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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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92,287
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18156
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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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],
[
[
1739,
1772
]
],
[
[
1860,
1862
]
],
[
[
6683,
6691
],
[
10264,
10272
]
],
[
[
6950,
6961
],
[
12396,
12407
]
],
[
[
6984,
6994
]
],
[
[
7187,
7197
]
],
[
[
7203,
7213
]
],
[
[
7938,
7958
],
[
9952,
9968
]
],
[
[
9105,
9123
],
[
12442,
12460
]
],
[
[
9144,
9151
]
],
[
[
9697,
9716
],
[
12410,
12428
]
],
[
[
9970,
10008
]
],
[
[
12463,
12503
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12324, 12366
|
6523, 10707
|
295, 302
|
12528, 12528
|
3507, 6158
|
13677, 15026
|
2437, 2524
|
11590, 12301
|
12387, 12507
|
11142, 11567
|
12711, 13654
|
6174, 6500
|
2539, 3193
|
3209, 3488
|
10728, 11116
|
235, 257
|
330, 1554
|
12543, 12687
|
1576, 2105
|
2121, 2421
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
"553.21",
"401.9",
"V10.3",
"244.9",
"574.10",
"157.0",
"562.10",
"518.81",
"518.53",
"416.8",
"429.4",
"787.22",
"997.39",
"518.0"
] |
icd9cm
|
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[
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362,
378
]
],
[
[
1393,
1396
]
],
[
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1388,
1428
]
],
[
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1501
]
],
[
[
5953,
5983
]
],
[
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6253
]
],
[
[
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10094
]
],
[
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14315
]
],
[
[
21134,
21162
]
],
[
[
21222,
21243
]
],
[
[
21245,
21263
]
],
[
[
21290,
21317
]
],
[
[
21319,
21335
]
],
[
[
21345,
21355
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20989, 21068
|
13670, 19120
|
302, 480
|
21380, 21387
|
1966, 13647
|
22840, 22953
|
19348, 20966
|
21089, 21359
|
19146, 19325
|
21411, 22817
|
1703, 1947
|
242, 264
|
508, 1366
|
1388, 1643
|
1659, 1688
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,563
| 155,738
|
42184
|
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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"427.32",
"410.51",
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"780.4",
"428.33",
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[
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[
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[] |
icd9pcs
|
[
[
[]
]
] |
10895, 11011
|
6895, 9780
|
240, 246
|
11242, 11242
|
5471, 6872
|
12238, 12683
|
4539, 4618
|
10277, 10872
|
11032, 11221
|
9806, 10254
|
11426, 12215
|
4633, 4633
|
3360, 3495
|
4655, 5452
|
375, 3230
|
274, 357
|
11257, 11402
|
3526, 4252
|
3274, 3340
|
4268, 4507
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,572
| 198,039
|
40520
|
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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"272.4",
"572.0",
"V15.82",
"038.49",
"428.31",
"584.9",
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icd9cm
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[
618,
620
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[
2452,
2454
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],
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625
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1470,
1478
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[
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5771
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],
[
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2624,
2652
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],
[
[
5666,
5676
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],
[
[
6961,
6981
]
],
[
[
7063,
7081
]
],
[
[
8615,
8627
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8493, 8588
|
5663, 7116
|
316, 535
|
8672, 8672
|
3093, 5640
|
9590, 10692
|
2672, 2747
|
7236, 8470
|
8609, 8651
|
7142, 7213
|
8822, 9567
|
2762, 2762
|
263, 278
|
563, 2423
|
2776, 3074
|
8687, 8798
|
2445, 2549
|
2565, 2656
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,910
| 129,743
|
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**]
|
[
"V45.82",
"355.8",
"V15.82",
"427.31",
"427.81",
"162.5"
] |
icd9cm
|
[
[
[
1259,
1274
]
],
[
[
1381,
1390
]
],
[
[
1432,
1459
]
],
[
[
2894,
2912
]
],
[
[
2919,
2937
]
],
[
[
6133,
6159
]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[
4989,
4993
]
]
] |
6054, 6112
|
2498, 5230
|
305, 535
|
6184, 6184
|
2137, 2475
|
7007, 7651
|
1522, 1665
|
5324, 6031
|
6133, 6163
|
5256, 5301
|
6335, 6984
|
1680, 2118
|
245, 267
|
563, 1235
|
6199, 6311
|
1257, 1416
|
1432, 1506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
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"429.4",
"285.1"
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[
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14085, 14094
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11153, 13827
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293, 894
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15100, 15109
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2339, 2382
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15133, 15142
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2397, 2397
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2410, 2420
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234, 255
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9800, 11130
|
922, 1531
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1553, 2159
|
2175, 2323
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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90,233
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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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12157, 12301
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,123
| 151,973
|
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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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**]
|
[
"442.83",
"427.89",
"414.00",
"V45.81",
"403.90",
"272.4",
"285.29",
"585.2",
"715.16",
"V15.82"
] |
icd9cm
|
[
[
[
230,
259
],
[
636,
659
]
],
[
[
1033,
1043
],
[
2391,
2407
]
],
[
[
1413,
1415
]
],
[
[
1417,
1434
]
],
[
[
1450,
1452
]
],
[
[
1454,
1456
]
],
[
[
1458,
1482
]
],
[
[
1484,
1514
]
],
[
[
1516,
1541
]
],
[
[
1732,
1799
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4962, 5019
|
3092, 3912
|
300, 331
|
5094, 5094
|
2691, 3069
|
5769, 6068
|
1966, 2188
|
4072, 4939
|
5040, 5073
|
3938, 4049
|
5245, 5746
|
2203, 2672
|
230, 262
|
359, 1391
|
5109, 5221
|
1413, 1716
|
1732, 1950
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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"459.81"
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icd9cm
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11297
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[
[
11317,
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],
[
[
11374,
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]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11132, 11202
|
4706, 8820
|
301, 334
|
11434, 11434
|
4357, 4357
|
12310, 12479
|
3574, 3652
|
9402, 11109
|
11223, 11413
|
8846, 9379
|
11570, 12043
|
3667, 4338
|
12072, 12287
|
253, 263
|
362, 3081
|
4373, 4683
|
11449, 11546
|
3103, 3472
|
3488, 3558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
"414.01",
"425.4",
"V45.02",
"403.90",
"272.4",
"585.9",
"V49.72",
"V45.81",
"250.40",
"585.3",
"250.50",
"250.60",
"530.81",
"V15.82",
"038.12"
] |
icd9cm
|
[
[
[
391,
393
]
],
[
[
404,
426
]
],
[
[
466,
468
]
],
[
[
475,
487
]
],
[
[
480,
482
]
],
[
[
485,
487
]
],
[
[
490,
509
]
],
[
[
1898,
1901
]
],
[
[
2167,
2174
],
[
2319,
2329
]
],
[
[
2214,
2245
]
],
[
[
2290,
2300
]
],
[
[
2303,
2312
]
],
[
[
2493,
2496
]
],
[
[
3119,
3177
]
],
[
[
9146,
9156
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9116, 9125
|
7787, 8558
|
300, 307
|
9180, 9189
|
4099, 4099
|
9245, 9284
|
3276, 3400
|
9084, 9093
|
9146, 9159
|
8584, 9061
|
9213, 9222
|
3415, 4080
|
255, 262
|
335, 1854
|
4115, 7764
|
1876, 3021
|
3037, 3260
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,465
| 142,964
|
490049
|
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
|
[
"443.0",
"537.89",
"456.21"
] |
icd9cm
|
[
[
[
4824,
4832
]
],
[
[
10656,
10673
]
],
[
[
10687,
10704
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4612, 4612
|
6118, 11151
|
28, 4568
|
4593, 4593
|
4631, 6095
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
|
[
[
[
535,
544
]
],
[
[
908,
914
]
],
[
[
918,
930
]
],
[
[
951,
953
]
],
[
[
956,
971
]
],
[
[
3488,
3495
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3363, 3440
|
1731, 2748
|
365, 486
|
3540, 3549
|
1364, 1708
|
4873, 5053
|
1169, 1186
|
2842, 3340
|
3461, 3461
|
2774, 2819
|
3573, 4504
|
1201, 1345
|
273, 327
|
4516, 4850
|
514, 886
|
3480, 3519
|
908, 1025
|
1041, 1153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
93,578
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538274
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Physician
|
Intensivist Note
|
SICU
HPI:
65M w/new mass lesions LUL and [**Doctor Last Name 414**] w/edema no shift.admission exam
LUE ataxia, alt proprioception. S/P mediastinoscopy and crni with
pariet lobe resection
Chief complaint:
Brain Mass
PMHx:
HTN, Dyslipidemia, BPH
Current medications:
20 mEq Potassium Chloride / 1000 mL D5NS 2. Docusate Sodium 3.
Famotidine 4. Gentamicin 5. HYDROmorphone (Dilaudid)
6. Heparin 7. Influenza Virus Vaccine 8. Labetalol 9. Phenytoin 10.
Phenytoin 11. Potassium Phosphate
12. Senna 13. Vancomycin
24 Hour Events:
ARTERIAL LINE - START [**2106-10-29**] 06:44 PM
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Gentamicin - [**2106-10-30**] 02:00 AM
Infusions:
Other ICU medications:
Famotidine (Pepcid) - [**2106-10-29**] 10:00 PM
Other medications:
Flowsheet Data as of [**2106-10-30**] 07:55 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**10**] a.m.
Tmax: 36.7
C (98.1
T current: 36.6
C (97.8
HR: 68 (67 - 84) bpm
BP: 111/52(71) {111/52(71) - 164/90(118)} mmHg
RR: 13 (10 - 24) insp/min
SPO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Total In:
700 mL
788 mL
PO:
Tube feeding:
IV Fluid:
700 mL
788 mL
Blood products:
Total out:
1,110 mL
770 mL
Urine:
1,110 mL
770 mL
NG:
Stool:
Drains:
Balance:
-410 mL
18 mL
Respiratory support
O2 Delivery Device: None
SPO2: 94%
ABG: ///27/
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : )
Abdominal: Soft
Left Extremities: (Edema: Absent)
Right Extremities: (Edema: Absent)
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities
Labs / Radiology
186 K/uL
12.4 g/dL
179 mg/dL
0.7 mg/dL
27 mEq/L
4.7 mEq/L
27 mg/dL
97 mEq/L
134 mEq/L
36.2 %
19.4 K/uL
[image002.jpg]
[**2106-10-30**] 02:55 AM
WBC
19.4
Hct
36.2
Plt
186
Creatinine
0.7
Glucose
179
Other labs: PT / PTT / INR:12.3/22.0/1.0, Ca:8.2 mg/dL, Mg:2.3 mg/dL,
PO4:4.8 mg/dL
Assessment and Plan
.H/O HYPERTENSION, BENIGN, PULMONARY NODULE (LUNG NODULE), [**Last Name **]
PROBLEM - ENTER DESCRIPTION IN COMMENTS
Parietal Mass, .H/O DYSLIPIDEMIA (CHOLESTEROL, TRIGLYCERIDE, LIPID
DISORDER)
Assessment and Plan: 65M w/new mass lesions LUL and [**Doctor Last Name 414**] w/edema no
shift.admission exam LUE ataxia, alt proprioception. S/P
mediastinoscopy and crni with pariet lobe resection
Neurologic: Neuro checks Q: 2 hr, Pain controlled
Cardiovascular: stable
Pulmonary: stable
Gastrointestinal / Abdomen:
Nutrition: Regular diet
Renal: Foley
Hematology:
Endocrine:
Infectious Disease: vanc/gent
Lines / Tubes / Drains: Foley
Wounds:
Imaging:
Fluids:
Consults: Neuro surgery
Billing Diagnosis: Post-op complication
ICU Care
Nutrition:
Glycemic Control: Comments: stable
Lines:
Arterial Line - [**2106-10-29**] 06:44 PM
18 Gauge - [**2106-10-29**] 06:44 PM
16 Gauge - [**2106-10-29**] 06:44 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle:
Comments:
Communication: Patient discussed on interdisciplinary rounds Comments:
Code status:
Disposition: Transfer to floor
Total time spent: 31 minutes
|
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92,648
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40576
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Discharge summary
|
Report
|
Admission Date: [**2117-1-15**] Discharge Date: [**2117-2-5**]
Date of Birth: [**2036-4-6**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Constipation, nausea, SBO
Major Surgical or Invasive Procedure:
exploratory laparascopy, lysis of adhesions, primary repair
serosal defects, rigid sigmoidoscopy
History of Present Illness:
80F with history of rectal CA s/p LAR and ileostomy take-down
[**2116-12-15**], presents with acute onset of low abdominal pain and
distention for the past 6 hours. She reports she has been doing
very well recently, and had a normal bowel movement around 1pm
today. Around 5pm she had some home-made chicken soup
with beans, and about an hour later developed the pain and
distention. She describes the pain as crampy and wave-like in a
band across her lower abdomen. She has not had any nausea,
vomiting, or diarrhea. She has had difficulty with diarrhea
since her ileostomy reversal, and recently started taking
metamucil and Immodium.
