PM BLOOD CRP-5.8*
[**2167-7-8**] 05:29AM BLOOD Vanco-10.3
[**2167-7-7**] 03:43AM BLOOD Glucose-70 Lactate-0.6
[**2167-7-9**] 12:05PM BLOOD Lactate-1.5 K-4.2
[**Last Name (un) **] Stim-
[**2167-7-10**] 08:19PM BLOOD Cortsol-23.8*
[**2167-7-10**] 09:47PM BLOOD Cortsol-43.5*
CXR ([**2167-7-7**]) - IMPRESSION: No pneumonia. Mild pulmonary
congestion.
CT A/P ([**2167-7-7**]) - IMPRESSION:
1. Prior gastric bypass surgery with enteroenteric
intussusception in the
left upper quadrant at the distal anastomosis. No evidence of
proximal
dilation of bowel to suggest obstruction at the time of the
examination but correlation with physical examination is
recommended.
2. Destructive change of L3-4 endplates with appearance of
widening of
intervertebral space, unchanged from CT of lumbar spine of
[**2167-6-29**], may
again represent noninfective spondyloarthropathy although
superimposed
infection (discitis/osteomyelitis) cannot be entirely excluded
and clinical correlation is necessary.
3. Cholelithiasis in a moderately distended gallbladder. Cannot
assess
gallbladder wall without IV contrast. If concern for acute
cholecystitis,
recommend ultrasound or HIDA. Unchanged probable stone or sludge
in the CBD.
4. Bilateral pleural effusions, moderate to large on the left
and small on
the right. Ascites and anasarca.
5. Marked coronary artery calcifications. Marked vascular
calcifications
throughout the abdomen.
CT A/P ([**2167-7-7**]) - IMPRESSION:
1. Persistent jejunojejunal intussusception at the distal
anastomosis with
marked bowel wall edema in the intussuscepted bowel and partial
small bowel obstruction.
2. Oral contrast in the excluded stomach and afferent limb,
consistent with either represent reflux secondary to obstruction
from the intussusception or a fistula between the gastric
remnant and the excluded stomach or components of both
processes.
3. Bilateral enhancing renal masses. The largest one in the left
upper pole demonstrates interval increase in size. Findings are
again concerning for renal cell carcinoma.
4. Unchanged cystic pancreatic lesions. Could be further
assessed by MR [**First Name (Titles) **] [**Last Name (Titles) 40806**]y indicated.
5. Similar destructive appearance of L3-L4 compared to the prior
L-spine CT study eight days ago. Findings again may represent
renal spondyloarthropathy but clinical correlation is necessary
to exclude osteomyelitis/discitis.
6. Similar cholelithiasis and choledocholithiasis, without
evidence of acute cholecystitis.
Brief Hospital Course:
70 yo M with [**Hospital 7235**] medical problems including ESRD on HD
M/W/F, diabetes, sCHF EF 40%, HTN, HLP, borderline PD who was
found to be unresponsive at HD with BP 70/40 and fingerstick to
fs 41 thought to be secondary to UTI.
# Hypoglycemia: Etiology unclear. In the MICU, patient initially
required D10 gtt which was then weaned off. However, several
hours after the D10 gtt was stopped, the patient's blood sugars
dropped back down to the 60's, ultimately requiring the D10 gtt
to be restarted. [**Last Name (un) **] stim was unrevealing and TSH was WNL.
Patient transferred to the floor. There remained off D10gtt
however blood sugars remained labile with pre-prandial fs
runnning in the 70s during which patient asymptomatic. [**Last Name (un) **]
following the patient and also unclear on etiology of persistent
hypoglycemia. Per their rec's sent C-peptide and insulin level
which is still pending. He will follow up with [**Hospital 387**] clinic for
further workup of this. He has had stable blood sugars for
several days on the general medical floor on no anti-glycemic
medications.
.
# UTI: UA on admission grossly positive. As had history of
pseudomonal urosepsis, decision was made initially to treat with
cefepime. However, urine cultures ultimately grew Klebsiella
resistant to cefepime, so the patient was switched to meropenem,
to complete a 7 day course (end date [**7-18**]). Midline placed to
facilitate antibiotic administration as outpatient. PICC line
unable to be placed as subclavian thrombosed per IR. Etiology of
recurrent UTIs felt secondary to stasis therefore foley was
d/c'ed with decision for QD/[**Hospital1 **] bladder scans and straight cath.
Patient will continue to need QD/[**Hospital1 **] straight caths in future -
and education will be needed for both patient and wife in order
to be able to do this at home. There are also plans for him to
follow up with Dr. [**Last Name (STitle) 3748**] (urology) for evaluation and possible
nephrectomy as he has a renal mass seen on multiple CT scans
(this admission and prior) and this may keep him from making
urine which he retains causing the frequent UTIs. Dr. [**Last Name (STitle) 3748**]
will set him up with an appointment in the next few weeks.
.
#History of C.diff. In house C.diff negx2. However, given
patient's history of severe c.diff infection and current use of
meropenem, ID consult service recommended treating empirically
for c.diff with flagyl for 14day (end date [**7-25**]).
.
# Hypoxia: Occurred in MICU in setting of IVF for hypotension
and known sCHF 40% EF. CXR with mild volume o/l. Resolved with
HD and fluid removal. On the floor patient saturated well on RA.
# Hypotension: Occurred at HD and in ED on presentation.
Persisted in the MICU and gradually resolved with IVF and
antibiotics likely in setting of infection. Patient
asymptomatically hypotensive on floor with SBP ranging between
80s-110s. Difficult to obtain accurate [**Location (un) 1131**] in HD patient.
Anti-hypetensives were held. Occasional 250mL Boluses were given
if SBP<80.
# Intussception: See on CT, moderate-to-large. Surgery
recommended admission to medicine service for initial
management. However, surgicaly repair remained an option.
Ultimately, the decision was made to monitor patient with serial
abdominal exam and lactate levels. Surgery was reassured with
lactate level of 0.6. On the floor patient without pain and
tolerating a regular diet without nausea, vomiting or pain. Plan
to follow-up with GI as outpatient as there is concern regarding
the nidus for intussception ?cancer ?polyp.
# Discitis: Appears old - seen on prior imaging. Ortho spine
and ID consulted and per imaging was not felt to be a likely
source of infection. In addition, nl WBC and lack of fever not
suggestive of active infection. Pain was managed with plan to
follow-up L3-L4 endplate degeneration as outpatient. Current
pain regimen has been adequately controlling his back pain for
the last 2 days while hospitalized.
# ESRD: On HD through HD line which was changed on [**2167-6-11**].
Continued on HD on MWF schedule. Not transplant candidate [**2-10**]
likely RCC. Per renal notes, question possible nephrectomy in
the future and will follow up with Dr. [**Last Name (STitle) **] for this as above.
# Diabetes: On insulin at nursing home per NH paperwork, however
insulin held secondary to hypoglycemia. [**Last Name (un) **] followed in house
and will follow him as an outpatient as above.
# Systolic Heart Failure: EF 40%, mild edema on CXR.
# HTN: Anti-HTN meds held due to persistent asymptomatic
hypotension.
# Hyperlipidemia: Statin continued.
# BPH: Home medication regimen continued
# Renal Masses: High concern for RCC per out pt notes, patient
aware with plan to follow-up as outpatient with Dr. [**Last Name (STitle) 3748**] of
urology.
# Hypothyroidism: Thyroid medications initially held in MICU as
patient was not taking in adequate PO. As diet/nutrition
improved levothyroxine 200mcg QD was restarted on the floor.
# CAD: On initial presentation troponins elevated 0.4 (baseline
0.3). No changes on EKG and per cardiology low liklihood for
ACS. Bblocker held secondary to hypotension.
# Code: Full (discussed with patient)
.
# Dispo. Patient received PT/OT consult prior to discharge to
rehab facility.
Medications on Admission:
- Calcium Acetate 1334 mg three times daily with meals
- Calcium Carbonate 1300 mg three times a day
- Cholecalciferol 1000 units daily
- Ferrous sulfate 325 mg every Mon, Wed, Fri
- Finasteride 5 mg daily
- Gabapentin 200 mg three times a day
- Heparin SC 5000 units q8hrs
- Humalog SS
- Levothyroxine 200 mcg daily
- Lidocaine Patch
- Loperamide 2 mg daily
- Omeprazole 20 mg daily
- Oxycontin 30 mg [**Hospital1 **]
- Oxycodone 5 mg four times a day
- Pentoxifylline CR 400 mg once daily
- Sevelamer 800 mg three times a day with meals
- Anusol Suppositories 1 [**Hospital1 **]
PRNS:
- Acetaminophen 650 mg q4 hours PRN
- Bisacodyl 10 mg daily PRN
- Loperadime 2 mg q6hrs PRN
- Lorazepam 0.5 mg q4 hours PRN
- Morphine Oral Conc 8 mg q 1 hr PRN pain
- Oxycodone 5 mg q4hrs PRN pain
- Psyllium Seed 1 tsp [**Hospital1 **] PRN
- Senna 17.2 mg daily PRN
- Trazodone 50 mg qHS PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO TID (3 times a day).
16. Meropenem 500 mg IV Q24H
Administer dose after HD on HD days
17. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
PRIMARY
Urosepsis, Klebseilla PNA
Hypoglycemia
Intussussception
SECONDARY:
ESRD on HD
Discitis
CHF
Hypoglycemia
Intussception
Discharge Condition:
Mental Status: oriented to person and place
Hemodynically stable
Unable to ambulate without assistance.
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
after becoming unresponsive at dialysis. At that time were
sugars and blood pressure was found to be low. We felt your low
pressures resulted from an infection in your urine. We treated
your low pressures with IV fluids and antibiotics. A PICC line
was placed to faciliate antibiotic administration after you
leave the hospital. The source of your recurrent urine
infections is felt to be due to stasis of urine in the bladder
and it is recommended to perform straight catherization daily to
ensure the the bladder is empty.
You continued to experience back pain while hospitalized. Pain
resulted both from inflammation of an area of your spine as well
as irritation of the skin on your backside. We worked with the
pain team to create a treatment regimen and with the wound care
nurses to care for your ulcers, skin sores.
The kidney doctors followed [**Name5 (PTitle) **] [**Name5 (PTitle) 1028**] you were hospitalized and
you continued dialysis on your M,W,F schedule.
You experienced abdominal pain while in the ICU and a picture of
belly showed an intussception. Surgery was consulted and did not
feel that you needed surgical intervention but it is important
that you follow-up with GI doctors [**First Name (Titles) **] [**Last Name (Titles) 4656**] this.
You were discharged to a rehab facility for continued care and
assistance.
Followup Instructions:
Department: HEMODIALYSIS
When: WEDNESDAY [**2167-7-15**] at 7:30 AM
Department: INFECTIOUS DISEASE
When: MONDAY [**2167-7-27**] at 11:30 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Last Name (un) **] Diabetes Center
When: Monday [**2167-7-27**] 2:00pm
With: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**]
Location: [**Last Name (un) 3911**] [**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2384**]
Department: GASTROENTEROLOGY
When: TUESDAY [**2167-7-28**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Dr. [**Last Name (STitle) 3748**] (your urologist) will also be in touch with you re:
an appointment in follow up of the mass in your kidney and
whether you need to undergo surgery for this mass.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2167-7-17**]
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36727
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Discharge summary
|
Report
|
Admission Date: [**2191-12-23**] Discharge Date: [**2191-12-23**]
Date of Birth: [**2140-1-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Morphine / Hydrocodone / Oxycodone / Ativan
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
generalized weakness, diffuse abdominal pain, abnormal labs
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Patient is a 51 year old male with cirrhosis reportedly
secondary to alcohol and hemochromatosis complicated by
encephalopathy who presents to ED with concern for hyperkalemia
noted on labs with outside provider.
.
In the ED, his potassium was noted to be normal though he
appeared altered and reported generalized weakness and new
diffuse abdominal pain without fever, chills, dysuria and
headache. His physical exam was notable for SIRS criteria with
heart rate of 110 and MAP of 50.
Bedside TTE showed normal ejection fraction though showed
collapsed IVC whose diameter improved with 2 liters of NS
resuscitation and 150 g of albumin resuscitation though no
response to his MAP with CVP 8 - 12 and SvCO2 of 97%. RIJ line
was placed and levophed was started with concern for septic
shock. He was given Vancomycin 1 gm IV x 1, ceftazidime 2 gm IV
x 1 and flagyl 500 mg IV x 1 as empiric coverage and admitted to
MICU for management of septic shock with likely nidus of
infection being SBP.
.
Of note, FAST in the ED showed trace free fluid without any
ascites though abomdinal ultrasound later confirmed moderate
ascites. Labs notable for elevated creatinine to 3.9, lactate
of 4.4, WBC of 3.8, elevated liver enzymes, INR of 2.09 and
T.bili of 4.7.
.
CXR showed no acute cardiopulmonary process with satisfactory
positioning of RIJ line. UA was WNL except for high specific
gravity. EKG showed diffusely low voltage. He also has
cellulitis.
.
Vitals prior to tranfer were 133/92 on levo gtt.
.
On arrival to the MICU, he was encephalopathic with somnolence
but did arouse to voice and sternal rub. He answered questions
with simple yes and no. He denied bloody bowel movements and
vomiting blood although he had copious amounts of dried blood in
his mouth. He was not making urine in the foley.
Past Medical History:
1. Cirrhosis [**2-16**] alcohol, question of hemochromatosis given
elevated iron levels (ferritin ~1500, TIBC ~200). Saw
cardiology here in [**2191-4-15**], who performed an MRI and saw iron
deposits in liver concerning for hemochromatosis. Mild CHF on
last echo (LVEF 50-55%) may be due to EtOH vs. hemachromatosis.
2. Recurrent cellulitis of left leg
3. DVT following trauma to left leg (MVA) Was on warfarin for 1
year.
4. Chronic low back pain
5. Depression
6. Anxiety
Social History:
No current tobacco use, former tobacco ~ 10 pack years (quit 3
years ago). Former alcohol and Klonopin abuse. Patient lives
in [**Hospital 169**] Center, he does not work. He is separated from
his wife. The patient's weekly exercise regimen consists of
walking daily around the building. Patient usually tries to
adhere to a sensible diet and manages ADLs well with assistance.
He is separated from his wife. [**Name (NI) **] has 3 grown children ages 31,
27 and 23 who live in [**Location (un) 17927**]. He quit smoking 3 years ago.
Family History:
His father died of lung cancer and his mother has diabetes. He
has 3 sisters and 1 brother who are healthy. His 3 children who
are healthy.
Physical Exam:
Vitals: temperature 91.1, BP 80s/40s, HR 130s, RR 8-10, O2 sats
100% 5LNC
General: somnolent, arouses to voice and sternal rub, answers
"yes" to some questions but not clearly appropriately
HEENT: Very mild scleral icterus, dried blood in the mouth
Neck: supple, difficult to assess JVP
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal rhythm, soft heart sounds
Abdomen: firm, obese, diffusely tender with guarding, worse in
the RUQ
Ext: cold, left radial pulse 2+, right trace pulse, b/l DP trace
Pertinent Results:
[**2191-12-23**] 09:59AM BLOOD WBC-4.2 RBC-1.71* Hgb-6.4* Hct-21.0*
MCV-123*# MCH-37.5* MCHC-30.5* RDW-16.9* Plt Ct-28*
[**2191-12-23**] 09:29AM BLOOD WBC-4.4 RBC-1.95* Hgb-7.2* Hct-22.5*
MCV-116* MCH-36.8* MCHC-31.8 RDW-17.1* Plt Ct-46*
[**2191-12-23**] 05:01AM BLOOD WBC-4.2 RBC-2.26* Hgb-8.4* Hct-25.5*
MCV-113* MCH-37.3* MCHC-33.1 RDW-17.0* Plt Ct-33*
[**2191-12-22**] 09:40PM BLOOD WBC-3.8* RBC-2.52* Hgb-9.5* Hct-28.6*
MCV-114*# MCH-37.7* MCHC-33.2 RDW-17.0* Plt Ct-24*
[**2191-12-23**] 09:59AM BLOOD Plt Smr-VERY LOW Plt Ct-28*
[**2191-12-23**] 09:59AM BLOOD PT-24.1* PTT-88.5* INR(PT)-2.3*
[**2191-12-23**] 09:29AM BLOOD Plt Ct-46*
[**2191-12-23**] 09:29AM BLOOD PT-21.9* PTT-53.7* INR(PT)-2.1*
[**2191-12-23**] 05:01AM BLOOD Plt Ct-33*
[**2191-12-23**] 05:01AM BLOOD PT-22.0* PTT-65.2* INR(PT)-2.1*
[**2191-12-22**] 11:05PM BLOOD PT-22.0* PTT-150* INR(PT)-2.09*
[**2191-12-23**] 09:59AM BLOOD Glucose-513* UreaN-48* Creat-3.3* Na-135
K-4.1 Cl-101 HCO3-17* AnGap-21*
[**2191-12-23**] 09:29AM BLOOD Glucose-336* UreaN-48* Creat-3.3* Na-136
K-4.4 Cl-100 HCO3-17* AnGap-23*
[**2191-12-23**] 05:01AM BLOOD Glucose-304* UreaN-54* Creat-3.5* Na-134
K-4.3 Cl-97 HCO3-23 AnGap-18
[**2191-12-22**] 09:40PM BLOOD Glucose-340* UreaN-57* Creat-3.9*# Na-134
K-5.0 Cl-98 HCO3-22 AnGap-19
[**2191-12-23**] 09:59AM BLOOD CK(CPK)-76
[**2191-12-23**] 05:01AM BLOOD ALT-73* AST-112* LD(LDH)-277* CK(CPK)-65
AlkPhos-241* TotBili-5.3*
[**2191-12-22**] 09:40PM BLOOD ALT-83* AST-138* AlkPhos-282*
TotBili-4.7*
[**2191-12-23**] 09:59AM BLOOD Calcium-9.6 Phos-7.0* Mg-3.5*
[**2191-12-23**] 09:29AM BLOOD Calcium-8.3* Phos-6.9* Mg-2.4
[**2191-12-23**] 05:01AM BLOOD Calcium-9.0 Phos-7.0*# Mg-2.7*
[**2191-12-23**] 10:43AM BLOOD Lactate-8.1*
[**2191-12-23**] 10:17AM BLOOD Lactate-7.9*
[**2191-12-23**] 09:43AM BLOOD Lactate-5.4*
[**2191-12-23**] 07:27AM BLOOD Lactate-4.1*
[**2191-12-23**] 03:17AM BLOOD Lactate-3.5*
[**2191-12-23**] 01:08AM BLOOD Lactate-3.7*
[**2191-12-22**] 11:07PM BLOOD Lactate-4.4*
Brief Hospital Course:
Mr. [**Known lastname **] is a 51 year old male with a history of alcoholic
cirrhosis and hepatic encephalopathy presented with new
abdominal pain, altered mental status, and hypotension.
.
# Septic shock: Admitted to MICU with MAP 58 after 2L IVF.
Etiology seemed to be SBP vs pneumonia, CXR was not c/w
pneumonia. Cardiac causes less likely given normal bedside echo
in ED w/ FAST negative for pericardial effusion. RUQ showed some
ascites but did not characertize hepatic vasculature well. He
was continued on pressors to maintain his MAP >65, and treated
per standard MUST protocol. He was also started on vancomycin
and zosyn in the ED. Despite aggressive goal-directed
resuscitation and prompt antibiotic treatment, his septic
physiology rapidly worsened and his lactate continued to rise
and his blood pressure progressively fell. He subsequently went
into PEA arrest as described below.
.
# Altered mental status: Most likely a combination of his
baseline hepatic encephalopathy with infection and superimposed
delirium. There is also concern that his MAP is not high enough
to maintain cerebral perfusion pressure at this point since he
has had low MAP for >3 hours and is also not making urine. We
continued aggressive fluid resucication and pressors to maintain
MAP. He was also continued on lactulose and rifaximin, but
ultimately had to be intubated for declining mental status.
.
# Acute kidney injury: His creatinine is acutely elevated from
baseline < 1. The possible etiologies include HRS versus ATN.
We had planned to obtain renal consult in the morning. Patient
had little to no urine output overnight, renal ultrasound in ED
negative for obstruction or hydronephrosis.
.
# Coagulopathy: Patient with baseline coagulopathy and
thrombocytopenia and presented with dried blood in his mouth.
Anesthesia also found blood in the oropharynx. He was not known
to have varicies. Given septic shock there was a concern for DIC
as his condition worsened.
.
# Cirrhosis: Known to be alcoholic and suspected also
hemochromatosis. His synthetic function is poor now with
increasing INR and decreasing albumin. His known
decompensations include hepatic encephalopathy and SBP.
.
# Cardiac arrest: Despite continued aggressive intervention with
pressors, antibiotics, and fluid resuscitation, the patient's
condition continued to decline with decreasing blood pressure,
increasing lactate, and no clinical improvement. Bedside echo
showed poor cardiac systolic function. He subsequently went into
PEA cardiac arrest for which standard ACLS protocol was
initiated. He briefly return of spontaneous circulation, and
showed mildly improved systolic cardiac function on repeat
bedside echo. Within one hour of ROSC his blood pressure started
to trend downward, and family meeting was initiated at the
bedside. During this meeting the family decided not to continue
resuscitation of the patient given poor prognosis on maximal
support (he was on four pressors at that time). His family and
the medical team were all in agreement with this decision.
Chaplain was called to the bedside, and supportive care was
withdrawn. Patient subsequently expired.
Medications on Admission:
- rifaximin 550 mg Tablet PO BID
- lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated topical
to back and hip
- tramadol 50 mg Tablet PO Q6H prn pain
- testosterone 5 mg/24 hr Patch 24 hr Q24H
- Calcium Citrate + D 315-200 mg-unit [**Hospital1 **]
- folic acid 1 mg Tablet daily
- thiamine HCl 100 mg Tablet daily
- multivitamin daily
- pyridoxine 25 mg Tablet daily
- heparin (porcine) 5,000 unit/mL Solution TID
- omeprazole 20 mg [**Hospital1 **]
- nystatin 100,000 unit/g twice a day as needed for rash
-lactulose 10 gram/15 mL 30 ML PO QID
-acetaminophen 325 mg Q6H prn pain: limit to 2g/24hrs
-polyethylene glycol 17 gram/dose PO DAILY
-insulin lispro 100 unit/mL sliding scale.
-midodrine 10 mg PO tid
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic shock
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2191-12-24**]
|
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7425,
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7725,
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[] |
icd9pcs
|
[
[
[]
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| 908
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| 10
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| 0
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| 1,990
| 0
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95,770
| 140,927
|
38678
|
Discharge summary
|
Report
|
Admission Date: [**2147-11-20**] Discharge Date: [**2147-11-25**]
Date of Birth: [**2071-5-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
shortness of breath x 4-6 weeks
Major Surgical or Invasive Procedure:
cardiac catheterization with bare metal stent to the right
coronary artery
History of Present Illness:
Patient is a 76 year-old female with a past medical history of
diabetes who presented to her PCP's office earlier today with
worsening DOE x 4-6 weeks. An ECG done at the PCP's office
showed old inferior q waves with new ST elevations in II,III,
aVF. She was taken to BIDN, where labs at notable for CK 6.2
and trop 0.014 at noon today. On arrival to the ED there, her
initial vitals were 28-34, o2 sat 95% r/a, bp 151/94, hr 115,
and she was becoming increasingly dyspneic. She was started on
a heparin and integrillin gtt, given plavix 600 mg, aspirin 325,
metoprolol 5 IV, and transferred to [**Hospital1 18**] for urgent
catheterization.
.
In the cath lab, patient was increasingly tacypneic and was thus
intubated prior to the procedure. There was a 100% occlusion of
the RCA, and a BMS was placed over this lesion. She also had a
90% diag, 90% mid LAD, 90% mid Lcx. Right heart cath notable
for a PCWP 31, PA oressures 54/32. She was given 40 mg IV Lasix
and transferred to the CCU intubated.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
psoriatic arthritis
depression
NIDDM
Macular degeneration
PAST SURGICAL HISTORY:
Appendectomy, bilateral vein ligation, and right knee surgery.
s/p right breast partial masectomy [**10-7**]
Social History:
SOCIAL HISTORY: Pt lives alone, has daughter in [**Name (NI) 620**]. Was
previously independent. no history of smoking, alcohol, drugs,
as per OSH documentation; patient intubated here
Family History:
FAMILY HISTORY:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission PE:
VS: 98.1 93/53 71 16 98% intubated on 60% FIO2
GENERAL: NAD, intubated
HEENT: NCAT
NECK: Supple
CARDIAC: RR, normal S1, S2. No m/r/g.
LUNGS: anterior lung fields clear to ausculation b/l
ABDOMEN: soft, nondistended, +BS
EXTREMITIES: no LE edema, warm, well perfused, with soft cast
on R leg
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
..
GENERAL: 76 yo F in no acute distress
HEENT: no lymphadenopathy, JVP non elevated
CHEST: crackles bibasilar, [**Month (only) **] from prior.
CV: S1 S2 Normal in quality and intensity RRR,
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. gait
WNL.
SKIN: no rash
PSYCH: alert, oriented, fair understanding of medical condition.
Pertinent Results:
Admission labs:
[**2147-11-20**] 05:14PM BLOOD WBC-10.3 RBC-3.68*# Hgb-11.2*# Hct-32.1*#
MCV-87 MCH-30.5 MCHC-35.0 RDW-14.1 Plt Ct-259
[**2147-11-20**] 11:31PM BLOOD Hct-27.9* Plt Ct-212
[**2147-11-21**] 03:58AM BLOOD WBC-7.7 RBC-3.10* Hgb-9.7* Hct-27.3*
MCV-88 MCH-31.3 MCHC-35.4* RDW-14.2 Plt Ct-199
[**2147-11-21**] 02:00PM BLOOD WBC-8.3 RBC-3.81* Hgb-11.3* Hct-34.0*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.2 Plt Ct-250
[**2147-11-20**] 05:14PM BLOOD PT-15.0* PTT-93.7* INR(PT)-1.3*
[**2147-11-22**] 05:52AM BLOOD PT-14.3* INR(PT)-1.2*
[**2147-11-20**] 05:14PM BLOOD Glucose-141* UreaN-17 Creat-1.0 Na-142
K-3.2* Cl-107 HCO3-21* AnGap-17
[**2147-11-20**] 11:31PM BLOOD Na-143 K-3.9 Cl-107
[**2147-11-21**] 03:58AM BLOOD Glucose-132* UreaN-15 Creat-0.9 Na-142
K-4.0 Cl-107 HCO3-23 AnGap-16
[**2147-11-21**] 02:00PM BLOOD Glucose-124* UreaN-14 Creat-1.0 Na-141
K-3.5 Cl-104 HCO3-23 AnGap-18
[**2147-11-20**] 05:14PM BLOOD CK-MB-7 cTropnT-0.01
[**2147-11-20**] 11:31PM BLOOD CK-MB-6
[**2147-11-21**] 03:58AM BLOOD CK-MB-5 cTropnT-0.04*
[**2147-11-20**] 05:14PM BLOOD Calcium-9.2 Phos-5.0* Mg-1.7
[**2147-11-21**] 03:58AM BLOOD Calcium-8.8 Phos-3.4# Mg-1.9 Cholest-90
[**2147-11-21**] 02:00PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.7*
[**2147-11-21**] 11:00PM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
[**2147-11-21**] 03:58AM BLOOD %HbA1c-6.4* eAG-137*
[**2147-11-21**] 03:58AM BLOOD Triglyc-100 HDL-38 CHOL/HD-2.4 LDLcalc-32
[**2147-11-20**] 05:57PM BLOOD Type-ART Temp-36.7 Rates-16/ Tidal V-450
PEEP-5 FiO2-100 pO2-332* pCO2-38 pH-7.35 calTCO2-22 Base XS--3
AADO2-346 REQ O2-62 -ASSIST/CON Intubat-INTUBATED
[**2147-11-20**] 06:53PM BLOOD Type-ART Temp-36.8 Rates-16/ Tidal V-450
PEEP-5 FiO2-60 pO2-135* pCO2-40 pH-7.37 calTCO2-24 Base XS--1
-ASSIST/CON Intubat-INTUBATED
D/C labs:
[**2147-11-24**] 07:35AM BLOOD WBC-11.6* RBC-4.23 Hgb-13.2 Hct-38.4
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.9 Plt Ct-250
[**2147-11-25**] 06:35AM BLOOD WBC-11.1* RBC-4.24 Hgb-13.0 Hct-38.2
MCV-90 MCH-30.8 MCHC-34.1 RDW-13.7 Plt Ct-294
[**2147-11-23**] 05:30PM BLOOD Glucose-119* UreaN-22* Creat-1.0 Na-141
K-4.1 Cl-98 HCO3-32 AnGap-15
[**2147-11-24**] 07:35AM BLOOD Glucose-130* UreaN-25* Creat-1.0 Na-141
K-4.1 Cl-99 HCO3-35* AnGap-11
[**2147-11-25**] 06:35AM BLOOD Glucose-111* UreaN-35* Creat-1.1 Na-140
K-3.9 Cl-99 HCO3-33* AnGap-12
[**2147-11-21**] 03:58AM BLOOD CK(CPK)-89
[**2147-11-23**] 05:06AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.3
[**2147-11-23**] 05:30PM BLOOD Calcium-9.8 Phos-3.0 Mg-2.1
[**2147-11-24**] 07:35AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.1
Studies:
ECHO: [**2147-11-21**]
Left ventricular wall thicknesses are normal. The left
ventricular cavity is dilated. Overall left ventricular systolic
function is severely depressed (LVEF= 15 %) secondary to
extensive apical akinesis, inferior posterior akinesis, and
septal akinesis with focal dyskinesis. The right ventricular
free wall thickness is normal. Right ventricular chamber size is
normal. with borderline normal free wall function. [Intrinsic
right ventricular systolic function is likely more depressed
given the severity of tricuspid regurgitation.] There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Cath [**2147-11-20**]
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe diastolic ventricular dysfunction.
3. Inferior wall STEMI.
4. Acute occlusion at the level of mid-RCA successfully treated
with a
bare metal Vision stent(3.0 x 12 mm).
Brief Hospital Course:
ASSESSMENT & PLAN:
76 year-old female with a past medical history of diabetes who
presented to her PCP's office with worsening DOE x 4-6 weeks,
found to have ST elevations in inferior leads and now s/p BMS to
mid-RCA, 3-vessel disease on cath.
.
# Acute systolic CHF: A post cath ECHO showed that the patient
had an EF of 15% with apical/septal/poterior AK and focal DK.
Also has 3+ TR and 1+MR. [**Name13 (STitle) 17221**] than being an acute change, her
poor heart function was though to be a more chronic progression
over thelast few months. This is consistent with the patient's
description of NHYA class [**3-2**] symptoms at home. The patient
initially had crackles on exam, that improved during the
hospitalization, as well as no peripheral edema. Initially the
patient was very tachypneic during the cath, and was intubated.
She also received 40 mg IV lasix at the time and made good
urine. Her respiratory status continued to improve as fluid was
taken off. The patient did no have an oxygen requirment on
discharge, and was sent home on Torsemide 40 mg daily. The
patient was also medically optimized for her CHF and started on
metoprolol, atorvastatin, and her home lisinopril dose was
increased. She was also started on spironolactone. The patient
should have a repeat ECHO in about one month to assess for any
changes in her heart failure now that she has been started on a
heart failure medication regimen.
.
# Inf MI: The patient was found to have old Q waves in the
inferior leads, as well as new ST elevations in II, III, and
aVF. The patient did not make troponins, with peak being 0.04.
She was taken to the cath lab and found to have a 100% occlusion
of the RCA, and a BMS was placed over this lesion. She also had
a 90% diag, 90% mid LAD, 90% mid Lcx. Other vessels not stented
because of distal nature of occlusions. The patient was started
on ASA 325 mg, as well as plavix 75 mg for at least one month.
Post procedure, the patient was continued on integrillin drip
for 18 hours. The patient was found to have an A1c of 6.4. Her
lipid panel showed TC 90, TG 100, HDL 38, and LDL of 32. The
patient was started on atorvastatin 80 mg daily.
.
# elevated wedge/respiratory status: Pt was increasingly
tachypneic prior to cath and was intubated, on assist control
with TV 450 cc, resp rate 16, PEEP 5, on 60% FIO2. Also found to
have right heart cath notable for a PCWP 31, PA oressures 54/32.
She was given 40 mg IV Lasix and transferred to the CCU
intubated. Right heart cath notable for a PCWP 31, PA oressures
54/32. She was given 40 mg IV Lasix and transferred to the CCU
intubated. The patient was extubated the next morning, and
diuresis was continued, and her respiratory status continued to
improve. The patient was discharged on torsemide, and was
instructed to follow up labs as an outpatient.
.
# HTN: The patient's home dose of lisinopril was increased from
2.5 mg daily to 5 mg daily, and she was started on metoprolol
12.5 mg [**Hospital1 **], that was later transitioned to 50 mg of metoprolol
succinate daily. The patient was also started on spironlactone
12.5 daily.
.
# Diabetes type 2: The patient was taken metformin at home; it
was held during the hospitalization and she was kept on humalog
sliding scale. While in patient, she required minimal amounts
of insulin and A1c was found to be 6.4. She was discharged on
her home dose of metformin.
.
# Psoriatic Arthritis: The patient was continued on her home
dose of methotrexate. She has a rheumatologist at NWH who
follows her.
.
# Depression/mood disorder: The patient is followed by
outpatient psychiatrist. Her lithium and effexor were initially
held, but then restarted after she was extubated. The patient
had a lithium level that was checked, which was normal.
..
Transitional Issues:
- the patient will need to have her lytes checked on [**12-1**] and
have her results faxed to her primary care doctor's office.
- the patient will need to have a repeat ECHO done, as she has
been started on medications for her heart failure.
Medications on Admission:
Lisinopril 2.5mg PO Daily
Metformin 850mg PO BID
Methotrexate 2.5mg tabs 6 tabs by mouth once weekly
Folic acid 1mg PO daily
Effexor 75mg PO TID
Lithium 300mg tabs, 2 tabs by mouth [**Hospital1 **] (1200mg total) (managed
by Dr. [**Last Name (STitle) 85917**]
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. venlafaxine 75 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
8. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
11. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please check basic metabolic profile on [**12-1**]. Please fax
results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 483**] at [**Hospital1 18**] [**Location (un) 620**].
13. methotrexate sodium 2.5 mg Tablet Sig: Six (6) Tablet PO
once a week.
Discharge Disposition:
Home With Service
Facility:
Care Group Home Care
Discharge Diagnosis:
Coronary Artery Disease
Myocardial Infarction, not acute
Acute Systolic Dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 10351**],
You had increasing shortness of breath at home that is from
congestive heart failure and an old heart attack. You had some
changes on your ECG and was transferred to [**Hospital1 18**] for a cardiac
catheterization. A stent was placed in your right coronary
artery and you have other blockages that were not fixed at this
time. You were started on aspirin and clopidogrel, Plavix, to
keep the stent from clotting off. Do not stop taking plavix or
aspirin for any reason unless Dr. [**Last Name (STitle) **] tells you it is OK. You
risk having another heart attack if you do not take these
medicines. The plan is to treat you with medicines to help your
heart pump better and recover from the heart attack. Your heart
function is very weak after the heart attack and you will need
to take all of your medicines every day and check for any fluid
build up. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes
up more than 3 lbs.You also need to follow a low sodium diet.
.
We made the following changes to your medicines:
1. START taking aspirin 325mg (not baby) and clopidogrel every
day for at least one month and possibly longer to keep the stent
from clotting off
2. START taking metoprolol to lower your heart rate and help
your heart pump better.
3. Increase the lisinopril to lower your blood pressure and help
your heart pump better
4. START taking atorvastatin to lower your cholesterol
5. START taking spironolactone daily to help your heart pump
better
6. START taking torsemide daily to get rid of extra fluid
Please have electrolytes checked with your primary care
physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 483**]. An order for these blood tests will be
provided in your discharge paperwork.
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: FRIDAY [**2147-12-1**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 85918**], MD [**Telephone/Fax (1) 3070**]
Building: None [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: CARDIAC SERVICES
When: TUESDAY [**2147-12-26**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2147-11-27**]
|
[
"362.50",
"428.21",
"397.9",
"410.41",
"402.91",
"250.00",
"696.0",
"311",
"296.90",
"414.01"
] |
icd9cm
|
[
[
[
2242,
2261
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],
[
[
7749,
7766
]
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[
7884,
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[
[
8933,
8939
]
],
[
[
10345,
10347
]
],
[
[
10627,
10641
]
],
[
[
10910,
10929
]
],
[
[
11046,
11055
]
],
[
[
11057,
11069
]
],
[
[
13293,
13315
]
]
] |
[
"36.06"
] |
icd9pcs
|
[
[
[
367,
411
]
]
] | 52
| 3,786
| 0
| 78
| 1
| 0
| 0
| 0
| 0
| 1
| 0
| 0
| 629
| 118
| 0
| 0
| 0
| 1,338
| 0
| 87
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| 262
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| 222
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| 1,790
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| 111
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| 1,543
| 0
| 0
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| 3,584
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| 171
| 0
| 0
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| 0
| 0
| 0
| 0
| 0
|
91,549
| 169,861
|
41774
|
Discharge summary
|
Report
|
Admission Date: [**2161-9-5**] Discharge Date: [**2161-9-16**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
s/p Arrest
Major Surgical or Invasive Procedure:
Intubated with endotracheal tube
History of Present Illness:
[**Age over 90 **]M with history of Afib on coumadin, PVD, hypothyroidism
admitted to [**Hospital1 18**] s/p arrest found to have small
intraventricular hemorrage, unclear etiology of arrest. Per
sister, who lives in apt below, patient has been in usual state
of health. She found him this am in bathtub with water running -
reported to be breating. EMS arrived, AED with VT, had CPR, no
shock given. Loaded with amiodorone in the field, transferred to
Lawsrence [**Hospital1 107**]. At [**Hospital3 1443**], Febrile to 100.8,
recieved avalox for possible PNA and Rocephin for UTI. CT with
left intraventricular hemorrhage. Recieved Vitamin K for
elevated INR and fosphenytoin for seizure prophylaxis.
Transferred on propofol for comfort. Of note, no written report
of PEA arrest at OSH that was verbally reported in sign-out.
.
On arrival to [**Hospital1 18**], patient arrived hypotensive 60-70/30 with
HR 56. Propofol was discontinued, levophed started. He went into
PEA arrest at 1244, recieved epi 1 mg (?2 mg), levophed titrated
up, right femoral CVL placed. Large incontinence of stool.
Neurosurgery consulted and recommended no intervention at this
time with serial CT Head and managment of coagulopathy. Neuro
felt seizure unlikely the cause of shock. Due to acidosis,
started on bicarb gtt. Placed on Fentanyl/Versed for sedation.
Also recieved 18 units of Factor 9 to reverse coagulopathy and
4L IVF. After ROSC, he was moving all 4 extremities. Not cooled
due to ICH.
.
Most recent set of vitals prior to transfer: 127 143/69 100% on
vent 98.6F rectally.
Past Medical History:
Atrial Fibrillation
Hypertension
NIDDM - diet controlled
PVD
Hypothyroidism
CHF diagnosed in [**2156**], no known ischemic disease
Social History:
Lives above sister, who is HCP.
[**Name (NI) 1139**]: none
Family History:
Non-contributory
Physical Exam:
Vitals: afebrile, 97 134/67 100% on vent AC 500/18 (breathing at
26)/50%/5
General: intubated/sedated, opens eyes intermittently, does not
respond to commands, withdrawal to pain
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, NT/ND
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
[**2161-9-8**] 05:22AM BLOOD WBC-19.2* RBC-3.94* Hgb-12.2* Hct-35.7*
MCV-91 MCH-31.0 MCHC-34.2 RDW-15.6* Plt Ct-84*
[**2161-9-7**] 04:21AM BLOOD WBC-15.4* RBC-3.83* Hgb-11.9* Hct-36.4*
MCV-95 MCH-31.0 MCHC-32.6 RDW-15.1 Plt Ct-99*
[**2161-9-7**] 04:21AM BLOOD Neuts-80* Bands-12* Lymphs-5* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2161-9-8**] 05:22AM BLOOD Plt Ct-84*
[**2161-9-8**] 05:22AM BLOOD PT-21.6* PTT-42.0* INR(PT)-2.0*
[**2161-9-5**] 12:30PM BLOOD Fibrino-350
[**2161-9-8**] 05:22AM BLOOD Glucose-174* UreaN-86* Creat-4.3* Na-138
K-6.1* Cl-106 HCO3-12* AnGap-26*
[**2161-9-7**] 04:01PM BLOOD Glucose-200* UreaN-76* Creat-3.7* Na-137
K-5.6* Cl-105 HCO3-14* AnGap-24*
[**2161-9-8**] 05:22AM BLOOD ALT-1881* AST-1045* CK(CPK)-1113*
AlkPhos-40 Amylase-47 TotBili-2.9*
[**2161-9-6**] 05:50AM BLOOD CK-MB-60* cTropnT-1.95* proBNP-[**Numeric Identifier **]*
[**2161-9-6**] 06:30AM BLOOD TSH-0.31
[**2161-9-8**] 05:22AM BLOOD Vanco-7.6*
[**2161-9-7**] 01:13PM BLOOD Type-[**Last Name (un) **] pO2-34* pCO2-41 pH-7.21*
calTCO2-17* Base XS--12
[**2161-9-7**] 01:13PM BLOOD Lactate-3.1*
[**2161-9-5**] 08:26PM BLOOD freeCa-1.02*
Brief Hospital Course:
[**Age over 90 **]M admitted to [**Hospital1 18**] s/p PEA arrest. He was found in his
bathrub with water running. Had CPR in the field with no shock
given, amiodarone given. At [**Hospital3 1443**] Hosp, he was
treated with avalox and rocephin for possible pneumonia and UTI
respectively. CT showed left intraventricular hemorrhage.
Transferred to [**Hospital1 18**] hypotensive. Started on levophed. Again
went into PEA arrest with epinephrine given, levophed titrated
up, bicarb given due to acidosis. He was placed on
fentanyl/versed for sedation, given 18 u factor 9 to reverse
coagulopathy. Not cooled due to ICH. Decision was made to make
patient CMO. He was extubated and transferred to the medicine
service for futher care.
# Cardiac arrest: He achieved return of spontaneous circulation
in the ED. He was transferred to the ICU intubated on pressure
support with levophed for a MAP >60. Attempts were made to
determine the etiology of the arrest. He had an echocardiogram
which showed an "ejection fraction of 25%, mildly dilated LA,
mild symmetric LVH, mid-distal anteroseptal and apical akinesis
and hypokinesis elsewhere, RV cavity dilated with moderate
global free wall hypokinesis, mild AR, mild MR, no pericardial
effusion." Cardiac enzymes did not suggest massive new MI.
Bilateral LENIs did not show any DVTs. Cardiac arrhythmia
possible given hx of A-fib. A family meeting was held in which
the patient's code status was changed to DNR (no shocks or chest
compressions). It was determined that we would not further
escalate care or pursue more invasive measures such as a-line
placement or HD at this time. On [**9-7**] he passed SBT with a RSBI
of 23 and he was switched to pressure support. Upon further
discussion with the family, it was decided to palliatively
extubate. The palliative care team was made aware and will help
make patient as comfortable as possible. Pt was extubated on
[**9-8**] and made comfort measures only.
.
# Hypotension: Unclear etiology of hypotension; echo showed
depressed ejection fraction so maybe cardiogenic in origin.
Unlikely to be hypovolemia given lack of bleeding source and
lack of response to aggressive fluid resucitation. Attempts were
made to place radial and femoral a-lines but were unsuccessful
due to peripheral arterial disease. IVF and levophed were used
to keep urine output >30cc/hr and a MAP >60. ACEI and BB were
held throughout.
.
# CHF/A-fib: Acuity of his CHF is unclear as discussed above.
His supratherapeutic INR was reversed in the setting of IVH and
his anti-coagulation was held. His ACEI and BB were held in the
setting of hypotension.
.
# IVH: likely secondary to fall in the setting of
supratherapeutic INR. Bleed is not large enough to precipitate
PEA arrest. A CT head showed no interval change in
intraventricular hemorrhage in the temporal and occipital horns
of the left lateral ventricle. He received frequent neuro
checks. The neurosurgery team felt no need for intervention at
this time.
.
# AG metabolic acidosis and appropriate compensatory respiratory
alkalosis: AG likely due to lactic acidosis. No evidence of DKA
or other toxin exposures. He was given aggressive fluid
resuscitation and his lactate trended down throughout his MICU
stay.
.
# [**Last Name (un) **]: Was likely to be pre-renal or ATN in the setting of
shock. We do not know the baseline status of his renal function.
His lisinopril and HCTZ were held throughout his stay. He was
given adequate fluid resucitation. On [**9-7**] he had a potassium
of 5.7. An EKG did not demonstrate peaked T-waves. He was given
30mg of kayexalate.
.
# DM - diet controlled with fingersticks qACHS, start gentle
insulin SS
.
# hypothydroidism - thyroid medication dosage not confirmed
prior to his status as being made CMO.
.
# Lung nodules - a CT demonstrate ground glass opacities and a
nodules that should be followed up in [**2-1**] months.
.
# Comfort measures only
The decision was made to make the patient CMO. He was extubated
and transferred to the medicine service. Palliative care was
consulted. Patient was made comfortable with morphine and
scopolamine and other comfort measures. He was admitted to
hospice care and expired on [**2161-9-16**].
Medications on Admission:
HCTZ
Lisinopril 2.5
Coumadin 4mg 6xweek/5mg 1xweek
Pravastatin 80 mg daily
Nifedipine (dose unknown)
Equate vision
Multivitamins
Trental 500 TID
ASA 81 mg daily
Synthroid - dose unknown
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
Completed by:[**2161-9-16**]
|
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Discharge summary
|
Report
|
Admission Date: [**2151-2-17**] Discharge Date: [**2151-3-2**]
Date of Birth: [**2072-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
Brain Abscess drainage
Bronchoscopy with biopsy
History of Present Illness:
78 F presents from [**Hospital3 **] for acute mental status
changes and bilateral frontal mass lesions. She began prednisone
therapy for 4 days ago for BOOP. She complained of a headache on
over the weekend, which was unusual for her. Her family noted
increasing confusion x a few days, then yesterday she was noted
to have some slurred speech and then this morning she couldn't
speak - could only say "[**Last Name (un) 46536**]..." and "no." She was not able to
bathe herself this AM as she forgot what to do. She normally
cares for herself and is high functioning. She was taken to her
PCP (Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 80583**]), where a mini mental was given, she could only
do about half the items on the test -- this is a dramatic change
for her. Therefore, she was sent to the [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4117**] ED. CT
revealed 2.4 cm lesion in the L frontoparietal region and a 20
mm lesion in the Right frontal lobe. At OSH ED given decadron 24
mg x1. Transferred to [**Hospital1 18**] for neurosurg eval.
The patient developed what was thought to be "the flu" in
[**Month (only) 359**]; this then developed into pneumonia in [**Month (only) 1096**]. The
pneumonia did not go away despite a few rounds of antibiotics. A
biopsy was performed [**2151-2-5**] which showed "metaplastic alveolar
epithelial cells, fibroblasts and rare inflammatory cells"
thought to be consistant with BOOP. She was started Prednisone 4
days prior to admission.
She has not had a colonoscopy. She has yearly mammograms that
have been fine. Her daughter is not sure about her [**Name (NI) **] history.
In the [**Hospital1 18**] ED: Neurosurgery was consulted. She was loaded with
dilantin. She was admitted to medicine for further workup.
Past Medical History:
1. COPD
2. BOOP- diagnosed 3 weeks ago by CT guided biopsy
3. Pneumonia ([**1-22**]) 3 days admission- [**Hospital1 **]
4. Glaucoma
5. Anxiety
6. Bipolar D/O -- well controlled x 20 years
7. Cataract
8. fluid retention
9. Neuropathy
10. hyperlipidemia
Social History:
Lives at home with daughter, completes most ADLs. Smoked 3ppd
for many years, quit over 20 years ago. No EtOH.
Family History:
Father- lung ca, CAD
Physical Exam:
Gen: NAD
HEENT: MMM. PERRL, EOMI.
CV: RRR
Pulm: CTA, minimal fine crackles at bases
Abd: obese, soft, NT/ND
LE: warm, no edema
Neuro: alert, oriented to person and place. speech is slow,
mostly limited to yes and no responses. seems to have some
wordfinding difficulty. cranial nerves grossly intact. moves all
4 ext with good strength, no gross sensory deficits.
Pertinent Results:
[**2151-3-2**] 06:10AM BLOOD WBC-13.2* RBC-3.62* Hgb-11.2* Hct-33.2*
MCV-92 MCH-31.1 MCHC-33.8 RDW-16.5* Plt Ct-135*
[**2151-3-1**] 05:49AM BLOOD WBC-14.0* RBC-3.62* Hgb-11.1* Hct-33.2*
MCV-92 MCH-30.5 MCHC-33.3 RDW-16.2* Plt Ct-143*
[**2151-2-28**] 06:54AM BLOOD WBC-19.7* RBC-3.86* Hgb-11.9* Hct-35.4*
MCV-92 MCH-30.8 MCHC-33.5 RDW-16.2* Plt Ct-163
[**2151-2-27**] 05:29AM BLOOD WBC-14.9* RBC-3.87* Hgb-11.7* Hct-35.0*
MCV-91 MCH-30.2 MCHC-33.4 RDW-16.3* Plt Ct-171
[**2151-2-26**] 05:40AM BLOOD WBC-14.0* RBC-3.67* Hgb-11.1* Hct-33.2*
MCV-91 MCH-30.3 MCHC-33.4 RDW-15.7* Plt Ct-163
[**2151-2-28**] 06:54AM BLOOD Neuts-64 Bands-0 Lymphs-21 Monos-7 Eos-5*
Baso-0 Atyps-2* Metas-1* Myelos-0
[**2151-3-2**] 06:10AM BLOOD Glucose-86 UreaN-14 Creat-0.5 Na-143
K-4.2 Cl-105 HCO3-33* AnGap-9
[**2151-3-1**] 05:49AM BLOOD Glucose-80 UreaN-14 Creat-0.6 Na-143
K-4.2 Cl-104 HCO3-33* AnGap-10
[**2151-2-28**] 06:54AM BLOOD Glucose-67* UreaN-14 Creat-0.6 Na-145
K-4.0 Cl-104 HCO3-31 AnGap-14
[**2151-2-27**] 05:29AM BLOOD Glucose-105 UreaN-12 Creat-0.5 Na-139
K-4.0 Cl-102 HCO3-32 AnGap-9
[**2151-2-27**] 05:29AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1
==========================================================
MICROBIOLOGY:
[**2151-2-17**]: Bld Culture x 1 Negative
[**2151-2-17**]: Urine Cx x 1 negative
[**2151-2-18**]: Tissue Cx Left Frontal Brain Abscess Wall: PMN
Leukocytes 2+, no micro-organisms.
[**2151-2-23**] BAL: PMN Leukocytes, no microorganisms, no Fungus, No
AFBs
[**2151-2-23**] RUL Tissue (during bronchoscopy)
GRAM STAIN: POLYMORPHONUCLEAR LEUKOCYTES, NO MICROORGANISMS
SEEN. NO GRWOTH
ANAEROBIC CULTURE: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2151-2-18**] BRAIN ABSCESS DRAINAGE
GRAM STAIN (Final [**2151-2-19**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 80584**] @ 00:08A [**2151-2-19**].
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final [**2151-2-25**]):
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
NOT VIABLE FOR SENSITIVITIES.
VIRIDANS STREPTOCOCCI. RARE GROWTH. SECOND MORPHOLOGY.
NOT VIABLE FOR SENSITIVITIES.
ANAEROBIC CULTURE (Final [**2151-2-25**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2151-2-19**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Brief Hospital Course:
## Brain Abscess: Pt was admitted to [**Hospital1 18**] from an outside
hospital following her history of altered mental status as well
evidence of frontal bilateral masses. Pt underwent a CT scan and
MRI which showed the appearance of cystic lesion. Pt was started
on IV steroids and neurosurgery were consult. On the night of
admission pt underwent an open bone flap and drainage to assess
whether lesion was metastatic versus an infection. Pus was noted
and drained noted to have brain abscess on biopsy/drainage
performed on [**2-18**]. Pt was then admitted and observed in the
Neurosurgical ICU where she underwent a second procedure to
remove her remaining rt sided lesion. Streptococcus Viridans was
cultured and pt was started on a course of Vancomycin and then
transitioned to Ceftriaxone per Infectious disease
recommendations 2gm IV q 12hrs on [**2-26**]. Per Neurosurgery
recommendations pt was started on Keppra for seizure
prophylaxis. Pt currently has two sutures in place at time of
discharge, the largest will dissolve, the second will need to be
removed during a follow up visit to Dr.[**Name (NI) 12757**] office on
[**2151-3-8**] 11:30. Pt will need a repeat CT scan as an outpatient
which has been scheduled for [**2151-3-23**] 2:00, after CT head scan
pt will see Dr. [**Last Name (STitle) **]. Pt will need a minimum of a 4 week
course of Ceftriaxone 2gm IV q12hrs. Pt will have, during this
duration, a follow up Infectious Disease Clinic appointment
where they will decide whether she needs additional treatment.
Pt underwent a TTE that did not show any endocarditis. TEE was
deferred as it would not change management and was felt to be a
high risk
procedure per our cardiology team. The most likely etiology of
her brain abscesses is seeding from her lung infection (see
below) or from endocarditis.
## Lung Lesion: Pt underwent a biopsy of lung mass recently that
was positive for BOOP. As the possibility of malignancy still
existed the pt's RUL mass went to the bronchoscopy suite where
she underwent 6 biopsies, BAL, brush examination. Biopsies
showed alveolar and peribronchial tissue with mixed inflammatory
infiltrate, suggestive of acute pneumonia. Bronchial mucosa with
mildly increased goblet cells and focal acute inflammation. No
malignancy was identified. Pt was discharged with a 7 day
steroid taper per Interventional Pulmonary. Pt will f/u with a
repeat CT chest with contrast scan on [**2151-4-9**] 1030 to check the
RUL mass. Results will be faxed to Dr. [**Name (NI) 80585**], pt will follow
up with Dr. [**Last Name (STitle) 80585**] on [**2151-4-15**] 17:15.
##. Mobility: Pt had bone flap removed for abscess drainage. She
will need to wear the helmet whenever she is mobile. She will
later need a graft however this will not be performed until
several months from now.
## Leukocytosis: Pt's WBC was noted to trend up and then down
prior to discharge. Pt noted to have thrush as well as yeast in
her urine. Pt was started on a 14 day course of oral
Fluconazole.
- continue total 14 days Course of Fluconazole
## Endometrial thickening: On CAT scan pt's endometrial lining.
Recommend pt undergo a transvaginal U/S to evaluate endometrial
thickening as an outpatient.
## FEN: pt underwent bedside and swallow evaluation. Per speech
and swallow recommendations pt was started and tolerated a soft
diet with thin liquids.
## Psych: Pt has history of bipolar disorder, for which she
usually takes Thoridazine. After discussion with Neurosurgery it
was decided that the Thoridazine would have a potential to
interfere with the pt's neurological examination. Pt will be
re-evaluated by Dr. [**Last Name (STitle) **] on [**3-23**], at that time a decision
will be made whether Thoridazine can be restarted.
- Recommend discussing with Dr. [**Last Name (STitle) **] on [**3-23**] whether pt can
start her Thoridazine again.
## COPD: Pt noted intermittently to be wheezing on examination
during the first days of admission. Pt was discharged on
Tiotropium Bromide.
## Code status: FULL CODE
Medications on Admission:
Prednisone 20 mg Daily (Started [**2151-2-13**])
Gabapentin 300 mg TID
HCTZ 25 mg Daily
Simvistatin 20 mg Daily
Spiriva 18 mg Daily
Albuterol
Betaxolol Ophth Susp 0.25%
Thioridazine 40 mg qHS
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours) for 33 days: Your
last day of antibiotics will be on [**2151-4-3**].
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
11. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 28 days: Your last dose will be [**2151-3-29**].
12. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 13 doses: Please follow taper.
[**Date range (3) 80586**] Please take 15mg of Prednisone once a day.
[**Date range (1) 80587**] Please take 10mg of Prednisone once a day.
[**Date range (1) 52680**] Please take 5mg of Prednisone once a day.
[**Date range (1) 80588**] Please take 2.5mg of Prednisone once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Bilateral Brain Abscesses
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital after it was found that you
had two brain abscesses. You were taken to the operating room by
the Neurosurgeons who drained your abscesses. The abscesses were
positive for a bacteria called Streptococcus Viridans. We
checked your blood cultures, performed an echo of yor heart
check for a source of the infection, all were negative. We
consulted the infectious disease specialists who recommended a
minimum 4 weeks of antibiotics. They will see you as an
outpatient to see whether you will need more antibiotics.
Prior to leaving the hospital you were fitted for a helmet which
you will need to wear whenever you are walking as a part of you
skull was removed for the abscess drainage.
Please take your medications as prescribed:
You will be on a Prednisone taper:-
[**Date range (3) 80586**] Please take 15mg of Prednisone once a day.
[**Date range (1) 80587**] Please take 10mg of Prednisone once a day.
[**Date range (1) 52680**] Please take 5mg of Prednisone once a day.
[**Date range (1) 80588**] Please take 2.5mg of Prednisone once a day.
You were also started on two antibiotics:
1. Ceftriaxone 2gm IV every 12 hours, your last dose currently
will be given on [**2151-4-3**].
2. Fluconazole for the yeast in your urine and oral thrush.
Please take 100mg Fluconazole once a day day. Your last dose
will be [**2151-3-29**].
Please follow up with all of your appointments.
You have been scheduled for 2 CAT scans.
Your first scan is of your head and will be followed by Dr.
[**Last Name (STitle) **], This is to check the progression of your abscesses and
if they have come back. It is scheduled for [**2151-3-23**] 14:00 and
it will be on the [**Location (un) **] of [**Hospital Ward Name 23**].
The second CAT scan is of your chest to see the progression of
the mass in your chest that was biopsied by Dr. [**Last Name (STitle) 80585**] and us.
The results will be faxed to Dr. [**Last Name (STitle) 80585**]. It is scheduled for
[**2151-4-9**] 10:30 and it will be on the [**Location (un) **] of the [**Hospital Ward Name 23**]
building.
If you experienced any seizures, fevers, chills, difficulty
breathing please call your doctor or return to the ED.
Followup Instructions:
You will continue to receive antibiotics for a total of 4 weeks.
You can call [**Telephone/Fax (1) **] to reach the infectious disease
doctors [**First Name (Titles) **] [**Hospital1 **] for any questions.
SUTURE REMOVAL APPOINTMENT: (DR.[**Doctor Last Name **] OFFICE) [**2151-3-8**] 11:30
OFFICE Located aT [**Doctor First Name **]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-3-23**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12760**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2151-3-23**] 2:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2151-4-2**]
11:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-4-9**] 10:30
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Date/Time: [**2151-4-15**] 17:15
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
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38740
|
Discharge summary
|
Report
|
Admission Date: [**2129-9-20**] Discharge Date: [**2129-9-23**]
Date of Birth: [**2102-6-6**] Sex: M
Service: MEDICINE
Allergies:
Fentanyl
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
27year old male with Hajdu-[**Location (un) 2987**] Syndrome, (bone disorder) with
restrictive lung disease from severe scoliosis and COPD (current
smoker) at home on 4L O2 by nasal cannula and then SIMV by
ventilator at night presenting to ED with increased SOB x 2days
and increasing secretions. Patient was recently admitted to
[**Hospital1 18**] with right olecranon osteomyelitis. He has been treated
for 1.5 weeks with vancomycin for this infection. Since then he
reports very little improvement in the infection.
Patient has history of ventilator-associated pneumonia with
resistant pseudomonas in recent cultures (sensitive only to
tobramycin but treated with cefepime with good result) and
reports that over the last few days he has had increasing SOB
worse than baseline. In addition he has had increasing
secretions. He thinks he may also have been having fevers
(low-grade). No sick contacts but says this feels like his prior
PNAs so he came to ED.
.
VS on arrival to the ED: T:98.9 HR:122 BP:109/79 RR:22 O2Sat:98
on 5L trach mask. Reportedly received cefepime and/or levoquin
in the ED for history of pseudomonal VAP since already on
Vancomycin for osteomyelitis was covered for MRSA. Also takes
prednisone at home and got 60mg in the ED for ?COPD
exacerbation.
.
VS prior to transfer: T 99 HR 108 BP 124/72 RR 20 O2 97% on 5L
trach mask.
.
On the floor, patient complained of SOB and requested nebulizer
treatments. He denied chest pain, dysuria, N/V/abdominal
pain/diarrhea.
Past Medical History:
1. Hajdu-[**Location (un) 2987**] Syndrome
2. Osteomyelitis, right olecranon (pressure-related)
3. Chronic obstructive/restrictive lung disease
4. h/o multiple pneumonias, including Pseudomonas pna and VAP
Social History:
Lives at home with his grandparents and brother. [**Name (NI) **] a Home
Health Aide.
- Tobacco: active tobacco use ([**5-16**] cigarettes a day)
- Alcohol: denies
- Illicits: denies
Family History:
Mother and brother with [**Location (un) 86059**] syndrome.
Physical Exam:
Vitals: T: 98.2 BP: 135/92 P:108 R: 24 O2: 99% on 40% trach mask
General: Alert, oriented, no acute distress, small stature with
marked [**Last Name (un) 2043**] abnormalities of extremities and back.
HEENT: Sclera anicteric, dry MM, oropharynx clear, trach in
place without erythema around site
Neck: supple, JVP not elevated
Lungs: Rales right middle lobe but left side clear. No wheezing.
tachypneic but not in acute distress.
CV: tachycardic and regular normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, edema
Pertinent Results:
[**2129-9-20**] 01:09PM LACTATE-0.9
[**2129-9-20**] 02:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2129-9-20**] 01:00PM WBC-9.3 RBC-3.85* HGB-10.2* HCT-31.7* MCV-83
MCH-26.5* MCHC-32.1 RDW-13.9
[**2129-9-20**] 01:00PM GLUCOSE-128* UREA N-17 CREAT-0.4* SODIUM-138
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-34* ANION GAP-12
[**2129-9-20**] 01:00PM NEUTS-94.8* LYMPHS-4.1* MONOS-0.7* EOS-0.3
BASOS-0.1
Micro:
GRAM STAIN (Final [**2129-7-30**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2129-8-1**]):
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. PREDOMINATING
ORGANISM.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 2 S
.
Images:
CXR (wet read): limited study secondar to pt body
habitus/scoliosis; RML consolidation - may represent aspiration
vs PNA
.
EKG: Sinus tachycardia with <1mm STE I avl slightly worse than
prior and TWI III.
Brief Hospital Course:
# Respiratory distress/SOB: Afebrile, no leukocytosis and no
evidence of pneumonia on chest xray (although exam difficult due
to patient anatomy.) Initially started on cipro, cefepime for
history of Pseudomonas pneumonia. Continued on vanco for
osotemyelitis and home vent settings for night/day. No
microbiologic evidence of bacteria from sputum, Legionella
antigen negative. Thought likely secondary to Enterococcus
bacteremia, and cipro, cefepime were discontinued. Patient's
symptoms subjectively improved.
# R Olecranon Osteomyelitis: Increased vancomycin dose initially
due to low trough, then switched to daptomycin after
consultation with ID as clinically no improvement. Presumably
no response to vancomycin.
# Enterococcal bacteremia: Initial blood cultures grew
Enterococcus and coag neg Staph. Patient was continued on
daptomycin and after extensive discussion with ID the decision
was made to continue antibiotic treatment via his picc. The
risks of removing the picc were high as the patient has
difficult iv access and requires a long course of iv
antibiotics. The patient will follow up with ID on an
outpatient basis (as he was doing prior to admission for his
osteomyelitis.)
# Chronic obstructive/restrictive pulmonary disease: Continued
on home dose of prednisone 15mg daily and bactrim prophylaxis
with prn nebs and chest PT. Home regimen of trach mask collar
and SIMV at night was continued.
# Hajdu-[**Location (un) 2987**] Syndrome: Home pain medications were continued
including methadone, morphine, baclofen, gabapentin, and
ibuprofen (with holding parameters for somnolence). Bowel
regimen prn constipation.
Medications on Admission:
MSIR 60mg QID
Methadone 40mg TID
Baclofen 40mgs QAM, 20mg at 11am 20mg at 7pm
Gabapentin 800mg TID
Motrin 800mg TID with food
Lorazepam 1mg HS
Singulair daily
Omprazole daily
Prednisone 15mg daily (given 60mg in ED)
Atrovent neb Q4H PRN
Albuterol [**Doctor First Name **] Q4H PRN
Pulmicort neb [**Hospital1 **]
Patient also was supposed to have been taking Bactrim DS daily
for PCP prophylaxis as he is on chronic daily prednisone;
however this was not on his home medication list.
Discharge Medications:
1. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection once
a day.
Disp:*1 month's supply* Refills:*2*
2. Outpatient Lab Work
Please check CBC/diff, BUN/Cr, ESR, CRP, CK and fax to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1419**]
3. Daptomycin 500 mg Recon Soln Sig: One (1) vial Intravenous
once a day: Give at 5pm.
Disp:*1 month's supply* Refills:*2*
4. Morphine 30 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
5. Methadone 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
6. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO QAM (once a day
(in the morning)).
7. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TWICE DAILY AT
11AM AND 7PM ().
8. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
9. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours): WITH FOOD.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24
Hours).
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Testosterone 5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q12H (every 12 hours).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
19. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Budesonide 1 mg/2 mL Suspension for Nebulization Sig: One
(1) neb Inhalation twice a day.
21. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
22. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
23. Bactrim DS q day [This was accidentally omitted from
patient's discharge medications but he was taking this in-house
and should be taking this at home.]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Enterococcal bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing. We
think this was because your infection in the arm was not treated
enough and you felt sicker than usual which made you too weak to
cough well. Your antibiotics were switched to daptomycin (from
vancomycin). We left in your PICC line because it was very
difficult to place and putting in a new one would be riskier
than treating your infection through the line. You should
continue to follow along with your infectious disease doctor as
you were.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-9-28**] 9:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2129-10-28**] 10:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2129-9-23**]
|
[
"491.21",
"V46.2",
"730.13",
"790.7"
] |
icd9cm
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[
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485,
500
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[
[
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5130
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[
[
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9417
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[] |
icd9pcs
|
[
[
[]
]
] | 50
| 1,654
| 0
| 7
| 1
| 0
| 0
| 0
| 0
| 1,522
| 0
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| 62
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99,806
| 133,851
|
7479
|
Discharge summary
|
Report
|
Admission Date: [**2107-9-24**] Discharge Date: [**2107-9-29**]
Date of Birth: [**2041-4-11**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 665**] is a 66 yo M with DM2, PVD, s/p surgical debridement
of right thigh MRSA abscess sent to ED for evaluation when he
was found to have elevated potassium at his PCP's office. He
reports that he presented to his PCP's for a scheduled follow up
visit but otherwise was without specific complaints. He does
endorse weight gain of 21 pounds since his hospital discharge on
[**9-11**]. Due to this he took some of his wifes water pills, the
name he cant remember for three doses total. Otherwise he
reports recent decrease in his total daily naproxen dose and
slight increase in his tramadol dose. He has recently been
taking Bactrim and Augmentin following surgical debridement
Recent admission [**Date range (1) 27372**] to vascular surgery service for right
groin mass c/w abscess on CTA without any evidence of
communication with prior right CIA to SFA graft. He had
ultrasound guided drainage which showed purulent material so he
was taken to the OR for surgical debridement. He was discharged
on bactrim and augmentin with a wound vac in place.
In the ED, initial vs were: T 98 P 58 BP 118/46 R 18 O2 sat 100%
RA. Potassium was checked in the ED and was noted to be 7.8.
Patient was given calcium gluconate 1g IV x1, insulin 10 units
x1, D50 x 1 amp, bicarb x1amp and kayexalate 30g po. He had an
EKG which showed PR prolongation compared with baseline but no
other changes. Following this therapy he became
asymptomatically hypoglycemic with decrease in blood sugar to 56
from 114 on arrival and he was given a second amp of D50.
Repeat glucose three hours later was persistently low at 40 and
he was given a third amp of d50. He reports being asymptomatic
with all of these levels.
On the floor, he reports feeling at his baseline. His FSBG was
100 on arrival.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denied cough, he does
endorse occasional dyspnea on exertion. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
Past Medical History:
DM2 - last A1C 5.9 [**1-/2106**]
HTN
severe DJD
hyperlipidemia
PVD
testicular CA
Anemia - unknown cause (bl HCT ~30)
chronic renal insufficiency (bl creatinine ~1.5)
.
Surgical History:
s/p right common iliac artery to SFA bypass
s/p gastric bypass [**2101**]
right groin dissection and XRT
right cataract surgery
appendectomy tonsillectomy
multiple foot surgeries
Social History:
lives with wife, works as CEO of company and does a lot of
travelling for work, remote smoking history of 1 PPD x12 years
quit in [**2071**], denies ETOH or drug use.
Family History:
both parents died from aplastic anemia
Physical Exam:
Vitals: T: 98.1 BP: 177/48 P:76 R:19 O2: 100% RA
General: Alert, oriented, no acute distress
Skin: warm, scattered bruises over extremities
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, well healed surgical
scars, bowel sounds present, no rebound tenderness or guarding,
no organomegaly
Ext: 2+ pitting edema of LE's bilaterally, atrophy of right
lower leg muscles, clean bandage in placeover toes of letf foot.
Pertinent Results:
[**2107-9-23**] 02:45PM BLOOD WBC-6.1 RBC-3.07* Hgb-9.3* Hct-30.1*
MCV-98 MCH-30.2 MCHC-30.8* RDW-14.8 Plt Ct-404#
[**2107-9-23**] 02:45PM BLOOD Neuts-45.0* Lymphs-40.5 Monos-8.4
Eos-5.4* Baso-0.7
[**2107-9-23**] 11:00PM BLOOD PT-12.8 PTT-30.1 INR(PT)-1.1
[**2107-9-23**] 02:45PM BLOOD UreaN-14 Creat-1.6* Na-132* K-7.8* Cl-107
HCO3-21* AnGap-12
[**2107-9-23**] 11:00PM BLOOD ALT-18 AST-28 LD(LDH)-157 CK(CPK)-27*
AlkPhos-136* TotBili-0.2
[**2107-9-23**] 11:00PM BLOOD Albumin-2.7* Calcium-8.5 Phos-3.8 Mg-1.9
[**2107-9-23**] 02:45PM BLOOD VitB12-1824*
[**2107-9-23**] 02:45PM BLOOD Triglyc-76 HDL-51 CHOL/HD-2.9 LDLcalc-80
[**2107-9-24**] 07:43AM BLOOD TSH-9.0*
[**2107-9-24**] 07:43AM BLOOD Free T4-1.0
[**2107-9-24**] 02:09AM BLOOD Cortsol-6.5
[**2107-9-24**] 07:43AM BLOOD Cortsol-15.5
[**2107-9-29**] 06:55AM BLOOD WBC-5.9 RBC-3.06* Hgb-9.4* Hct-29.5*
MCV-96 MCH-30.9 MCHC-32.1 RDW-14.0 Plt Ct-281
[**2107-9-29**] 01:10PM BLOOD UreaN-17 Creat-1.6* Na-134 K-4.8 Cl-97
HCO3-32 AnGap-10
[**2107-9-29**] 06:55AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.6
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
#Hyperkalemia - Patient presented with severe hyperkalemia K of
7.8 with EKG changes of prolonged PR interval, it was 3.8 less
than a month ago. Unclear etiology, but differential diagnoses
include adrenal insufficiency given hyponatremia, hyperkalemia,
and peripheral eosinophilia. However, he does not have
hypotension. Morning cortisol was within normal limits. Other
consideration would be hyperkalemia associated with metabolic
acidosis, although ph normal on ABG. Another consideration was
renal tubular acidosis given elevated potassium and low serum
bicarbonate on admission. No evidence of tissue breakdown or
hemolysis with normal CK. Hypoaldosteronism was also a possible
cause, however he was not volume depleted on examination.