Past Medical History:
Rectal Adenocarcinoma
Osteoporosis
Arthritis
Carotid Endarterectomy
Hysterectomy
Peptic Ulcer Disease
H. Pylori treated
Venous Insuffieciency
PSH: Carotid Endarterectomy, Hysterectomy, Robotic LAR w/
diverting loop ileostomy ([**2116-10-22**]), ileostomy take-down
[**2116-12-15**], left upper lobectomy [**2116-8-31**]
Social History:
Widow. Retired radiolgoy tech
Tobacco: quit many years ago. ETOH social
Family History:
Mother died age [**Age over 90 **] old age
Father died age 86 bladder CA
Physical Exam:
On Discharge: Patient doing well, ambulating with assist of
nurse/aide and walker. OOB to chair. Patient tolerating
food/liquids, and PO meds per speech and swallow. No respirtory
distress.
Vitals- 98.3, 97.5, 95, 131/60, 20, 98% RA
Gen- NAD, A+O x3, Left PICC line in place
Cardiac- RRR, holosystolic [**3-8**] murmur, no bruits or gallops,
normal S1/S2
Resp- CTAB, no crackles, no wheezing, stridor dramatically
improved from original episode.
Abd- flat non-distended, soft, midline incision closed with
steri-strips without signs of infection, no redness/drainage or
other sign of infection.
ext- warm, no edema
Pertinent Results:
[**2117-1-15**] 01:00AM BLOOD WBC-9.4 RBC-4.00* Hgb-10.8* Hct-33.5*
MCV-84 MCH-27.1 MCHC-32.2 RDW-16.0* Plt Ct-323
[**2117-1-18**] 05:59AM BLOOD WBC-20.2*# RBC-4.04* Hgb-11.0* Hct-33.9*
MCV-84 MCH-27.3 MCHC-32.4 RDW-16.0* Plt Ct-314
[**2117-1-19**] 06:55AM BLOOD WBC-12.9* RBC-3.49* Hgb-9.4* Hct-29.4*
MCV-84 MCH-27.1 MCHC-32.2 RDW-15.4 Plt Ct-261
[**2117-1-20**] 06:20AM BLOOD WBC-13.8* RBC-3.95* Hgb-10.6* Hct-33.9*
MCV-86 MCH-26.7* MCHC-31.1 RDW-15.6* Plt Ct-325
[**2117-1-21**] 06:45AM BLOOD WBC-11.0 RBC-3.57* Hgb-9.6* Hct-29.8*
MCV-83 MCH-26.9* MCHC-32.3 RDW-15.3 Plt Ct-293
[**2117-1-22**] 03:59PM BLOOD WBC-9.4 RBC-3.61* Hgb-9.8* Hct-31.8*
MCV-88 MCH-27.1 MCHC-30.7* RDW-15.2 Plt Ct-344
[**2117-1-23**] 05:31AM BLOOD WBC-11.5* RBC-3.82* Hgb-10.2* Hct-33.9*
MCV-89 MCH-26.8* MCHC-30.2* RDW-15.5 Plt Ct-410
[**2117-1-24**] 03:06AM BLOOD WBC-12.9* RBC-3.45* Hgb-9.3* Hct-29.6*
MCV-86 MCH-27.1 MCHC-31.5 RDW-15.8* Plt Ct-427
[**2117-1-25**] 03:34AM BLOOD WBC-14.9* RBC-3.25* Hgb-8.7* Hct-27.5*
MCV-85 MCH-26.8* MCHC-31.7 RDW-15.5 Plt Ct-388
[**2117-1-24**] 03:06AM BLOOD PT-17.9* PTT-33.8 INR(PT)-1.7*
[**2117-1-25**] 03:34AM BLOOD PT-14.1* PTT-29.8 INR(PT)-1.3*
[**2117-1-15**] 01:00AM BLOOD Glucose-123* UreaN-17 Creat-0.7 Na-132*
K-4.8 Cl-96 HCO3-27 AnGap-14
[**2117-1-18**] 05:59AM BLOOD Glucose-133* UreaN-19 Creat-0.7 Na-135
K-3.9 Cl-95* HCO3-35* AnGap-9
[**2117-1-19**] 06:55AM BLOOD Glucose-115* UreaN-15 Creat-0.6 Na-130*
K-3.8 Cl-92* HCO3-31 AnGap-11
[**2117-1-20**] 06:20AM BLOOD Glucose-123* UreaN-12 Creat-0.5 Na-131*
K-3.6 Cl-93* HCO3-27 AnGap-15
[**2117-1-21**] 06:45AM BLOOD Glucose-118* UreaN-11 Creat-0.4 Na-135
K-3.2* Cl-99 HCO3-26 AnGap-13
[**2117-1-22**] 04:55AM BLOOD Glucose-118* UreaN-10 Creat-0.5 Na-135
K-3.8 Cl-100 HCO3-26 AnGap-13
[**2117-1-22**] 03:59PM BLOOD Glucose-119* UreaN-10 Creat-0.6 Na-137
K-3.8 Cl-105 HCO3-23 AnGap-13
[**2117-1-25**] 09:25PM BLOOD Glucose-829* UreaN-18 Creat-0.4 Na-110*
K-6.3* Cl-83* HCO3-23 AnGap-10
[**2117-1-25**] 11:13PM BLOOD Glucose-119* UreaN-22* Creat-0.5 Na-135
K-3.9 Cl-99 HCO3-28 AnGap-12
[**2117-1-26**] 05:55AM BLOOD Glucose-109* UreaN-19 Creat-0.4 Na-133
K-6.5* Cl-98 HCO3-31 AnGap-11
[**2117-1-29**] 06:04AM BLOOD Glucose-100 UreaN-18 Creat-0.4 Na-138
K-4.0 Cl-103 HCO3-31 AnGap-8
[**2117-1-21**] 03:15PM BLOOD CK(CPK)-12*
[**2117-1-24**] 03:06AM BLOOD ALT-8 AST-14 CK(CPK)-57 AlkPhos-57
TotBili-0.2
[**2117-1-18**] 05:59AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.6
[**2117-1-19**] 06:55AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.1
[**2117-1-20**] 06:20AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.9
[**2117-1-21**] 06:45AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.0
[**2117-1-22**] 04:55AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.9
[**2117-1-25**] 03:34AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
[**2117-1-25**] 09:25PM BLOOD Mg-2.7*
[**2117-1-26**] 05:55AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.8
[**2117-1-27**] 06:40AM BLOOD Calcium-8.6 Phos-3.6# Mg-2.0
[**2117-1-29**] 06:04AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1
[**2117-1-30**] 09:00AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2
[**2117-1-26**] 05:55AM BLOOD Triglyc-179*
[**2117-1-23**] 06:57PM BLOOD Type-ART FiO2-35 pO2-123* pCO2-43 pH-7.37
calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2117-1-25**] 11:57AM BLOOD Type-ART O2 Flow-37 pO2-123* pCO2-47*
pH-7.43 calTCO2-32* Base XS-6
[**2117-1-25**] 11:07PM BLOOD Type-ART pO2-75* pCO2-46* pH-7.49*
calTCO2-36* Base XS-10
[**2117-1-23**] 06:57PM BLOOD Lactate-0.6
[**2117-1-25**] 11:07PM BLOOD Glucose-120* Lactate-0.7 Na-132* K-3.5
Cl-91*
IMAGING:
KUB [**2117-1-15**]
No bowel obstruction or free air
CT ABD [**2117-1-15**]
IMPRESSION:
1. Striking fecal loading within the colon, without obstruction.
2. A focally dilated loop of small bowel in the mid abdomen
contains contrast and fecalized contents. There is also slowed
motility, though a stricture or ischemia are not excluded on
this study. Note is made on this study of atherosclerotic SMA
disease. 3. New hypodense collection anterior to the liver
measures 1.6 cm, and is new compared with 6/[**2116**]. This may be a
small postsurgical fluid collection. This is too small for
intervention. Follow up MRI or PET CT may be of utility for
further evaluation. 4. Mild ascites and mesenteric edema, which
may be reactive to relatively recent surgery. 5. The low rectal
anastomosis appears intact, without surrounding fluid collection
to suggest leak.
CT Abd [**2117-1-18**]
IMPRESSION:
1. Compared to the prior study, the amount of fecal loading
within the colon has improved. There are focally dilated loops
of small bowel, likely
mid-to-distal ileum, which when compared to the prior study,
appear more
dilated. 2. Again noted is atherosclerotic calcification of the
abdominal aorta, focal low-attenuation lesion in the dome of the
liver, loculated left pleural effusion. 3. Compared to the prior
study, there is increased opacity in the left lower lobe.
Findings are consistent with an inflammatory or infectious
etiology. Aspiration should also be considered.
CXR [**2117-1-18**]
The NG tube tip is in the proximal stomach and should be
advanced. Current
study demonstrates interstitial pulmonary edema, moderate in
severity. The
left mediastinal shift is unchanged. Loculated left pleural
effusion has
slightly increased in the interim. Bibasal opacities might
reflect areas of infection, although they potentially could
reflect interstitial edema as well. Evaluation of the patient
after diuresis is highly recommended.
KUB [**2117-1-22**]
IMPRESSION:
1. Partial small bowel obstruction which is essentially
unchanged from prior; however, the amount of retained enteric
contrast has slightly decreased. 2. Unconventional position of
an NG tube should be correlated to functioning. No findings to
suggest free air.
CXR [**2028-1-23**]
FINDINGS: Unchanged small loculated effusion on the left with
decreasing
extent of the retrocardiac atelectasis. No pulmonary edema. No
newly
appeared focal parenchymal opacities. Borderline size of the
cardiac
silhouette. Unchanged course of the nasogastric tube.
UExt US [**2117-1-24**]
IMPRESSION: No DVT in the left upper extremity. Findings were
discussed in
person with Dr. [**Last Name (STitle) **] at 12:15 p.m. on [**2117-1-24**].
CXR [**2117-1-25**]
FINDINGS: As compared to the previous radiograph, the left
pleural effusion has mildly increased. There is increasing
subsequent atelectasis in the left retrocardiac lung areas.
Newly appeared is a right lower lobe opacity, likely
representing a combination of pneumonia and pulmonary edema.
Unchanged borderline size of the cardiac silhouette. The
presence of a small right pleural effusion cannot be excluded.
CXR [**2028-1-26**]
IMPRESSION: Interval decrease in right basal opacity after
diuresis though
the residual remains concerning for pneumonia.
Video Swallow [**2117-1-29**]
Fluoroscopic video oropharyngeal swallow evaluation was
performed in
collaboration with the speech and swallow therapist. Thin
barium, thick
barium, and barium-coated cookie were administered. There is
penetration with thin barium; however, no frank aspiration was
observed. For more details, please refer to speech and swallow
therapist note in the medical record.
CXR [**2117-1-30**]
IMPRESSION: AP chest compared to [**1-22**] through [**1-27**]:
Lungs are severely hyperinflated. Previous bibasilar
atelectasis, quite
severe on the right, has entirely resolved. There is no
pulmonary edema.
Small residual bilateral pleural effusions are smaller still.
Heart size is normal. There is no pneumothorax. A left PIC line
ends in the mid left
brachiocephalic vein. Findings are most consistent with severe
bronchospasm as a cause of respiratory insufficiency. The larynx
and subglottic trachea are not evaluated by this study.
KUB [**2117-1-31**]
There is disproportionate distention of the large bowel with
respect to small bowel with abrupt change in caliber in the
large bowel at the proximal sigmoid. Since there is formed stool
in the rectum, this could be functional, such as a developing
colonic ileus. Leftward displacement of the rectum raises the
possibility of an adjacent pelvic fluid collection, but it does
not directly compress the rectum or sigmoid. If there is concern
for hematoma or pelvic infection, CT scanning would be required.
Maximum caliber of the right colon is 9 cm in the cecum and
there is preservation of normal haustral architecture and no gas
in the wall of the colon. There is no pneumoperitoneum.
[**Numeric Identifier 4684**] FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE Study Date of
[**2117-2-2**] 1:07 PM
IMPRESSION: Uncomplicated exchange of left-sided venous catheter
for a 5
French 38 cm PICC with its tip at the mid SVC, under
fluoroscopic guidance. Please see above for details. PICC is
ready for use.
EMG Study Date of [**2117-2-3**]
Clinical Interpretation: Abnormal study. There is
electrophysiologic evidence for a chronic neurogenic lesion
involving the left recurrent laryngeal nerve with incomplete
reinnervation. Evidence for synkinesis is also present. The
right recurrent laryngeal nerve is normal.
Brief Hospital Course:
The patient was admitted to the colorectal surgery service on
[**2117-1-15**] for a small bowel obstruction and had an exploratory
laparotomy with lysis of adhesions on HD 8 after medical
management failed. There were no complications from the
procedure and the patient tolerated the procedure well. Please
refer to the operative note for more details on the procedure.
Neuro: During her stay and post-operatively, the patient
received IV morphine as needed along with IV Tylenol, all with
good effect and adequate pain control. When tolerating oral
intake and clears by speech and swallow to take pills orally,
the patient was transitioned to oral pain medications.