Transtubular potassium gradient was 2.5, suggesting that
patient's hyperkalemia was likely secondary to
hypoaldosteronism. Renal was consulted who suggested that
hyperkalemia was likely due to renal K secretion inhibition by
multiple medications (benzapril, [**Last Name (un) **], triamtereme, nsaids,
bactrim). All were discontinued. IV lasix was started to enhance
K secretion and remove volume. On discussion with ID, patient's
bactrim was replaced with linezolid. Pt's K currently corrected
to 4.8, and he is being discharged on Lasix 10mg PO Daily.
#MRSA abscess s/p surgical debridement with wound vac in place -
Patient was evaluated by vascular surgery team in the ED, no
acute issues. As bactrim may have played a role in patient's
hyperkalemia, it was replaced with linezolid after discussing
with ID. given the risk for serotonin syndrome, his Tramadol was
discontinued.
#DM2 - Diabetes was very well controlled per history with last
A1c in our system of 5.9. Humalog sliding scale was continued,
and NPH [**Hospital1 **] was held per patient's request.
#Hypertension - Clonidine 0.3mg qam and 0.2mg qpm was continued
while metoprolol and benicar were held in the setting of
hyperkalemia. His blood pressures remained well-controlled.
#PVD - Arterial insufficiency ulcers were seen on lower
extremities bilaterally. Aspirin was continue during his stay in
the hospital.
Medications on Admission:
Reconciled on [**2107-9-26**] [**Doctor Last Name **]
Lotrel (Amlodipine/benazepril) 5/20 QD
Benicar (olmesartan/hctz) 40/25 one tab [**Hospital1 **]
Bactrim DS 160-800 mg One (1) Tablet PO BID x 4 weeks.
Augmentin 875-125 mg one po tid (stopped [**9-22**])
Metoprolol Tartrate 50 [**Hospital1 **]
Clonidine 0.3mg AM and 0.2mg PM
Pantoprazole 40 mg [**Hospital1 **]
Januvia (Sitagliptin) 100mg QD
Aspirin-Coated 325 mg PO QD
NPH 2 units [**Hospital1 **]
Humulin R 10 units AM, 8 NOON, 9 PM
Zetia 10mg [**Hospital1 **]
Naproxen 220mg [**Hospital1 **]
Tramadol 50mg qam and 100mg qpm
Aspirin 325 mg PO DAILY
Protonix Pantoprazole Sodium 40mg in the morning
Ferrous Sulfate Ferrous Sulfate 325(65)mg 1 time per day
Multivitamin Multivitamins 1 per day
Vitamin C Ascorbic Acid 1000mg 1 per day
Vitamin B-6 Pyridoxine Hcl 100mg twice a day
Viactiv Ca Carbonate/vitamin D3/vit K 500-500-40 twice a day
Vitamin B12 Cyanocobalamin 100mcg 1 time per day
Vitamin E Vitamin E Acetate
Super B Complex Vitamin B Complex 1 per day
Glucagon Emergency Kit Glucagon 1mg as directed
Folic Acid Folic Acid 0.4mg take 1 tablet (0.4MG) by ORAL route
every day
Chromium Picolinate Calcium Phosphate/[**First Name9 (NamePattern2) 27373**] [**Last Name (un) 27374**]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
4. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: As directed
Injection ASDIR (AS DIRECTED).
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperkalemia
Discharge Condition:
Improved
Discharge Instructions:
Please return to the hospital if you develop fevers, chills,
nausea, vomiting, chest pain or shortness of breath. It is very
important that you have your blood drawn tomorrow to make sure
your potassium and creatinine are stable. Dr.[**Last Name (STitle) 5263**] will
follow-up those results and help adjust your medications. You
also need to follow-up in the [**Hospital 1944**] clinic to have your
blood pressure checked since two of your blood pressure
medicines have been stopped.
Followup Instructions:
Dr. [**Last Name (STitle) **], [**Location (un) **], Central Suite, [**Hospital **] Clinic:
Monday [**10-3**] 8:30 [**Telephone/Fax (1) 250**]
[**Name6 (MD) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2107-10-19**]
11:00
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2107-10-27**]
12:40
[**First Name4 (NamePattern1) 1877**] [**Last Name (NamePattern1) **],MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 721**] Date/Time:[**2107-10-28**]
9:00
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Discharge summary
|
Report
|
Admission Date: [**2120-1-25**] Discharge Date: [**2120-2-1**]
Date of Birth: [**2053-1-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypoxic respiratory distress
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
67yoM w/ h/o squamous cell esophageal cancer s/p XRT with a
gastric pull-up in [**2104**] w/ subsequent tracheo-esophageal fistula
and eventual tracheostomy/ PEG tube placement who presents from
rehab with respiratory distress. Apparently pt vomiting earlier
in the day, then noted to desaturate down to 70s off vent and
became apneic (up until this point pt had been doing well off
the vent per report). He has been placed back on the vent since
the desaturations and is noted to be tachypnic.
.
Initially presented on [**2119-4-13**] with complaints of difficulty
swallowing and productive cough and who was found to have a
right base pneumonia. A failed swallow evaluation prompted a CT
neck that revealed a tracheoesophageal fistula just below the
level of the thoracic inlet, confirmed via barium swallow, then
at bronchoscopy. TE fistula determined to be benign by
pathological exam of biopsies. After J-tube placement for
nutrition support, the TE fistula was repaired and esophageal
stricture resected on [**2119-8-3**]. This was c/b left vocal cord
paralysis after the operation (had to remove left recurrent
laryngeal nerve), and required tracheostomy from respiratory
failure after anastomotic incompetence on [**2119-8-18**]. Since
discharge after an admission [**2119-10-3**] - [**2119-11-8**] for large bowel
obstruction, he has been weaned from the ventilator to trach
collar with humidified air. She continued to have a TEF and
underwent a rigid bronchoscopy with fibrin injection into the
fistula on [**2120-1-22**]. Apparently the fibrin clotted the fistula
and he was admitted overnight for monitoring, though no other
complications per OMR.
.
In the ED, initial vs were: T98.6 HR88 BP106/76 PO288% (though
noted to be difficult to get an accurate sat). CXR showed right
upper lobe opacity concerning for PNA, pulmonary vascular
congestion and small b/l pleural effusions. EKG was reportedly
unremarkable. ABG was 7.41/38/184/25 on pressure support
ventilation. Remarkable labs include lactate 2.7, WBC 13.7 with
94% PMN no bands, Na 147. Patient was given levaquin in the ED
(ordered also for CTX and levaquin, but not yet received).
Patient was noted to gradually drop systolic pressure to 70's.
Felt to be mentating well in the ED, though orientation was not
assessed. No UOP as per ED resident. Received 2L IVF. On the way
to the ICU, levophed gtt was started for hypotension.
.
On arrival to ICU, patient noted to have low tidal volumes,
elevated airway pressures, BP's in 70's systolic, and
saturations in 70's to 80's. With anesthesia and RT at bedside,
trach was repositioned (likely had been auto-PEEPing). Bronch
performed which showed trach well-seated in trachea. Currently
pt states breathing more comfortable, c/o pain at site of
abdominal wound. Denies CP, states intermittent diarrhea. States
he doesn't remember what brought him to the hospital. Does not
recall vomiting.
Past Medical History:
-Hypertension
-Hypothyroidism
-Prostate cancer s/p XRT
-h/o esophageal CA s/p XRT with 3-hole esohagectomy in [**2104**] at
[**Hospital1 112**]. Recently hospitalized at [**Hospital1 18**] for PNA and found to have
stricture near cricopharyngeus, with evidence of TEF. EGD showed
no cancer recurrence. J-tube placed [**4-/2119**]
-Small bowel obstruction
-Cognitive deficit NOS vs limited safety awareness
-Orthostatic hypotension - hospitalization [**1-/2119**] after fall
-DVT of the L subclavian and L axillary vein
-R hip fracture s/p ORIF by Dr. [**Last Name (STitle) **] @ [**Hospital1 112**]
-RLL PNA [**1-11**], treated with levofloxacin
-multiple stab wounds to the abdomen in the [**2079**]
-right sided PTX after bronchoscopy s/p CT placement
-Tonsillectomy and adenoidectomy
-R wrist and hand surgery
-large bowel obstruction in [**2119**] s/p exploratory laparotomy with
reduction of a paraesophageal hernia and was left with an open
abdomen due to edema and bowel distention s/p closure on [**2119-10-17**]
Social History:
Originally from [**State 9512**]. He has three daughters. One daughter
lives in [**State 4260**], another is in [**Name (NI) 86**], [**First Name3 (LF) 2184**] who is very involved.
Reports he recently stopped smoking. Although he has a history
of binge drinking, he reports he hasn't drank since [**Month (only) 1096**] of
[**2118**]. Retired construction worker and plumber.
Family History:
Mother died of a blood clot. Doesn't know what his father died
of. Sister died of obesity and "fat around her heart"
Physical Exam:
On admission to the MICU:
Vitals: T 101 HR 77 BP 72/45 18 97% on RA
-low tidal volumes, elevated airway pressures, BP's in 70's
systolic, and saturations in 70's to 80's
General: Alert, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: trached
Lungs: Upper airway sounds heard throughout
CV: Tachycardic rate, regular
Abdomen: scaphoid, soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, PEG in place, well healing
abdominal wound with pink granulation tissue
GU: no foley
Ext: warm, well perfused
.
On discharge,
O2 sats 97% on 50% trach mask; equal breath sounds bilaterally
J tube site with mild erythema around site
abd wound with granulation tissue, appears to be healthy and
healing
Pertinent Results:
Admission Labs:
.
Images:
CXR [**1-25**]:
1. Increased right upper lobe opacity concerning for PNA.
2. Pulmonary vascular congestion with mild interstitial edema.
3. Small bilateral pleural effusions.
.
EKG: Rate 138, LAD appears to be sinus but unclear if
consistent P waves given poor baseline. Again difficult to
assess but ? rate related ST depressions in V4-V6 in lateral
leads.
.
[**2120-1-25**] 03:05AM BLOOD WBC-13.7* RBC-3.30* Hgb-9.2* Hct-29.1*
MCV-88 MCH-28.0 MCHC-31.7 RDW-17.7* Plt Ct-422
[**2120-1-25**] 03:05AM BLOOD Neuts-94.0* Lymphs-3.9* Monos-1.6*
Eos-0.3 Baso-0.2
[**2120-1-25**] 03:05AM BLOOD PT-14.4* PTT-33.6 INR(PT)-1.3*
[**2120-1-25**] 03:05AM BLOOD Glucose-125* UreaN-31* Creat-1.3* Na-147*
K-5.9* Cl-112* HCO3-25 AnGap-16
[**2120-1-26**] 02:27AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.4* Iron-14*
[**2120-1-25**] 03:05AM BLOOD TSH-27*
[**2120-1-25**] 03:05AM BLOOD Free T4-0.98
[**2120-1-25**] 03:51AM BLOOD Type-ART pO2-184* pCO2-38 pH-7.41
calTCO2-25 Base XS-0
[**2120-1-25**] 03:10AM BLOOD Lactate-2.7* K-4.3
[**2120-1-25**] 12:20PM BLOOD Lactate-3.2*
[**2120-1-25**] 03:08PM BLOOD Lactate-1.8
.
Discharge labs:
[**2120-2-1**] 03:33AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.0* Hct-30.8*
MCV-87 MCH-28.3 MCHC-32.6 RDW-17.2* Plt Ct-222
[**2120-2-1**] 03:33AM BLOOD Glucose-91 UreaN-11 Creat-0.5 Na-138
K-3.9 Cl-102 HCO3-30 AnGap-10
[**2120-2-1**] 03:33AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.4*
[**2120-1-26**] 02:27AM BLOOD calTIBC-183* Ferritn-687* TRF-141*
.
SB follow-through:
IMPRESSION:
Within the limits of a small bowel follow-through, there are no
fistulae or
strictures identified. Transit time through the small intestine
is within
expected (normal) range.
.
CXR:
IMPRESSION:
1. Increased right lower lobe density, which may either
represent fissural
fluid or consolidation.
2. Stable bilateral loculated pleural effusions.
3. Stable left lower lobe atelectasis.
4. Mild worsening pulmonary edema.
5. Contrast opacification of the large bowel with further small
bowel
opacification, if an enteroenteric fistula is suspect, further
evaluation with
fluroscopy or an abdominal radiograph is suggested to localize
the small bowel
loop and assess a potential fistulous communication with large
bowel.
Brief Hospital Course:
67yoM h/o squamous cell esophageal cancer s/p XRT with a gastric
pull-up in [**2104**] w/ subsequent tracheo-esophageal fistula and
eventual tracheostomy/ PEG tube placement who presents from
rehab with respiratory distress.
.
# Shock: Pt with BP in 70s/40s on arrival to the MICU and
febrile to 101. Lactate 2.7 -> 3.2 -> 1.8 in first 24 hours with
~7-8L of fluid. Was initially on levophed but this was weaned by
hospital day #2. Antibiotics were started on arrival to the ICU
- were eventually broadened to meropenem/linezolid as patient
had persistent hypotension. CXR showed new RUL infiltrate
concerning for pneumonia. U/A looked infected. Sputum culture
grew morganella morganii, sensitive to meropenem - identical
culture to earlier admission. Patient's lactate normalized and
he was weaned off pressors. He was continued on meropenem for
g-negative rods in sputum and finished his course on [**2-1**].
.
# Hypoxemic respiratory distress: Given timing of hypoxic
respiratory distress, likely had aspiration event most
immediately. On arrival to the floor, patient was seen by
anesthesia and a bronchoscopy was performed out of concern for
trach displacement. The trach was visualized in the correct
location. The patient was initially ventilated on A-C, but this
was weaned and on ICU day #2 was on PSV. Antibiotics were
administered as above out of concern for RUL pneumonia. The
patient's trach was changed on HD #2 because of problems with
ongoing cuffleaks. The original trach was found to have a
defective balloon. The patient's tidal volumes improved with new
trach. The patient remained stable from a respiratory standpoint
for the rest of his MICU stay and tolerated trach mask; he was
satting in the high 90s on 50% trach mask prior to discharge.
.
# TE fistula: Pt is s/p fibrin injection [**2120-1-22**]. Patient with
known TEF s/p recent injection. On HD #5, IP performed a
bronchoscopy, which showed a partially closed TE fistula. The
patient had 2 episodes of bilious contents being suctioned from
his trach. Thoracic surgery was consulted and attempted to place
an NG tube endoscopically; the attempt was not successful given
his complicated anatomy and will not attempt again. IP has no
plans to attempt another injection for pts TE fistula.
.
# J tube leakage: The patient has had a chronic problem with his
jtube leaking and has had it changed 3 times in the recent past.
The patient had continued profuse leakage while in the MICU. His
tube feeds were stopped and PPN was started. Surgery was
consulted who recommended a KUB with gastrografin, which was
normal. care was also consulted. Patient complained of abdominal
pain and received prn IV morphine. Abd exam was benign.
Thoracics recommended a barium swallow through the j tube with
small bowel follow through showed no abnormalities. Given this,
tube feeds were re-started on [**1-31**]. Thoracics will not attempt
to replace the j-tube given his complicated anatomy.
.
# Anemia: The patient had a Hct of 20.5 on ICU day #2. Stool was
guaiac negative. He was transfused 2U PRBC with appropriate
response. Iron studies showed elevated ferritin (likely as acute
phase reactant). His Hct stayed stable ~27 to 28 for the
remainder of his hospitalization.
.
# Hypernatremia - Na in the 145-150 range; stable over recent
admissions. TF and free water flushes were utilized. Na was
trended daily and improved to the normal range for the remainder
of his admission.
.
# Prophylaxis was with subcutaneous heparin. Communication was
with the patient and Daughter [**First Name8 (NamePattern2) 2184**] [**Known lastname 93756**] [**Telephone/Fax (1) 93877**]. He
remained full code during this admission.
Medications on Admission:
1. kayexelate MWF
2. citalopram 20 mg Tablet daily
3. Prilosec 20mg daily
4. ergocalciferol (vitamin D2) 8,000 unit/mL Drops [**Telephone/Fax (1) **]: 5000
units weekly
5. combivent/albuterol nebs
6. levothyroxine 125 mcg Tablet *** TSH [**2120-1-16**] 16***** [**Month (only) 116**]
need adjustment per last DC summary.
7. Tylenol 325 mg Tablet [**Month (only) **]: 1-2 Tablets PO every 4-6 hrs PRN
pain
Discharge Medications:
1. citalopram 20 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily).
2. ergocalciferol (vitamin D2) 8,000 unit/mL Drops [**Month (only) **]: 5000
(5000) Units PO once a week.
3. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Month (only) **]: [**2-4**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
4. levothyroxine 125 mcg Capsule [**Month/Day (2) **]: One (1) Capsule PO once a
day.
5. acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO every [**5-9**]
hours.
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
7. oxycodone 20 mg/mL Concentrate [**Last Name (STitle) **]: 2.5-5 mg PO every [**7-11**]
hours as needed for pain.
8. acetaminophen 325 mg/10.15 mL Suspension [**Month/Day (3) **]: 325-650 mg PO
every 4-6 hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Sepsis
Pneumonia
TE fistula
Anemia
.
Secondary:
Hypertension
s/p esophageal radiation and gastric pull-up surgery
Discharge Condition:
Mental Status: Clear and coherent --> pt did not use speaking
valve but would communicate by writing and mouthing words
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
Dear Mr. [**Known lastname 93756**],
You were admitted for respiratory distress and with low blood
pressure. We treated you with IV fluids, blood
pressure-supporting medications, and antibiotics and you
improved. You were initially on a breathing machine to help
support your lungs. We believe the source of the low blood
pressure was an infection in your lungs. You were able to
breathe well with the trach mask in place prior to your
discharge. The pulmonary doctors also looked to see if the
abnormal connection between your trachea and esophagus was
healed - they found that it was partially healed. Finally, we
had the thoracic surgeons evaluate your J-tube. A study was
performed, which showed that the J-tube was working normally and
that you had normal bowel function. You did have leakage around
the J-tube but the surgeons thought it would be too dangerous to
attempt to fix.
.
We made the following changes to your medications:
We STOPPED Kayexelate because your potassium levels were normal
We STARTED oxycodone 2.5-5 mg (liquid) every 6-8 hours as needed
for abdominal pain
We STOPPED Prilosec
We STARTED Lansoprazole (rapid dissolve tablet) 30 mg once per
day
.
You should continue to see the medical doctor at your rehab
facility. Your follow-up appointments are listed below.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2120-2-20**] at 9:45 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2120-2-20**] at 10:30 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
|
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"V15.82",
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"458.9",
"486",
"285.9",
"276.0",
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[
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[
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icd9pcs
|
[
[
[
330,
341
]
],
[
[
10922,
10939
]
]
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| 3,680
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| 15
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| 119
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| 2,916
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91,929
| 100,463
|
55049
|
Discharge summary
|
Report
|
Admission Date: [**2109-7-29**] Discharge Date: [**2109-7-31**]
Date of Birth: [**2045-11-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (un) 11220**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubation and extubation
History of Present Illness:
[**Hospital Unit Name 153**] Admission Note
Primary Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1437**] ([**Location (un) **])
Neurologist: Dr. [**Last Name (STitle) **] ([**Location (un) **])
Chief Complaint: respiratory failure and altered mental status
Reason for MICU transfer: intubated
History of Present Illness: 63 yo F (real name [**First Name5 (NamePattern1) **] [**Known lastname 11135**])
with PMHx of alcohol abuse with withdrawal seizures, a SDH s/p R
craniotomy, HTN and HL who presents intubated from [**Hospital1 2519**] for confusion.
Per OSH records, patient fell the night prior to arrival on
cousin's floor and struck her head; denied LOC, but c/o left
brow pain, heaache, chipped tooth and sore R shoulder. A
preliminary head CT showed no acute intracranial abnormality
with chronic findings (old R parietal craniotomy, old R burr
hole). Labs were notable for lactate 1.2, normal chem 7, normal
CBC, normal UA, ammonia 32 (WNL). Tox negative for ethanol,
salicylates, acetominophen. The patient was intubated for
failure to oxygenate/ventilate and inability to protect airway
(sedation and confusion). CXR showed R mainstem intubation-->
pulled back 1 cm and improved L lung aeration.
In the ED, initial VS were: 98.7, 91, 137/78, 21, 99%. Labs
notable for UA with small WBC, Pos nitrite, few bact. ABG
7.33/41/421 on 450/100%. Initially in the ED, she was "fighting
the vent" and was making purposeful movements of all 4
extremities to attempt to remove the ETT, she was then heavily
sedated in the ED with fentanyl and midazolam. She received
500mg azithromycin and 1g of ceftriaxone. Neurology was
consulted who recommended EEG.
On arrival to the MICU, patient's VS. 94.5, 73, 97/64. Patient
was intubated and sedated. Vent 450/12/40%/5.
Review of systems: unable to perform, patient intubated and
sedated
Past Medical History:
SDH with coma for 3 mo about 5 years ago s/p Burr hole
Seizures
Alcoholism
HTN
HLD
chronic cough of unclear etiology (sig second-hand smoke
exposure)
h/o colostomy for unclear reasons
8 pregnancies (G8)
h/o breast bx x 2
foot and ankle fractures
Social History:
Patient lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in [**Hospital1 **]. She has a brother in
law in the area but often spends time with her cousin, [**Name (NI) 553**],
who is local. She is currently disabled. Denies having any
problems with alcohol currently, but did before her stroke.
Drinks 3 glasses of wine a night, no significant beer or liquor,
CAGE negative, denies illicits or tobacco but her ex-husband
(married for 25 years) smoked a lot
Family History:
Mother died of congenital heart condition in her 40s. Brother
died of an MI in his 60s. Otherwise, denies.
Physical Exam:
ADMISSION EXAM
94.5, 73, 97/64. Vent 450/12/40%/5.
General: sedated, non-responsive
HEENT: Sclera anicteric, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anterior lung fields, no wheezes,
rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated, non-responsive
Pertinent Results:
ADMISSION LABS
[**2109-7-29**] 05:44AM BLOOD WBC-4.7 RBC-3.51* Hgb-11.8* Hct-35.4*
MCV-101* MCH-33.5* MCHC-33.2 RDW-13.7 Plt Ct-104*
[**2109-7-29**] 05:44AM BLOOD PT-11.1 PTT-26.3 INR(PT)-1.0
[**2109-7-29**] 05:44AM BLOOD UreaN-17 Creat-0.6
[**2109-7-30**] 05:20AM BLOOD Glucose-100 UreaN-7 Creat-0.3* Na-139
K-3.1* Cl-110* HCO3-22 AnGap-10
[**2109-7-29**] 05:44AM BLOOD ALT-20 AST-24 LD(LDH)-275* CK(CPK)-138
AlkPhos-81 TotBili-0.4
[**2109-7-30**] 05:20AM BLOOD Calcium-7.0* Phos-2.2* Mg-1.9
[**2109-7-29**] 05:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-POS
[**2109-7-29**] 05:57AM BLOOD Type-ART Tidal V-450 FiO2-100 pO2-421*
pCO2-41 pH-7.33* calTCO2-23 Base XS--4 AADO2-252 REQ O2-49
-ASSIST/CON
[**2109-7-29**] 06:30PM BLOOD Type-ART pO2-83* pCO2-36 pH-7.39
calTCO2-23 Base XS--2 Intubat-NOT INTUBARED
MICRO
IMAGING
CXR 8.20
A feeding tube is noted with tip at the level of the gastric
antrum. ET tube is at the carina and should be repositioned.
Bilateral low lung volumes are noted with crowding of
bronchovascular markings. Cardiac silhouette is accentuated by
low lung volumes. Additionally, opacification at the left lung
base and in the retrocardiac region appears concerning for
either pleural effusion versus atelectasis, infectious process
such as pneumonia cannot be completely excluded in the correct
clinical setting.
CXR 8.21
In comparison with the study of [**7-29**], there again are lower lung
volumes. Cardiac silhouette is within upper limits of normal or
slightly
enlarged. Minimal poor definition of pulmonary vessels could
reflect slight
elevation of pulmonary venous pressure. Blunting of
costophrenic angles could
reflect small effusions or pleural thickening.
No definite pneumonia is appreciated, though in the appropriate
clinical
setting a supervening consolidation would be difficult to
exclude in lower
zones.
Brief Hospital Course:
63 yo F with PMH alcohol abuse with seizures, SDH s/p burr hole
5 years ago admitted with acute change in mental status.
# Acute Respiratory Failure: Patient arrived to the ICU
intubated for respiratory failure in settting of acute
confusional state. The patient's initial ABG was reassuring and
she was deemed able to extubate. She was extubated on the day
of arrival to the ICU and tolerated it well. Her oxygen
saturation remained in the mid to high 90s on room air. The
etiology of her respiratory was felt to be her toxic-metabolic
encephalopathy as noted below.
# Toxic-metabolic encephalopathy: The patient presented with
acute altered mental status with history of alcohol abuse and
seizures, also with history of SDH s/p craniotomy 5 years ago.
The etiology was unclear, but the differential included alcohol
withdrawal/seizure, toxic metabolic (hepatic encephalopathy),
CVA/ICH, sepsis, wernicke's encephalopathy. UA unremarkable.
Ammonia level normal. Lactic acid WNL. Drug induced possible,
home medications were difficult to clarify (the patient and her
family were poor historians). The patient showed no signs of
alcohol withdrawl and required only one dose of diazepam on the
CIWA protocol, which was mostly given for insomnia. She was
given thiamine. Neurology was consulted and they performed an
EEG, which showed no epileptiform activity. The day of
discharge, she developed a headache, but a repeat head CT was
normal, and she felt better after Tylenol and ibuprofen so was
discharged to follow-up as an outpatient.
# Chronic cough: the pt had a non-productive cough during your
admission, which has been present for several years, according
to the patient. She had no fevers, chills, oxygen requirement
or leukocytosis, so she was not treated for a pneumonia, and she
felt this was at her baseline. I suspect she may have COPD due
to second hand smoke exposure (ex-husband smoked for 25 years
with her). She should have outpatient PFTs done to further
evaluate this.
# Coordination of care: I attempted to speak with the patient's
PCP and Neurologist, but neither were available by phone on the
day of discharge. They will be sent a copy of this summary.
# Inactive issues: The patient was continued on her home
amitriptyline, fluoxetine, furosemide, gabapentin, topiramate,
and methocarbamol.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/CaregiverPharmacy.
1. risedronate *NF* 35 mg Oral WEEKLY
2. Amitriptyline 100 mg PO HS
3. Klor-Con *NF* (potassium chloride) 40 mg Oral [**Hospital1 **]
4. Furosemide 40 mg PO DAILY
5. Methocarbamol [**Telephone/Fax (1) 22024**] mg PO Q6H:PRN muscle pain
6. Gabapentin 1200 mg PO TID
7. Fluoxetine 60 mg PO DAILY
8. Topiramate (Topamax) 100 mg PO QAM
9. Topiramate (Topamax) 200 mg PO HS
Discharge Medications:
1. Amitriptyline 100 mg PO HS
2. Fluoxetine 60 mg PO DAILY
3. Gabapentin 1200 mg PO TID
4. Methocarbamol [**Telephone/Fax (1) 22024**] mg PO Q6H:PRN muscle pain
5. Topiramate (Topamax) 100 mg PO QAM
6. Topiramate (Topamax) 200 mg PO HS
7. Furosemide 40 mg PO DAILY
8. Klor-Con *NF* (potassium chloride) 40 mg Oral [**Hospital1 **]
9. risedronate *NF* 35 mg Oral WEEKLY
Discharge Disposition:
Home
Discharge Diagnosis:
Toxic-metabolic encephalopathy of unclear etiology -- resolved
spontaneously
Acute respiratory failure related to above -- resolved
spontaneously
Subdural hematomat with coma for 3 months about 5 years ago
status post Burr hole
Seizures, possibly related to alcoholism in the past
Hypertension
Hyperlipidemia
Chronic cough of unclear etiology (significant second-hand smoke
exposure)
History of colostomy for unclear reasons
8 pregnancies (G8)
History of breast biopsy x 2
Foot and ankle fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You developed confusion at home, fell and struck your head,
suffering a headache, chipped tooth and sore R shoulder. You
became progressively more confused until you were taken to
[**Hospital1 18**]-[**Hospital1 **] where your evaluation included a head CT, which was
unchanged from your prior (not normal due to your history of
subdural hemorrhage ~5 yrs ago with old R parietal craniotomy,
old R burr hole). Lab testing was unremarkable. You were
intubated (placed on a breathing machine) because your mental
status was so poor and you could not protect your airway and you
were transferred to [**Hospital1 18**]-[**Location (un) 86**]. Here you were quickly
extubated (taken off the breathing machine) and you
spontaneously improved. The Neurology consult team saw you and
could not explain what had happened. You developed a headache
on the day of discharge, but a repeat head CT was normal, and
you felt better after Tylenol and ibuprofen so were discharged
to follow-up as an outpatient.
Followup Instructions:
Primary Care
Please follow-up with your primary care doctor within the next
few weeks. Dr. [**Last Name (un) **] (your [**Hospital1 18**]-[**Location (un) 86**] discharging
physician) called Dr. [**Last Name (STitle) 1437**], but he was unavailable. After
reviewing your discharge summary, his office will call you with
an appointment. Please be sure to discuss your medications and
possible pulmonary function testing at this appointment.
Neurology
Please follow-up with Dr. [**Last Name (STitle) **] as you had previously planned.
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
Completed by:[**2109-7-31**]
|
[
"V15.52",
"303.93",
"V15.51",
"780.52",
"349.82",
"518.81",
"401.9",
"272.4",
"786.2"
] |
icd9cm
|
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[
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[
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8942,
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[
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]
],
[
[
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] |
[
"96.71"
] |
icd9pcs
|
[
[
[
2174,
2177
]
]
] | 7
| 2,201
| 0
| 29
| 1
| 0
| 0
| 0
| 0
| 1,890
| 0
| 0
| 666
| 112
| 0
| 0
| 0
| 372
| 0
| 501
| 0
| 486
| 0
| 0
| 0
| 0
| 998
| 0
| 0
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| 0
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| 0
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| 0
| 0
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| 0
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 538
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
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| 0
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| 0
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 52
| 0
| 0
| 0
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 86
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 1,460
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 122
| 0
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| 113
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| 248
| 489
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| 0
| 0
|
95,000
| 138,606
|
15545
|
Discharge summary
|
Report
|
Admission Date: [**2145-2-6**] Discharge Date: [**2145-2-11**]
Date of Birth: [**2059-7-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Black stools
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
This is an 85 year old male with h/o CAD, CVA, HTN, COPD, with
black/maroon stools x 6-7 days. He has had 2 black BMs today
with increased fatigue and some lightheadedness when moving from
a sitting to standing position. He first noticed these dark
bowel movements a few months ago, but they were intermittent and
would resolve on their own. They start to increased in
frequency of the past 6-7 days, but did not result in any
increased stool output and he describes them currently as
intermittent. He denies any recent use of NSAIDs and has been
taking his Coumadin normally, without changing any doses. He
denies any hematemesis, BRBPR, chest tightness/discomfort during
these episodes. He does acknowledge coughing up pink-tinged
sputum from time to time, but this has not worsened recently.
Over the past year, since his CVA, he has complained of chronic
pins/needles over his right side, which seem to have worsened
slightly during the last week or so. When he arrived at
[**Location (un) 620**], his INR was measured at 5.6, for which he was given Vit
K 10mg PO x 1 and 2 units FFP. Hct reportedly measured at 31.
Patient has been taking his [**Location (un) **], coumadin, and plavix at home
and still has his biliary drain in place from the placement in
[**Month (only) 404**]. He has gotten a few colonoscopies at [**Location (un) 620**] in the
past 10 years, but does not remember the results.
.
Of note, during a hospitalization back in [**2144-3-26**], endoscopic
CABG was performed d/t worsening exertional chest pain. His
hospital course was c/b the need to return to the OR for
re-exploration of his chest for bleeding after increased chest
tube output was noted with a L sided pleural effusion and
increased O2 requirement. 1 week after discharge, the patient
re-presented in [**2144-4-25**] with his 1st bout of acute
cholecystitis. Since he was deemed a poor surgical candidate,
PTC was placed and he completed a 10-day course of Cipro/Flagyl.
However, this hospitalization was c/b an acute stroke wit head
CT and MRI showing acute infarctions in the left occipital lobe,
left thalamus, left cerebellar hemisphere and right superior
cerebellum with resulting right-sided deficits. The etiology
was thought to be cardioembolic and he was started on lifelong
anticoagulation with coumadin.
.
He was most recently admitted on [**2144-12-30**] with right upper
quadrant pain, with management of acute cholecystitis once again
with placement of a percutaneous cholecystostomy tube, resulting
in removal of purulent bile. He was treated with augmentin for
2 weeks. This was immediately proceeded by an ERCP in [**2144-6-25**]
with stent placement for suspected cholangitis.
.
In the ER, VS 99.8 81 111/72 16 100%. Hct dropped form 31 at OSH
to 23. Pt had a NG lavage with minimal coffee grounds. Protonix
gtt was started. RBCs x 2 units ordered. Noted to have ARF with
Cr 1.4 from baseline on 0.9 to 1.0. PIV 16 and 18 g. GI made
aware and plan to see patient in AM for likely EGD. At transfer,
VS were 97.5 65 121/64 24 95% on 4L.
.
In the ICU, he is comfortable, breathing well on 2-4L NC. He is
not usually on O2 at home. He has not had any bowel movements
since coming to the hospital yesterday. He is feeling well with
some mild epigastric tenderness.
Past Medical History:
- CAD s/p right coronary artery stent x2 ([**10-3**], [**3-4**]) and s/p
elective CABG on [**2144-4-21**] (LIMA-> LAD), c/b re-exploration
required for bleeding
- h/o stroke
- h/o acute cholecystitis s/p perc chole placement on [**2144-5-12**]
- Hypertension
- Hyperlipidemia
- Chronic obstructive pulmonary disease
- Asbestos exposure
- Chronic back pain
- Insomnia and obstructive sleep apnea (untreated)
Social History:
He lives with his wife. Defers all medical decisions to son who
is a chiropractor.
He is a retired postal worker.
Tobacco: 3 PPD x 30 years, quit 45 years ago
ETOH: None
Family History:
Non-contributory.
Physical Exam:
Admission exam
VS: T 97.5, BP 133/63, HR 70, RR 16, O2 98% on 2L NC
GEN: pleasant, comfortable, NAD, AAOx3
HEENT: PERRL, EOMI, anicteric, MMM, OP without lesions or
bleeding, no supraclavicular or cervical lymphadenopathy, no
JVD, no carotid bruits, no thyromegaly or thyroid nodules
RESP: bibasilar rales, R>L, with otherwise good air exchange B/L
CV: RR, soft S1 and S2, no m/r/g appreciated
ABD: NABS, soft, ND, mild tenderness in to right of umbilicus,
no tenderness over PTC drain, with dressings C/D/I and draining
well, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 4/5 strength of right arm and
leg, [**4-29**] on left. Mild sensory deficits to light touch on right
side. Hyporeflexic DTR's - patellar and biceps
Pertinent Results:
[**2145-2-7**] 04:30AM BLOOD Hct-31.5*
[**2145-2-6**] 10:00PM BLOOD Hct-30.9*
[**2145-2-6**] 01:20PM BLOOD Hct-29.6*
[**2145-2-6**] 05:58AM BLOOD Hct-29.5*
[**2145-2-6**] 12:23AM BLOOD WBC-6.2 RBC-2.41* Hgb-8.0* Hct-23.8*
MCV-99* MCH-33.1* MCHC-33.4 RDW-14.1 Plt Ct-388
.
[**2145-2-7**] 04:30AM BLOOD ALT-16 AST-19 LD(LDH)-151 AlkPhos-62
TotBili-0.6
[**2145-2-6**] 10:00PM BLOOD CK(CPK)-36*
[**2145-2-6**] 05:58AM BLOOD ALT-17 AST-19 LD(LDH)-149 AlkPhos-62
TotBili-1.2
[**2145-2-6**] 12:23AM BLOOD ALT-18 AST-23 LD(LDH)-143 CK(CPK)-39*
AlkPhos-69 TotBili-0.3
.
[**2145-2-6**] 12:23AM BLOOD Neuts-64.5 Lymphs-23.0 Monos-7.5 Eos-4.8*
Baso-0.3
.
[**2145-2-7**] 04:30AM BLOOD PT-19.4* PTT-27.8 INR(PT)-1.8*
.
[**2145-2-7**] 04:30AM BLOOD Glucose-73 UreaN-25* Creat-1.1 Na-140
K-4.0 Cl-110* HCO3-19* AnGap-15
[**2145-2-7**] 04:30AM BLOOD Glucose-73 UreaN-25* Creat-1.1 Na-140
K-4.0 Cl-110* HCO3-19* AnGap-15
.
[**2145-2-7**] 04:30AM BLOOD ALT-16 AST-19 LD(LDH)-151 AlkPhos-62
TotBili-0.6
[**2145-2-6**] 10:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-2-6**] 10:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-2-6**] 12:23AM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-2-7**] 04:30AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1
EKG ([**2145-2-6**]): Baseline artifact. Sinus rhythm. Low amplitude P
waves with slight P-R interval prolongation of about 220
milliseconds. Borderline low
limb lead voltage. Slow R wave progression in leads V1-V2 which
is
non-diagnostic. Cannot exclude underlying anteroseptal
myocardial infarction. Compared to the previous tracing of
[**2144-12-30**] no diagnostic change.
EGD ([**2145-2-10**]): Large hiatal hernia. Sloughing in the whole
esophagus compatible with ischemic injury to esophagus. Erythema
and granularity in the antrum compatible with antral gastritis.
Normal mucosa in the duodenum. Otherwise normal EGD to third
part of the duodenum
Brief Hospital Course:
ICU course
85M with hx of CAD, CVA, PTC x2 for recurrent cholecystitis and
ERCP for suspected cholangitis, now presenting with GI bleed.
.
# GI bleed/acute blood loss anemia: Patient has had maroon/dark
stools and symptoms of orthostasis in setting of acute hemtocrit
drop. NG lavage was mildly positive + [**Last Name (LF) **], [**First Name3 (LF) **] likely a upper
GI source. Pt at risk due to [**First Name3 (LF) **], plavix and coumadin. INR was
supratheraputic at [**Location (un) 620**] and reversed with FFP and Vitamin K.
The patient received two units of packed red blood cells, and
his hematocrit responded appropriately. Over the course of the
next day, his hematocrit remained stable.
The patient was started on a PPI drip, but then changed to PPI
iv BID. The patient's triple anticoagulation of aspirin,
Coumadin, and Plavix was held, but metoprolol was
restarted once blood pressures were likely to remain stable. Pt
then underwent EGD on [**2145-2-10**] which revealed hiatal hernia,
antral gastritis, and ischemic damage to esophageal mucosa with
sloughing. GI thought that the latter represented a healing
process. He was then transitioned to po PPI and did fine
throughout his hospital stay without any further evidence of
bleeding.
.
# Acute renal failure: Acute rise to 1.4 from a baseline of 0.9
to 1.0. With concomitant increase in BUN, likely
pre-renal/hypovolemia due to GI bleed. Given 2 units pRBCs. By
transfer from ICU, creatinine was 1.1, so no further work-up
pursued.
.
# Percutaneous biliary drain: placed [**2144-12-31**] with good drainage,
and patient is without pain. The patient had previously
considered a poor surgical candidate due to multiple
comorbidities. Liver function tests were within normal limits.
.
# History of CAD: No signs or symptoms of ACS upon this
admission. No evidence of demand ischemia, no EKG changes and
no chest discomfort. Negative CE. Some mild epigastric pain,
but patient not troubled by it. Aspirin and Plavix were held
during the admission. We contact[**Name (NI) **] Dr. [**Last Name (STitle) 11302**], her PCP, [**Name10 (NameIs) 1023**]
agreed that we could stop his plavix (initial plan was to
continue until 3/[**2144**]). He was therefore discharged only on
aspirin with follow up with Dr. [**Last Name (STitle) 11302**].
.
# CVA hx: On lifelong coumadin [**1-27**] likely cardioembolic etiology
of CVA in past. Residual right-sided "pins/needles" sensation
and mild weakness with decreased functional ability. Held
coumadin for EGD, and reversed with FFP and vit K. Neurology was
contact[**Name (NI) **] regarding need for lifelong coumadin, given that his
cardioembolic CVA was in the setting of off-pump CABG. It was
decided that he would not need coumadin, given the risk-benefit
profile, and he was thus discharged without coumadin. He will
follow-up with stroke neurologist Dr. [**Last Name (STitle) **] for further
management.
.
# COPD: Stable, no home O2 at baseline. Mild bibasilar rales,
without coughing or URI sx. No evidence of an acute
exacerbation on this admission. CXR if worsening oxygenation or
increased respiratory symptoms. He was continued on home [**Last Name (STitle) **]
and spiriva, with albuterol nebs PRN. Pt noted, however, that he
has stopped taking [**Last Name (LF) **], [**First Name3 (LF) **] this medication was discontinued.
.
# Recurrent cholecystitis: Prior to hospitalization, there have
the discussions about elective cholecystectomy given pt
anticoagulation. We contact[**Name (NI) **] surgery during this admission for
possible cholecystectomy given that pt is off of
anticoagulation. Given signs of ischemic injury (though
resolving) in esophagus, surgery chose to defer surgery for now.
He will have outpt follow up with Dr. [**First Name (STitle) 2819**].
Medications on Admission:
-fluticasone-salmeterol 250-50 mcg/dose [**Hospital1 **]
-tiotropium bromide 18 mcg Capsule, DAILY
-albuterol sulfate 2.5 mg /3 mL (0.083 %) neb q6h prn
-Plavix 75 mg once a day
-metoprolol tartrate 25 mg Tablet PO BID
-Colace 100mg [**Hospital1 **]
-MV qday
-Zocor 20mg HS
-Coumadin 4mg qday
-[**Hospital1 **] 81ng
-Tylenol prn
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily). Cap(s)
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
3. simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO [**Hospital1 **] (once a
day (at bedtime)).
4. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
5. zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
[**Hospital1 **]:*qs Tablet(s)* Refills:*0*
7. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
[**Hospital1 **]:*60 Capsule(s)* Refills:*2*
8. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
[**Hospital1 **]:*qs Suppository(s)* Refills:*0*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. aspirin 81 mg po daily
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area [**Location (un) 269**]
Discharge Diagnosis:
Primary: Gastritis
.
Secondary:
chronic obstructive pulmonary disease
history of stroke
coronary artery disease
hypertension
Hyperlipidemia
Discharge Condition:
Mental status - alert and appropriate
Ambulatory status - ambulatory
Overall - good
Discharge Instructions:
You have been admitted with a bleed from your stomach worsened
by the fact that you are on multiple blood thinning agents. We
have evaluated your stomach and found the source, which does not
appear to be serious. You should however take your new
medication, which reduces the acid in your stomach.
.
You were considered for possible removal of your gallbladder
during this admission, but the surgeons felt that you should
best weight until your stomach issues have completely resolved.
You are scheduled with follow-up appointments with your PCP, [**Last Name (NamePattern4) **].
[**First Name (STitle) 2819**], and the gastroenterologist who saw you during this
admission, Dr. [**First Name (STitle) 679**].
.
Medication changes:
1. Stop plavix
2. Stop coumadin
3. Stool softeners for constipation as needed
4. Proton pump inhibitor for your stomach inflammation
Followup Instructions:
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appt: [**2-18**] at 12noon
Name: [**Last Name (un) **],PERMINDER
Address: [**Apartment Address(1) 45001**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 29110**]
Appt: [**2-19**] at 11:15am
Department: SURGICAL SPECIALTIES
When: MONDAY [**2145-3-8**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD [**Telephone/Fax (1) 2998**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
[**2145-3-1**] 03:30p [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] C.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
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Discharge summary
|
Report
|
Admission Date: [**2186-6-17**] Discharge Date: [**2186-6-28**]
Date of Birth: [**2140-2-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Jaundice and malaise
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
The patient is a 46 year old female with a history of
hypertension, OSA, and depression who was transferred from [**Hospital1 **] after presenting to the ED there with 4 days of
nausea, vomiting, diarrhea, and worsening jaundice. She was
hypotensive to the 70s in triage and received IV fluids. She
was noted to have creatinine 8, TBili 10, and Lipase 3400. RUQ
ultrasound showed biliary sludge with no visible stone. CT
abdomen showed colitis. She was treated with Levofloxacin 500
mg IV and Metronidazole 500 mg IV, and transferred to [**Hospital1 18**] for
ERCP due to concern for biliary obstruction, cholangitis, and
gallstone pancreatitis.
.
In the ED, initial vital signs were T 97.1, BP 103/60, HR 100,
RR 20, SpO2 98% on RA. She arrived on her seventh liter of NS,
but was still hypotensive in the 90s systolic. Central access
was obtained with a right IJ line. She also has access with two
18g PIVs. Foley catheter was placed for urine output
monitoring. She was mentating well and in no acute distress.
Initial labs showed multiple electrolyte abnormalities including
Na 126, Ca 6.7, and bicarb 12 with anion gap 16 and lactate 2.3.
Her creatinine had decreased to 4.6 from 8 at OSH after IV
fluids. Her LFTs were still abnormal but generally improved
from OSH labs. She had a leukocytosis with WBC 13.9 and anemia
with Hct 23.6. Her INR was elevated to 1.6. Her stool was
guaiac negative. ERCP and Surgery were consulted in the ED, and
she is planned for ERCP this morning. She was admitted to the
ICU for further monitoring and management. Vitals prior to
transfer were BP 114/57, HR 102, and CVP 8.
.
Once in the ICU, she denied any pain or other specific
complaints besides the Foley catheter being uncomfortable. She
was in no acute distress and mentating well. She denied any
current nausea or abdominal pain.
.
Review of systems:
(+) Per HPI. She noted some chills at home prior to admission
but no fevers. She reports losing about 25 lbs over the last
few weeks due to lack of appetite. She has an occasional cough
which has not changed recently.
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea, or congestion. Denies shortness of
breath or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies abdominal pain. Denies
dysuria, frequency, urgency, or change in urine. Denies
arthralgias or myalgias. Denies rashes or skin changes besides
jaundice.
Past Medical History:
# Hypertension
# Obstructive Sleep Apnea
-- uses CPAP at home
# Depression
Social History:
Social History:
# Tobacco: Smoked 1 PPD for five years in the distant past.
# Alcohol: Prior alcohol abuse, none in two years, now on
Campral.
# Illicits: None
# Lives at home with husband, [**Name (NI) **] [**Telephone/Fax (1) 90543**]
Family History:
Family History:
# Father: died from lymphoma at age 57
# Mother: CAD with CABG, rapidly progressive dementia recently
# Oldest Sister: died from alcohol abuse
# Sister: cholecystectomy
# Brother: GERD and hypertension
Physical Exam:
Admission Physical Exam:
Vitals: T 97.1, BP , HR 107, RR 23, SpO2 100% on RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, slightly dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Mildtachycardia with regular rhythm. Normal S1, S2. Blowing
holosystolic murmur at LLSB with radiation to axilla.
Abdomen: Bowel sounds present. Soft, non-tender, mildly
distended, no rebound tenderness or guarding.
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema
ICU Discharge Physical Exam:
VS Tc 36.7 HR 98 BP 120/66 RR 21 O2 97/RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, slightly dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Mild tachycardia with regular rhythm. Normal S1, S2.
Blowing holosystolic murmur at LLSB with radiation to axilla.
Abdomen: normoactive bowel sounds present. Soft, non-tender,
mildly distended, no rebound tenderness or guarding.
GU: no foley
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema
DISCHARGE EXAM:
Vitals: 97.9 98/62 94 20 95/RA 1000+300/BRP
General: AAOx3 NAD
HEENT: Scleral icterus, MMM, oropharynx clear
Neck: supple, no LAD JVP 3+sternal angle
Lungs: CTAB no r/r/w
CV: RRR. Normal S1, S2. holosystolic mumur LLSB radiates to
axilla.
Abdomen: Soft, non-tender, distended no rebound tenderness or
guarding, liver palpable, +BS
Ext: Warm, well perfused, 2+ pulses. No c/c/e
Pertinent Results:
ADMISSION LABS:
[**2186-6-17**] 01:00AM BLOOD WBC-13.9* RBC-2.28* Hgb-8.1* Hct-23.6*
MCV-104* MCH-35.6* MCHC-34.3 RDW-15.0 Plt Ct-200
[**2186-6-18**] 05:17AM BLOOD WBC-16.4* RBC-2.47* Hgb-8.7* Hct-25.3*
MCV-102* MCH-35.3* MCHC-34.5 RDW-15.1 Plt Ct-202
[**2186-6-17**] 01:00AM BLOOD Neuts-86.8* Lymphs-8.5* Monos-2.5 Eos-1.7
Baso-0.4
[**2186-6-18**] 05:17AM BLOOD Plt Ct-202
[**2186-6-18**] 05:17AM BLOOD PT-18.8* PTT-37.1* INR(PT)-1.7*
[**2186-6-18**] 05:17AM BLOOD Glucose-100 UreaN-32* Creat-1.7*# Na-137
K-4.0 Cl-105 HCO3-18* AnGap-18
[**2186-6-17**] 05:58AM BLOOD Glucose-91 UreaN-53* Creat-3.7* Na-131*
K-4.0 Cl-102 HCO3-14* AnGap-19
[**2186-6-18**] 05:17AM BLOOD ALT-50* AST-170* LD(LDH)-429*
AlkPhos-497* TotBili-8.4*
[**2186-6-17**] 01:00AM BLOOD ALT-53* AST-149* AlkPhos-463*
TotBili-8.8*
[**2186-6-18**] 05:17AM BLOOD Lipase-514*
[**2186-6-17**] 01:00AM BLOOD Lipase-760*
[**2186-6-17**] 05:58AM BLOOD TotProt-5.3* Calcium-6.7* Phos-3.6 Mg-1.6
Iron-50
[**2186-6-17**] 05:58AM BLOOD calTIBC-163* VitB12-1777* Folate-6.0
Hapto-142 Ferritn-921* TRF-125*
[**2186-6-17**] 12:34AM BLOOD Lactate-2.3* K-4.5
.
DSICHARGE LABS:
[**2186-6-28**] 06:13AM BLOOD WBC-19.2* RBC-2.39* Hgb-8.4* Hct-25.2*
MCV-106* MCH-35.2* MCHC-33.3 RDW-17.1* Plt Ct-252
[**2186-6-28**] 06:13AM BLOOD Glucose-93 UreaN-13 Creat-1.2* Na-134
K-4.0 Cl-100 HCO3-24 AnGap-14
[**2186-6-28**] 06:13AM BLOOD ALT-29 AST-113* LD(LDH)-202 AlkPhos-324*
TotBili-11.1*
[**2186-6-28**] 06:13AM BLOOD Albumin-2.9* Calcium-9.0 Phos-4.7* Mg-2.2
.
OTHER PERTINENT LABS:
[**2186-6-17**] 05:58AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2186-6-17**] 05:58AM BLOOD HCV Ab-NEGATIVE
[**2186-6-19**] 04:55AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2186-6-19**] 04:55AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2186-6-17**] 05:58AM BLOOD PEP-NO SPECIFI IgG-1232 IgA-424* IgM-138
IFE-NO MONOCLO
[**2186-6-19**] 04:55AM BLOOD tTG-IgA-61*
[**2186-6-17**] 05:58AM BLOOD calTIBC-163* VitB12-1777* Folate-6.0
Hapto-142 Ferritn-921* TRF-125*
[**2186-6-19**] 04:55AM BLOOD TSH-13*
[**2186-6-19**] 04:55AM BLOOD T4-7.2 T3-56*
.
--------
--------
MICRO
[**6-17**], [**6-20**], [**6-21**], [**6-22**], 8/5 Blood Cultures NEGATIVE except [**11-20**]
bottles on [**6-20**] which grew:
Blood Culture, Routine (Final [**2186-6-26**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2186-6-22**]):
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2186-6-22**] 8:45AM
9-0958.
GRAM POSITIVE COCCI IN CLUSTERS.
-------
-------
IMAGING
.
[**6-17**] CXR:
INDICATION: Central line placement.
COMPARISON: None available.
FRONTAL RADIOGRAPH OF THE CHEST: A right internal jugular
central venous line terminates with the tip at the upper
cavoatrial junction. There is no
pneumothorax. Lung volumes are low with resultant vascular
crowding. Cardiac silhouette is top normal. Mediastinal and
hilar contours are normal. There is no pleural effusion or
pneumothorax.
.
[**6-20**] CXR
IMPRESSION No evidence of pneumonia.
.
[**6-25**] CXR
FINDINGS: In comparison with the study of [**6-20**], there is no
interval change or
evidence of acute cardiopulmonary disease. Specifically, no
pneumonia,
vascular congestion, or pleural effusion.
.
[**6-17**] ERCP
Impression: Successful biliary cannulation was achieved.
Partial opacification of the biliary tree was performed because
of clinical suspicion of cholangitis- no evidence of stones or
filling defects was seen.
Successful placement of a 7cm x 10Fr stent for biliary drainage-
with drainage of clear bile.
Otherwise normal ERCP to 3rd portion of duodenum.
Recommendations: Juices when awake and alert, then advance diet
as tolerated.
Continue antibiotics.
No definitive explanation for jaundice found on ERCP, although
contrast opacification limited. It is possible that the patient
passed a stone. Consider evaluation for other causes of jaundice
including viral hepatitis. Follow-up ERCP will allow for
complete evaluation of intrahepatics given possibility of PSC.
Repeat ERCP in 4 weeks for stent removal and complete evaluation
of biliary tree.
.
[**6-18**] RUQ US
FINDINGS: The liver is diffusely increased in echogenicity,
consistent with
fatty infiltration of the liver. No focal hepatic mass is
definitely noted.
There is no intrahepatic or extrahepatic ductal dilatation with
the common
bile duct measuring 4mm. However, the known common bile duct
stent is not
visualized. The main portal vein is patent with hepatopetal
flow.
The gallbladder is mildly distended, without wall thickening,
pericholecystic
fluid, or son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. Sludge is visualized within
the
gallbladder. Additionally, there are echogenic foci with dirty
posterior
shadowing in nondependent portions of the gallbladder is
consistent with air
within the gallbladder lumen, likely from recent ERCP and
sphincterotomy.
The spleen is mildly enlarged measuring 13 cm. There is no
ascites.
Bilateral kidneys are without evidence of hydronephrosis. The
pancreas is not
well visualized due to overlying bowel gas.
IMPRESSION:
1. Gallbladder sludge without acute cholecystitis. There is also
evidence of
air within the gallbladder lumen, likely from recent ERCP and
sphincterotomy.
2. Echogenic liver consistent with fatty infiltration of the
liver. More
significant liver disease including significant hepatic
fibrosis/cirrhosis
cannot be excluded based on this study.
3. No biliary dilatation, although the common bile duct stent is
not
visualized.
.
[**6-21**] MRCP
MR ABDOMEN WITH IV CONTRAST: There is marked diffuse fatty
deposition of the
liver in addition to more focal areas of almost mass-like fatty
deposition
surrounding the gallbladder fossa (3A:9, 12). There is also
deposits of
increased fat within the periphery of the liver. There is a
heterogeneous
enhancement pattern to the liver suggesting diffuse liver
disease beyond fatty
deposition. This appearance could be seen with chronic fibrosis,
although
there are no other findings on this study to suggest cirrhosis.
The hepatic
and portal veins are patent. There is no intra- or extra-hepatic
biliary
dilation.
A stent is noted in place within the common bile duct. While
there is mild
enhancement of the bile duct wall at the level of the stent,
above the level
of the stent, the bile ducts do not demonstrate any abnormal
enhancement to
suggest cholangitis.
There is diffuse gallbladder wall edema which is likely related
to the
underlying liver process. There is no hyperenhancement of the
gallbladder
wall or surrounding liver to suggest acute cholecystitis. The
gallbladder
contains sludge.
No pancreatic mass is identified. The pancreas demonstrates
normal
homogeneous enhancement throughout. The pancreatic duct appears
normal. There
is small amount of peripancreatic fluid/edema consistent with
patient's
diagnosis of acute pancreatitis. The splenic vein and superior
mesenteric
veins remain patent. There are no fluid collections.
There is a trace amount of perihepatic and perisplenic ascites.
The spleen,
adrenal glands, kidneys, and stomach are within normal limits.
There is no
retroperitoneal or mesenteric lymphadenopathy.
IMPRESSION:
1. No evidence of pancreatic mass. Small amount of
peripancreatic fluid/edema
is consistent with uncomplicated acute pancreatitis. Trace
perihepatic and
perisplenic ascites.
2. Marked diffuse fatty deposition in the liver. However,
heterogeneous
enhancement of the liver suggests diffuse liver disease beyond
fatty liver,
possibly reflecting hepatitis oor fibrosis, though there is not
overt
cirrhosis.
3. Gallbladder wall edema, likely due to underlying liver
disease.
Gallbladder sludge.
4. Biliary stent in place without intra or extraphepatic biliary
dilation.
Mild enhancement of the common bile duct is likely from stent
placement.
There is no evidence of abnormal biliary ductal enhancement
above the level of
the stent to suggest cholangitis.
.
[**6-28**] ECHO
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Estimated cardiac
index is normal (>=2.5L/min/m2). TDI E/e' < 8, suggesting normal
PCWP (<12mmHg). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild thickening of mitral valve chordae. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). 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) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mitral regurgitation is seen. There is mild
to moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild to moderate pulmonary hypertension.
Brief Hospital Course:
46 year old female with a medical history of hypertension &
depression transferred from [**Hospital6 2561**] after
presenting with 4 days of nausea, vomiting, diarrhea, and
worsening jaundice. Admitted to the ICU, found to have acute
alcoholic pancreatitis and hepatitis.
.
# Acute Alcoholic Pancreatitis:
Pt presented to OSH with symptoms consistent with acute
pancreatitis. The patient has a history of alcohol abuse, but
initial denied alcohol use within the past 2 years, so gallstone
pancreatitis was suspected. RUQ ultrasound at OSH reportedly
showed sludge without visible stone. She underwent ERCP with CBD
stent placement. Lipase was initially quite elevated and trended
down moderately after aggressive IVF. Other possible causes for
her pancreatitis were explored, including the possibility of
abdominal trauma suffered in a single-car accident the patient
suffered two weeks before this admission. However, MRCP was
negative. When TTG was elevated and patient was confronted with
the lack of other explanations for her acute
pancreatitis/hepatitis, she admitted to drinking 1.5 bottles of
wine/day prior to admission (see below, alcohol abuse).
.
# Acute Alcoholic Hepatitis:
Pt also presented with elevated LFTs and jaundice. Alcoholic
hepatitis was diagnosed when biliary obstruction and viral
hepatitis were ruled out. She had initially been started on
antibiotics in the ED, but these were stopped given lack of
concern for infection. Patient provided additional history of
recent MVA with 6 g/day tylenol use for 3 days thereafter
([**Date range (1) 24996**]) + intermittent alcohol use. Hepatology was consulted
in the ICU with concern for PSC or other liver parenchymal
process, in addition to alcohol and possible tylenol overdose;
the patient was transferred to the hepatology service after
discharge from the ICU. Her leukocytosis persisted, LFTs
remained elevated and she continued to spike fevers. These were
thought to be [**12-21**] underlying alcoholic hepatitis rather than
infection, especially since only 1 bottle of many many blood
culture samples was ever positive for bacterial growth, and thus
was thought to be a lab contaminant. She received a 7-day course
of vancomycin, then was started on pentoxyfilline.
.
# Coagulopathy:
Related to hepatitis. The patient??????s INR was elevated to 1.6 on
arrival at the [**Hospital1 18**] ED. She does not have a reported history of
liver disease and is not on anticoagulation at home. Best
explained by new diagnosis of acute alcoholic hepatitis.
.
# Hypotension:
Related to pancreatitis. Patient was hypotensive on admission
with SBP 90s despite receiving significant IV fluids at OSH.
Her hypotension was likely related to fluid shifts from acute
alcoholic pancreatitis rather than sepsis. SBP improved to the
110s with IV fluids. She was restarted on a decreased dose of
home metoprolol (25 mg QD) but home lisinopril was held given
acute renal injury (below). Lisinopril was restarted at
discharge.
.
# Hyponatremia:
Related to pancreatitis/hepatitis. Resolved with current Na 137
in the ICU, up from 126 on admission and 123 at OSH. This
likely represented hypovolemic hyponatremia from her
pancreatitis and volume depletion from GI losses and poor PO
intake.
.
# [**Last Name (un) **]:
Creatinine 8.0 on admission to OSH, fell gradually during this
admission, to 1.2 at discharge. Baseline creatinine was unknown.
The most likely etiology was prerenal from hypotension and fluid
shifts in the context of pancreatitis. Maintained urine output
in the context of aggressive IVF hydration as above.
.
# Metabolic Acidosis:
Patient had an anion gap acidosis at the OSH. Lactate was 1.2 at
OSH and 2.3 here. Acidosis thought to be related to
pancreatitis, [**Last Name (un) **], and ketones from alcohol intake/poor
nutrition prior to admission. Resolved by time of discharge,
with bicarb 24 and anion gap 10.
.
# Anemia:
Hct was 28.2 at OSH. Baseline Hct unknown. She reports recent
diarrhea that was sometimes black, but her stool was guaiac
negative in the ED. She has not had a menstrual period since
[**Month (only) 404**]. Her RBCs are macrocytic with MCV 104. Iron panel was
difficult to interpret in the setting of her current acute
illness. Hct was trended, iron panel, B12, and folate were
checked. She received B12, folate, and iron supplementation
during this admission.
.
# Leukocytosis:
Patient presented with a leukocytosis, WBC 13.9; this rose
during admission. Attributed to alcoholic hepatitis. Cultures
all negative apart from a single spuriously-positive GPC blood
culture. WBC remained >15 after treatment with vancomycin.
.
# Depression:
Reports 25-lb weight loss in past 3 weeks secondary to stress.
She is on Lexapro for depression and . These should be held for
now pending improvement in her renal and hepatic function, both
of which are currently impaired. Recent alcohol use likely
contributed to her current presentation, and should be
readdressed prior to and after discharge as she will continue to
need support for this ongoing issue.
.
# Alcohol Abuse:
Patient has longstanding history of alcohol abuse; she sees a
therapist [**Hospital1 **]-weekly and a psychopharmacologist for Campral
prescription. Denies alcohol use within the past 2 years until
confronted with laboratory data (GGT) confirming her providers'
suspicion of ongoing alcohol use. Family meeting was held prior
to discharge, to discuss prognosis for alcoholic hepatitis,
request that husband remove all alcohol from the home, agree
upon a plan for post-discharge detox program, and to re-inforce
the absolute importance of abstinence for her survival.
Inpatient social work has arranged for outpatient detox, to
begin the Monday after discharge ([**7-3**]); patient was unwilling
to be discharged directly to a detox facility. Outpatient
therapist aware and will follow-up; psychopharmacologist alerted
by telephone.
.
# Recent motor vehicle accident:
Large bruise noted on pt's lower back during physical
examination in the ICU. Pt reported history of a single-vehicle
car accident on [**6-5**]: she drove over two curbs in trying to
avoid other drivers, resulting in two blown tires. She denies
steering wheel impact and did not seek police or medical
attention after the accident. Denied alcohol use prior to this
accident. Took 6 g/day tylenol in the 3 days following, which
may have contributed to her liver failure.
TRANSITIONAL ISSUES
1. ***Alcohol abuse follow-up.*** Patient has agreed to
inpatient detox but wanted to go home first to see her
8-year-old son. Inpatient social worker [**Name (NI) 636**] [**Name (NI) 12471**] and
outpatient therapist will follow-up to ensure this happens.
Medications on Admission:
Lexapro 30 mg PO daily
Lisinopril 10 mg PO daily
Metoprolol 50 mg PO BID
Campral (Acamprosate) 333 mg 2 tabs TID
Omeprazole OTC PO daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain: Please limit to 2gm.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lexapro 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Campral 333 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO three times a day.
10. pentoxifylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO TID (3 times a day).
Disp:*90 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Alcoholic Pancreatitis
Alcoholic Hepatitis
.
Secondary Diagnoses:
Depression
Alcohol Abuse
Sleep Apnea
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for allowing us to participate in your care.
.
You were admitted to the hospital for abdominal pain and
jaundice.
.
You underwent an endoscopic procedure called ERCP, to visualize
your gallbladder and biliary tree. No gallstones or obstruction
was seen. A stent was placed in the bile duct, to allow free
drainage of bile into your intestines, in case there was some
mild obstruction not seen on the test.
.
Your liver and pancreas enzyme levels were followed during this
admission. These were very elevated when you first arrived, but
they trended down with IV fluids and time. However, they were
still elevated at the time of discharge and you were still
jaundiced. You were not having any abdominal pain. We looked for
infection but did not see any signs. The inflammation in your
pancreas and liver appeared to be from another non-infectious
cause.
.
We thought your liver and pancreas inflammation was due to
alcohol consumption. Lab tests showed that this was true. You do
have several reasons for increased stress in your life recently.
You met with a social worker during this hospitalization who
will help coordinate your care after you leave the hospital. We
felt it was very important that you get adequate support after
you leave the hospital so that you can stay sober. Drinking
alcohol will further injury your pancreas and liver, which are
already fragile. You will see your own therapist, [**Female First Name (un) **], twice a
week from now on. She will help you follow-through with your
intention to enroll in a full-time alcohol detox program within
a week after leaving the hospital.
.
When you first arrived, we treated you with intravenous
antibiotics to fight a possible bacterial infection in your
gallbladder. Later we gave you antibiotics again when we
suspected an infection in your blood. Laboratory tests showed
that you were not infected at the time you left the hospital.
.
We made the following changes to your medications:
1. We DECREASED your metoprolol dose to 25 mg per day.
2. We STARTED you on Pentoxifylline 400 mg PO three times daily
3. We STARTED you on multivitamins and thiamine which you should
take daily
.
Please continue to take all other medications as prescribed, or
as instructed by your doctor.
.
Followup Instructions:
We arranged a follow-up appointment with your primary care
doctor:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **]
Location: [**Hospital **] MEDICAL ASSOCIATION
Address: [**Apartment Address(1) 83440**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
Appointment: Friday [**6-30**] 2:15 PM
.
Please call Dr.[**Name (NI) 90544**] office if you need to reschedule this
appointment.
Please also call your Psychopharmacologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 90545**] at [**Telephone/Fax (1) 90546**] to book a follow up appointment within
1 week.
.
You should also see your therapist next week. The [**Hospital1 18**] social
worker will be in contact with your therapist to ensure a smooth
transition so you can receive the support you need.
.
You will also need to follow-up with the ERCP service, to have
the stent removed. Dr[**Name (NI) 90547**] administrator, [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 15954**],
will call you to arrange this appointment. If you don't hear
from her by next Monday, please call her at [**Telephone/Fax (1) 21143**].
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Discharge summary
|
Report
|
Admission Date: [**2194-8-14**] Discharge Date: [**2194-8-25**]
Date of Birth: [**2150-10-24**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
1. Biliary obstruction.
2. Biliary stricture secondary to chronic pancreatitis.
3. Status post fulminant necrotizing pancreatitis.
4. Status post intraabdominal sepsis.
Major Surgical or Invasive Procedure:
1. Extensive lysis of adhesions.
2. Open cholecystectomy with common bile duct exploration.
3. Partial wedge hepatectomy.
4. Choledochoduodenostomy biliary bypass.
History of Present Illness:
43F with history of severe hemorrhagic pancreatitis ([**8-15**])
complicated by pancreatic necrosis & retroperitoneal abcess
formation & ampullary stricture s/p necrosectomy and abcess
drainage [**10/2192**] with PTBD drain placement. She has had multiple
exchanges of this drain, the last on [**2194-8-7**]. She presented
for the following scheduled operation:
1. Extensive lysis of adhesions.
2. Open cholecystectomy with common bile duct exploration.
3. Partial wedge hepatectomy.
4. Choledochoduodenostomy biliary bypass.
Past Medical History:
PMH: necrotizing pancreatitis [**8-/2192**], HCV, HTN, depression,
chronic back pain, asthma
PSH: pancreatic necrosectomy, left and right peritoneal abscess
wide drainage ([**2192-10-23**]); bilateral RP abscess washout and
J-tube
placement ([**2192-10-25**]); tracheostomy ([**2192-11-1**]); PTC with
placement of 8-Fr internal/external biliary drain ([**2192-12-24**])
for ampullary stenosis with multiple subsequent dilations and
exchanges of PTC drain, most recently [**2192-4-14**] where a 12 Fr
int/ext drain was placed
Social History:
SH: 2 children. Lives in [**Location 3610**]. Does not currently smoke
and
quit drinking alcohol since her episode of severe pancreatitis
in
[**2192**].
Family History:
FH: liver disease and bone cancer, no known pancreatic issues
Physical Exam:
Upon Discharge:
All vitals stable and within normal limits, afebrile
Gen - AAOx3, in no apparent distress
CV - RRR +S1/S2 no murmurs/rubs/gallops
Resp - CTAB no wheezes/crackles/rhonchi
Abd - soft, mildly tender to palpation appropriately near
incision, non-distended, +BS, no rebound/rigidity/guarding, no
palpable masses
Inc - clean/dry/intact, with no erythema/induration/drainage
Ext - no edema/clubbing/cyanosis
Pertinent Results:
OPERATIVE PATHOLOGY ([**8-14**]):
Gallbladder, open cholecystectomy:
- Chronic cholecystitis.
- Cystic lymph node with reactive, florid follicular
hyperplasia and sinus histiocytosis.
DRAIN STUDY AND REMOVAL OF DRAIN ([**8-20**]):
- Patent choledochoduodenostomy tract with free flow from the
upper common bile duct into the duodenum. The ampulla appears
to be fully obstructed. There was no appreciable flow along
this anatomic pathway, though this is likely just higher
resistance than the bypass. No intrahepatic strictures
identified. Left-sided ducts were not filled during this
examination.
- Uncomplicated removal of indwelling biliary drain. Patient
may continue to have some leaking into the bandage. Please
change the dressing p.r.n. with a pressure-type dressing. The
tract should close completely in several days.
RUQ ULTRASOUND ([**8-24**]):
1. Diffuse pneumobilia, unchanged from prior. No significant
biliary ductal dilatation.
2. No definite fluid collection within the region of the porta
hepatis.
Examination is limited due to overlying bowel gas. If high
clinical
suspicion, consider CT for further assessment.
3. Unchanged splenomegaly.
4. Mild abdominal ascites.
BILATERAL LE ULTRASOUND ([**8-24**]): No lower extremity DVT
DISCHARGE LABS:
[**2194-8-25**] 07:10AM BLOOD WBC-4.9 RBC-3.12* Hgb-9.4* Hct-28.7*
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 Plt Ct-177
[**2194-8-25**] 07:10AM BLOOD Plt Ct-177
[**2194-8-23**] 01:28AM BLOOD Glucose-123* UreaN-5* Creat-0.7 Na-131*
K-4.1 Cl-101 HCO3-26 AnGap-8
[**2194-8-19**] 05:10AM BLOOD ALT-34 AST-38 AlkPhos-344* TotBili-0.7
DirBili-0.3 IndBili-0.4
[**2194-8-23**] 01:28AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.6
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2194-8-14**], the patient underwent
the following procedure:
1. Extensive lysis of adhesions.
2. Open cholecystectomy with common bile duct exploration.
3. Partial wedge hepatectomy.
4. Choledochoduodenostomy biliary bypass.
This procedure went well without complication (reader referred
to the Operative Note for details). After her operation, the
patient was admitted to the ICU NPO, on IV fluids, on a 1-day
course of antibiotics, with a foley catheter, JP drain, PTBD,
and NGT in place. She remained intubated, on a ventillator, and
was hemodynamically stable.
On POD#1, the patient was successfully extubated, and placed on
a ketamine drip for pain control. Later that day, the ketamine
drip was discontinued, and an epidural was placed for pain
control. For a short period (approximately 1 hour) after placing
the epidural, the patient required a small dose of pressor
support to maintain her blood pressures. Thereafter, she no
longer required this, and tolerated the epidural well. Her
drains were maintained. She remained NPO, with all her drains
and tubes still in place.
On POD#2, the patient was transfused 2 units of PRBC. Her
epidural and drains/tubes were maintained. She was out of bed to
chair.
On POD#3, she was well enough to be transferred out of the ICU,
and onto the general surgical floor. She remained NPO, with JP,
PTBD, NGT and foley in place, as well as the epidural continued
for pain control.
On POD#5, her NGT was clamped, and epidural and all other drains
were maintained. On this day, due to some concern about erythema
around her incision, she was stared on IV cefazolin. Her
epidural was removed, and she was transitioned to a PCA for pain
control, which she tolerated well. Her foley was removed and she
urinated independently. Later in the day, her NGT was removed,
and she was permitted to have clear liquids, which she tolerated
very well.
On POD#6, her PTBD had a drain study performed on it, and upon
satisfactory results (reader referred to "Pertinent Results")
the drain was removed. Additionally, her JP drain was
discontinued. Due to some concern for nausea, she was made NPO.
However, upon feeling much better in the evening, she was put
back on clear liquids, and then a regular diet. She tolerated
this very well.
On POD#7, due to a marked improvement in the appearance of her
incision, her IV cefazolin was discontinued. Her epidural was
removed, and she was transitioned to oral pain medications,
which she tolerated well. She was seen by Physical Therapy, and
ambulated mutiple times per day.
She continued to progress well. On POD#9, she was noted to spike
a fever to 102.4, upon which a fever workup was initiated, and
all results were negative for any infectious process. A second
fever on POD#10 prompted ultrasounds of the LEs and RUQ, both of
which were unconcerning as well. Thereafter, the patient had no
more fevers. She continued to feel well, with good pain control,
ambulating multiple times per day, and tolerating regular diet.
Her staples were removed on POD#10 and steri strips were placed.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization. Electrolytes were routinely
followed, and repleted when necessary. The patient's white blood
count and fever curves were closely watched for signs of
infection. Wound care was performed regularly and thoroughly.
The patient's blood sugar was monitored throughout his stay;
insulin dosing was adjusted accordingly. The patient received
subcutaneous heparin and venodyne boots were used during this
stay; was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
methadone 20''', oxycodone 30''', losartan 50', ibuprofen 600'
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 capsule(s) by mouth twice per day Disp #*60
Capsule Refills:*0
2. Methadone 20 mg PO TID
3. Losartan Potassium 50 mg PO DAILY
Hold for SBP<110 and HR<60
4. Senna 1 TAB PO BID
RX *senna 8.6 mg 1 tablet by mouth twice per day Disp #*30
Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once per day Disp
#*60 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 30 mg PO Q8H
RX *oxycodone 30 mg 1 tablet(s) by mouth every 8 hours Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
1. Biliary obstruction.
2. Biliary stricture secondary to chronic pancreatitis.
3. Status post fulminant necrotizing pancreatitis.
4. Status post intraabdominal sepsis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for an open
cholecystectomy and choledocoduodenostomy . You have done well
in the post operative period and are now safe to return home to
complete your recovery with the following instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-15**] lbs until you follow-up with your
[**Month/Year (2) 5059**], who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your [**Month/Year (2) 5059**] and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 2835**]
Date/Time:[**2194-9-1**] 11:00
Location: [**Hospital Ward Name **] BUILDING, [**Location (un) **]
Completed by:[**2194-8-25**]
|
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icd9pcs
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567,
591
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597,
633
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97,488
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40603
|
Discharge summary
|
Report
|
Admission Date: [**2128-4-8**] Discharge Date: [**2128-4-13**]
Date of Birth: [**2061-7-1**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
perirectal abscess
Major Surgical or Invasive Procedure:
drainage of perirectal abscess on [**4-8**]
History of Present Illness:
66M transferred from [**Hospital1 18**] [**Location (un) 620**] with 4 weeks of
perirectal pain and purulent drainage from his rectum. Patient
didnt go to the ED before with the hope that this would resolve,
but pain has been steady and worsening during the past 3 days.
The purulent drainage started 3 weeks ago, associated with
fevers, chills and diaphoresis, and it has been increasing
during
the past week. Patient went to [**Location (un) **] ED and was found to have
a
T 102.2, a WBC of 12 and Glucose of 490 requiring insulin
boluses. Here on arrival with new onset of A.Fib with RVR up to
150s.
Past Medical History:
HTN, CHF, DM, GERD
Social History:
Smoker of 1 1/5 packs a day for 30 years. Drinks
EtOH occasionally.
Family History:
mother had [**Name2 (NI) 499**] cancer in the 60s.
Physical Exam:
ON DISCHARGE:
Vitals: 98.8 77 154/80 18 96% RA
GEN: A&O, NAD
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds
RE: drainage coming out of the rectum around penrose drain. No
erythema. Slightly TTP (appropriate). no fluctuant masses
Ext: No LE edema, LE warm and well perfused dependent rubor
Pertinent Results:
CT pelvis [**4-12**]:
1. Interval perirectal abscess drainage without residual fluid
collection. The drain remains in place.
2. Mild-to-moderate proctocolitis.
3. Chondroid lesion in the right iliac bone which has a benign
appearance and might represent an enchondroma. If the patient
complains of regional pain this could be further evaluated with
MRI to exclude a more aggressive lesion
Brief Hospital Course:
Mr. [**Known lastname 17811**] was admitted to the ACS surgery service for [**Known lastname **]
of the perirectal abscess. On [**4-8**] he underwent an I/D of the
large perirectal abscess and placement of a penrose drain.
Intraop he was in afib with RVR and was transferred to the ICU
for [**Month/Year (2) **]. The following day, he was hemodynamically stable
and was in NSR with betablocker so he was transferred to the
floor. He was put on broad spectrum antibiotics. He was also
having significant hyperglycemia requiring insulin boluses.
[**Last Name (un) **] was consulted for glycemic control. Also, nutrition was
consulted for diabetic diet education. The atrial fibrillation
recurred postoperatively after a brief period in NSR. A CT scan
was obtained to rule out ongoing infection/undrained perirectal
abscess. The CT showed that the abscess was adequately drained.
Cardiology was consulted for assistance in [**Last Name (un) **] of the
paroxysmal atrial fibrillation. They recommended continuation of
home Metoprolol XL 100mg PO daily, anti-coagulation for
paroxysmal AF, [**Doctor Last Name **] of Heart Monitor on discharge, f/u with
cardiology in [**3-24**] weeks, continuing ASA, ACEI and statin for
CHF.
He was discharged in good condition, tolerating a regular diet,
afebrile, ambulating, pain well controlled.
Medications on Admission:
furosemide 40 mg daily, omeprazole 20 mg daily, simvastatin 40
mg daily, metoprolol succinate ER 100 mg daily, actos 45 mg Tab
daily, aspir-81 81 mg daily, lisinopril 40 mg daily, glipizide
20 mg [**Hospital1 **]
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. insulin syringes (disposable) 1 mL Syringe Sig: syringe
Miscellaneous four times a day.
Disp:*100 syringes* Refills:*12*
8. insulin safety needles (disp) 29 x [**12-21**] Needle Sig: needle
Miscellaneous four times a day.
Disp:*100 needle* Refills:*2*
9. glucometer Sig: glucometer four times a day.
Disp:*1 glucometer* Refills:*0*
10. test strips Sig: for glucometer four times a day.
Disp:*100 test strips* Refills:*2*
11. Lantus 100 unit/mL Cartridge Sig: Twenty Six (26) units
Subcutaneous at bedtime.
Disp:*30 cartridge* Refills:*2*
12. Humalog KwikPen Subcutaneous
13. insulin sliding scale
check blood glucose 4 times a day. Take 26 units of lantus every
night.
Blood glucose 100-160 take 10 units of Humalog
Blood glucose 161-200 take 13 units of Humalog
Blood glucose 201-240 take 16 units of Humalog
Blood glucose 241-280 take 19 units of Humalog
Blood glucose 281-320 take 22 units of Humalog
Blood glucose 321-360 take 25 units of Humalog
Blood glucose >360 seek medical attention
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
perirectal abscess
diabetes
paroxysmal atrial fibrillation
Discharge Condition:
MS: intact. Alert and oriented x 3
Ambulating
Discharge Instructions:
-You have a perirecatal abscess. A penrose drain was placed to
facilitate drainage of the abscess and allow for it to heal
properly. The penrose drain will be removed in surgery clinic.
In order to ensure that this heals well, you must control your
diabetes and see a primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of the
diabetes. You also developed atrial fibrillation or an irregular
heart rate. Cardiology wants you to have a heart monitor and
start anticoagulation. You should follow up with them for
[**Last Name (Titles) **] of the atrial fibrillation.
Followup Instructions:
-Follow up with a primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of diabetes
and atrial fibrillation
-Follow up with Cardiology for [**Last Name (Titles) **] of atrial fibrillation
in [**3-24**] weeks. Call for an appointment [**Telephone/Fax (1) **]
-Follow up in [**Hospital 2536**] clinic in [**12-21**] weeks. Call for an appointment.
[**Telephone/Fax (1) 600**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
|
[
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icd9pcs
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93,078
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|
10509
|
Discharge summary
|
Report
|
Admission Date: [**2182-12-9**] Discharge Date: [**2182-12-10**]
Date of Birth: [**2142-12-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Tetanus / Morphine
/ Cefoxitin / Codeine / Lactose
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
[**2182-12-9**]:
EGD with dilation and left main stem cryoablation of granulation
tissue.
History of Present Illness:
Ms [**Known lastname 27785**] is a 39-year-old woman with a complicated medical
history including acute lymphocytic leukemia at age 4, status
post bone marrow transplant, radiation therapy complicated by
lung fibrosis requiring living donor lung transplant from her
father. This was further complicated by left main stem stenosis
requiring metal stent placement 5 years ago. Since then she has
been requiring repeated bronchoscopies for stent evaluation,
clean out and granulation tissue removal. She was last seen by
interventional pulmonary service in [**2182-5-4**]. After that time
she
had been doing OK in terms of her breathing, but about one month
ago she started having dry cough, and then dyspnea on exertion,
both of which have been worsening, which prompted her consult
with us today. Her cough is worse at night, and is not
productive. Her dyspnea is currently with mild to moderate
exertion, like going up one flight of stairs. She was brought in
for rigid bronch and cryoablation of left main stem granulation
tissue.
The patient also has esophageal stricture requiring past EGD
with dilation. Given dysphagia, the patient was also brought in
for combined EGD with dilation.
Past Medical History:
PAST MEDICAL HISTORY:
1- ALL since age 4
2- S/P Bone marrow transplant, and lung transplant from
radiation
fibrosis. The both of them were donated by her father.
3- Pneumocystis Jiroveci Pneumonia in [**2152**]
4- Herpes Simplex 2 (oral)
5- TMJ Ankylosis with small oral opening
6- Bilateral cataracts
7- Esophagel stricture
8- LL pneumonia ([**2179-3-7**])
9- Intestinal Adhesions
10- Basal Cell Ca (Back - upper chest)
11- Edentulous with full dentures due to major dental work (now
missing her lower dentures, as described above).
PAST SURGICAL HISTORY:
1- Surgical Debridement of thigh abcess from IM pentamidine [**2152**]
2- Appendectomy [**2163**]
3- Laparoscopy to remove ovarian cysts [**2162**]
4- S.P Small bowel perforation complicated with candidal and
bacterial paeritonitis requiring antifungals and antibiotics
5- Cholecystectomy
6- Pulmonary fibrosis S/P living related donor from father [**Name (NI) 25730**]
transplant)
7- Post pericardiotomy syndrome [**2170**]
8- L MS bronchomalacia
9- Bilat SAH
10- Ilesotomy and enterococcus fistula and reversed 10 months
later at [**Hospital1 112**]
11- Closing of enterocutaneous fistula and ostomy [**2174**]
12- S/P port placement for IV access [**9-7**]
13- LMS granuloma debridement and mitomycin
14- Esophageal dilatation [**2-11**] - [**7-11**]
15- Debridement of granulation tissue around stent
[**88**]- Pneumothorax post bronchoscopy with stent granulation tissue
debridement.
Social History:
Lives at home alone, with family that can help her. No smoking.
Physical Exam:
VS on day of discharge.
T 97.8, HR 90's SR , BP 95/45, RR 18 94% RA
Physical Exam on discharge:
Gen: pleasant in NAD
Neuro: alert and oriented x 4 without deficits
Lungs: wheezes t/o
CV: Fast RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: warm, without edema
Pertinent Results:
[**2182-12-9**] 10:42PM BLOOD WBC-21.0*# RBC-3.04* Hgb-9.1* Hct-27.4*
MCV-90 MCH-30.1 MCHC-33.4 RDW-13.9 Plt Ct-475*#
[**2182-12-9**] 10:42PM BLOOD Neuts-95.0* Lymphs-2.5* Monos-1.7*
Eos-0.4 Baso-0.3
[**2182-12-9**] 10:42PM BLOOD Glucose-72 UreaN-9 Creat-0.3* Na-134
K-3.9 Cl-99 HCO3-26 AnGap-13
[**2182-12-9**] 10:42PM BLOOD Calcium-7.9* Phos-2.3* Mg-1.7
CXR [**2182-12-10**]:
FINDINGS: As compared to the previous radiograph, the
pre-existing left
parenchymal opacities have slightly decreased in severity. The
right upper
lobe opacity is unchanged. There is no evidence of pneumothorax.
CXR [**2182-12-9**]:
FINDINGS: As compared to the previous radiograph, there is
minimal
improvement with better ventilation of both lungs and minimal
regression of both the right upper lobe and the left lower lobe
opacity. No parenchymal opacities have newly occurred. The size
of the cardiac silhouette is unchanged. There is no evidence of
pneumothorax.
Brief Hospital Course:
Ms. [**Known lastname 27785**] was taken to the operating room on [**2182-12-9**] by Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **] where she underwent EGD with dilation for her
esophageal stricture and rigid bronchoscopy with cryoablation of
the granulation tissue surrounding the left main stem stent. She
recovered in the PACU, but over the evening developed
respiratory distress, therefore was admitted under Thoracic
surgery and stayed in PACU with Bipap. Her respiratory status
improved with bipap, albuterol, and morphine. She was observed
and in the morning, after examination by IP attending Dr. [**Last Name (STitle) **]
and the Thoracic surgery service, and review of chest xray, the
patient was deemed stable for discharge home. The patient was
ambulating oxygenating mid 90's on RA, stating she felt much
improvement from the evening without shortness of breath. She
was tolerating a regular meal without dysphagia. She did not
have any pain. She was given albuterol for wheezing per the
pulmonary team with a script for guaifenesin with codeine for
cough. Her home medications were resumed.
Medications on Admission:
amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO twice a day.
Vagifem 10 mcg Tablet Sig: One (1) tab Vaginal three times per
week.
Climara Pro 0.045-0.015 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal as directed.
Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
vitamin K 100 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation q 4 hours prn as needed for shortness
of breath or wheezing.
Disp:*1 2* Refills:*0*
2. amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. Guaifenesin AC 10-100 mg/5 mL Liquid Sig: Ten (10) ML PO q 6
hours prn as needed for cough: do not drive while on this as it
may cause drowsiness. Take stool softeners to avoid
constipation.
Disp:*250 ML(s)* Refills:*0*
4. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO twice a
day.
5. Vagifem 10 mcg Tablet Sig: One (1) tab Vaginal three times
per week.
6. Climara Pro 0.045-0.015 mg/24 hr Patch Weekly Sig: One (1)
patch Transdermal as directed.
7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
8. vitamin K 100 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Left main stem stenosis
Esophageal stricture
PAST MEDICAL HISTORY:
1- ALL since age 4
2- S/P Bone marrow transplant, and lung transplant from
radiation
fibrosis. The both of them were donated by her father.
3- Pneumocystis Jiroveci Pneumonia in [**2152**]
4- Herpes Simplex 2 (oral)
5- TMJ Ankylosis with small oral opening
6- Bilateral cataracts
7- Esophagel stricture
8- LL pneumonia ([**2179-3-7**])
9- Intestinal Adhesions
10- Basal Cell Ca (Back - upper chest)
11- Edentulous with full dentures due to major dental work (now
missing her lower dentures, as described above).
PAST SURGICAL HISTORY:
1- Surgical Debridement of thigh abcess from IM pentamidine [**2152**]
2- Appendectomy [**2163**]
3- Laparoscopy to remove ovarian cysts [**2162**]
4- S.P Small bowel perforation complicated with candidal and
bacterial paeritonitis requiring antifungals and antibiotics
5- Cholecystectomy
6- Pulmonary fibrosis S/P living related donor from father [**Name (NI) 25730**]
transplant)
7- Post pericardiotomy syndrome [**2170**]
8- L MS bronchomalacia
9- Bilat SAH
10- Ilesotomy and enterococcus fistula and reversed 10 months
later at [**Hospital1 112**]
11- Closing of enterocutaneous fistula and ostomy [**2174**]
12- S/P port placement for IV access [**9-7**]
13- LMS granuloma debridement and mitomycin
14- Esophageal dilatation [**2-11**] - [**7-11**]
15- Debridement of granulation tissue around stent
[**88**]- Pneumothorax post bronchoscopy with stent granulation tissue
debridement.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr. [**First Name (STitle) **] or Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you experience:
fevers, chills, nightsweats, shakes, difficult or painful
swallowing, shortness of breath or cough.
Resume all home medications.
Given is a script for albuterol which will help you if you have
wheezing or a tight airway with shortness of breath. If used and
your breathing does not improve call us.
Followup Instructions:
Followup with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] in two weeks. Please obtain
a chest xray 30 minutes before your visit. You should here from
our office in the next few days regarding your appointment time,
if not call [**Telephone/Fax (1) 2348**].
Completed by:[**2182-12-11**]
|
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"530.3",
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"054.8",
"524.61",
"366.9",
"568.0",
"519.19",
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icd9pcs
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[
[
[]
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| 0
| 93
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98,647
| 167,391
|
3758
|
Discharge summary
|
Report
|
Admission Date: [**2156-2-28**] Discharge Date: [**2156-3-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
femur fracture s/p fall
Major Surgical or Invasive Procedure:
[**2156-3-1**]: s/p open reduction internal fixation, left hip.
History of Present Illness:
[**Age over 90 **] y.o. Russian speaking M with HTN, CRI, dementia from [**Hospital 100**]
Rehab who was brought by ambulance to the ED s/p witnessed
mechanical fall (backed into chair and fell after getting up
without walker). Reportedly did not strike his head strike and
no LOC. Was noted to have left leg pain/deformity. Per report,
patient A & O x 0 at baseline. Was seen by staff physician and
given morphine. Initial ED VS 96.9, 112 irregular, 118/82, 18,
100/RA. Exam with left hip deformity, LLE shortening and
internal rotation, 1+ palpable distal pulses. Baseline Hct 35.8
([**2156-1-14**]). Given Morpine 2mg IV, Morphine 4mg x 1, NS 2L, Haldol
5mg, 1U PRBC. Foley placed. FAST negative per report but not
in ED documentation. Ortho consulted, consented patient for
surgery and placed pin, currently in traction. Given unclear
source of bleeding and hypotension on arrival, patient admitted
to MICU for closer monitoring. VS on transfer 97.3, 100,
136/86, 22, 100/2L. Upon admission to MICU, patient appears in
pain.
.
While in ED patient denied chest pain, pressure, fever,
chills/rigors, SOB, cough.
Past Medical History:
1. Hypertension.
2. Chronic renal insufficiency.
3. Benign prostate hypertrophy.
4. Dementia
5. Depression
6. Peptic ulcer disease
7. s/p hernia repair
Social History:
Lives in behavioral unit at [**Hospital 100**] Rehab. No tobacco, 'may have
up to one glass of wine per day'.
Family History:
non-contributory
Physical Exam:
On admission:
Vitals: 97.3, 100, 136/86, 22, 100/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs:
[**2156-2-28**] 12:00PM BLOOD WBC-12.8*# RBC-3.62* Hgb-11.4* Hct-34.9*
MCV-97 MCH-31.5 MCHC-32.6 RDW-12.8 Plt Ct-258
[**2156-2-28**] 12:00PM BLOOD Neuts-86.3* Lymphs-9.2* Monos-3.9 Eos-0.5
Baso-0.1
[**2156-2-28**] 02:32PM BLOOD PT-13.8* PTT-22.0 INR(PT)-1.2*
[**2156-2-28**] 03:00PM BLOOD ESR-16*
[**2156-2-28**] 12:00PM BLOOD Glucose-205* UreaN-40* Creat-1.9* Na-140
K-4.6 Cl-105 HCO3-23 AnGap-17
[**2156-2-28**] 12:00PM BLOOD ALT-25 AST-33 CK(CPK)-90 AlkPhos-105
TotBili-0.5
[**2156-2-28**] 12:00PM BLOOD cTropnT-0.07*
[**2156-2-28**] 12:00PM BLOOD Lipase-40
[**2156-3-8**] 05:10AM BLOOD WBC-9.4 RBC-3.28* Hgb-10.1* Hct-30.5*
MCV-93 MCH-30.8 MCHC-33.1 RDW-16.3* Plt Ct-208
[**2156-3-8**] 05:10AM BLOOD PT-14.0* PTT-27.9 INR(PT)-1.2*
[**2156-3-8**] 05:10AM BLOOD Glucose-141* UreaN-37* Creat-1.2 Na-135
K-4.0 Cl-105 HCO3-28 AnGap-6*
[**2156-3-2**] 04:23AM BLOOD CK-MB-9 cTropnT-0.08*
[**2156-2-28**] 12:00PM BLOOD ALT-25 AST-33 CK(CPK)-90 AlkPhos-105
TotBili-0.5
[**2156-3-8**] 05:10AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.2
.
Admission Imaging:
Hip X-ray IMPRESSION: Comminuted fracture proximal femur.
.
CT Pelvis / Pelvis W/O Contrast -- [**2156-2-28**]
** Preliminary **
Comminuted left intertrochanteric femoral fracture. No acute
intra-abdominal findings: no free air or fluid, no hematoma. No
bowel
obstruction, although rectum is distended with stool. 3mm
nonobstructing renal calculus (versus vascular calcification).
Fluid-filled gallbladder without wall thickening,
pericholecystic fluid or other evidence of cholecystitis.
.
CT C-Spine W/O Contrast -- [**2156-2-28**]
** Preliminary **
No fracture. Marked degenerative changes with reversal of
lordosis in the mid c-spine resulting in moderate canal
narrowing.
.
CT Head W/O Contrast -- [**2156-2-28**]
** Preliminary **
No ICH or acute abnormality
.
Chest X-ray [**2156-2-28**]
** Preliminary **
Low lung volumes, marked deviation of trachea to the right,
otherwise lungs are normally aerated. Prior CXR with tracheal
deviation.
.
EKG: 120 BPM, ?sinus tachy cardia but very poor baseline, slight
LAD, no clear ST/TW changes but poor study. Compared to
[**2155-1-4**], similar axis.
ABDOMEN, [**3-7**]
HISTORY: Colonic pseudo-obstruction. Please measure colonic
diameter.
IMPRESSION: Three views of the abdomen show no appreciable
change in the
diameter of the widest part of the colon, the ascending, 84 mm
yesterday and 88 mm today. There is no appreciable wall
thickening or intramural emphysema to suggest ischemia.
Generalized gaseous distention is moderate throughout the GI
tract except for the stomach which is decompressed by a
nasogastric tube.
KUB ([**2156-3-8**])
1. Interval improvement in patient's colonic dilatation, with
scattered
air-filled loops of small and large bowel without evidence of
significant
dilatation. Air-fluid levels are identified on the decubitus
view.
Brief Hospital Course:
[**Age over 90 **] yo M, Russian speaking only, with dementia, CKD, BPH
presented after witnessed mechanical fall at rehab and found to
have a comminuted left intertrochanteric femoral fracture
.
# Left femur fracture: Ortho was consulted in the ED and
consented patient for surgery and placed pin for traction. The
pt presented with Hct 34 (Baseline Hct 35.8 [**2156-1-14**]). He was
given Morpine 2mg IV, Morphine 4mg x 1, NS 2L, Haldol 5mg, and
1U PRBC. His post transfusion Hct dropped to 29 and he was
transfused a second unit without appropriate bump (Hct stayed at
29). Foley was placed. Given unclear source of bleeding and
hypotension on arrival, the patient was admitted to MICU for
closer monitoring. VS on transfer were 97.3, 100, 136/86, 22,
100/2L. Upon admission to MICU, the patient appeared in pain.
The patient's BP normalized after 2L. Hypotension was thought
secondary to morphine amdinistration in the ED. He was afebrile
with negative cardiac enzymes. It was unclear where his source
of bleeding was but the patient was guaiac negative. His thigh
had been firm and it was suspected that he may a hematoma there.
He remained hemodynamically stable and was thought appropriate
for transfer to medicine. He was transferred to the medicine
floor on [**2-29**] and taken for surgery on [**3-1**], where he underwent
ORIF of his left hip. He went to the SICU post-op to recover, as
he was transiently hypotensive during the procedure. His SICU
course included UTI and post op ileus (see below). On [**2156-3-4**]
he was called out to the medicine floor. He continued to have a
large amount of serous fluid drain from the traction wounds in
his knee. His Hct remained stable in the low 30s. Ortho
recommendations were to continue weight beairng as tolerated,
lovenox for DVT prophylaxis and tylenol for pain. He should
follow up in two weeks in ortho clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
NP.
# Abdominal distension/ileus: In the MICU the patient was found
to have a mildly distended abdomen that was soft and non tender,
with an unclear baseline. It was noted in the records that the
patient required agressive bowel regimen at rehab it was thought
that he had chronic constipation and was given an aggressive
bowel regimen. After the patient went to the OR he developed a
post op ileus confirmed by KUB and had an NGT placed to suction.
He had a rectal tube placed for decompression but this failed.
On PO D# 4 he was started on PPN for nutrition. GI was
consulted and they felt this was a pseudoobstruction. They
recommended continued NG suction, avoiding narcotics and
anticholinergics, and changing his position every hour. He
should have a daily KUB and if his colon diameter is between
10-12 cm, surgery should be consulted because this is a surgical
emergency. It was 8.8cm on [**2156-3-7**], and unchanged on [**2156-3-8**].
NGT was taken off suction and patient had low residuals. NG was
discontinued per general surgery recs on [**2156-3-9**]. Receiving TPN.
Patient will need speech and swallow evaluation on admission to
rehab.
# UTI: In the SICU the patient was found to have a proteus uti.
His foley was changed and he was started on ceftriaxone on [**3-3**]
and should complete a 14 day course.
# CKD: The patient presented with Cr of 1.9. He had an unclear
baseline. His most recent creatinine in OMR was 2.1 on [**8-16**].
The rest of his electrolytes were normal. Urine lytes were
consistent with pre-renal azotemia. Over the course of
hospitlaization the patient's creatinine improved to 1.2. It
was 0.9 on discharge.
# Dementia with behavioural disturbances: The patient lives in
the behavioural unit at [**Hospital 100**] Rehab. He is oriented x 1 a
baseline. Prior to the surgery the patient was functioning
below baseline per family members, taking [**Name2 (NI) 16910**] to recognize
them then normal. After the operation he remained verbally
unresponsive to family members and would not follow commands.
He was not given narcotics for worsening of his mental status.
The patient was continued on his home dose Quetiapine 150 mg
[**Hospital1 **].
# Depression / Anxiety: Unclear severity. The patient was
continued on his Citalopram 40 mg po daily.
# Elevated troponin: The patient was initially found to have an
elevated troponin compared to his baseline, however it did not
trend up and repeat EKG showed no changes so it was not thought
to be from ACS.
# BPH: The patient had a foley placed, His terazosin was
initially held in the ICU given concern for hypotension.
# Code Status: DNR/DNI (this was reversed temporarily for the
operation then DNR/DNI again)
Medications on Admission:
Morphine 4mg po Q4H PRN
Acetaminophen 650 mg Q4H PRN
Milk of Magnesia 30 mL po daily
Citalopram 40 mg po daily
Miralax 17gm po daily
Terazosin 2 mg po QPM
Quetiapine 150 mg po BID
Lorazepam 0.5 mg po BID PRN
Eucerin 1 application daily
Ferrous sulfate 325 mg po daily
Cyanocobalamin 1000 mcg daily
Sodium Fluoride 10 mL QHS Swish
Bisacodyl suppository 10 mg daily
Senna 2 tabs [**Hospital1 **]
Mirtazapine 15 mg QHS
Omeprazole 20 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Quetiapine 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily).
7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) 17
grams/dose powder PO DAILY (Daily).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical DAILY (Daily).
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nauesa.
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 4 days: Last
dose [**2156-3-12**].
18. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical DAILY (Daily).
19. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
20. regular insulin sliding scale
21. Radiology
supine abdomen daily. if colon is over 10cm contact surgery.
22. Pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous
once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Left hip fracture.
2. Ileus/Pseudopbstruction
3. urinary tract infection
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You came to the hospital after you fell and were found to have a
left hip fracture. You required several blood transfusions and
went to the operating room to have your hip fixed. You remained
in the surgical intensive care unit for 4 days after your
operation. You developed a post operative ileus ([**Last Name **] problem
with your gut working) and you were not able to eat food for
several days. We gave you IV fluids and nutrition through your
vein.
Please go to your follow up appointment with the orthopedic
doctors (see below). They have also provided the following
special instructions after your surgery:
Wound Care:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
Activity:
-Continue to be full weight bearing on your left leg.
-You should not lift anything greater than 5 pounds.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
2 weeks (the week of [**2156-3-15**]) in the [**Hospital **] clinic with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to make this
appointment.
Completed by:[**2156-3-9**]
|
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 838
| 0
| 0
| 0
| 0
| 0
| 0
| 1,132
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 506
| 0
| 141
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 155
| 112
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
93,610
| 164,181
|
5309
|
Discharge summary
|
Report
|
Admission Date: [**2181-1-5**] Discharge Date: [**2181-2-7**]
Service: MEDICINE
Allergies:
Nsaids / Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer from Neurosurg to MICU for Acute renal failure
Major Surgical or Invasive Procedure:
IVC Filter Placement
Central Line placement
Arterial Line placement
Hemodialysis
Intubation/Mechanical Ventilation
History of Present Illness:
85M with prior DVT, HTN and CKD was admitted to NEBH with
decreased appetite and LE swelling. Found to have extensive DVT
and acute on chronic RF. Was started on heparin gtt and
yesterday was noted to have a right facial droop and increased
dysarthria, R-sided weakness and somnolence. He developed what
appeared to be a R-sided seizure and then a grand-mal seizure in
the CT scanner at the OSH. He was intubated for airway
protection and transferred to [**Hospital1 18**] to the neurosurgery service.
He was noted to be hypotensive after intubation (without
sedation) prior to transfer and was started on neo. An aline was
placed also prior to transfer.
.
This morning, the neurosurgery attending asked that the MICU
take over his care given the complexity of his medical problems.
.
On eval, he was intubated and sedated. Does not follow commands.
Not on sedation although received 2 mg of IV ativan within the
past 2 hours for possible seizure.
.
Per his son who is at his bedside, he was doing well until about
2 months ago at which point they noticed a 15 pound weight loss
and hematuria. Bladder cancer was discovered and he had a
cystoscopic removal of tumor. 2 weeks ago, his son noted that he
was increasingly tired w/ decreased appetite and LE swelling. He
fell and hit his head about 1 week ago but his son noticed only
a small cut and so did not have him evaluated. Over the week
prior to admission, he became unable to walk and needed a
wheelchair to get around.
Past Medical History:
HTN
thoracic and abdominal aortic aneurysm
h/o transitional cell bladder cancer
CKD
h/o lumbar laminectomy
tertiary hyperparathyroidism
BPH
DVT in the past, s/p IVC filter placement
bilateral cataracts s/p removal
glaucoma
s/p L TKR
?[**Name (NI) **] unclear per records
PVD ? Fem/[**Doctor Last Name **] bipass
Social History:
Was living independently prior to 2 weeks ago.
Physical Exam:
Admission Exam:
General: Intubated and sedated, bites down on ETT
HEENT: Sclera anicteric, pinpoit pupils, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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: cool feet bilaterally w/ eschar on R great toe, LLE
swelling w/ +2 edema, not able to palpate pedal pulses;
doplerable LLE dp/pt and R dp.
Pertinent Results:
Admission Labs:
[**2181-1-5**] 06:58PM BLOOD WBC-17.1* RBC-2.73* Hgb-8.5* Hct-24.1*
MCV-88 MCH-31.0 MCHC-35.1* RDW-16.9* Plt Ct-175
[**2181-1-5**] 06:58PM BLOOD Neuts-88.8* Lymphs-6.7* Monos-4.3 Eos-0.1
Baso-0.1
[**2181-1-5**] 06:58PM BLOOD PT-13.7* PTT-27.6 INR(PT)-1.2*
[**2181-1-5**] 06:58PM BLOOD Glucose-162* UreaN-51* Creat-3.6* Na-141
K-4.2 Cl-107 HCO3-21* AnGap-17
[**2181-1-5**] 06:58PM BLOOD ALT-32 AST-45* CK(CPK)-778* AlkPhos-46
Amylase-44 TotBili-1.1
[**2181-1-5**] 06:58PM BLOOD CK-MB-5 cTropnT-0.12*
[**2181-1-6**] 03:38AM BLOOD CK-MB-6 cTropnT-0.14*
[**2181-1-6**] 01:23PM BLOOD CK-MB-7 cTropnT-0.15*
[**2181-1-5**] 06:58PM BLOOD Albumin-2.6* Calcium-7.5* Phos-4.7*
Mg-1.9
[**2181-1-5**] 06:58PM BLOOD Free T4-1.1
[**2181-1-5**] 06:58PM BLOOD TSH-1.5 [**2181-1-5**] 06:58PM BLOOD
Phenyto-14.7
[**2181-1-5**] 07:08PM BLOOD Type-ART pO2-306* pCO2-28* pH-7.48*
calTCO2-21 Base XS-0
[**2181-1-5**] 07:08PM BLOOD Lactate-1.8
.
Radiology Studies:
.
CT head on admission:
FINDINGS: A mixed but predominantly hyperdense collection
overlies the entire left cerebral hemisphere, measuring up to 19
mm in greatest transverse dimension, and extending along the
left tentorium. It is consistent with a predominantly acute
subdural hematoma. This exerts mass effect upon the left
hemisphere, predominantly in the frontal and temporal lobes,
with effacement of the underlying cerebral sulci and mild left
frontal edema. There is a mild rightward shift of the anterior
falx, septum pellucidum and third ventricle.
There is mild mass effect upon the left lateral ventricle. No
intraventricular hemorrhagic extension and no parenchymal
hemorrhage is
identified.
Prominence of the cerebral sulci is compatible with age-related
involutional change. Periventricular regions of hypodensity are
compatible with chronic microvascular ischemic change.
No fracture is identified. The paranasal sinuses and mastoid air
cells are
well aerated. The orbits are unremarkable. Endotracheal and
nasogastric
tubes are noted.
IMPRESSION: Large acute subdural hematoma along the convexity
and tentorium, with mass effect as described above.
.
CT Head on [**1-21**] for follow up:
FINDINGS: An evolving subdural hematoma along the left cerebral
convexity
again likely extends along the left tentorium cerebelli.
Minimal, 1 mm,
rightward midline shift is unchanged. Ventricular and sulcal
caliber is
unchanged and no new intracranial hemorrhage is identified.
Moderate-to-severe periventricular white matter hypodensity is
consistent with chronic small vessel ischemic changes.
Atherosclerotic calcifications involve the cavernous carotids
and intracranial vertebral arteries bilaterally. The imaged
portions of the paranasal sinuses appear well aerated.
IMPRESSION: Evolving left cerebral convexity subdural hematoma
with unchanged minimal mass effect, stable compared to the CT
from [**1-18**].
.
MRI Head:
FINDINGS: Areas of slow flow and restricted diffusion are seen
in the right posterior parietal periatrial region with high
signal on diffusion images and low signal on ADC map indicative
of acute infarcts. Small acute infarcts are also seen in right
parietal and left frontal lobes.
There is subacute subdural hematoma identified extending from
frontal to
occipital region on the left with a maximum width of
approximately 1.5 cm to 2 cm at the convexity with indentation
on the sulci. Increased signal along the sulci may indicate
small amount of subarachnoid hemorrhage or stasis of the CSF
secondary to subdural. Small amount of subdural collection is
also seen along the left side of the tentorium. There is no
midline shift seen. Moderate to severe brain atrophy and
moderate changes of small vessel disease are identified. There
is no midline shift. Sagittal T2 images were obtained to
evaluate the brainstem, but are limited by motion. Changes of
cervical spondylosis are visualized, which are further evaluated
with cervical spine
MRI. Bilateral basal ganglia lacunes are seen.
IMPRESSION:
1. Small areas of restricted diffusion in the left frontal lobe,
right
parietal lobe, and left periatrial region suggestive of embolic
infarcts.
2. Left-sided subdural hematoma extending from frontal to
occipital region
with obliteration of adjacent sulci. No midline shift. Brain
atrophy and
small vessel disease.
.
MRI C-Spine
IMPRESSION:
1. Limited study due to motion. Multilevel degenerative change
is seen.
2. Moderate spinal stenosis at C4-5 and mild-to-moderate spinal
stenosis at C5-6 and C6-7 with extrinsic indentation on the
spinal cord.
3. Postoperative changes with posterior bony bar at C3-4
slightly indenting the spinal cord. Atrophic changes in the
spinal cord at C3-4 level.
.
ECHOs:
[**1-8**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
basal inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 50 %). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction c/w CAD (PDA distribution).
Dilated ascending and descending thoracic aorta. Mild pulmonary
artery systolic hypertension.
.
[**2-5**]:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the
inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 50 %). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2181-1-23**], a
prominent left pleural effusion is now identified and the
estimated pulmonary artery systolic pressure is lower. Left
ventricular wall motion is similar.
.
Lower Extremity Cath:
COMMENTS:
1. Access via LFA via 4F catheter.
2. Imaging of the distal aorta with a Omniflush catheter at L1
revealed
mild aortic disease with no renal artery stenosis. The iliacs
were very
tortuous on both sides but without flow limiting lesions. The
CFA's
were without lesions.
3. Imaging of the right leg with a Slip cath in the right SFA
revealed
a mid SFA 10cm occlusion. There was a high grade popliteal
lesion and
single vessel run off to the foot via a peroneal. There was
only very
faint filling of plantars and DP.
4. Referral to vascular surgery for right leg BKA.
FINAL DIAGNOSIS:
1. Right SFA occlusion with severe infra-popliteal disease.
.
Renal US:
IMPRESSION: Probably no hydronephrosis.
.
CT abdomen and Pelvis Follow up:
FINDINGS
100 cc of contrast was administered through G-tube. There is no
contrast
extravasation. Extensive pneumoperitoneum is again noted.
However, this is
unchanged from the prior examination from the previous day.
There is bilateral pleural effusion, small in quantity, not
significantly
changed from the prior study. The unenhanced liver and spleen
appear
unremarkable. There is bilateral hydronephrosis and mild
hydroureter. This
is likely on the basis of the significant wall thickening seen
in the urinary bladder.
Aneurysmal abdominal aorta at the diaphragmatic crura is
unchanged from prior study, with atherosclerotic changes.
The gallbladder appears dilated, though unchanged from the prior
study.
Again noted is prominence of the left psoas muscle, with an area
of
hypodensity, which may represent fluid collection, however,
infection cannot be excluded.
There is no evidence of bowel dilatation.
IVC filter is again noted. There are degenerative endplate
changes in the
thoracolumbar spine.
IMPRESSION:
1. No evidence for G-tube extravasation.
2. No interval change in enlargement of the left psoas muscle
with hypodense collection in the left flank. While this may
represent old hematoma, a loculated infected collection cannot
be excluded and intravenous contrast would be necessary for
additional evaluation.
3. Again noted mild bilateral hydronephrosis, which is likely
secondary to
significant bladder wall thickening.
4. Unchanged pneumoperitoneum.
.
CT chest:
IMPRESSION: Dilated ascending aorta and thoracoabdominal
junction. Bilateral psoas hematoma, much larger on the left,
extending in the retroperitoneum.
.
Labs on Discharge:
CHMS ADDED 2253 [**2181-1-5**]
141 / 107 / 51 162 AGap=17
----------------
4.2 / 21 / 3.6
WBC 9.4, Hct 28.5, Plt 249
all have been stable over the last several days
estGFR: 16/20 (click for details)
CK: 778 MB: 5 Trop-T: 0.12
Comments: cTropnT: Called [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 21654**],303am,[**2181-1-6**]
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 7.5 Mg: 1.9 P: 4.7
ALT: 32 AP: 46 Tbili: 1.1 Alb: 2.6
AST: 45 LDH: Dbili: TProt:
[**Doctor First Name **]: 44 Lip: 13
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Comments: Positive Tricyclic Results Represent Potentially Toxic
Levels;Therapeutic Tricyclic Levels Will Typically Have Negative
Results
TSH:1.5 Free-T4:1.1
Phenytoin: 14.7
PT: 13.7 PTT: 27.6 INR: 1.2
Fibrinogen: 351
.
Of note in microbiology,
pt only grew [**Female First Name (un) **] albicans in urine, otherwise all cultures
were negative without any obvious organism.
Brief Hospital Course:
85 year old gentleman with CRI, HTN, Bladder CA and known R [**Hospital **]
transferred from NEBH with Subdural Hematoma, Seizures, and new
acute on chronic renal failure requiring dialysis. He was
transfered to our Neurosurgical service then MICU for evaluation
of altered mental status and sepsis.
# Altered mental status: AMS began with the development of a
SDH after treatment of extensive LLE DVT with a heparin gtt.
The patient was transfered to the MICU on [**1-8**].
Neurosurgery was the initial primary team (then consulting) and
based on family discussions and repeat head imaging no
intervention was performed. His neurologic status did improve
over time, but persistent deficits lead to subsequent neurologic
consultation. The following problems were addressed by the
neurology team:
for his ENCEPHALOPATHY: toxic-metabolic work up identified the
following possible etiologies: yeast UTI, PNA, R LE necrosis, L
DVT, ESRD on HD. His sedating medications were limited. A
repeat routine EEG demonstrated no evidence of subclinical sz
activity. MRI of the brain, however, demonstrated small areas
of restricted diffusion in the left frontal love, right parietal
love, and left periatal region suggestive of embolic infarcts;
improving SDH.
for his STROKES: MRI of the brain demonstrated actute embolic
infarcts. A subsequent TTE on [**1-23**] demonstrated regional left
ventricular systolic dysfunction consistent with coronary artery
disease. A left atrial/ [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] thrombus cannot be excluded
by TTE. If clinically indicated, a TEE would better assess for
this possibility. No significant change from prior. Carotid
ultrasound noted: Less than 40% stenosis in the right and left
internal carotid arteries. MRA was held due to concern for
acute on chronic renal disease. The patient was placed on ASA
to treat the embolic strokes after consultation with
neurosurgery.
for his QUADRAPARESIS: MRI of the C-spine: Multilevel
degenerative change is seen, with Moderate spinal stenosis at
C4-5 and mild-to-moderate spinal stenosis at C5-6 and C6-7 with
extrinsic indentation on the spinal cord, and postoperative
changes with posterior bony bar at C3-4 slightly indenting the
spinal cord. Atrophic changes in the spinal cord at C3-4 level.
The patient was transferred to the MICU minimally responsive to
stimuli on intermittent ativan. He was intubated for airway
protection and maintained on pressure support with minimal
requirements. His altered mental status was attributed to a
combination of new subdural hematoma, which remained stable
throughout admission, and resulting seizure activity. On
transfer he is responsive to questions with the appropriateness
of his garbled answers uncertain.
As treatment for the seizures, he was started on keppra and
should be continued on this until neurology follow up is
arranged. The dose is keppra 500 mg [**Hospital1 **].
#. Subdural hematoma: After discovery of an extensive DVT of
the LLE at an OSH, the patient was started on a heparin gtt. He
subsequently developed right facial droop and increased
dysarthria, R-sided weakness and somnolence. He developed what
appeared to be a R-sided seizure and then a grand-mal seizure in
the CT scanner at the OSH. He was intubated for airway
protection and transferred to [**Hospital1 18**] to the neurosurgery service.
He was noted to be hypotensive after intubation (without
sedation) prior to transfer and was started on neo. Heparin was
stopped due to head bleed and IVC Filter placed. The patient
developed a subdural hematoma at the outside hospital presumed
secondary to heparin therapy for a DVT. Neurosurgery was the
initial primary team (then consulting) and based on family
discussions and repeat head imaging no intervention was
performed. The hematomas were stable on transfer. See below
for seizure treatment related to hematoma.
.
# Seizures: The patient developed right sided seizures likely
due to his subdural hematoma as confirmed by EEG and neuro
consult. The patient was started on ativan, dilantin, and keppra
for seizure control. He will be tapered off of dilantin,
transitioned to Keppra and the ativan held.
.
# Acute on Chronic renal failure: Acute on chronic kidney
failure likely due to contrast induced nephropathy, despite
pretreatment with IVF and bicarb. The patient was admitted with
temporary HD line in place after 3 days of HD. He was seen by
our renal service and dialyzed once through the temporary line
with no further indication for dialysis at the time of transfer.
The patient developed a fever of unknown origin, and the
temperary HD line was pulled due to concern that it would be
seeded by infection. He subsequently developed fluid overload,
resistent to medical therapy. Nephrology then saw him and
placed a permanent HD line, and received regular HD. He
develops moderated hypotension during HD but was otherwise
asymptomatic. The plan is to continue Monday and Thursday
dialysis indefinitely for now. The renal team will directly
contact the receiving rehab facility about dialysis information.
.
# Pneumonia: Gram [**Last Name (un) **] suggestive of infection treated with 7
days of Vanc/Zosyn followed by Unasyn with a resolution of white
count and no fevers early in the admission. He did have another
infection of unclear source which resulted in sepsis and a
second transfer to the MICU. See below for details of that
infection.
.
# Right toe eschar-unable to palpate, + Doppler pulses and
concern is for arterial insufficiency. Vascular
consulted-follow recs suggested nitropaste only, no intervention
given bleed and contraindication for heparin. Due to
intermittant hypotension, the nitropaste was discontinued. He
went for catheterization, which demonstrated severe, diffuse
disease, not amenable to stenting. Due to prior SDH, patient
was not a candidate for anticoagulation. Prelim report on US
showed SFA occlusion with reconstitution distal to popliteal.
.
#. DVT: The patient was found to have extensive DVT and acute on
chronic RF. Was started on heparin gtt and subsequently
developed a SDH. The heparin was stopped and an IVC filter was
placed in [**Doctor Last Name 2434**]. He does not have signs of PE with good
oxygenation on room air.
.
# Hematuria: insetting of change of [**Last Name (un) 21655**] and [**Last Name (un) 21655**] care. The
patient also has a history of bladder cancer; urology saw
patient earlier in admission. Several U/As were positive for
yeast infection. The patient had a prolonged course of oral
fluconazole and topical miconazole. The yeast infection cleared
on subsequent U/A. But per urology recs, he is to complete a 14
day course of fluconazole. The end date of fluconazole is 11
days from day of discharge on [**2-17**]. He should not have his foley
changed once at rehab as it was placed with cystoscopy and is a
difficult change. He should follow up with urology in 2 weeks
after his fluconazole is completed for reevaluation of need for
foley. In setting of ARF, he does still make small amounts of
urine.
.
# Inability to swollow: Possibly multifactorial with left sided
SDH and acute embolic areas of infarction, in addition to severe
cervical spinal stenosis. Speach and swallow evaluation
occurred on more than one occasion, and he was unable to protect
his airway, and did not have a gag reflex. After a significant
amount of time with an NG tube, and multiple conversations with
the Son, her received a G-tube. He is receiving tube feeds and
reached his goal rate.
.
# Hypotension developed within two days of G-tube placement and
in the setting of penile instrumentation. Etiology could be from
a number of cuases including bleeding in the setting of his
recent G-tube placement, hypovolemia, perhaps increased vagal
tone from bladder distention, sepsis from gangrenous foot, and
ACS. A CT of his abdomen demonstrated a fluid collection that
was not consistent with blood by [**Doctor Last Name **], but could not differentiate
between sterile fluid collection or an abscess without contrast.
The patient received fluid boluses, narcan to reverse the
potential effects of the 1mg of i.v. morphine the patient
received. In addition, the patient had blood and urine
cultures. The urine culture wa positive for bacteria and >50
WBCs, > 50 RBCs. The patient remained persistently hypotensive
despite IVF and was transferred to the MICU for concern for
urosepsis. See below for MICU course.
.
# Anemia: Hct 25.5 in setting of hemodilution and hematuria-no
further hematuria overnight after foley replaced by urology.
Iron studies were obtained and were consistent with anemia of
chronic disease. The HCT remained stable.
.
# Thrombocytopenia: Resolved.
_____________________________________________
MICU admission [**Date range (1) 21656**]: Patient was transferred to MICU on
[**2-3**] for hypotension in the setting of concern for sepsis with a
possible complication of the G-tube placement. Imaging did not
show problems with the G tube placement and patient became
afebrile and resolved leukocytosis on vanc/zosyn/fluconazole.
Surgery followed and determined that the G tube was safe to use.
Pressures were MAP>60 and SBP in 90s, higher than pressures on
admission. Pressure throughout the course of hospitalization
have not been greater than SBP 110.
.
# Sepsis - his hypotension that resulted in transfer to the MICU
was likely urosepsis, although no organism was ever grown in
culture. Other sources could have been the intraabdominal fluid
collection, although surgery consulted and did not think it was
an infection. He responded to a course of vanco and zosyn and
should complete a two week course of the antibiotics. The end
date is [**2-12**]. He had a midline placed for abx
administration. He recovered quickly without any need for
pressure support. He was not dialyzed during this time because
of his hypotension, but has been dialyzed the last two days
prior to discharge and was run even. He maintained his BPs
during this time.
.
# Pneumoperitoneum on CT scan - during imaging while working up
his hypotension, CT revealed pneumoperitoneum around the G tube
placement. He had a benign abdomen exam and it was not thought
to be cause of his hypotension. His tube feeds were initially
held, but with surgery following along were restarted several
days prior to discharge. He quickly reached goal and did not
have high residuals.
.
# SVT - The day prior to discharge, the patient developed [**4-18**]
transient episodes of SVT with rates of 140. The episodes last
approximately 1-20 minutes and were asymptomatic to the patient.
He maintained a normal blood pressure during these episodes.
Most of the episodes broke with vagal manuevers or with a
spontaneous PVC. We started diltiazem for rate control at a
very low dose as to not drop his blood pressures. He tolerated
the diltiazem well and should be continued on it.
.
IN SUMMARY:
85 y/o M who presented after anticoagulated DVT resulted in SDH.
Also found to have old strokes, now with resultant
quadraparesis. Had seizures that were treated with keppra.
Also initially had a pneumonia, s/p treatment. While receiving
imaging during workup of these above issues developed acute on
chronic renal failure and started on HD, now due for Monday and
Thursday dialysis. Had workup of ischemic feet, showed diseased
vasculature, but no intervention done. No infection of necrotic
toes. Was recovering well but after G tube placement had
hypotension likely from sepsis of unclear etiology, although
urine most likely source. Has known yeast infection in bladder;
urology following and has permanent foley cath in. Is being
treated with vanco and zosyn and fluconazole for sepsis. Had
SVTs treated with diltiazem.
.
So, once at rehab, he should continue his antibiotic course of
vanco, zosyn and fluconazole. He can start PT/OT. He should
follow up with neuro, urology and his PCP.
Medications on Admission:
oxycodone
Calcitrol
Prilosec
Mentax
avocat
Flomax
Timoptic
Travatan
Dyazide
vitamin D
Vitamin B12
.
On transfer:
Lorazepam 2 mg IV ONCE Duration: 1 Doses Order date: [**1-5**] @
[**2115**]
IV access: Temporary central access (ICU) Location: Left
Subclavian, Date inserted: [**2181-1-5**] Order date: [**1-5**] @ 2124
Lorazepam 1-5 mg IV Q4H seizure activity hold if oversedated
Order date: [**1-6**] @ 0820
1000 mL NS Continuous at 80 ml/hr Order date: [**1-5**] @ [**2183**]
Magnesium Sulfate 2 gm IV ONCE Duration: 1 Doses Order date:
[**1-6**] @ 0428
1000 mL NS Bolus 1000 ml Over 60 mins Order date: [**1-5**] @ 2250
Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO SBP >
100mmHg Order date: [**1-5**] @ [**2183**]
500 mL NS Bolus 500 ml Over 30 mins Order date: [**1-5**] @ 2149
Pantoprazole 40 mg IV Q24H Order date: [**1-5**] @ [**2183**]
500 mL NS Bolus 500 ml Over 30 mins Order date: [**1-5**] @ 2149
Phenytoin 100 mg IV Q8H Hold am dose until trough level back.
Order date: [**1-5**] @ 2250
Acetaminophen 650 mg PR Q4H:PRN fever or pain Order date: [**1-5**]
@ [**2183**]
Piperacillin-Tazobactam Na 2.25 g IV ONCE Duration: 1 Doses
*Awaiting ID Approval* ID Approval is required for this order.
Order date: [**1-6**] @ 0058
8. Calcium Gluconate 2 gm / 100 ml D5W IV ONCE Duration: 1 Doses
Order date: [**1-6**] @ 0428
Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**1-5**] @
[**2176**]
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **] Use only
if patient is on mechanical ventilation. Order date: [**1-5**] @
[**2114**]
Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral
line: Flush with 3 mL Normal Saline every 8 hours and PRN. Order
date: [**1-5**] @ [**2183**]
Influenza Virus Vaccine 0.5 mL IM ASDIR Follow Influenza
Protocol Document administration in POE Order date: [**1-5**] @ [**2175**]
Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary
Central Access-ICU: Flush with 10mL Normal Saline daily and PRN.
Order date: [**1-5**] @ 2124
Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:
[**1-5**] @ [**2183**] 22. Vancomycin 1000 mg IV ONCE Duration: 1 Doses
Order date: [**1-6**] @ 0058
Discharge Medications:
1. Latanoprost 0.005 % Drops [**Month/Year (2) **]: One (1) Drop Ophthalmic HS (at
bedtime).
2. Timolol Maleate 0.5 % Drops [**Month/Year (2) **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical QD (): Apply to mid
back.
4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Hospital1 **]: One
(1) PO TID (3 times a day).
6. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for cough.
10. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Five Hundred (500) MG
PO BID (2 times a day).
14. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q48H (every
48 hours) for 11 days: Monitor for interaction with statin.
Watch for ck elevation or rhabdo. .
15. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
gram Intravenous HD PROTOCOL (HD Protochol): through [**2-12**]. .
16. Piperacillin-Tazobactam 2.25 gram Recon Soln [**Month (only) **]: One (1)
Intravenous twice a day: through [**2-12**].
17. Insulin Lispro 100 unit/mL Solution [**Month (only) **]: Per sliding scale
Subcutaneous ASDIR (AS DIRECTED): Please see sliding scale.
18. Epoetin Alfa 10,000 unit/mL Solution [**Month (only) **]: At hemodialysis
Injection ASDIR (AS DIRECTED).
19. Verapamil 40 mg Tablet [**Month (only) **]: One (1) Tablet PO Q12H (every 12
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
-Deep venous thrombosis
-Subdural Hemorrhage
-Seizure disorder
-End Stage Renal Disease on Hemodialysis
-SVT treated with vagal maneuvers
Discharge Condition:
Vital signs were stable, SBP occassionally drops to 80s but pt
is without change in mental status. Patient with G-tube in
place. Patient is communicative with non-verbal signs.
Afebrile. Completing course of antibiotics.
Discharge Instructions:
You were admitted initially at [**Hospital1 **]-[**Location (un) 620**] with decreased
appetite and leg swelling. You were found to have extensive DVT
and acute on chronic renal failure. You were later noted to have
right-sided weakness and somnolence, developed what appeared to
be a right-sided seizure and then a grand-mal seizure. You were
intubated for airway protection and transferred to [**Hospital1 18**].
Here we treated you for your seizures. We found that they were
likley caused by a large subdural hematoma in your brain. You
also developed renal failure and needed to start hemodialysis.
He placed a Gtube in your stomach to feed you. We also needed
to treat you for a severe infection that caused your blood
pressure to get low. You were on antibiotics and improved. You
will now continue to recover at rehabilitation, complete your
course of antibiotics, and work on your strength.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please call [**Telephone/Fax (1) 164**] to make an appointment with Dr. [**Last Name (STitle) 770**]
- Urologist for follow-up 2 weeks after discharge.
Please call [**Telephone/Fax (1) 21657**] to make and appointment with Dr. [**Last Name (STitle) **]
(Neurology) for follow-up for 4-6 weeks after discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2181-2-7**]
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41965
|
Discharge summary
|
Report
|
Admission Date: [**2192-11-20**] Discharge Date: [**2192-12-27**]
Date of Birth: [**2130-8-8**] Sex: F
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
OPERATIONS PERFORMED [**2192-11-23**]:
1. Ultrasound-guided puncture of left brachial artery.
2. Catheterization of aorta.
3. Abdominal aortogram with mesenteric angiography.
4. Selective catheterization of superior mesenteric artery.
5. Balloon angioplasty and stent of proximal superior
mesenteric artery.
6. Brachial artery cutdown with primary repair
[**2192-11-23**]: Exploratory Laparoscopy
[**2192-12-5**]: EGD
[**2192-12-6**]: Colonoscopy
[**2192-12-15**]: EGD
[**2192-12-20**]: EGD and Sigmoidoscopy
History of Present Illness:
62 year old female with history of severe bilateral PVD, s/p
bilateral lower extremity angio with occluded fem-PT bypasses
bilaterally, now presenting
to the ED w/abdominal pain of 5 days duration. We are consulted
for an evaluation of mesenteric ischemia. Patient reports sudden
onset of severe abdominal 5 days ago. The pain has remained high
in intensity and constant. Patient has been unable to tolerate
food. She had no episodes of frank emesis, but reports retching
and some "yellow secretion". The pain is located in the
mid-abdomen radiates to substernal region and to flanks and
lower back. Patient denies fevers, but reports chills over the
past few days. She denies diarrhea. Her stools are formed and
regular. She denies any hematochezia or melena. She denies ever
having this type of abdominal pain in the past. She stopped
taking majority of her medications a few days ago as she was
concerned it may contribute to her pain.
Past Medical History:
PAD, Hypertension, Hyperlipideia, Thalasemia, Gout
PSH:
Left Lower Extremity Bypass [**2180**](appears to be fem-PT), revision
in [**2187**]; Right Lower Extremity Bypass [**2185**] (appears to be
fem-AT); BLE angio - [**2192-10-17**]; cholecystectomy; hysterectomy
Social History:
Currently smokes [**11-26**] ppd, former 1 ppd for last 50 years,
denies EtOH or illicit drugs
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
VS: 97.7 100 131/78 18 100% RA
CV: RRR, no murmur
pulm: CTA b/l
abd: obese, + BS, tender especially in the RLQ, also reports
subjective pain in the mid abdomen, but not fully evident on
exam
guaiac positive
extremities: minimal lower extremity edema
Pulses:
Fem [**Doctor Last Name **] AT DP PT
R palp dop dop faint dop dop
L palp dop dop NS dop
Discharge Exam:
(per progress note)
VS: 100.1 98 88 151/76 20 99% ra
Gen: Obese female, alert and oriented x 3,
Card: RRR
Lungs: CTA bilat
Abd: obese, soft, no m/t/o
Extremities: warm, mild lower extremity edema
Pulses: Rad Fem DP PT
right p p d d
left p p d d
Pertinent Results:
Admission:
[**2192-11-20**] 12:35PM BLOOD WBC-8.4 RBC-2.41* Hgb-9.7* Hct-29.4*
MCV-122* MCH-40.2* MCHC-33.0 RDW-16.9* Plt Ct-347
[**2192-11-20**] 12:35PM BLOOD PT-31.5* PTT-43.7* INR(PT)-3.1*
[**2192-11-20**] 12:35PM BLOOD Glucose-143* UreaN-38* Creat-1.9* Na-141
K-3.6 Cl-103 HCO3-26 AnGap-16
[**2192-11-20**] 12:35PM BLOOD ALT-13 AST-12 AlkPhos-65 TotBili-0.2
[**2192-11-21**] 04:23AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.9
Discharge:
[**2192-12-27**] 06:46AM BLOOD WBC-7.3 RBC-3.25* Hgb-10.2* Hct-30.0*
MCV-92 MCH-31.4 MCHC-34.0 RDW-19.9* Plt Ct-304
[**2192-12-27**] 06:46AM BLOOD PT-33.5* PTT-45.6* INR(PT)-3.3*
[**2192-12-27**] 06:46AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9
Other pertinent labs:
[**2192-11-23**] 4:59 pm MRSA SCREEN SOURCE:NASAL SWAB.
**FINAL REPORT [**2192-11-26**]**
MRSA SCREEN (Final [**2192-11-26**]): No MRSA isolated.
[**2192-12-6**] 5:25 am SEROLOGY/BLOOD CHEM # 60812J [**12-6**] 5:25AM.
**FINAL REPORT [**2192-12-7**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2192-12-7**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
[**2192-12-9**] 11:15 am URINE Source: CVS.
**FINAL REPORT [**2192-12-10**]**
URINE CULTURE (Final [**2192-12-10**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2192-12-20**] EGD: A single superficial non-bleeding 5 mm ulcer was
found in the duodenal bulb. This ulcer had a clean base and was
not bleeding. There were two adherent clots adjacent to the
ulcer, one proximal and one distal. The distal clot was removed
with aggressive washing and suctioning, and no underlying lesion
could be identified. The proximal clot remained adherent despite
aggressive washing. One endoclip was successfully applied to the
proximal adherent clot for the purpose of hemostasis.
[**2192-12-20**] Flexible Sigmoidoscopy: The previously seen single
pedunculated 2 cm polyp was found in the distal sigmoid colon at
20cm. The polyp was not bleeding.
Poor bowel prep
[**2192-12-16**] 08:43AM HEPARIN DEPENDENT ANTIBODIES POSITIVE
-
[**2192-11-23**] 09:42PM HEPARIN DEPENDENT ANTIBODIES Negative
Brief Hospital Course:
Ms. [**Known lastname 6515**] was admitted with abdominal pain and non occlusive
SMA thrombus. She was put on a heparin gtt, plavix and aspirin
325mg. SHe was transfused for a low hct. Her pain resolved and
she was started on sips with close monitoring. On [**11-24**] her
pain increased and she had a stat CTA which showed an unchanged
appearance of SMA thrombus and no direct or indirect evidence of
mesenteric ischemia. She was then pre-op'd and consented and
taken to the angio suite where she had:
1. Ultrasound-guided puncture of left brachial artery.
2. Catheterization of aorta.
3. Abdominal aortogram with mesenteric angiography.
4. Selective catheterization of superior mesenteric artery.
5. Balloon angioplasty and stent of proximal superior
mesenteric artery.
At completion of the procedure, upon removal of the wire, it
was noted there was extensive clot seen on the wire. The
patient had been receiving full heparin drip and was fully
anticoagulated as well as having a therapeutic INR on Coumadin,
as well as being on full-dose aspirin and Plavix prior to the
presentation in the operating room. This led to our decision to
not rebolus her with more heparin. However, due to the nature
of the clot that was seen on the wire upon exchange to the
5-French short sheath, and then upon attempt to flush the short
sheath we were not able to draw back, there was significant
concern for a clot in the brachial
artery. We therefore did a: Brachial artery cutdown with
thrombectomy and primary repair. ACS then did an exploratory
laparoscopy and found no evidence of bowel ischemia. Their ports
were closed and the patient was monitored closely. She had
respiratory distress and was re-intubated and taken to the
CVICU. Given her hypercoaguable state, heme was involved and she
was started on an argatroban gtt. She was extubated on [**11-25**] and
did well. She was transfused again for a falling hct. She
remained hemodynamicaly stable and was transfered to the VICU
and [**Month/Day (4) 8337**] a clear diet on [**11-25**]. She continued to make steady
progress , tolerating a regular diet, ambulating and voiding
when her foley was removed. Her coumadin was restarted with an
INR goal of 3.0-3.5 . She continued to make progress but on [**12-2**]
reported seeing blood on her toilet paper, after a bowel
movement and was found to be guiac positive. Her h/h had fallen
and she was transfused for a hct of 25 on [**12-3**]. She responded
appropriately but on [**12-4**] her hct was down to 25.1. She
received 1 unit prbc without much of a response and got another
1 unit. By this point she was having melena and her hct
continued to fall. GI was consulted on [**12-4**]. She was prepped
appropriately and had an EGD on [**12-5**] which showed erosive
gastritis in the stomach body and antrum. Then on [**12-6**] she had
colonoscopy which showed a 20 mm polyp which was treated with an
endoloop. Her h/h was stable for several days, and her INR was
therapeutic and discharge planning was initiated. On [**12-11**], her
hct was drifting down. She was transfused appropriately but
didn't respond appropriately. She was still having melena. GI
was monitoring the patient. Her surgical issues were stable and
the decision was made to transfer the patient to the medicine
team for further monitoring and treatment.
On [**12-14**], we were called to the bedside by night merit team for
persistent hypotension to the 70s. Reviewing vitals flowsheets
places her BP in the 100 systolic range, though she repeatedly
dropped into the upper 80s throughout the day. As of 2300, her
BP slipped into the 70s, though she continued to mentate
normally without lightheadedness, chest pain or pressure. She
has been having daily melenotic stools for the past few days.
Her bp meds were stopped and she received a liter of NS and her
fourth pRBC transfusion of the day with improvement of her SBP
to 100-105. After consulting with GI, decision made to transfer
to MICU6 for endoscopy in the AM. She has undergone 18 red cell
transfusions this admission. Her current INR was 4.3. In the
MICU, the patient continued to have melena, but otherwise
hemodynamically stable. An EGD was performed that showed
friability and erythema of the esophagus, stomach and duodenum.
Cautery was used to stop bleeding from the duodenal bulb. After
EGD, the patient cotninued to have melena. She was maintained on
her coumadin, plavix, aspirin, and heparin. The patient was then
transfered to the VICU for further management.
Ms. [**Known lastname 6515**] remained hemodynamically stable following transfer to
the VICU. Her hematocrit was routinely monitored and she was
transfused as needed for Hcts in the low - mid 20s. Given the
persistence of her melena, however, she underwent flexible
sigmoidoscopy and EGD on [**2192-12-20**], the results of which were
notable only for a nonbleeding polyp in the sigmoid colon
(previously seen on prior [**Last Name (un) **]) as well as some friability of
the duodenum which was clipped and injected with epinephrine.
Following this procedure, Ms. [**Known lastname 6515**] [**Last Name (Titles) 8337**] her diet well.
She was transfered to the [**Last Name (Titles) 1106**] floor where she was monitored
for another week. She remained on an argatroban gtt until her
true INR was >3.0 . On [**2192-12-27**] she was stable from a medical and
surgical standpoint. Her true INR wasd 3.3 and she was not
having any melena or other GI symptoms.
At the time of discharge, Ms. [**Known lastname 6515**] was hemodynamically stable,
mentating and ambulating at baseline, and with a stable
hematocrit. Her INR is therapeutic and she is scheduled for very
close monitoring of her h/h and INR with her PCP. [**Name10 (NameIs) **] will also
have her BP monitored, and discuss restarting meds with her PCP.
[**Name10 (NameIs) **] will be followed by her PCP, [**Name10 (NameIs) 1106**] surgery, hematology
and GI. She has been instructed regarding her post-discharge
plans and verbally expressed understanding and agreement with
these plans.
Medications on Admission:
Hydroxyurea 1000mg daily
Valsartan/HCTZ 320/25 daily
Crestor 10mg daily
KCL 10mEq daily
Metoprolol ER 50mg po daily
Folic Acid 1mg po daily
Neurontin 600mg po TID
[**Name10 (NameIs) **] 81mg po daily
Pletal 100mg po BID
Coumadin 5mg po Daily
Discharge Medications:
1. hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
6. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
call PCP for refills.
Disp:*30 Tablet(s)* Refills:*0*
7. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for pain.
13. BLOOD PRESSURE MONITORING
We stopped all of your BP meds (valsartan/hctz and toprol xl).
Please have your blood pressure checked several times per week.
Follow up with PCP regarding restarting your blood pressure meds
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Abdominal pain/ Mesenteric ischemia
-Left Brachial artery emboli
-GI bleed/ Erosive gastritis
-Heparin Induced Thrombocytopenia
Secondary:
Bilateral Lower extremity ischemia with pain
HTN
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of [**Name10 (NameIs) **] and Endovascular Surgery
Endovascular Discharge Instructions
You were admitted with abdominal pain and had a complicated
hospital course. You had mesenteric ischemia and had a stent
placed in your superior mesenteric artery through a brachial
(arm) sheath. After the procedure you were found to have a blood
clot in your brachial artery, and had to have that surgically
removed. You then had an exploratory laparoscopy to evaluate for
dead bowel. You had no evidence of this. You remained in the
hospital and were carefully anticoagulated. You had concern for
GI bleeding and had an endoscopy and colonoscopy by the GI team.
The egd (upper scope) showed erosive esophagitis which was
thought to be the cause of bleeding. The colonoscopy showed a
polyp in the sigmoid colon which was removed, and diverticulosis
in the sigmoid colon. You were started on several new
medications including carafate and omeprazole.
Your INR will continue to be followed by the Atrius anti-coag
team. You will follow up with Gastroenterology, [**Name10 (NameIs) **] surgery
and hematology.
Medications:
?????? Take Aspirin 325mg daily
?????? Take Plavix 75mg once daily.
Take Coumadin daily as directed - your INR goal is now
3.0 - 3.5
Do not stop Aspirin/Plavix/or Coumadin unless your [**Name10 (NameIs) **]
Surgeon instructs you to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**12-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-1**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
HEMATOLOGY:
[**2193-1-18**] 1030am
[**Telephone/Fax (1) 91089**]
[**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD
[**First Name8 (NamePattern2) **] [**Last Name (Titles) **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
PCP/INR FOLLOW UP:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Fax: [**Telephone/Fax (1) 6808**]
She will follow your INR and your CBC 2 x week for your GI
bleed. Please go to get your labs drawn tomorrow, [**2192-12-28**].