CV: The patient was more or less stable from a cardiovascular
standpoint; She was intermittently tachycardic on the floor
prior to surgery and in the [**Hospital Unit Name 153**] after which was successfully
managed with IV Lopressor (please refer to the [**Hospital Unit Name 153**] course
below). Occasional hypertension was successfully treated with
hydralazine. Vital signs were routinely monitored. The patient
was transitioned to home dose of Metoprolol and the patient's
blood pressure was adequately controlled.
Pulmonary: The patient had some pulmonary issues during her
hospital stay. Post operatively, she had some desaturation on RA
(to the 80's) as well as increasing stridor. A CXR was
concerning for possible aspiration vs hospital acquired
pneumonia and she was started on a 10 day course of
levofloxacin. ENT was consulted for the apparent upper
respiratory obstructive stridor and it was found that her left
vocal cord was non functional from a previous injury (possibly
during the CEA) and the right vocal cord was not functioning
well which is what likely contributed to the stridor. The pt was
transferred to the [**Hospital Unit Name 153**] on POD 1 for respiratory precautions in
case of deterioration and need for intubation. Antibiotic
coverage was broadened on POD 3 to include vancomycin and Zosyn
due to a worsening CXR. Racemic epinephrine and Decadron
improved her symptoms. She never needed to be intubated and
eventually was satting well on RA. Please refer to the ICU
course below for more details. She was transferred back to the
floor on POD4 with markedly improved stridor and dyspnea.
Thereafter, her saturations and vitals remained stable despite
occasional subjective dyspnea while supine. ENT was following
throughout and noted improvement in the right vocal cord.
Albuterol and ipratropium nebulizer treatments were given every
6 hours. All vital signs were routinely monitored. The patient
was taken to the [**Hospital **] clinic for LEMG on [**2116-2-4**] which showed left
vocal fold paralysis and right vocal fold paresis. The ENT
attending recommended reassessment of motion this week, if no
changes would recommend observation given that her symptoms are
stable. If symptoms worsen or limit her, will consider L. vocal
fold
Botox injection vs. temporary suture lateralization. The ENT
team was comfortable with diet per speech and swallow and
primary teams.
GI/GU: Due to no improvement and in fact worsening obstructive
picture, the pt ended up having an ex-lap on HD 8. Prior to
that, she was only having minimal flatus and bowel movements
with aggressive suppository treatments. She was kept NPO the
whole time. Post-operatively, the patient was also kept NPO for
a while aggressive awaiting return of bowel function. NGT tube
was removed on POD 2 due to very low output. A PICC line was
placed on POD 3 and TPN was initiated shortly thereafter. She
had bowel sounds throughout this whole time and abdominal
distention was improving. On POD 6 she began passing flatus. Due
to the possible aspiration pneumonia and vocal cord issues, a
speech and swallow study was ordered before advancing her diet.
She failed this study. The next day, a video swallow study was
ordered which she passed and was allowed to start a diet with
many aspiration precautions in place. She was advanced to sips
on POD 7 which was tolerated well with no coughing or gagging.
However, the next day she stopped passing flatus and had some
abdominal distention and was thus made back to an NPO status.
Her distention and obstipation continued to worsen and a KUB was
obtained which showed colonic ileus. The patient was given
bisacodyl suppositories in the mornings. On [**2116-2-5**] the patient
was passing flatus and having bowel movements. Her diet was
advanced from clear liquids to full liquids which were tolerated
well. On [**2117-2-5**] was advanced to ground mechanical soft diet with
ensure supplements. Because of prolonged NPO status the patient
was started on TPN and was followed closely by inpatient
nutrition. The patient was to be discharged on TPN cycled
overnight with intention of tapering TPN as her PO intake
increased. Please see speech and swallow note attached to
discharge paperwork. The patient will need continued speech
therapy during her rehabilitation hospital stay.
Due to urinary retention in the beginning, a Foley was placed.
It was removed on HD 8. It was again replaced on HD 9/POD1 for
close urine output monitoring given respiratory status and
desire to keep from fluid overload. It was removed on POD 5. She
had no urinary issues since and has been making adequate urine
on her own throughout the rest of her stay. Intake and output
were closely monitored.
ID: refer to the antibiotic regimen mentioned above in the
pulmonary section.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. The heparin was then administered in the TPN.
[**Hospital Unit Name 153**] course:
#Stridor: patient was scoped by ENT who noted sluggish vocal
cords and recommended steroids. She received 3 doses of
dexamethasone, racemic epinephrine nebs and ipratropium nebs
with some improvement in symptoms. She was kept on face mask in
the ICU and her O2 sat was stable. On repeat scope, she was
noted to have paralyzed left vocal cord with interval
improvement in right vocal cord. Left vocal cord paralysis
suspected to be chronic issue related to past surgeries. Right
vocal cord was hyperkinetic, likely stunning related to
intubation. Her stridor improved with time.
#Healthcare acquired pneumonia: After patient's stridor
improved, she was noted to have continued O2 requirement and
repeat CXR showed a new RLL consolidation and she was started on
treatment for HCAP with vancomycin and cefepime on [**2117-1-25**].
#Tachycardia: patient intermittently in sinus tachycardia,
thought to be multifactorial including pain and anxiety. PE
considered given recent surgery, however patient hemodynamically
stable. Less likely hypovolemia given adequate UOP. Given her
NPO status, her home metoprolol was converted to IV and
patient's tachycardia responded well to metoprolol. Her pain was
controlled with IV morphine prn and her anxiety was controlled
with Ativan prn.
# Nutrition: As patient was NPO due to stridor and
post-operative from abdominal surgery, a PICC line was placed
and TPN was initiated.
At the time of discharge on [**2116-2-6**] the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
caltrate +D, metoprolol 12.5", mvi, metamucil", oxycodone
prn, immodium prn
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: please refer
to insulin sliding scale order Injection ASDIR (AS DIRECTED):
Please see sliding scale attatched. Please administer only while
on TPN. Patient does not take insulin at baseline.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
3. ipratropium bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 7 days: Do not administer more than 4000mg of
Tylenol in 24 hours.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp<100 or HR<65.
7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain for 7 days: hold for increased sedation or
RR<12.
8. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1) Small bowel obstruction due to adhesions.
2) Stridor r/t vocal cord injury.
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 a small bowel
obstruction. This obstruction was managed conservatively with
nasogastric tube decompression and intravenous hydration.
However, you developed acute abdominal pain which required Dr.
[**Last Name (STitle) **] to preform an exploratory laparotomy, lysis of
adhesionss, and repair serosal defects. These adhesions were
thought to be causing the obstruction. Prior to this procedure
you were noted to have a possible aspiration pneumonia on chest
Xray for which you were treated with a full course of
Levofloxacin intravenously. After the additional surgery, you
developed airway difficulty called Stidor. The ENT doctors
followed [**Name5 (PTitle) **] as well as speech and swallow. You have damage to
your vocal cords which will be followed by ENT as an outpatient
and may require an injection. You should continue to follow a
Regular Mechanical soft diet and follow chin tuck instructions
given to you by the speech and swallow team. You were evaluated
multiple times at the bedside by the speech and swallow team and
you will be reevaluated at the rehab to progress your diet
further after the repeat study of your vocal cords. Your bowel
function has taken an extended period of time to return and you
should continue to eat small frequent meals of ground food.
Because you are not going to be able to meet your caloric needs
right away from food alone, you will be discharged to rehab with
an order for TPN and this will be gradually decreased overtime
and eventually stopped. You will be discharged to rehab today.
The [**Hospital3 2558**] in [**Location (un) **] is very close to the hospital
and if there is any issue, you can be brought back to the
hospital easily. Please continue to participate in speech and
physical therapy.
Please monitor your bowel function closely. You have had a bowel
movement and are passing gas however, you have required
assistance to do this by a suppository. You should not have
prolonged constipation. Some loose stool and passing of small
amounts of dark, old appearing blood are expected however, if
you notice that you are passing bright red blood with bowel
movements 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. 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, prolonged loose stool, or
constipation.
You have a long vertical incision on your abdomen. The staples
have been removed, steri-strips applied, and the incision is
intact. This incision can be left open to air or covered with a
dry sterile gauze dressing if it begins to drain. If the
incision begins to drain, please call Dr. [**Last Name (STitle) **] at the
colorectal surgery office. Please monitor the incision for signs
and symptoms of infection including: increasing redness at the
incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run over
the incision line and pat the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
exercise with Dr. [**Last Name (STitle) **].
You will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
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. Good luck!
Followup Instructions:
Please call the colorectal surgery office at [**Telephone/Fax (1) 160**] to
make a follow-up appointment for 7-14 days after discharge with
Dr. [**Last Name (STitle) **]. Please call this number with any questions or
concenrns.
Please have speech and swallow follow-up and evaluate patient
depending on ENT reevaluation and advize on advancing diet to
avoid aspiration.
Dr. [**Last Name (STitle) 51039**] from ENT [**Telephone/Fax (1) 41**] [**2-1**] wks, His office will also
be in touch with the rehabilitaion hospial.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2117-3-24**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], PA [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2117-3-24**] at 3:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], 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
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2117-3-24**] at 3:00 PM
With: DR. [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2117-2-5**]
|
[
"V10.06",
"733.00",
"V12.71",
"V15.82",
"785.0",
"401.9",
"786.1",
"560.1",
"788.20",
"486",
"560.81"
] |
icd9cm
|
[
[
[
1119,
1139
]
],
[
[
1141,
1152
]
],
[
[
1200,
1219
]
],
[
[
1488,
1515
]
],
[
[
12097,
12107
],
[
17857,
17867
]
],
[
[
12310,
12321
]
],
[
[
12682,
12688
],
[
17025,
17031
]
],
[
[
15621,
15625
]
],
[
[
16331,
16347
]
],
[
[
17606,
17634
]
],
[
[
20079,
20119
],
[
20371,
20393
]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[
14860,
14862
]
]
] |
19985, 20055
|
11331, 18647
|
326, 425
|
20179, 20179
|
2274, 11308
|
24725, 26274
|
1549, 1624
|
18774, 19962
|
20076, 20158
|
18673, 18751
|
20330, 24702
|
1639, 1639
|
1653, 2255
|
261, 288
|
453, 1097
|
20194, 20306
|
1119, 1442
|
1458, 1533
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,636
| 128,511
|
35990
|
Discharge summary
|
Report
|
Admission Date: [**2157-12-1**] Discharge Date: [**2157-12-4**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Nsaids
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
This is a 86 year-old female with a history of mild CHF,
diverticulitis who was transfered from OSH with
cholangitis/choledocolithiasis for ERCP. The patient reports
that she has been having watery diarrhea, gas and mild abd pain
for several weeks - stopped taking lasix [**1-2**] diarrhea. She
recently saw her PCP who had placed her on two antibiotics. Her
diarrhea began to resolve. However, she then underwent a abd CT
scan with barium on [**2157-11-21**] and then began having diarrhea
since then. She saw her PCP again on [**2157-11-29**] and was doing
well. On her return home, she began to feel very weak. Her
daughter, a nurse, noted that she was unstable, confused and had
her BIBA to an OSH ED. There she had a repeat CT scan and RUQ
showing common bile duct stones. In addition, she had a fever to
105, abdominal pain and vomiting x 2 and was given Unasyn and
Levofloxacin. She was then transfered to [**Hospital1 18**] ED for ERCP.
In the ED, the patient was febrile to 103. RUQ U/S confirmed
choledocolithiasis. GI contact[**Name (NI) **] - ERCP when IR less than 1.5.
She was given tylenol and one liter IVF. On exam in the ED, she
was well appearing, mildly diffusely tender in her abd,
initially tachycardic to 155. She also had one large watery foul
smelling stool. Vitals: temp 100.1 Hr 95, Bp 110/50 19 97% 2L.
Past Medical History:
Diverticulitis- s/p colectomy and reanastamosis may years ago
? Mild CHF
Hypothyroidism
Hernia
Social History:
widowed, lives with her daughter, [**Name (NI) 15310**] in [**Name (NI) 5669**], no
tob/Etoh/drugs
Family History:
NC
Physical Exam:
On admission:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, 3/6 systolic ejection murmur, normal S1 S2, radial
pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mildly tender in RLQ w/o guarding or rebound, ND,
+BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs:
[**2157-12-1**] 02:38AM WBC-16.6* RBC-3.93* HGB-11.4* HCT-33.3*
MCV-85 MCH-29.1 MCHC-34.3 RDW-12.7
[**2157-12-1**] 02:38AM NEUTS-92.3* LYMPHS-3.2* MONOS-4.1 EOS-0.3
BASOS-0.2
[**2157-12-1**] 02:38AM PLT COUNT-457*
[**2157-12-1**] 02:38AM PT-18.1* PTT-28.2 INR(PT)-1.7*
[**2157-12-1**] 02:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2157-12-1**] 02:30AM URINE RBC-[**10-20**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0
[**2157-12-1**] 02:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2157-12-1**] 02:38AM DIGOXIN-1.0
[**2157-12-1**] 02:38AM ALBUMIN-3.1*
[**2157-12-1**] 02:38AM ALT(SGPT)-13 AST(SGOT)-42* ALK PHOS-67 TOT
BILI-0.4
[**2157-12-1**] 02:38AM GLUCOSE-133* UREA N-11 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
[**2157-12-1**] 02:59AM LACTATE-1.7
Ultrasound: The liver shows normal echogenicity. No focal
hepatic
lesion is identified. The intra- and extra-hepatic bile ducts
are dilated.