Your goal INR is 3-3.5
[**Month/Day/Year **] SURGERY:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2193-1-22**]
8:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2193-1-22**] 9:15
GASTROENTEROLOGY:
[**1-22**] 11am
[**Hospital Unit Name 1825**] - [**Hospital Ward Name 516**] [**Location (un) 453**]
([**Telephone/Fax (1) 2233**]
Completed by:[**2192-12-27**]
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[] |
icd9pcs
|
[
[
[]
]
] | 7
| 6,069
| 0
| 518
| 1
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99,872
| 108,939
|
4708
|
Discharge summary
|
Report
|
Admission Date: [**2137-8-12**] Discharge Date: [**2137-8-16**]
Date of Birth: [**2083-1-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a 54y/o woman with a PMH of H. pylori and
depression admitted with DOE and anemia with HCT of 19. The
patient noted onset of DOE 2 days prior to presentation, with
worsening so that she was unable to ambulate without significant
difficultly over the past 24 hours. She noted black stools 24
hours prior to presentation. Denies previous recent history of
bleeding. She underwent a routine screening colonoscopy in [**2134**]
which demonstrated grade 1 internal hemorrhoids. She denies any
other bleeding (urine, gums). She denies weight changes, fevers,
chills, night sweats. She has nto had any bowel movements since
admission.
In the ED, initial vitals T 98.2, HR 80, BP 119/75, RR 16, O2
100% RA. On exam she was found to have dark, guaiac + stools. NG
lavage negative. 2 18 guage PIV were placed. She was transfused
1U PRBC.
On arrival to the MICU, the patient is resting comfortably, in
NAD. Denies current CP/SOB. The GI performed an upper endoscopy
on arrival to the MICU which demonstrated a large polyp with no
evidence of current bleeding. Intervention was deferred
overnight for planned excision and biopsy with EUS. She was
transfused 3 units PRBC's with appropriate improvement in her
hct and has been hemodynamically stable in the ICU.
10 point review of systems otherwise negative except as noted
above.
Past Medical History:
Melanoma in-situ, lentigo maligna type - L cheeck [**2133**]
Depression
H. Pylori
Social History:
The patient is married and has one teenage son. She runs the
Gift Shop at [**Hospital1 18**]. The patient denies tobacco, EtOH, IVDU.
Denies over the counter herbal supplements.
Family History:
Nephew with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19839**] deficiency
Physical Exam:
VS: T 97.3 HR 59 BP 102/69 RR 18 Sat 99% RA
Gen: wll appearing woman in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates,
conjunctiva pink
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, asterixis absent, speech fluent,
DTR's 2+ patellar, achilles, biceps, triceps, brachioradialis
bilaterally, babinski down-going bilaterally
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
[**2137-8-12**] 05:57PM COMMENTS-GREEN TOP
[**2137-8-12**] 05:57PM HGB-7.8* calcHCT-23
[**2137-8-12**] 05:50PM GLUCOSE-87 UREA N-20 CREAT-0.8 SODIUM-141
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12
[**2137-8-12**] 05:50PM WBC-5.5 RBC-2.22* HGB-6.8* HCT-20.4* MCV-92
MCH-30.8 MCHC-33.4 RDW-14.0
[**2137-8-12**] 05:50PM NEUTS-68.4 LYMPHS-24.4 MONOS-5.5 EOS-1.4
BASOS-0.2
[**2137-8-12**] 05:50PM PLT COUNT-211
[**2137-8-12**] 05:50PM PT-11.3 PTT-21.8* INR(PT)-0.9
[**2137-8-12**] 01:46PM GLUCOSE-95
[**2137-8-12**] 01:46PM UREA N-23* CREAT-0.8 SODIUM-141 POTASSIUM-4.4
CHLORIDE-109* TOTAL CO2-29 ANION GAP-7*
[**2137-8-12**] 01:46PM estGFR-Using this
[**2137-8-12**] 01:46PM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-57 TOT
BILI-0.2
[**2137-8-12**] 01:46PM WBC-3.9* RBC-2.13*# HGB-6.4*# HCT-18.9*#
MCV-92 MCH-30.0 MCHC-32.8 RDW-14.1
[**2137-8-12**] 01:46PM NEUTS-64.6 LYMPHS-24.2 MONOS-8.8 EOS-1.9
BASOS-0.5
[**2137-8-12**] 01:46PM PLT COUNT-177
[**2137-8-12**] 01:46PM PT-11.9 PTT-23.5 INR(PT)-1.0
[**2137-8-12**] 01:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2137-8-12**] 01:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
EGD [**2137-8-12**]: Impression: Polyp in the second part of the
duodenum on wall opposite ampulla Otherwise normal EGD to third
part of the duodenum
Recommendations: Patient will require polypectomy of this polyp.
We do not have the equipment to perform this as an emergency
procedure. Can have clear liquids. give Protonix 40 mg twice
daily.
Colonoscopy [**2137-8-12**]: Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
This is a 54y/o woman with a h/o H. pylori and depression with
acute blood loss anemia, GIB, duodenal polyp.
1. Acute blood loss anemia due to GI bleeding: She presented
with blood loss anemia, secondary to slow GI bleed. She had an
emergent EGD which showed a duodenal polyp. She improved with
transfusion of 3 units of blood with stable hematocrit. She
will need to restart an [**Month/Day/Year **] supplement on discharge.
.
2. Duodenal polyp: Underwent EUS on [**8-15**] for evaluation of polyp
found on initial EGD. EUS showed 3 cm pedunculated polyp in the
second part of the duodenum. The ampulla was identified and was
separate from the mass. The ampulla appeared normal.
On EUS, this lesion appeared as a pedunculated polyp. No
extension of the lesion beyond the submucosa was noted. The
muscularis was clearly identified and was intact. She went for
removal on [**2137-8-16**]. During that EGD, EGD on she was found to
have angioectasia in the stomach (treated with thermal therapy),
a polyp in the second part of the duodenum (treated with
polypectomy, endoclip, and otherwise normal EGD to third part of
the duodenum. She was discharged home after the polypectomy,
with advise to return in the event of pain, hematemesis, or
worsening melena. She will have a CBC approximately 5 days post
discharge, results to her PCP.
.
3. Depression: continuee wellbutrin and celexa.
.
OUTSTANDING TESTS:
Polyp, pathology pending
Medications on Admission:
On Admission:
Bupropion HCl 200 mg Tablet SR daily
Citalopram 20 mg Tablet daily
Lorazepam 0.5 mg Tablet one half to one Tablet(s) by mouth @ hs
no more than 3 nights per week
Ferrous Sulfate 325 mg (65 mg [**Date Range **]) Tablet [**Hospital1 **]
Multivitamin Tablet 1 Tablet(s) by mouth daily (OTC)
On transfer:
BuPROPion (Sustained Release) 200 mg PO QAM
Citalopram Hydrobromide 20 mg PO DAILY
Pantoprazole 40 mg IV Q12H
Discharge Medications:
1. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. [**Hospital1 **] (Ferrous Sulfate) 325 mg (65 mg [**Hospital1 **]) Tablet Sig: One
(1) Tablet PO once a day.
4. Outpatient Lab Work
CBC, [**2137-8-21**]. Results to Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] phone
[**Telephone/Fax (1) 250**].
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Acute blood loss anemia
Duodenal polyp
Depression
Discharge Condition:
Stable, hematocrit 31.5, no active bleeding, ambulating without
shortness of breath
Discharge Instructions:
You were admitted with anemia, due to blood loss. The most
likely cause was the polyp in your duodenum, which was slowly
oozing. You improved with transfusions with a stable blood
count throughout your stay after the transfusion. You had the
polyp removed on the day before discharge.
.
No aspirin, or NSAIDs. You do not need to take protonix.
.
Return to the ED if you get short of breath or dizzy. Your
stool will probably turn black from the [**Last Name (LF) **], [**First Name3 (LF) **] that is
expected.
.
Start eating solid food tonight. Stay well hydrated in the next
few days.
Followup Instructions:
Call the GI department to make an appointment with [**Doctor First Name 4370**] [**Doctor Last Name **] in
the next 2-3 weeks. The phone number is [**Telephone/Fax (1) 9557**]. They
will give you the results of your polyp removal.
.
Provider: [**Name10 (NameIs) **] [**Name6 (MD) **] [**Name8 (MD) 19840**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2137-9-3**] 3:00 (resident working with Dr. [**Last Name (STitle) 5263**]
.
Blood count check next week.
|
[
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"211.1",
"311"
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[
"99.04",
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icd9pcs
|
[
[
[
1120,
1146
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],
[
[
4317,
4319
]
],
[
[
4662,
4672
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[
[
5852,
5862
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] | 7
| 1,440
| 0
| 6
| 86
| 0
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| 0
| 1,706
| 0
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| 469
| 96
| 0
| 0
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| 475
| 0
| 67
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| 1
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| 595
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| 180
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|
97,864
| 168,708
|
37449
|
Discharge summary
|
Report
|
Admission Date: [**2163-8-14**] Discharge Date: [**2163-8-21**]
Date of Birth: [**2103-3-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
altered mental status, DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 year old gentleman with history of metastatic melanoma to the
brain and the liver, on decadron (higher dose compared to prior
admission; from 4 mg q 6 hr to 6 mg q 6 hr given gradual
weakness), presented with progressive worsening. [**Name (NI) **] wife
reports a steady decline over the last week, culminating on the
day admission with inability to walk or verbalize. Patient was
seen by Dr. [**Last Name (STitle) 724**] in clinic on Monday, and LP was performed. This
LP showed no evidence of infection. Patient is not on
chemotherapy or radiation therapy at this time. Wife reports
that patient was able to function minimally over the past week
but since night prior to admission has really not been able to
walk or verbalize. He is able to follow commands and understand
everything that is spoken to him. Patient triggered on arrival
to ED for nursing concern.
Of note, he was previously admitted to [**Hospital1 18**] from [**Date range (1) 8767**] with
confusion that was attributed to cerebral edema from his head
metastases. He carries a diagnosis of melanoma metastatic to the
head, lung, and liver. He was receiving treatment from Dr. [**First Name (STitle) **] at
[**Hospital1 3278**], including gamma-knife in [**2163-3-10**], and had multiple
similar admissions in [**Month (only) **] and [**Month (only) 205**] for confusion that improved
with pulse dexamethasone. Attempts to wean steroids were met
with worsening confusion. He and his wife chose to transfer care
to [**Hospital1 18**] for a second opinion from Dr. [**Last Name (STitle) 724**]. He follows in the
biologics clinic here, receiving off-label ipilimumab. He
received a huge bolus of dexamethasone (10mg at home, 10IV in
the ED) with improvement of his confusion, however his FSG
ascended into the 400s requiring insulin coverage. They
remained elevated in the 300 range at the time of discharge- and
he was sent out on metformin with FSG testing supplies, and an
appointment with his [**Name8 (MD) 6435**] NP was established within a few days
of discharge to assess the need for insulin. He unfortunately
failed to followup, and his FSG were 300+ at home. 4-5 days
prior to admission he noted progressive weakness and decreased
strength of voice prompting ED presentation.
On admission to the [**Hospital Unit Name 153**], he had a glucose of 432 and an anion
gap of 30. He was treated with an insulin gtt, aggressive
hydration, and repletion of electrolytes. His gap subsequently
closed and basal/bolus SubQ insulin was started, guided by
[**Last Name (un) **] consult. FSG were still intermittently into the 300-400
range, and glargine was uptitrated as needed.
In the ED, T 98.4 HR 109 BP 142/96 RR 16 Sat100%RA. CT head was
done and per prelim report shwoed multiple hyperattenuating
supratentorial lesions with surrounding edema compatible with
metastatic disease, unchanged since [**2163-8-1**] CT exam. CXR did
not show acute process. UA was not suggestive of UTI. ALT was
notable to be 49 otherwise normal LFT. Lactate was 2.1. Serum
tox was negative.
On arrival to the MICU, patient's VS were: 98.1, HR 111, BP
135/80, RR 13, Sat 97%RA. FS 242.
Review of systems:
(+) Per HPI, constipation
(-) Denies fever, chills, night sweats. Denies shortness of
breath, cough, dyspnea or wheezing. Denies chest pain, chest
pressure, palpitations. Denies abdominal pain, diarrhea, dark or
bloody stools. Denies dysuria, frequency, or urgency.
Past Medical History:
PAST ONCOLOGIC HISTORY: from OMR notes
In [**8-/2159**], Mr. [**Known lastname **] [**Last Name (Titles) 1834**] biopsy of a right cheek skin
lesion revealing lentigo maligna. He [**Last Name (Titles) 1834**] a wide local
excision with a focal positive margin with no further resection
at that time. In [**2161-9-9**], he [**Year (4 digits) 1834**] abdominal US to
evaluate abdominal pain which revealed small gallstones. There
were liver nodules noted consistent with hemangiomas. He
[**Year (4 digits) 1834**] a liver MRI on [**2162-3-11**], revealing a dominant liver
nodule concerning for possible metastatic disease. Torso CT
revealed lung nodules. On [**2162-3-18**], he [**Year (4 digits) 1834**] a brain MRI
revealing three brain lesions. On [**2162-3-22**], he [**Year (4 digits) 1834**] a
CT-guided liver biopsy confirming melanoma. He was subsequently
referred to [**Hospital 3278**] Medical Center to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for a gamma
knife evaluation. He [**Last Name (NamePattern1) 1834**] gamma knife treatment to three
brain lesions on [**2162-4-9**] with brain MRI one month later
revealing stability. He began off protocol ipilimumab on
[**2162-6-1**]. F/U brain MRI in early [**Month (only) 216**] showed several new small
brain lesions without associated edema. He had evidence of
regression in SQ nodules at this time so he was observed. F/U
brain MRI revealed resolution of the largest CNS lesion with
growth in some smaller lesions felt to be ipilimumab effect.
Torso CT revealed continued improvement in systemic disease. He
[**Month (only) 1834**] Gamma knife therapy to 5 lesions on [**2163-4-9**] by Dr. [**First Name (STitle) **].
Torso CT was stable. He was admitted in [**2163-6-10**] twice at [**Hospital1 3278**]
for mental status changes responsive to steroids, presumably due
to edema surrounding known metastatic disease.
PAST MEDICAL HISTORY:
1. Status post traumatic neck injury in [**2160**]
after falling off a ladder, status post C-spine fusion;
2. history of chronic dysphagia from nutcracker esophagus
syndrome; 3. history of a frozen shoulder status post physical
therapy with
improvement in mobility
4. history of lentigo maligna of the right cheek.
5. Metastatic Melanoma as above
Social History:
The patient is married. He is a nonsmoker. He drinks rare ETOH
and has no illicit drug use. He worked as a painting contractor
as well as real estate [**Doctor Last Name 360**].
Family History:
no history of melanoma
Physical Exam:
ADMISSION EXAM
98.1, HR 111, BP 135/80, RR 13, Sat 97%RA. FS 242
GENERAL: NAD, sitting in bed, speaking with very soft voice.
pleasant. moon face.
HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva, MM
relatively dry
CARDIAC: RRR,normal S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mild distention and tympany throughout, +BS, nontender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing. pitting edema at the
ankles bilaterally. pulses palpable +2 bilaterally.
NEURO: Alert and oriented x 3, CN II-XII intact, gait deferred.
LE weakness 3+/5 bilaterally. sensation intact bilaterally with
no sensory level in both UE's and LE's.
SKIN: vitiligo.
DISCHARGE EXAM
99.1 118-130/74-82 89-97 16 98/RA
BG 190 dinner, 199 HS, 95 AM
GENERAL: NAD, cushingoid appearance with moon fascies
CARDIAC: RRR S1/S2, no murmurs, gallops, or rubs
LUNG: crackles at the right base
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
SKIN: distal vitiligo
Pertinent Results:
ADMISSION LABS
[**2163-8-14**] 02:00PM BLOOD WBC-10.6 RBC-4.03* Hgb-12.8* Hct-35.3*
MCV-88 MCH-31.7 MCHC-36.2* RDW-15.6* Plt Ct-273#
[**2163-8-14**] 02:00PM BLOOD Glucose-432* UreaN-31* Creat-0.5 Na-133
K-4.0 Cl-96 HCO3-7* AnGap-34*
[**2163-8-14**] 02:00PM BLOOD ALT-49* AST-14 AlkPhos-62 TotBili-0.7
[**2163-8-14**] 05:18PM BLOOD Calcium-8.3* Phos-1.6*# Mg-1.8
[**2163-8-14**] 02:33PM BLOOD Lactate-2.1*
IMAGING
CT HEAD WITHOUT CONTRAST ([**2163-8-14**])
FINDINGS:
Multiple supratentorial hyperdense lesions are again
demonstrated, compatible
with metastatic disease and are largely unchanged since CT exam
of [**2163-8-1**]. For example, an 8 x 10 mm left temporal lobe
hyperattenuating lesion
with surrounding edema is unchanged (2A:16). Left frontal 14 x
8 mm lesion is
also stable (2A:21). Bilobed focus of hyperattenuation in the
left
frontoparietal vertex is unchanged (2:23). Surrounding edema is
also noted.
There is no mass effect or shift of normally midline structures.
No new
lesions detected on the CT exam. Basal cisterns are patent. No
vascular
territorial infarction. Sulci and ventricles are unchanged in
size and
configuration. Imaged paranasal sinuses and mastoid air cells
are well
aerated. No fracture.
IMPRESSION:
In comparison to [**2163-8-1**] CT exam, there is no significant
change in
multiple hyperdenselesions, compatible with metastatic disease,
as described above. However, consider MR for better assessment.
NOTE:
A focus of increased density in the left frontal lobe anteriorly
at the vertex ( se 2a, im 25)- ? artifact/real correlate with
MRI for better assessment if not CI.
The study and the report were reviewed by the staff radiologist.
MRI BRACHIAL PLEXUS ([**2163-8-15**])
1. Progression of disease with significant increase in size of
lung
metastases since [**2163-7-10**]. The largest lung metastasis is a
cavitating
lesion in the left upper lobe. The known brain metastases were
incompletely
imaged at this time.
2. Edema within the supraspinatus and infraspinatus muscle
bellies at their
scapular origin - this is possibly secondary to myositis.
3. Unremarkable appearance of the brachial plexus. Metallic
hardware
artifact along the right side of the lower cervical spine (C6-7)
consistent
with prior fixation. Evaluation of cervical nerve roots would
be better
assessed on the cervical MRI performed [**2163-8-3**].
CXR ([**2163-8-14**])
1. No acute cardiopulmonary process. Known subcentimeter
pulmonary nodules
not well visualized.
2. Triangular opacity in peripheral left midlung likely
artifact. Consider
repeat CXR to confirm.
3. Stable pectus excavatum deformity.
CXR ([**2163-8-16**])
Small to moderate right pleural effusion is new, accompanying a
large region of interstitial infiltration in the right lower
lung, and growing
heterogeneous opacification of the left suprahilar lung.
Although there could be a component of pulmonary edema, it is
likely that there is bilateral pneumonia. A triangular opacity
in the periphery of the left upper lobe, new on [**8-14**] and
still present is either infection or infarction. Fullness in
both hila and the paratracheal regions of the mediastinum could
be due to vascular engorgement or lymph node enlargement.
Calcification of granulomatous lymph nodes is documented on the
[**2163-7-12**] torso CT. Heart size is normal.
EMG ([**2163-8-18**])
FINDINGS:
Motor nerve conduction studies (NCSs) of the right median nerve
demonstrated
normal distal latency, mildly reduced response amplitudes,
normal conduction
velocity, and normal F-minimum latency.
Motor NCSs of the right ulnar nerve demonstrated normal distal
latency,
moderately reduced response amplitudes, normal conduction
velocity, and
slightly prolonged F-minimum latency.
Sensory NCS of the right median nerve was normal. Sensory NCS of
the right
ulnar nerve was normal. Sensory NCS of the right radial nerve
was normal.
Sensory NCS of the right lateral antebrachial cutaneous nerve
was normal.
Sensory NCS of the left lateral antebrachial cutaneous nerve
demonstrated
decreased response amplitude and normal conduction velocity.
Repetitive nerve stimulation at 3 Hz demonstrated no abnormal
decrement.
Stimulation of the right ulnar nerve, recording ADM, pre- and
post-10 seconds
of maximal voluntary contraction demonstrated no post-exercise
facilitation.
Concentric needle electromyography (EMG) of selected right upper
extremity
muscles revealed short duration, polyphasic motor units, many of
which were
low-amplitude but some of which were normal amplitude, with
early recruitment
in deltoid, biceps, infraspinatus and first dorsal interosseous.
EMG of
deltoid also revealed increased insertional activity in the form
of occasional
positive sharp waves.
Concentric needle EMG of right tibialis anterior and vastus
lateralis revealed
short duration, mostly low-amplitude (some normal amplitude),
polyphasic motor
units with early recruitment.
IMPRESSION:
Abnormal study. There is electrophysiological evidence for a
generalized
myopathy without associated denervating ("inflammatory")
features. The
absence of denervating features does not rule out an
inflammatory myopathy
(myositis), particularly in the setting of concomitant
glucorticoid use.
THYROID ULTRASOUND [**2163-8-18**]
FINDINGS: The right thyroid lobe measures 1.5 x 1.9 x 4.5 cm
and contains a
well-circumscribed, avascular, hypoechoic nodule measuring 0.3 x
0.2 x 0.2 cm
in the middle portion of the thyroid lobe. The remainder of the
thyroid gland
demonstrates homogeneous echogenicity and normal vascularity.
The left thyroid lobe measures 1.5 x 1.4 x 4.2 cm and
demonstrates homogeneous
echogenicity and normal vascularity without thyroid nodules.
No lymphadenopathy is identified in the neck.
IMPRESSION: Small right thyroid lobe nodule most likely
represents a colloid
cyst. No lymphadenopathy in the neck
CXR [**2163-8-19**]
IMPRESSION: Improving right pleural effusion. Worsening
interstitial edema.
Increase in perihilar opacity likely due to vascular engorgement
or lymph node
enlargement.
CT Chest [**2163-8-20**]
IMPRESSION:
1. Diffuse ground glass and solid nodular opacities with more
confluent
opacity at the right lung base are new from [**2163-7-12**]. Two
opacities have
central cavitation. The findings are concerning for infection,
including
fungal, and septic emboli. While these may represent markedly
increased
melanoma metastases, reassessment after treatment for infection
is
recommended.
2. Interlobular septal thickening at the right lung base is
unchanged from
[**2162-3-12**].
3. Small, nonhemorrhagic bilateral pleural effusions.
Brief Hospital Course:
Active issues:
# DKA: Patient was noted to be insulin resistant on prior
admissions, this presentation is likely [**2-10**] increase in decadron
dosing. Possible that infection played a role in increasing
insulin resistance. Patient was started on insulin drip in the
ED, his anion gap decreased from 34 on admission to 17 by the
time he was on the floor. He was started on D51/2NS and
electrolytes were monitored Q6H and replaced as needed. His
mental status improved within several hours of insulin therapy
and he became responsive to questioning.
# IDDM: His sugars were initally difficult to control in the
ICU. [**Last Name (un) **] consult was placed. Patient's sugars remained in
the 300s-400s while on 25U lantus and ISS. His regimen was
being uptitrated when he was transferred to the floor. On the
floor, blood sugars remained labile, and patient had several AM
episodes of hypoglycemia. At [**Last Name (un) **] recommendation, patient's
insulin titrated to 30U qAM and 25U qHS of Lantus, as well as
QACHS sliding scale, with improved blood sugar control.
# Neurological deterioration: this has been ongoing problem for
which he was seen by Dr. [**Last Name (STitle) 724**] as an outpatient. LP was done,
which did not show any results c/w infection. Could be [**2-10**]
progressing metastatic disease (as shown on MRI [**2163-8-3**]) vs.
metabolic due to uncontrolled diabetes. Patient was at baseline
before being transferred to the floor. Dr. [**Last Name (STitle) 724**] saw the patient
in the ICU- he had suspicion that his recurrent AMS was
secondary to possible leptomeningeal spread and CNS infiltration
of the melanoma. No malignant cells were seen on LP [**8-5**] and
MRI C spine revealed no malignant leptomeningeal disease. A
finding of right arm weakness prompted MRI of the brachial plexi
which were neurologically unremarkable, but reflected a
worsening burden of pulmonary metastases. EMG was done, which
showed diffuse myopathy with no definitive inflammatory
features. Steroid taper was begun while patient on the floor,
with no confusion or change in mental status. If steroid wean
not feasible, PCP prophylaxis will have to be started.
# Pan-hypopituitarism: TSH/T4/[**Last Name (un) **]/Prolactin/Testosterone were
all found to be decreased during admission. Ddx includes
autoimmune endocrinopathy from ipilimumab or post-radiation
pituitary damage. Endocrinology was consulted. Patient was
started on thyroid hormone replacement and testosterone
replacement. No mineralocorticoid replacement was indicated at
this time.
# Dyspnea: Patient developed shortness of breath the evening of
[**8-13**] with desaturations. He was also tachycardic to the 100-110s.
His CXR at that time reflected a possible multilobar pneumonia
which was broadly covered as HCAP with vancomycin and cefepime.
His dyspnea improved, and by day of discharge he was satting
well on room air and had been afebrile for multiple days. Chest
CT on [**8-20**] showed diffuse ground glass and solid nodular
opacities with more confluent opacity at the right lung base,
with 2 lesions with central cavitation. These were felt to most
likely represent metastases, but infectious causes (including
fungal or mycobacterial infectious) were also a significant
concern given patient's high dose steroid use. Blood cultures
were repeatedly negative, so septic emboli felt to be less
likely. Infectious disease was consulted and initial fungal
studies were sent. Additional workup, including serial AFB
sputum cultures to rule out TB were recommended. However, the
patient and his family felt very strongly about going home.
Despite being advised to stay and continue work-up, they chose
to go home on levofloxacin on [**2163-8-21**].
# METASTATIC MELANOMA WITH HEAD METASTASES: Patient with
metastatic melanoma currently being treated with off label
ipilimumab. MRI of brachial plexus and CT of chest showed
probable progression of metastatic burden in lungs.
Transition issues:
- recheck TFTs [**2163-8-25**] and adjust dose of thyroid hormone
- Beta glucan, galactomannan, cryptococcal antigen, legionella
antigen
- sputum culture (including AFB) not done as inpatient;
mycobacterial infection cannot be decisively ruled out
Medications on Admission:
1. Dexamethasone 6 mg PO Q6H
2. LeVETiracetam 500 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Sodium Chloride 1 gm PO THREE TIMES A DAY (stopped given
lower extremity swelling)
5. Tamsulosin 0.4 mg PO HS
6. metformin 500 mg 1 tablet(s) by mouth twice a day
Discharge Medications:
1. Dexamethasone 4 mg PO Q8H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*56 Tablet Refills:*0
2. LeVETiracetam 500 mg PO BID
3. Tamsulosin 0.4 mg PO HS
4. Omeprazole 20 mg PO DAILY
5. Testosterone 4 mg Patch 1 PTCH TD DAILY
RX *Androderm 4 mg/24 hour apply 1 new patch to skin and remove
old patch daily Disp #*30 Transdermal Patch Refills:*0
6. Levofloxacin 750 mg PO Q24H Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
7. Glargine 30 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *Lantus 100 unit/mL inject 30 units subcutaneously before
breakfast and 20 units subcutaneously qHS qAM and qHS Disp #*1
Vial Refills:*0
RX *Humalog 100 unit/mL inject subcutaneously per sliding scale
four times a day Disp #*1 Vial Refills:*0
RX *insulin syringe-needle U-100 31 gauge X [**5-25**]" use as
directed QIDACHS Disp #*1 Box Refills:*0
8. Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine 88 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN severe pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*56 Tablet Refills:*0
10. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet
Refills:*0
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
12. Outpatient Lab Work
Please check TSH, free thyroxine, T3 on [**2163-8-25**] and fax results
to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at Phone: [**Telephone/Fax (1) 3402**]; Fax: [**Telephone/Fax (1) 84154**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Diabetic ketoacidosis
Metastatic melanoma
Healthcare Associated Pneumonia
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:
Dear Mr. [**Known lastname **],
You were admitted to the hospital for progressive weakness and
were found to have very elevated blood sugar and a diabetic
ketoacidosis. You were treated with insulin, fluids and
electrolytes, and this resolved. During your hospitalization,
you were found to have a pneumonia and treated with antibiotics.
A chest CT [**2163-8-19**] showed new lung lesions. They may be related
to your melanoma, but we cannot rule out infection as a cause
including fungal or less likely myobacterial infection. Fungal
lab studies were sent. We discussed that work-up of these
lesions was not yet complete, and that further workup would
include sputum testing to rule out tuberculosis. However, you
and your family decided that it was important for you to go home
today. Your outpatient oncology team will arrange for additional
infectious disease follow-up pending initial results.
Changes to your medications include:
- inject 30 units of insulin glargine (Lantus) subcutaneously in
the morning and 20 units of insulin glargine (Lantus)
subcutaneously at bedtime
- inject Humalog subcutaneously with meals per sliding scale
- take dexamethasone 4mg every 12 hours
- apply one 4mg Androderm patch to your skin each day (and
remove old patch)
- start levofloxacin 750mg daily for 5 more days
- start levothyroxine 88mcg daily
- oxycodone 5mg every 6 hours as needed for pain
- start docusate and senna as needed for constipation (because
oxycodone can cause constipation)
It was a pleasure taking care of you during your hospitalization
and we wish you all the best going forward.
Followup Instructions:
You have a post-discharge appointment with Dr. [**First Name (STitle) **], Tan at
[**Last Name (un) **]. Please call [**Telephone/Fax (1) 25521**] if you have more questions.
Please call DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**] to see if they
would like to see you sooner than [**8-30**].
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-8-30**] at 3:00 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-8-30**] at 3:00 PM
With: [**Doctor First Name 10838**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call Dr [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 724**] for an appointment within 1-2 weeks
of discharge. [**Telephone/Fax (1) 1844**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2163-8-23**]
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Discharge summary
|
Report
|
Admission Date: [**2121-8-28**] Discharge Date: [**2121-8-29**]
Date of Birth: [**2045-1-14**] Sex: F
Service: MEDICINE
Allergies:
Valsartan / Tikosyn
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
increased shortness of breath leading to an elective right and
left heart catheterization with aortic valvuloplasty and
echocardiogram during procedure
Major Surgical or Invasive Procedure:
Cardiac catheterization
Aortic balloon valvuloplasty
History of Present Illness:
76F with severe aortic stenosis, biventricular heart failure,
atrial fibrillation on warfarin and s/p dual-chamber pacemaker,
and dilated cardiomyapathy who presents to the CCU after having
a right and left heart catheterizaton with aortic valvuloplasty
in the setting in increased SOB. The patient is s/p aortic
valvuloplasty in [**2117**] after she was not felt to be a candidate
for cardiac surgery. She also has dilated cardiomyopathy with an
EF of 20%. She is s/p biventricular ICD placement in [**2117**] with
recent generator change performed [**2121-7-8**]. She has been
experiencing increased shortness of breath with minimal exertion
and recently underwent right and left heart catheterization by
Dr. [**Last Name (STitle) **] [**2121-7-9**] which demonstrated low gradient/low flow
aortic stenosis, severe pulmonary hypertension with an elevated
PCWP(=36 mmHg), and acute on chronic systolic and diastolic
heart failure. Patient is on warfarin which was stopped [**2121-8-23**]
per Dr.[**Name (NI) 32659**] instructions. Patient is now referred for right
and left heart catheterization with aortic valvuloplasty and
echocardiogram during the procedure.
.
The patient does not have any chest pain or PND. She has 2
pillow orthopnea. Occassional lower extremity edema. No
dizziness. She walks at home with a cane, but her ambulation is
limited, more by pain in her leg than by dyspnea. She had a
mechanical fall in [**2120-9-21**] leading to ORIF for a right
supracondylar femur fracture. She does feel fatigued and SOB
with minimal activity, such as dressing herself. Her boyfriend
[**Name (NI) 12239**] is also her caretaker and ensures that she takes all her
medications every day. She has had no falls in [**2120**], but the
year prior she had the mechanical fall leading to the femur
fracture, as well as 4 episodes of syncope/LOC attributed to
Tikosyn, which has since been stopped.
.
Prior Diagnostics:
[**2121-7-9**]: Cardiac Cath
-Low gradient (31), low flow aortic stenosis (valve area 0.52)
-Insignificant coronary artery disease (30% stenosis in mid LAD
second diagonal branch, and RCA proximal)
-Severe pulmonary hypertension with an elevated PCWP(=36 mmHg),
RA pressure of 17, PA 73/28 (45)
-Acute on chronic systolic and diastolic heart failure
.
[**2121-7-10**] Echo: left ventricular EF 20% (severe global systolic
dysfunction), left atrium moderately dilated, left ventricle
moderately dilated, right ventricle size normal with NML free
wall motion, critical aortical valve area (<0.8), mild (1+)
aortic regurg, moderate to severe (3+) mitral regurg, 2+
tricuspid regerg, moderate pulm systolic HTN
.
[**5-/2121**]: PASP 43mmHg. Mean gradient 33mmHg.
.
In the cath lab, initial vitals were 70, 93/49, 23, 98% (on RA).
Though the patient has an ICD, a temporary pacing wire was
inserted via catheter in order to rapidly pace her heart in
order to empty out the left ventricle prior to valvuloplasty.
However, the rapid pacing caused the patient to go into V tach.
Chest compressions were started (for 20 sec), and she was
shocked, which resolved the arrythmia. She was briefly on Neo
and dopamine during the procedure, but these were taken off soon
after the catheterization with SBPs in the 110s and MAPs in the
60s. Valvuloplasty was performed with 3-4 inflations of a 23mm
balloon. The gradient was decreased from 38 to 28, and the valve
area was increased from 0.38cm2 to 0.56cm2. PCWP was measured to
be 26. The sheaths were removed.
.
Vitals on transfer to the CCU were 70, 114/49, 20, and 99% (on
2L by NC?).
.
On arrival to the floor, patient was feeling well and denied
chest pain or SOB. She had mild pain at her ICD and mild pain
att the femoral catheter site.
Past Medical History:
- Hyperlipidemia
- Hypertension
- Diabetes Mellitus on insulin
- Dilated cardiomyopathy
- Aortic stenosis s/p csurg evaluation by Dr. [**Last Name (STitle) **] [**2117**]; not
a surgical candidate
- S/P aortic valvuloplasty [**5-/2118**]
- Cath [**2120**]: non-obstructive/non-significant CAD
- BIV/ICD placed [**2117**] and [**Company 1543**] generator change [**2121-7-8**]
- Open reduction/internal fixation of right femur after
mechanical fall
- Chronic kidney disease
- Thyroid disease
- S/P shingles
- Short term memory issues
Family History:
SON s/p MI at AGE 49, DAUGHTER WITH DILATED CARDIOMYOPATHY,
MOTHER WITH CAD AND MIs- died age 79.
Physical Exam:
VS: T=97.7, BP=116/53 (69), HR=73, RR=13, O2 sat=97% on 2L by NC
GENERAL: cachectic, frail, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP difficult to assess as patient is supine.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No r/g. [**2-25**] cresendo/decresendo murmur
best heard at sternal border. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly, no
crackles, wheezes or rhonchi. ICD is surrounded by edema, mild
TTP (pt reports that for months there has been a hematoma in ICD
pocket, now slowly resolving).
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/only trace edema at ankles. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP and PT dopplerable
Left: DP 1+ PT 1+
Pertinent Results:
[**2121-8-28**] 10:00AM PT-19.4* PTT-53.8* INR(PT)-1.8*
[**2121-8-28**] 10:00AM PLT COUNT-239
[**2121-8-28**] 10:00AM WBC-10.4 RBC-4.06*# HGB-14.4# HCT-44.1#
MCV-109* MCH-35.5* MCHC-32.7 RDW-15.9*
[**2121-8-28**] 10:00AM estGFR-Using this
[**2121-8-28**] 10:00AM GLUCOSE-106* UREA N-111* CREAT-2.5*
SODIUM-140 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-32 ANION GAP-17
[**2121-8-28**] 10:50PM CALCIUM-9.7 PHOSPHATE-4.2 MAGNESIUM-2.1
[**2121-8-28**] 10:50PM GLUCOSE-202* UREA N-103* CREAT-2.5*
SODIUM-135 POTASSIUM-3.3 CHLORIDE-94* TOTAL CO2-30 ANION GAP-14
.
.
ECHO [**2121-8-28**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is severely depressed
(LVEF = 25 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. Significant aortic stenosis is present (not
quantified). Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is moderate thickening of the mitral valve
chordae. Mild to moderate ([**12-23**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. [Due to acoustic shadowing, the
severity of tricuspid regurgitation may be significantly
UNDERestimated.] Significant pulmonic regurgitation is seen.
There is no pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2121-7-10**], the transaortic valvular pressure gradients are
similar, but the left ventricular stroke volume is higher.
Therefore, the aortic valve orifice area is increased, although
it could not be calculated with vertainty due to technical
factors. The mitral regurgitation appears significantly reduced,
although the aortic regurgitation is increased.
.
.
Cardiac Catheterization [**2121-8-28**]:
The right and left heart pressures were elevated (mean PAP 35,
PCWP 26). The heart was 86 bpm, the CO was 2.65 L/min, mean
gradient 38.25 mmHg, and the aortic valve area was 0.38 cm2.
.
Interventional details
During test rapid ventricular pacing, the patient developed
ventricular tachycardia that degenerated into ventricular
fibrillation. She was cardioverted to paced rhythm with return
in her BP following a Neo infusion.
.
The aortic valve was dilated without rapid ventricular pacing
using a 20 mm Hg and a 22 mm Hg x 6 cm valvuloplasty balloons.
.
After balloon valvuloplasty, the heart was 79 bpm, the CO was
2.65 L/min, mean gradient 27.27 mmHg, and the aortic valve area
was 0.56 cm2.
.
Assessment & Recommendations
1. Critical aortic stenosis
2. s/p successful balloon aortic valvuloplasty up to 22 mm
balloon with > 50% in the aortic valve area but residual severe
aortic stenosis
3. To CCU overnight
.
.
EKG [**2121-8-28**]: AV paced, regular, rate ~70, small p waves, wide QRS
.
.
PPM Interrogation [**2121-8-29**] (PRELIMINARY REPORT):
Device Brand: [**Company 1543**]
Model: [**Name6 (MD) 39503**] XT CRT-D D314TRG
Presenting rhythm: A-biV sequentially paced
Intrinsic Rhythm: Junctional bradycardia at ~ 30 bpm
Programmed Mode: DDDR
Battery Voltage: 3.17 V
.
RA lead
Intrinsic amplitude: 1.6 mV
Pacing impedance: 475 ohms
Pacing threshold: 0.75 V @ 0.4 ms
.
RV lead
Intrinsic amplitude: 6.3 mV
Pacing impedance: 418 ohms
Pacing threshold: 1.375 V @ 0.4 ms
.
LV lead
Intrinsic amplitude: N/A
Pacing impedance: 418 ohms
Pacing threshold: 0.5 V @ 1.0 ms
.
Defib Coil impedance: 42/43 ohms
.
Pacing:
AS-VS: <0.1%
AS-VP: 0.2%
AP-VS: 0.1%
AP-VP: 99.7%
.
Diagnostic information: High rate, Mode switch:
2 episodes of NSVT
1 episode of VT in the monitor zone x 35 sec
No ICD therapies needed
.
Programming changes (details):
With threshold testing the patient noted diaphragmatic pacing
with LV lead amplitudes > 1.5 V @ 1.0 ms, and intermitant
diaphragmatic pacing with LV lead amplitudes between 1.25 - 1.5
V @ 1.0 ms. The measured LV threshold was 0.5 V @ 1.0 ms. The
patient's LV amplitude was previously set at 1.25V @ 1.0 ms, so
the LV amplitude was decreased to 1.0 V @ 1.0 ms [**First Name (Titles) **] [**Last Name (Titles) **] her
symptoms.
.
Summary (normal / abnormal device function):
Normally functioning biventricular ICD. Intermittent
diaphragmatic pacing due to high LV thresholds which where were
decreased as noted above. Patient has device clinic follow-up
in a few weeks.
Brief Hospital Course:
76F with severe aortic stenosis, biventricular diastolic heart
failure, atrial fibrillation on warfarin and s/p dual-chamber
pacemaker, and dilated cardiomyapathy who presents to the CCU
after having a right and left heart catheterizaton with aortic
valvuloplasty in the setting in increased SOB.
.
# Aortic Stenosis: Pt was turned down for cardiac surgery in
[**2117**] and had an aortic valvuloplasty at that time. Recently had
worsening SOB and presented for elective valvuloplasty; the
valvuloplasty increased her aortic area by 50% and decreased the
gradient from 38 to 28. Given the risk of serious complications
following her procedure, she was admitted to the CCU for 24
hours of monitoring. She did well in the CCU after the
valvuloplasty. She did not complain of SOB or chest pain and
had no bleeding from the femoral catheter insertion site.
Post-cath labs were reassuring. She was discharged with follow
up with her PCP (Dr. [**Name (NI) 23019**]), her primary cardiologist
(Dr. [**Last Name (STitle) **], and the interventional cardiologist Dr. [**Last Name (STitle) **]. She
also has an appointment with Dr. [**Last Name (STitle) **], who has been
following her for her ICD.
.
# Biventricular ICD/Rhythm: s/p successful generator change in
[**Month (only) 205**] with hematoma since this procedure, which is slowly
resolving according to the patient and her significant other.
Dr. [**Last Name (STitle) **] has been following this in the outpatient setting.
The patient has known a fib and is on warfarin (was held this
week prior to procedure). She had a brief episode of v tach in
the setting of rapid pacing in the cath lab, but she had not
such episodes afterwards. While in the CCU, the patient
complained of a sensation of a beat in her epigastrum that was
concerning for diaphragmatic pacing. Her device was
interrrogated and adjusted (see results section), and she will
follow up with Dr. [**Last Name (STitle) **] next week. She was continued on her
home amiodarone and metoprolol during her hospital stay. Her
warfarin was held prior to the cardiac cath, but it was
restarted in the CCU. She will follow up with her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
for INR/warfarin monitoring and adjustments.
.
# Chronic Systolic and Diastolic Heart Failure: Pt has dilated
cardiomyopathy, EF 20%, and currently with PCWP of 26 and PAPs
in the 70s systolic (mean 30s). The patient was continued on
her home digoxin, losartan, metoprolol, and aspirin. We
diuresed her with IV Lasix given her elevated PCWP. She was
sent home on her regular torsemide and metolazone.
.
# Chronic Kidney Disease: Pre-procedure the pt's Cr was 2.5, and
the pt received a small amount of contrast in the procedure.
Patient's B/L Cr is 1.5-2.2. Unclear reason for increase,
perhaps worsening cardiac function or hypovolemia in setting of
decreased PO intake. The patient's medications were renally
dosed, and her creatinine was followed, which remained in the
2.5-2.6 range. She will follow up with her PCP.
.
# HTN: Chronic problem, but pt not currently hypertensive. The
patient's losartan and metoprolol were continued.
.
# DM: FSBG post procedure was 155. Patient was put on glargine
insulin [**Hospital1 **] and humalog SS QID during the brief hospitalization.
She resumed her home insulim regimen on discharge.
.
Transitional Issues
# CODE: Confirmed full
# Health Care Proxy: daughter [**Name (NI) **] [**Name (NI) 20774**] ([**Telephone/Fax (1) 45875**])
# Contact: [**Name (NI) 892**] (caregiver and significant other) ([**Telephone/Fax (1) 45876**])
# INR: Was subtherapeutic on the day of discharge at 1.7. PCP
[**Last Name (NamePattern4) **]. [**Name (NI) 45877**] will follow up with the patient in 3 days.
# Heart Failure Management: Future caregivers may wish to
consider starting spironolactone if there is no
contraindication.
# Home Services: The patient was evaluated by physical therapy,
who recommended home PT. She will also get a home skilled
nursing visit.
Medications on Admission:
allopurinol 300 mg daily
amiodarone 100 mg [**Hospital1 **]
bupropion HCl SR 150 mg daily in PM
digoxin 125 mcg every other day
donepezil 10 mg daily
folic acid 1 mg daily
Novolog 100 unit/mL Sub-Q sliding scale with meals four times
daily
Levemir 100 unit/mL Sub-Q 22 units in the am; 4 units in the PM
Levothroid 112 mcg tablet daily
losartan 12.5 mg daily
Namenda 10 mg tablet [**Hospital1 **]
metolazone 2.5 mg on Tuesday and Thursday
metoprolol tartrate 12.5 mg [**Hospital1 **]
omeprazole delayed release 20 mg TID
oxazepam 10 mg daily
Ditropan XL 5 mg daily
potassium chloride 10 % Oral Liquid 15 cc by mouth daily
torsemide 40 mg [**Hospital1 **]
warfarin 3 mg tues thurs sat sun, 2mg mwf
aspirin 81 mg daily
calcium carbonate-vitamin D3 500 mg(1,250 mg)-400 unit TID
cetirizine 10 mg daily
ferrous sulfate 325 mg (65 mg iron) daily
Discharge Medications:
1. Allopurinol 300 mg PO DAILY
2. Amiodarone 100 mg PO BID
3. Aspirin 81 mg PO DAILY
4. BuPROPion (Sustained Release) 150 mg PO QPM
5. Calcium Carbonate 500 mg PO Q 8H
6. Digoxin 0.125 mg PO EVERY OTHER DAY
7. Donepezil 10 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Levothyroxine Sodium 112 mcg PO DAILY
11. Memantine 10 mg PO BID
12. Metoprolol Tartrate 12.5 mg PO BID
13. Omeprazole 20 mg PO Q 8H
14. Oxazepam 10 mg PO HS
15. Torsemide 40 mg PO BID
16. Vitamin D 1200 UNIT PO DAILY
17. Warfarin 3 mg PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA)
Tues, Thurs, Sat, Sun
18. Warfarin 2 mg PO 3X/WEEK (MO,WE,FR)
19. Losartan Potassium 12.5 mg PO DAILY
20. Metolazone 2.5 mg PO QTUTHUR (TU,TH) Duration: 1 Doses
21. Potassium Chloride 15 cc PO DAILY
10% oral liquid
22. Cetirizine *NF* 10 mg Oral daily
23. Ditropan XL *NF* (oxybutynin chloride) 5 mg Oral daily
24. Levemir 22 Units Breakfast
Levemir 4 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care Services
Discharge Diagnosis:
Aortic stenosis
Acute on chronic systolic congestive heart failure
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:
Ms. [**Known lastname 20774**],
You were admitted to the hospital for evaluation and treatment
of your aortic stenosis. You had a cardiac catheterization and
a balloon valvuloplasty, where a balloon was temporarily
inflated to open up your aortic valve and improve the aortic
stenosis. Your heart went into a rhythm called ventricular
tachycardia for about 20 seconds during the procedure. A shock
was administered and resolved this rhythm, and you had no other
issues during or after the procedure.
Because of the risk of complications in the hours immediately
following this procedure, you were admitted to the CCU (the
cardiac intensive care unit) for monitoring. You were continued
on most of your regular medications, and there was no evidence
of complications from the procedure.
Upon discharge, please resume taking all your regular
medications. Please follow up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 5076**], and
Dr. [**Last Name (un) **] at the times listed below. Please weigh
yourself every morning, and call Dr. [**Last Name (STitle) **] if your weight goes
up more than 3 lbs in a day or more than 5 lbs in 3 days.
A physical therapist saw you while you were in the CCU and
recommended that you get physical therapy as an outpatient. You
will have a physical therapist and visiting nurse when you leave
the hospital.
There have been no changes in your medications. However, please
ask Dr. [**Name (NI) 23019**] if you should adjust your Namenda dose or
any of your other medications due to your renal function.
Followup Instructions:
Name: [**Doctor Last Name **]-[**Last Name (LF) **],[**First Name3 (LF) **] Z.
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
We are working on a follow up appointment with your primary care
physician within [**Name Initial (PRE) **] week. The office will contact you at home
with an appointment. If you have not heard from the office
within 2 business days please call them at [**Telephone/Fax (1) 45878**].
Department: CARDIAC SERVICES
When: WEDNESDAY [**2121-9-3**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 488**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital **] MEDICAL GROUP-[**Location (un) 8720**] CARDIOLOGY
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY, [**Location 8723**],[**Numeric Identifier 18655**]
Phone: [**Telephone/Fax (1) 8725**]
**APPOINTMENT Tuesday [**2121-9-9**] 2:00pm***
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Physician
|
Physician Resident Progress Note
|
Chief Complaint:
24 Hour Events:
URINE CULTURE - At [**2156-2-28**] 10:14 PM
NASAL SWAB - At [**2156-2-28**] 10:14 PM
EKG - At [**2156-2-28**] 10:15 PM
- Head CT: No acute intracranial abnormality
- Hct: 34.9 -> 29.5 -> (1RBC) -> 29.8 -> (1RBC) -> 30.9
Patient unable to provide history: Language barrier
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Morphine Sulfate - [**2156-2-29**] 05:00 AM
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2156-2-29**] 06:59 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**58**] AM
Tmax: 36.2
C (97.2
Tcurrent: 36.2
C (97.1
HR: 94 (87 - 105) bpm
BP: 150/82(98) {115/66(82) - 151/90(100)} mmHg
RR: 24 (20 - 32) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Total In:
781 mL
721 mL
PO:
TF:
IVF:
222 mL
530 mL
Blood products:
559 mL
191 mL
Total out:
105 mL
160 mL
Urine:
105 mL
160 mL
NG:
Stool:
Drains:
Balance:
676 mL
561 mL
Respiratory support
O2 Delivery Device: None
SpO2: 100%
ABG: ///20/
Physical Examination
General Appearance: Anxious, Speaking unintelligibly, likely in Russian
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,
Diminished: )
Abdominal: Soft, Bowel sounds present, Distended
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: 1+
Musculoskeletal: Left leg in traction, with pin through knee
Skin: Not assessed
Neurologic: Responds to: Verbal stimuli, Movement: Not assessed, Tone:
Not assessed
Labs / Radiology
173 K/uL
10.6 g/dL
179 mg/dL
1.7 mg/dL
20 mEq/L
4.6 mEq/L
37 mg/dL
116 mEq/L
143 mEq/L
30.9 %
9.8 K/uL
[image002.jpg]
[**2156-2-28**] 09:40 PM
[**2156-2-29**] 02:15 AM
WBC
9.8
Hct
29.8
30.9
Plt
173
Cr
1.7
Glucose
179
Other labs: PT / PTT / INR:13.6/22.7/1.2, Ca++:7.6 mg/dL, Mg++:1.9
mg/dL, PO4:3.4 mg/dL
Imaging: [**2-28**] CT Head: No acute intracranial abnormality.
[**2-28**] CT C-spine: 1. No fracture of the cervical spine. 2. Reversal of
cervical lordosis between C4 and C7 narrows the spinal canal. 3.
Bilateral neural foraminal narrowing at multiple levels.
[**2-28**] Hip X-ray: Acute comminuted proximal left femur fracture involving
the lesser trochanter and extending to the subtrochanteric region.
[**2-28**] CT Abd/Pelvis (Preliminary Read): No acute intra-abdominal
findings: no free air or fluid, no hematoma. No bowel obstruction,
although rectum is distended with stool. 3mm nonobstructing renal
calculus (versus vascular calcification). Fluid-filled gallbladder
without wall thickening, pericholecystic fluid or other evidence of
cholecystitis.
[**2-28**] CXR: No acute intrathoracic process. Air filled, distended gastric
bubble.
Assessment and Plan
[**Age over 90 **] yo M, Russian speaking only, with dementia, CKD, BPH; presenting
after witnessed mechanical fall at rehab with comminuted left
intertrochanteric femoral fracture, pinned in ED with plan to go to OR
in AM.
.
# Left femur fracture: Had pin placed in ED, leg kept in traction
overnight. Ortho consult plan for operative fixation today. Given CKD,
age, poor mental status at baseline, patient is high operative risk
candidate for high risk surgery. Most recent cardiac assessment Echo
[**5-/2153**] with Ef 55%, mild symmetric left ventricular hypertrophy, mild
AR, MR & pulmonary artery hypertension.
- NPO post-MN given mental status, position
- Transfuse to Hct > 30, will re-check hematocrit today
- Post-pin films pending
- Pain management with standing Tylenol per rectum & PRN morphine
.
# Hypotension: Resolved prior to admission to the ICU. Possibly [**2-10**]
meds (Morphine IV multiple times), bleeding (no clear source though
abdomen is somewhat firm; CT negative), undiagnosed infection (CXR
prelim clear, U/A fairly unrevealing), cardiac event (flat troponins,
poor quality EKG). Most concerning features are new anemia, distended
abdomen and ?behavioral change if ambulating without walker.
- Final reads CT abdomen / pelvis, CXR
- Serial adominal exams
- Serial Hct, with transfusion goal: Hct 30
- Telemetry
- Repeat EKG
- If recurs, consider TTE, check random cortisol
- T&C x 4 units
.
# Abdominal distension: Unclear baseline. Unclear if TTP but some
element of voluntary guarding. Formal CT report pending, but large
amount of stool clearly visible in rectal vault. Prelim Abd/Pelvis
without concerning features for acute pathology.
- Serial abdominal exam
- Final read CT Abd/Pelvix
- Aggressive bowel regimen (give suppository today), consider
disimpaction if tenderness or distension worsens.
.
# Anemia: High normocytic. Sub-optimal response to blood transfusions
overnight. Goal Hct 30, given surgery. On B12 as outpatient. No
evidence of external bleeding; no hematoma over hip but thigh firmness
L>R this morning
- Serial Hct Q6H
- stool guaiac x 3
- maintain active type/screen, several units cross matched for OR
- Monitor thigh tension
will call Ortho to do compartment pressures
if concerning
.
# Leukocytosis: Elevated to 12.8 with resolution to 9 on multiple
repeat labs. Possible stress reaction, hemoconcentration or
undiagnosed infectious source. U/A unrevealing (few bacteria, negative
leuks/nitrites). CXR negative for consolidation, pneumothorax, or
pleural effusions.
- Final read CT abdomen / pelvis
- Monitor CBC
- Culture if spikes fever
.
# CKD: Unclear recent baseline creatinine. Most recent creatinine in
OMR was 2.1 in [**8-16**]. Electrolytes generally normal. FeNa 0.7%,
consistent with perfusion-related kidney injury. Improved from 1.9 on
admission to 1.7 this morning, after IV fluids overnight.
- Prior labs from [**Hospital 328**] Rehab RE: current baseline
- Renally dose medications
- Monitor BUN/creatinine
.
# Dementia with behavioural disturbances: In behavioural unit at [**Hospital 328**]
Rehab.
- Continue Quetiapine 150 mg [**Hospital1 7**]
- Niece will visit today
try to orient patient and have family at
bedside as often as possible
.
# Depression / Anxiety: Unclear severity.
- Continue Citalopram 40 mg po daily
- Hold Lorazepam given increased narcotics, concern for impending
delirium
.
# Elevated troponin: Baseline compared to prior. EKG in MICU unchanged
from prior
.
# BPH: Foley in place, hold Terazosin given concern for hypotension.
.
# GERD: Continue PPI once advance beyond NPO. If continued HCT drop
would start IV PPI empirically for possible GI source.
.
# FEN: Maintenance IVF, replete electrolytes PRN, ice chips / NPO for
OR
# Prophylaxis: Pneumoboots given unclear source of blood loss, to OR in
AM; post-OR will need anticoagulant given high risk Orthopedics surgery
will reassess possibility of starting heparin SQ this afternoon if
hemodynamically stable
# Access: 18g x1, 16g x1
# Communication: Patient; HCP
# Code Status: DNR/DNI (per [**Hospital 328**] Rehab, copy in chart) but after
speaking with HCP [**Name (NI) 5564**] [**Name (NI) 13505**] [**Telephone/Fax (1) 13506**] (h), [**Telephone/Fax (1) 13507**] (w)
would like pt to be FULL CODE
# Disposition: ICU pending clinical improvement, post-operative course
ICU Care
Nutrition:
Glycemic Control:
Lines:
16 Gauge - [**2156-2-28**] 08:45 PM
18 Gauge - [**2156-2-28**] 08:45 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: DNR (do not resuscitate)
Disposition:
|
[
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"396.3",
"416.8",
"458.29",
"285.21",
"288.60"
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icd9cm
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icd9pcs
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[]
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94,525
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54367
|
Discharge summary
|
Report
|
Admission Date: [**2183-2-21**] Discharge Date: [**2183-2-27**]
Date of Birth: [**2128-9-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Truvada
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
[**2183-2-21**] - Rapid sequence intubation with mechanical ventilation
History of Present Illness:
60yo M with uncertain past medical history, who was BIBEMS after
experiencing a seizure. Patient called EMS after experiencing a
reported seizure. EMS found him standing outside, but became
combative and subsequently experienced a seizure while enroute
to [**Hospital1 18**]. FS at time of seizure was 150.
.
On presentation to [**Hospital1 18**] ED, initial vital signs were 134 130/64
13 100%. Exam was notable for cold extremities and wet
clothing, hematoma and abrasion over R parietal area . He was
lethargic and reported to be confused. Given lethargy, patient
was unable to provide any history at that time. He was
recognized as a patient who is frequently seen in the [**Hospital1 18**] ED
for intoxication with a history of withdrawal seizures (thought
to be named [**Name (NI) **] [**Known lastname **], MR [**Numeric Identifier 111312**]). Labs were notable for WBC
7.9 (N73), Hct 39.8, Cr 1.0, ALT/AST 50/88, lactate of 10.2,
unremarkable UA, negative serum and urine tox screens. At that
time patient became combative, and was induced and intubated to
allow completion of medical workup. CXR was unremarkable, NCHCT
without acute intracranial process, and CT Cspine without acute
fracture. Patient was felt to have had seizure's [**1-23**] EtOH
withdrawal and was sedated on fentanyl/midazolam. Patient was
bolused with IV normal saline. Post-intubation ABG 7.33/48/108.
Repeat lactate returned 0.9 after 3LNS. ED course otherwise
notable for agitation requiring increasing of midazolam drip to
20mg/hr. He was given thiamine, folate and was admitted to [**Hospital Unit Name 153**]
for further management. Labs prior to transfer were 100.6 132
154/77 14 100%AC. Access was 18gauge x 2.
.
On arrival to the ICU, vital signs were 100.5 128 104/60 18 100%
on PS 8/5 60%FiO2. Patient was intubated, comfortable appearing
and very lethargic. Nursing reported pressence of copious light
brown secretions from ET tube.
.
Unable to complete review of systems given intubation.
Past Medical History:
PAST MEDICAL HISTORY
** none available per patient, have included past medical
history of [**Known firstname **] [**Known lastname **], the supposed identity of this patient **
- Atypical Chest Pain - cardiac catheterization [**4-24**] w/o
significant lesions, EF >55% ([**2180**]), pMibi [**2176**] negative
- Polysubstance abuse (EtOH, BZD, cocaine, heroin), w h/o DT and
withdrawal seizures, multiple detox admissions including 25-day
[**Location (un) 1475**] detox/incarceration
- Depression - prior suicide attempts
- Hypertension
- Hyperlipidemia
- DM - diet controlled
- DVT in prison treated with coumadin
- Hiatal hernia
- Barrett's Esophagus
- h/o HCV
- h/o PPD+ s/p isoniazid x9mo
- h/o Lyme disease
- s/p appendectomy
Social History:
* none available per patient, have included past medical history
of [**Known firstname **] [**Known lastname **], the supposed identity of this patient * Drinks 2L
vodka daily for the last 30+ years. He also has a 30+ pack year
history. H/o IVDU - last heroin use 1 month ago. Current
cocaine/crack and crystal meth use. Had an ex-boyfriend
of 9 years, by whom he was abused. Ex-boyfriend currently in
prison for abuse, and patient feels safe.
Family History:
** none available per patient, have included past medical
history of [**Known firstname **] [**Known lastname **], the supposed identity of this patient **
Significant for premature coronary artery disease: father w MI
at 46 (4 [**Known lastname **] total), twin brother had MI at 43. Father w DM,
mother w Breast Ca, HTN.
Physical Exam:
ADMISSION EXAM:
.
Vitals: 100.5 128 104/60 18 100% on PS 8/5 60%FiO2
General: Intubated, sedated, very lethargic, spontaneously
moving
HEENT: PERRL 2mm, sclera anicteric, MMM
Neck: Supple, no JVD, no LAD
Lungs: Coarse breath sounds bilaterally without no wheezes,
rales, rhonchi
CV: Tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, NT/ND, naBS
GU: + foley
Ext: WWP, 2+ DP/radial equal bilaterally, no cyanosis/edema
Derm: Scattered papules over extremities, corresponding w hair
folicles c/w folliculitis
.
DISCHARGE EXAM:
.
Vitals: Tm 101.5 Tc 99.5, HR 70s, BP 120s/60s, RR 18, O2 95-97%
on RA
General: alert, oriented, speaking coherently, sitting up in a
chair and eating breakfast
HEENT: PERRL 2mm, sclera anicteric, MMM
Neck: Supple, no JVD, no LAD
Lungs: Coarse breath sounds bilaterally without wheezes, rales,
rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, NT/ND, naBS
Ext: WWP, 2+ DP/radial equal bilaterally, no cyanosis/edema
Derm: Scattered papules over extremities, not corresponding with
hair follicles ?????? some psoriatic appearing plaques and numular
plaque-like red lesions with scaling noted over groin and
proximal extremities
Pertinent Results:
ADMISSION LABS:
.
[**2183-2-21**] 11:00AM BLOOD WBC-7.9 RBC-4.25* Hgb-13.3* Hct-39.8*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.2 Plt Ct-212
[**2183-2-21**] 11:00AM BLOOD PT-10.6 PTT-27.9 INR(PT)-1.0
[**2183-2-21**] 11:00AM BLOOD Glucose-193* UreaN-10 Creat-1.0 Na-135
K-3.9 Cl-92* HCO3-18* AnGap-29*
[**2183-2-21**] 11:00AM BLOOD ALT-50* AST-88* AlkPhos-71 TotBili-0.5
[**2183-2-21**] 08:55PM BLOOD Calcium-7.6* Phos-2.1* Mg-1.2*
[**2183-2-21**] 11:00AM BLOOD Albumin-4.9
[**2183-2-21**] 08:55PM BLOOD Osmolal-277
[**2183-2-21**] 03:50PM BLOOD Type-ART Temp-37.8 pO2-108* pCO2-48*
pH-7.33* calTCO2-26 Base XS--1 -ASSIST/CON Intubat-INTUBATED
[**2183-2-21**] 11:25AM BLOOD Lactate-10.2*
[**2183-2-22**] 04:58AM BLOOD freeCa-1.04*
.
DISCHARGE LABS:
[**2183-2-26**] 03:54AM BLOOD WBC-4.5 RBC-3.76* Hgb-11.4* Hct-34.8*
MCV-93 MCH-30.4 MCHC-32.9 RDW-13.9 Plt Ct-160
[**2183-2-26**] 03:54AM BLOOD Glucose-107* UreaN-13 Creat-0.9 Na-142
K-3.5 Cl-105 HCO3-27 AnGap-14
[**2183-2-26**] 03:54AM BLOOD ALT-49* AST-51* LD(LDH)-239 CK(CPK)-585*
AlkPhos-63 TotBili-0.7
.
IMAGING STUDIES:
.
[**2183-2-21**] CT C-SPINE W/O CONTRAST - No acute fracture or
malalignment is present. There is exaggeration of normal
cervical lordosis. NG tube and ET tube are partially imaged. The
thyroid gland is unremarkable. The partially imaged lung apices
show mild paraseptal emphysema. The partially imaged mastoid air
cells are well aerated.
.
[**2183-2-21**] CT HEAD W/O CONTRAST - Evaluation is limited due to
patient motion. Within these limitations, no acute intracranial
hemorrhage, large vascular territory infarct, shift of midline
structures or mass effect is present. The ventricles and sulci
are normal in size and configuration. The visible paranasal
sinuses and mastoid air cells show minimal mucosal thickening in
the posterior ethmoidal air cells and the sphenoidal sinus.
.
[**2183-2-25**] CXR: The ET tube tip is 5 cm above the carina. The NG
tube tip is in the stomach. Heart size and mediastinum appear
unchanged. There is interval progression of widespread
multifocal opacities, highly concerning for multifocal
pneumonia, potential aspiration in origin. Small amount of
bilateral pleural effusion, left more than right, cannot be
excluded. There is no pneumothorax.
.
[**2183-2-25**] EKG: Sinus rhythm. Low limb lead voltage. Since the
previous tracing of [**2183-2-21**] atrial premature beats are no longer
seen and the rate is slower. ST-T waves have improved.
.
MICROBIOLOGIC DATA:
.
[**2183-2-21**] Urine culture ?????? negative
[**2183-2-21**] Blood culture (x 2) ?????? negative
[**2183-2-21**] MRSA screen ?????? negative
[**2183-2-21**] Sputum ?????? 2+ GPC, 1+ GNRs, commensal growth
[**2183-2-25**] Sputum ?????? contaminated, culture cancelled
[**2183-2-25**] UCx ?????? negative
[**2183-2-25**] BCx pending
[**2183-2-26**] urine legionella antigen ?????? negative
[**2183-2-26**] UCx pending
[**2183-2-26**] BCx pending
Brief Hospital Course:
IMPRESSION: 60M with uncertain PMH history who presented with
lethargy and evidence of alcohol withdrawal seizures who was
intubated for airway protection and behavioral concerns. Patient
was successfully extubated and treated with pneumonia. Patient
eloped on [**2183-2-27**].
.
# DELIRIUM - During and after extubation, patient intermittently
very agitated, trying to get out of bed and punching staff
members - occasionally becoming physical. He was treated with
PRN IV Haldol for agitation and had an infectious and metabolic
work-up for causes of delirium which was unrevealing. Once
Precedex was weaned (see below), his mental status improved.
.
# ALCOHOL WITHDRAWAL SEIZURES - Patient with witness generalized
tonic-clonic seizure activity in the ED. Neurologic exam was
without deficits on admission and head CT imaging was
reassuring. Toxic ingestion, overdose and alcohol withdrawal
were all considered, with laboratory and physical evidence of
alcohol withdrawal seizure. No clear evidence of toxidrome on
laboratory and physical exam work-up. He remained intubated and
required intensive sedation with Midazolam and Propofol
infusions, as well as Fentanyl for comfort. Diazepam was started
via his OGT as well. We switched him to Precedex to promote
down-titration of his narcotics and benzodiazepines, and we were
able to transition him to PO Diazepam for withdrawal concerns.
His electrolytes were optimized, although he had some
intermittent episodes of non-sustained ventricular tachycardia
which were short-lived and asymptomatic. Multivitamin, folate
and thiamine were all started on admission.
.
# ACUTE RESPIRATORY CONCERNS - Intubation for behavioral issues,
ventilating well, with copious brown liquid being suctioned from
ET tube initially; given these findings, there was some concern
for aspiration in the setting of seizure or peri-intubation. He
had low grade temperatures without leukocytosis on admission
attributed to his withdrawal physiology. Given his increased
sedation requirements, he required mechanical ventilatory
support. His CXR did demonstrated some evidence of pulmonary
congestion and possible consolidation concerning for aspiration
pneumonitis vs. pneumonia. He was antibiosed with Vancomycin and
Cefepime for pneumonia coverage given his sputum culture gram
stain demonstrating gram positive cocci and gram negative rods;
speciating commensal organisms only.
.
# SINUS TACHYCARDIA - Likely multifactorial and secondary to
hypovolemia and presumed alcohol withdrawal with sympathetic
overdrive; no obvious sources of infection and afebrile. EKG on
admission reassuring, with improvement in his rate following
sedation. His electrolytes were aggressively repleted.
.
# THROMBOCYTOPENIA - Patient presented with worsening
thrombocytopenia that stabilized following admission. He
demonstrated no evidence of active bleeding. He was maintained
on heparin prophylaxis without issue. He had no evidence of
infection.
.
# IDENTIFICATION - Identification was confirmed as [**Known firstname **] [**Known lastname **]
after 3-days of his hospital stay. Once identification was
confirmed, his medication reconcilitation was performed. His
brother arrived to confirm his identification.
.
Medications on Admission:
** none available per patient, have included past medical
history of [**Known firstname **] [**Known lastname **], the supposed identity of this patient **
- Thiamine 100mg daily
- Aspirin 81mg daily
- Diltiazem 120mg QID
- Atorvastatin 10mg daily
- Isosorbide Mononitrate SR 30mg daily
- Omeprazole 20mg daily
- Folic Acid 1mg daily
- MVI
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Alcohol withdrawal seizure
Secondary Diagnosis: Aspiration pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
patient eloped.
Followup Instructions:
patient eloped.
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icd9pcs
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[
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10539
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Discharge summary
|
Report
|
Admission Date: [**2182-12-11**] Discharge Date: [**2183-1-1**]
Date of Birth: [**2142-12-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Tetanus / Morphine
/ Cefoxitin / Codeine / Lactose
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Bronchoscopy
G-tube placement
History of Present Illness:
This is a 40-year-old with history of ALL s/p allo BMT [**2151**], c/b
radiation-induced pulmonary fibrosis, underwent left lower lobe
transplant [**2170**], this was c/b left mainstem bronchomalacia, s/p
stenting, recently s/p bronchoscopy on [**2182-12-9**] for cryo to
granulation tissue now presenting with respiratory distress.
.
History was obtained from medical records. On [**2182-12-9**], the
patient underwent bronchoscopy for cryotherapy debridment of the
metallic left main stent under rigid bronchoscopy followed by
esophageal dilation via thoracic surgery. Her post operative
course was complicated by respiratory distress and profound
bronchospasm, which responded to positive pressure noninvasive
ventilation and albuterol nebs. The patient was monitored
overnight, and discharged on [**2182-12-10**]. The patient presented to
an OSH ED on [**2182-12-11**] early am complaining of SOB that had
started the prior evening. At OSH ED the pt was noted to have a
pneumonia, and received levoquin 750mg and 500cc NS. The patient
was transfered to the [**Hospital1 18**] ED for further management.
.
At the [**Hospital1 18**] ED, the pt's initial vitals were 98.3 92 126/72 18
100% NRB. Patient was found to have worsening shortness of
breath, was tachypneic to 30s with ABG: 7.18/85/166. The pt was
intubated and bronchoscopy was performed. ABG after intubation
showed: 7.00/99/196. Vent changed with decreased volume and
increased rate. Blood pressures dropped after being sedated. An
A line and CVL (femoral) were placed. Sedation stopped with
improvement in blood pressures. Two liters IVF given. Patient
was started on neosynephrine with mild improvement in blood
pressures. Given Vanc/Zosyn.
Past Medical History:
-ALL - [**2147**], treated with Vincristine, prednisone,
Methotrexate, Adriamycin (total 450 mg/m2), 6MP and
L-Asparaginase, and cranial XRT. Bone marrow relapse [**2150**]
treated with COAP, stopped secondary to toxicity. Reinduced with
Prednisone, L-Asparaginase and oral Methotrexate in [**2151**] and
underwent allogeneic bone marrow transplant with whole body
radiation.
-Small bowel perforation - [**2167**]
-Pulmonary fibrosis and left lobe transplant - [**2170**],
complicated by pericardial and pleural effusion
-Staph aureus bronchitis - [**2171**]
-Left mainstem bronchomalacia, s/p stent placement [**2176**]
-Chronic sinus tachycardia
-Dyspnea on exertion and with lying supine
-G-tube placement
-Esophageal strictures - s/p multiple dilations
-Moderate MR ([**3-12**])
-Basal Cell Ca (Back - upper chest)
-Edentulous with full dentures due to major dental work (now
missing her lower dentures, as described above)
.
PAST SURGICAL HISTORY:
1- Surgical Debridement of thigh abcess from IM pentamidine [**2152**]
2- Appendectomy [**2163**]
3- Laparoscopy to remove ovarian cysts [**2162**]
4- S.P Small bowel perforation complicated with candidal and
bacterial paeritonitis requiring antifungals and antibiotics
5- Cholecystectomy
6- Pulmonary fibrosis S/P living related donor from father [**Name (NI) 25730**]
transplant)
7- Post pericardiotomy syndrome [**2170**]
8- L MS bronchomalacia
9- Bilat SAH
10- Ilesotomy and enterococcus fistula and reversed 10 months
later at [**Hospital1 112**]
11- Closing of enterocutaneous fistula and ostomy [**2174**]
12- S/P port placement for IV access [**9-7**]
13- LMS granuloma debridement and mitomycin
14- Esophageal dilatation [**2-11**] - [**7-11**]
15- Debridement of granulation tissue around stent
[**88**]- Pneumothorax post bronchoscopy with stent granulation tissue
debridement
Social History:
Patient lives independently and has fantastic family support.
She helps take care of her 2-year-old nephew and 1-month-old
niece 5 days/week. She has never smoked. She does not drink
alcohol on a regular basis.
Family History:
Parents are both living. Father (66; aortic stenosis); Mother
(65 years; smoking, hyperlipidemia). She has 3 siblings (one
brother has a history of testicular cancer). She has no
children.
Physical Exam:
VS: Afebrile, 130, 100/58, 34, 100% on AC
Gen: Petite woman, appears older than stated age, sedated
HEENT: left pupil>right pupil, both reactive, no icterus, MMM
Neck: Supple, no cervical LAD, no supraclavicular LAD
Heart: tachycardic, no m/r/g
Pulm: Coarse & diffuse bronchial breath sounds and rhonchi
bilateral anteriorly
Chest: left chest port in place
Abd: soft, flat, NT/ND, no hepatosplenomegaly
Ext: 2+ pulses, warm, no cyanosis or edema
Neuro: Sedated, does not respond to noxious stimuli
Skin: No rashes
Pertinent Results:
Labs on admission:
.
[**2182-12-11**] 07:18AM WBC-25.3* RBC-3.03* HGB-9.1* HCT-27.6* MCV-91
MCH-30.0 MCHC-32.9 RDW-14.0
[**2182-12-11**] 07:18AM NEUTS-83* BANDS-6* LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2182-12-11**] 07:18AM PT-15.1* PTT-25.5 INR(PT)-1.3*
[**2182-12-11**] 07:24AM LACTATE-0.7
[**2182-12-11**] 04:12PM GLUCOSE-66* UREA N-8 CREAT-0.2* SODIUM-142
POTASSIUM-4.3 CHLORIDE-115* TOTAL CO2-21* ANION GAP-10
.
CT CHEST/ABDOMEN/PELVIS [**2182-12-22**]
1. Interval improvement in right lower lobe consolidation,
however
development of patchy consolidations and ground-glass opacities
throughout
almost the entire left lung. Ground-glass opacity also involves
the right
lower lobe and right upper lobe. The differential diagnosis is
broad, as
findings are nonspecific, and includes infection, edema and
hemorrhage.
2. No specific signs of empyema, however, superinfection of
simple pleural
effusions cannot be excluded.
3. No abdominal fluid collection.
4. Decompressed distal descending and sigmoid colon. No clear
wall thickening.
5. Trace abdominal ascites.
6. Mild perirectal stranding. The differential diagnosis
includes proctitis and third spacing in the setting of fluid
overload.
.
ECHO [**2182-12-23**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**1-5**]+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild moderate mitral regurgitation. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function.
Compared with the prior study (images reviewed) of [**2181-3-6**], the
findings are similar.
.
CLINICAL IMPLICATIONS:
Based on [**2179**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
G-TUBE PLACEMENT [**2182-12-25**]:
Successful uncomplicated placement of 12 French Wills-[**Doctor Last Name 12433**]
gastrostomy feeding tube. The tube can be used after 24 hours
and needs to be left to
gravity drainage overnight.
.
LENIS [**2182-12-20**]:
No evidence of deep vein thrombosis in either leg.
.
ABDOMINAL ULTRASOUND [**2182-12-31**]: No ascites in all four
quadrants. No subcutaneous fluid collection about G-tube
insertion site.
Brief Hospital Course:
This is a 40-year-old woman with a history of ALL, s/p BMT [**2151**]
complicated by radiation therapy-related pulmonary fibrosis
requiring LLL lung transplant from her father [**5-/2171**] (on no
immunosuppresants), further complicated by L main stem bronchus
stenosis s/p metal stent placement [**9-/2176**] requiring serial
debridements over the years who on [**2182-12-9**] had bronchoscopy with
debridement/cryotherapy and EGD with esophageal dilatation and
presents [**2182-12-11**] with hypercarbic respiratory failure.
# RESPIRATORY FAILURE: One day prior to admission, patient
underwent IP stenting, debridement and re-opening of stenosis as
well as esophageal manipulation. On admisison, Ms. [**Known lastname 27785**] had
impressive multi-focal infiltrates suggestive of overwhelming
pneumonia, likely the result of recent manipulations. Patient
was started on broad spectrum antibiotics (initially Vanc/
zosyn/ levoflox/ tobramycin/ tamiflu-->subsequently
Naf/Cipro/zosyn/Azithro then Naf/Vanc/Cipro/Azithro); her final
antibiotic regimen includes VANCOMYCIN and CEFEPIME. She will
finish a 14-day course of vancomycin and cefepime on [**2183-1-6**].
.
Ms. [**Known lastname 27785**] was eventually extubated on [**12-20**] however, became
increasingly tachycardic and tachypneic with RR of 40 and was
unable to speak in full sentances. Ms. [**Known lastname 27785**] was re-intubated
on [**12-21**]. She underwent bronchoscopy on [**12-24**] for evaluation of
stent patency (was patent). Lower extremity dopplers on [**12-20**]
were negative for DVTs. Percutaneous Tracheostomy was placed on
[**12-27**] and ventilator setting were slowly weaned. Prior to
transfer, patient was doing well on trach collar. She
occasionally required suctioning for mucus plugging.
.
# LEUKOCYTOSIS: Trended down once antibiotics changed to Vanco
and Cefepime on [**12-22**]. All repeat cultures NGTD. Only culture
pending is a B-glucan.
.
# HYPOTENSION: Patient had hypotension requiring neosynephrine.
This was felt to be secondary to infection/sepsis, sedation and
PEEP. Pressors were weaned off on [**12-26**] and she remained
hemodynamically stable with MAP> 55-60.
.
#. RIGHT GOING HEMATOMA: Small hematoma at sight of prior
femoral line.
.
# ELEVATED LIVER ENZYMES: with mixed pattern of hepatocellular
injury and cholestasis. DDx is resolving shock, drug toxicity
and also acalculous cholecystitis. Per US on [**12-13**], Ms. [**Known lastname 27785**]
is status-post cholecystectomy. Enzymes are trending down.
.
# MALNUTRITION WITH COAGULOPATHY, ANEMIA, AND HYPOCALCEMIA: A
G-tube was placed and Ms. [**Known lastname 27785**] was started on Nutren
Pulmonary TFs. These were supplemented with MCT. Banana flakes
were added for diarrhea; c.diff was negative.
.
# ANEMIA: Hematocrit basically remained stable throughout
hospitalization. Patient was guaiac positive from below
intermittently, though unclear source. Ms. [**Name14 (STitle) 34709**] was
maintained on an H2 blocker.
.
# ANXIETY AND NIGHTMARES: Amitryptyline 20 qhs.
.
# ABDOMINAL PAIN: Ms. [**Known lastname 27785**] complained of abdominal pain
around the site of her G-tube. An ultrasound was performed on
[**12-31**], which was negative for subcutaneous fluid collection
about G-tube insertion site.
.
# POSITIVE B-GLUCAN: B-glucan was positive during admission.
There are multiple reasons for a positive B-glucan aside from
fungal infection. Ms. [**Known lastname 27785**] was [**Doctor Last Name **] exceptionally well on
vancomycin and cefepime and as such, fungal coverage was not
started. If patient does poorly, she will need to be
re-evaluated with fungal infection on the differential.
Medications on Admission:
Per records, unable to be reconciled
amitriptyline 20 mg daily, carvedilol 6.25 mg [**Hospital1 **], codeine
sulfate 15 mg q4-6h prn cough, estradiol 10 mcg vaginal
suppository 3x weekly, estradiol-levonorgestrel 0.045-0.015
mg/24 hr TD weekly, cholecalciferol 1,000U daily, medium chain
triglycerides (7.7 kcal/mL) 1 tbsp TID (pt cannot afford med
yet), Nutren Pulmonary Lacfree 3 cans daily, polyvinyl alcohol
drops prn, Vit K 100mcg daily
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-5**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
4. amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheeze.
8. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dryness.
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
10. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
12. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain or fever.
13. medium chain triglycerides 7.7 kcal/mL Oil Sig: Fifteen (15)
ML PO BID (2 times a day).
14. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
17. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
18. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours).
19. diphenhydramine HCl 50 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for itching.
20. lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for anxiety, insomnia.
21. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours).
22. fentanyl citrate (PF) 50 mcg/mL Solution Sig: One (1)
Injection Q4H (every 4 hours) as needed for breakthrough pain.
23. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
24. heparin lock flush (porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
25. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**]
Discharge Diagnosis:
1. Pneumonia
2. Respiratory failure
3. Tracheostomy and G-tube placement
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:
Dear Ms. [**Known lastname 27785**],
It was a pleasure taking care of you on this admission. You
came to the hospital with a bad pneumonia. We treated you with
antibiotics and you improved. A bronchoscopy revealed a patent
stent. It was difficult to wean you from the ventilator so we
ended up putting in a tracheostomy. You are doing very well
with the trach, and hopefully you will continue to wean at
rehab.
.
Please see the attached updated medication list.
.
Please keep all of your follow-up appointments.
.
Return to the hospital if you develop worsening shortness of
breath, chest pain, nausea, vomiting, diarrhea, headache,
fevers, chills, or any other concerning signs or symptoms.
Followup Instructions:
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2183-1-13**] at 6:45 AM ARRIVAL
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5072**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2183-1-13**] at 7:30 AM [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2183-1-13**] at 8:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5072**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST PROCEDURAL CENTER
When: MONDAY [**2183-1-13**] at 8:00 AM
With: WPC ROOM TWO [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
NOTE: NOTHING TO EAT OR DRINK AFTER MIDNITE BEFORE THESE APPTS
ON [**2183-1-13**]. YOU WILL ALSO BE HAVING A FLEXIBLE BRONCHOSCOPY ON
THIS DAY. ANY QUESTIONS, CALL DR [**Last Name (STitle) **].
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Discharge summary
|
Report
|
Admission Date: [**2184-3-27**] Discharge Date: [**2184-3-28**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
88yo woman with PMH CAD on plavix was found down by her
daughter at 7AM today. Initially she was arousable and
complained
of headache. She was taken to OSH by ambulance where she
reportedly decompensated in the ED requiring intubation. BP was
recorded as 184/84. Head CT revealed large posterior fossa IPH.
She was life flighted to [**Hospital1 18**] and Neurosurgery consultation was
requested.
Past Medical History:
Celiac Disease
CAD
DM
Pacemaker
Hysterectomy
MI s/p stents and plasty. most recently in [**2179**] @ [**Hospital1 2025**]
Social History:
married, lives with husband and daughter. no e/t/d
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
GCS: E-3 V-1 M-6
O: BP: 184/84 HR: 83 R 14 O2Sats 100%
Gen: Intubated and sedated (prop held for exam)
HEENT: Pupils: 3mm sluggish b/l. + corneals, + gag
Neck: hard collar
Extrem: Warm and well-perfused
Neuro:
Mental status: EO to voice
Cranial Nerves:
II: Pupils equally round and reactive to light 3mm, very
sluggish
mm bilaterally.
Motor: MAE's. B/L UE's antigravity to command
On Discharge:
No [**Last Name (LF) **], [**First Name3 (LF) 2995**] to noxious
Pertinent Results:
[**2184-3-27**] 03:00PM PLT COUNT-226
[**2184-3-27**] 03:00PM PT-13.8* PTT-18.8* INR(PT)-1.2*
[**2184-3-27**] 03:00PM NEUTS-92.9* LYMPHS-4.2* MONOS-1.9* EOS-0.6
BASOS-0.4
[**2184-3-27**] 03:00PM WBC-10.3 RBC-3.86* HGB-12.2 HCT-35.5* MCV-92
MCH-31.5 MCHC-34.3 RDW-13.6
[**2184-3-27**] 03:00PM CALCIUM-9.6 PHOSPHATE-3.1 MAGNESIUM-1.3*
[**2184-3-27**] 03:00PM CK-MB-3 cTropnT-<0.01
[**2184-3-27**] 03:00PM CK(CPK)-48
[**2184-3-27**] 03:00PM estGFR-Using this
[**2184-3-27**] 03:00PM GLUCOSE-186* UREA N-20 CREAT-1.0 SODIUM-136
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18
[**2184-3-27**] 03:08PM GLUCOSE-181* LACTATE-3.1* K+-4.7
[**2184-3-27**] 03:45PM TYPE-ART PO2-252* PCO2-38 PH-7.38 TOTAL
CO2-23 BASE XS--1 INTUBATED-INTUBATED
[**2184-3-27**] 05:40PM URINE MUCOUS-RARE
[**2184-3-27**] 05:40PM URINE RBC-1 WBC-125* BACTERIA-FEW YEAST-NONE
EPI-<1 RENAL EPI-<1
[**2184-3-27**] 05:40PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2184-3-27**] 05:40PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.026
CHEST (PORTABLE AP) Study Date of [**2184-3-27**] 2:50 PM FINDINGS:
Endotracheal tube ends 3.0 cm above the carina. An NG tube
passes beyond the GE junction into the antrum of the stomach.
There are low lung volumes but no evidence of pleural effusion
or pneumothorax. Mild left retrocardiac opacity likely
represents atelectasis.
IMPRESSION:
1. ET tube ends 3 cm above the carina.
2. Left basilar opacity, likely atelectasis, but aspiration is
not excluded.
CTA HEAD W&W/O C & RECONS Study Date of [**2184-3-27**] 3:38 PM
Preliminary Report !! WET READ !!
No evidence of aneuryms. However, reformats which are necessary
for
interpretation are still pending.
CT HEAD W/O CONTRAST Study Date of [**2184-3-27**] 11:12 PM
Findings compatible with rapidly-evolving obstructive
hydrocephalus due to extensive intraventricular hemorrhage,
predominately in the fourth ventricle, with extension into
prepontine cisterns and occipital horns. Focal hemorrhage may
also be present in the left cerebellum. Left parietal and left
supratentorial subdural hemorrhage are not well seen on
preceding outside exam.
Brief Hospital Course:
Pt was admitted to the neurosurgery service for close
observation. Upon admission a discussion was held with the
daughter (official HCP). She wished to make her mother DNR. She
was told the risk of developing hydrocephalus and need for EVD
placement. She said she would think about this but was not sure
if she would want to proceed with it.
Overnight on [**3-27**] - [**3-28**] the patient became less responsive. A
head CT was obtained which revealed developing hydrocephalus.
The daughter was [**Name (NI) 653**] and said that she did not want to
proceed with the EVD. The patient was made CMO at that time and
extubated at approximately 6AM.
The daughter [**Name (NI) 653**] the ICU later in the morning and
requested that the patient be transferred to [**Hospital3 15402**] so that
she would be closer to home. The bed facilitator was [**Hospital3 653**]
and once transport was arranged she was discharged.
Medications on Admission:
Medications prior to admission:
Nitroglycerine
Plavix
glucophage
metoprolol
gemfibrozil
alprazolam
isosorbide mononitrate
flagyl
Discharge Medications:
1. morphine (PF) in D5W 100 mg/100 mL (1 mg/mL) Parenteral
Solution Sig: 5-20 mg Intravenous TITRATE TO (titrate to desired
clinical effect (please specify)).
2. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
3. midazolam in 0.9 % NaCl 1 mg/mL Solution Sig: 5-20 mg
Intravenous TITRATE TO (titrate to desired clinical effect
(please specify)).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
cerebellar hemorhage, hydrocephelus
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.
Discharge Instructions:
Pt is DNR/DNI and CMO. Transfer to [**Hospital3 15402**] per family's
request.
Followup Instructions:
N/A
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2184-3-28**]
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| 0
| 0
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| 22
| 0
| 0
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| 0
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| 125
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98,198
| 122,654
|
35910
|
Discharge summary
|
Report
|
Admission Date: [**2176-1-4**] Discharge Date: [**2176-1-26**]
Date of Birth: [**2117-6-30**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
MRI under anesthesia
[**1-8**]: Open left parietal craniotomy for biopsy
History of Present Illness:
Mr [**Name13 (STitle) 4027**] is a 58 y/o right handed man with history of DM2
and CAD who presented from OSH with increasing confusion,
forgetfulness, peripheral vision loss and agraphia. The patient
was in his usual state of health until [**2175-12-28**] when he was in a
minor car accident after making a wrong turn on a familiar
street, hitting a post from the R side. He was not injured in
the
fender-bender. The next day, he was forgetful and left his car
door open when at work. On Saturday [**12-30**], he stated to his wife
that he felt "muttled", but did not complain of any specific
deficits nor did his wife note any. However, the next day his
daughter reported that he mixed up words when speaking with her.
On Monday ([**1-1**]), he could not remember his address when asked
by
the auto-mechanic. He was able to go to work at court, but was
worried when he could not figure out how to sign his name.
Specifically, he had difficulty writing letters and was
perseverative. Though he knew what he wanted to write, he was
not
able to do so correctly. This event prompted him to consult his
PCP who discovered [**Name Initial (PRE) **] small right peripheral visual field deficit
which Mr. [**Name (NI) 21862**] wife states was "about 10% of his vision".
He
had never had this before. He had no headache. His doctor
requested a head CT which he had on [**1-3**]. The CT scan revealed a
left parietal/occipital mass. The next day, his symptoms
persisted and he was admitted to this hospital.
Per his wife, in the days leading up to admission, Mr. [**Name13 (STitle) 4027**]
did not have any fever, cough, weight changes, nausea, vomiting,
or diarrhea, or other signs of infection. He did not complain of
numbness, weakness, tingling, or hearing changes. No recent
travel or tick exposure. Most recent immunization was Influenza
vaccine in [**2175-9-20**], which he had received in prior years
without problems. [**Name (NI) **] prior such episodes.
On admission, his R visual field cut was noted to be more
pronounced. Over the next couple of days([**Date range (1) 61317**])), he had
decreased speech production, decreased attention, and decreased
orientation to his surroundings. He could not remember how to
use
the phone. Because of his clinical deterioration and concern for
high-grade glioma, on [**1-8**], he had a stereotactic brain biopsy
of
the left occipital/parietal mass. He was intubated and sedated
until the morning of [**1-9**]. During the night he was noted to not
be moving his RUE as much as the left, stat head CT was
unchanged. He was extubated and given Haldol 2.5mg for
aggitation
at 9:30am (1.5 hours before exam). He has been on broad-spectrum
empiric Abx (Vanc/gent/Levoflox) given concern for abscess
though
prelim path gram stain was sterile. He has also been placed on
empiric Keppra prophylaxis though no clinical episodes
concerning
for seizure.
Past Medical History:
1. DM2 with poor control and peripheral neuropathy
2. Coronary artery disease s/p CABGx4 and stent deployment circa
[**2164**]
3. Obstructive sleep apnea (uses CPAP at night)
4. Obesity
5. Dyslipidemia
6. Seasonal Allergies
Social History:
The patient is an atorney in [**State 1727**]. He is a college graduate
and received the highest possible score on his LSAT examination.
He is married for 29 years and lives with his wife. [**Name (NI) **] does not
use drugs. He has never had a blood transfusion.
Wife [**Name (NI) **] may be reached at [**Telephone/Fax (1) 81578**], Daughter [**Name (NI) **] may
be reached at [**Telephone/Fax (1) 81579**].
Family History:
No family history of demyelinating disease such as MS, no
history of neurologic conditions or autoimmune disorders.
Physical Exam:
T-97.5 BP-131/64 (126-154/57-65) HR-93(74-91)SR RR-20 O2Sat-95%
on Fi40% ventimask
Gen: Lying in bed restrained, NAD
HEENT: Has neurosurgical wound on posterior left aspect of head,
dry oral mucosa.
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: Unable to assess
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Ext: no edema
Skin: No rashes
Neurologic examination:
MS:
General: Awake but drowsy, normal affect, very perseverative
Orientation: Not oriented to person, place, time, or situation.
Attention: Very inattentive, but temporarily redirectable.
Speech/[**Doctor Last Name **]: He is able to express basic thoughts and give basic
yes/no replies; comprehension intact to simple commands,
repetition intact to "today is a sunny day" but impaired to more
abstarct sentence, could not name or read but claimed to not be
able to see what was being shown and was inattentive
Memory: N/A due to inattention
Calculations: N/A due to inattention
L/R confusion: Appears confused, but difficult to assess given
inattentiveness
Praxis: N/A due to inattention
CN:
I: not tested
II,III: Patient inattentive but appears to have a right
homonomous hemianopsia, PERRL 2mm to 1.5mm,
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**4-23**] on Left, [**2-22**] on right.
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and ?mild increased tone RLE; no tremor,
asterixis or myoclonus.
Pronator drift N/A due to inattention.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 5 5 5 5 5 5
R 3 3 3 3 3 3 3
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 4- 4- 4- 4- 4- 4-
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0 0 0 2 0 Extensor
R 0 0 0 2 0 Extensor
Sensation: grimaces and attempts withdrawal from noxious in all
extremities purposefully
Coordination: finger-nose-finger normal on left but R not assess
given hemiparesis.
Gait: N/A
Romberg: N/A
Pertinent Results:
[**2176-1-26**] 06:08AM BLOOD WBC-9.1 RBC-3.72* Hgb-10.7* Hct-32.6*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.4 Plt Ct-121*
[**2176-1-24**] 05:40AM BLOOD WBC-12.9* RBC-3.98* Hgb-11.9* Hct-35.0*
MCV-88 MCH-29.8 MCHC-33.9 RDW-15.7* Plt Ct-186
[**2176-1-23**] 08:40AM BLOOD WBC-9.4 RBC-4.03* Hgb-11.8* Hct-34.9*
MCV-87 MCH-29.3 MCHC-33.9 RDW-15.7* Plt Ct-152
[**2176-1-22**] 09:40PM BLOOD WBC-11.1* RBC-4.03* Hgb-12.0* Hct-35.3*
MCV-88 MCH-29.8 MCHC-34.1 RDW-15.5 Plt Ct-156
[**2176-1-19**] 06:09AM BLOOD WBC-11.9* RBC-4.14* Hgb-12.1* Hct-35.1*
MCV-85 MCH-29.2 MCHC-34.4 RDW-15.3 Plt Ct-185
[**2176-1-18**] 06:15AM BLOOD WBC-11.4* RBC-4.12* Hgb-12.4* Hct-35.5*
MCV-86 MCH-30.0 MCHC-34.8 RDW-15.4 Plt Ct-180
[**2176-1-16**] 05:25AM BLOOD WBC-10.7 RBC-4.40* Hgb-13.1* Hct-38.0*
MCV-86 MCH-29.6 MCHC-34.4 RDW-15.4 Plt Ct-209
[**2176-1-14**] 07:20AM BLOOD WBC-7.7 RBC-4.35* Hgb-12.7* Hct-37.5*
MCV-86 MCH-29.2 MCHC-33.8 RDW-15.2 Plt Ct-221
[**2176-1-13**] 07:45AM BLOOD WBC-6.1 RBC-4.08* Hgb-12.0* Hct-35.5*
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.9 Plt Ct-205
[**2176-1-12**] 04:13AM BLOOD WBC-7.4 RBC-3.70* Hgb-11.1* Hct-31.3*
MCV-85 MCH-30.1 MCHC-35.6* RDW-15.3 Plt Ct-181
[**2176-1-11**] 03:05AM BLOOD WBC-11.0 RBC-3.98* Hgb-11.6* Hct-33.5*
MCV-84 MCH-29.1 MCHC-34.6 RDW-15.2 Plt Ct-207
[**2176-1-10**] 02:44AM BLOOD WBC-9.3 RBC-4.16* Hgb-12.1* Hct-35.2*
MCV-85 MCH-29.1 MCHC-34.4 RDW-15.4 Plt Ct-187
[**2176-1-9**] 07:26PM BLOOD WBC-13.9* RBC-4.06* Hgb-11.9* Hct-34.3*
MCV-85 MCH-29.4 MCHC-34.8 RDW-15.5 Plt Ct-184
[**2176-1-9**] 03:26AM BLOOD WBC-13.2* RBC-4.02* Hgb-11.8* Hct-33.7*
MCV-84 MCH-29.4 MCHC-35.1* RDW-15.6* Plt Ct-205
[**2176-1-8**] 04:14PM BLOOD WBC-11.6* RBC-4.31* Hgb-12.7* Hct-36.7*
MCV-85 MCH-29.4 MCHC-34.5 RDW-15.3 Plt Ct-220
[**2176-1-7**] 07:50AM BLOOD WBC-8.2 RBC-4.61 Hgb-13.5* Hct-40.0
MCV-87 MCH-29.3 MCHC-33.7 RDW-15.2 Plt Ct-188
[**2176-1-6**] 07:25AM BLOOD WBC-8.5 RBC-4.39* Hgb-12.7* Hct-37.5*
MCV-86 MCH-29.1 MCHC-33.9 RDW-15.3 Plt Ct-200
[**2176-1-5**] 05:48AM BLOOD WBC-11.6* RBC-4.19* Hgb-12.6* Hct-36.2*
MCV-87 MCH-30.1 MCHC-34.8 RDW-15.3 Plt Ct-194
[**2176-1-4**] 01:45AM BLOOD WBC-10.0 RBC-4.35* Hgb-12.8* Hct-37.1*
MCV-85 MCH-29.5 MCHC-34.6 RDW-15.5 Plt Ct-235
[**2176-1-3**] 11:00PM BLOOD WBC-10.9 RBC-4.58* Hgb-13.4* Hct-38.8*
MCV-85 MCH-29.2 MCHC-34.4 RDW-15.4 Plt Ct-230
[**2176-1-18**] 06:15AM BLOOD Neuts-75.4* Lymphs-17.5* Monos-6.0
Eos-0.7 Baso-0.4
[**2176-1-3**] 11:00PM BLOOD Neuts-68.2 Lymphs-20.7 Monos-5.6 Eos-4.5*
Baso-1.0
[**2176-1-23**] 08:40AM BLOOD PT-14.0* PTT-23.0 INR(PT)-1.2*
[**2176-1-22**] 10:30AM BLOOD PT-13.7* PTT-22.7 INR(PT)-1.2*
[**2176-1-12**] 04:13AM BLOOD PT-15.2* PTT-20.7* INR(PT)-1.3*
[**2176-1-11**] 03:05AM BLOOD PT-14.5* PTT-20.9* INR(PT)-1.3*
[**2176-1-10**] 02:44AM BLOOD PT-14.9* PTT-23.3 INR(PT)-1.3*
[**2176-1-9**] 03:26AM BLOOD PT-14.4* PTT-21.9* INR(PT)-1.3*
[**2176-1-8**] 04:14PM BLOOD PT-14.3* PTT-24.4 INR(PT)-1.2*
[**2176-1-7**] 07:50AM BLOOD PT-15.0* PTT-26.1 INR(PT)-1.3*
[**2176-1-6**] 07:25AM BLOOD PT-14.2* PTT-25.1 INR(PT)-1.2*
[**2176-1-5**] 05:48AM BLOOD PT-14.7* PTT-24.5 INR(PT)-1.3*
[**2176-1-4**] 01:45AM BLOOD PT-15.1* PTT-24.4 INR(PT)-1.3*
[**2176-1-3**] 11:00PM BLOOD PT-14.7* PTT-24.5 INR(PT)-1.3*
[**2176-1-4**] 01:45AM BLOOD ESR-28*
[**2176-1-26**] 06:08AM BLOOD Glucose-81 UreaN-10 Creat-0.7 Na-138
K-3.3 Cl-101 HCO3-27 AnGap-13
[**2176-1-24**] 05:40AM BLOOD Glucose-80 UreaN-12 Creat-0.9 Na-140
K-4.2 Cl-105 HCO3-26 AnGap-13
[**2176-1-23**] 08:40AM BLOOD Glucose-164* UreaN-15 Creat-0.8 Na-138
K-3.7 Cl-105 HCO3-26 AnGap-11
[**2176-1-22**] 09:40PM BLOOD Glucose-259* UreaN-17 Creat-0.9 Na-140
K-4.3 Cl-103 HCO3-26 AnGap-15
[**2176-1-19**] 06:09AM BLOOD Glucose-54* UreaN-19 Creat-0.8 Na-141
K-3.5 Cl-106 HCO3-26 AnGap-13
[**2176-1-18**] 06:15AM BLOOD Glucose-112* UreaN-18 Creat-0.8 Na-140
K-3.9 Cl-107 HCO3-26 AnGap-11
[**2176-1-17**] 06:15AM BLOOD Glucose-155* UreaN-18 Creat-0.8 Na-137
K-4.4 Cl-101 HCO3-27 AnGap-13
[**2176-1-16**] 05:25AM BLOOD Glucose-216* UreaN-18 Creat-0.7 Na-139
K-4.4 Cl-104 HCO3-28 AnGap-11
[**2176-1-14**] 07:20AM BLOOD Glucose-235* UreaN-22* Creat-0.8 Na-137
K-4.2 Cl-102 HCO3-27 AnGap-12
[**2176-1-13**] 07:45AM BLOOD Glucose-262* UreaN-22* Creat-0.8 Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
[**2176-1-12**] 04:13AM BLOOD Glucose-270* UreaN-22* Creat-0.8 Na-138
K-4.1 Cl-104 HCO3-28 AnGap-10
[**2176-1-11**] 03:05AM BLOOD Glucose-111* UreaN-19 Creat-0.7 Na-138
K-4.3 Cl-103 HCO3-29 AnGap-10
[**2176-1-10**] 02:44AM BLOOD Glucose-172* UreaN-12 Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
[**2176-1-9**] 03:26AM BLOOD Glucose-263* UreaN-15 Creat-0.8 Na-136
K-3.9 Cl-104 HCO3-23 AnGap-13
[**2176-1-8**] 04:14PM BLOOD Glucose-228* UreaN-18 Creat-1.0 Na-135
K-5.4* Cl-102 HCO3-23 AnGap-15
[**2176-1-7**] 07:50AM BLOOD Glucose-275* UreaN-16 Creat-0.8 Na-136
K-4.4 Cl-101 HCO3-23 AnGap-16
[**2176-1-6**] 07:25AM BLOOD Glucose-192* UreaN-14 Creat-0.8 Na-136
K-4.4 Cl-100 HCO3-26 AnGap-14
[**2176-1-6**] 07:25AM BLOOD Glucose-192* UreaN-14 Creat-0.8 Na-136
K-4.4 Cl-100 HCO3-26 AnGap-14
[**2176-1-5**] 05:48AM BLOOD Glucose-171* UreaN-16 Creat-0.7 Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2176-1-4**] 01:45AM BLOOD Glucose-174* UreaN-14 Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-27 AnGap-13
[**2176-1-3**] 11:00PM BLOOD Glucose-105 UreaN-13 Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-26 AnGap-14
[**2176-1-24**] 05:40AM BLOOD ALT-72* AST-54* LD(LDH)-277* AlkPhos-84
TotBili-0.5
[**2176-1-17**] 06:15AM BLOOD ALT-91* AST-43* LD(LDH)-271* CK(CPK)-229*
AlkPhos-88 TotBili-0.5
[**2176-1-10**] 02:08PM BLOOD ALT-62* AST-53* LD(LDH)-217 AlkPhos-96
Amylase-14 TotBili-0.3
[**2176-1-9**] 03:26AM BLOOD CK(CPK)-1776*
[**2176-1-8**] 04:14PM BLOOD CK(CPK)-196*
[**2176-1-4**] 01:45AM BLOOD ALT-42* AST-38 AlkPhos-101 TotBili-0.4
[**2176-1-10**] 02:08PM BLOOD Lipase-11
[**2176-1-9**] 03:26AM BLOOD CK-MB-30* MB Indx-1.7 cTropnT-<0.01
[**2176-1-8**] 04:14PM BLOOD CK-MB-5 cTropnT-<0.01
[**2176-1-24**] 05:40AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.1 UricAcd-5.2
[**2176-1-22**] 09:40PM BLOOD Calcium-8.4 Phos-2.4*# Mg-2.0
[**2176-1-18**] 06:15AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.4
[**2176-1-17**] 06:15AM BLOOD TotProt-6.6 Albumin-3.5 Globuln-3.1
Calcium-8.2* Phos-3.5 Mg-2.4
[**2176-1-12**] 04:13AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.3
[**2176-1-11**] 03:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.3
[**2176-1-10**] 02:08PM BLOOD Albumin-3.6
[**2176-1-10**] 02:44AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
[**2176-1-9**] 03:26AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
[**2176-1-8**] 04:14PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
[**2176-1-6**] 07:25AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2
[**2176-1-5**] 05:48AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
[**2176-1-4**] 01:45AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
[**2176-1-10**] 02:08PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2176-1-10**] 02:08PM BLOOD HCG-<5
[**2176-1-23**] 06:57PM BLOOD PSA-0.1
[**2176-1-10**] 02:08PM BLOOD AFP-1.9
[**2176-1-4**] 01:45AM BLOOD CRP-8.9*
[**2176-1-17**] 06:15AM BLOOD PEP-NO SPECIFI
[**2176-1-18**] 06:15AM BLOOD HIV Ab-NEGATIVE
[**2176-1-11**] 07:42AM BLOOD Vanco-12.1
[**2176-1-10**] 02:08PM BLOOD HCV Ab-NEGATIVE
[**2176-1-10**] 02:54AM BLOOD Type-ART pO2-96 pCO2-44 pH-7.40
calTCO2-28 Base XS-1
[**2176-1-9**] 12:30PM BLOOD Type-ART pO2-110* pCO2-44 pH-7.37
calTCO2-26 Base XS-0
[**2176-1-9**] 08:45AM BLOOD Type-ART pO2-155* pCO2-36 pH-7.42
calTCO2-24 Base XS-0
[**2176-1-9**] 03:34AM BLOOD Type-ART pO2-102 pCO2-38 pH-7.45
calTCO2-27 Base XS-2
[**2176-1-8**] 10:09PM BLOOD Type-ART pO2-91 pCO2-33* pH-7.46*
calTCO2-24 Base XS-0
[**2176-1-8**] 06:37PM BLOOD Type-ART pO2-240* pCO2-39 pH-7.41
calTCO2-26 Base XS-0
[**2176-1-8**] 04:30PM BLOOD Type-ART pO2-232* pCO2-47* pH-7.35
calTCO2-27 Base XS-0
[**2176-1-8**] 01:45PM BLOOD Type-ART pO2-204* pCO2-36 pH-7.44
calTCO2-25 Base XS-1 Intubat-INTUBATED
[**2176-1-8**] 11:48AM BLOOD Type-ART pO2-199* pCO2-41 pH-7.41
calTCO2-27 Base XS-1 Intubat-INTUBATED Vent-CONTROLLED
ANGIOTENSIN CONVERTING 10 [**8-/2134**] U/L
ENZYME
MRI Brain [**2176-1-4**]:
CONCLUSION: Left parietal lesion with inhomogeneous peripheral
enhancement,
surrounding edema, and strikingly slow diffusion in portions of
the periphery.
Although a malignant neoplasm must be considered, the properties
of the
margin, including the diffusion characteristics, raise the
possibility of an
inflammatory or demyelinating process as discussed above.
CT Abd, pelvis [**2176-1-5**]:
IMPRESSION:
1. Large left retroperitoneal soft tissue mass as well as large
retroperitoneal lymphadenopathy. Primary diagnostic
considerations include
paraganglioma, extra-adrenal pheochromocytoma and metastatic
disease.
2: Cholelithiasis.
CT Chest: [**2176-1-5**]:
Airways are patent to the subsegmental levels bilaterally. Lung
volumes are
low bilaterally. Bibasilar dependent atelectasis is visualized.
No focal
pulmonary nodule or mass is visualized. There is no axillary or
mediastinal
lymphadenopathy. Atherosclerotic calcification is visualized of
the coronary
arteries as well as of the aorta. The heart and great vessels
are otherwise
unremarkable. Note is made of a large amount of mediastinal fat.
A large right
pretracheal node measures 13x12 mm (3:14). A large right
epicardiac node
measures 13x9 mm
Brain mass pathology:
1. "Left occipital lobe tumor #1" (A - B):
Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).
2. "Left occipital lobe tumor #2" (C - D):
Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).
3. "Left deep occipital tumor" (E - F):
Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).
4. "Left occipital lobe tumor" (G):
Leptomeninges and gliotic white matter.
Note: By immunohistochemistry (blocks A-D), the majority of the
lymphocytes are CD-3 and CD-8 positive cytotoxic cells. A
smaller subset stains positive for CD4. Only rare scattered
B-lymphocytes are present, marking with CD20. CD68 highlights
the diffuse infiltrates of macrophages within the white matter.
Polyoma virus ([**Male First Name (un) 2326**] and SV40), EBV latent membrane protein (LMP),
and CMV immunostains are negative. . Special stains were
performed on blocks A-D. Luxol fast blue (LFB) shows a near
complete loss of myelin staining in the white matter, with
scattered staining present within macrophages. No hemosiderin
deposition is seen on iron stain arguing against a chronic
vasculitis. Bodian stain reveals areas within the white matter
showing preserved demyelinated axons. In other white matter
areas there is axon loss.
The findings supportive of an acute and chronic primary
demyelinating disorder (e.g., multiple sclerosis).
Clinical: Specimen submitted: 1. Left occipital lobe tumor #1 2.
Left occipital lobe tumor #2 3. Deep left occipital tumor 4.
Left occipital lobe tumor.
Clinical diagnosis and data: Tumor left brain.
Gross: The specimen is received fresh in four parts, labeled
with the patient's name, "[**Known lastname **], [**Known firstname **]" and the medical record
number.
Part 1 is additionally labeled "left occipital lobe tumor #1".
It consists of multiple tan-pink soft tissue fragments measuring
0.7 x 0.7 x 0.4 cm in aggregate. 50% of the specimen was frozen
and smeared and the intraoperative diagnosis by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: "Brain with loss of parenchyma, macrophage,
infiltrate, and gliosis and scattered atypical astroglia". The
specimen is entirely submitted as follows: A = frozen section
remnant, B = remaining tissue.
Part 2 is additionally labeled "#2 frozen left occipital tumor".
It consists of multiple tan-pink soft tissue fragments measuring
1.5 x 0.7 x 0.3 cm in aggregate. 50% of the specimen was frozen
and smeared and the intraoperative diagnosis by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: "Destructive white matter process, with gliosis,
macrophages and scattered microglia. Focal neutrophilic
infiltrate". The specimen is entirely submitted as follows: C =
frozen section remnant, D = all remaining tissue.
Part 3 is submitted for intraoperative consultation additionally
labeled "left deep occipital tumor #3". It consists of multiple
tan-pink soft tissue fragments that measure 0.8 x 0.7 x 0.3 cm
in aggregate. 50% of the specimen was used for smear and frozen
section. The frozen section and smear diagnosis by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: "[**Doctor Last Name **] matter and necrotic white matter. Smear
contains some calcified and fibrotic material (? abscess wall)".
The specimen is then entirely submitted as follows: E = frozen
section remnant, F = all remaining tissue.
Part 4 is additionally labeled "left occipital lobe tumor". It
consists of multiple tan-pink fragments that measure 0.5 x 0.2 x
0.1 cm in aggregate. The specimen is entirely submitted in
cassette G.
MRI brain [**2176-1-9**]:
1. Allowing for post-biopsy changes, the left parietal lesion
appears similar
to [**2176-1-4**]. Pathology is pending.
2. No evidence of acute intracranial abnormalities.
3. Normal head MRA.
EEG [**2176-1-10**]:
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background, bursts of generalized slowing, and additional focal
delta
slowing in the left posterior quadrant. The first two
abnormalities
signify a widespread encephalopathy. Medications, metabollic
disturbances, and infection are among the most common causes.
The
additional focal slowing indicates subcortical dysfunction in
the left
posterior quadrant, likely related to the reported mass. There
were no
clearly epileptiform features.
retroperitoneal mass needle biopsy:
DIAGNOSIS:
Left retroperitoneal mass, core biopsy:
1. Fibrous tissue with lymphoplasmacytic inflammation; see
hemepath note.
2. Refer to separate cytology report (C09-3221) for
additional information.
Hemepath note (Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]):
H&E sections show small, tight clusters of CD20-positive
B-cells, with a small population of scattered CD3-positive
T-cells. Although a reactive process is favored, a low-grade
B-cell lymphoma cannot be ruled out.
Clinical: Rest of retroperitoneal mass. 58 year old male found
to have large left retroperitoneal mass with lymphadenopathy.
Gross: The specimen is received in a formalin-filled container
labeled with the patient's name "[**Last Name (LF) 4027**], [**Known firstname **] F" and the
medical record number and consists of multiple fragments of core
biopsy and tissue measuring up to 1.0 cm in length. The specimen
is strained through a biopsy bag and submitted entirely in A.
Retroperitoneal mass, needle biopsy touch-prep:
SUSPICIOUS for malignancy.
A few clusters of highly atypical cells have large nuclei
and prominent nucleoli. The cytoplasm is stripped and
further classification is not possible
Scrotal US [**2176-1-23**]
IMPRESSION:
1. No testicular mass. Normal epididymis.
2. Diffusely heterogeneous left testis, without enlargement.
This appearance
likely reflects prior injury such as remote trauma or orchitis
Brief Hospital Course:
This 58 yo man was admitted with confusion and right visual
field loss as outlined in the HPI. His brain MRI showed a large
left posterior lesion, suspicious for tumor. Since this may have
been a met, a CT torso was pursued, which showed a large
retroperitoneal mass with enlarged lymph nodes. He underwent an
open biopsy of his brain lesion, and the intraop pathology
suggested there were no tumor cells and this was a demyelinating
lesion. He was placed on a 5-day course of IV solumedrol
followed by a slow prednisone taper from 60 mg to off over ~ 2
weeks. He has improvement, but not complete resolution of his
visual field loss and confusion. He also sustained some right
weakness, particularly in the delt post brain surgery, however
this improved to nearly full strength over days. He next
received an IR-guided needle bx of his retroperitoneal mass. The
touch-prep of this was suspicious for malignant cells, however
the core histology just showed an inflammatory process. Because
of this disparity, he underwent a laproscopic biopsy of his
retroperitoneal mass. The preliminary results of this suggested
a cancer. The final pathology is still pending, but the
pathologists were able to tell us that it was not a cancer that
required immediate treatment. He received an oncology consult,
and will be followed in the oncology clinic. During the duration
of his admission, he was followed closely by the [**Last Name (un) **] team.
They changed his regimen to Humalog 75/25 90/50/50 TID QAC. His
neurological exam on DC was significant for ongoing deficits in
attention and memory and a right inferior quadrantanopsia.
Medications on Admission:
1. Plavix
2. Humalog 160 Units Qam and Qpm
3. Humulin 20 Units Qam and Qpm
4. Metformin 300 mg Qam and 200mg Qpm
5. Lyrica 200 mg [**Hospital1 **]
Discharge Medications:
1. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): Take 750 mg twice daily for 7 days, then 500 mg
twice daily for 7 days, then stop. .
Disp:*70 Tablet(s)* Refills:*0*
3. Bariatric Rolling Walker
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension
Sig: 50-90 units Subcutaneous TID QAC: Take 90 units before
breakfast, 50 units before lunch, and 50 units before dinner.
Disp:*1 month's supply* Refills:*3*
8. your plavix was held at your admission and you should
continue to hold this until final pathology on the
retroperitoneal mass returns and you follow up with oncology
Discharge Disposition:
Home With Service
Facility:
Community Health and Nursing Services
Discharge Diagnosis:
left posterior tumefactive demyelinating lesion
retroperitoneal cancer, final pathology pending
Discharge Condition:
stable. Ongoing trouble with attention and memory.
Discharge Instructions:
You were admitted with a large demyelinating lesion in the
posterior part of your left brain, causing some confusion and
visual loss. You were placed on a course of steroids and have
improved over time. You also had a CT of your abdomen and were
found to have a retroperitoneal mass, which was biopsied. The
final results of this biopsy are pending at the time of
discharge, but preliminary resulys sugges this is a type of
cancer. You can follow up with both oncology and the [**Hospital **] clinic
who can discuss these results with you.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
Followup Instructions:
Follow-Up Appointment Instructions
- Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 2 weeks for a wound check.
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 81580**]
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2176-2-8**] 11:00
Dr.[**Name (NI) **] office from oncology will call you Mon or
Tuesday for an appointment. If you do not hear from them by
[**1-31**], call [**Telephone/Fax (1) 81581**] to schedule.
Completed by:[**2176-1-26**]
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54412
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Discharge summary
|
Report
|
Admission Date: [**2125-1-4**] Discharge Date: [**2125-1-9**]
Service: MEDICINE
Allergies:
Nystatin / Tetracycline
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
L Femoral Line placement and then removal.
History of Present Illness:
This [**Age over 90 **] year old lady was found at [**Hospital 100**] Rehab to have an
episode of vomiting of undigested food followed by 5 episodes
coffee ground emesis in the setting of a supratherapeutic INR on
Warfarin for PE and plavix for CAD. She was given Compazine PR,
and Coumadin has been held since [**1-3**]. At that time per ED Call
in, she denied chest pain, dyspnea or abdominal pain. She has
resided at [**Hospital 100**] Rehab MACU [**2124-12-6**]-since [**2124-12-30**], Floor
[**2124-12-31**]-Present after a Rt ankle fracture from [**Hospital3 **]
hospital. She was recently on Cipro for a UTI.
In the ED, initial VS: 98.5 138 101/71 20 93. The patient was
found to be in rapid Afib (rate 130s) with a non-tender abdomen
and guaiac negative; unsuccessful NG lavage. She was given NS
and 1 unit FFP and Vitamin K 10mg IV x1 for elevated INR.
Femoral line and peripheral placed, T&S obtained, started on
Protonix Bolus/Gtt. Given an elevated WBC count, cough, CXR
appearance and infected appearing U/A, the patient was started
on Vanc/Zosyn and admitted to the ICU.
With the assistance of a translator, the patient reports that
she is currently comfortable but for dry mouth. She has a cough
but is unsure of its duration and is unsure if she has had
fevers. She recalls that she was nauseated and vomiting last
night and was nauseous earlier today but is without nausea or
abdominal pain at this time. She denies any bleeding and bloody
stools. She denies chest pain and reports that her breathing is
"bad as usual." Interview limited as she is hard of hearing and
also intermittently awake. Of note, the patient declines any
blood until her daughter arrives.
Her daughter confirms that the patient did not receive a stent
at [**Hospital3 **], her diagnosis of PE was uncertain. Critical
care consent reviewed and signed.
ROS: Denies chest pain, abdominal pain, active nausea, diarrhea,
constipation, BRBPR, melena, hematochezia.
Past Medical History:
- CAD s/p MI in [**2118**]; NSTEMI [**2124-11-17**]
- COPD
- History of TB s/p Rx
- Anemia
- Colon CA
- Hiatal Hernia
- Recurrent Falls
- R malleolar Fx (Admission c/b sepsis and hypotension- tubed
and on pressors)
- Hx of Enterobacter UTIs
- ? of PE, currently anticoagulated
Social History:
Russian speaking. Currently at [**Hospital 100**] Rehab, habits unknown.
Daughter involved in her care.
Family History:
nc
Physical Exam:
Vitals - T: 99.2 BP: 104/50 HR: 125 RR: 23 02 sat: 98% 2L
GENERAL: Elderly, ill appearing, intermittently awake but easily
arousable
HEENT: JVP~ 7cm
CARDIAC: S1 & S2 rapid and irregular
LUNG: Rhonchi in all fields, R>L, bibasilar dull breath sounds,
not using accessory muscles
ABDOMEN: Nontender or distended
EXT: R cast in place, L femoral line oozing from insertion site.
NEURO: Oriented while awake
********
On discharge, rhonchi and rales present. R leg with brace.
Pertinent Results:
Admission Labs:
[**2125-1-4**] 03:50AM WBC-21.2* RBC-4.12* HGB-12.7 HCT-38.7 MCV-94
MCH-30.8 MCHC-32.8 RDW-16.1*
[**2125-1-4**] 03:50AM CK-MB-NotDone cTropnT-0.10*
[**2125-1-4**] 03:50AM CK(CPK)-74
[**2125-1-4**] 03:50AM GLUCOSE-141* UREA N-51* CREAT-1.1 SODIUM-144
POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-26 ANION GAP-19
[**2125-1-4**] 03:57AM LACTATE-2.2* K+-3.8
[**2125-1-4**] 10:40AM ALBUMIN-3.3* CALCIUM-8.7 PHOSPHATE-3.3
MAGNESIUM-1.9
[**2125-1-4**] 10:40AM GLUCOSE-131* UREA N-48* CREAT-1.1 SODIUM-145
POTASSIUM-3.2* CHLORIDE-106 TOTAL CO2-27 ANION GAP-15
[**2125-1-4**] 07:43PM HCT-31.8*
.
Imaging:
CHEST, SINGLE AP VIEW: The heart is mildly enlarged. A calcified
right
fibrothorax, with calcified pleural densities and volume loss in
the right
upper lobe, are similar in appearance. Bilateral pleural
effusions with
bibasilar opacities are new. A large hiatal hernia appears
larger.
IMPRESSION:
1. Mild cardiomegaly.
2. Calcified right fibrothorax, with new small bilateral pleural
effusions
with associated atelectasis of the adjacent lower lobes.
3. Large hiatal hernia.
.
[**1-4**] Echo:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mildly dilated right ventricle with preserved global
and regional biventircular systolic function. Mild aortic and
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
.
[**1-4**] ECG:
Atrial fibrillation with rapid ventricular response. Diffuse
ST-T wave changes that are non-specific. Compared to the
previous tracing of [**2109-10-15**] atrial fibrillation is new.
.
[**1-4**] abdominal x-ray:
IMPRESSION: No evidence of bowel obstruction or perforation.
.
[**1-8**] CXR:
As compared to the previous radiograph, there is a minimal
improvement with reduction of the bilateral pleural effusions
and minimal
improvement in ventilation of the right lung. Otherwise, the
radiograph is
unchanged, unchanged size of the cardiac silhouette.
.
[**1-5**] ankle x-ray:
There is again seen a bimalleolar fracture with a transversely
oriented
fracture line to the medial malleolus and obliquely oriented
fracture line to the distal fibula. The ankle mortise is grossly
preserved. There is some bridging callus however the fracture
lines are still visualized. There is generalized soft tissue
swelling about the ankle. No additional fractures are seen.
.
Discharge labs:
[**2125-1-9**] 07:50AM BLOOD WBC-11.9* RBC-3.68* Hgb-10.6* Hct-33.9*
MCV-92 MCH-28.8 MCHC-31.3 RDW-15.9* Plt Ct-228
[**2125-1-9**] 07:50AM BLOOD Glucose-114* UreaN-34* Creat-0.7 Na-146*
K-3.5 Cl-107 HCO3-32 AnGap-11
[**2125-1-9**] 07:50AM BLOOD Calcium-9.3 Phos-2.4* Mg-1.9
Brief Hospital Course:
A [**Age over 90 **] year old admitted to the MICU from [**Hospital 100**] Rehab with coffee
ground emesis in the setting of a supratherapeutic INR.
#. Hematemesis: The patient was admitted after 4-5 episodes of
coffee grounds emesis without hemodynamic instability, on
Aspirin, Plavix and Warfarin for a recent NSTEMI and ? PE during
a [**Month (only) 404**] admission to [**Hospital3 **]. Her INR was elevating
to [**2-19**], likely due to a Ciprofloxacin interaction without a
concomittant dosage change.
GI Consulted, no EGD necessary. 1 unit pRBCs transfused
although the patient only experienced a drop in hematocrit
consistent with fluid hydration. ASA restarted, Plavix and
Warfarin held at time of transfer out of the ICU. PPI converted
from drip to bolus and the patient was able to advance her diet
without issue. Based on risk/benefit ratio (CHADS = 1), are
holding plavix and coumadin, but continuing aspirin on
discharge. Patient without stent or hardware, so also has
presumed history of pulmonary embolism, no clear indication for
plavix even in setting s/p NSTEMI. As such, given concern for
bleed greater than benefit of antiplatelet, we have discontinued
plavix. Opted to continue aspirin however. Hematocrit stable,
after initial drop, through rest of ICU stay as well as on the
floor.
#. Atrial Fibrillation with Rapid Ventricular Rate: The patient
was admitted with a sustained rate of 120s-130s in atrial
fibrillation and a history of paroxysmal atrial fibrillation.
She spontaneously converted to sinus rhythm with fluid and blood
rescuscitation with a period of transient hypotension that
resolved. Her beta blocker was held while admitted to the MICU.
.
Several days into her course patient spontaneously converted
back into atrial fibrillation with rapid rate, accompanied by
worsening dyspnea and pulmonary edema. Rate was controlled with
IV metoprolol which was later converted to PO metoprolol, which
was later uptitrated for better rate control. Rate was well
controlled on this regimen.
.
Given CHADS 1 and recent GI bleed (as well as h/o recurrent
falls), the decision was made not to anticoagulate, coumadin is
discontinued.
# Pulmonary edema: In the setting of afib with RVR, patient
develoepd pulmonary edema. She was diuresed gently with 10 mg IV
lasix boluses and was approximately 2 L net negative over the
next 24 hours with improvement in dyspnea and oxygenation. If
she becomes SOB again, we strongly recommend considering fluid
overload with potential treatment with low-dose lasix (as well
as consideration of aspiration).
#. Leukocytosis with bacteruria: The patient had a rapidly
rising WBC with Left shift but no bands, positive U/A (recent
Enterobacter infection) and ? PNA on CXR. She received
Vanc/Zosyn in the ED presumably for a PNA but was converted to
Vanc/Cefepime/Cipro then Vanc/Cefepime. No clear source
identified initially. Given persistence of WBC prior to leaving
the ICU, repeat cultures were sent, and CXR showed worsening
infiltrates. To continue to cover hospital-acquired pneumonia
(including pseudomonas), she was continued on cefepime only -
planning for 8 day course, so 2 days more of once daily
antibiotics (cefepime) at rehab.
#. Hypoxia/COPD: The patient has an O2 requirement that was
initially likely secondary to COPD and/or pneumonia (see above).
Nebulizers were continued. On room air at discharge.
.
#. CAD/Recent NSTEMI: Patient was on ASA, Plavix and metoprolol
after recent NSTEMI, no percutaneous intervention or hardware
present. Troponin elevated here, but with normal CK/CK-MB, and
the troponin remained flat. With impaired GFR and recent NSTEMI
this may represent old MI, renal failure or MI within the last 7
days. EKG was not revealing of ST changes. Decided to
discontinue plavix in setting of GI bleed and risk > benefit.
Did restart 162mg enteric-coated ASA.
#. Dysphagia: Patient had witnessed aspiration event. Evaluated
by speech & swallow. Placed on dysphagia diet. Concern for
aspiration continues.
.
#. ? PE: The patient has an uncertain history of PE based on
elevated PA pressure from [**Hospital3 5097**], no confirmatory test
performed per HebReb records and daughter. [**Name (NI) 227**] uncertainty
(and CHADS = 1) and her current high bleeding risk, we
discontinued coumadin and let her INR drift down.
#. R bimallelor fracture: Spoke with Orthopedics Dr. [**Last Name (STitle) 57141**]
[**Telephone/Fax (1) 111375**]; [**Telephone/Fax (1) 111376**] (Cell) from [**Hospital3 **]. The
patient is due for cast removal, but must have an Aircast Ankle
brace to replace it until ~ [**2125-1-16**]. Patient is Bed to Chair
and Touch Down Weight Bearing per her orthopedist. Cast removed
by ortho. With ankle brace in place upon discharge.
# Had femoral line originally in setting of GI bleed, then
removed.
# CODE: DNR/DNI dated [**1-2**] in chart (Confirmed with daughter)
# CONTACT: Daughter [**Name2 (NI) 111377**] [**Name2 (NI) 111378**] Home [**Telephone/Fax (1) 111379**],
Cell: [**Telephone/Fax (1) 111380**]
Medications on Admission:
ASA 325mg PO Daily
Clopidogrel 75mg PO daily
Metoprolol 12.5mg PO BID
Bumetanide 1mg PO daily
Albuterol/Ipratropium
Acetaminophen 650mg PO TID
Mirtazapine 7.5mg PO QPM
Megestrol 400mg PO daily
Famotidine 20mg PO daily
Lactobacillus 1 tab PO Daily
Maalox 15mL PO BID
Bisacodyl 10mg PR daily
Senna 2 tabs PO Daily
NTG 0.3 PRN chest pain
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for HR<60 or SBP <110. If HR is elevated
and blood pressure can tolerate, consider uptitration of this
medication.
3. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulization
Inhalation Q6H (every 6 hours) as needed for wheeze/sob.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulization Inhalation every [**2-20**]
hours as needed for wheeze/sob.
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain: Do not exceed 4gm/day.
7. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO QPM.
8. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10) mL
PO once a day.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lactobacillus Acidophilus Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
11. Maalox 200-200-20 mg/5 mL Suspension Sig: Three (3)
suspensions PO twice a day.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as needed as needed for chest pain.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Cefepime 1 gram Recon Soln Sig: One (1) gram Recon Soln
Injection Q24H (every 24 hours) for 2 doses: To be given on [**1-10**]
and [**1-11**].
.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Hematemesis
Atrial fibrillation with [**Hospital 5509**]
Hospital-acquired pneumonia
Dysphagia
Pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the hospital with vomiting blood. This
resolved on its own, without any procedure other than medical
management. Gastreoenterology was consulted and monitored your
course. Your blood level (hematocrit) remained stable after the
initial admission decrease.
.
You had an irregular heartbeat (atrial fibrillation) that became
rapid (rapid ventricular response) on 2 occasions, and responded
to fluid resuscitation as well as diuresis. After that, with
medication, your heart rate control has improved.
.
You had some fluid on your lungs, and diuresis with low-dose
lasix improved your respiratory status. If you have more
shortness of breath, consideration to give another one-time low
lasix would be important.
.
You were on medications for a presumed pulmonary embolism
(plavix and aspirin) but we feel that given you had a bleed,
your risk of bleed outweighs the benefits, and so we are
discharging you solely on aspirin, and not on plavix anymore.
.
You were on coumadin for atrial fibrillation and for a presumed
pulmonary embolism, but given your history of falls and your
gastrointestinal bleed on this admission, it is felt that the
risk of bleed outweighs the benefit of stroke prevention, and so
we have discontinued your coumadin.
.
You were found to be aspirating, so your diet was changed per
speech & swallow recommendations.
.
You had evidence of a pneumonia, so you are being empirically
treated, and you have 2 more days of IV antibiotics to finish
your course.
Followup Instructions:
Please see your primary care physician after you leave from
[**Hospital 100**] Rehab.
Completed by:[**2125-1-9**]
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Discharge summary
|
Report
|
Admission Date: [**2108-2-23**] Discharge Date: [**2108-2-25**]
Date of Birth: [**2048-8-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest pain secondary to jailed diagonal artery during elective
cardiac catheterization with DES to LAD.
Major Surgical or Invasive Procedure:
Cardiac Catheterization with drug eluting stent placement.
History of Present Illness:
This 59 year old man with hypertension, hyperlipidemia and an
extensive cardiac history s/p several MI's and multiple coronary
stents to the LAD and RCA, presents following elective cardiac
catheterisation here today , when a diagonal branch off the LAD
was jailed during stenting. He is being admitted to the CCU for
monitoring.
.
Cardiac catheterisation revealed tight stenosis with
calcification near the prior LAD lesion. Drug-eluting stent was
placed, jailing the diagonal, which remained occluded. He
experienced some chest pain peri-procedurally, which improved
with 20 mcg nitroglycerin. Radial access for cath was
attempted, but failed due to vessel tortuosity. TR band was
placed on right wrist. Femoral access was obtained instead and
was successful. He has been hemodynamically stable since the
procedure. . He is receiving peri-procedural integrillin and
is on a nitro drip for chest pain.
.
The patient reports that approximately three weeks ago he had
severe heartburn and nausea which was very similar to what he
experienced with his MI in [**2105**]. He did not seek treatment for
this and his symptoms eventually went away. Again last week, the
patient had similar "heartburn symptoms" with radiation to the
jaw and throat. These symptoms occurred at night and were
associated with nausea but no vomiting. He was evaluated at
[**Hospital3 7571**]Hospital and transferred to [**Hospital1 18**] where he ruled
out for an MI. It was felt that his symptoms were more likely GI
in origin and he was discharged to home on Pantoprazole and his
normal cardiac medications.
.
His most recent events include an MI in [**2105**] while in
[**State 4565**], requiring RCA stenting x [**Street Address(2) 28710**] elevation
IMI in [**2107-3-1**] while on Plavix therapy. At this time he
was treated at [**Hospital 1727**] Medical Center where a drug eluting stent
was placed in the posterolateral branch of the RCA at a site of
ISR. LVEF by ventriculogram was preserved at 57%. A residual LAD
stenosis of 50% was mentioned. Prasugrel was added to his
medical regimen.
.
Continuing to have 5/10 chest pain, dyspnea, palpitations, LE
edema, orthopnea, PND, lightheadedness, claudication
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY: CAD with large IMI ([**2094**] and [**2097**]), stenting
of RCA/LAD. Also had MI in [**State 4565**] in [**2104**], treated at [**First Name8 (NamePattern2) **]
[**Doctor First Name **], unknown territory but [**3-2**] stents placed. MI in [**State 1727**] in
[**3-/2107**], with 2 more stents.
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
-> RCA [**2094**], [**2097**] (velocity stent), LAD [**3-/2097**] (velocity
stent), PTL [**10/2098**] (pixel stent)
-> [**2104**], [**3-2**] more stents to unknown territory
-> [**2107**], 2 more stents to unknown territory
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- L ankle fracture s/p pinning
- Dyslipidemia
- Hypertension
Social History:
Retired elevator technician, stopped working [**2107-4-29**]. Lives
at home with his wife, 2nd daughter and granddaughter.
- Tobacco history: none
- ETOH: 1 beer every [**1-30**] month
- Illicit drugs: none
Family History:
Mother died of heart problems at age 68, also had aortic
aneurysm problems. Siblings without history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVP elevation.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Right groin bandage
in place, no hematoma, no bruits, distal pulses readily
palpable. TR band on right wrist, no hematoma, some dried blood
around site.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2108-2-25**] 07:19AM BLOOD WBC-8.2 RBC-4.45* Hgb-13.0* Hct-38.3*
MCV-86 MCH-29.2 MCHC-33.9 RDW-13.5 Plt Ct-181
[**2108-2-24**] 12:40PM BLOOD WBC-8.2 RBC-4.51* Hgb-13.3* Hct-38.8*
MCV-86 MCH-29.5 MCHC-34.3 RDW-13.2 Plt Ct-181
[**2108-2-24**] 05:18AM BLOOD Hct-36.1* Plt Ct-167
[**2108-2-25**] 07:19AM BLOOD Plt Ct-181
[**2108-2-25**] 07:19AM BLOOD PT-12.1 PTT-26.5 INR(PT)-1.1
[**2108-2-24**] 12:40PM BLOOD PT-11.8 PTT-25.6 INR(PT)-1.1
[**2108-2-24**] 05:18AM BLOOD Plt Ct-167
[**2108-2-23**] 11:15PM BLOOD Plt Ct-176
[**2108-2-23**] 02:23PM BLOOD Plt Ct-198
[**2108-2-25**] 07:19AM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-142
K-4.5 Cl-105 HCO3-32 AnGap-10
[**2108-2-24**] 12:40PM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-141
K-4.0 Cl-105 HCO3-28 AnGap-12
[**2108-2-24**] 05:18AM BLOOD Glucose-118* UreaN-16 Creat-0.9 Na-138
K-4.1 Cl-101 HCO3-28 AnGap-13
[**2108-2-25**] 07:19AM BLOOD CK(CPK)-319
[**2108-2-24**] 12:40PM BLOOD CK(CPK)-602*
[**2108-2-24**] 05:18AM BLOOD CK(CPK)-670*
[**2108-2-23**] 11:15PM BLOOD CK(CPK)-496*
[**2108-2-23**] 02:23PM BLOOD CK(CPK)-143
[**2108-2-25**] 07:19AM BLOOD CK-MB-9 cTropnT-0.64*
[**2108-2-24**] 12:40PM BLOOD CK-MB-33* MB Indx-5.5 cTropnT-1.03*
[**2108-2-24**] 05:18AM BLOOD CK-MB-42* MB Indx-6.3* cTropnT-0.95*
[**2108-2-23**] 11:15PM BLOOD CK-MB-34* MB Indx-6.9* cTropnT-0.37*
[**2108-2-23**] 02:23PM BLOOD CK-MB-5 cTropnT-<0.01
[**2108-2-25**] 07:19AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.2
[**2108-2-24**] 12:40PM BLOOD Calcium-9.2 Phos-2.7 Mg-2.2
[**2108-2-24**] 05:18AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
.
[**Known lastname **],[**Known firstname 5684**] [**Medical Record Number 28711**] M 59 [**2048-8-12**]
Cardiovascular Report Cardiac Cath Study Date of [**2108-2-23**]
*** Not Signed Out ***
BRIEF HISTORY: 59 year old man with a history of coronary
artery
disease status post multiple prior myocardial infarctions and
interventions. His last myocardial infarction was on [**2107-3-5**] in
[**State 1727**]. He
had a right postero-lateral in-stent restenosis that was
re-stented and
he was changed from plavix to prasugrel at that time. He has
also had
stents placed to his LAD and RCA in multiple other facilities.
Over the
last few months he has had episodes of chest burning consistent
with his
symptoms prior to his previous myocardial infarctions. He
underwent
exercise-ECG testing which was non-diagnostic and is now
referred for
cardiac catheterization.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class II, stable.
Prior non q
wave inferior MI, [**2107-3-5**]. Prior PTCA [**2107-3-5**]. ETT
PROCEDURE:
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.07 m2
HEMOGLOBIN: 12.9 gms %
FICK
**PRESSURES
AORTA {s/d/m} 114/72/88
**CARDIAC OUTPUT
HEART RATE {beats/min} 46
**PTCA RESULTS
LAD
PTCA COMMENTS:
Initial angiography showed 70% stenosis in mid LAD prior to
previous
stent. We planned to treat this with PTCA and stenting. Due to
extreme
tortuosity of the right subclavian artery, we performed the PCI
from the
RFA. HEparin and integrilin were started prophylactically. A 6F
XB 3.5
guiding catheter provided adequate support for the procedure. A
BMW wire
crossed the LAD lesion with minimal difficulty. The LAD lesion
was
dilated with a 2.5x10mm Spriter legend balloon at 12-14 atms. A
2.5x15mm
Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was deployed in the mid LAD at 14 atms.
Interval
angiography showed occlusion of a small caliber, medium sized
diagonal
branch. The patient did experience chest pain at this point. The
stent
was postdilated with a 2.5x12mm NC Quantum apex balloon at 12
and 22
atms. Despite nitroglycerin, the diagonal remained occluded.
Mulitple
attempts were made to cross into the occluded diagonal (BMW,
prowater,
PT [**Last Name (Prefixes) **] intermediate, and Run-through wires), however, we
were unable
to wire the diagonal. Final angiography showed no residual
stenosis in
the LAD and occluded diagonal branch that had been jailed by the
stent.
There were faint collaterals to the diagonal territory. There
was no
angiographically apparent dissection and tIMI 3 flow in the LAD.
The
patient was started on IV nitroglycerin with improving chest
pain. The
patient was transferred to CCU for monitoring in stable
condition.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 49 minutes.
Arterial time = 1 hour 45 minutes.
Fluoro time = 48.8 minutes.
Effective Equivalent Dose Index = 2850 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 155 ml
Premedications:
Midazolam 1 mg IV
Fentanyl 100 mcg IV
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 8000 units IV
Other medication:
Atropine 0.5mg
Eptifibatide 32mg bolus and 28.4ml/hr drip
TNG 400mcg bolus IA
TNG 30mcg/hr drip
Verapamil 5mg IA
Cardiac Cath Supplies Used:
- [**Company **], MAGIC TORQUE 180CM
- [**Doctor Last Name **], BMW UNIVERSAL 190CM
- [**Doctor Last Name **], PROWATER 190CM
- [**Company **], CHOICE PT [**Name (NI) **] INTERMEDIATE
300CM
2.5MM [**Company **], SPRINTER 06MM
2.5MM [**Company **], APEX 12
5FR CORDIS, XB 3.5
6FR CORDIS, XB 3.5
6FR [**Doctor Last Name **], PERCLOSE PROGLIDE
5FR COOK, [**Last Name (un) 28712**] 70CM
5FR COOK, [**Last Name (un) 28712**] 90CM
2.5MM [**Company **], PROMUS RX 15MM
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
5FR TERUMO, JACKY RADIAL CATHETER
5FR ARROW, TRANSRADIAL ARTERY ACCESS KIT
- TERUMO, ANGLED 260CM GLIDEWIRE
- [**Doctor Last Name **], PRIORITY PACK 20/30
- TERUMO, TR BAND LARGE
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary disease. The LMCA was
patent. The
LAD had a 70% stenosis proximal to the prior stent. There were
also
stenoses to 20-30% in the mid and distal LAD. The LCX had mild
luminal
irregularities. The RCA had widely patent stents with less than
20-30%
narrowings in the mid-distal vessel.
2. Limited resting hemodynamics revealed normotension.
3. There was extreme tortuosity in the right subclavian artery
that
required placement of a 5 French [**Last Name (un) 12297**] sheath into the ascending
aorta.
The diagnostic procedure was then performed via the right radial
artery.
4. Successful PTCA and stenting of mid LAD with 2.5x15mm Promus
drug
eluting stent postdilated with 2.5 Nc balloon, jailing diagonal.
5. Unsuccessful attempt to rescue jailed diagonal (unable to
wire).
6.Successful hemostasis of RRA with TR band.
7. Successful closure of RFA arteritomy with Perclose.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PCI of LAD with DES; diagonal branch jailed.
3. Unsuccessful attempt to rescue jailed diagonal.
4. Successful RRA TR band.
5. Successful RFA PErclose.
6. Monitor in CCU
7. ASA, plavix.
[**Hospital1 18**] ATTENDING OF RECORD: [**Last Name (LF) **],[**First Name3 (LF) **] E.