The common duct at the head of the pancreas measures 1 cm.
Multiple shadowing echogenic foci are identified within the
common bile duct consistent with stones. The gallbladder
contains multiple stones. There is no evidence of cholecystitis.
The visualized pancreas is normal. The right kidney measures
10.4 cm and shows mild dilatation of the collecting system and
ureter
ERCP:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree: Three stones ranging in size from 3mm to 6mm that
were causing partial obstruction were seen at the lower third of
the common bile duct and middle third of the common bile duct.
Otherwise the bile duct was normal. No pus was noted.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire. 3
stones were extracted successfully using a balloon. Occlusion
cholangiogram did not show any filling defects.
Impression: Stones in the bile duct, otherwise normal biliary
tree. No pus was seen. A biliary sphincterotomy was performed.
Stones were extracted using a balloon. (sphincterotomy, stone
extraction)
Recommendations: Absence of pus and normal LFTs do not eliminate
cholangitis as the cause of patients high fevers, but make it
less likely. Consider evaluation for colits given diarrhea and
thickening in the sigmoid colon on CT scan.
[**2157-12-3**] CT abd/pelvis with contrast:
STUDY: CT of the abdomen and pelvis.
HISTORY: 86-year-old female with recurrent diarrhea, fevers and
question of
colon mass seen at outside hospital.
COMPARISONS: None.
TECHNIQUE: Following the administration of intravenous contrast,
MDCT axial
images were acquired from the lung bases to the pubic symphysis.
Coronal and
sagittal reformatted images were then obtained.
CT OF THE ABDOMEN WITH IV CONTRAST: Tiny bilateral pleural
effusions with
associated atelectasis are present at the lung bases. Left-sided
pneumobilia
which may relate to the patient's recent ERCP two days prior is
evident.
Minimal intrahepatic biliary dilatation is present. The liver is
otherwise
unremarkable without focal lesion. Layering gallstones are
evident. However,
the gallbladder is not distended and no wall edema or
pericholecystic fluid is
seen. The pancreatic duct is prominent at the level of the
pancreatic head
measuring 4 mm in diameter (2:26). The pancreatic duct at the
level of the
body and tail is normal in caliber. Mild stranding at the level
of the amuplla
is compatibel with recent ERCP. The spleen and adrenal glands
are
unremarkable. Several low- attenuation foci within the left
kidney are too
small to characterize but likely represent simple cysts. The
stomach and small
bowel are unremarkable. There is no free air within the abdomen.
The abdominal
portion of the colon is unremarkable.
CT OF THE PELVIS WITH IV CONTRAST: A few diverticula of the
sigmoid colon are
present. The wall of the sigmoid colon along the majority of its
entire
course is irregular and oral contrast material does not pass
distal to the
lower aspect. Several foci of probable extraluminal air are
noted along the
antimesenteric border (2:58). These may represent outpouchings
of the wall
and diverticula or contained perforation. A long segment of
sigmoid colonic
wall irregularity, extending to the rectosigmoid junction, spans
a distance of
approximately 7 mm and mild surrounding inflammatory change is
also evident.
The bladder is unremarkable, although it contains a moderate
amount of air. No
Foley catheter is seen. Intrapelvic loops of small bowel are
unremarkable. No
adnexal masses. No pathologically enlarged inguinal or pelvic
lymph nodes are
present.
OSSEOUS STRUCTURES: Degenerative change at the L2-3 level with
associated
endplate sclerosis. No suspicious lytic or blastic lesions.
IMPRESSION:
1. Long segment of lower sigmoid colonic wall irregularity and
possible
associated contained foci of extraluminal air. A few sigmoid
colonic
diverticula are noted. The differential diagnosis includes long
segment
diverticulitis with contained perforation, but given the
irregular appearance of the wall of the lower sigmoid colon in
particular, carcinoma must also be considered and direct
visualization via endoscopy is advised.
2. Pneumobilia likely related to recent ERCP. Minimal
intrahepatic biliary
dilatation.
3. Mild pancreatic ductal dilatation at the level of the
pancreatic head may be related to recent ERCP procedure.
4. Cholelithiasis without evidence of acute cholecystitis.
[**2157-12-1**] ERCP:
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree: Three stones ranging in size from 3mm to 6mm that
were causing partial obstruction were seen at the lower third of
the common bile duct and middle third of the common bile duct.
Otherwise the bile duct was normal. No pus was noted.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
3 stones were extracted successfully using a balloon. Occlusion
cholangiogram did not show any filling defects.
Impression: Stones in the bile duct, otherwise normal biliary
tree. No pus was seen.
A biliary sphincterotomy was performed.
Stones were extracted using a balloon.
(sphincterotomy, stone extraction)
Recommendations: Return to ICU.
Absence of pus and normal LFTs do not eliminate cholangitis as
the cause of patients high fevers, but make it less likely.
Consider evaluation for colits given diarrhea and thickening in
the sigmoid colon on CT scan.
Brief Hospital Course:
MICU COURSE:
86year-old female with a history of mild CHF, diverticulitis who
was transfered from OSH with cholangitis/choledocolithiasis for
ERCP. At the OSH she was febrile to 105 and CT scan there
showed biliary dilation. She was started on cipro/flagyl on
admission to [**Hospital1 18**]. Here, her RUQ ultrasound also showed biliary
dilation. She underwent ERCP on [**2157-12-1**] which showed several
large steons which were removed by no frank pus or other
evidence of cholangitis. Of note, she also reported having 4
weeks of intermittent watery diarrhea which is improving. She is
currently free of abdominal pain at rest, has minimal pain with
palpation.
1. Leukocytosis, fever, Diverticulitis: with LLQ pain and
copious/watery diarrhea most concerning for
colitis/diverticulitis. OSH CT consistent with colitis, but
also demonstrates choledocholithiasis. Underwent ERCP (see
below) and large stone removed, but no pus. LFTs wnl, not
consistent with biliary obstruction. Initially treated with
levofloxacin and flagyl for presumed LLQ source. CT abd/pelvis
with contrast performed at [**Hospital1 18**] revealed a long segment of
lower sigmoid colonic wall irregularity and possible associated
contained foci of extraluminal air and a few sigmoid colonic
diverticula are noted. The differential diagnosis includes long
segment diverticulitis with contained perforation, but given the
irregular appearance of the wall of the lower sigmoid colon in
particular, carcinoma must also be considered and direct
visualization via endoscopy is advised.
The surgical service was consulted regarding the CT findings and
the patient's recurrent diverticulitis and the plan was made for
outpatient surgical evaluation. The patient was discharged on a
prolonged course of cipro/flagyl to continue for another 14 days
after discharge (for a total of almost 21 days) given the CT
findings of diverticulitis with contained perforation.
-Patient to f/u closely with surgery and PCP as outpatient.
-Patient needs outaptient colonoscopy when diverticulitis flare
has resolved.
2. Choledocholithiasis: ERCP on [**2157-12-1**]--sphincterotomy performed
and 3 stones removed. With abscence of pus or LFT
abnormalities, ascending cholangitis thought to be less likely
source of high fever and leukocytosis. General surgery consult
for consideration of cholecystectomy was placed. Given the
patient's ventral hernia and prior abdominal surgery, the plan
was for an outpatient elective open cholecystectomy.
-Outpatient open cholecystectomy.
3. Diarrhea: large volume and watery for weeks prior to
admission. Had improvement with an initial course of
antibiotics. Stool studies pending. CT also demonstrates
fecal-loaded colon--but given ongoing diarrhea, bowel regimen
not started. Treated with levofloxacin and flagyl.
4. Elevated INR: 1.8 on admission, 1.6 day after admission.
Patient not on anticoagulation. Likely related to protein loss
with the diarrhea. Also has low albumin. FFP given prior to
ERCP.
5. Code Status: Full code.
Medications on Admission:
Digoxin 0.25mg every other day
Digoxin 0.125mg every other day
protonix
lasix - stopped recently for diarrhea
Alendronate
recently started on Levofloxacin and Flagyl on [**2157-11-30**]
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days.
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home
Discharge Diagnosis:
Choledicholithiasis
Diverticulitis, Acute
Diarrhea
Supratherapeutic INR
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to the ED if you are having high fevers, vomiting, severe
abdominal pain, unable to tolerate food, rigors, confusion, low
blood pressure.
Followup Instructions:
Please call the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to arrange an
appointment to discuss open cholecystectomy. She can be reached
at [**Telephone/Fax (1) 8792**].
Patient's daughter to arrange f/u with patient's PCP:
[**Name10 (NameIs) **],[**First Name3 (LF) 251**] D [**Telephone/Fax (1) 79695**] for appointment in 2 weeks.
The patient needs a colonoscopy in [**5-8**] weeks.
|
[
"428.0",
"244.9",
"562.11",
"558.9",
"574.50",
"553.29",
"790.92"
] |
icd9cm
|
[
[
[
341,
343
]
],
[
[
1719,
1732
]
],
[
[
10478,
10491
]
],
[
[
10556,
10562
]
],
[
[
11865,
11883
],
[
13781,
13799
]
],
[
[
12183,
12196
]
],
[
[
12609,
12620
],
[
13832,
13851
]
]
] |
[
"51.88",
"99.07"
] |
icd9pcs
|
[
[
[
4943,
4964
]
],
[
[
12771,
12773
]
]
] |
13754, 13760
|
9785, 12826
|
255, 261
|
13875, 13895
|
2561, 2561
|
14088, 14516
|
1874, 1878
|
13062, 13731
|
13781, 13854
|
12852, 13039
|
13919, 14065
|
1893, 1893
|
209, 217
|
289, 1624
|
2578, 9762
|
1908, 2542
|
1646, 1742
|
1758, 1858
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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[] |
icd9pcs
|
[
[
[]
]
] |
18933, 18999
|
8748, 17216
|
290, 313
|
19101, 19349
|
3054, 3054
|
21971, 22911
|
2242, 2260
|
17548, 18910
|
19020, 19080
|
17242, 17525
|
19373, 21948
|
2275, 3035
|
3830, 8725
|
237, 252
|
341, 1951
|
3068, 3816
|
1973, 2061
|
2077, 2226
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
99,231
| 156,779
|
46683
|
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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92,252
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42419
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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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[] |
icd9pcs
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[
[
[]
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5741, 5838
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2356, 3964
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309, 418
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5946, 5953
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8107, 8187
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6110, 6303
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260, 271
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6339, 6806
|
6818, 7918
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446, 569
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591, 748
|
764, 780
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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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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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[
12297,
12321
]
],
[
[
12569,
12571
]
],
[
[
12680,
12683
],
[
16610,
16628
]
],
[
[
13126,
13128
]
],
[
[
13163,
13166
]
],
[
[
13168,
13176
]
],
[
[
13178,
13191
]
],
[
[
13237,
13246
]
],
[
[
13302,
13305
]
],
[
[
16575,
16586
]
],
[
[
16589,
16607
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16368, 16417
|
8964, 13364
|
404, 518
|
16653, 16653
|
4632, 4632
|
18099, 19080
|
3345, 3370
|
14641, 16345
|
16438, 16632
|
13766, 14618
|
16836, 18076
|
5660, 8941
|
3385, 3980
|
3996, 4613
|
13385, 13740
|
353, 366
|
546, 2527
|
4648, 5644
|
16668, 16812
|
2549, 3195
|
3211, 3329
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
99,255
| 155,692
|
31115
|
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**]
|
[
"557.1",
"410.71",
"250.40",
"272.4",
"585.6",
"496",
"404.91",
"428.32",
"V43.65"
] |
icd9cm
|
[
[
[
227,
262
]
],
[
[
264,
269
]
],
[
[
914,
918
]
],
[
[
920,
933
]
],
[
[
936,
938
]
],
[
[
941,
944
]
],
[
[
2650,
2652
]
],
[
[
2761,
2775
]
],
[
[
2793,
2818
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14580, 14631
|
9044, 12268
|
310, 850
|
14990, 15019
|
3929, 6985
|
15942, 16614
|
3167, 3249
|
12864, 14557
|
14652, 14969
|
12294, 12841
|
8146, 9021
|
15043, 15919
|
3264, 3910
|
227, 272
|
878, 2624
|
2646, 2856
|
2872, 3151
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
96,377
| 108,086
|
38499
|
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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10012, 10112
|
5396, 8101
|
334, 371
|
10225, 10225
|
3737, 4462
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11295, 11439
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3076, 3166
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8385, 9989
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10133, 10204
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8127, 8361
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10450, 11272
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3181, 3718
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4476, 5373
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275, 296
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399, 1612
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10240, 10426
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2729, 2791