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Doctor Last Name **]
FELLOW: [**Last Name (LF) **],[**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 28713**],[**Doctor First Name 28714**]
INVASIVE ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Brief Hospital Course:
# CAD: PMH of multiple MIs, recent ETT with exertion dependent-
ST-T wave changes. s/p LAD stenting with with jailing of
diagonal artery on [**2108-2-23**], with new EKG changes suggestive of
small infarct in diagonal distribution. We obtained serial EKGs
whioch showed improvement of the ST changes with time. Pain was
controlled with nitroglycerin drip initially and then with
morphine, and he was chest-pain free at the time of discharge.
Cardiac enzymes also peaked trended down appropriately. He was
monitored on telemetry and remained chest pain free throughout
his hospitalization. We continued aspirin and plavix, but
plavix was switched to his home prasugrel for ongoing
anti-platelet therapy. Atorvastatin was increased to 80 mg
daily. Eptafibatide was continued for 18 hours post-procedure.
Home metoprolol and lisinopril were intially held due to mild
hypotension post-procedure, but were restarted prior to
discharge.
.
# RHYTHM: sinus bradycardia, asymptomatic, [**Last Name (un) 2677**] from prior.
As above, we held metoprolol post-procedure but restarted it
prior to discharge.
.
# Hypertension: Lisinopril and metoprolol were restarted at home
doses prior to discharge.
.
# Hyperlipidemia: Atorvastatin was increased to 80mg daily.
Medications on Admission:
Medications - Prescription
ATORVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet -
1
Tablet(s) by mouth every evening
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth every morning
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth twice a day
NITROGLYCERIN - (Prescribed by Other Provider) - 0.4 mg Tablet,
Sublingual - 1 Tablet(s) sublingually every five minutes for
chest discomfort. Call 911 if pain persists longer than 15
minutes
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth every morning
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every five minutes for chest discomfort. Call 911 if
pain persists longer than 15 minutes.
7. omega-3 fatty acids-fish oil Oral
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Cardiac catheterization with drug eluting stent
placement in the Left Anterior descending Artery, with jailing
of the diagonal artery. Myocardial infarction in the territory
supplied by the diagonal artery.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 28708**],
It was a pleasure taking care of you at the [**Hospital1 771**]. You underwent a cardiac
catheterisation with the placement of a stent in one of your
coronary arteries during which a small blood vessel in your
heart became obstructed. You had some chest pain with this
episode and you were admitted to our cardiac intesive care unit
for monitoring. We treated your pain and your blood tests and
symptoms improved overnight.
We made the following changes to your medications:
STOPPED Pantoprazole
INCREASED Atorvastatin to 80 mg daily
Please continue taking your other medications as usual. Please
note that it is very improtant that you consistently take
PRASUGREL and ASPIRIN following your stent placement, and that
failure to take these medications may result in your stents
becoming blocked.
Please followup with your doctors, see below.
Followup Instructions:
Please call your cardiologist's office on Monday to schedule a
followp appointment within 15 days following discharge.
Please also call your primary care practioner's office on Monday
and schedule an appointment within 5 days following discharge to
discuss this hospitalization.
Completed by:[**2108-2-25**]
|
[
"996.09",
"401.9",
"272.4",
"412",
"V45.82"
] |
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[
597,
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[
[
615,
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[] |
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 2,528
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 372
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 2,029
| 0
| 0
| 0
| 106
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 2,737
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 113
| 0
| 0
| 0
| 63
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
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| 53
| 210
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|
95,235
| 140,261
|
40801
|
Discharge summary
|
Report
|
Admission Date: [**2161-8-20**] Discharge Date: [**2161-9-1**]
Date of Birth: [**2101-11-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Dilantin / Ancef
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Subarachnoid Hemorrhage
Major Surgical or Invasive Procedure:
Coiling of left ACA aneurysm
Right frontal EVD
History of Present Illness:
59 y/o F with history of HTN presents s/p syncopal episode at
work. Per co-workers, patient collapsed but was caught and
placed
on the floor, no trauma to head was witnessed. She was brought
to
OSH where head CT revealed diffuse SAH. Patient was alert and
oriented per OSH notes, but had multiple episodes of n/v. She
was
intubated and sedated with fentanyl and versed and transferred
to
[**Hospital1 18**] for further neurosurgical intervention. Patient was placed
on propofol once at [**Hospital1 18**]. Per family at OSH, they state that
patient stopped taking her HTN medication about a couple months
ago. Was seen to have HTN when arrived at [**Hospital1 18**] and placed on
nicardipine gtt.
Past Medical History:
HTN
Social History:
Married
School superintedant
Family History:
Unknown
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 4 GCS E: 3 V: 1T Motor:6
Gen: intubated and on propofol
HEENT: atraumatic, normocephalic
Pupils: 2 minimally reactive bilaterally EOMs: tracking
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date, nods
appropriately off propofol
EO to voice
Follows simple commands
MAE
Exam on Discharge:
AOx3, [**Last Name (LF) 2994**], [**First Name3 (LF) 2995**] w/full motor strength
Pertinent Results:
[**2161-8-20**] CTA Head:
1. Diffuse subarachnoid hemorrhage involving the cerebral sulci,
the Sylvian fissures and the interhemispheric fissure.
Effacement of the cerebral sulci from hemorrhage and some degree
of cerebral edema. Increased density in the interhemispheric
fissure as well as the parafalcine sulci due to denser
hemorrhage in that area.
2. Small saccular aneurysm arising from the distal portion of
the A2 segment of the anterior cerebral artery. Recommend
interventional neuroradiology consult and conventional angiogram
for appropriate management and detection of any other additional
aneurysms.
3. Hemorrhage extending into the thecal sac; limited assessment
of position of cerebellar tonsils.
4. Thinning/dehiscence of the bone in the postero-lateral part
of the petrous portions/carotid canal adjacent to the right
internal carotid artery without obvious extension of the artery
into middle ear.
[**2161-8-20**] CT Head:
IMPRESSION:
1. Diffuse subarachnoid hemorrhage involving the cerebral sulci,
the sylvian fissures and interhemispheric fissure, unchanged in
distribution from prior study. No evidence of new hemorrhage or
infarction.
2. Interval placement of a right frontal approach ventricular
catheter
terminating in the frontal [**Doctor Last Name 534**] of the right lateral ventricle,
with no change in ventricular size. Small amount of
intraventricular hemorrhage in the occipital horns and fourth
ventricle, unchanged from prior study.
3. Coil pack in the interhemispheric fissure with associated
artifact at that level.
[**2161-8-21**] Femoral (right) Ultrasound:
IMPRESSION: Normal appearance of right common femoral artery and
common
femoral vein with no evidence of pseudoaneurysm.
[**2161-8-23**] CTA Head:
HEAD CTA: The intracranial internal carotid and vertebral
arteries, and their major branches, appear patent. There is no
evidence of caliber change in the anterior or posterior
circulation to suggest vasospasm. Evaluation for residual
filling of the previously coiled distal left anterior cerebral
artery aneurysm is limited by streak artifact. No additional
aneurysms are identified.
IMPRESSION:
1. Decreased subarachnoid hemorrhage.
2. Redistribution of intraventricular hemorrhage without
evidence of new
hemorrhage. Stable ventricular size without hydrocephalus.
3. No evidence of vasospasm.
CTA Head [**2161-8-27**]:
IMPRESSION:
1. Decrease in extent and density of subarachnoid hemorrhage.
2. No new hemorrhage. Stable ventricular size without
hydrocephalus.
3. The A1 and A2 segments of the left anterior cerebral artery
are minimally decreased in caliber compared to study on [**8-20**], [**2161**]. This may indicate minimal but nonocclusive vasospasm,
but may be related to procedure.
Lower Extremity Doppler US [**2161-8-28**]:
***
Chest Xray [**8-29**]: A right subclavian central line is present, tip
at SVC/RA junction. No pneumothorax is detected.
The heart is not enlarged. The aorta is minimally unfolded. No
CHF, focal
infiltrate, or effusion is identified.
CTA Head [**2161-8-29**]: IMPRESSION:
1. Head CT shows removal of the right frontal ventricular drain
without
evidence of hydrocephalus. Blood is seen in the ventricles. No
new
hemorrhage.
2. CT angiography of the head demonstrates improvement in the
caliber of the anterior cerebral arteries without evidence of
vasospasm. No vascular
occlusion is seen.
Brief Hospital Course:
Ms. [**Known lastname 8529**] was admitted to the Neurosurgery service and taken to
the angio suite emergently for an angiogram and coiling.
An External ventricular drain was placed in the INR suite
showing ICP in the 20s. A Left ACA artery aneurysm was
successfully coiled. She was transported to the ICU intubated.
Patient was extubated on post coiling day #1 and maintained a
stable and non focal neurological exam. She was febrile to 102
on [**8-22**] and a work up was initiated. She had a CTA on [**8-23**] that
showed no evidence of vasospasm.
On [**8-24**] she was febrile and CSF was sent. The gram stain was
negative and later final cultures showed no growth. Her exam
remained stable and her EVD was raised to 15 without issue. On
[**8-25**] her exam and ICPs remained stable and her EVD was raised to
20. TCDs were obtained which showed no evidence of vasospasm.
On [**8-26**], her EVD was clamped during the day. Pt had mild
elevations while awake to around 23-25 mmHg. As a result it was
reopened. CTA on [**8-27**] revealed spasm in the A2, we elevated her
blood pressure to 160-180 and started IVF.
On [**8-28**] LENIs were performed which revealed no evidence of a
DVT. A routine CT performed revealed stable ventricular size,
but we opted to keep the ventricular drain in place given
intermitant elevations in her ICP. Over the next 24 hours the
patient remained neurologically stable without sustained
elevation in ICPS and so her EVD was removed on [**8-29**]. CTA was
performed after Drain removal which demonstrated improvement in
vasospasm, no hemorrhage with stable ventricular size. On [**8-30**],
patient remained stable after EVD removal and she was closely
monitored over the day for any changes in neuro exam. On [**8-31**],
patient was transferred to the floor. Her blood pressure was
liberalized to 90-160. She remained stable. On [**9-1**] she
ambulated with PT and was cleared to go home.
On [**9-1**] she was discharged home.
Medications on Admission:
Unknown
Discharge Medications:
1. senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-18**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever,pain.
8. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours): Full 21 day course- rx called to CVS .
Disp:*16 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
hydrocephalus
intracranial hypertension
Pyrexia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
**** Continue Nimodipine as prescribed, if there is an high
co-pay please call our office prior to purchasing. ****
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
_________, to be seen in _______weeks.
?????? You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a MRI/MRA w/ and w/o contrast ([**Doctor Last Name **] protocol)
* Staple removal 10 days from EVD removal on [**8-29**] - please call
our office to make this appointment. *****
Completed by:[**2161-9-1**]
|
[
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icd9cm
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icd9pcs
|
[
[
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| 1,971
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89,232
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51487
|
Discharge summary
|
Report
|
Admission Date: [**2200-1-14**] Discharge Date: [**2200-1-24**]
Date of Birth: [**2120-4-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
hypoglycemia, hypertensive urgency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 y/o F with PMHx of type II DM, CRI & HTN who presented to
clinic today for follow up of elevated creatinine and was found
to be profoundly hypoglycemic with BS of 20 that did not improve
with po trial. Per family, pt has not been taking much po for
the last few days and has been complaining of fatigue. She has a
long history of poor med compliance and has been living with her
daugter for the last 2 months who has been managing her
medications. Pt was seen in clinic on [**2200-1-2**] and was noted to
be increasingly hypertensive, for which Lisinopril was increased
to 40mg daily. Follow up labs were notable for a progressive
rise in creatinine from 1.5 to 2.9. During this time, Lisinopril
was stopped and Glipizide was increased to 15mg [**Hospital1 **]. Pt denies
having low BS at home and reports decreased appetite and dark
urine. Per family, there were no significant changes in MS prior
to presenting to clinic today. Pt received some juice prior to
transfer to the ED.
.
VS on arrival to ED: T 97.8 BP 194/90 HR 56 RR 18 Sat 100% on
RA. BS on arrival was noted to be 35, she received a total of
2.5 amps of dextrose, Glucagon, Octreotide 50mcg, 1L of NS and
started on D5 1/2 NS for BS that would transiently come up above
100 and then fall back to 40s. EKGs were essentially unchanged
and CXR was clear. Pt was given Hydralazine 50mg X 1 po for sbp
in 200s, followed by Hydralazine 10mg IV. SBPs came down to 170s
prior to transfer.
.
On arrival to the ICU, pt was responding slowly but denying any
chest pain, shortness of breath, abdominal pain, nausea,
headache, fevers, chills and feels generally improved since
arrival to the ED.
.
Review of sytems:
+ recent wt loss of 15 lbs, decreased appetite and dark yellow
urine
.
Denies fever, chills, headache, sinus tenderness, rhinorrhea or
congestion, shortness of breath, chest pain, nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
DM II
HTN
Thyroid Nodule
Anemia
Bilateral Cataracts
s/p TAH
Social History:
The patient currently lives with her daughter [**Name (NI) **] in [**Name (NI) 2268**].
The patient is reported at baseline to be completely independent
in all ADL, she currently works a 40 hour work week in the [**Hospital1 18**]
lab cleaning glassware, etc.
Tobacco: None
ETOH: None
Illicits: None
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:99.6 BP:178/69 P:95 R:14 O2:100% on RA
General: responsive but sleepy, oriented to day and "shakiro"
only
HEENT: Sclera anicteric, pupils enlarged bilaterally s/p
cataract surgery, oropharynx clear, MM dry, no precervical LN
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, harsh gr 3 SEM loudest over LUSB, radiates through
precordium and to left carotid, S2 preserved, no rubs or gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no HSM
Ext: Warm, well perfused, 2+ distal pulses, no edema
Neuro: CN 2-12 grossly intact, strength 5/5 in all four
extremities, finger to nose very slow, not following directions
easily and mildly disoriented, gait not assessed.
Pertinent Results:
Admission Labs:
[**2200-1-14**] 05:00PM BLOOD WBC-7.0 RBC-4.57 Hgb-12.8 Hct-37.8 MCV-83
MCH-28.0 MCHC-34.0 RDW-14.2 Plt Ct-249
[**2200-1-15**] 03:06AM BLOOD PT-14.3* PTT-39.1* INR(PT)-1.2*
[**2200-1-14**] 05:00PM BLOOD Glucose-102 UreaN-64* Creat-3.0* Na-138
K-4.1 Cl-96 HCO3-30 AnGap-16
[**2200-1-15**] 03:06AM BLOOD ALT-13 AST-27 CK(CPK)-65 AlkPhos-160*
TotBili-0.6
[**2200-1-15**] 03:06AM BLOOD TotProt-6.4 Albumin-3.1* Globuln-3.3
Calcium-12.5* Phos-3.9 Mg-2.2
[**2200-1-14**] 05:03PM BLOOD Lactate-2.2*
[**2200-1-17**] 01:00AM BLOOD WBC-4.2 RBC-3.44* Hgb-9.9* Hct-28.3*
MCV-82 MCH-28.9 MCHC-35.1* RDW-14.1 Plt Ct-190
[**2200-1-17**] 01:00AM BLOOD Glucose-129* UreaN-47* Creat-2.7* Na-135
K-3.4 Cl-103 HCO3-25 AnGap-10
[**2200-1-15**] 03:06AM BLOOD ALT-13 AST-27 CK(CPK)-65 AlkPhos-160*
TotBili-0.6
[**2200-1-14**] 05:00PM BLOOD CK-MB-4 cTropnT-0.13*
[**2200-1-15**] 03:06AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2200-1-15**] 03:06AM BLOOD TotProt-6.4 Albumin-3.1* Globuln-3.3
Calcium-12.5* Phos-3.9 Mg-2.2
[**2200-1-15**] 04:00PM BLOOD Calcium-12.7* Phos-4.0 Mg-2.0
[**2200-1-17**] 08:40AM BLOOD Calcium-11.0* Phos-3.5 Mg-1.8
[**2200-1-17**] 01:00AM BLOOD Albumin-2.8* Calcium-11.5* Phos-3.7
Mg-1.9
[**2200-1-16**] 06:15AM BLOOD calTIBC-259* Ferritn-248* TRF-199*
[**2200-1-16**] 03:58PM BLOOD PTH-12*
[**2200-1-17**] 01:40AM BLOOD freeCa-1.51*
[**1-15**] TTE
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The right
ventricular free wall is hypertrophied. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-20**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2193-1-18**], the left ventricle is more
hypertrophied with increased severity of mitral regurgitation.
[**1-15**] Head CT
No evidence of acute intracranial hemorrhage, edema or mass.
[**1-15**] Renal US with dopplers
IMPRESSION: Limited examination. Bilateral brisk systolic
upstrokes in the
main renal arteries at the hilum are present and therefore no
evidence of renal artery stenosis is present. Blunted systolic
upstrokes of intrarenal waveforms could reflect parenchymal
abnormality but cannot be reliably assessed due to limitations
of the examination. If further evaluation is required then non-
gadolinium- enhanced MRA may be attempted.
.
[**2200-1-18**] CHEST CT W/O CONTRAST
IMPRESSION:
1. No evidence of pulmonary nodule or mass.
2. Cardiomegaly, with coronary artery calcification, as
described above.
3. Heterogeneous, enlarged thyroid, with calcifications as
described above. The patient has not had a thyroid ultrasound at
this institution since [**2191**], and if there has not been a recent
evaluation, repeat assessment is recommended.
.
[**2200-1-20**] THYROID U/S
THYROID ULTRASOUND: Evaluation is somewhat limited due to
patient
positioning. The right lobe measures 7.2 x 4.8 x 3.2 cm. The
left lobe
measures 4.8 x 3.22 x 2.9 cm. Both lobes are heterogeneous with
multiple
nodules. Again, nodules range from hyper to hypoechoic and some
nodules
contains cystic areas. The largest nodule is again located in
the lower pole of the right lobe, a solid nodule measuring 4.1 x
2.4 x 3.9 cm. On the left, the largest (spongy) nodule measures
1.8 x 2.1 x 1 cm. In the isthmus, a mixed cystic and solid
nodule measures 1.2 x 0.9 x 1.2 cm.
IMPRESSION: Multinodular goiter. The gland and nodules have
enlarged since
the prior study of [**2191**], although technical differences make
direct comparison difficult. The overall appearance is generally
unchanged with no new dominant nodules or masses.
.
[**2200-1-20**] RENAL U/S
RENAL ULTRASOUND: Both kidneys are slightly increased in
echogenicity
diffusely. The right kidney measures 9.2 cm and the left kidney
measures 10.5 cm. There is no hydronephrosis, stones or masses
of either kidney. Simple cysts are again noted of both kidneys.
The largest is located on the left, measuring up to 1.4 cm. The
urinary bladder is collapsed around a Foley catheter and
balloon.
IMPRESSION: Slightly increase in diffuse echogenicity of both
kidneys,
otherwise no change since renal ultrasound of [**2200-1-15**]. This can
be seen in
chronic renal disease.
.
[**2200-1-21**] BONE SCAN
Whole body images of the skeleton were obtained in anterior and
posterior
projections and demonstrate several areas of increased uptake in
the knees, and ankles, consistent with degenerative changes.
There is also intense increased uptake in the region of L5 and a
smaller region laterally in L4. These are most likely due to
degenerative changes, however plain xray or CT imaging of the
lower lumbar spine may be of assistance for further evaluation,
if clinically indicated. The remainder of the bony skeleton
appears normal. The kidneys and urinary bladder are visualized,
the normal route of tracer excretion.
No prior studies available.
IMPRESSION: Probable degenerative changes as discussed above. If
hyperparathyroid adenoma is considered as a cause of
hypercalcemia, suggest nuclear medicine parathyroid scanning.
.
Brief Hospital Course:
#Hypoglycemia - Thought to be due to sulfonylurea therapy in the
setting of acute on chronic renal insufficiency. Oral
hypoglycemics were held. Corrected with dextrose, glucagon, and
octeotide in the MICU. Patient tolerated the eventual
reintroduction of basal and sliding scale insulin therapy.
.
#Hypertensive Urgency - Remained asymptomatic. Lisinopril had
been discontinued one week prior in the setting of acute on
chronic renal insufficiency. Initially treated with a
betablocker, norvasc, and hydralazine but the former was
subsequently held due to bradycardia. HCTZ was held in the
setting of hypercalcemia. The home dose of hydralazine was
increased to 75 mg QID and imdur was started at a dose of 30 mg
daily with subsequent improvement in blood pressure control.
Renal ultrasound did not reveal evidence of renal artery
stenosis, consistent with the results of an MRA in [**2195-4-18**].
.
# Hypercalcemia: [**Year (4 digits) 32883**] calcium peaked at 12.7 with a peak
ionized calcium of 1.51. The level improved modestly with
aggressive IVF. [**Name (NI) 32883**] PTH was low. Workup for an underlying
cause was unremarkable, including [**Name (NI) **] cortisol, SPEP/UPEP,
chest x-ray, non-contrast CT of the chest/abdomen/pelvis, and
bone scan. [**Name (NI) 32883**] vitamin D and PTHrP are pending at the time of
discharge. She will continue receiving saline infusions at rehab
to ensure adequate hydration. The importance of adequate oral
hydration was nonetheless reinforced with the patient and her
family. She will follow up with endocrinology clinic as an
outpatient.
.
#Acute on Chronic Renal Failure - Creatinine improved from 3.0
to 1.9 with volume repletion. A new baseline was attributed to
the progression of nephropathy as evidenced by diffuse
echogenicity in both kidneys on ultrasound.
.
#Acute uncomplicated cystitis - Treated with ciprofloxacin for 7
days.
.
#DMII - Oral hypoglycemic agents were held initially in the
setting of hypoglycemia and were not restarted due to renal
insufficiency. She was started on basal and sliding scale
insulin, as above.
.
#Thyroid nodule - Chest CT incidentally discovered a
heterogeneous enlarged thyroid with asymmetric enlargement of
the right lobe and coarse calcifications in both lobes. Thyroid
ultrasound revealed multinodular goiter with the largest nodule
in the lower pole of the right lobe measuring 4.1 x 2.4 x 3.9
cm. The patient may benefit from outpatient FNA.
Medications on Admission:
AMLODIPINE 10 mg daily
GLIPIZIDE 15 mg Tablet [**Hospital1 **]
HYDRALAZINE 50mg q6hrs
PRAVASTATIN 40 mg daily
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 mg-25 mg daily
Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime:
hold for sbp<100.
2. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO every six (6)
hours: hold for sbp<100.
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for sbp<100.
5. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
6. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) packet PO once a day as needed for constipation.
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Through [**2200-1-27**].
11. Humalog 100 unit/mL Solution Sig: ASDIR inj Subcutaneous
QACHS: Goal blood sugar
150-200 mg/dL;
For BREAKFAST:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 2 units
151-200: 4 units
201-250: 6 units
251-300: 8 units
301-350: 10 units
351-400: 12 units
>400 Notify MD
For LUNCH AND DINNER:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 1 units
151-200: 2 units
201-250: 4 units
251-300: 6 units
301-350: 8 units
351-400: 10 units
>400 Notify MD
For BEDTIME:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 0 units
151-200: 0 units
201-250: 2 units
251-300: 4 units
301-350: 6 units
351-400: 8 units
>400 Notify MD.
12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO twice a
day: please give if no BM in 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary
1. Hypoglycemia
2. Hypertensive urgency
3. Hypercalcemia
4. Acute on chronic renal insufficiency
5. Acute uncomplicated cystitis
6. Diabetes mellitus type II
Secondary
1. Thyroid nodule
2. Anemia of chronic disease
Discharge Condition:
Asymptomatic with stable vital signs.
Discharge Instructions:
You were admitted to the hospital with very low blood sugar,
possibly because your kidneys weren't properly clearing your
diabetes medication from the blood. We have therefore
discontinued GLIPIZIDE. In its place, we recommend that you
begin taking insulin shots to help control your diabetes.
You were also found to have high levels of calcium in the blood.
The cause of this problem remains unclear despite many tests.
Please stop taking TRIAMTERENE-HYDROCHLOROTHIAZIDE because it
can raise calcium levels. It is imperative that you stay
well-hydrated by drinking plenty of fluids to help keep the
calcium level down.
You had a urinary tract infection which was partially treated
with the antibiotic ciprofloxacin. Please continue taking this
medication through Monday [**1-27**].
The following changes to your blood pressure medications were
recommended:
1) Start taking ISOSORBIDE MONONITRATE (IMDUR) 30 mg daily.
2) Increase HYDRALAZINE to 75 every 6 hours.
3) Discontinue TRIAMTERENE-HYDROCHLOROTHIAZIDE.
Please have repeat blood work done on Monday, [**1-27**].
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] on [**2-12**] at 8:10
AM.
Please attend your follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital 18**] [**Hospital 6091**] Clinic on [**2200-2-19**] at
4:00 PM. The phone number is [**Telephone/Fax (1) 1803**] if you would like to
reschedule.
Please call your physician or return to the Emergency Department
if you experience fever, chills, sweats, dizziness,
lightheadedness, confusion, chest pain, cough, shortness of
breath, abdominal pain, vomiting, diarrhea, or bloody or dark
stools.
Followup Instructions:
Please have repeat blood work done on Monday, [**1-27**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2200-2-12**] 8:10
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2200-2-19**] 4:00
Completed by:[**2200-1-24**]
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30192
|
Discharge summary
|
Report
|
Admission Date: [**2146-11-28**] Discharge Date: [**2146-12-26**]
Date of Birth: [**2100-1-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Leg pain, fever
Major Surgical or Invasive Procedure:
Transesophageal echo
Urgent aortic valve replacement with size 23 St.
[**Male First Name (un) 923**] Epic tissue valve [**2146-12-21**]
History of Present Illness:
is 46 yo F with hx of IVDU, HCV, granulomatous disease of GI
tract, liver, spleen, and bone, hx of cellulitis, osteomyelitis
of spine, and chronic leg ulcers, and anxiety who p/w 2 days of
leg pain, right worse than left, bilateral leg swelling that
feel hot to touch. She was in her usual state of health until 2
days ago when she noticed that her R leg was painful and
swollen, she took 6 Advil for pain relief which did not help.
Measured her fever at home to be 103. Yesterday, she began to
notice swelling and pain in her L leg. No recent trauma in the
area, no open cuts or wounds preceding swelling. She was seen
yesterday at OSH where she was advised to be admitted for
antibiotics, she left AMA because she had a negative experience
during an admission last year. Did not get any antibiotics PO on
discharge. Last night, she used a pin to put a hole in her R leg
in hopes of relieving pressure, noticed minimal clear drainage
from the area. Of note, pt has chronic venous stasis changes
with erythema on R leg. Also has large ulcers in inguinal areas
L>R (6cm ulcer with pus and drainage in L inguinal area, 1cm
ulcer in R), she does dressing changes for these daily at home
using Silvedene. Inguinal ulcers are [**3-1**] heroin injection, pt
reports she has not injected in about 6 months and ulcers have
improved since then. She never injected in her toes, has not
injected in arms in many years due to scarring. Pt says she was
tested for HIV since stopping drugs and has been negative, HCV
infection is "inactive" per her, she was never treated for this.
.
In ED vitals were 99.2, 96/49, 78, 16, 97% RA, she received 1g
vancomycin.
.
Review of systems:
+ Weight loss of 15 lbs in past month, decreased appetite;
chronic headaches; + non-productive cough of few days
No N/V, no diarrhea, no changes in urine or bowel, abdominal
distension at baseline per pt
Past Medical History:
Hepatitis C antibody positive, negative VL [**4-/2143**], neg VL [**4-5**]
HIV negative as of [**4-5**]
IVDU with unclear timeline of use
[**Name (NI) **] Deficiency Anemia
Septic R shoulder s/p drainage and debridement of rotator cuff
Osteo of spine
Thigh ulcers (left upper thigh ulcer for >7 years)
MSSA bacteremia with endocarditis resulting in 8 week [**Hospital1 2025**]
admission in [**4-4**]
MSSA osteo [**2143**] resulting in 7 week [**Hospital1 18**] admission in [**2143**]
Non-caseating granulomas ([**6-3**]): liver biopsy, bone marrow,
gastric antrum thought to be the etiology of her elevated alk
phos (likely a result of injecting heroin with cocaine
containing talc)
Social History:
Lives with parents given need for assistance but has her own
home. Parents are incredibly supportive and caring. Patient also
has a sister, brother and step-brother who are involved in her
life. She no longer works. Hx of IVDU, cocaine, heroin but clean
for 6 months. >60 pack year history now 6 cigs/day, Hx of EtOH
abuse now quit 10 years ago. Had daughter who died 2 years ago
at age 24 from overdose.
Family History:
Denies famiy history of CA, HTN, heart disease, liver disease.
Physical Exam:
GA: AOx3, NAD
HEENT: PERRLA, moist oral mucosa, anicteric sclera
Cards: RRR, S1/S2, holosystolic murmur [**4-2**] in LUSB
Pulm: coarse breath sounds B/L, no wheezes or rales
Abd: soft, distended, + hepatosplenomegaly, no appreciable fluid
wave, non-tender, no rebound/guarding
6x6cm draining ulcer in L inguinal area; 1x1cm ulcer in R
inguinal area
Extremities: R>L edema and erythema, no distinct border, warm to
touch b/l, erythematous, small draining tract on R dorsal shin,
scaling b/l, 2+ distal pulses
Neuro/Psych: CNs II-XII intact. no motor deficits, gait not
assessed
Pertinent Results:
Admission labs:
.
[**2146-11-28**] 12:35PM BLOOD WBC-6.4# RBC-2.94* Hgb-9.2* Hct-27.4*
MCV-93 MCH-31.4 MCHC-33.7 RDW-14.7 Plt Ct-217
[**2146-11-28**] 12:35PM BLOOD Neuts-81.4* Lymphs-13.3* Monos-3.0
Eos-2.1 Baso-0.3
[**2146-11-28**] 12:35PM BLOOD Glucose-94 UreaN-33* Creat-1.9* Na-134
K-5.5* Cl-101 HCO3-22 AnGap-17
[**2146-11-29**] 07:30AM BLOOD ALT-24 AST-25 AlkPhos-276* TotBili-0.4
[**2146-11-29**] 07:30AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
[**2146-12-1**] 07:15AM BLOOD calTIBC-147* Hapto-189 Ferritn-761*
TRF-113*
[**2146-12-2**] 07:00AM BLOOD VitB12-419 Folate-12.2
[**2146-11-29**] 07:30AM BLOOD AFP-1.2
.
[**2146-12-26**] 05:54AM BLOOD WBC-4.9 RBC-2.67* Hgb-8.4* Hct-24.7*
MCV-93 MCH-31.5 MCHC-34.1 RDW-17.3* Plt Ct-215
[**2146-12-25**] 03:38AM BLOOD WBC-5.1 RBC-2.67* Hgb-8.5* Hct-24.7*
MCV-93 MCH-31.6 MCHC-34.2 RDW-17.4* Plt Ct-217
[**2146-12-26**] 05:54AM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-139
K-3.2* Cl-101 HCO3-31 AnGap-10
[**2146-12-25**] 03:38AM BLOOD Glucose-93 UreaN-21* Creat-1.3* Na-137
K-3.0* Cl-98 HCO3-31 AnGap-11
[**2146-12-24**] 03:17AM BLOOD Glucose-114* UreaN-17 Creat-1.3* Na-139
K-3.8 Cl-102 HCO3-27 AnGap-14
[**2146-12-21**] TEE
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium or the right
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-35 %). The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. There
is a mass in the right ventricle. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to XX cm from the incisors. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. Severe (4+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is a very small pericardial effusion. There are
no echocardiographic signs of tamponade.
POSR CPB:
1. Improved [**Hospital1 **]-ventricular systolci function with inotropic
support
2. Bioprosthetic valve in aortic p[osition. Well seated and good
leaflet excursion (PG =30 mm Hg
3. RV mass in the subvalvular apparatus is still visible
4. No other change
Brief Hospital Course:
Pt is 46 yo F with hx of IVDU, HCV, hx of cellulitis and
osteomyelitis who p/w chronic non-healing ulcers [**3-1**] heroin use
b/l and fever, found to have MSSA bacteremia and aortic valve
endocarditis.
.
# MSSA Bacteremia - blood cultures ([**3-3**]) bottles from admission
positive for MSSA. The most likely source is the bilateral
chronic non-healing ulcers [**3-1**] heroin use. Though pt reports not
having used heroin in the past 6 months, ulcers have not healed
despite dressing changes at home. On admission, ulcers appeared
infected and pt was febrile. Pt was started on IV nafcillin for
MSSA, to complete a total 6-week course. Of note, pt has history
of MSSA infections in the past (abscesses, bacteremia, and R
sided endocarditis) for which she completed nafcillin courses.
Pt also had history of thoracic osteomyelitis in [**2144**] treated at
[**Hospital1 2025**], though this was considered as possible source of bacteremia
on this admission, it seems less likely given no clinical
symptoms of back pain and more likely source of ulcers. Pt
refused MRI imaging, but should consider outpatient open MRI if
does not continue to have improvement. All surveillance cultures
since admission have had no growth to date. As described below,
pt was found to have aortic valve vegetation and infective
endocarditis with no abscess seen on TEE.
.
# Endocarditis - in setting of MSSA bacteremia, pt was found to
have 1.4cm vegetation on aortic valve, new since echo in [**3-9**],
with moderate aortic insufficiency. Started on 6-week course of
IV nafcillin as above. Cardiology and CT surgery were consulted
and did not recommend acute surgical intervention given
bacteremia and no decompensated heart function. Daily ECGs did
not show any abnormalities, pt had hypotension to SBP 100
throughout most of hospital stay and one episode of fever to
100.5 a week into therapy; given this, a TEE was done to
evaluate for cardiac abscess and was negative for this.
-Patient was transferred into MICU after code was called on
floors for hypoxic respiratory failure. This respiratory
failure was quickly reversed with diuresis and NIMV, and was
thought to be [**3-1**] severe aortic valve insufficiency in the
setting of patient anxiety. Similar episodes occurred
intermittently in the ICU with any mild increase in SVR, so
patient was kept with sedative/opiate regimen to stave off
anxiety. Cardiac surgery was consulted, and it was agreed that
surgical correction of valve was only viable therapeutic option.
.
# Inguinal ulcers - [**3-1**] long-standing heroin use though pt
reports no use for past 6 months. She had been doing daily
dressing changes at home though these ulcers were likely
infected on admission (6x6cm in L anterior thigh area, 2x2cm in
R). Wound care and plastic surgery were consulted, plastic
surgery did not recommend surgical debriding, pt had wet-to-dry
dressing changes three times a day which required 1mg IV
dilaudid for pain control beforehand. Once pt completes
antibiotic course for bacteremia and endocarditis, she will
follow up with plastic surgery to consider flap placement to
ensure healing. Pt had bilateral venous stasis changes and 1+
edema below knees, in addition to leg elevation and
betamethasone cream, she was diuresed with lasix and had
decrease in edema and pain in legs.
.
# Acute renal insufficiency - likely pre-renal given poor PO
intake recently and infection. Cr improved to 1.3 today, FeNa
2.5% and FeUrea 52% both of which suggest resolution of
pre-renal state
- encourage PO intake
- continue to trend Cr
.
# Hypotension - now improved, SBP 110s-120s. Given aortic valve
vegetation, will maintain high suspicion for valve dysfunction
contributing to hypotension.
- encourage PO intake
- monitor on tele, daily ECGs
- continue abx as above
.
# Anemia - chronic, HCT baseline 26-27, [**Month/Day (2) **] studies in [**2145**]
revealed likely etiology as anemia of chronic inflammation. [**Year (4 digits) **]
panel indicates likely ACI, no evidence for hemolysis. HCT
bumped appropriately to 1U RBC. HCT stable today.
- T+S, PIV
- peripheral smear - no schistocytes
- B12 / folate - normal
.
# Anxiety - continue home 1mg TID ativan
.
# HCV - "inactive", never treated for this. Pt had liver biopsy
in [**6-6**] which showed fibrosis with no clear etiology for
hepatomegaly. She follows in [**Hospital **] clinic here. Recent poor
appetite and weight loss is concerning for malignancy, though
AFP not elevated.
- outpt work-up for ?malignancy
- LFTs stable
# IVDU - pt reports being clean for 6 months
- social work consult
MICU Course
The patient is a 46 yo F with hx of IVDU complicated by MSSA
verebral osteo [**2143**], and prior history of endocarditis [**2145**] at
[**Hospital1 2025**], h/o MRSA/pseudomonal hip wound infection, HCV,
granulomatous disease of GI tract, chronic inguinal ulcers, and
anxiety with MSSA endocarditis who was transferred to the MICU
for hypercarpic respiratory failure and code blue after being
briefly unresponsive.
.
#. Hypercarpic Respiratory Failure: Pt initial ABG showed ph
6.84 and PCO2 of 112. The differential for her respiratory
failure was medication related especially opioid use causing
respiratory depression. Although pt with high tolerance and has
been stable on dilaudid dosing and no recent increase. The
patient does have a history of drug abuse and could have had an
alternate source of drugs or been hording her medications. Pt
also could have fallen because of a seizure with head injury
leading to bleed or embolic/hemorrhagic stroke given
endocarditis, but pt awake and interactive making major CNS
process unlikely. Pt does not have a history of COPD or other
history of bronchospasm. CXR did not show clear evidence of
acute pathology. LENIs performed yesterday negative for DVT,
making PE less likely. Pt was extubated after being intubated
for 2 days and sating well on 2L NC/RA.
.
#. MSSA Endocarditis: Pt previously on Nafcillin for MSSA
endocarditis seen on TEE. Pt had stat ECHO performed at bedside
by cardiology ID consulted and recommended changing to
vancomycin and meropenem given concern for sepsis upon initial
presentation to ICU, which was later switched back to Nafcillin
given stable BP's and clinical status, as this provides better
coverage of her MSSA bacteremia.Follow-up blood, urine and
sputum cultures
.
# Hypotension: Likely [**3-1**] cardiogenic shock given markedly
decreased EF. Sepsis was initially also a concern in this pt
with MSSA endocarditis but given mixed venous of < 70,
cardiogenic is more likely. Required briefly phenylephrine but
was later weaned off and tolerated well without. TTE repeated
yesterday showed EF 40%, worsening AR. Was transfused 2 units
of PRBC's.
.
#. ECG Changes: Pt with inverted t-waves in the setting of her
severe acidosis and tachycardia. Troponin peaked at 0.27 and
trended down at 0.22. Per cardiology, will not pursue
anticoagulation for concern of ACS , according to ECHO report
patient most likely experienced coronary artery embolization
from her endocarditis
.
#. S/p Fall: Pt found down for undetermined time. She is
currently complaining of neck pain. MRI of the cervial and
thoracic spine was unremarkable and trauma surgery cleared the
patient.
.
# Inguinal ulcers - [**3-1**] long-standing heroin use. No evidence
of infection and was being followed by plastics.
- wound care with wet to dry dressings TID
.
# HCV - Never underwent treatment. Pt had liver biopsy in [**6-6**]
which showed fibrosis with no clear etiology for hepatomegaly.
Trended LFTs Q daily
.
# IVDU - pt reports being clean for 6-8 months per prior notes
.Social work following
.
#[**Last Name (un) **]??????Cr elevated to 1.6 from low of 1.1 a few days ago. [**Month (only) 116**] be
hypoperfusion [**3-1**] cardiogenic shock. UA also positive; may have
thrown septic emboli to kidneys. Urine lytes showed a boderline
prerenal etiology with Fe urea 28%. Eosinophil smear showed.....
.
# Chronic Pain??????on opioids for pain. However, given respiratory
failure after receiving dilaudid and ativan, will be
conservative in dosing, ordered Lorazepam 1 mg PO/NG Q6H:PRN
anxiety , HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN
pain/agitation
.
#Anemia: Hct drop from 27 to 22 this morning, 20 on repeat.
Transfused 2 units PRBCs,did not increase appropiately to first
unit and DIC labs were sent which were unremarkable, Guiac
stools...
Cardiac Surgery Course:
The patient was brought to the operating room on [**2146-12-21**] where
the patient underwent aortic valve replacement with 23mm Porcine
tissue valve. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. The patient
remained intubated on POD 1 as she had no cuff leak and had been
intubated multiple times during this admission, and it was
decided to manage her conservatively. She remained on
epinephrine and propofol drips. Decadron was initiated for lack
of cuff leak on POD 2.
POD 3 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Acute pain service was consulted, as she
has a h/o IVDA and refused MS Contin or Oxycontin.
Recommendations were made for dilaudid. ID continued to follow
and the patient is to be maintained on Nafcillin for a 6 week
course through [**2147-1-9**]. PICC was placed to facilitate therapy.
Fluconazole was initiated for yeast in the urine. Beta blocker
was initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 5, the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to [**Hospital1 **], [**Location (un) 701**] in good condition with
appropriate follow up instructions.
Medications on Admission:
Currently taking only 1 mg lorazepam three times a
day for anxiety. Does not take any other medications at
present.
Medications were reviewed and reconciled with the patient.
Discharge Medications:
1. betamethasone valerate 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day): apply to both legs twice a day.
2. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. hydromorphone 2 mg Tablet Sig: 3-5 Tablets PO Q3H (every 3
hours) as needed for pain.
8. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
13. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. Nafcillin 2 g IV Q4H
15. nafcillin 2 gram Recon Soln Sig: One (1) Intravenous every
four (4) hours for 2 weeks: Last day of treatment [**2147-1-9**].
16. HYDROmorphone (Dilaudid) 1 mg IV BID:PRN dressing changes
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
18. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
MSSA bacteremia
Infective endocarditis, s/p AVR
PMH:
IVDA -heroin(says clean 6months).
Ulcers/cellulitis B thighs. HepC, ascites,T9 osteo w/paraspinal
abscess [**2143**],hepatosplenomegaly
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- 1+ LEs
Discharge Instructions:
Medical Service:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
with fevers and leg pain. We found a bacteria growing in your
blood called MSSA (which you have had in the past) and we
started you on appropriate antibiotics for this. We did an
echocardiogram of your heart which showed that the bacteria had
spread to a valve in your heart. Your heart function was
monitored and was stable throughout your hospital stay. The most
likely source for your infection are the ulcers on your legs.
Our plastic surgery team recommended that you get these debrided
during dressing changes by using wet-to-dry dressings, which we
have been doing three times a day in the hospital. We gave you
some water pills to take the fluid out of your legs. You should
continue your antibiotic course for a total of 6 weeks
.
We have made the following changes to your medications:
Continue nafcillin for 6 weeks total (last day = [**2147-1-9**])
CARDIAC SURGERY:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
The following appointments have already been scheduled for you:
.
Department: DIV OF PLASTIC SURGERY
When: FRIDAY [**2147-1-6**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD [**Telephone/Fax (1) 6742**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: [**Hospital3 249**]
When: MONDAY [**2147-1-23**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2147-2-2**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Cardiac Surgery
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2147-1-16**] 1:30
Cardiology:
Dr [**First Name (STitle) **] on [**2-2**] at 11:40am
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2146-12-26**]
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42137
|
Discharge summary
|
Report
|
Admission Date: [**2158-8-10**] Discharge Date: [**2158-8-16**]
Date of Birth: [**2087-12-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
abnormal EKG
Major Surgical or Invasive Procedure:
[**2158-8-10**] Coronary bypass grafting x4 with left internal mammary
artery to left anterior descending coronary artery, with
extended patch angioplasty, reverse saphenous vein graft from
the aorta to the first obtuse marginal coronary artery; reverse
saphenous vein graft from the aorta to the second obtuse
marginal coronary; reverse saphenous vein graft from the aorta
to the posterior descending coronary artery, Endoscopic left
greater saphenous vein harvesting.
History of Present Illness:
70 year old male without any previous known cardiac disease, who
was found to have an abnormal EKG during preoperative workup for
Bladder and Kidney stones. He was sent for an echo which
revealed low-normal systolic function with
an EF of 50-55%. He was sent for a Persantine Stress which
revealed a large previous infarct in the anterior and
anteroseptal walls extending from the mild LV to the apex with
mild peri-infarct ischemia. He does report 2 very brief
episodes of a gurgling sensation around his breast bone several
months occur. Each episode lasted only seconds, occurred while
lying down, with no associated symptoms, and resolved on its
own. He is overall very sedentary. He has been overweight and
has never exercised. He fell down a couple stairs last week and
injured his left foot. He still has localized swelling. An XRAY
did not reveal any fracture. He is still having difficulty
getting around secondary to the pain. He was referred for
cardiac catheterization and was found to have coronary artery
disease. He is now referred to cardiac surgery for
revascularizaiton.
Past Medical History:
? Silent MI
Type 2 DM - most recent HbA1c 7.6 in [**2158-5-17**] on insulin for 5
years
HTN
Hypercholesterolemia
Obesity
Bladder and Renal Stones/Hematuria
Prostate CA s/p XRT therapy
CKD stage II
Social History:
SOCIAL HISTORY: He lives with his wife in [**Name (NI) 5028**]. He is
retired, used to be a delivery person. He has two adult
children. He does not use any assistive devices.
TOBACCO: never
ETOH: rare
Drugs: none
Family History:
Father died of heart disease in his 70's. Father also diabetic.
Mother died in her 50's of peritonitis.
Physical Exam:
Admission Physical Exam
Pulse:80 Resp:18 O2 sat:99/RA
B/P Right:171/87 Left:160/83
Height:5'[**56**]" Weight:276 lbs
General:
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [x], well-perfused [x] Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Palp Left: palp
DP Right: Palp Left: dop
PT [**Name (NI) 167**]: Palp Left: dop
Radial Right: Plap Left: Palp
Carotid Bruit Right: None Left: None
Pertinent Results:
Echocardiogram
Left Atrium - Four Chamber Length: 4.5 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *2.6 cm2 >= 3.0 cm2
Mitral Valve - Pressure Half Time: 53 ms
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.67
Mitral Valve - E Wave deceleration time: 182 ms 140-250 ms
LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20
cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low
normal LVEF.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
PRE-BYPASS: The left atrium and right atrium are normal in
cavity size. No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is low normal (LVEF 50-55%). There is apical
hypokinesis. The remaining left ventricular segments contract
normally. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified
in person of the results at time of surgery.
POST-BYPASS: The patient is on no inotropes. Biventricular
function is unchanged. No new valvular abnormalities are seen.
The aorta is intact after removal of the bypass cannula.
ekg
Atrial fibrillation. Left axis deviation. Poor R wave
progression and lack
of R waves in the anterolateral leads suggestive of prior
myocardial
infarction. Small R waves in the inferior leads suggest possible
inferior
myocardial infarction. Compared to the previous tracing of
[**2158-8-11**] atrial
fibrillation is new and there is modest J point elevation in
leads III and aVF raising the possibility of an acute process.
Suggest clinical correlation and repeat tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 0 124 422/425 0 -58 90
CXR [**8-15**]
COMPARISON: [**2158-8-12**].
FINDINGS: Upright PA and lateral views of the chest show
improvement of a
small left pleural effusion. There is an unchanged tiny right
pleural
effusion. Left retrocardiac atelectasis is stable. No change in
mild
cardiomegaly. No pneumothorax or focal consolidation to suggest
pneumonia. A right IJ sheath has been removed.
IMPRESSION: Improved, now small, left pleural effusion.
[**2158-8-16**] 07:30AM BLOOD WBC-11.1* RBC-3.42* Hgb-10.6* Hct-30.9*
MCV-90 MCH-31.0 MCHC-34.3 RDW-13.7 Plt Ct-336#
[**2158-8-10**] 02:36PM BLOOD WBC-19.2*# RBC-4.34* Hgb-13.7* Hct-37.9*
MCV-87 MCH-31.7 MCHC-36.3* RDW-13.4 Plt Ct-206
[**2158-8-16**] 07:30AM BLOOD Plt Ct-336#
[**2158-8-16**] 07:30AM BLOOD PT-15.9* INR(PT)-1.4*
[**2158-8-15**] 05:05PM BLOOD PT-14.5* INR(PT)-1.3*
[**2158-8-10**] 12:30PM BLOOD PT-14.3* PTT-31.1 INR(PT)-1.2*
[**2158-8-10**] 12:30PM BLOOD Fibrino-292
[**2158-8-16**] 07:30AM BLOOD Glucose-109* UreaN-36* Creat-1.6* Na-142
K-5.1 Cl-104 HCO3-30 AnGap-13
[**2158-8-13**] 09:10AM BLOOD Glucose-172* UreaN-46* Creat-2.0* Na-136
K-4.8 Cl-101 HCO3-27 AnGap-13
[**2158-8-10**] 02:36PM BLOOD UreaN-18 Creat-1.3* Na-141 K-5.3* Cl-112*
HCO3-22 AnGap-12
[**2158-8-14**] 05:45AM BLOOD ALT-7 AST-25 LD(LDH)-282* AlkPhos-55
Amylase-45 TotBili-0.6
[**2158-8-16**] 07:30AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.6
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. See operative report
for further details. Post operatively he was taken to the
intensive care unit for management. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact
and was extubated without complications. Of note he initially
was in complete heart block requiring epicardial pacing but his
rhythm recovered and went into atrial fibrillation. He was
treated with amiodarone, which converted back to sinus rhythm.
Betablockers were held and he was continued on amiodarone with
intermittent short burst of atrial fibrillation. He was started
on coumadin for anticoagulation due to ongoing episodes of
atrial fibrillation. Physical therapy worked with him on
strength and mobility. On post opeerative day five he was
started on low dose betablockers which he tolerated. He
continued to do well and was ready for discharge to rehab on
telemetry on post operative day six to [**Hospital6 **].
Medications on Admission:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2
times a day) for 5 days: Please swab in nose for 5 days before
surgery. .
Disp:*1 tube* Refills:*0*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
units Subcutaneous as directed: 58 unit am, 32 units at night.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Telemetry
To monitor rhythm due to atrial fibrillation and post operative
heart block
7. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
8. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
please give 400 mg twice a day until [**8-22**] then decrease to 400 mg
once a day until [**8-29**], then decrease to 200 mg once a day until
follow up with cardiologist .
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: twice
a day for one week then decrease to daily .
11. Zaroxolyn 5 mg Tablet Sig: One (1) Tablet PO once a day for
5 days: give with am lasix .
12. Outpatient Lab Work
please check bun, Cr Magnesium, potassium on [**8-18**] due to lasix
and continue twice a week with diuresis
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever, pain.
15. Insulin
Regular before each meal
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 2 Units
160-199 mg/dL 4 Units 4 Units 4 Units 4 Units
200-239 mg/dL 6 Units 6 Units 6 Units 6 Units
240-279 mg/dL 8 Units 8 Units 8 Units 8 Units
16. Insulin NPH
please give 30 units with breakfast and 18 units with dinner
17. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
pleae give 5mg on [**8-17**] then check INR [**8-18**] for further dosing
based on INR goal INR 2.0-2.5 for atrial fibrillation .
18. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Atrial fibrillation
Chronic kidney disease stage II
Diabetes mellitus type 2
Hypertension
Hypercholesterolemia
Obesity
Prostate cancer
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol and ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema +2 lower extremity
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] on [**9-19**] at 1:15 pm
Cardiologist Dr [**First Name (STitle) **] on [**9-5**] at 2:15pm
Please call to schedule appointment with primary care physician
after discharge from rehab Dr [**Last Name (STitle) 84032**] [**Telephone/Fax (1) 28612**]
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2-2.5
First draw [**8-18**] Friday
Please check INR monday and wednesday and friday for two weeks
then decrease as instructed by physician
Coumadin to be managed by rehab physician based on INR results
and then please arrange for continued management with primary
care physician
Completed by:[**2158-8-16**]
|
[
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"250.00",
"403.90",
"272.0",
"278.00",
"V10.46",
"585.2",
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icd9cm
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[
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[
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[] |
icd9pcs
|
[
[
[]
]
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| 1,044
| 0
| 476
| 244
| 0
| 0
| 0
| 0
| 5,094
| 0
| 0
| 751
| 107
| 0
| 0
| 0
| 2,110
| 0
| 171
| 0
| 674
| 0
| 0
| 0
| 0
| 795
| 0
| 0
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| 0
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| 0
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| 691
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97,683
| 119,454
|
50353
|
Discharge summary
|
Report
|
Admission Date: [**2105-2-19**] Discharge Date: [**2105-2-26**]
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / Terazosin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
88 M admitted to [**Hospital1 **] [**Location (un) 620**] with CAP and atrial fibrillation
with RVR on [**2-16**]. He was treated with levaquin and then changed
to CTX/azithro/flagyl and subsequently transferred to ICU for
hypoxia thought to be due to acute heart failure. TTE showed
preserved systolic function but did show moderate RV dilation so
a CTA chest was done which was negative for PE. Remained hypoxic
and placed on BIPAP which fell on his head causing laceration,
has had 2 CTH which were unrevealing for ICH. Has been on
diltiazem gtt for rate control and VSS at time of transfer wre
90s on NRB and stable BP and HR.
Upon arrival to the ICU patient comfortable and in no acute
distress, speaking in full sentences with clear sensorium. No
complaints.
Patient then became difficult to mantain adequate oxygenation on
NRB and subsequently on BIPAP with saturations in the 90s,
patient became progressively delirious and intubation was
undertaken.
Past Medical History:
atrial fibrillation
atrial flutter
CAD s/p CABG
history of PFO
ulcerative colitis
glaucoma
hypertension
BPH s/p TURP
Social History:
Lives at home. Prior smoker quit several years ago
Family History:
unremarkable.
Physical Exam:
General Appearance: Intubated, sedated
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: Irregular
Respiratory / Chest: Rhonchi bilaterally up to [**1-25**]
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: No lower extremity edema
Skin: Warm
Neurologic: Intubated, sedated
Pertinent Results:
Labs on Admission:
[**2105-2-19**] 07:34PM BLOOD WBC-25.3*# RBC-3.02* Hgb-9.8* Hct-29.7*
MCV-98 MCH-32.3* MCHC-32.9 RDW-13.9 Plt Ct-308
[**2105-2-19**] 07:34PM BLOOD Neuts-90.1* Lymphs-6.8* Monos-2.7 Eos-0.3
Baso-0.1
[**2105-2-19**] 07:34PM BLOOD PT-15.6* PTT-27.7 INR(PT)-1.4*
[**2105-2-19**] 07:34PM BLOOD Glucose-125* UreaN-40* Creat-1.0 Na-150*
K-3.9 Cl-107 HCO3-32 AnGap-15
[**2105-2-19**] 07:34PM BLOOD CK(CPK)-309
[**2105-2-19**] 07:34PM BLOOD CK-MB-11* MB Indx-3.6 cTropnT-0.54*
[**2105-2-20**] 03:52AM BLOOD CK-MB-5 cTropnT-0.54*
[**2105-2-20**] 05:27PM BLOOD cTropnT-0.45*
[**2105-2-19**] 07:34PM BLOOD Calcium-9.4 Phos-2.8 Mg-2.6
[**2105-2-19**] 08:18PM BLOOD Type-[**Last Name (un) **] pO2-57* pCO2-55* pH-7.38
calTCO2-34* Base XS-5 Comment-GREEN TOP
[**2105-2-19**] 09:09PM BLOOD Lactate-2.1*
Labs on Discharge:
Micro:
Studies:
ECHO ([**2-20**]): The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with mid- to
distal anterior and anteroseptal hypokinesis. The remaining
segments contract normally (LVEF = 35%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-24**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. Severe
pulmonic regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w LAD disease. Mild to moderate mitral
regurgitation. Mild pulmonary hypertension.
CXR ([**2-21**]): Asymmetrically distributed pulmonary edema improved
substantially between [**2-19**] and [**2-20**] and heart size decreased.
Allowing for lower lung volumes, there has been no subsequent
change. Since 8:10 p.m. on [**2-20**] more confluent areas of
pulmonary abnormality in the axillary subsegments of the right
upper lobe and right lung base posteriorly, could be pneumonia
but could also be asymmetric edema and atelectasis, particularly
the latter. There is no appreciable pleural effusion. ET tube is
in standard placement. Nasogastric tube ends in the stomach. No
pneumothorax.
CXR ([**2-23**]): In comparison with the study of [**2-22**], there is
continued elevation of pulmonary venous pressure with
atelectasis at the left base medially.
Video swallow study ([**2-24**]): ****
Brief Hospital Course:
88 year old male with CAD s/p CABG, remote smoking history,
atrial fibrillation, [**Hospital **] transferred from [**Hospital1 **] [**Location (un) 620**] with
hypoxia after being treated for a CAP
.
# Hypoxia: Initially intubated given difficulty with
oxygenation. TTE revealed regional akinesis and hypokinesis, as
well as LVEF 35%, possibly attributable to acute heart failure.
He was placed on furosemide gtt but was intermittently held for
hypotension. Was placed on empiric antibiotics for CAP. Was
evaluated by Speech & Swallow therapy, and was believed to be
aspirating as well has collecting significant pharyngeal
residue, to which he was insensate. This was potentially
secondary to irritation of his oropharynx from his brief
intubation. His hypoxia improved greatly, and it was felt that
his swallow would likely recover over time. A dobhoff was
placed for temporary nutrition and med administration. ****
.
# Atrial fibrillation with RVR: Placed on diltiazem gtt for rate
control. Amiodarone was initially held for concern for
amiodarone-induced pneumonitis, but this was eventually
restarted. Warfarin was restarted on [**2-21**]. Dilt was switched
over to PO and increased to 60qd with good rate control. At
dishcarge his home dose of verapamil SR was restarted.
.
# CAD s/p CABG/CHF: Added lisinopril to home regimen.****
.
# HTN: Well controlled on home regimen.
Medications on Admission:
Amiodarone 200 mg daily.
Accupril 5 mg daily.
Ursodiol 300 mg t.i.d.
Levothyroxine 25 mcg daily.
Sulfadiazine 100 mg b.i.d.
Coumadin.
Verapamil SR 180 mg daily.
Xalatan eye drops.
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Metipranolol 0.3 % Drops Sig: One (1) drop Ophthalmic qd ().
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Accupril 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO three times a
day.
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. Verapamil SR 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Multifocal Pneumonia
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 transferred to [**Hospital3 **] for better managment of your
low oxgyen levels which had required intubation at the outside
hospital. It was determined that you had a complicated
pneumonia, which responded well to antibiotics. It was
determined that you need tube feeds to temporarily protect your
wind pipe while your swallowing is not strong.
The following changes were made to your outpatient regimen:
Your warfarin was changed to 2mg per day.
Followup Instructions:
As needed with Rehab Facility MD
Provider [**Name9 (PRE) 161**] [**Name8 (MD) 6476**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2105-7-2**]
11:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2105-3-1**]
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icd9pcs
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99,322
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|
608964
|
Physician
|
Intensivist Note
|
TSICU
HPI:
52y F with PMHx dwarfism, asthma, COPD, OSA on CPAP presents with c/o
chronic dry cough, wheezing and dyspnea with moderate activities,
intermitted dysphagia. Pt was found to have TBM on outpt eval in
[**Location (un) 2339**], and presents to [**Hospital1 1**] on [**2146-10-24**] for further eval and
potential stent trial. S/p flexible bronchoscopy [**2146-10-24**] which showed
severe tracheobronchomalacia that involved all of the traceha, right
mainstem, bronchus intermedius and left mainstem. S/p rigid bronch
[**2146-10-28**] with placement of 3 metal stents (2 in trachea, 1 in left
main). Pt discharged, however, on [**2146-10-31**], pt with with increased SOB,
worsening cough, sore throat, and febrile to 105 F. EMS called, SBP
230's, given lasix and SL nitro and placed on nonreabrether. Pt taken
to [**Hospital1 49**] where she was bronched with removal of stent in left main
bronchus. Pt also with WBC 17 and found to have pneumonia (?aspiration
PNA as pt was witnessed to aspirate with liquids when taking po meds).
Pt started on ABX vanco/cefepime/l evaquin and on lasix for CHF like
symptoms. Transferred to [**Hospital1 1**] TICU [**2146-11-2**] for further management.
Chief complaint:
difficulty breathing
PMHx:
dwarfism, glaucoma, asthma, CHF, COPD, OSA on CPAP 13cm H2O,
osteoporosis, severe TBM
Current medications:
Acetaminophen (Liquid) 3. Benzonatate 4. Calcium Gluconate 5.
Chlorhexidine Gluconate 0.12% Oral Rinse
6. Dextrose 50% 7. Fluoxetine 8. Furosemide 9. Glucagon 10. Heparin
Flush (10 units/ml) 11. Heparin
12. 13. Insulin 14. Ipratropium Bromide Neb 15. Lidocaine 1% 16.
Lorazepam 17. Magnesium Sulfate
18. Montelukast Sodium 19. OxycoDONE-Acetaminophen Elixir 20. Potassium
Chloride 21. Potassium Phosphate
22. Sodium Chloride 0.9% Flush 23. Xopenex Neb 24. traZODONE
24 Hour Events:
INVASIVE VENTILATION - STOP [**2146-11-21**] 08:01 AM
INVASIVE VENTILATION - START [**2146-11-21**] 09:45 PM
INVASIVE VENTILATION - STOP [**2146-11-22**] 02:01 AM
[**11-21**] - vent rehab screening, S&S re-eval (no need for video swallow),
regular diet. Nutr recs d/c'ing Tfs if pt tolerated 3 cans Ensure +
food. Insomnia o/n-trazodone ordered.
Post operative day:
POD#8 - s/p flex bronch w/ stent removal and tracheostomy .
Allergies:
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Heparin Sodium (Prophylaxis) - [**2146-11-21**] 08:00 PM
Other medications:
Flowsheet Data as of [**2146-11-22**] 06:50 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**48**] a.m.
Tmax: 37.6
C (99.7
T current: 36.9
C (98.5
HR: 99 (79 - 123) bpm
BP: 103/42(56) {89/40(54) - 134/85(88)} mmHg
RR: 23 (20 - 51) insp/min
SPO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 67 kg (admission): 71.9 kg
Height: 55 Inch
Total In:
1,585 mL
518 mL
PO:
600 mL
Tube feeding:
495 mL
338 mL
IV Fluid:
100 mL
Blood products:
Total out:
1,025 mL
250 mL
Urine:
1,025 mL
250 mL
NG:
Stool:
Drains:
Balance:
560 mL
268 mL
Respiratory support
O2 Delivery Device: Trach mask
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 339 (339 - 339) mL
PS : 12 cmH2O
RR (Spontaneous): 19
PEEP: 8 cmH2O
FiO2: 60%
PIP: 21 cmH2O
SPO2: 99%
ABG: ///36/
Ve: 9.4 L/min
Physical Examination
General Appearance: No acute distress, Anxious, Well nourished
HEENT: PERRL, EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -
Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
(Responds to: Verbal stimuli), Moves all extremities
Labs / Radiology
390 K/uL
9.7 g/dL
146 mg/dL
0.5 mg/dL
36 mEq/L
4.2 mEq/L
15 mg/dL
101 mEq/L
142 mEq/L
29.7 %
7.2 K/uL
[image002.jpg]
[**2146-11-16**] 02:00 AM
[**2146-11-16**] 02:08 AM
[**2146-11-17**] 02:20 AM
[**2146-11-18**] 02:00 AM
[**2146-11-18**] 02:38 AM
[**2146-11-19**] 02:51 AM
[**2146-11-19**] 02:00 PM
[**2146-11-20**] 02:04 AM
[**2146-11-21**] 02:42 AM
[**2146-11-22**] 02:03 AM
WBC
7.1
7.2
5.5
10.5
6.5
6.1
7.2
Hct
29.5
26.9
27.3
31.5
28.6
28.7
29.7
Plt
[**Telephone/Fax (3) 9718**]
390
Creatinine
0.6
0.5
0.4
0.5
0.5
0.5
0.5
TCO2
30
Glucose
115
101
101
105
122
127
137
110
146
Other labs: PT / PTT / INR:12.9/41.0/1.1, Lactic Acid:1.0 mmol/L,
Ca:9.8 mg/dL, Mg:2.2 mg/dL, PO4:4.4 mg/dL
Imaging: [**11-3**] CXR - L retrocardiac opacity, pneumomediastinum (postop
changes)
[**11-4**] CXR - unchanged pneumomediastinum. Bibasilar opacities L>R,
unchanged: PNA vs. atelectasis.
[**11-6**] CXR - little to no change
[**11-7**] CXR - persistant L sided opacity - pna vs atelectasis
[**11-12**] CT ABD/PEL - No renal calculi or renal masses. No hydronephrosis.
Thickening of urinary bladder wall may be due to underdistension and
the urinary catheter seen in situ.
[**11-14**] CXR - R>L interstitial prominence, vascular redistribution most
likely asymmetric pulmonary edema.
[**11-15**] CXR - L sided opacity - PNA vs. LLL collapse
[**11-17**] CXR - Ill-defined opacity in RUL
[**11-18**] CXR - The Dobbhoff catheter in distal stomach. R suprahilar
opacity stable and RUL density, most likely atelectasis unchanged.
[**11-18**] CXR - Improved R suprahilar opacity, stable LLL atelectasis versus
infection.
[**11-19**] CXR - LLL atelectasis
[**11-20**] CXR - ill-defined RUL opacity persists, w/small focus laterally in
mid lung. suggests PNA. Opacity @R base c/w volume loss and pleural
effusion. possibility of another focus of consolidation in this region.
[**11-21**] CXR - B/l parenchymal opacity most likely PNA, incr on R &improved
on L.
Microbiology: [**11-1**] Sputum ([**Hospital1 49**]) - staph aureus Res to PCN G, otherwise
pan-sensitive including: cipro, levo, mox, clinda, tmx, methacillin,
vanco, Bactrim, linezolid. Sputum also showed [**Female First Name (un) 444**].
[**11-2**] UCX - no growth
[**11-4**] UCX - mixed bacterial flora c/w skin/genital contamination
[**11-6**] Sputum Cx - sparse growth Commensal Respiratory Flora. sparse
growth yeast.
[**11-7**] Sputum Cx - extensive contamination with upper respiratory
secretions
[**11-18**] Sputum - no growth
Assessment and Plan
TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), ANXIETY
Assessment and Plan: 52yF with TBM s/p metal stenting and subsequent
PNA admitted to TSICU with significant respiratory distress.
Respiratory status improved and pt transferred to floors. Pt to OR
[**2146-11-14**] for tracheostomy, bronch and stent removal and admitted to
TICU postop management.
Neurologic: Pain controlled, Ativan 1-2mg q2h prn for anxiety. Seen by
psych on this admission, may consider repeat visit. Restarted
fluoxetine 40mg qd.
Neuro checks Q: shift
Pain: Roxicet prn.
Cardiovascular: Hemodynamically stable. Hx of CHF, on lasix 20mg PO
QD. Intermittent tachycardia to 120s, pt refusing Ativan [**11-21**] day.
Pulmonary: Trach, Pt admitted with PNA and completed 7 day course of
levofloxacin. TBM s/p 3 stents and removal of 2 stents and Tracheostomy
placed [**2146-11-14**]. On trach collar, occasional coughing fits and spasms
with min desaturation. Placed back on CPAP at night. Cont xopenex nebs,
atrovent nebs, &tessalon perles prn. Restarted singulair. Longterm plan
includes tracheobronchoplasty in few weeks. [**Hospital **] rehab screening.
Gastrointestinal / Abdomen: Video swallow [**11-18**] ok thin liquids, soft
solids ([**11-21**] no need to repeat), Dobhoff placed [**11-17**]. Cycling TF at
night to stimulate PO intake during the day; Nutr recs d/c'ing Tfs if
pt tolerated 3 cans Ensure + food.
Nutrition: Tube feeding, Regular diet, Speech and Swallow eval
Renal: Adequate UO, On home dose of lasix. Keep dry.
Hematology: Hct stable. Monitor Daily.
Endocrine: RISS
Infectious Disease: Currently not on ABX. Afebrile.
S/p 10 day course of levofloxacin for PNA. OSH cultures showed S.Areus
sensitive to all abx except PCN, as well as [**Female First Name (un) 444**]. S/p 7 day course
of acyclovir for herpes on gluteus.
Lines / Tubes / Drains: PICC (placed [**11-2**]), Trach, Dobhoff
Wounds:
Imaging:
Fluids: KVO
Consults: Interventional Pulm, Thoracic, Urology
Billing Diagnosis: (Respiratory distress), Other: Respiratory Distress,
Tracheobronchomalacia
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
PICC Line - [**2146-11-14**] 06:50 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: Not indicated
VAP bundle: HOB elevation, Mouth care
Comments:
Communication: Patient discussed on interdisciplinary rounds , Family
meeting held , ICU consent signed Comments:
Code status: Full code
Disposition: Transfer to rehab / long term facility
Total time spent:
|
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icd9cm
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99,957
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45095
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Discharge summary
|
Report
|
Admission Date: [**2157-2-20**] Discharge Date: [**2157-3-4**]
Date of Birth: [**2089-2-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
OSH transfer for pneumococcal meningitis and cerebritis
Major Surgical or Invasive Procedure:
Stereotactic Burr hole drainage of subdural empyema.
History of Present Illness:
68M with PMH of DM, HTN, HL, CAD s/p distant MI, who is
transferred from [**Hospital **] Hospital, where he presented on [**2157-2-13**]
with fever, cough, and sore throat. He was initially treated for
pneumonia with ceftriaxone and azithromycin. On the afternoon of
admission, he was noted to be acutely aphasic, with word finding
difficulty. There was concern for acute stroke. Neurology was
consulted, he was transferred to the ICU, and a stat head CT was
performed. Given that he was also febrile with an elevated WBC
count to 27 with 27% bands, an LP was performed. This revealed
7800 WBCs with 94% polys, a glucose of 5, and a protein of 447.
He was initially covered with vanc/CTX/ampicillin/acyclovir. CSF
and blood cultures from [**2-13**] grew strep pneumo. ID was consulted,
and recommended PCN G and rifampin, which were started on
[**2157-2-13**]. He was followed by neurology and ID. He steadily
improved and was transferred out fo the ICU on [**2157-2-15**]. An MRI
performed [**2157-2-16**] showed right cerebral meningeal enhancement c/w
his h/o meningitis, as well as concern for mastoiditis
(non-communicating with the meninges). There was no evidence of
abscess or hemorrhage, but a small frontal hygroma vs. subdural
empyema. Nsurg was consulted, and there was NTD per them.
On [**2-19**], ENT performed a right myringotomy, and a copious amount
of seromucoid purulent material was aspirated; tubes were
placed. Per his report, later that day he developed tingling of
both upper extremities and the LLE, as well as left hand
weakness and general poor coordination. Neurology was
re-consulted, and exam revealed left sided neglect and poor
coordination without frank dysmetria. A repeat MRI was
performed, the preliminary report of which showed evidence of
cerebritis. Plans were initiated tranfer him to the [**Hospital1 18**] neuro
ICU, but they refused. He was instead accepted by the MICU.
Prior to transfer, rifampin was resumed, and keppra was begun
for seizure ppx. His temp was 100.2 and he was hemodynamically
stable.
On arrival to the [**Hospital1 18**] MICU, he complained of nausea. He
endorsed ongoing numbness in his hands and feet since
yesterday's ear operation.
Past Medical History:
PMH:
1. CAD - s/p MI in [**2138**], [**2151**] tx with angioplasty
2. HTN - currently managed w/ toprol XL 200mg
3. DM2 - managed on glucophage 1000mg [**Hospital1 **], glyburide 3.75
4. Hyperlipidemia - on lipitor 40mg
5. S/p ORIF for R zygomatic fx, and orbital fx with 2 plate
insertion
6. Atypical pneumonia in [**2144**], complicated by bronchocentric
granulomatosis and cold agglutinins hemolytic anemia
7. Cystic pancreatic disease
8. BPH s/p TURP
9. Appendicitis s/p appendectomy
10. S/p bladder polypectomy
Social History:
Mr. [**Known lastname 410**] is a retired immunologist at the [**Hospital3 328**] whose
research interest was in monoclonal antibodies. He and his wife
live in [**Name (NI) 1439**], MA. He has at least one son and one daughter.