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2807, 3060
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
94,546
| 148,583
|
47227
|
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**]
|
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icd9cm
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[
[
427,
437
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],
[
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1346,
1348
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[] |
icd9pcs
|
[
[
[]
]
] |
7432, 7529
|
5386, 7130
|
311, 317
|
7594, 7594
|
3786, 5363
|
8763, 9381
|
1556, 1587
|
7221, 7409
|
7550, 7573
|
7156, 7198
|
7932, 8740
|
2462, 3528
|
1602, 2071
|
3544, 3767
|
251, 273
|
345, 1324
|
7609, 7908
|
1346, 1394
|
1410, 1540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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"311",
"276.2",
"345.90",
"117.9",
"590.10"
] |
icd9cm
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[
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14977
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[
[
14983,
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]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14886, 14951
|
11110, 13940
|
368, 399
|
15129, 15135
|
2663, 7401
|
15793, 16050
|
2212, 2230
|
14188, 14863
|
14972, 15108
|
13966, 14165
|
15159, 15770
|
2245, 2644
|
7434, 7574
|
7609, 11087
|
260, 330
|
427, 1529
|
1551, 1918
|
1934, 2196
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
98,174
| 176,070
|
42708
|
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**]
|
[
"401.9",
"414.01",
"V15.82",
"157.0"
] |
icd9cm
|
[
[
[
1786,
1788
]
],
[
[
1845,
1847
]
],
[
[
1907,
1956
]
],
[
[
8482,
8499
]
]
] |
[
"52.22",
"45.31",
"99.04"
] |
icd9pcs
|
[
[
[
324,
365
]
],
[
[
3870,
3892
]
],
[
[
6566,
6580
]
]
] |
8406, 8444
|
3708, 7229
|
304, 455
|
8524, 8524
|
2659, 3685
|
10399, 10848
|
2058, 2255
|
7408, 8383
|
8465, 8503
|
7255, 7385
|
8675, 9253
|
9268, 10376
|
2270, 2270
|
2284, 2640
|
249, 266
|
483, 1759
|
8539, 8651
|
1781, 1881
|
1897, 2042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
"427.32",
"427.31",
"V45.01",
"402.91",
"428.0",
"290.10",
"428.22",
"562.12",
"V12.54"
] |
icd9cm
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397
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[
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[] |
icd9pcs
|
[
[
[]
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] |
7624, 7702
|
4203, 6769
|
224, 240
|
7862, 7985
|
2257, 2262
|
9039, 9427
|
1576, 1594
|
7165, 7601
|
7723, 7841
|
6795, 7142
|
8009, 9016
|
1609, 2238
|
179, 186
|
3440, 4180
|
268, 1124
|
2276, 3421
|
1146, 1383
|
1399, 1544
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
|
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[
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[
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[
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11055
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[
[
11057,
11069
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[
[
13293,
13315
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]
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[
"36.06"
] |
icd9pcs
|
[
[
[
367,
411
]
]
] |
13221, 13272
|
7501, 11286
|
338, 415
|
13400, 13400
|
3640, 3640
|
15363, 15991
|
2630, 2747
|
11861, 13198
|
13293, 13379
|
11577, 11838
|
7257, 7478
|
13551, 15340
|
2286, 2396
|
2762, 3621
|
2095, 2174
|
11307, 11551
|
267, 300
|
443, 1985
|
3657, 7240
|
13415, 13527
|
2205, 2263
|
2007, 2075
|
2428, 2598
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
"427.31",
"244.9",
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"443.9",
"427.5",
"458.9",
"428.0",
"853.05",
"276.2",
"276.3",
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icd9cm
|
[
[
[
359,
362
]
],
[
[
382,
395
]
],
[
[
1934,
1945
]
],
[
[
1947,
1951
],
[
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7352
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],
[
[
1971,
1973
]
],
[
[
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4501
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],
[
[
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[
[
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[
[
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6758
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[
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6789,
6799
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[
[
7527,
7538
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] |
[] |
icd9pcs
|
[
[
[]
]
] |
8235, 8244
|
3750, 7958
|
261, 295
|
8303, 8320
|
2590, 3727
|
8384, 8430
|
2140, 2158
|
8195, 8212
|
8265, 8282
|
7984, 8172
|
8344, 8361
|
2173, 2571
|
211, 223
|
323, 1892
|
1914, 2047
|
2063, 2124
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,886
| 110,191
|
35347
|
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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93,336
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43658
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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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[
"33.21",
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icd9pcs
|
[
[
[
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341
]
],
[
[
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10939
]
]
] |
12931, 13030
|
7880, 11559
|
330, 344
|
13197, 13197
|
5637, 5637
|
14774, 15467
|
4741, 4859
|
12016, 12908
|
13051, 13176
|
11585, 11993
|
13457, 14367
|
6775, 7857
|
4874, 5618
|
14396, 14751
|
262, 292
|
372, 3287
|
5653, 6759
|
13212, 13433
|
3309, 4331
|
4347, 4725
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
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"303.93",
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"349.82",
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"401.9",
"272.4",
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] |
icd9cm
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[
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icd9pcs
|
[
[
[
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2177
]
]
] |
8915, 8921
|
5649, 7849
|
325, 353
|
9463, 9463
|
3737, 5626
|
10634, 11299
|
3055, 3166
|
8521, 8892
|
8942, 9442
|
8013, 8498
|
9614, 10611
|
3181, 3718
|
2214, 2265
|
622, 707
|
735, 2194
|
7866, 7987
|
9478, 9590
|
2287, 2534
|
2550, 3038
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
97,683
| 119,454
|
720680
|
Physician
|
Physician Attending Progress Note
|
TITLE:
Chief Complaint: resp failure, CAP, afib RVR
I saw and examined the patient, and was physically present with the ICU
Resident for key portions of the services provided. I agree with his /
her note above, including assessment and plan.
HPI:
24 Hour Events:
-progress weaning vent
-diuresed
History obtained from [**Hospital 19**] Medical records
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Unknown;
Terazosin
Unknown;
Last dose of Antibiotics:
Ceftriaxone - [**2105-2-21**] 08:15 AM
Azithromycin - [**2105-2-21**] 09:00 AM
Infusions:
Midazolam (Versed) - 0.5 mg/hour
Fentanyl (Concentrate) - 25 mcg/hour
Furosemide (Lasix) - 5 mg/hour
Other ICU medications:
Fentanyl - [**2105-2-20**] 12:30 PM
Midazolam (Versed) - [**2105-2-20**] 12:30 PM
Famotidine (Pepcid) - [**2105-2-21**] 08:00 AM
Other medications:
Changes to medical and family history:
PMH, SH, FH and ROS are unchanged from Admission except where noted
above and below
Review of systems is unchanged from admission except as noted below
Review of systems:
Flowsheet Data as of [**2105-2-21**] 11:28 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**07**] AM
Tmax: 37.8
C (100.1
Tcurrent: 36.7
C (98
HR: 94 (76 - 103) bpm
BP: 116/64(85) {82/48(61) - 135/69(95)} mmHg
RR: 17 (15 - 28) insp/min
SpO2: 96%
Heart rhythm: AF (Atrial Fibrillation)
Wgt (current): 58 kg (admission): 55.9 kg
Height: 67 Inch
Total In:
2,606 mL
494 mL
PO:
TF:
IVF:
2,506 mL
434 mL
Blood products:
Total out:
1,555 mL
1,060 mL
Urine:
1,555 mL
1,060 mL
NG:
Stool:
Drains:
Balance:
1,051 mL
-566 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: PSV/SBT
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 520 (471 - 520) mL
PS : 5 cmH2O
RR (Set): 16
RR (Spontaneous): 19
PEEP: 0 cmH2O
FiO2: 50%
RSBI: 53
PIP: 6 cmH2O
Plateau: 17 cmH2O
SpO2: 96%
ABG: 7.44/53/143/31/10
Ve: 9.6 L/min
PaO2 / FiO2: 286
Physical Examination
General Appearance: Thin
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: (S1: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :
anteriorly)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Trace, Left lower extremity
edema: Trace
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
9.7 g/dL
309 K/uL
104 mg/dL
1.1 mg/dL
31 mEq/L
3.7 mEq/L
42 mg/dL
106 mEq/L
146 mEq/L
29.1 %
13.3 K/uL
[image002.jpg]
[**2105-2-19**] 07:34 PM
[**2105-2-19**] 09:09 PM
[**2105-2-19**] 11:51 PM
[**2105-2-20**] 03:52 AM
[**2105-2-20**] 04:35 AM
[**2105-2-20**] 05:27 PM
[**2105-2-20**] 05:47 PM
[**2105-2-21**] 03:35 AM
[**2105-2-21**] 03:50 AM
[**2105-2-21**] 08:49 AM
WBC
25.3
15.8
13.3
Hct
29.7
28.6
29.1
Plt
[**Telephone/Fax (3) 11219**]
Cr
1.0
1.2
1.1
1.1
TropT
0.54
0.54
0.45
TCO2
32
32
34
35
35
37
Glucose
125
164
124
104
Other labs: PT / PTT / INR:15.9/29.6/1.4, CK / CKMB /
Troponin-T:377/5/0.45, Differential-Neuts:80.1 %, Band:0.0 %,
Lymph:15.0 %, Mono:3.1 %, Eos:1.3 %, Lactic Acid:1.8 mmol/L, Ca++:8.7
mg/dL, Mg++:1.8 mg/dL, PO4:2.8 mg/dL
Assessment and Plan
88 yo man with hypoxemic respiratory failure due likely combination of
pneumonia and diastolic CHF. Also with afib/RVR
1. Respiratory Failure
-Cont CTX/azithro empirically pending cx results
-Cont diuresis
-SBT - assess for possibility of extubation
-weaning sedation - following commands
2. Afib/RVR
-Rate well controlled
-able to wean dilt gtt
-cont amiodarone
3. Hypertension
4. Hypernatremia resolved with fH20
5. Access - place PICC
6. Mental status
-improving with sedation wean
7. Met alkalosis
-? Contraction from diuresis
-has compensatory mild resp acidosis
Remainder of issues per ICU team.
ICU Care
Nutrition:
Glycemic Control:
Lines:
22 Gauge - [**2105-2-19**] 06:36 PM
Arterial Line - [**2105-2-19**] 11:28 PM
20 Gauge - [**2105-2-21**] 09:55 AM
Prophylaxis:
DVT:
Stress ulcer:
VAP:
Comments:
Communication: Comments:
Code status: Full code
Disposition :
Total time spent: 35 minutes
Patient is critically ill
|
[
"402.91",
"276.3"
] |
icd9cm
|
[
[
[
5245,
5256
]
],
[
[
5386,
5394
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
949, 1110
|
1132, 4587
|
27, 930
|
4599, 5879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
95,673
| 190,860
|
41650
|
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**].
|
[
"401.9",
"327.23",
"311",
"782.4",
"285.9",
"V15.82",
"575.8",
"571.8",
"577.0",
"303.90",
"571.1"
] |
icd9cm
|
[
[
[
413,
424
]
],
[
[
427,
429
]
],
[
[
436,
445
]
],
[
[
579,
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]
],
[
[
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],
[
[
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],
[
[
10306,
10323
]
],
[
[
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]
],
[
[
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12090
],
[
15384,
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],
[
16059,
16076
]
],
[
[
15262,
15270
]
],
[
[
16078,
16086
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
22975, 22981
|
15028, 21711
|
325, 331
|
23160, 23160
|
5059, 5059
|
25594, 26793
|
3190, 3394
|
21898, 22952
|
23002, 23066
|
21737, 21875
|
23311, 25248
|
3434, 4031
|
23087, 23139
|
4661, 5040
|
25277, 25571
|
2227, 2804
|
265, 287
|
359, 2208
|
5075, 6563
|
6585, 15005
|
23175, 23287
|
2826, 2903
|
2935, 3158
|
4056, 4645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
97,488
| 152,542
|
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**]
|
[
"566",
"402.91",
"428.0",
"250.00",
"530.81",
"305.1",
"213.6",
"427.31"
] |
icd9cm
|
[
[
[
261,
278
]
],
[
[
1019,
1022
]
],
[
[
1024,
1026
]
],
[
[
1029,
1030
]
],
[
[
1033,
1036
]
],
[
[
1056,
1082
]
],
[
[
1868,
1879
]
],
[
[
3095,
3107
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5218, 5277
|
2025, 3357
|
319, 364
|
5380, 5428
|
1608, 2002
|
6062, 6565
|
1142, 1195
|
3620, 5195
|
5298, 5359
|
3383, 3597
|
5452, 6039
|
1210, 1210
|
1224, 1589
|
261, 281
|
392, 997
|
1019, 1040
|
1056, 1126
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
94,636
| 149,941
|
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**]
|
[
"401.9",
"272.4",
"282.40",
"274.9",
"305.1",
"532.90",
"211.3",
"557.0",
"444.21",
"535.01",
"289.84",
"403.90",
"562.10"
] |
icd9cm
|
[
[
[
1803,
1814
]
],
[
[
1817,
1829
]
],
[
[
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[
[
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[
[
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],
[
[
4421,
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],
[
[
4973,
4977
]
],
[
[
5316,
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]
],
[
[
13044,
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]
],
[
[
13086,
13094
]
],
[
[
13113,
13128
]
],
[
[
13187,
13189
]
],
[
[
14215,
14228
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12965, 12971
|
5235, 11303
|
290, 807
|
13229, 13229
|
2965, 3638
|
17084, 17349
|
2200, 2218
|
11595, 12942
|
12992, 13208
|
11329, 11572
|
13380, 16491
|
16517, 17061
|
2258, 2643
|
2659, 2946
|
17360, 18216
|
236, 252
|
835, 1776
|
3660, 5212
|
13244, 13356
|
1798, 2071
|
2087, 2184
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
99,164
| 120,468
|
46775
|
Discharge summary
|
Report
|
Admission Date: [**2124-10-24**] Discharge Date: [**2124-10-31**]
Service: MEDICINE
Allergies:
Tetanus Antitoxin / Aspirin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
GI bleed and decreased po intake
Major Surgical or Invasive Procedure:
Percutaneous G- tube placement
History of Present Illness:
85 yo m w/ hx AD, diverticulosis, recently diagnosed colon CA,
status post hemicolectomy on [**2124-10-9**] presents with dark stools.