Daughter is an OB/Gyn at [**Hospital1 18**]. Denies EtOH. Tob use: 20 pack
year hx, d/c in [**2136**].
Family History:
Non-contributory
Physical Exam:
Upon transfer to medical service:
VS: 98.9 120/54 106 w/ PVCs 24 95RA
Gen: Well-nourished elderly man, lying in bed, talking to son,
not SOB, in pain, or otherwise distressed.
HEENT: H: R eye palpabral fissure slightly smaller than L (9mm
vs. 12mm), no signs of trauma. E: PERRLA 3mm->2mm, conjunctiva
not pale, anicteric. E: Slightly tender to palpation. No
drainage appreciated. N: No signs of epistaxis. T: Moist
mucous membranes, no erythema or exudate.
Neck: Soft, supple. No LAD at pre/post auricular, ant/post
cervical, submandibular, supraclavicular nodes. No carotid
bruits. No mastoid tenderness.
CV: Tachycardic, reg rhythm with nl S1, S2. No m/r/g. Pulses 2+
in all 4 extremities (DP and PT on feet). No splinter
hemorrhages.
Lungs: Nl excursion on inspiration. No dullness to percussion.
No tactile fremitus. Lungs clear to auscult, bilat and ant/post.
No crackles, wheezes or rhonchi. Diaphragms symmetric.
Abd: Soft, non-tender. Slightly distended, but not tympanic.
Hypoactive bowel sounds. Liver percussed at 8cm. No renal
bruits.
Back: No spinal tenderness. No CVA tenderness. No paraspinal
tenderness.
Ext: No edema, erythema. WWP.
Neuro: AAOx3. Gives identifiers without prompting. Able to name
past 2 presidents only. Can multiply 6x7. Cannot subtract 17
from 81. Able to talk briefly about his research. Three word
recall intact at 2min. Full strength (unable to break) in
deltoids, biceps, triceps, IPs, and gastrocs, bilaterally. R
does seem slightly stronger however. Able to hold pen in L
hand, but trouble re-capping. Dysmetria w/ finger to nose on
the L. CN II: Lower left quadrant cut bilaterally. III, IV,
VI:EOMS intact. (son notes no ptosis as compared to baseline) V:
Sensation intact to light touch. VII/VIII: Face symmetric aside
from eyes as mentioned above. Hearing intact to snaps, not light
rustle. IX/X: coughs. XII:SCM intact, trap intact. XII:tongue
midline.
Upon Discharge:
c/o sl. HA controlled
A&Ox3, PERRL, follows commands, 5/5 strength, wound C/D/I
Pertinent Results:
FROM OUTSIDE HOSPITAL PRIOR TO TRANSFER:
MICRO:
[**2-13**] CSF HSV PCR: negative
[**2-13**] CSF gram stain: GPCs in P+C, culture neg
[**2-13**] BCx + pansenstive strep PNA
[**2-13**] UCx: <10,000 CFU, mixed flora
No right ear fluid cultures sent from OR on [**2-19**]
.
OSH IMAGING:
[**2-13**] CT-A:
no evidence of PE. Calcified right costophrenic sulcus plaque
with associated.
.
[**2-15**] Head CT without contrast
new small amound of hypodense fluid in the right frontal
subdural space/ While this may represent a subdural hygroma,
given the patient's h/o bacterial meningitis, a subdural empyema
should be considered. Complete opacification of the right
mastoid air cells with fluid int he right middle ear, as seen
previously.
.
[**2157-2-15**] Temporal Bone CT
bilateral cerumen plugs, extensive opacifiaction of the right
mastoid air cells, antrum, and middle ear suggesting
otomastoiditis. No bony destruction.
.
[**2-16**] MRI Brain:
extra-axial collection right cerebral hemisphere suggestive of
meningeal enchancement c/w clinical hx of bacterial meningitis.
No abscess or hemorrhage is seen.Non-aeration of mastoid air
cells with fluid signal c/w mastoiditis. However, this does not
appear to have broken through the subjacent meninges. Normal
venous sinuses.
.
[**2-16**] B/L carotid U/S:
< 20% ICA stenosis on both sides
.
[**2-16**] TTE
LVEF 40-45%, with inferior and posterior akinesis. Normla RV. 2+
MR, 1+ TR. Negative bubble study.
.
[**2-17**] CXR
fibrosis and scarring at the right base, small right pleural
effusion. PICC line at jxn of SVC and RA.
.
[**2-21**] CT Head w/ and w/o contrast:
"1. Right otomastoiditis.
2. Unchanged small right parietal subdural collection,
concerning for a
subdural empyema.
3. Persistent cortical swelling in the right parietal, posterior
frontal, and temporal lobes, compatible with known cerebritis."
.
[**2-21**] CT Orbits, Sella w/ contrast:
"Findings compatible with severe right otomastoiditis with
possible coalescence of the mastoid septae. There is also
thinning and demineralization of the tegmen tympani. Would
recommend MRI with skull base protocol to assess for meningeal
extension of infection.
Additionally, there is a tiny subdural collection on the
right, again
recommend MRI for further evaluation and to exclude a subdural
empyema."
.
[**2-22**] MR [**Name13 (STitle) 430**] w/ and w/o contrast, MRV Head:
"1. Unchanged small right parietal subdural empyema.
2. Right cortical edema consistent with cerebritis is again
seen. New mild
slow diffusion suggests interval worsening.
3. Mild right-sided leptomeningeal enhancement, consistent with
meningitis.
4. Right otomastoiditis again seen.
5. No evidence of venous sinus thrombosis. "
.
[**2-24**] CT Head:
"No significant change from prior studies, with unchanged right-
sided subdural collection, consistent with previously
characterized subdural empyema. Persistent opacification of
right mastoid air cells and middle ear cavity. "
.
[**2-26**] CT Head:
"Stable examination demonstrating unchanged right subdural
collection consistent with previously characterized subdural
empyema. No
interval change in opacification of right mastoid air cells and
middle ear
cavity.
"
.
[**2-28**] MR [**Name13 (STitle) 430**]:
"Stable appearance since [**2157-2-22**]. Evidence of right
mastoiditis with adjacent subdural empyema, extensive dural
enhancement,
leptomeningeal enhancement, and no evidence of infarction or
sinus
thrombosis. "
.
CBC:
[**2157-2-20**] 11:14PM WBC-14.5*# RBC-3.88* HGB-13.0*# HCT-35.7*#
MCV-92 MCH-33.4* MCHC-36.3* RDW-13.1
[**2157-2-20**] 11:14PM NEUTS-87.7* LYMPHS-9.3* MONOS-1.9* EOS-1.0
BASOS-0
[**2157-2-20**] 11:14PM PLT COUNT-399#
[**2157-3-3**] 04:50AM 7.9 4.12* 13.5* 37.6* 91 32.8* 36.0* 13.7
328
Coags:
[**2157-2-20**] 11:14PM PT-15.2* PTT-33.9 INR(PT)-1.3*
[**2157-3-3**] 04:50AM 16.2* 33.7 1.4*
Chem 7:
[**2157-2-20**] 11:14PM GLUCOSE-114* UREA N-15 CREAT-0.8 SODIUM-133
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-24 ANION GAP-15
[**2157-3-3**] 04:50AM 128* 18 1.0 139 4.1 101 28 14
LFTs:
[**2157-2-27**] 06:17AM 29 18 186 66 0.3
Head CT [**3-3**]
There is a new posterior parietal burr hole, and pneumocephalus
overlying the left posterior frontal and parietal lobes. Small
low-density extra-axial collection layers dependently, and
appears slightly more dense in comparison to [**2156-2-26**]. Effacement
of the underlying sulci is unchanged.
There is no hydrocephalus or shift of normally midline
structures. No
intracranial hemorrhage is identified. [**Doctor Last Name **]-white matter
differentiation
remains normally preserved.
Complete opacification of the right mastoid air cells persist.
Brief Hospital Course:
68M with PMH of DM, HTN, CAD s/p MI, who is transferred from an
OSH with resolving pneumococcal meningitis and new neurological
deficits, found to have mastoiditis, cerebritis, and subdural
empyema.
.
# Meningitis: Mr. [**Known lastname 410**] was treated with IV Ceftriaxone 2mg IV
q12, in addition to 50mg [**Hospital1 **] Metronidazole upon arrival.
Metronidazole was replaced with Clindamycin following a seizure,
but was changed back to metronidazole following the start of
levetiracem. Since his transfer here, Mr. [**Known lastname 410**] has remained
afebrile, with a WBC trending down. Clinically, Mr. [**Known lastname 410**]
improved dramatically over the course of his stay to the point
where no neurological deficits can be noted noted. He has no
meningeal signs at present.
.
#Cerebritis - Empyema was followed serially by CT and MR imaging
without any change over his stay. There was no involvement of
the sinuses. The decision was made on [**2156-2-29**] by medicine,
neurosurgery, and ID to surgically drain the fluid collection
via stereotactic biopsy.
.
# Mastoiditis- Patient has ear tubes bilaterally that have
drained minimally. He has remained afebrile since his arrival
and w/o pain. Hearing remains sensitive to loud snaps only. He
continues on Ciprofloxicin ear drops 0.3% Ophth Soln 4-10 drops
to the right ear.
.
# Seizure - Patient had a single generalized, tonic clonic
seizure in the MICU on [**2156-2-20**] while on Keppra 500mg.
Metronidazole was stopped temporarily and the patient was loaded
with additional Keppra. Pt has not seized since MICU stay. He
remains on Keppra, now tritrated up to 1g for neurosurgical
intervention.
.
# HTN - Mr. [**Known lastname 410**] was never hypotensive during his stay and his
pressures largely ranged in the 130s sytolic. Metoprolol was
started at 25 mg [**Hospital1 **] and titrated up to 50 mg tid, with the
discharge goal of home dosing of 200mg qd.
.
#Diabetes - Mr. [**Known lastname 410**] was initially covered under a sliding
scale. When full diet was resumed, his glucose values were in
the high 200s. Medication was changed to pt's home PO metformin
and glyburide, with modest effect. Hyperglycemia thought to be
resultant of stress and illness.
.
#CAD, hx of MI - Stable, no events. Continued statin. Given
possibility of intervention, ASA was held throughout the stay.
.
#Anemia - Pt was down from baseline of 47.7 in [**2155**] to 37.8.
Because of history of cold agglutinin hemolysis, patient was
worked up for anemia. Haptoglobin was within normal limits.
Iron labs were consistent with anemia of inflammation, with
normal MCV, lower transferrin, and lower TIBC.
On [**3-2**] he was brought to the OR by Dr. [**Last Name (STitle) **] for a
steriotactic burr hole placement and washout of subdural
empyema. He tolerated the procedure and was transferred to the
floor where he ambulated with nursing and tolerated a regular
diet. He was then safe to be d/c'd home with services and follow
up appointment
Medications on Admission:
Home Meds:
Lipitor 40 mg
ASA 650 mg daily
Glucophage 1000mg [**Hospital1 **]
Glyburide 3.75mg [**Hospital1 **]
Toprol XL 200 mg
MVI
.
Transfer Meds:
Rifampin
Keppra 250mg po bid ([**2-20**] - )
RISS
Floxin otic gtt to right ear [**Hospital1 **]
PCN G 4 million units q4h IV
metformin 1000mg [**Hospital1 **]
tylenol q4h prn prn
metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Ciprofloxacin 0.3 % Drops Sig: 4-10 Drops Ophthalmic TID (3
times a day): Right ear only.
Disp:*1 1* Refills:*2*
5. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 13 days: Do not consume alcohol while taking this
medication.
Disp:*40 Tablet(s)* Refills:*0*
7. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours) for 13 days.
Disp:*26 IV Piggyback* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: Please do not exceed 4 grams per day. .
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Headache: Please do not drink or drive
while taking this medication.
Disp:*50 Tablet(s)* Refills:*0*
12. PICC Line Care
Saline flush 10cc SASH PRN
Heparin flush 10u/ml 3cc SASH PRN
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary: Streptococcus pneumoniae meningitis, cerebritis, and
mastoiditis.
Secondary:
Diabetes Mellitus, Type II, non-insulin dependent
Coronary artery disease
HTN
Discharge Condition:
Stable.
Discharge Instructions:
You were transferred from [**Hospital **] Hospital with an infection of
your brain and your mastoid bone. While you were here, you
received intravenous antibiotics, anti-seizure medication, and
repeated imaging of your brain. The medicine, [**Hospital 1083**]
disease, and neurosurgery teams decided that having surgical
drainage of the [**Hospital 1083**] collection around your brain would
best help clear the infection.
You were started on the following NEW medications, all of which
you will continue:
1. Ceftriaxone 2 g IV Q12H
2. Metronigazole (Flagyl) 500 mg PO Q8H
3. Ciprofloxicin Ear Drops
4. Levitracetam 1g PO BID
The first medication will be given through the picc line in your
arm. A visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 5050**] this. The flagyl will be
an oral medication, in the same amount, to be taken three times
a day. [**Last Name (Titles) **] disease will determine the length of your
antibiotics.
Because of the antibiotic ceftriaxone can interfere with your
liver on rare occassion, you will need your liver enzymes tested
once per week. Please have blood drawn and tested for CBCs,
Chem 7, and LFTs each week and send the results to the
[**Last Name (Titles) 1083**] disease clinic at ([**Telephone/Fax (1) 1353**].
If you should become febrile, confused, lose bowel or bladder
function, have a strong headache, experience any loss in vision,
or lose conciousness, please return to the emergency room
immediately.
You will need follow-up appointments with your PCP, [**Name10 (NameIs) **]
Disease, Neurology, Neurosurgery, and ENT.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen
etc.
-You haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
*******You may resume your Asprin on [**2157-3-12**]******
Followup Instructions:
Please be sure to follow up with the following physicians:
1. [**Date Range **] Disease - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)
[**2157-3-22**] 11:30am
2. Ear, Nose and Throat - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**]
[**Apartment Address(1) 96381**], [**Location (un) 55**]
[**3-8**] @ 10:15 am, Tuesday
[**Telephone/Fax (1) 2349**]
4. PCP
[**2157-3-8**] at 10am
Dr [**First Name4 (NamePattern1) 449**] [**Known lastname 410**]
[**Location (un) **], [**Location (un) **], MA.
Because of the antibiotic ceftriaxone can interfere with your
liver on rare occassion, you will need your liver enzymes tested
once per week. Please have blood drawn and tested for LFTs each
week and send the results to the [**Location (un) 1083**] disease clinic at
FAX number [**Telephone/Fax (1) 11959**].
Neurosurgical Follow-Up Appointment Instructions
??????Please return to the office [**2157-3-11**] for removal of your sutures
and a wound check. This appointment can be made with the Nurse
Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????You have an appointment with Dr. [**Last Name (STitle) **] on [**2157-3-15**] at 9a at [**Hospital Unit Name **], [**Hospital Unit Name **]
If you have any questions please call ([**Telephone/Fax (1) 88**]
??????You are scheduled for an MRI of the brain with and without
gadolinium contrast on [**3-15**] at 730 am in the [**Hospital Ward Name 517**]
Basement.
Completed by:[**2157-3-4**]
|
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[] |
icd9pcs
|
[
[
[]
]
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| 3,010
| 0
| 56
| 11
| 0
| 0
| 0
| 0
| 2,725
| 0
| 0
| 1,720
| 19
| 0
| 0
| 0
| 1,347
| 0
| 168
| 0
| 363
| 0
| 0
| 0
| 0
| 3,280
| 0
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 58
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 83
| 2,204
| 0
| 0
| 0
| 1,705
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 519
| 338
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
90,538
| 105,088
|
37596
|
Discharge summary
|
Report
|
Admission Date: [**2146-3-10**] Discharge Date: [**2146-4-27**]
Date of Birth: [**2117-12-8**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents / Dilaudid
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, tachycardia.
Major Surgical or Invasive Procedure:
[**2146-3-10**]: Ultrasound-guided pancreatic pseudocyst drainage with
drain placement.
.
[**2146-3-18**]: CT-guided drainage of upper abdominal pseudocyst
.
[**2146-4-14**]: Ultrasound-guided fluid aspiration of a left flank
collection.
.
[**2146-4-14**]: Ultrasound-guided placement of left pleural pigtail
catheter.
.
[**2146-4-21**]: Ultrasound-guided left flank fluid collection
drainage with placement of a 8-French [**Last Name (un) 2823**] pigtail catheter.
History of Present Illness:
Patient is a 28M well-known to the West 2 surgical service. He
was discharged [**2146-3-9**] after a prolonged hospital course for
gallstone pancreatitis. This was complicated by DVT,
respiratory/renal failure requiring mechanical ventillatory
support and CVVHD, and pancreatic necrosis requiring
percutaneous drainage. He improved and was discharged yesterday
to a rehabilitation facility. Today, he returns with tachycardia
and increased abdominal pain. The patient states that he began
to experience abdominal pain yesterday afternoon while working
with PT. He states that this pain is similar to the epigastric
pain he has experienced all along only worse. He rated this as
an [**9-6**] though currently [**7-7**]. He states that he was able to eat
dinner (grilled chicken) without difficulty. He was eating
breakfast this morning and became nauseated while eating grapes.
He had several episodes of non-bilious emesis and was brought to
[**Hospital1 18**] for further care given increased abdominal pain and
tachycardia.
Past Medical History:
PMH: Gallstone pancreatitis as above, obesity, congenital
blindness in right eye, left common iliac DVT .
PSH: Laparoscopic cholecystectomy [**1-5**]
Social History:
Recently married. He lives with his wife and their dog. No kids.
Works as an investment manager. Never smoker. Rare alcohol.
Smokes marijuana, denies other drugs.
Family History:
Diverticulosis in both of his parents. DM in grandmother. HTN in
father. [**Name (NI) **] 2 sisters and one brother.
Physical Exam:
On Admission:
VS: 99.4 150 136/88 28 100%RA
General: awake and alert, diaphoretic and sweaty
CV: Tachycardic
Lungs: Tachypnic, CTA bilaterally
Abdomen: Obese, soft, (+) palpable phlegmon in RUQ, (+) diffuse
tenderness greatest in epigastrium, no rebound/guarding,
hypoactive BS
Ext: warm, no edema.
.
At Discharge:
VS: T 99.2 HR 93 BP 106/54 RR 18 SaO2 98% RA
GEN: Deconditioned in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: Slightly decreased at bases, otherwise clear.
COR: RRR
ABD: Protuberant. (L) LQ abdominal JP drain (into pancreatic
pseudocyst) patent/intact. (L)flank drain patent/intact. Both
drains with scant output. Prior sub-umbilical drain site clean,
healed without drainage. BSx4. Soft/NT/ND.
EXTREM: WWP; mild LE edema, no cyanosis, clubbing.
NEURO: A+Ox3. Very deconditioned. Requires assistance with gait.
Pertinent Results:
On Admission:
[**2146-3-10**] 08:28PM TYPE-ART PO2-138* PCO2-42 PH-7.55* TOTAL
CO2-38* BASE XS-13 INTUBATED-NOT INTUBA
[**2146-3-10**] 08:28PM freeCa-0.98*
[**2146-3-10**] 05:10PM OTHER BODY FLUID AMYLASE-[**Numeric Identifier **]
[**2146-3-10**] 05:10PM PT-20.2* INR(PT)-1.9*
[**2146-3-10**] 02:50PM WBC-22.5* RBC-3.31*# HGB-8.5*# HCT-28.0*#
MCV-85 MCH-25.7* MCHC-30.4* RDW-18.2*
[**2146-3-10**] 02:50PM PLT COUNT-511*
[**2146-3-10**] 02:07PM GLUCOSE-196* UREA N-19 CREAT-1.3* SODIUM-134
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-30 ANION GAP-15
[**2146-3-10**] 02:07PM CALCIUM-7.7* PHOSPHATE-6.2* MAGNESIUM-1.5*
[**2146-3-10**] 01:52PM PT-22.6* PTT-33.6 INR(PT)-2.1*
[**2146-3-10**] 07:29AM WBC-30.7*# RBC-4.67# HGB-11.7*# HCT-39.7*#
MCV-85 MCH-25.0* MCHC-29.4* RDW-17.4*
[**2146-3-10**] 07:29AM NEUTS-89* BANDS-3 LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2146-3-10**] 07:29AM PLT SMR-VERY HIGH PLT COUNT-818*#
[**2146-3-10**] 05:46AM GLUCOSE-149* LACTATE-2.5* NA+-136 K+-4.6
CL--99* TCO2-17*
.
Prior to Discharge:
[**2146-4-27**] PT/INR: 31.9/3.2
.
IMAGING:
[**2146-3-10**] AP CXR: Low lung volumes with LLL consolidation, could
reflect atelectasis, however, pneumonia cannot be excluded.
.
[**2146-3-10**] CTA CHEST W&W/O C&RECONS, ABD/PELVIC CT W/CONTRAST:
1. Minimal interval increase in size of right upper quadrant
pancreatic pseudocyst. Interval decrease in size of remaining
loculated fluid collections.
2. No pulmonary embolism present. Large bilateral pleural
effusions with associated compression atelectasis.
3. Increased amount of abdominal and pelvic free fluid.
.
[**2146-3-11**] BILAT LOWER EXT VEINS:
1. Persistent non-occlusive thrombus in the left common femoral
vein.
2. No right lower extremity DVT.
3. Small right popliteal cyst.
.
[**2146-3-15**] CXR:
Cardiomediastinal silhouette is unchanged as well as there is no
change in extremely low lung volumes and bilateral pleural
effusions, left more than right. There is mild prominence of the
vasculature that appears to be more pronounced than on the prior
study and might represent some degree of volume overload. The
right internal jugular line tip appears to be atleast at the
cavoatrial junction, but also may be present in the proximal
right atrium.
.
[**2146-3-16**] ABD/PELVIC CT W/CONTRAST:
1. Enlargement of the previously seen fluid collection and
appearance of the numerous new large collections in the
peritoneum. The drained collection has significantly decreased
in size.
2. Increase in pleural effusions: Left moderate and right
minimal size, findings are accompanied by compressive
atelectasis.
3. Minimal residual of the left common femoral vein and left
external iliac vein thrombus.
.
[**2146-3-17**] AP CXR:
In comparison with the study of [**3-15**], there is still extremely
low lung volumes. Hazy opacification at the left base is
consistent with pleural fluid. Obscuration of the hemidiaphragm
suggests volume loss in the left lower lobe. The right lung is
essentially clear and there is no evidence of pulmonary vascular
congestion. The tip of the right IJ catheter is difficult to see
but appears to be in the mid-to-lower portion of the SVC.
.
1. Markedly decreased size of drained collection anterior to the
stomach and surroiunding the left hepatic lobe. New extensive
stranding and fluid within the gastrohepatic ligament and porta
hepatis, possibly induced by leakage from one of the adjacent
collections or recurrent pancreatitis. Slight re-accumulation of
fluid within the previously drained collection in the anterior
abdomen, now measuring 14.3 x 1.6 x 5.4 cm. Otherwise, overall
decrease in multiple remaining peritoneal and extraperitoneal
fluid collections compared to the prior study.
2. Persistent bile duct dilation likely secondary to
pancreatitis. Increased attenuation of patent portal vein from
adjacent new inflammation. Persistent marked attenuation of the
splenic vein. Smaller splenic infarcts.
3. Unchanged bilateral pleural effusions and associated
compressive atelectasis.
4. Unchanged thrombus within the left external iliac and common
iliac veins.
.
[**2146-3-28**] CXR:
Stable size of left pleural effusion with associated
consolidation which likely represents atelectasis but
superimposed infection cannot be excluded.
.
[**2146-4-13**] ABD/PELVI CT W/CONTRAST:
1. In this patient with known history of necrotizing
pancreatitis, there is enhancement of the distal body and tail
of the pancreas with non visualization of the remainder of the
pancreas. Multiple extensive peripancreatic fluid collections
have decreased in size since the prior study.
2. A small fluid collection adjacent to the inferior edge of
right lobe of liver measuring 4.9 x 3.2 x 2.0 cm, is new since
the prior study.
3. Unchanged left femoral vein thrombosis. Infrarenal IVC filter
in place.
4. Mild interval improvement in the small-to-moderate left
pleural effusion. Compressive atelectasis of the left lower
lobe is unchanged.
.
[**2146-4-15**] CXR:
Status after withdrawal of a left-sided chest tube. Minimal
apical and lateral basal pneumothorax without evidence of
tension. Unchanged minimal atelectasis at the left lung base. No
other changes. Normal cardiac silhouette.
.
[**2146-4-18**] CXR:
1. Low lung volumes with left basilar subsegmental atelectasis,
likely related to the recent abdominal surgery and ongoing
intra-abdominal process.
2. No appreciable residual left pneumothorax.
3. Left-sided PICC likely at the junction of that axillary and
subclavian vein; this may need to be advanced into a more
central vein, depending on the indication for its use.
.
[**2146-4-20**] ABD/PELVIC CT W/O CONTRAST:
1. Slightly decreased size of dominant central abdominal fluid
collection with left drain in satisfactory position. Right
catheter has been removed.
2. Other fluid collections are little changed [**2146-4-13**].
3. Resolving left pleural effusion with pleural air secondary to
left thoracic drain placement and removal. No new peripancreatic
fluid collection.
4. Hypodensity of the blood pool relative to the ventricular
myocardium is suggestive of anemia.
5. Moderate biliary dilatation likely secondary to CBD
obstruction by pseudocyst is similar to [**2146-4-13**].
.
MICROBIOLOGY:
FLUID/WOUND CULTURES:
[**2146-4-21**] 10:15 am FLUID,OTHER LEFT FLANK ABSCESS.
**FINAL REPORT [**2146-4-25**]**
GRAM STAIN (Final [**2146-4-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2146-4-25**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2146-4-25**]): NO ANAEROBES ISOLATED.
.
[**2146-4-16**] 4:30 pm FLUID,OTHER LEFT JP DRAIN FLUID.
**FINAL REPORT [**2146-4-19**]**
GRAM STAIN (Final [**2146-4-16**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 10PM [**2146-4-16**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final [**2146-4-19**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
[**2146-4-14**] 9:51 am PERITONEAL FLUID
GRAM STAIN (Final [**2146-4-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO DR.[**First Name (STitle) **] [**Doctor Last Name **] ON [**2146-4-14**] AT
03:50 PM.
FLUID CULTURE (Final [**2146-4-17**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2146-4-18**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2146-4-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
.
[**2146-4-14**] 9:57 am PLEURAL FLUID
GRAM STAIN (Final [**2146-4-14**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
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 (Final [**2146-4-17**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-4-20**]): NO GROWTH.
ACID FAST SMEAR (Final [**2146-4-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
.
[**2146-4-5**] SWAB GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC
CULTURE-FINAL:
[**2146-4-5**] 3:09 pm SWAB PSEUDO CYST FLUID.
**FINAL REPORT [**2146-4-11**]**
GRAM STAIN (Final [**2146-4-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2146-4-7**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-4-11**]): NO GROWTH.
.
[**2146-3-28**] 9:25 am PERITONEAL FLUID
**FINAL REPORT [**2146-4-1**]**
GRAM STAIN (Final [**2146-3-28**]):
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 (Final [**2146-4-1**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6976**] @ 1:20 PM ON [**2146-3-29**].
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
RARE GROWTH OF THREE COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2146-4-1**]): NO ANAEROBES ISOLATED.
.
[**2146-3-23**] 10:43 pm FLUID,OTHER DRAIN FLUID.
**FINAL REPORT [**2146-3-28**]**
GRAM STAIN (Final [**2146-3-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2146-3-27**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2146-3-28**]): NO ANAEROBES ISOLATED.
.
[**2146-3-10**] FLUID,OTHER GRAM STAIN-FINAL; WOUND CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL:
GRAM STAIN (Final [**2146-3-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2146-3-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-3-16**]): NO GROWTH.
.
BLOOD & URINE CULTURES:
[**2146-4-18**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-15**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-14**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-12**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-28**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-28**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-23**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-23**] URINE CULTURE-FINAL: NO GROWTH.
[**2146-3-23**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-19**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-19**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-18**] FLUID CULTURE: NO GROWTH - FINAL.
[**2146-3-17**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-17**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-10**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-10**] BLOOD CULTURE: NO GROWTH - FINAL.
.
RESPIRATORY/OTHER CULTURES:
[**2146-4-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL:
Upper respiratory contamination.
[**2146-4-13**] CATHETER TIP-IV WOUND CULTURE-FINAL: NO SIGNIFICANT
GROWTH.
[**2146-4-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL:
Upper Respiratory Contamination.
[**2146-3-10**] MRSA SCREEN MRSA: NEGATIVE.
Brief Hospital Course:
The patient was re-admitted on [**2146-3-10**] back to the General
Surgical Service for evaluation and treatment of abdominal pain
and tachycardia. Admission abdominal/pelvic CT revealed minimal
interval increase in size of right upper quadrant pancreatic
pseudocyst, but decrease in size of remaining loculated fluid
collections. Large bilateral pleural effusions with associated
compression atelectasis were noted, as well as increased amount
of abdominal and pelvic free fluid. He was admitted to the SICU,
made NPO, started on vigorous IV fluid rescusitation, a foley
was placed, and he received IV pain medication with good effect.
He had a very long, and complicated hospital course.
.
In the process of repairing his florid necrotizing pancreatitis
secondary to his history of severe gallstone pancreatitis, he
ultimately developed recurrent pseudocyts, which have plagued
him throughtout his hospital stays since [**48**]/[**2145**]. To date, these
pseudocyts have been managed largely with percutaneous catheter
drainage of the pseudocysts. Initially, during this admission,
this was the approach to managing the patient's recurring
pseudocyts. The patient underwent drainage of pancreatic
pseudocysts on [**2146-3-10**] and [**2146-3-18**], Ultrasound and CT-guided,
respectively. However, he developed an accumulating posterior
retroperitoneal cyst, which continued to progress, and there was
evidence of a disconnected pancreatic remnant within it. The
recent drainages of the other satellite lesions have dried them
up. The main retroperitoneal cyst continued to grow in size, and
became symptomatic for him. He was unable to eat full meals and
has a diminished capacity to keep food down, as well as a poor
appetite. He also repeatedly spiked temperatures.
.
Given his history of a left lower extremity acute deep venous
thrombosis, Vascular Surgery was consulted. In lieu of planned
surgical intervention on [**2146-4-5**] for treatment of the above
pseudocyst with adhesions, the patient underwent placement of a
Bard G2 inferior vena cava filter, which went without
complication. Then on [**2146-4-5**], the patient underwent external
drainage of pancreatic pseudocyst and extended adhesiolysis,
which also went well without complication (see Operative Note).
After a brief, uneventful stay in the PACU, the patient was
returned to the floor NPO with an NG tube, on IV fluids and TPN,
with a foley catheter and two JP drains in place (one in the
pseudocyst and one in the abdomen to drain ascites), he was
continued on a Fentanyl patch and was given a Morphine PCA with
good effect. He was hemodynamically stable.
.
NEURO: Upon admission, the patient received IV pain medication
PRN transitioned to a Morphine PCA with good effect and adequate
pain control. When tolerating oral intake, he was transitioned
to oral pain medications. After the surgery on [**2146-4-5**], the
Chronic Pain Service was consulted. His pain was controlled once
the Fentanyl dose was increased to 75mcg/72Hr plus the Morphine
PCA. When again tolerating a diet post-operatively, the PCA was
discontinued, and he was started on oral pain medication in
addition to the Fentanyl patch with continued good effect. He
remained neurologically intact.
.
CV: Upon admission, tachycardia responded to vigorous IV fluid
rescusitation and beta-blockade with Metoprolol 50mg TID.
Metoprolol was increased to 75mg TID with eventual excellent
rate and BP control. By discharge, the Metoprolol was decreased
to 50mg [**Hospital1 **]. The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
.
PULMONARY: Tachypnea on admission. Chest CTA revealed large
bilateral pleural effusions with associated compression
atelectasis. Tachypnea resolved with diuresis with Lasix and
supplemental oxygen. He was given Albuterol and Atrovent
nebulizer treatments, good pulmonary toilet and use of the
incentive spirrometry were encouraged, and the patient received
chest PT with improvement in overall respiratory status. Able to
wean off supplemental oxygen. CXR on [**3-17**] revealed still
extremely low lung volumes. Hazy opacification at the left base
is consistent with pleural fluid. Obscuration of the
hemidiaphragm suggests volume loss in the left lower lobe. The
right lung was essentially clear and there was no evidence of
pulmonary vascular congestion.
Starting on [**4-12**], he spiked a temperature to 103 PO and his WBC
increased from 13 to 23,000. He had a CT abdomen performed
which demonstrated a left pleural effusion
on the upper cuts of the abdomen. Thoracic surgery was consulted
for management of the pleural effusion. On [**2146-4-14**], he underwent
ultrasound-guided thorocentesis and placement of left pleural
pigtail catheter. Plural fluid for culture, gram stain,
cytology, chemistries, and AFB was sent. The pleural pigtail
catheter was removed on [**4-15**]; post-removal CXR revealed minimal
apical and lateral basal pneumothorax without evidence of
tension. Unchanged minimal atelectasis at the left lung base. A
follow-up CXR on [**2146-4-18**] showed continued low lung volumes with
left basilar subsegmental atelectasis, likely related to the
recent abdominal surgery and ongoing intra-abdominal process. No
appreciable residual left pneumothorax was seen. The patient
remained stable from a pulmonary standpoitn thereafter.
Respiratory toilet, incentive spirrometry, and frequent
ambulation was encouraged.
.
GU/FEN: On admission, the patient was made NPO and he received
vigorous IV fluid rescusitation. A foley catheter was placed.
Allowed clears on [**3-11**] and [**3-12**], but an NG tube was placed on
[**3-13**] for increased abdominal distension and emesis resulting
with 1400mL bilious output. After successful clamp trial
overnight, the NG tube was discontinued on [**3-15**] in the morning.
Given persistent problems with tolerating oral intake, a PICC
was placed, and TPN was started on [**2146-3-14**]. With the decision
to proceed to surgery, TPN was continued through [**2146-4-12**]. When
not NPO for procedures, his diet was advanced back to low fat
regular with good tolerability and intake. When the foley
catheter was removed after surgery, he was able to void without
problem. Patient's intake and output were closely monitored, and
IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
.
GI: Admission liver and pancreatic enzymes were elevated.
Shortly after admission, the patient underwent ultrasound-guided
pseudocyst drainage measuring 1.7 liters of fluid with a
drainage catheter left in place to gravity on [**2146-3-10**]. Liver
and pancreatic enzymes began trending down. Follow-up
abdominal/pelvic CT on [**3-16**] demonstrated enlargement of the
previously seen fluid collection and appearance of the numerous
new large collections in the peritoneum. The drained collection
had significantly decreased in size. On [**3-18**], the patient
returned to Interventional Radiology for drainage of an anterior
collection, and placement of a new drainage catheter to gravity.
The previous drain was removed, and upper abdominal pseudocyst
was succesfully drained with a catheter left in place to
gravity. Unfortunately, as noted above, he developed an
accumulating posterior retroperitoneal cyst, which continued to
progress, and there was evidence of a disconnected pancreatic
remnant within it. He underwent external drainage of pancreatic
pseudocyst and extended adhesiolysis as described above. A (L)
flank drain was left in place. After the surgery, his symptoms
improved.
.
ID: Admission blood cultures were negative. [**3-10**] fluid culture
had no growth. On [**3-17**] after receiving FFPs, the patient mounted
a fever with a Tmax 101.5 PO. Blood cultures were negative.
Fluid cutlure from the [**3-18**] drainage also revealed no growth.
The patient's white blood count and fever curves were closely
watched for signs of infection. Admission MRSA screen was
negative. After the [**2146-4-5**] surgery, cultures from the peritoneal
fluid on [**4-14**], the (L) JP on [**4-19**], and the flank drain on [**4-21**]
all grew out MRSA. The patient had been started on empiric IV
Vancomycin, Ciprofloxacin, and Flagyl when he spiked a
temperature on [**4-14**]. Fluconazole for empiric coverage after the
thorocentesis was started on [**4-15**]. Flagyl, Cipro, and
Fluconazole were discontinued on [**4-16**]. Cipro restarted on [**4-21**].
Infectious Disease was consulted for discharge antibiotic
recommendations; their input was greatly appreciated. Cipro was
discomntinued, and oral Levofloxacin and Flagyl started on [**4-26**]
with Vancomycin continued. At discharge, the patient was sent
home on a two week course oral Linezolid, and a total of four
weeks of oral Levofloxacin and Flagyl.
.
ENDOCRINE: The patient's blood sugar was monitored throughout
his stay when he was on TPN; sliding scale insulin was
administered accordingly. He did not require exogenous insulin.
.
HEMATOLOGY: Upon admission, Coumadin was stopped, and the
patient received 5 untis of Fresh Frozen Plasma (FFPs) prior to
fluid collection drainage in Intervention Radiology. On [**3-17**],
FFPs were again administered in preparation for IR drainage of a
large anterior abdominal fluid collection, but was stopped after
the patient experienced severe lower back pain after initiation
of the second unit of FFP. On [**3-18**], he received a total of 4
units of FFPs prior to IR drainage of the aforementioned
collection. Prior to [**2146-4-5**] surgery, the patient received 2
units of PRBCs for a HCT of 22.2. He did not require any further
blood products after this date. At discharge, his HCT was 23.7.
.
PROPHYLAXIS: History left common iliac DVT and HITs. Repeat
duplex ultra-sound on admission confirmed persistent
non-occlusive thrombus in the left common femoral vein; no right
DVT was seen. Chest CTA did not reveal a PE. On admission,
Coumadin stopped, and Agatroban started. After the drainage of
the collection on [**3-10**], Agatroban was stopped, and Coumadin
restarted. Coumadin also restarted after reversal for second
collection drainage. After the surgery on [**2146-4-5**], the patient
was restarted on Argatroban. He was again converted back to
Coumadin prior to discharge, at which time the INR was
therapeutic at 3.2 on a Coumadin dose of 2.5mg daily. INR goal
2.5 with a therapeutic range of [**3-2**].
.
MOBILITY: The patient worked with Physical and Occupation
therapy extensively. By discharge, he was able to ambulate
independently. He was discharge home with PT and OT services.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with minimal assistance, voiding without
assistance, and pain was well controlled. He was discharged
home with VNA and PT services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever.
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
7. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for back pain.
8. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. Methadone 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
10. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
sliding scale Subcutaneous ASDIR (AS DIRECTED).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for btp.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Adjust dose according to INR. .
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust daily dose according to INR.
17. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
[**Hospital1 **]:*60 Capsule(s)* Refills:*2*
3. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Over-the-counter.
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Hospital1 **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*11*
5. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO every 4-6 hours as
needed for pain.
[**Hospital1 **]:*120 Tablet(s)* Refills:*0*
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain.
[**Hospital1 **]:*10 Patch 72 hr(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours.
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
[**Hospital1 **]:*120 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 4 weeks.
[**Hospital1 **]:*84 Tablet(s)* Refills:*0*
12. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 weeks.
[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
13. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 14 days.
[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO daily in the
evening or as directed by PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO As directed by
PCP: **This Prescription should only be used if advised by your
PCP.**.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] homecare VNA
Discharge Diagnosis:
1. Necrotizing gallstone pancreatitis.
2. Multiple pancreatic pseudocysts.
3. Non-occlusive thrombus in the left common femoral vein.
4. Left Pleural effusion
5. Anemia
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:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-6**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD (Hematology).
Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2146-5-18**] 2:00. Location: [**Hospital Ward Name 23**] 7,
[**Hospital Ward Name 516**].
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-5-26**] 2:45.
Location: [**Hospital Ward Name 23**] 4, [**Hospital Ward Name 516**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Infectious Disease). Phone:
([**Telephone/Fax (1) 6732**]. Date/Time: Friday, [**2146-5-27**] at 10:00AM. Location:
[**Last Name (un) 6752**] GB, [**Last Name (NamePattern1) 439**], [**Hospital1 18**] [**Hospital Ward Name 517**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:
Friday, [**2146-5-27**] at 11:30AM. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 84361**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 84362**] (PCP) in [**3-2**] weeks.
Completed by:[**2146-4-27**]
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| 0
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91,289
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19530
|
Discharge summary
|
Report
|
Admission Date: [**2189-12-6**] Discharge Date: [**2189-12-31**]
Date of Birth: [**2128-3-31**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids / Lisinopril / Celebrex / Rofecoxib / Tegaderm
/ Ciprofloxacin / Allopurinol
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Pre-TACE hydration
Reason for Transfer to [**Hospital Unit Name 153**]: Hypoxemia
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy
Left radial arterial line
History of Present Illness:
61F with pancreatic neuroendocrine CA metastatic to the liver
s/p CBD stent and chronic diastolic CHF admitted to OMED [**12-6**]
for hydration prior to TACE on [**12-7**]. Started on zosyn [**12-6**],
followed by vanc/cefepime/flagyl on [**12-9**] for possible
aspiration pneumonia. Notably, CT chest [**12-11**] showed ethiodol
uptake in the lung, concerning for a portosystemic shunt.
Azithromycin was added [**12-15**], and cefepime was stopped in favor
of levo/[**Last Name (un) 2830**] on [**12-15**]. She has also been treated with bolus
diuresis for acute diastolic CHF. She states that she felt as if
she was improving on treatment as of yesterday but then became
more short of breath with minimal exertion, with a cough
productive of yellow-light green sputum. She endorses orthopnea
but denies PND. No fever, chills, sweats, chest pain,
palpitations, nausea, vomiting, diarrhea, or calf pain.
On routine vitals found to have O2sat 88%5L (had been on 5L NC
since [**12-14**]) - improved to 92-94%8L FM. Given lasix 20 mg IV
with 300 UOP. ABG on NRB 7.45/47/72/34. CXR showed extensive
right-sided airspace disease. Vital signs prior to transfer 97.3
102/59 95 22 98%NRB.
Past Medical History:
Oncologic History (from Dr.[**Name (NI) 52983**] [**9-16**] note)
[**1-6**]: Had UGI bleeding, EGD revealed gastric ulcer (official
report unavailable)
[**2-7**]: Developed chronic fatigue and anorexia soon after
returning home from let hip and knee surgery.
[**3-10**]: Presented to PCP with [**Name9 (PRE) 5283**] pain and worsening jaundice for
2 weeks. RUQ US demonstrated pancreatic head mass and multiple
liver nodules suspicious for metastasis. Admitted to [**Hospital **]
hospital, where CT scan confirmed US findings. ERCP at [**Hospital1 18**]
demonstrated duodenal invasion (with stigmata of recent
bleeding,) and extrinsic compression of CBD, which was stented.
Duodenal biopsy returned poorly differentiated neuroendocrine
carcinoma. MRCP demonstrated numerous hepatic metastases.
US-guided biopsy of one hepatic lesion revealed same findings as
duodenal biopsy. The picture was consistent was metastatic,
poorly differentiated neuroendocrine carcinoma.
.
Other PMH:
1. Chronic anemia, underwent EGD and diagnosed with bleeding
ulcer in [**11/2186**] and 12/[**2187**].
2. Colonoscopy [**12-6**] --> polyp, repeat from [**1-6**] --> normal
3. Arthritis
-Hip replacement [**2183**] and revision in [**2184**].
-Hip debridement in [**2-7**]
-Left knee torn cartilage repair in [**2-7**].
4. Hysterectomy for fibroids
5. Mitral valve prolapse
6. Obstructive sleep apnea
7. Asthma
8. Coronary artery "spasms" based on cath in [**2162**] and [**2179**]
9. Diabetes mellitus, type II
10. Hypertension
11. Hyperlipidemia
12. Obesity
13. Chronic diastolic CHF
14. Depression
Social History:
Widow, husband murdered in [**2162**]. Lives with daughter and her
family in [**Name (NI) **], MA. Has two healthy children and 3 healthy
grandchildren. Previously worked as lab technician in hospital.
Tob: smoked for six months in [**2149**]; none current
EtOH: none
Family History:
Half sister died from uterine cancer in her 40s
Paternal half sister - uterine cancer
Paternal brother -- esophageal cancer in 50s
Maternal cousin died of renal cancer at 46
Maternal cousin died of lung cancer at 46.
Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: T 97.6 HR 93 BP 100/48 RR 20 O2sat 93%NRB
GEN: Cachectic, appears comfortable, resp nonlabored
HEENT: pale OP clear dry MM
NECK: JVP 10 cm H20
CV: reg rate nl S1S2 no m/r/g
PULM: coarse rales [**3-4**] right lung field and at left base no
wheeze
ABD: soft NTND
EXT: warm, dry +PP tr pedal edema no calf tenderness
NEURO: awake, alert, conversing appropriately
Pertinent Results:
[**2189-12-6**] 01:26AM BLOOD WBC-3.9* RBC-3.24* Hgb-10.2* Hct-32.6*
MCV-100* MCH-31.6 MCHC-31.5 RDW-15.4 Plt Ct-128*
[**2189-12-6**] 01:26AM BLOOD Neuts-67.4 Lymphs-22.6 Monos-6.6 Eos-2.7
Baso-0.7
[**2189-12-6**] 01:26AM BLOOD PT-17.8* PTT-33.3 INR(PT)-1.6*
[**2189-12-6**] 01:26AM BLOOD Glucose-118* UreaN-5* Creat-0.7 Na-141
K-3.9 Cl-106 HCO3-29 AnGap-10
[**2189-12-6**] 01:26AM BLOOD ALT-34 AST-54* LD(LDH)-143 AlkPhos-191*
TotBili-0.5
[**2189-12-6**] 01:26AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0
[**2189-12-8**] 08:50PM BLOOD ALT-236* AST-562* LD(LDH)-722*
AlkPhos-269* TotBili-1.2
[**2189-12-8**] 06:45AM BLOOD Lipase-7
[**2189-12-9**] 06:40AM BLOOD proBNP-1324*
[**2189-12-7**] 07:05AM BLOOD CEA-7.2* AFP-2.1
[**2189-12-16**] 06:04AM BLOOD Digoxin-<0.2*
[**2189-12-16**] 06:34AM BLOOD Type-ART pO2-72* pCO2-47* pH-7.45
calTCO2-34* Base XS-7
[**2189-12-16**] 03:39PM BLOOD Lactate-1.4
[**2189-12-16**] 03:08PM BLOOD B-GLUCAN- < 31 pg/mL negative
[**2189-12-16**] 03:08PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1,
negative
[**2189-12-18**] 08:03AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2189-12-18**] 08:03AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2189-12-18**] 08:03AM URINE RBC-9* WBC-0 Bacteri-MOD Yeast-NONE Epi-0
[**2189-12-18**] 08:03AM URINE AmorphX-MANY
[**2189-12-18**] 08:03AM URINE Eos-NEGATIVE
[**2189-12-18**] 08:03AM URINE Hours-RANDOM UreaN-533 Creat-142 Na-<10
K-45 Cl-<10
[**2189-12-18**] 08:03AM URINE Osmolal-363
===================
MICROBIOLOGY
===================
[**2189-12-15**]
- urine legionella antigen- negative
[**2189-12-16**]
- MRSA screen- negative
- BAL: No polys seen. No microbes seen. Respiratory cultures
negative. Legionella culture negative. Negative PCP. [**Name10 (NameIs) **]
fungal (prelim). AFB negative. AFB culture negative (prelim).
Viral culture negative (prelim)
- Urine cx- negative
- Blood cx- negative
[**2189-12-17**]
- Blood cx- negative
[**2189-12-18**]
- Blood cx [**3-3**]- pending
- Rapid respiratory viral screen & culture: negative
- sputum: moderate growth of yeast
- Urine cx- negative
[**2189-12-19**]
- Blood cx- pending
- Urine cx- negative
[**2189-12-20**]
- Blood cx- pending
- C. diff toxin- negative
===============
INTERNVETION
===============
[**2189-12-7**]
- Common hepatic artery and left hepatic artery arteriogram.
- Transarterial chemoembolization of the left lobe of liver.
- Angio-Seal closure device deployment to the right common
femoral artery
access site.
FINDINGS:
1. There is conventional celiac axis anatomy as demonstrated on
previous
arteriograms.
2. Common hepatic artery arteriogram demonstrates multiple
arterially
enhancing masses throughout both lobes of liver.
3. The left hepatic artery arteriogram confirmed large enhancing
masses in the left lobe of liver, which was successfully
targeted with the
chemotherapeutic [**Doctor Last Name 360**], with 60 mg of doxorubicin, 20 mL of
lipoidol, and 20 mL of intra-arterial lidocaine, and one and a
half vials of 100-300 micron Embospheres administered.
IMPRESSION: Satisfactory left hepatic artery chemoembolization
======================
IMAGING
======================
[**2189-12-8**]
- CT Abdomen/Pelvis: There is dependent atelectasis at the
bilateral lung bases without effusion or focal consolidation to
suggest pneumonia. Some hyperdensity is newly seen at the lung
bases, which most likely reflects systemic ethiodol distribution
secondary to small intrahepatic portosystemic shunt. Coronary
calcifications are noted. Hyperdense material within multiple
right lobe liver lesions is stable from [**2189-11-13**],
compatible with sequelae of prior chemoembolization.
Additionally, there is newly noted extensive hyperdense material
within the left lobe of the liver and caudate lobe, most
concentrated at the sites of previously noted
arterially-enhancing lesions, compatible with recent left
hepatic artery chemoembolization. Other than the aforementioned
hyperdensity at the lung bases, there is no definite evidence of
extrahepatic Ethiodol uptake. Hyperdense material dependently
within stomach appears intraluminal, most likely reflecting
ingested medication. The spleen, adrenal glands, and kidneys
remain unremarkable. Contrast in the collecting system reflects
recent angiography. There are no contour-altering renal mass
lesions. The pancreatic tail is again noted to be atrophic. The
known pancreatic head mass is not well appreciated without
intravenous contrast. Stranding inferior to the pancreatic head
is noted, possibly reflecting the sequelae of prior
pancreatitis. There is a metallic common bile duct stent in
standard position, with left lobe pneumobilia compatible with
stent patency. The stomach, duodenum, and intra-abdominal loops
of small and large bowel are
normal in caliber and configuration. There is no bowel
distention or bowel wall thickening. There is no free fluid or
free air identified.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions
identified.
IMPRESSION:
1. Extensive Ethiodol uptake within the left lobe of the liver,
most
concentrated at the site of previously noted
arterially-enhancing lesions seen on [**2189-11-13**].
2. Hyperdensity at the lung bases is most compatible with
Ethiodol, likely secondary to a small intrahepatic
porto-systemic shunt. There is no further evidence of
extrahepatic Ethiodol uptake.
3. Common bile duct stent in standard position. Left lobe
pneumobilia is
compatible with stent patency. Known pancreatic head mass is not
well
appreciated given lack of intravenous contrast.
[**2189-12-11**]
- Echo: The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and low normal global left ventricular systolic
function.
[**2189-12-14**]
- The heart is normal in size. Mitral annular calcifications are
noted.
Atherosclerotic calcifications of the aortic arch are present.
Low attenuation of the intracardiac blood pool suggests
underlying anemia. There is a right central venous catheter,
with tip terminating within the SVC. A right paratracheal lymph
node is mildly enlarged measuring 15 mm, which is larger from
prior study, and is likely reactive. The airways are patent to
the subsegmental level. There is interval development of diffuse
ground-glass airspace opacities, most severely involving the
upper lobes. These findings are new compared to a CT Torso from
[**2189-9-30**]. The previously seen hyperdense foci within the lower
lobes suggestive of extra-hepatic Ethiodol are less apparent on
this study. The previously seen dense consolidation of the lower
lobes are also improved. There is no pleural or pericardial
effusion. This examination is not tailored for subdiaphragmatic
evaluation. Extensive Ethiodol uptake within the left lobe of
the liver is again noted. Osseous structures reveal no
suspicious lesion.
IMPRESSION:
1. Interval development of diffuse ground-glass opacities
throughout the lungs, most severe within the upper lobes
bilaterally. The differential diagnosis includes infection
(including atypical infections from PCP or fungal if the patient
is immunocompromised), pulmonary edema, and pulmonary
hemorrhage.
2. Previously seen hyperdense foci in the lung bases felt to
represent extra-hepatic Ethiodol are less apparent on this
study.
3. Extensive Ethiodol uptake within the left lobe of the liver.
[**2189-12-16**]
- LENIS: The deep veins of bilateral lower extremity, namely the
common femoral vein, the superficial femoral vein, the popliteal
vein, the peroneal and the posterior tibial veins proximally in
the calf region are patent, show normal caliber,
compressibility, and phasicity. On spectral wave Doppler, good
augmentation and phasicity waves are noted. There is no evidence
of acute or chronic thrombus at this time .
IMPRESSION: No evidence of deep venous thrombosis in the
bilateral lower
extremity deep veins on the available images at the time of the
study.
[**2189-12-19**]
- CXR: Pulmonary consolidation has been severe in the right lung
since [**12-13**]. Today, it has progressed dramatically in the
left upper lobe. Whether this is pneumonia or pulmonary
hemorrhage is radiographically indeterminate. Sparing of left
lower lobe suggests that it is not edema. Severe cardiomegaly
persists along with mediastinal and hilar vascular engorgement.
Tip of the endotracheal tube is above the upper margin of the
clavicles, no less than 3 cm from the carina. No pneumothorax.
[**2189-12-21**]
- Echo: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is high
(>4.0L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2189-12-11**],
left ventricular systolic function is more dynamic and the heart
rate is higher. The estimated pulmonary artery systolic pressure
is now higher.
[**2189-12-23**]
- CT Chest
Brief Hospital Course:
61 y/o with metastatic neuroendocrine CA admitted for hydration
prior to TACE on [**12-7**], presented to the ICU with hypoxemic
respiratory failure due to what was thought to be
hospital-acquired pneumonia vs acute on chronic diastolic CHF vs
pneumonitis secondary to a portosystemic shunt communicating
from her TACE procedure. Ms. [**Name14 (STitle) 52984**] had a prolonged course in
the ICU, requiring ventilatory assitance
# Hypoxemic respiratory failure/Lung infiltrates. Patient was
transferred from oncology service after her TACE for increased
respiratory distress with a subacute decompensation, which was
initially thought to be from acute on chronic diastolic heart
failure, pneumonia, aspiration, hemorrhage or VTE with a small
component of portosystemic shunt. She was intubated for
increased work of breathing on [**2189-12-16**]. However, subsequent
bronchoscopy did not suggest an infectious or hemorrhagic
etiology as BAL was negative and bronchoscopy showed mostly
clear aspirate. She was continued on vancomycin which was
started prior to her transfer to ICU, and she was started also
on meropenem so that both would cover for HAP as well as
levofloxacin to cover atypical pneumonia. She completed a 5 day
course of levofloxain and 12 day course of vancomycin.
Meropenem was kept for pseudomonal coverage for a planned course
of 14 days. Methylprednisolone was initiated at 20 mg q8h for
possible pneumonitis as patient's hypoxic respiratory failure
persists despite antibiotics treatments. Her respiratory status
continued to be without progress on the steroid, requiring FiO2
of 50-60%. Thoracic surgery was consulted for possible VATS
biopsy to obtain a more definitive diagnosis to patient's
parenchy infiltrates seen on CXR and CT. However, no VATS is
possible given her clinical status, and the risk outweighs the
benefit for patient to undergo open thoracotomy for tissue
biopsy. As her sepsis improved, she was able to tolerate
intermittent dose of lasix to diurese the presumed pulmonary
edema as her total length of state fluid balance was positive.
Family meeting was held to discuss her respiratory status, and
patient was made CMO. Patient was extubated on the night of
[**12-30**] and she passed away shortly therafter.
# Shock, liekly [**3-3**] distributive/sepsis with SvO2 78% and
initial SVV [**5-17**]. Patient initially required Levophed support
as well as fluid boluses to maintain her MAP and urine output.
The likely source for the sepsis is pulmonary
infection/inflammation based on radiographical evidence as her
other culture data have been negative. No evidence of adrenal
insufficiency, thyroid toxicosis, PE. She was able to be weaned
off pressors.
# Acute Renal insufficiency, likely from pre-renal azotemia
secondary to sepsis. This was noted as her Crt trended up to 1.5
from baseline 0.6-0.8. FeUrea was found to be < 35% and FENa <
1%. She initially required pressors and IVF boluses for the low
urine output. Her SVO2 and SVV were monitored closely to help
guide therapy. She gradually improved and was able to be weaned
off of pressors and tolerate diuresis with improved and stable
Crt.
# Hypernatremia. Free water deficit initially about 3.8L. She
was treated with D5W fluid bolus then maintenance with the
likely goal of starting free water flushes into her tube feed.
# Acute on Chronic Diastolic CHF, likely with some component of
pulmonary edema which contributes some to the respiratory
function. Initial echocardiogram showed LVEF of 50-55%. Diovan
and diltiazem were soon held after her arrival to the [**Hospital Unit Name 153**]
secondary to hypotension and requirement of pressor, Levophed.
Her repeat echocardiogram showed hyperdynamic ventricular
function, correlating to her distributive shock picture. As she
was weaned off pressor on [**2189-12-21**]. She was able to tolerate
intermittent low dose of furosemide for diuresis given that
patient's length of stay fluid balance was positive.
#Pancytopenia, likely [**3-3**] recent chemotherapy. Her CBC was
monitored on a daily basis. Her white count, anemia, and
thrombocytopenia were stably low. She did not have episodes of
acute bleeding. Active type and screen were maintained.
# Neuroendocrine cancer. Patient was admitted to the hospital
for TACE. Her LFT was elevated after TACE, but gradually
trended downward during her stay in the ICU.
# Diabetes Mellitus. Patient was placed on an insulin sliding
scale with 70/30 and regular finger stick blood sugar
monitoring.
# Goals of Care. Full code, confirmed on [**2189-12-16**]. However,
prior to intubation, patient voiced that she would not want to
be on the ventilator for a prolonged period of time, and she
would give herself 4-6 weeks on the ventilator only if she was
unable to be successfully extubated. She stated that she would
not want to have a trach or a PEG prior to [**2189-12-16**]. Her
health care proxy is her daughter, [**Name (NI) **] [**Name (NI) 16745**] [**Telephone/Fax (1) 52985**].
A fmily meeting was held on [**2189-12-30**]. At that point Ms. [**Known lastname 52986**]
family decided that in light of her continued deterioration and
in respect for her clear wish not to have prolonged life
supporting care if her lung function was not improving to make
comfort the sole goal and will discontinue any therapy not
directed at comfort. She passed away that evening.
Medications on Admission:
Deceased.
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2190-1-1**]
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"038.9",
"276.0",
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"209.30",
"250.00",
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45001
|
Discharge summary
|
Report
|
Admission Date: [**2168-2-13**] Discharge Date: [**2168-2-17**]
Date of Birth: [**2104-8-29**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / Diphenhydramine
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stents x2 to the left
circumflex artery and the left main coronary artery
History of Present Illness:
This is a 63 year old man with a history of CAD s/p 2 vs 3v
CABG, HL who presented to the ED with chest pain while walking
his dog today. He reported that prior to walking his dog at
5:10pm he was showering and developed SOB and dizzyness.
Subsequently, while walking his dog he developed SOB, [**9-14**] SS
chest pain and paramedics were called. On the ride to [**Hospital1 18**], his
pain started radiating to his left arm. A 12-lead ECG
demonstrated inferior ST elevations and ST depressions in the
lateral and precordial leads.
In the ED, initial vital signs were the following: HR: 83 BP:
118/75 Resp: 18 O(2)Sat: 100 Normal. He was given ASA 325 mg,
Plavix 600 mg, heparin 5000 units IV, as well as 125 mg IV
solumedrol, and 50 mg IV famotidine (for contrast allergy) and
taken emergently to the cath lab where native coronary
angiography demonstrated a 70% ostial LM lesion, a totally
occluded mid LAD, a 95% thrombotic appearing mid LCX lesion, and
a totally occluded mid RCA. Graft angiography revealed a patent
SVG to RCA/PDA, and a patent LIMA to LAD. The third vein graft
was not found despite non-selective power injection of the
aortic root, and was thought to likely be a SVG to OM that was
occluded. Subsequent reports from [**Hospital1 2025**], revealed that he only had
a 2-vessel CABG (per cath report from [**2164**]). The LCX lesion was
thought to the the culprit given its appearance, and this was
opened with a BMS. After this lesion was opened the patient
converted into AIVR which lasted about 5 minutes. Given that LM
had a 70% ostial stenosis, it was decided that the patient would
benefit from increased coronary inflow, and a BMS was also
placed in the LM. After both interventions, the patient's chest
pain and prior ECG changes resolved. He was transferred to the
CCU for close monitoring in good condition.
Of note, the patient had significant confusion during the
cardiac cath, asking repetitively where was and how he had
arrived in the cath lab. The patient noted a prior history of
mental status changes with benadryl, and it was unclear if the
patient??????s mental status changes in the cath lab were the result
of the fentanyl and versed that he received.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
- CABG: LIMA to LAD, SVG to PDA
3. OTHER PAST MEDICAL HISTORY:
CAD s/p 2 vessel CABG, LIMA to LAD, SVG to PDA, [**2157**] at [**Hospital1 2025**]
Temporal lobe epliepsy
ADHD
Psoriasis
Appendectomy
Hyperlipidemia
Social History:
- Tobacco history: never
- ETOH: rarely
- Illicit drugs: never
Lives with wife, [**Name (NI) **], in [**Location (un) **]
Has 2 sons works as department head at [**Hospital3 **]
Family History:
- No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death
- Mother: lupus, cardiac disease died in 70's from MI
- Father: MI x2, died at age 55 from MI
- strong family h/o HL including both parents and eldest son.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T= 97.8 BP= 115/71 HR=82 RR=16 O2 sat= 97% on 2L
GENERAL: NAD. Oriented x3. anxious.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. old midline scar well healed
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB on anterior exam,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3,
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
GENERAL: 63 YO M in no acute distress
HEENT: no lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 2+. right groin with no ecchymosis
or hematoma, angioseal palpated.
NEURO: Speech clear. 5/5 strength in U/L extremities. gait WNL.
SKIN: no rash
PSYCH: alert, mildly anxious, appears tired, cooperative.
Pertinent Results:
LABS ON ADMIT:
[**2168-2-13**] 06:30PM BLOOD WBC-10.7 RBC-4.92 Hgb-15.0 Hct-41.4
MCV-84 MCH-30.4 MCHC-36.2* RDW-12.5 Plt Ct-194
[**2168-2-13**] 06:30PM BLOOD PT-10.2 PTT-29.5 INR(PT)-0.9
[**2168-2-13**] 06:30PM BLOOD Fibrino-292
[**2168-2-13**] 06:30PM BLOOD Glucose-103* UreaN-22* Creat-0.8 Na-142
K-4.2 Cl-104 HCO3-26 AnGap-16
[**2168-2-13**] 11:02PM BLOOD CK(CPK)-645*
[**2168-2-14**] 05:38AM BLOOD CK(CPK)-922*
[**2168-2-14**] 01:55PM BLOOD CK(CPK)-726*
[**2168-2-14**] 03:30PM BLOOD CK(CPK)-638*
[**2168-2-13**] 06:30PM BLOOD cTropnT-<0.01
[**2168-2-13**] 11:02PM BLOOD CK-MB-97* MB Indx-15.0* cTropnT-1.36*
[**2168-2-14**] 05:38AM BLOOD CK-MB-137* MB Indx-14.9* cTropnT-2.67*
[**2168-2-14**] 01:55PM BLOOD CK-MB-100* MB Indx-13.8* cTropnT-2.11*
[**2168-2-14**] 03:30PM BLOOD CK-MB-87* MB Indx-13.6* cTropnT-1.85*
[**2168-2-15**] 06:15AM BLOOD CK-MB-21* MB Indx-8.4* cTropnT-1.67*
[**2168-2-16**] 05:45AM BLOOD CK-MB-5
[**2168-2-13**] 06:30PM BLOOD Calcium-9.8 Phos-2.2* Mg-2.0
[**2168-2-13**] 11:02PM BLOOD Valproa-85
[**2168-2-13**] 06:41PM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-33* pH-7.51*
calTCO2-27 Base XS-3 Comment-GREEN-TOP
[**2168-2-13**] 06:41PM BLOOD Glucose-94 Lactate-2.3* Na-142 K-4.2
Cl-100
[**2168-2-13**] 06:41PM BLOOD freeCa-1.12
LABS on DC:
[**2168-2-17**] 06:45AM BLOOD WBC-8.8 RBC-4.38* Hgb-13.6* Hct-37.9*
MCV-87 MCH-31.0 MCHC-35.9* RDW-12.7 Plt Ct-178
[**2168-2-17**] 06:45AM BLOOD UreaN-19 Creat-0.8 Na-143 K-4.7 Cl-105
HCO3-30 AnGap-13
[**2168-2-15**] 06:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9
ECG [**2168-2-13**]:
Normal sinus rhythm. Intra-atrial conduction abnormality.
Diffuse ST-T wave abnormalities. Inferior ST segment elevation.
Anterolateral ST segment depression. Consider acute inferior
myocardial infarction.
CATH [**2168-2-13**]:
1. Selective native coronary angiography in this right dominant
system
demonstrated severe 3 vessel and left main coronary artery
disease. The
LMCA had a 70% ostial lesion. The LAD was totally occluded in
its mid
segment. The LCx had a 95% thrombotic appearing lesion in its
mid
segment. The RCA was totally occluded in its mid segment.
2. Selective venous conduit angiography demonstrated a patent
SVG to
distal RCA graft.
3. Non-selective arterial conduit angiography demonstrated a
patent LIMA
to LAD with a kink in its midcourse.
4. Supravalvular aortography did not demonstrate any additional
grafts.
5. Primary PCI was delayed due to difficulty in locating the
patient's
prior bypass grafts and therefore determining the culprit artery
(no
reports of the anatomy were available and the patient stated
that he had
3 grafts despite our ability to only locate 2), and because
patient
agitation due to a paradoxical reaction to fentanyl caused a
delay in
the ability to safely carry out the procedure.
6. Successful direct stenting of the Cx with a 3.0x12mm
INTEGRITY
stent. Final angiography revealed no residual stenosis, no
angiographically apparent dissection and TIMI III flow (see PTCA
comments).
7. Successful direct stenting of the LMCA with a 4.5x18mm ULTRA
stent.
Final angiography revelaed no residual stneosis, no
angiographically
aparent dissection and TIMI III flow (see PTCA comments).
8. Patient went into AIVR post stenting of the Cx lesion. Rhythm
lasted
five minutes, and patient remained hemodynamically stable
throughout.
9. Successful closure of the 6 French right femoral arteriotomy
site
with a 6 French Angioseal VIP device with good resultant
hemostasis.
11. Limited resiting hemodynamics revealed normal systemic
arterial
blood
pressure with a central aortic blood pressure of 126/77.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease with a 95%
thrombotic LCx
lesion thought to the cause of the patient's acute STEMI.
2. Patent LIMA to LAD.
3. Patent SVG to RCA.
4. No other grafts demonstrated on aortography.
2. Successful direct stenting of the Cx with a BMS.
3. Successful direct stenting of the LMCA with a BMS.
4. Successful closure of the right femoral arteriotomy site with
an
Angioseal VIP device.
8. Normal central aortic blood pressure.
ECHO [**2168-2-15**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). 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. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No pathologic valvular abnormality seen.
SUBMAXIMAL STRESS [**2168-2-17**]:
No anginal symptoms with nonspecific ST segment changes.
Attaining a submaximal level of 7 METs indicates an average
exercise
tolerance for his age, however patient could have attained
higher level
of work. Appropriate hemodynamic response to exercise. Echo
report sent
separately.
STRESS ECHO [**2168-2-17**]:
The patient exercised for 9 minutes and 0 seconds according to a
Modified [**Doctor First Name **] treadmill protocol (7 METS) reaching a peak heart
rate of 125 bpm and a peak blood pressure of 134/40 mmHg. The
test was stopped because of fatigue. This level of exercise
represents an average exercise tolerance for age (submaximal
test obtained as the patient is s/p STEMI). In response to
stress, the ECG showed no diagnostic ST-T wave changes (see
exercise report for details). There were normal blood pressure
and heart rate responses to stress.
Resting images were acquired at a heart rate of 69 bpm and a
blood pressure of 104/59 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Doppler
demonstrated no aortic stenosis, aortic regurgitation or
significant mitral regurgitation or resting LVOT gradient.
Echo images were acquired within 45 seconds after peak stress at
heart rates of 120-97 bpm. These demonstrated appropriate
augmentation of all left ventricular segments.
IMPRESSION: Average functional exercise capacity (submaximal
workload as patient is s/p STEMI). No diagnostic ECG changes in
the absence of 2D echocardiographic evidence of inducible
ischemia to achieved workload.
Brief Hospital Course:
HOSPITAL COURSE: 63 year old man with a history of CAD s/p CABG
who presented to the ED with chest pain while walking his dog
and was found to have an inferior STEMI. Received BMS
implantation to native LCX and LM.
# Inferior STEMI: The patient presented with STE of II,III, and
avF and STD depression in V2-V5. In the cath lab, his native
coronary angiography demonstrated a 70% ostial LM lesion, a
totally occluded mid LAD, a 95% thrombotic appearing mid LCX
lesion, LM had a 70% ostial stenosis and a totally occluded mid
RCA. Graft angiography revealed a patent SVG to RCA/PDA, and a
patent LIMA to LAD. A BMS was placed to the LCX and LM. He had
several episodes of [**2165-12-8**] resting CP in the two days after the
intervention that were relieved with sublingual nitroglycerin. A
submaximal stress echo was performed which demonstrated no
evidence of ischemia by ECG or echocardiogram. Pt was discharged
on ASA, plavix, metoprolol, lisinopril, sl ntg, imdur and
rosuvastatin. Creatinine was stable despite contrast load.
# Hyperlipidemia: on rosuvastatin at home, switched to high dose
atorvastatin hwile an inpatient given STEMI. Changed to
rosuvastatin 40 at discharge.
# Hyperglycemia: BS moderately elevated on routine labs. Pt
states his blood sugar has been elevated at times but A1C has
been nl. A1c was normal on recheck.
# Temporal lobe epliepsy- per patient develops flushing,. We
continued depakote 250mg 5 times daily (qAM, qNoon, qPM, and 2
tabs qHS). He remained well controlled.
# ADHD: we continued venlafaxine and held strattera due to risk
of adverse cardiovascular outcomes.
TRANSITONAL ISSUES: Followup with PCP and cardiologist was
arranged. Dr [**Last Name (STitle) 96196**] was made aware of hopsital course.
Medications on Admission:
ASA 325
Crestor 10mg Daily
Depakote 250mg tablets 1 tablet qAM, 1 tablet qNoon, 1 tablet
qPM, 2tablets pHS
Effexor XR 150mg daily
Strattera 100mg daily
Discharge Medications:
1. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO qHS ().
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
5. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablet* Refills:*0*
8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
10. Outpatient Lab Work
Please check Chem-7 on Friday [**2168-2-19**] with results to Dr.