HCTs have trended down from 30 at NH --> 26--> 23.
In the ED, VS: T 99.2 HR 67 BP 146/69 RR 18 99% RA. NG lavage
was negative. Patient was transferred to [**Hospital Unit Name 153**] for further
monitoring with plan for EGD in AM.
Past Medical History:
1) Colon ca s/p r colectomy [**2124-10-9**] - mucinous adenocarcinoma
with 1 out of three lymph nodes positive
2) diverticulosis
3) right knee and shoulder surgery
4) benign prostatic hypertrophy s/p TURP with history of ARF
attributed to post-obstructive uropathy, requiring transient
indwelling Foley
5) nephrolithiasis
6) Alzheimer's
7) Chronic anemia
8) Depression
Social History:
Lives in [**Location 2299**] Nursing House. No smoking. Minimal alcohol use.
Formerly in the Navy, worked as a tailgunner during WW2.
Family History:
2 brothers died of lung cancer, one brother died of colon cancer
Physical Exam:
VS: Afebrile, HR 70, BP 140/76, 98%RA
GEN: Elderly man, pleasant, in NAD
HEENT: EOMI, PERRL
NECK: Supple, JVP at clavicle
CV: RRR, S1S2, no m/r/g
ABD: Soft/ NT/ ND, +BS
EXT: warm, no cyanosis or edema
SKIN: no rashes
NEURO: AAO x 2: [**Hospital **] hospital ([**Hospital1 756**]); CN ii-Xii intact
Pertinent Results:
[**2124-10-31**] 10:30AM BLOOD WBC-9.0 RBC-4.12* Hgb-10.6* Hct-33.4*
MCV-81* MCH-25.8* MCHC-31.7 RDW-17.1* Plt Ct-474*
[**2124-10-31**] 10:30AM BLOOD Glucose-115* UreaN-6 Creat-0.8 Na-144
K-4.0 Cl-112* HCO3-24 AnGap-12
[**2124-10-29**] 12:15AM BLOOD ALT-8 AST-19 AlkPhos-73 Amylase-81
TotBili-0.5
[**2124-10-31**] 10:30AM BLOOD TSH-1.5
<b> CT ABDOMEN<b/>
INDICATION: Recent percutaneous gastrostomy placement. Evaluate
placement.
<br>
COMPARISON: CT torso of [**2124-9-13**] and abdomen radiograph of
[**2124-10-29**].
<br>
TECHNIQUE: Contiguous axial images from the mid chest through
the abdomen
were obtained without IV contrast. Coronal and sagittal
reformatted images
were generated.
<br>
PRELIMINARY REPORT: Gastrostomy tube terminates in the
esophagus,
repositioning is recommended. Filling defect in the mid
esophagus. Bilateral pleural effusions, right greater than left.
Small right lung base consolidation. Large bilateral renal
cysts. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
<br>
CT ABDOMEN WITHOUT IV CONTRAST: There is a moderate right
pleural effusion
and small left pleural effusion, simple in attenuation. There is
adjacent
atelectasis and/or consolidation within a portion of the
posterior right lung base. There is a small pericardial
effusion. All effusions are increased since [**2124-8-25**]. There
are coarse coronary artery calcifications, particularly
involving the LAD.
<br>
In the epigastric region, a percutaneous gastrostomy has been
placed into the gastric antrum. The tube courses cephalad
through the body of the stomach, through the gastroesophageal
junction, and with the tip into the lowermost esophagus. Oral
contrast has been administered via the gastrostomy tube, which
opacifies the lower esophagus. Within the lumen of the uppermost
imaged esophagus (at the level of the carina), there is a round
soft tissue attenuation structure with air, which may represent
retained food. Small amounts of oral contrast are seen within
the gastric lumen.
<br>
The non-contrast appearance of the liver is unremarkable except
for the
occasional calcified granuloma. Minimal high-density material is
seen
dependently within the gallbladder, possibly representing
layering stones.
Multiple calcified granulomas are seen in the spleen. A splenule
is noted.
The non-contrast appearance of the pancreas is unremarkable. The
adrenal
glands are minimally bulky, without a focal mass lesion,
unchanged. There is no hydronephrosis of the kidneys. Bilateral
renal cysts are noted, which are unchanged in appearance. The
previously described hyperenhancing focus in the lower pole of
the right kidney is not apparent on non-contrast imaging.
<br>
The abdominal aorta is normal in caliber, with moderately-severe
atherosclerotic calcification, particularly involving the origin
of the SMA.
<br>
The patient is post-right hemicolectomy. Oral contrast opacifies
the remaining portion of the colon, or several diverticula are
seen. Visualized small bowel loops also contains some oral
contrast, but are otherwise unremarkable. There is no free air
in the abdomen. There is no free fluid. Small retroperitoneal
nodes are seen adjacent to the IVC measuring up to about 7 cm
size (2:36). These are not markedly changed from the prior
examination.
<br>
No concerning osseous lesions are seen.
<br>
IMPRESSION:
1. The gastrostomy tube has been placed percutaneously into the
gastric
antrum, but the tube is oriented cephalad, with the tip in the
lowermost
esophagus. Oral contrast is seen within the lower half of the
esophagus, and a rounded structure within the lumen of the mid
esophagus at the level of the carina likely represents retained
food.
2. Increased size of bilateral pleural effusions, right greater
than left,
and there is a small pericardial effusion.
3. Diffuse atherosclerotic disease as described.
Findings reviewed with the GI fellow on [**2124-10-30**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4346**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2124-10-31**] 2:44 AM
<br>
<br>
<b>EGD from admission:<b/>
Findings: Esophagus: Normal esophagus.
Stomach: Mucosa: Atrophy of the mucosa was noted in the antrum.
Duodenum: Protruding Lesions There was a question of a small
sub-mucosal mass of benign appearance at the duodenal bulb.
Excavated Lesions A few ulcers were found in the duodenal bulb
as well as duodenitis. These were considered low risk for
bleeding. Other procedures: As ulcers and duodenitis were
considered low risk, decision was made to proceed with PEG
placement. A 20FR percutaneous gastrostomy tube (PEG) was placed
successfully using standard techniques at the stomach body.
<br>
Impression: Atrophy in the antrum
Low risk ulcers and duodenitis in the duodenal bulb
Successful PEG placement (PEG)
Question of small submucosal mass in duodenal bulb.
Otherwise normal EGD to third part of the duodenum
Recommendations: High dose protonix 40 mg twice a day
Please check H. Pylori serology and treat if positive
No further intervention for now for question of submucosal mass
unless symptomatic or further bleeding.
[**Month (only) 116**] use tube for essential meds if needed tonight. Can start
tube feeding tomorrow.
Duodenitis and ulcer may have accounted for slow hct decline.
<br>
Brief Hospital Course:
Mr. [**Known lastname **] is a 85 year old man with a history of Alzheimer's,
diverticulosis, recently diagnosed colon CA, status post
hemicolectomy on [**2124-10-9**] presented with dark stools and acute
blood loss anemia and malnutrition from The [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
In the [**Last Name (LF) **], [**First Name3 (LF) **] NG lavage was negative by report. He was
initially admitted to the Medical ICU, and given 2 Units of
PRBCs. He was hemodynamically stable and underwent EGD,
revealing: "Atrophy in the antrum, Low risk ulcers and
duodenitis in the duodenal bulb, Successful PEG placement (PEG),
Question of small submucosal mass in duodenal bulb, Otherwise
normal EGD to third part of the duodenum." It was felt these
ulcers were likely accounting for the blood loss and occult
blood positive stools. H. pylori Ab was positive and he was
started on antimicrobial therapy as well as twice daily PPI
treatment.
<br>
Mr. [**Known lastname **] was called out of the unit to the general medical
floor. Once on the General Medical Floor, he had trouble
tolerating his TFs initially with emesis and nausea. CT scan
revealed the G tube curled up proximally into the esophagus.
The GI Fellow pulled the tube back and abdominal x-ray showed it
no longer in the esophagus. TFs were resumed and the patient
had no difficuties thereafter.
<br>
Alzheimer's Dementia and Depression: Pt oriented to self, but
not place or time. He was continued on Namenda and Aricept per
home regimen. He was continued on his mirtazapine and his TSH
was normal.
<br>
Submucosal Mass seen on EGD: Unclear if this requires
follow-up. See EGD report attached.
<br>
Remaining open surgical wound: minimal opening, excellent
granulation tissue, no evidence for infection, appears to be
healing well. Continue conservative care as directed.
<br>
Mucinous Adenocarcinoma with 1/3 positive lymph nodes,
adenopathy seen on CT scan: Consider outpatient follow up with
GI oncology if patient/family desire. I personally discussed
the above findings and recommendations with the patient's HCP
and son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 99269**] and his questions were
answered to his apparent satisfaction.
<br>
During the patient's admission, he was a FULL CODE. You may
consider readdressing this in the future.
<br>
Please note, the patient may have some dark stools given his
recent GI bleed, but this should resolve over time. You may
consider checking a Hct if you are concerned that he is bleeding
again, though the suspicion that his duodenal ulcers will bleed
any more is small as he is on treatment for H. pylori and a high
dose PPI.
Medications on Admission:
Remeron 15mg qHS
Omeprazole 20 mg PO bid
Celexa 20mg daily
Aricept 10mg daily
Namenda 10mg daily
Senna
Ferrous sulfate
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed: hold for loose stools.
4. Acetaminophen 500 mg Capsule Sig: [**1-26**] Capsules PO Q 8 hours
as needed.
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 10 days.
7. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 10 days.
8. Protonix 40 mg Susp,Delayed Release for Recon Sig: Forty (40)
mg PO twice a day.
9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Three
Hundred (300) mg PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1) Acute Blood Loss Anemia - likely secondary to duodenal
ulcerations, H. pylori Ab positive
2) Malnutrition, s/p G tube placement
Secondary:
--Adenocarcinoma s/p hemicolectomy in [**2124-9-25**], metastatic
to 1 out of three lymph nodes, CT report from this admission,
showed "Small retroperitoneal nodes are seen adjacent to the IVC
measuring up to about 7 cm size (2:36). These are not markedly
changed from the prior examination."
--Alzheimer's Dementia
--Possible depression
--history of renal failure secondary to obstructive uropathy
[**2122**]
Discharge Condition:
good
Discharge Instructions:
Please [**Name8 (MD) 138**] MD if Mr. [**Known lastname **] is unable to tolerate his Tube
Feeds, develops respiratory distress, pain, fever, or other
concerning symptoms.
Followup Instructions:
Please ensure patient has transporation to see his Urologist,
DR. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2124-11-16**] 10:30
Please ensure patient has transportation to see his Colonic
Surgeon
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2124-11-23**] 11:15
Consider Oncologic evaluation for adjuvant therapy for his
advanced mucinous adenocarcinoma
|
[
"154.0",
"196.2",
"311",
"535.60",
"331.0",
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"285.1",
"263.9",
"532.40",
"041.86",
"294.10"
] |
icd9cm
|
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[
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10985
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[
[
11344,
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]
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[
"43.11",
"99.04"
] |
icd9pcs
|
[
[
[
6412,
6464
]
],
[
[
7635,
7640
]
]
] |
10791, 10864
|
7158, 9853
|
269, 302
|
11470, 11477
|
1657, 7135
|
11697, 12183
|
1258, 1324
|
10022, 10768
|
10885, 11449
|
9879, 9999
|
11501, 11674
|
1339, 1638
|
197, 231
|
330, 698
|
720, 1090
|
1106, 1242
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
89,952
| 145,241
|
54412
|
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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89,232
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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**]
|
[
"250.80",
"401.9",
"585.9",
"403.00",
"V15.81",
"275.42",
"584.9",
"595.0",
"241.0",
"285.21"
] |
icd9cm
|
[
[
[
275,
286
]
],
[
[
289,
308
]
],
[
[
417,
419
]
],
[
[
423,
425
]
],
[
[
716,
734
]
],
[
[
10253,
10265
]
],
[
[
10942,
10971
]
],
[
[
11169,
11196
]
],
[
[
11441,
11454
]
],
[
[
14010,
14034
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13718, 13791
|
9350, 11796
|
349, 355
|
14059, 14099
|
3629, 3629
|
15943, 16303
|
2772, 2776
|
12010, 13695
|
13812, 14038
|
11822, 11987
|
14123, 15920
|
2816, 3610
|
275, 311
|
2055, 2354
|
383, 2037
|
3645, 9327
|
2376, 2438
|
2454, 2756
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
89,459
| 144,644
|
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**]
|
[
"414.01",
"250.00",
"403.90",
"272.0",
"278.00",
"V10.46",
"585.2",
"427.31"
] |
icd9cm
|
[
[
[
434,
448
]
],
[
[
1958,
1959
]
],
[
[
2027,
2029
]
],
[
[
2031,
2050
]
],
[
[
2052,
2058
]
],
[
[
2095,
2105
]
],
[
[
2123,
2134
]
],
[
[
6415,
6433
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12228, 12302
|
8331, 9374
|
324, 799
|
12514, 12757
|
3215, 8308
|
13598, 14348
|
2385, 2491
|
10096, 12205
|
12323, 12493
|
9400, 10073
|
12781, 13575
|
2506, 3196
|
271, 286
|
827, 1917
|
1939, 2138
|
2170, 2369
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,289
| 109,818
|
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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90,716
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45001
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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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92,841
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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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],
[
[
9869,
9883
]
],
[
[
9932,
9944
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9744, 9791
|
5874, 8322
|
296, 776
|
10003, 10009
|
3272, 5851
|
10633, 10901
|
1644, 1718
|
8495, 9721
|
9812, 9982
|
8348, 8472
|
10033, 10610
|
1733, 3253
|
241, 258
|
804, 1225
|
1247, 1373
|
1389, 1628
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
"404.91",
"571.2",
"458.9",
"414.01",
"414.2",
"785.51",
"412",
"V12.54",
"274.9",
"290.10",
"327.23",
"362.50",
"272.4",
"427.69",
"585.9",
"707.05",
"410.71",
"428.21",
"599.0",
"584.9",
"707.21"
] |
icd9cm
|
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[
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[
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14823
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[
[
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14910
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[
"37.61",
"36.06",
"37.23"
] |
icd9pcs
|
[
[
[
286,
320
]
],
[
[
325,
405
],
[
2890,
2949
]
],
[
[
2000,
2026
]
]
] |
14574, 14681
|
7934, 14371
|
283, 408
|
14848, 14914
|
5171, 5839
|
15768, 15887
|
4053, 4126
|
14702, 14827
|
14397, 14551
|
5855, 7911
|
14938, 15745
|
4141, 5152
|
233, 245
|
436, 3508
|
3530, 3835
|
3851, 4037
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,170
| 105,063
|
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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icd9pcs
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8900, 8906
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
99,339
| 142,289
|
38024
|
Discharge summary
|
Report
|
Admission Date: [**2145-11-19**] Discharge Date: [**2145-11-23**]
Date of Birth: [**2068-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Increasing pleural effusion
Major Surgical or Invasive Procedure:
Pleurex catheter drainage
History of Present Illness:
77M with history of recently diagnosed metastatic NSCLC and
known malignant right effusion, presenting with enlarging
effusion at rehab, now admitted to MICU with tachypnea and
respiratory distress. He was diagnosed with lung cancer in
[**2145-8-31**] now follows with Dr. [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **] at [**Hospital 8**]
Hospital. In [**Month (only) 359**] he developed acute cord compression and had
decompression on [**2145-10-15**]. Discharged to rehab. He was
readmitted to [**Hospital1 18**] from [**Date range (1) 56568**] for shortness of breath
with new finding of large right sided pleural effusion and a RUL
post obstructive pneumonia; mass abutting RUL bronchus and PA.
During last admission he underwent thoracentesis and, later,
pleurex catheter placement on [**11-17**]. Pleural fluid positive for
malignant cells, AFB smear negative. Also initiated palliative
XRT to RUL. IP did not feel mass was amenable to stenting. Notes
in discharge summary state that patient was DNR/DNI at
discharge.
Patient was discharged to [**Hospital 392**] Rehab. At rehab this morning it
was discovered that there were not appropriate supplies to drain
pleurex. Had his usual session XRT this AM. He also had CXR
which was read as complete R sided opacification. When arrived
back at rehab, he was sent to the ED due to inability to drain
the effusion.
In the ED, initial vs were: T96.8 70 146/88 22 96% on 15L O2.
HRs have since been in the 130s - not clear if HR 70 truly
accurate. Has been tachypneic to 30s. CXR performed with finding
of interval increase in pleural effusion and R lung base
opacificition. IP saw patient and drained 550 cc fluid from
patient's pleurex catheter. A bedside ultrasound was obtained
showing no pericardial effusion. Patient was given vancomycin
and zosyn. Attempts were made to contact interpreter but this
was not possible - could not confirm DNR status and seemed to
suggest that patient was full code.
In the MICU, patient interviewed with an interpreter. Notes he
gets dyspneic at times but no different lately. Actually denies
shortness of breath currently. + cough, productive of white
sputum, denies hemoptysis. No CP, no pleuritic pain. Notes
occasional palpitations. No fevers/chills. Endorses thirst and
general poor PO intake. Notes continued numbness and weakness in
his lower extremities since his acute cord compression. +lower
extremity edema x few weeks. + weight loss.
Past Medical History:
1. Nonsmall Cell Lung Cancer with metastatic disease to the
spine
- s/p T7-L1 laminectomy, decompression, fusion, and tumor
debluking and fusion for acute cord compression on [**2145-10-15**]
- Primary Oncologist Dr. [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) **]
2. H/o C diff colitis in [**2145-9-30**]
3. COPD
4. Atrial fibrillation
Social History:
Originally from [**Country 651**], immigrated to the US > 10 years ago; was
living with his son and daughter until discharge yesterday
(discharged to rehab in [**Hospital1 392**]). Worked as a factory worker in
[**Country 651**]. Previous history of heavy tobacco use (at least 1PPD x 50
years); not currently smoking. No known TB contacts.
Family History:
No family history of malignancy
Physical Exam:
Vitals: T: 99.2 BP: 128/59 P: 76 R: 26 SaO2: 97 RA
General: Cachectic male, alert, oriented, moderately tachypneic
with some accessory muscle use.
HEENT: PERRL, sclera anicteric, MM slightly dry, oropharynx view
poor but appears clear
Neck: supple, JVD low at 1-2 ASA.
Lungs: Decreased breath sounds on right, few rales, somewhat
rhonchorous with ?pleural rub. Left relatively clear. No
wheezes.
CV: tachycardic, irregularly irregular, no murmurs, rubs,
gallops appreciated
Abdomen: soft, thin, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Suprapubic area feels slightly ?firm though nontneder. +TTP over
lower right anterior ribs.
Ext: warm, well perfused, [**1-1**]+ LE edema, symmetric bilaterally.
No calf tenderness.
Neuro: A/O x 3. CN II-XII intact, UE strength and sensation
grossly intact. Reports LE numbness bilaterally. LE strength
impaired - cannot lift R leg off bed, L can be lifted very
slightly.
Pertinent Results:
Admission Labs:
[**2145-11-18**] 06:15AM WBC-15.8* RBC-3.95* HGB-11.9* HCT-37.7*
MCV-95 MCH-30.1 MCHC-31.5 RDW-17.1*
[**2145-11-18**] 06:15AM PLT COUNT-332
[**2145-11-19**] 04:20PM CK-MB-3
[**2145-11-19**] 04:20PM cTropnT-<0.01
[**2145-11-19**] 04:20PM GLUCOSE-109* UREA N-18 CREAT-0.5 SODIUM-144
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-31 ANION GAP-12
[**2145-11-19**] 07:06PM LACTATE-1.8
[**2145-11-19**] 07:06PM TYPE-ART PO2-204* PCO2-47* PH-7.42 TOTAL
CO2-32* BASE XS-5
Studies:
[**2145-11-20**] Echo:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild
global left ventricular hypokinesis (LVEF = 45 %). Systolic
function of apical segments is relatively preserved suggesting a
non-ischemic etiology. Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial anterior pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild global
hypokinesis c/w diffuse process (toxin, metabolic, etc.). Mild
pulmonary artery systolic hypertension.
[**2145-11-20**] Bilateral lower extremity ultrasound:
Peroneal veins not visualized. No evidence of deep venous
thrombosis.
[**2145-11-21**] Chest Xray
There is essentially no change in chest findings with right
upper lobe
complete opacification, right pleural effusion, ground-glass
opacity and
mass-like consolidation in the right lower lobe, nodular opacity
projecting in the left upper lobe and peribronchial
abnormalities in the left lower lobe or due to patient's known
non-small cell lung cancer. There are no new lung abnormalities.
Cardiomediastinal contours are unchanged. Right apical chest
tube remains in place. Spinal hardware is present. There is no
pneumothorax.
Brief Hospital Course:
77 year old male with metastatic lung cancer and malignant
pleural effusion admitted for pleural catheter drainage.
# Pleurex catheter drainage: He initially presented to the
emergency room after a radiation oncology appointment and
inability to drain pleurex at rehab facility. Per son, this was
likely due to not accessing pleurex catheter appropriately. In
total, patient has had approximately 2500 cc of fluid removed
during his stay. He was initially admitted overnight to the
MICU after experiencing shortness of breath, tachypnea and
hypoxia in the emergency room; however, this quickly resolved.
# Shortness of Breath: He has baseline shortness of breath due
to persistent malignant effusion and post-obstructive pneumonia
secondary to mass. Resolved with drainage of pleurex catheter.
This should be drained daily after discharge. Information
provided to nursing director at [**Hospital 392**] rehab by interventional
pulmonary service and video is sent with patient. Please call
[**Telephone/Fax (1) 3020**] if any questions or concerns regarding drainage.
# Pneumonia/Hypoxia: Patient completed a course for
post-obstructive pneumonia and other than leukocytosis as below
has no other signs or symptoms of infection. Has been C. diff
negative during this admission. UA negative, CXR without new
findings, C. diff negative as above, blood cultures are no
growth to date and patient ruled out for flu, parainfluenza,
adenovirus and RSV. Tachypnea and hypoxia improved as above
with drainage of pleurex. LENIs negative as well making PE
less likely. He was given a few doses of vancomycin and
cefepime while in the intensive care unit, but these were
discontinued upon transfer to the floor.
# Stage IV NSCL and Malignant effusion: Known mets to spine and
malignant effusion. Already undergoing palliative xrt, last dose
today. Too debilitated for chemo at this time. We continued
pain control as per prior to admission. Follow up scheduled
with oncology service as per discharge paperwork.
# Leukocytosis: C. diff negative, CXR unchanged other than
effusion, UA negative and blood cultures no growth to date.
Patient remained afebrile and non-toxic appearing, though
chronically ill. [**Month (only) 116**] be secondary to malignancy.
# Tachycardia: Sinus tach vs MAT. No clear Afib history and he
was intermittently irregular making MAT more likely (though
difficult to appreciate p waves when accelerated rhyhtm). Rate
controlled with metoprolol which was increased to 37.5 mg three
times daily.
# Prophylaxis: Continued on fondaparinux, ppi
# Code status: DNR/I
# Communication: Liping (daughter) [**Telephone/Fax (1) 84933**], [**Name (NI) **] (son)
[**Telephone/Fax (1) 84934**]
Medications on Admission:
- Morphine SR 15 mg Q12H
- Acetaminophen 325 mg Q6H as needed for pain, fever.
- roxanol 0.25 ml Q3H prn pain
- Omeprazole 40 mg DAILY
- Guaifenesin 100 mg/5 mL: 5-10 MLs PO Q6H as needed for cough.
- Benzonatate 100 mg TID
- Megestrol 400 mg/10 mL : Twenty (20) ml PO once a day.
- Fondaparinux 2.5 mg Subcutaneous once a day.
- Albuterol Sulfate [**1-1**] nebs Q4H prn shortness of breath or
wheeze.
- Catheter Drainage Please drain IP catheter three times/wk
- Docusate Sodium 100 mg twice a day.
- Senna 8.6 mgTwo (2) Tablet PO twice a day
Discharge Medications:
1. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
2. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
3. Roxanol Concentrate 20 mg/mL Solution Sig: 0.25 ml PO q3h as
needed for pain.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Guaifenesin 100 mg/5 mL Liquid Sig: [**5-9**] mL PO every six (6)
hours as needed for cough.
6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
7. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Twenty (20)
mL PO once a day.
8. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 mg Subcutaneous
DAILY (Daily).
9. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
[**1-1**] Nebulizations Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
10. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
12. Catheter Drainage
Please drain Pleurex catheter daily after discharge. For any
questions or if it is felt that it can be drained less often,
please contact the Interventional Pulmonary office at [**Hospital1 18**] at
[**Telephone/Fax (1) 3020**].
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1)
nebulization Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis:
Non-small cell lung cancer
Malignant pleural effusion
Secondary Diagnosis:
COPD
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Sleepy but arousable
Activity Status: Bedbound
Discharge Instructions:
You were admitted to the hospital to have your Pleurex catheter
drained. You experienced an episode of shortness of breath and
were initially admitted to the medical intensive care unit.
Your catheter was drained three times while you were in the
hospital.
You also had a fast heart rate (atrial fibrillation). We
increased your metoprolol from 25 mg three times daily to 37.5
mg three times daily.
It is important that you go to your follow-up appointments as
scheduled.
Please take all your other medications as you were prior to
hospitalization.
Please also read the aftercare instructions regarding the
radiation therapy of your chest.