[**Last Name (STitle) 96196**] at Phone: [**Telephone/Fax (1) 96197**]
Fax: [**Telephone/Fax (1) 96198**]
11. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hyperlipidemia
Temporal Lobe epilepsy
Coronary Artery disease
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack and was brought to [**Hospital1 18**] for a cardiac
catheterization. The catheterization showed that your grafts
from the operation were open and had good blood flow but there
was a clot in your left circumflex artery that was causing the
heart attack. You received a bare metal stent but also needed a
bare metal stent in your left main artery to increase blood flow
to the area. You will need to take plavix for at least one year
and possibly longer to prevent the stent from clotting off. Do
not stop taking Plavix or aspirin or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr.
[**Last Name (STitle) 96196**] says it is OK. This is extremely important to prevent
another heart attack. An echocardiogram was done that showed
that your heart function is normal. You had some chest pain
after the cathererization which was treated with nitroglycerin
but this did seem to cause any damage to your heart. Your stress
test was negative. You will have nitroglycerin tablets to take
at home. Please take this for any chest pain that is similar to
the pain of your heart attack. You can take one pill, wait 5
minutes, then take another pill if you still have chest pain.
Call 911 if you still have chest pain after 2 [**Last Name (STitle) 4319**] of
nitroglycerin. Call Dr. [**Last Name (STitle) 96196**] if you use any nitroglycerin at
all. You can also call the heartline to talk to a cardiologist
or NP here who can help you with your symptoms.
You received a lot of contrast during your catheterization. This
can sometimes affect your kidney function. So far, you have not
had any changes in your kidney function but please get blood
drawn on Thursday to check again.
.
We made the following changes to your medicines:
1. Continue aspirin forever, talk to Dr. [**Last Name (STitle) 96196**] before you stop
the aspirin for any reason.
2. Increase the Crestor to 40 mg to lower your cholesterol
3. Start taking metoprolol to lower your heart rate and help
your heart recover from the heart attack
4. Start taking lisinopril to lower your blood pressure and help
your heart recover from the heart attack.
5. Start taking Clopidogrel (Plavix) to keep the stents from
clotting off and causing another heart attack. Do not stop this
medicine unless you talk to Dr [**Last Name (STitle) 96196**] first.
6. Start taking nitroglycerin as described above to treat chest
pain.
7. Stop taking Strattera, this is not good for your heart. You
can talk to your physician about an alternative.
8. Start taking imdur, this will prevent chest pain. Talk to Dr.
[**Last Name (STitle) 96196**] if the lightheadedness does not improve in a few days.
Followup Instructions:
Name: JUDGE,[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: AMBULATORY PRACTICE OF THE FUTURE
Address: [**Location (un) 96199**] [**Apartment Address(1) 12836**], [**Location (un) **],[**Numeric Identifier 10614**]
Phone: [**Telephone/Fax (1) 96200**]
Appointment: WEDNESDAY [**2-24**] AT 12PM
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern4) 4094**]: CARDIOLOGY
Location: [**Hospital6 **]
Address: [**Street Address(2) 12266**], YAWKEY CENTER 5800, [**Location (un) **],[**Numeric Identifier 18228**]
Phone: [**Telephone/Fax (1) 96197**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 96196**]
within 1 month. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**
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Discharge summary
|
Report
|
Admission Date: [**2164-9-19**] Discharge Date: [**2164-9-30**]
Date of Birth: [**2082-8-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fatigue/DOE/CHF
Major Surgical or Invasive Procedure:
[**2164-9-24**] - 1. Aortic valve replacement with a 21-mm [**Doctor Last Name **] Magna
aortic valve bioprosthesis. 2. Coronary artery bypass grafting
x2, left internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein single graft from the
aorta to the posterior descending coronary artery.3. Concomitant
right carotid endarterectomy performed by Dr. [**Last Name (STitle) **] and
dictated separately.
[**2164-9-20**] - Cardiac catheterization
History of Present Illness:
82 year old woman with complex past medical history including
PVD, aortic stenosis, and mitral regurgitation who has been
experiencing worsening fatigue, dyspnea on exertion, and
congestive heart failure. She has had several failed
catheterizations secondary to severe PVD (femoral, radial,
brachial). SHe is now admitted for cardiac catheterization and
surgical management of her valvular and coronary artery disease.
Past Medical History:
Dyslipidemia
Hypertension
aortic stenosis
Mitral regurgitation
PVD
COPD
Depression
Osteoporosis
Chronic systolic dysfunction
Social History:
Sheis retired. She is edentulous and therefore will not require
dental clearance. She is a 55-pack year history of smoking.
She quit smoking last year. She does not use any alcohol at
this time. She is widowed and speaks only Greek.
Family History:
She has two sisters with hypertension but no premature coronary
disease.
Physical Exam:
On examination, her heart rate was 68. Respiratory rate was 12.
Blood pressure on the right was 134/50 not taken on the left due
to recent brachial artery attempts at catheterization. She was
5
feet tall weighing 110 pounds. Overall, she appeared to be
quite
frail elderly woman in no apparent distress. She was using a
cane to ambulate. Skin was warm and dry without any cyanosis or
edema. She had mild clubbing. Her head was normocephalic and
atraumatic. Pupils were equally, round, and reactive to light.
Sclerae were anicteric. Oropharynx was benign. She was
edentulous. Her neck was supple with full range of motion and
no
JVD. Carotid bruits were present on both sides. She had
bibasilar crackles left greater than right and barrel chest
consistent with COPD. Heart was regular in rate and rhythm with
a grade III/VI systolic ejection murmur and grade I/VI diastolic
murmur with S1 and S2 tones present. She had right upper
quadrant tenderness today in the office with mild hepatomegaly.
Her extremities were warm and well perfused with very trace
peripheral edema and a little bit of mild clubbing on the left.
She had some ecchymosis of her abdomen from Heparin shots in the
hospital. She had noted varicosities. She was alert and
oriented x3 moving all extremities. Gait slow and steady using
the cane with 4/5 strength. She had 2+ bilateral femoral pulses
with a bruit present in her left femoral artery, trace DP
bilateral pulses, 1+ bilateral in the PTs, and 2+ bilateral
radial pulses.
Pertinent Results:
[**2164-9-19**] 08:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2164-9-19**] 09:34PM PT-13.7* PTT-25.4 INR(PT)-1.2*
[**2164-9-19**] 09:34PM WBC-6.9 RBC-3.07* HGB-9.6* HCT-29.3* MCV-96
MCH-31.3 MCHC-32.8 RDW-17.8*
[**2164-9-19**] 09:34PM ALT(SGPT)-19 AST(SGOT)-24 ALK PHOS-69 TOT
BILI-0.3
[**2164-9-19**] 09:34PM GLUCOSE-127* UREA N-41* CREAT-1.3* SODIUM-140
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
[**2164-9-19**] Abdominal U/S
Status post cholecystectomy. Common bile duct is dilated, which
is not an uncommon finding after cholecystectomy.
[**2164-9-24**] ECHO
PRE-BYPASS:
1. The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild regional
left ventricular systolic dysfunction with inferior basal
hypokinesis. Overall left ventricular systolic function is low
normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate to severe
aortic valve stenosis (area 0.8-1.0cm2). Moderate (2+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet.
6. Mild to moderate ([**1-11**]+) mitral regurgitation is seen.
Posterior leaflet appears slightly restricted, jet is central.
7. There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced.
1. A well-seated bioprosthetic valve is seen in the Aortic
position with normal leaflet motion and gradients (mean gradient
= 7 mmHg). No aortic regurgitation is seen.
2. LV function is unchanged.
3. MR is mild.
4. Other findings are unchanged.
[**2164-9-21**] Carotid duplex ultrasound
1. 80-99% right ICA stenosis.
2. 60-69% left ICA stenosis.
3. High-grade left external carotid artery stenosis.
[**2164-9-20**] Cardiac Catheterization
Showed 80% mid and distal LAD, 60% mid LCX, and a complicated
99% calcified proximal RCA lesion.
Brief Hospital Course:
Patient was admitted to the hospital on [**9-19**] for
pre-operative workup. Diagnsotic catheterization on [**2164-9-20**]
showed 80% mid and distal LAD, 60% mid LCX, and a complicated
99% calcified proximal RCA lesion. An aortogram was performed at
the end of the procedure and revealed severe aorto-iliac disease
extending into her Profunda and Superficial femoral arteries
bilaterally. Also on [**2164-9-20**] patient had carotid duplex scans
that revealed severe 80-99% right ICA stenosis, 60-69% left ICA
stenosis and a high-grade left external carotid artery stenosis.
The vascular surgery service was consulted who recommended a
concommittant right carotid endarterectomy. As she had right
upper quadrant tenderness, a right upper quadrant ultrasound was
obtained which showed a dilated common bile duct which was not
an uncommon finding after cholecystectomy. No other
abnormalities were seen. On [**2164-9-24**], Ms. [**Known lastname 7568**] was taken to the
operating room where she underwent an aortic valve replacement
with a 21-mm [**Doctor Last Name **] Magna aortic valve bioprosthesis, two
vessel coronary artery bypass grafting and a concomitant right
carotid endarterectomy performed by Dr. [**Last Name (STitle) **]. Please see
operative notes from both vascular and cardiac surgery for
details. Postoperatively she was transferred to the cardiac
surgical intensive care unit for further monitoring. Within 24
hours, Ms. [**Known lastname 7568**] [**Last Name (Titles) 5058**] neurologically intact and was extubated.
She was transfused with PRBCs for postoperative anemia and to
maintain hematocrit near 30%. She initially required atrial
pacing for an underlying junctional rhythm/sinus node
dysfunction, for which beta blockade was initially withheld. She
otherwise maintained stable hemodynamics and transferred to the
SDU on postoperative day two. On POD 5 the patient developed
atrial fibrillation. She was treated with lopressor 5mg IVP and
started on lopressor 12.5mg PO. Approximately one hour after
initiation of therapy, the patient converted to sinus rhythm,
with a long (22second) conversion pause. The patient's nurse
was in the room, witnessed this long pause, and chest
compressions were initiated. The patient came to immediately.
Follow up CXR reveals no rib fractures. The patient remained
stable in normal sinus rhythm for the next 24 hours. She was
discharged in good condition to rehab on POD 6.
Medications on Admission:
ASA 81', zocor 40', protonix 40', toprol xl 25', hctz 25',
boniva 150 monthly, calcium, vit d, tylenol, duragesic patch 25
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p AVR/CABG
Carotid Disease - s/p Right CEA
PMH: PVD, HTN, Hyperlipidemia, History of MI, MR, CHF(chronic,
systolic), COPD
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please call ([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. OK to shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-12**] weeks. [**Telephone/Fax (1) 74598**]
Completed by:[**2164-9-30**]
|
[
"428.22",
"424.1",
"443.9",
"272.4",
"402.91",
"496",
"311",
"733.00",
"414.01",
"433.10",
"412"
] |
icd9cm
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[
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[
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] |
[] |
icd9pcs
|
[
[
[]
]
] | 48
| 2,449
| 0
| 481
| 7
| 0
| 0
| 0
| 0
| 2,580
| 0
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| 269
| 75
| 0
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| 1,227
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| 171
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| 127
| 240
| 0
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| 0
| 0
| 0
| 0
| 0
| 0
|
98,335
| 196,522
|
38962
|
Discharge summary
|
Report
|
Admission Date: [**2150-4-3**] Discharge Date: [**2150-4-7**]
Date of Birth: [**2081-6-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2150-4-3**] Coronary artery bypass grafting x3 with left internal
mammary artery to the left anterior descending artery, and
reverse saphenous vein graft to the distal right coronary artery
and the obtuse marginal artery.
History of Present Illness:
68 year old male with progressive, exertional chest discomfort
over the past 6 months. He reports that he underwent a cardiac
catheterization at [**Hospital 1474**] hospital approximately 8-9 years
ago. He is unclear on the specifics of why he had the procedure,
but does not believe that he underwent PCI.Over the past six
months he has been bothered by chest discomfort, dyspnea and
fatigue. This can occur with walking about one block. In
addition, he notices right calf
pain with similar amounts of walking.Denies edema, orthopnea,
PND, lightheadedness. Cardiac workup with his PCP showed an
abnormal ETT and he was referred for an elective cardiac
catheterization [**2150-3-26**], which revealed three vessel coronary
disease. Cardiac surgery was consulted for evaluation of
coronary revascularization.
Past Medical History:
hypertension
hyperlipidemia
Diabetes
[**2150-2-4**] ETT: 5 minutes 30 seconds [**Doctor First Name **] protocol, 89% max
PHR. + Anginal discomfort with exercise. EKG with anterolateral
ST depression. Imaging: moderate in size, severe in intensity
territory of inferior reversibility. LVEF 55%.
Chronic renal insufficiency, creatinine 2.4
Left eye laser surgery approximately one month ago
Social History:
Lives with spouse
[**Name (NI) 1139**]: None
ETOH: None in 30 years
Family History:
No family history of premature CAD. Father died when patient was
5 years old-unknown cause.
Physical Exam:
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []few scattered rhonchi
Heart: RRR [x] Irregular [] NO Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +1 Left:+1
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2150-4-7**] 05:10AM BLOOD WBC-7.3 RBC-3.67* Hgb-10.3* Hct-32.6*
MCV-89 MCH-28.1 MCHC-31.7 RDW-14.4 Plt Ct-310
[**2150-4-3**] 11:40AM BLOOD WBC-7.4 RBC-2.85*# Hgb-8.4*# Hct-24.8*#
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.6 Plt Ct-199#
[**2150-4-3**] 11:40AM BLOOD Neuts-75.3* Lymphs-20.1 Monos-2.7 Eos-1.5
Baso-0.3
[**2150-4-7**] 05:10AM BLOOD Plt Ct-310
[**2150-4-3**] 11:40AM BLOOD Plt Ct-199#
[**2150-4-3**] 11:40AM BLOOD PT-14.2* PTT-30.5 INR(PT)-1.2*
[**2150-4-3**] 11:40AM BLOOD Fibrino-173
[**2150-4-7**] 05:10AM BLOOD Glucose-99 UreaN-22* Creat-1.5* Na-141
K-4.9 Cl-103 HCO3-31 AnGap-12
[**2150-4-3**] 12:45PM BLOOD UreaN-18 Creat-1.3* Cl-114* HCO3-25
[**2150-4-7**] 05:10AM BLOOD Mg-2.2
[**2150-4-3**] 05:59PM BLOOD Mg-2.3
Radiology Report CHEST (PA & LAT) Study Date of [**2150-4-6**] 1:48 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2150-4-6**] 1:48 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 86421**]
Reason: please do in afternoon [**4-6**] - eval for effusion
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
please do in afternoon [**4-6**] - eval for effusion
Final Report
TWO VIEW CHEST, [**2150-4-6**]
COMPARISON: [**2150-4-5**].
INDICATION: Status post coronary artery bypass surgery. Pleural
effusion
assessment.
FINDINGS: Status post median sternotomy and coronary bypass
surgery with
similar postoperative appearance of cardiomediastinal contours.
Improving
multifocal atelectasis with residual linear atelectasis in the
mid and lower
lungs. Persistent small lateral left pneumothorax as well as
bilateral small
pleural effusions. Retrosternal gas, probably postoperative
considering
recent surgery.
IMPRESSION: Persistent small lateral left pneumothorax and small
bilateral
pleural effusions. Improving multifocal atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2150-4-6**] 3:36 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 5259**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86422**] (Complete)
Done [**2150-4-3**] at 10:08:02 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2081-6-4**]
Age (years): 68 M Hgt (in): 65
BP (mm Hg): / Wgt (lb): 160
HR (bpm): 65 BSA (m2): 1.80 m2
Indication: Intraop CABG Evaluate wall motion, aortic contours,
valves
ICD-9 Codes: 424.0
Test Information
Date/Time: [**2150-4-3**] at 10:08 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: aw2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: *0.14 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 57 ml/beat
Left Ventricle - Cardiac Output: 3.71 L/min
Left Ventricle - Cardiac Index: 2.06 >= 2.0 L/min/M2
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec
Aortic Valve - LVOT pk vel: 0.80 m/sec
Aortic Valve - LVOT VTI: 15
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *2.2 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 84 ms
Mitral Valve - MVA (P [**2-14**] T): 2.6 cm2
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 0.86
Findings
LEFT ATRIUM: Normal LA size. Elongated LA. No thrombus in the
LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
Post Bypass: Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
Post Bypass: Patient is A paced, on phenylepherine infusion.
Preserved biventricular function. LVEF 55%. MR is now trace.
Aortic contours intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
Cardiology Report ECG Study Date of [**2150-4-3**] 2:08:28 PM
Sinus rhythm. Low QRS voltage. Non-diagnostic repolarization
abnormalities.
Compared to the previous tracing of [**2150-3-31**] QRS voltage is
diffusely reduced.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 162 104 372/387 84 0 -14
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. See operative report
for further details. He received cefazolin for perioperative
antibiotics. Post operatively he was transferred to the
intensive care unit for management. In the first twenty four
hours he was weaned from sedation, awoke, and was extubated
without complications. He continued to do well and was
transferred to the floor. His percocet was stopped due to
confusion which resolved. Physical therapy worked with him on
strength and mobility. He was ready for discharge home with
services on post operative day four.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth every morning
DILTIAZEM HCL - (Prescribed by Other Provider) - 300 mg
Capsule,
Sustained Release - 1 Capsule(s) by mouth every morning
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 34 units at bedtime
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - 14 units before breakfast, 8 units before
lunch, 14 units before dinner
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth every
morning
METFORMIN - (Prescribed by Other Provider) - 850 mg Tablet - 1
Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth qam
QUINAPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth every morning
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth every morning
OLMESARTAN-HYDROCHLOROTHIAZIDE [BENICAR HCT] - (Prescribed by
Other Provider; OTC) - 20 mg-12.5 mg Tablet - 1 Tablet(s) by
mouth daily every morning
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): 1 drop in each eye twice a day .
Disp:*qs qs* Refills:*0*
5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
7. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
9. Insulin Glargine 100 unit/mL Solution Sig: Thirty Four (34)
units Subcutaneous once a day.
Disp:*qs qs* Refills:*0*
10. Humalog 100 unit/mL Solution Sig: per scale Subcutaneous
before each meal : 14 units before breakfast, 8 units before
lunch, 14 units before dinner.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Diabetes mellitus type 2
Hyperlipidemia
Chronic renal insufficiency baseline cr 1.9
Discharge Condition:
Alert and oriented x2 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2150-5-6**] 1:00
Please call to schedule appointments
Primary Care Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 1057**] in [**2-14**] weeks [**Telephone/Fax (1) 14331**]
Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-14**] weeks [**Telephone/Fax (1) 8725**]
Completed by:[**2150-4-7**]
|
[
"403.90",
"272.4",
"250.00",
"414.01",
"585.9"
] |
icd9cm
|
[
[
[
1417,
1428
]
],
[
[
1430,
1443
]
],
[
[
1445,
1452
]
],
[
[
12831,
12853
]
],
[
[
12917,
12943
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] | 31
| 647
| 0
| 228
| 91
| 0
| 0
| 0
| 0
| 1,078
| 0
| 0
| 464
| 95
| 0
| 0
| 0
| 1,227
| 31
| 132
| 0
| 1,208
| 0
| 0
| 0
| 0
| 494
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 574
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 13
| 5,814
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 812
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 394
| 72
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
91,258
| 108,206
|
34858
|
Discharge summary
|
Report
|
Admission Date: [**2136-11-1**] Discharge Date: [**2136-11-8**]
Date of Birth: [**2057-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1. Intra-aortic balloon pump placement
2. Cardiac catheterization with left main coronary artery bare
metal stent placement
History of Present Illness:
The patient is a 79-year-old male with history of prior CVA,
hypertension, cirrhosis and prior NSTEMI which was treated
medically in [**2136-10-24**] who presents now as a transfer from OSH with a new NSTEMI.
He has been complaining of epigastric pain and "heart burn" for
5 days leading up to this admission. He had associated chest
pain radiating to his jaw and bilateral arms for several days,
almost continuously but waxing and [**Doctor Last Name 688**] in intensity. He
states that he felt better with burping, and his pain worsened
after eating food. He denies any shortness of breath, chills, or
sweats. The patient presented to OSH and was found to have
elevated Troponins to 2.0 with CK of 103. CXR showing mild
pulmonary edema. The patient was treated as an NSTEMI protocol
with heparin, [**Doctor Last Name **], [**Doctor Last Name 4532**] load and he was then transferred to
[**Hospital1 18**] for further management. Aditional review of his EKG at
[**Hospital1 18**] revealed normal sinus rhythm but prominent ST segment
depressions in I, II, aVL, V5-V6
and ST segment elevations in leads aVR and V1. After admission,
the patient was observed on telemetry in preparation for a
cardiac catheterization. He was given ongoing therapy with
[**Last Name (LF) 4532**], [**First Name3 (LF) **], Statin, beta-blocker, and IV heparin. Overnight, he
triggered for hypotension and was given fluid bolus of 500cc x2.
He remained chest pain free initially but had recurrent chest
pain in the early morning hours requiring IV morphine.
In the cardiac cath lab, a right heart catheterization
demonstrated RA Pressure of 19 mmHg,RVEDP 21 mm Hg, PASP 51 with
a mean of 39 mm Hg and PCWP 34 mm Hg. Fluids were discontinued
and Mr. [**Known lastname **] was given 40mg IV lasix. On left heart
catheterization, the LMCA had a distal 90% stenosis at the
trifurcation of the ramus intermedius, LAD, and LCX. The LAD had
mild diffuse disease with a large D1. The LCX had an OM1 with
diffuse 90% proximal stenosis. The RCA was totally occluded
proximally with faint left-right collaterals. Resting
hemodynamics revealed elevated right and left-sided filling
pressures consistent with cardiogenic shock. The cardiac output
was 4.2 l/min with an index of 2.0 l/min/m2 and left
ventriculography was deferred with plan to stabilize patient
with IABP and consider stent or CABG at later time. Ultimately,
the patient underwent stent placement on [**2136-11-2**] with stent
placed across LAD to distal left main coronary artery. Outcome
showed an improvement to 30% obstruction at trifurcation vs.
prior 90% blockage, with a TIMI 3 result.
.
On arrival to CCU, patient was chest pain free and had no
shortness of breath. He was lying flat in bed on 4L NC. He
denied any back, groin pain, LE pain. On review of systems, he
denied any prior history of deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, hemoptysis, black stools or red stools. He denied
exertional buttock or calf pain. All of the other review of
systems were negative.
Past Medical History:
NSTEMI ([**1-31**])
CVA
Gout
Cirrhosis - alcoholic, no biopsy, no known h/o varices or
complications from his liver disease.
Dementia
HTN
OSA
macular degeneration
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
Cardiac History: NSTEMI
Prior percutaneous coronary intervention: none
Pacemaker/ICD:None
Social History:
The patient lives in [**Location **] and is dependent in ADL's and IADL's and
is cognitively very intact. He denies any history of smoking,
current etoh use or any history of drug use.
Family History:
No premature cardiac disease in family, noncontributory family
history.
Physical Exam:
VS - afebrile, T 98.4, IABP Augmented Diastolic BP 105/50, HR
82, SaO2 95% 4L NC, RR 20
Gen: No acute distress, well-developed and well-appearing middle
aged male. Alert and oriented to person, place and time. Mood,
affect appropriate. Speech mildly slurred (without dentures) .
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma. PERRL, EOMI.
Neck: Thick neck, supine, 8cm JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, balloon pump on 1:1.
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use. CTA
anteriorly, decreased b/s at bases.
Abd: Soft, NTND. No HSM or tenderness. Abdominal aorta not
enlarged by palpation.
Ext: Slightly cool lower extemities with 1+ pedal pulses
bilaterally, no edema. No femoral bruits, R-groin w/o hematoma
or ecchymoses, IABP in place.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: dopplerable DP pulses, faintly dopplerable PT pulses
b/l.
Pertinent Results:
[**2136-11-1**] Admission EKG: sinus rhythm with nml axis, nml
intervals, ST depressions in V4-V6, I, AVL and ST elevation in
AVR. Borderline ST elevation in V1.
.
[**2136-11-2**] Cardiac Cath Report: 1. Successful PTCA and placement
of a 3.0x15mm Vision stent in the distal LMCA and origin LAD
were performed. The stent was postdilated proximally using a
4.5x8mm Quantum Maverick balloon and distally using a 3.5x12mm
Quantum Maverick balloon. Final angiography showed normal flow,
no apparent dissection, and a 30% residual stenosis at the
trifurcation site. (See PTCA comments.)
2. Left femoral arteriotomy closure was performed using an 8
French
Angioseal VIP. FINAL DIAGNOSIS:PTCA and placement of a
bare-metal stent in the distal LMCA to origin LAD.
.
[**2136-11-3**] ECHO :
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-15mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is
moderate global left ventricular hypokinesis (LVEF = 40 %).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. There
is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. Moderate (2+) mitral regurgitation
is seen. The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
pMIBI at OSH [**1-/2136**]: left ventricular dialtion with diffuse
hypokinesis and reduced EF to 35%. non-transmural inferior wall
perfusion defect on post-stress images. subendocarial ishemia
[**2136-11-1**] 10:42PM PTT-58.0*
LABS PRIOR TO DISCHARGE:
[**2136-11-8**] 05:55AM BLOOD WBC-8.1 RBC-3.14* Hgb-9.3* Hct-28.2*
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.6 Plt Ct-252
[**2136-11-8**] 05:55AM BLOOD Glucose-113* UreaN-45* Creat-1.7* Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
[**2136-11-5**] 07:00AM BLOOD ALT-26 AST-25 AlkPhos-73 TotBili-0.4
[**2136-11-8**] 05:55AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
[**2136-11-2**] 01:00AM BLOOD CK-MB-48* MB Indx-11.4* cTropnT-4.06*
proBNP-[**Numeric Identifier 79816**]*
[**2136-11-5**] 04:14PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2136-11-5**] 04:14PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2136-11-5**] 04:14PM URINE RBC-10* WBC-9* Bacteri-FEW Yeast-NONE
Epi-0
Brief Hospital Course:
In summary, the patient is a 79-year-old male with history of
hypertension, s/p NSTEMI [**1-/2136**] who was transferred from OSH
after presenting with 5 days of unstable angina with associated
dyspepsia and found to have NSTEMI with transient ST elevations
in AVR and ST depressions inferolaterally concerning for
significant left
main/proximal LAD disease with relative hypotension.
:
CORONARY ARTERY DISEASE/NSTEMI and CARDIOGENIC SHOCK: The
patient presented to OSH and was found to have elevated
Troponins to 2.0 with CK of 103. The patient was treated as an
NSTEMI protocol with heparin, [**Year (4 digits) **], [**Year (4 digits) 4532**] load and he was then
transferred to [**Hospital1 18**] for further management. Aditional review of
his EKG at [**Hospital1 18**] revealed normal sinus rhythm but prominent ST
segment depressions in I, II, aVL, V5-V6 and ST segment
elevations in leads aVR and V1. CK peaked peaked at 400. Patient
continued [**Last Name (LF) 4532**], [**First Name3 (LF) **], statin and heparin therapy. Patient's
beta blocker held in the setting of severe cardiogenic shock on
admission to CCU. Admission TTE/ECHO [**2136-11-1**] showed moderate
global left ventricular hypokinesis (LVEF = 40 %) and Grade
III/IV (severe) LV diastolic dysfunction. The right ventricle
was mildly dilated with mild global hypokinesis as well. The
patient was stabilized with the assistance of a intra-aortic
balloon pump to help augment BP. The patient was initially
placed on IABP 1:1 and gentle diuresis was given with lasix.
Diagnostic coronary angiography showed 2 vessel and left main
coronary artery disease as patient was found to have 90% L-main
occlusion. Due to significant comorbidities, there was
reluctance to offer CABG as reasonable option. After discussion
with family and patient he elected to undergo an attempt at PCI.
He underwent PTCA and placement of a bare-metal stent in the
distal LMCA to origin of LAD and recovered well with no notable
complications post-procedure.
.
PUMP FUNCTION: ECHO revealed LVEF of 35%. The patient had
initial elevation in BNP of [**Numeric Identifier 79816**] given his acute NSTEMI and CHF
with poor cardiac output. He received post catheterization
diuresis with Lasix and his CXRs showed improvement in his
pulmonary edema throughout his hospital course. The patient's
oxygen saturations were improved to 96 % on room air by time of
discharge and he had no clinical complaints of shortness of
breath and only trace lower extremity edema which had improved
from his initial presentation.
.
RHYTHM : The patient was monitored throughout his stay and per
telemetry he remained predominantly in normal sinus rhythm after
his PCI procedure with very limited PVCs.
.
ANTICOAGULATION: The patient's most recent ECHO revealed
moderate global left ventricular hypokinesis (LVEF =35-40 %)and
the right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. Thus, he was started on IV heparin and
bridged while starting coumadin therapy to reduce his risk of
thrombus and CVAs. The end INR goal being [**2-26**]. At time of
discharge the patient's INR was slightly supratherapeutic at 3.5
and his evening warfarin dose was held prior to his discharge.
.
ACUTE ON CHRONIC RENAL FAILURE : The patient's initial CRF
history was further challenged by his relative hypoperfusion in
the setting of his ACS/NSTEMI and during his cardiogenic shock.
Based on limited OSH records it is unclear what the patient's
true BUN/Cr baseline is. His Cr peaked at 2.4 and came down to
1.6/1.7 by time of discharge. He was given mucomyst pre and
post-procedure and IVFs were given sparingly due to the
patient's CHF/cardiogenic shock.
.
CIRRHOSIS : The patient had a GI consult for pre-op risk
stratification. Unclear if patient has true underlying cirrhosis
but ultrasound revealed a nodular liver. The patient was cleared
for surgery and he had LFTs within normal limits at the time of
discharge. Per GI records the patient had a classification of
Child Class B w/ 30% cirrhosis secondary to alcohol history. He
had no appreciable RUQ tenderness, jaundice, HSM on exam and he
will plan to follow-up with his usual PCP after discharge
regarding his GI management. Hepatitis B/C panels were done and
were all negative.
RECENT PNA : The patient was noted to have had a fever at OSH
and he had recently completed treatment for PNA. He had no
dullness to percusssion on exam and he had no significant cough
or productive sputum during his CCU course. At time of discharge
he had WBC count of 8.1 and was afebrile. Mr. [**Known lastname **] did have
leukocytosis to 19 at OSH but only mildly elevated WBC to 12
here and CXR clear other than mild effusions initially which had
improved to near resolution by time of discharge.
.
DEMENTIA : For the patient's mild dementia he was continued on
his daily Donepezil therapy.
.
URINARY TRACT INFECTION: On [**2136-11-5**] the patient had a routine
UA which revealed bacteria and WBCs and labs were consistent
with a UTI so he was started on Doxycycline for a 7 day regimen.
Follow-up urine cultures were negative. He was through 4/7 days
therapy at time of discharge and had no complaints of dysuria or
frequency.
FLUIDS AND ELECTROLYTES: The patients magnesium and potassium
were repleted on an as needed basis during his hospital stay and
daily electrolytes were monitored. He was started on a full
cardiac diet once he stabilized and he did very well with his
oral input and had a good appetite. IVF were used sparingly in
the setting of CHF.
.
SACRAL DECUBITUS: The patient's sacral stage 1 buttock sore
remained in tact and he had protective cream applied to avoid
any breakdown. Patient stable at time of discharge and will plan
to follow-up with his PCP regarding further monitoring.
.
PROPHYLAXIS: The patient was on anticoagulation for NSTEMI and
thrombus coverage in the setting of his hypokinetic heart and
was therefore covered for DVT prophylaxis as well. PT also
helped the patient to do exercises during his stay to maintain a
fair level of mobility. He was also given 40mg PO daily
Protonix for GI prophylaxis.
.
The patient was maintained as a full code
status for the entirety of his hospital stay. He was asked to
please return to the emergency room or call his primary
cardiologist or PCP as soon as possible if he had any worsening
shortness of breath, chest pain, dizziness or lightheadedness
after discharge.
Medications on Admission:
Home Medications on arrival:
Reglaid
Flonase
Sudafed
Celexa
Colchine
[**Date Range **]
Lopressor
Allopurinol
Aricept
Recently completed levaquin for PNA
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Acute Systolic Congestive Heart Failure
Urinary Tract Infection
Acute Renal Failure
Discharge Condition:
Stable
Creat: 1.6
BUN: 47
K: 4.2
Hct: 27.9
Stage 1 sacral ulcer
Discharge Instructions:
You had a heart attack and required a bare metal stent to open
one of your heart arteries. You will need to take [**Location (un) **] every
day for the rest of your life. You had some damage to your heart
muscle and now your heart is weak. Because of this, you will
need to follow a low salt diet, weigh your self every day and
call the doctor if you gain more than 3 pounds in 1 day or 6
pounds in 3 days. We changed some of your medicines.
Continue daily [**Location (un) **] to keep the cardiac stent open. Continue
doxycycline for 3 remaining days of therapy for a urinary tract
infection and continue daily Warfarin as prescribed to avoid
blood clots and to decrease stroke risk.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Cardiology: Pt will need follow-up with a cardiologist in [**2-27**]
weeks as a new pt.
Completed by:[**2136-11-8**]
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29370
|
Discharge summary
|
Report
|
Admission Date: [**2120-10-14**] Discharge Date: [**2120-10-28**]
Date of Birth: [**2057-12-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Hypoglycemia, hypoxemia, hypothermia
Major Surgical or Invasive Procedure:
endotracheal intubation
Arterial line placement
Central venous line placement
Peripherally-inserted venous catheter
History of Present Illness:
Ms. [**Known lastname 32496**] is a 62 yo wheelchair bound F with IDDM c/b
peripheral neuropathy with CHF 20%, s/p right BKA, daughter
nurse, picked her up at adult day care, noticed somnolence,
checked glu - 25. Went to local ER. Gave amp D50 and gave her
zosyn, but there is no documented temperature. She was noted to
desat to the 70s on RA, but she was asymptomatic. She was put
on nonrebreather. She was also noted to be bradycardic in 40s.
She was tx here for further management. Upon arrival, she was
again without complaints. She was noted to desat to 82 without
NRB.
Vitals in the ED: HR 60s. T 92-93 rectal. HR 60, BP 160/63, RR
19, 98%NRB. No other antibiotics. 1 blood and urine here. 2
bloods at outside ed. lactate 1.5. Cr 1.4 there, 1.8 here. No
CTA done, but she was placed on heparin out of concern for PE.
She was put on a warming blanket.
In the ICU, she endorsed cough x 2 days, atypical chest pain.
She denies abd pain, dysuria or increased frequency, diarrhea,
n/v. She subsequently developed hypotension with SBP 70s to
80s. Given her evolving sepsis picture, pulmonary edema,
possible benefit of better monitoring, and possible need for
pressors, an arterial line was placed and she was intubated.
Past Medical History:
#. Chronic Systolic CHF EF 20%:
- h/o hospitalizations for CHF exacerbation
- Echo [**10-17**]: Moderate symmetric LVH with severe global left
ventricular dysfunction (EF 20-25%) Moderate tricuspid
regurgitation. Moderate pulmonary hypertension. Small
pericardial effusion.
- MIBI [**2117**] with normal perfusion
#. DM II x 15 years - complicated by peripheral neuropathy;
retinopathy
#. HTN
#. CAD - h/o distant MI per family report, no PCI or CABG
#. History of Pancreatitis
- s/p pancreatic duct stent
#. CKD (baseline 1.1-1.3 per report, but was 0.7-0.9 in [**4-17**])
#. Anemia - Mixed iron deficient and anemia of chronic disease
#. Thrombocytopenia
#. h/o thickened endometrium per US
#. osteopenia
#. History of stroke
#. Dementia
#. ? Seizure disorder
Social History:
The patient was previously living in [**Location (un) **] with her other
daughter. She recently returned to [**Location 86**] to live with her
daughter [**Name (NI) 70555**] who is employed at [**Hospital1 18**] as a coworker
[**Name (NI) 1139**]: Quit 1 year ago, previously [**12-13**] PPD x 50 years
ETOH: Rare
Illicits: None
Family History:
Mother with DM, breast cancer, MI in her 70's. Brother has DM.
Sister with heart disease.
Physical Exam:
vitals: 92 axillary, HR 67 83/35-->121/84 RR20 O2 83-94% NRB
heent: ncat, mmm, eomi
neck: no lad
pulm: ctab, no w/r/r
cv: hrrr, no m/r/g
abd: s/nd, mild diffuse ttp, hypoactive bs
extr: s/p right BKA, multiple ulcers on left foot without
erythema. exudate between 3rd and 4th toes where there is an
ulcer.
neuro: ao x 1 (self)
Pertinent Results:
[**2120-10-14**] 11:06PM PO2-67* PCO2-35 PH-7.32* TOTAL CO2-19* BASE
XS--7
[**2120-10-14**] 11:06PM LACTATE-1.5
[**2120-10-14**] 10:55PM GLUCOSE-266* UREA N-23* CREAT-1.8* SODIUM-144
POTASSIUM-5.6* CHLORIDE-118* TOTAL CO2-19* ANION GAP-13
[**2120-10-14**] 10:55PM CK(CPK)-51
[**2120-10-14**] 10:55PM cTropnT-0.03*
[**2120-10-14**] 10:55PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2120-10-14**] 10:55PM TSH-11*
[**2120-10-14**] 10:55PM TSH-11*
[**2120-10-14**] 10:55PM T4-8.7
[**2120-10-14**] 10:55PM PLT SMR-NORMAL PLT COUNT-122* LPLT-3+
[**2120-10-14**] 10:55PM PLT SMR-NORMAL PLT COUNT-122* LPLT-3+
[**2120-10-14**] 10:55PM PT-11.6 PTT-31.3 INR(PT)-1.0
CXR [**10-23**]:
FINDINGS: In comparison with the study of [**10-22**], there is
persistence of
diffuse bilateral pulmonary opacifications. Again, this is
consistent with
ARDS, though vascular congestion or diffuse pneumonia can
certainly not be
excluded radiographically. Various monitoring and support
devices remain in place. The left hemidiaphragm is not sharply
seen on the current study. This could reflect some pleural
fluid, atelectatic change, or even focal
consolidation at the left base.
ABD/PELVIS CT [**10-18**]:
1. Significantly limited CT examination without intravenous
contrast with no source of infection identified. If there
remains a high clinical concern for an occult infection, can
consider correlation with a dedicated tagged white cell scan.
2. Ground glass and interstitial opacities within visualized
lung bases in
conjunction with small bilateral pleural effusions, small
pericardial
effusion, and probable compression atelectasis. These all likely
relate to
fluid overload/CHF with no discrete pneumonia noted.
3. Diffuse anasarca.
4. Unchanged pancreatic parenchymal calcifications again
suggestive of prior episodes of pancreatitis.
Brief Hospital Course:
62 yo female with DM, HTN, CAD, dementia, who presented with
hypothermia, hypoxia, and hypotension.
# Sepsis: The patient's clinical picture was consistent with
sepsis, initially concerning for urosepsis based on her UA in
the ED. Early goal-directed therapy was initiated, with prompt
transfer to the ICU. However, no bacteria grew from the urine,
and nothing was grown from blood and sputum cultures. She was
covered broadly with vancomycin, zosyn, and levofloxacin and she
improved clinically. She was ruled out for respiratory viruses.
Podiatry was consulted and did not feel that her left foot was
infected, only colonized. Bronchoscopy was also not revealing.
CT abd & pelvis were also unremarkable for source. Given no
clear source and clinical improvement she was given a 10-day
course of empiric antibiotics with the last doses on [**10-25**]. She
remained afebrile during the latter portion of her hospital
course.
# Hypotension/Hypertension: The patient was hypotensive on
admission requiring agressive fluid resuscitation (11L in the
first 24 hours) and pressors. She became hypertensive after the
second or third day of her ICU stay and was gradually started
back on some of her home medications, metoprolol and amlodipine.
Hydralazine was started due to hypertension and wanting to hold
enalapril and HCTZ given her acute renal failure. As kidney
function improved enalapril was started and gradually titrated
upward, while Hydralazine was discontinued. Her
anti-hypertensive regimen will need further adjustment as an
outpatient.
# Respiratory Failure: While in the ICU, she developed
progressive respiratory distress requiring endotracheal
intubation, the etiology of which proved unclear. Serial CXRs
appeared most consistent with ARDS, but lung compliance proved
good on the ventilator. Fluid overload was also postulated. She
was diuresed with Lasix, and successfully extubated on [**2120-10-23**].
Her length of stay fluid balance was still +4 L at the time of
discharge but she was autodiuresing well so no diuretics were
initiated.
# Acute Renal Failure: Creatinine was elevated to 1.8 on
admission and peaked at 2.1 but returned to a baseline of 1.2.
The patient likely had ARF [**1-13**] hypoperfusion.
# Question of DIC: Concering because of thrombocytopenia and
coagulopathy. However, Heme was consulted and did not think her
presentation was consistent with DIC. She also ruled out for
HIT. Her platelet count was stable at the time of discharge.
# Chronic diastolic heart failure: Pt. was found to have a
normal EF on ECHO (>55%) and severe diastolic dysfunction. She
was restarted on an ACEi as described above, a beta blocker, and
aspirin.
# History of seizure: Patient has a history of a recent seizure
of unclear etiology. It may be related to a past stroke,
however. She was managed with keppra.
# DM: Patient was managed on an ISS while inpatient. At the
time of discharge, her daughter reported episodes of
hypoglycemia as an outpatient and requested a script for
glucagon pens, which were given.
# Foot ulcers/bullae: Podiatry evaluated the patient's foot
ulcers and made recommendations for wound care. Her ulcers grew
pan-resistant bacteria (including VRE) but they felt that the
ulcers were not the cause of her septic presentation, and that
they were instead colonized. She additionally improved
clinically in the abscence of directed antimicrobial therapy
against VRE. She was discharged with wound care recommendations
for at-home wound care.
# CAD/hx of stroke: Patient was discharged on ASA and a beta
blocker.
Medications on Admission:
Per D/C summary [**10-8**]:
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Levetiracetam 500mg PO bid
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Silvadene 1 % Cream Sig: One (1) Topical once a day: Apply
to the blister once dry and stops draining.
Disp:*1 * Refills:*2*
13. Glargine 7 Units qAM
Insulin SC Sliding Scale
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Disp:*120 Tablet(s)* Refills:*2*
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Lantus 100 unit/mL Cartridge Sig: Seven (7) U Subcutaneous
QAM.
13. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED
Subcutaneous ASDIR (AS DIRECTED).
14. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for DIARRHEA.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Sepsis
2. Acute respiratory failure
3. Acute renal failure, resolved
4. Low-grade DIC
Secondary diagnoses:
1. Chronic diastolic heart failure, compensated
2. Hypertension
3. Diabetes mellitus type 2, controlled with complications
4. Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted because you had a serious infection in your
blood stream. We treated you with antibiotics to help clear the
infection. We also had to assist your breathing with a
breathing tube. Your condition improved gradually and we
discharged you home with physical therapy services.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Please call your doctor or return to the hospital if you
experience fevers, chills, sweats, chest pain, shortness of
breath or anything else of concern.
Followup Instructions:
Please schedule an appointment with your primary care doctor
within the next one to two weeks:
PCP: [**Name10 (NameIs) 70557**],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **] [**0-0-**]
We scheduled you for an appointment with a nurse practicioner at
[**Hospital1 18**] next week. To keep this appointment, you will need to
call the office (the number is below). If you would rather see
Dr. [**Last Name (STitle) **], please call his office to schedule an appointment
there.
Scheduled Appointments :
[**Hospital1 18**]--Provider [**Name9 (PRE) 10160**] [**Name9 (PRE) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2120-11-4**] 2:00
Please schedule an appointment with the podiatry clinic within
the next week:
Podiatry
[**Hospital1 18**], [**Location 70558**]
Office Phone: ([**Telephone/Fax (1) 4335**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2120-10-29**]
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92,170
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20247
|
Discharge summary
|
Report
|
Admission Date: [**2189-3-29**] Discharge Date: [**2189-4-2**]
Date of Birth: [**2117-3-31**] Sex: M
Service: MEDICINE
Allergies:
Coumadin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Dyspnea, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 yo Cantonese and Spanish speaking male with metastatic
pancreatic cancer was admitted from the ED with dyspnea, altered
mental status, and hyponatremia. History was obtained from
patient's son and [**Name (NI) **] as patient could not give complete
history.
.
Patient was recently admitted to the OMED service 4/22-24/09
with tachycardia and hypotension thought related to dehydration.
He was given IVF and 2 units pRBCs with improvement in his blood
pressure and heart rate. He was also treated with a 7-day course
of levofloxacin for presumed community-acquired pneumonia. [**Name (NI) 1094**]
son reports that his cough improved, but he gradually developed
increasing lower extremity edema and abdominal swelling.
Associated symptoms include worsening mental status and fatigue.
On review of systems, he denies fevers, shaking chills, night
sweats, abdominal pain, back pain, chest pain, and sick
contacts.
.
Of note, during his last admission, palliative care was
consulted for assistance with goals of care. Although the
patient has refused palliative chemotherapy and XRT, he has not
further discussed or re-addressed code status. He remains full
code.
.
Upon arrival to the ED, temp 98.4, HR 100, BP 122/70, and pulse
ox 97% on 2L. His exam was notable for increased edema and
ascites. His labs were notable for hyponatremia with a sodium of
103, elevated lactate to 6.6, and hyperkalemia to 5.5. He
received 1L IVF, vancomycin 1 g IV x 1, and zosyn 4.5g IV x 1.
Past Medical History:
1. Prostate cancer [**2183**] s/p resection
2. Hypertension
3. Atrial fibrillation off coumadin
4. Thalaseemia
5. CVA, multiple TIAS
6. Metastatic pancreatic cancer
Social History:
- Home: lives at home with wife and daughter [**Name (NI) **]; moved here
from [**Country 651**] in [**2168**]
- Occupation: worked in hotels and supermarkets
- EtOH: Denies
- Drugs: Denies
- Tobacco: Denies
Family History:
Denies any history of cancer in the family.
Physical Exam:
T 97.4, HR 82, BP 105/55, RR 19, O2sat 99%RA
Gen: Somnolent male difficult to arouse from sleep but in NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: Anterior breath sounds notable for rales at right base
and diminished breath sounds at left base.
ABD: Soft, nl BS, mildly distended, unable to appreciate fluid
wave
EXT: 2+ pitting LE edema extending to lower back and 1+ of upper
extremities b/l. 2+ DP pulses BL
SKIN: No lesions
NEURO: Arousable but not oriented. PERRL, unable to elicit rest
of neuro exam as pt too obtunded
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2189-3-29**] 01:40PM BLOOD WBC-27.2*# RBC-5.57# Hgb-11.4* Hct-34.3*
MCV-62* MCH-20.4* MCHC-33.1 RDW-23.7* Plt Ct-565*#
[**2189-3-29**] 01:40PM BLOOD Neuts-88* Bands-6* Lymphs-1* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2189-3-29**] 01:40PM BLOOD PT-15.3* PTT-32.6 INR(PT)-1.3*
[**2189-3-29**] 01:40PM BLOOD Glucose-65* UreaN-21* Creat-0.8 Na-103*
K-6.6* Cl-73* HCO3-19* AnGap-18
[**2189-3-29**] 01:40PM BLOOD ALT-41* AST-147* CK(CPK)-113 AlkPhos-684*
TotBili-1.4
[**2189-3-30**] 05:30AM BLOOD Albumin-2.1* Calcium-7.3* Phos-3.6 Mg-1.7
[**2189-3-29**] 01:40PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-4071*
[**2189-3-30**] 05:30AM BLOOD Osmolal-244*
[**2189-3-30**] 10:49AM BLOOD Cortsol-25.2*
[**2189-3-29**] 01:50PM BLOOD Lactate-6.0*
.
[**2189-4-1**] 05:31AM BLOOD WBC-25.5* RBC-4.58* Hgb-9.3* Hct-28.2*
MCV-61* MCH-20.3* MCHC-33.0 RDW-24.6* Plt Ct-458*
[**2189-4-1**] 05:31AM BLOOD Glucose-50* UreaN-21* Creat-0.8 Na-127*
K-4.3 Cl-98 HCO3-16* AnGap-17
[**2189-3-30**] 05:30AM BLOOD ALT-35 AST-96* LD(LDH)-765* AlkPhos-496*
TotBili-1.5
[**2189-4-1**] 05:31AM BLOOD Calcium-7.6* Phos-3.5 Mg-1.9
[**2189-3-31**] 08:14AM BLOOD Osmolal-259*
[**2189-4-1**] 02:04PM BLOOD Lactate-4.0*
.
[**2189-3-29**] EKG: Atrial fibrillation, ST-T changes are nonspecific,
Since previous tracing of [**2189-3-18**], T wave flattening noted.
.
[**2189-3-29**] CXR: Increasing left effusion/consolidation. Please refer
to CT
abd/pelvis performed subsequently for further details.
.
[**2189-3-29**] CT Abd/Pelvis:
- Marked interval progression of metastatic disease as detailed
above with increased disease burden in the pancreas, liver and
diffuse implants in the abdomen. Please see above for details.
- Stable multiple hypodense lesions in both kidneys.
- Bilateral pleural effusions, moderate, left greater than
right.
- Minimal ascites. Moderate anasarca.
- Small nonobstructing bilateral renal calculi.
.
[**2189-3-29**] CT Head: No acute intracranial process. MR is more
sensitive in the
detection of small masses.
Brief Hospital Course:
71 yo man with history of metastatic pancreatic cancer was
admitted with dyspnea, new ascites, and profound hyponatremia.
.
# Hyponatremia: Profound hyponatremia likely etiology of altered
mental status with improvement in lethargy with cautious
correction. Pt initially on hypertonic saline as thought to have
component from dehydration. However, per renal assessment,
appears to have baseline mild SIADH exacerbated by excessive po
fluid intake at home due to diagnosis of dehydration given at
last admission. Pt placed on 800cc to 1L fluid restriction with
improvement to likely baseline of 126-128.
.
# Hypotension: Per Renal, likely new baseline in setting of
progressive chronic disease. Ddx hypovolemia given tachycardia
but little response to fluid boluses. Initial concern of
hypoperfusion given elevated lactate but persistence of lactate
likely [**12-29**] to malignancy.
.
# Dyspnea: Infiltrate on CXR initially treated as HAP with vanco
and zosyn. Switched to cefpodoxime prior to discharge as MRSA
screen negative and pseudomonas unlikely given clinical picture.
Legionella negative. Rapid respiratory viral Ag test negative.
Prior to discharge, switched to cefpodoxime as MRSA screen
negative and low clinical suspicion for pseudomonas pneumonia.
Plan to complete 8-day today course of antibiotics, last dose on
[**2189-4-6**]. Small bilateral effusions on imaging (ddx parapneumonic
v. malignancy) may also have contributed to dyspnea.
.
# Bandemia: Likely [**12-29**] pneumonia, stable to mildly improved. No
other localizing sx. Urine cultures negative with no growth on
blood cultures to date. C. diff toxin test ordered but no sample
sent; unlikely etiology.
.
# Guaiac positive stools: Patient was found to have guiac
positive stools, likely related to his history of GI cancer and
it is unclear if he has any GI tract involvement of his cancer.
In light of guiac positive stools, held off on any
anticoagulation at this time.
.
# Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis. Unclear if
this represents a spontaneous thrombosis or is related to tumor
invasion. Family made aware of diagnosis, but anticoagulation
held as pt is poor candidate given his poor PO intake, multiple
comorbidities, and reported allergy to coumadin.
.
# Fluid overload: [**Month (only) 116**] be [**12-29**] increased metastatic disease, low
albumin. [**Month (only) 116**] have some diastolic dysfunction not assessed on
prior echo. [**Month (only) 116**] also have third-spacing [**12-29**] hyponatremia.
Nephrotic syndrome unlikely given U/A. ? of new ascites which is
likely related to his increased metastatic disease. Started on
high protein diet.
.
# Metastatic pancreatic Cancer: Evidence of progression of CT
abdomen/pelvis. Of note, OB positive stool seen in the setting
of known GI malignancy but with relatively stable Hct. He has
been offered palliative chemotherapy and radiation treatment,
which he has declined. Family meeting was held with palliative
care and oncologist Dr. [**Last Name (STitle) **] present. Decision made to discharge
pt home with hospice but to remain full code given hope of
seeing son who will be arriving from [**Location (un) 6847**] in 2 weeks.
.
# Afib: Off coumadin given h/o allergy. Was in RVR during
hospitalization but not rate controlled given low-running BP
although he remained hemodynamically stable.
.
# Nutrition: Speech & swallow and Nutrition recommended high
protein, pureed solids, nectar-thick liquids. Maintained on 1L
fluid restriction.
.
# DVT ppx: Pneumoboots.
.
# Code: FULL, as discussed at family mtg.
Medications on Admission:
Levofloxacin 750mg PO daily x 5 days (4/24-28/09) to complete
7-day course
Discharge Medications:
1. Cefpodoxime 100 mg/5 mL Suspension for Reconstitution Sig:
Two Hundred (200) mg PO twice a day for 4 days.
Disp:*1600 mg* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Hyponatremia
- Hospital acquired pneumonia
Secondary
- Metastatic pancreatic cancer
- Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for increasing cough and lethargy. You were
treated for a pneumonia, and we are giving you a prescription to
complete an antibiotic course at home. You were also found to
have a very low sodium level. This is thought to be due to an
underlying metabolic problem which was exacerbated by too much
water intake at home. You should not drink more than 800 cc of
water daily.
.
Please note that we found a blood clot in your splenic vein.
However, you were not started on blood thinners as the risks
outweighed the benefits.
.
The following changes were made to your medications:
- cefpodoxime - this is an antibiotic to treat your pneumonia.
.
As discussed during the family meeting, you will be sent home
with hospice care. Please seek medical attention if you develop
fevers or chills, increased difficulty breathing, chest pain, or
any other concerning symptoms.
Followup Instructions:
You have the following upcoming appointments already scheduled:
- [**Name6 (MD) **] [**Name8 (MD) **], MD. Phone:[**Telephone/Fax (1) 22**]. Date/Time:[**2189-4-3**] @
1:00pm.
- [**Name6 (MD) **] [**Name8 (MD) **], MD. Phone:[**Telephone/Fax (1) 22**]. Date/Time:[**2189-4-29**] @
1:30pm.
Completed by:[**2189-4-2**]
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| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 1,475
| 0
| 0
| 0
| 88
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 168
| 210
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
91,796
| 148,602
|
38520
|
Discharge summary
|
Report
|
Admission Date: [**2172-5-8**] [**Year/Month/Day **] Date: [**2172-5-14**]
Date of Birth: [**2091-10-3**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Quinolones
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80F with history of COPD on home O2 who was found to have a UTI
a week ago and started on Macrodantin by her urologist. She took
3 days of Macrodantin and felt very nauseated and dizzy. On [**5-7**]
while walking to the bathroom, she fell and started complaining
of hip pain. Four people at [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] rehab helped her up
and put her back into bed. She denied any loss of consciousness,
blurry vision, chest pain, shortness of breath. A CT scan done
showed multiple pelvic fractures, a question of a pulmonary
embolism in the RLL and a bladder pollyp. She had seen her
urologist one week prior for cystoscopy for hematuria. At [**Last Name (un) 1724**]
she had an IVC filter placed [**2172-5-7**] as well as a PICC line. Her
Urine Cx from [**2172-5-4**] was ESBL E.Coli for which she has been
treated with Imipenem/Cilistatin.
Past Medical History:
COPD, CO2 retainer on home oxygen 2 liters, GERD, DVT 6 years
ago, spinal stenosis, CHF, hypertension, osteoporosis, anxiety,
bladder cancer, UTI, and shingles.
PSH: varicose vein ligation, hysterectomy, IVC filter [**2172-5-7**]
Family History:
Noncontributory
Physical Exam:
Upon admission:
Afebrile, BP 111-141/48-70, HR 88-101, RR 19-29, Sat 89-98% on
4L
General: Elderly Caucasian Female with pursed lip breathing,
mild tacypnea
Pulmonary: Inspiratory crackles noted at the bases but overall
is markedly improved from yesterday.
Cardiac: RR, nl S1 S2, systolic ejection murmur noted over
sternum, no rubs or gallops appreciated
Abdomen: distended, soft, non-tender, tympanetic to percussion
Extremities: No edema noted in lower extremities
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact.
.
Pertinent Results:
[**2172-5-8**] 08:48PM GLUCOSE-108* UREA N-20 CREAT-0.5 SODIUM-140
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12
[**2172-5-8**] 08:48PM ALT(SGPT)-31 AST(SGOT)-21 ALK PHOS-60 TOT
BILI-0.4
[**2172-5-8**] 08:48PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-2.2*
MAGNESIUM-2.2
[**2172-5-8**] 08:48PM WBC-18.2* RBC-3.51* HGB-10.4* HCT-31.7*
MCV-90 MCH-29.5 MCHC-32.7 RDW-15.1
[**2172-5-8**] 08:48PM NEUTS-93.8* LYMPHS-2.8* MONOS-2.3 EOS-0.9
BASOS-0.2
[**2172-5-8**] 08:48PM PLT COUNT-178
[**2172-5-8**] 08:48PM PT-11.7 PTT-27.5 INR(PT)-1.0
CT: 1. Pelvic fractures: comminuted fx of left sacrum extending
into the first sacral arch. A second nondisplaced fx in the
inferior right sacral ala. Proximal left superior pubic ramus fx
and a comminuted fx of the left ischiopubic ramus. 2. Possible
thrombus in two pulmonary vessels of the right lower lobe. It is
unclear if these vessels are arteries or veins. 3. Small
bilateral pulmonary effusions with adjacent consolidations. 4. 1
cm bladder polyp.
CXR:
FINDINGS: In comparison with the study earlier in this date,
there is little change in the appearance of the heart and lungs.
Again, there is
hyperexpansion of the lungs with coarse interstitial markings
that could
reflect chronic pulmonary disease, elevated pulmonary venous
pressure, or
both. Bilateral pleural effusions or scarring with probable
bibasilar
atelectasis. Again, the possibility of supervening pneumonia
cannot be
definitely excluded.
Brief Hospital Course:
She was admitted to the Trauma service. She required ICU
admission for tenuous respiratory status given her history of
COPD. She required IV Lasix for diuresis which improved overall
respiratory function. Her home medications, including her home
oxygen, for her COPD were continued.
Orthopedics was consulted for her pelvic fractures. These
injuries did not require operative intervention; her weight
bearing status was as tolerated by patient without restriction.
Her pain regimen includes standing Tylenol, Ultram and prn
Oxycodone. She is also on a bowel regimen.
She is currently continuing treatment of her UTI with Meropenem;
stop date is [**2172-5-18**].
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay.
Medications on Admission:
Advair 250/50 b.i.d., Spiriva INH, dilt 240 daily, Ativan 0.5
b.i.d. p.r.n., Neurontin 300 b.i.d., Protonix 40 daily, Tylenol,
Celexa 10 daily, Colace 100 b.i.d., prednisone 5 daily, Mucinex
600 b.i.d., calcium 600, vitamin D 400, omeprazole 20, MiraLax,
senna 2tabs q.h.s., bisacodyl suppository as needed, milk of
magnesia 30 mL
[**Month/Day/Year **] Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection [**Hospital1 **] (2 times a day).
14. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
15. K Phos Di & Mono-Sod Phos Mono 250 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
16. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
20. Oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q4H (every 4
hours) as needed for pain.
21. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
22. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) MG Recon
Soln Intravenous Q12H (every 12 hours): Stop date [**2172-5-18**].
23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] at [**Location (un) 1821**]
[**Location (un) **] Diagnosis:
s/p Fall
Pelvic fractures:
Left comminuted sacral fracture
Inferior right sacral fracture
Left superior pubic ramus fracture
Left comminuted ischiopubic fracture
Urinary tract infection
Secondary diagnosis:
COPD on home oxygen
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
You were hospitalized following a fall; you sustained multiple
fractures of your pelvis which did not require any operations.
The Physical therapists are recommending that you go to rehab.
You may weight bear as tolerated on your lower extremities.
Followup Instructions:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP orthopedics for
your pelvic fractures; call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
Completed by:[**2172-5-14**]
|
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icd9pcs
|
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[
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98,552
| 198,795
|
34501
|
Discharge summary
|
Report
|
Admission Date: [**2187-9-22**] Discharge Date: [**2187-9-27**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 year old Female with Alzheimer's dementia, Atrial
Fibrillation, moderate malnutrition, transferred from [**Hospital 1562**]
Hospital for emergent ERCP for presumed gallstone pancreatitis
and septic shock. The patient was at her nursing home when she
was noted to have an episode of vomiting of large amount of
undigested food at 2 AM on [**2187-9-21**]. She then vomited a large
amount of brown liquid that was reportedly hemocult positive.
The nursing home physician was made aware and referred to ED.
The patient's oxygen saturation was noted to be 85-88% on room
air and 2L of oxygen via NC brought her saturation to 92%.
At [**Hospital 1562**] Hospital ED, VS: BP 129/68 P 83 R 18 Temp 100.3
O2 sat 93% on RA. EKG reported to have sinus rhythm with ST
depressions in V3-V6 consistent with digoxin artifact without
comparison. The patient was given Flagyl 500 mg IV x 1 and
Levaquin 500 mg IV x 1. An ultrasound of the abdomen there
reportedly showed cholelithiasis, a slightly enlarged CBD, and
pancreatic inflammation. Thought to have gallstone pancreatitis
and would need an ERCP, so she was transferred to [**Hospital1 **].
In [**Hospital1 18**] ED, her vitals were T 98.9 BP 99/62 HR 101 RR 19 O2
sat 93% 2L NC
2 L NS given. Flagyl 500 mg IV x 1, Vancomycin 1 gram IV x 1,
and Ceftriaxone 1 g IV x 1 were given. RUQ ultrasound, CXR, and
CT abdomen with contrast were performed. her urinalysis was
noted positive for infection. Urgent ERCP consult was obtained
with a plan to continue IV fluids and IV antibiotics. She was
noted hypotensive in the ED, and was admitted to the [**Hospital Unit Name 153**] for
further management.
A conservative approach to the cholangitis was followed given
her comorbitidities and her response to fluids and antibiotics.
She was also noted with a pneumonia. She was continued on
Vancomycin, along with levaquin and flagyl. After stabilizing,
she was transferred to the medical floor.
She subsequently defervesced, and slowly improved to baseline.
After being afebrile for 48 hours, she was stable to return to
her [**Hospital1 1501**].
Past Medical History:
Dementia
Atrial Fibrillation
Moderate Malnutrition
Social History:
Lives in [**Hospital3 **] facility, [**Hospital 4542**] Nursing Home.
Family History:
non-contributory
Physical Exam:
ROS:
GEN: - fevers
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
PHYSICAL EXAM:
GEN: NAD
Pain: 0/0
HEENT: Dry, - OP Lesions
PUL: CTA B/L
COR: Irregular, S1/S2, 2/6 SEM
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: non-verbal, minimally responsive
Pertinent Results:
[**2187-9-26**] 05:30AM BLOOD WBC-12.0* RBC-3.03* Hgb-9.5* Hct-28.7*
MCV-95 MCH-31.4 MCHC-33.2 RDW-12.8 Plt Ct-251
[**2187-9-23**] 11:07AM BLOOD WBC-13.6*# RBC-3.28* Hgb-10.3* Hct-31.2*
MCV-95 MCH-31.5 MCHC-33.2 RDW-13.0 Plt Ct-230
[**2187-9-22**] 04:01AM BLOOD Neuts-84* Bands-7* Lymphs-5* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2187-9-22**] 04:01AM BLOOD PT-13.9* PTT-30.5 INR(PT)-1.2*
[**2187-9-26**] 05:30AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-144
K-3.0* Cl-110* HCO3-25 AnGap-12
[**2187-9-24**] 05:10AM BLOOD Glucose-82 UreaN-18 Creat-0.7 Na-144
K-3.3 Cl-111* HCO3-24 AnGap-12
[**2187-9-21**] 08:20PM BLOOD Glucose-133* UreaN-25* Creat-0.8 Na-146*
K-4.3 Cl-109* HCO3-27 AnGap-14
[**2187-9-25**] 05:35AM BLOOD ALT-14 AST-14 AlkPhos-67 Amylase-73
TotBili-0.5
[**2187-9-24**] 05:10AM BLOOD ALT-19 AST-14 LD(LDH)-236 AlkPhos-68
Amylase-101* TotBili-0.6
[**2187-9-23**] 05:15AM BLOOD ALT-30 AST-22 LD(LDH)-205 AlkPhos-62
Amylase-305* TotBili-0.6
[**2187-9-22**] 04:01AM BLOOD ALT-50* AST-41* LD(LDH)-279* AlkPhos-69
Amylase-1107* TotBili-0.5
[**2187-9-21**] 08:20PM BLOOD ALT-70* AST-55* AlkPhos-75 TotBili-0.6
[**2187-9-25**] 05:35AM BLOOD Lipase-35
[**2187-9-24**] 05:10AM BLOOD Lipase-32
[**2187-9-23**] 05:15AM BLOOD Lipase-92*
[**2187-9-22**] 04:01AM BLOOD Lipase-1175*
[**2187-9-26**] 05:30AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.9
[**2187-9-25**] 05:35AM BLOOD Albumin-2.5* Calcium-7.5* Phos-2.3*
Mg-2.0
[**2187-9-23**] 05:15AM BLOOD Hapto-229*
[**2187-9-27**] 06:05AM BLOOD Vanco-12.9
[**2187-9-21**] 08:20PM BLOOD Digoxin-0.9
[**2187-9-22**] 03:45PM BLOOD Lactate-1.3
[**2187-9-22**] 09:59AM BLOOD Lactate-2.2*
[**2187-9-21**] 08:41PM BLOOD Lactate-3.1*
[**2187-9-22**] 09:59AM BLOOD freeCa-1.06*
[**2187-9-22**] 08:59PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2187-9-21**] 10:40PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024
[**2187-9-22**] 08:59PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2187-9-21**] 10:40PM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2187-9-22**] 08:59PM URINE RBC-65* WBC-12* Bacteri-FEW Yeast-NONE
Epi-0
[**2187-9-21**] 10:40PM URINE RBC-[**12-13**]* WBC-[**12-13**]* Bacteri-FEW
Yeast-NONE Epi-0-2
[**2187-9-21**] 8:20 pm BLOOD CULTURE
**FINAL REPORT [**2187-9-27**]**
Blood Culture, Routine (Final [**2187-9-27**]): NO GROWTH.
[**2187-9-21**] 11:17 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2187-9-23**]**
URINE CULTURE (Final [**2187-9-23**]): NO GROWTH.
[**2187-9-23**] 6:03 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2187-9-23**]**
GRAM STAIN (Final [**2187-9-23**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2187-9-23**]):
TEST CANCELLED, PATIENT CREDITED.
ECG Study Date of [**2187-9-21**] 8:57:54 PM
Sinus rhythm. Non-specific ST-T wave abnormalities. Clinical
correlation is suggested. No previous tracing available for
comparison.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2187-9-21**]
8:51 PM
IMPRESSION:
1. Cholelithiasis/biliary sludge. No son[**Name (NI) 493**] findings to
suggest acute
cholecystitis.
2. Mild right-sided calyectasis without hydronephrosis.
CHEST (SINGLE VIEW) Study Date of [**2187-9-21**] 9:27 PM
1. No evidence of pneumonia, slightly limited film due to
patient
incooperation and rotation.
2. Extensive mitral annular calcification.
CT ABDOMEN W/CONTRAST Study Date of [**2187-9-21**] 11:14 PM
IMPRESSION:
1. Moderately distended gallbladder without any intrahepatic
ductal
dilatation and mild prominence of the extrahepatic CBD which
measures 10 mm. No focal filling defects were identified;
however, CT is insensitive for detection of choledocholithiasis.
2. Peri-inflammatory changes and free fluid within the abdomen
consistent
with acute pancreatitis. No regions of pancreatic necrosis
identified.
3. Scattered tree-in-[**Male First Name (un) 239**] opacities reflecting an infectious
bronchiolitis
within the right lower lobe in this patient with a complete
mucoid impaction of the lower lobe bronchi bilaterally.
4. Incompletely characterized small hypoattenuating right
hepatic and right renal lesions, likely benign cysts, but too
small to definitively
characterize.
5. Extensive mitral annular calcification and atherosclerotic
disease within the coronary vessel and aorta.
CHEST (PORTABLE AP) Study Date of [**2187-9-23**] 4:50 AM
IMPRESSION: Increasing density in the left lung and right lung
base
concerning for pneumonia. Clinical correlation is recommended.
CHEST (PORTABLE AP) Study Date of [**2187-9-25**] 11:16 AM
FINDINGS: Bilateral pleural effusions and moderate interstitial
edema have
increased, compared with the prior study. The left upper lobe
opacity has
improved. Opacity in the right lower lung has increased in the
interval. Left retrocardiac opacity remains present. There is no
pneumothorax.
Brief Hospital Course:
1. Acute Pancreatitis, Choledocolithiasis with Obstruction,
Septicemia
- Patient was kept NPO, and given agressive IV rehydration
- Amylase trended down from 1107 to 305, lipase from 1175 down
to 92 on discharge from ICU.
- ERCP team was consulted, who believed that she had passed the
stone, given her improving labs.
- Levaquin and Flagyl were initiated
- Patient was on Vancomycin in hospital for MRSA empiric
coverage, discontinued prior to discharge
- Feeds were reintroduced on the floor and tolerated well
2. Bacterial UTI with Indwelling Catheter:
- Levaquin/Flagyl
- Foley changed
3. Acute Blood Loss Anemia due to Hematemesis
- Resolved on admission
- Likely [**Doctor First Name 329**] [**Doctor Last Name **] tear vs. mild gastritis
4. Bacterial Pneumonia
- Levaquin/Flagyl given possibility of aspiration
- Afebrile x48 hours at time of discharge
- Some element of fluid overload, so intermittant lasix given
5. Atrial fibrillation
- continue digoxin
6. Alzheimer's Dementia:
- at baseline, per family.
- Geriatrics consult was obtained, concur with current
management
- There is a suggestion by the geriatrics team, for her primary
team at the [**Hospital1 1501**] to consider hospice discussions with the family
Medications on Admission:
Milk of Magnesia prn
Acetaminophen prn
Compazine 25 mg PR q 12 hour prn
ASA 81 mg daily
Digoxin 250 mcg daily
Colace 100 mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal every six (6) hours as needed for fever or pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]
Discharge Diagnosis:
Acute Pancreatitis
Choledocolithiasis with Obstruction
Septicemia
Bacterial Pneumonia
Bacterial UTI with Indwelling Catheter
Moderate Malnutrition
Atrial Fibrillation
Acute Blood Loss Anemia
Hematemesis
Alzheimer's Dementia
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with fever, chills, nausea/vomitting,
hypotension, agitation.
Followup Instructions:
Follow up as needed with the medical staff at the facility
|
[
"331.0",
"294.10",
"427.31",
"263.0",
"577.0",
"574.91",
"038.9",
"599.0",
"285.1",
"578.0"
] |
icd9cm
|
[
[
[
290,
309
]
],
[
[
302,
309
]
],
[
[
312,
330
]
],
[
[
333,
340
]
],
[
[
8455,
8472
]
],
[
[
8475,
8492
]
],
[
[
8512,
8521
]
],
[
[
8970,
8978
]
],
[
[
9048,
9070
]
],
[
[
9079,
9089
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] | 97
| 1,235
| 0
| 7
| 7
| 0
| 0
| 0
| 0
| 5,248
| 0
| 0
| 62
| 19
| 0
| 0
| 0
| 802
| 0
| 226
| 0
| 133
| 0
| 0
| 0
| 0
| 87
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 165
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 15
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 2,102
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 53
| 73
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
| 0
|
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