Followup Instructions:
You have the following appointments scheduled:
Neurosurgery
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD
Phone: [**Telephone/Fax (1) 1669**]
Date/Time: [**2145-12-1**] 11:45am
Thoracic Hematology/Oncology
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD
Phone: [**0-0-**]
Date/Time: [**2145-12-2**] 10:30am
and
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4322**], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2145-12-2**] 10:30am
Interventional Pulmonology:
MD: [**First Name8 (NamePattern2) **] [**Doctor Last Name **] of interventional pulmonology
Day & Time: [**2145-12-8**] at 8:30 AM (Xray at 8:00 am)
Phone: [**Telephone/Fax (1) 3020**]
Special Instructions: You need a chest X-ray before this
appointment. Please show up at the [**Location (un) 10043**] of the clinical
center at 8:00am on [**2145-12-8**] for a chest radiograph. Afterward
your interventional pulmonology appointment is on the [**Location (un) 19201**] of the connected [**Hospital Ward Name 121**] building.
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[
"34.91"
] |
icd9pcs
|
[
[
[
345,
369
]
]
] |
11681, 11780
|
6845, 9566
|
345, 373
|
11924, 11924
|
4657, 4657
|
12724, 13759
|
3621, 3654
|
10161, 11658
|
11801, 11801
|
9592, 10138
|
12055, 12701
|
3669, 4638
|
278, 307
|
401, 2864
|
11896, 11903
|
4673, 6822
|
11820, 11875
|
11939, 12031
|
2886, 3247
|
3263, 3605
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
98,176
| 140,585
|
39882
|
Discharge summary
|
Report
|
Admission Date: [**2190-10-20**] Discharge Date: [**2190-10-25**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Aortic stenosis/ regurgitation
Major Surgical or Invasive Procedure:
aortic valve replacement (21mm St. [**Male First Name (un) 923**] porcine) [**2190-10-20**]
History of Present Illness:
This 86 year old white female has known aortic stenosis with
progressive dyspnea on exertion and fatigue over 7 months. She
has previously undergone catheterization to demonstrate clean
coronaries, despite a prior anterior infaction in [**2173**]. She is
admitted now for valve replacement.
Past Medical History:
Coronary artery disease s/p AMI '[**73**]
Ischemic cardiomyopathy (EF 35-40%)
Aortic stenosis/insufficiency
Hypertension
Hyperlipidemia
Diverticulitis
Past Surgical History: Right hip replacement s/p
fracture(MVA)'[**78**]
Bowel resection(diverticular dz)-'[**72**]
Incisional hernia repair '[**73**]
Bilat cataract removal
Ovarian cyst removal
Social History:
Race: Caucasian
Last Dental Exam: 1 month ago
Lives with: Husband
Occupation: Retired college professor/[**Male First Name (un) **]-Education([**University/College **])
Tobacco:Quit 40 yrs ago, previously smoked 1ppwk x20yrs
ETOH:1 drink every other month
Family History:
non-contributory
Physical Exam:
Pulse: 54 Resp: 16 O2 sat: 98%-RA
B/P Right: 160/72 Left:
Height: 65 in Weight: 176 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] MMM, normal oropharynx
Neck: Supple [x] Full ROM [x], no JVD or lymphadenopathy
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: [**2-20**] blowing murmur
Abdomen: Soft[x] non-distended[x] non-tender [x] +bowel
sounds[x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: minimal
Neuro: Grossly intact, A&O x3-MAE, nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit: radiated murmur Right: Left:
Pertinent Results:
[**2190-10-22**] 02:10AM BLOOD WBC-13.1* RBC-3.41* Hgb-10.1* Hct-30.2*
MCV-89 MCH-29.7 MCHC-33.4 RDW-14.4 Plt Ct-126*
[**2190-10-24**] 06:20AM BLOOD Na-135 K-4.5 Cl-101
[**2190-10-23**] 06:40AM BLOOD WBC-10.0 RBC-3.32* Hgb-9.9* Hct-29.6*
MCV-89 MCH-29.9 MCHC-33.5 RDW-14.0 Plt Ct-122*
[**2190-10-20**] 12:30PM BLOOD WBC-6.9 RBC-2.57*# Hgb-7.7*# Hct-22.4*#
MCV-87 MCH-29.9 MCHC-34.2 RDW-13.4 Plt Ct-122*#
[**2190-10-23**] 06:40AM BLOOD Glucose-113* UreaN-26* Creat-1.1 Na-138
K-4.2 Cl-103 HCO3-28 AnGap-11
[**2190-10-20**] 01:35PM BLOOD UreaN-10 Creat-0.7 Na-141 K-4.3 Cl-115*
HCO3-22 AnGap-8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 87732**] (Complete)
Done [**2190-10-20**] at 11:46:35 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2103-12-5**]
Age (years): 86 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: AVR
ICD-9 Codes: 786.05, 786.51, 424.1, 424.0
Test Information
Date/Time: [**2190-10-20**] at 11:46 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW-1: Machine: [**Doctor Last Name **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Aortic Valve - Peak Gradient: *56 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 35 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Critical AS (area
<0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: 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. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 - 50 %).
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Moderate
(2+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on no inotropes.
Preserved biventricular systolic fxn.
There is a prosthetic aortic valve with no leak and no
regurgitation.
Mean residual gradient = 10 mmHg.
No MR. [**First Name (Titles) **] [**Last Name (Titles) **].
Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2190-10-20**] 13:01
Brief Hospital Course:
Following admission she went to the Operating Room where aortic
valve replacement was undertaken. She operative note for
details. She weaned from bypass easily on Propofol alone. She
awoke anxious but intact, requiring nitroglycerin intravenously
for BP control. She was extubated on POD 1 and oral agents
(Valsartan and Lopressor). Diuresis towards her preoperative
weight was begun and she transferred to the floor on POD 2.
Physical Therapy worked with her for strength and mobility. CTs
and temporary pacing wires were removed per protocols. She had
a brief episode of atrial fibrillation in the 140s on POD 4,
which was well tolerated. This was treated with IV Lopressor
and amiodarone with restoration of sinus rhythm. She remained
volume overloaded and was discharged to rehab on IV lasix for 1
week.
On POD 5 she was ready for discharge and went TO [**Hospital 38**] Rehab
a MWMC in [**Location (un) 1110**].
Medications on Admission:
Metoprolol ER 25 daily
Simvastatin 40 daily
Zetia 10 daily
NTG-sl-prn
Aspirin 325 daily
Diovan 320 daily
Fish Oil
Vitamin E 400IU daily
Vitamin D 500mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 1 tab(200mg) [**Hospital1 **] for two weeks then one tab(200mg)
daily.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. psyllium Packet Sig: One (1) Packet PO BID (2 times a
day) as needed for constipation.
11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. furosemide 10 mg/mL Solution Sig: Four (4) Injection twice
a day for 1 weeks: 40mg IV lasix [**Hospital1 **] x 1 week, then re-evaluate.
13. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Aortic stenosis/reguritation
hypertension
s/p aortic valve replacement
s/p right total hip arthroplasty
ischemic cardiomyopathy
coronary artery disease
s/p colon resection for diverticular disease
s/p herniorraphy
s/p cataract extractions
hyperlipidemia
s/p ovarian cystectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema: 1+ bilateral LEs
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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) **] ([**Telephone/Fax (1) 6256**]) at [**Hospital1 **] on [**11-18**] at
9:00am Cardiologist:Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**] ([**Telephone/Fax (1) 6256**]) on
[**2190-12-20**] at 2:30pm
Please call to schedule appointments with:
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4640**] ([**Telephone/Fax (1) 20221**]) in [**3-22**] 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**
Completed by:[**2190-10-25**]
|
[
"424.1",
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"412",
"414.8",
"401.9",
"272.4",
"V43.64",
"V45.72",
"V15.82",
"427.31",
"276.69",
"V58.66"
] |
icd9cm
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[
"35.21"
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icd9pcs
|
[
[
[
301,
327
]
]
] |
8840, 8870
|
6392, 7320
|
301, 395
|
9191, 9372
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2164, 6369
|
10296, 10993
|
1376, 1394
|
7529, 8817
|
8891, 9170
|
7346, 7506
|
9396, 10273
|
913, 1086
|
1409, 2145
|
231, 263
|
423, 717
|
739, 890
|
1102, 1360
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,403
| 164,036
|
30855
|
Discharge summary
|
Report
|
Admission Date: [**2180-6-12**] Discharge Date: [**2180-6-14**]
Date of Birth: [**2148-11-12**] Sex: F
Service: MEDICINE
Allergies:
Nafcillin
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy
History of Present Illness:
31 y.o. female with history of autoimmune hepatitis complicated
by cirrhosis and recurrent ascites presenting with hematemesis
for one day. The patient reports on the morning of presentation
she woke up without significant abdominal pain or nausea but did
notice her abdomen was very distended. She then began to vomit
and had a paroxysm of vomiting where she had five episodes of
emesis each with about a half cup of dark blood per her report.
She called EMS and was brought to an OSH where she had an NG
passed that expelled a large amount of dark blood. Reports vary
and some sources (i.e. ED dash) said this was bright red blood
but after reviewing with patient it seems this was all maroon
with only flecks of dark red blood. Unfortunately, she vomited
out the NG tube. She was started on octreotide drip and
transferred to [**Hospital1 18**]. OSH Hct was 36.7.
In the ED VS: T 99.4, P 62, BP 122/75, RR 16, O2 97% 3L. On
arrival to [**Hospital1 18**] Hct was 36.4 and she remained HD stable without
tachycardia or hypotension. She was started on pantoprazole
drip. Liver was called and plan to scope patient tomorrow. She
was also started on ceftriaxone for PCP [**Name Initial (PRE) 31424**]. She was
sent to the MICU.
Currently, she denies any symptoms. Denies CP, SOB,
light-headedness. She reports abdominal distension leading to
SOB was worst symptom and this has resolved after having NG.
Past Medical History:
# Autoimmune hepatitis: [**Doctor First Name **]+, AMA-, [**Last Name (un) 15412**]+
# Cirrhosis:
# Rheumatoid Arthritis:
# Hep C: Genotype 3. most recent viral load undetectable.
# mulitple liver biopsies
# compartment syndrome in R arm s/p surgical decompression [**11-24**]
# herpes zoster
# C section in [**2175**]
# osteomyelitis [**2177**]
# Nephrolithiasis
Social History:
Lives with mother in [**Name (NI) 14663**].
Smokes 5 cig/day (down from before) x 15 yrs. Has h/o ETOH and
drug abuse (heroin and cocaine) but clean since 9/[**2178**].
Has a 11 year old son [**Doctor First Name **] and a 3 year old daughter ([**Name (NI) **]
[**Name (NI) **]).
Mom is point person.
Family History:
Aunt w/ breast Ca.
No h/o autoimmune hepatitis, early colon CA, or Crohn/UC.
Physical Exam:
Physical Exam on Admission:
Vitals:
Tcurrent: 36.2 ??????C HR: 64 BP: 108/54(66) RR: 14 SpO2: 95%
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
Discharge Physical Exam:
VSS, abdomen is distended, nontender, no fluid wave, no masses.
guiac positive stools. IV's present at time of elopement.
Pertinent Results:
Labs on admission:
===============================================================
WBC-6.9# RBC-3.24* Hgb-12.1 Hct-36.4 Plt Ct-51*
Neuts-76.7* Lymphs-14.6* Monos-5.8 Eos-2.1 Baso-0.7
PT-20.5* PTT-37.3* INR(PT)-1.9*
Glucose-97 UreaN-18 Creat-0.5 Na-137 K-4.7 Cl-112* HCO3-21*
AnGap-9
Albumin-2.4* Mg-1.9
Pertinent Labs and Studies:
Hct 36.4-->32.8
Liver U/S [**6-12**]: 1. Nodular cirrhotic liver with splenomegaly and
ascites suggesting the
presence of portal hypertension. Patent main portal vein with
hepatopedal
flow.
2. New echogenic focus in the left lobe of the liver, measuring
1.3 cm in
greatest dimension. Further characterization with non-emergent
MRI is
recommended.
EGD [**6-12**]: Grade I Varices at the lower third of the esophagus
and gastroesophageal junction
Duodenal varices
Otherwise normal EGD to third part of the duodenum
Discharge Labs:
[**2180-6-14**] 01:15PM BLOOD WBC-8.4# RBC-2.97* Hgb-11.2* Hct-32.8*
MCV-111* MCH-37.9* MCHC-34.2 RDW-16.1* Plt Ct-70*
[**2180-6-14**] 04:50AM BLOOD Glucose-160* UreaN-17 Creat-0.7 Na-133
K-4.4 Cl-103 HCO3-25 AnGap-9
[**2180-6-14**] 04:50AM BLOOD ALT-62* AST-67* AlkPhos-131* TotBili-1.8*
[**2180-6-14**] 04:50AM BLOOD PT-18.8* PTT-37.4* INR(PT)-1.7*
Brief Hospital Course:
31yo female with autoimmune liver disease presenting with UGIB
with bloody emesis x1 day, she is now s/p EGD which did not
reveal bleeding varices but did reveal small grade I varices in
the esophagus and the duodenum. She missed 4 days of Lasix doses
so we will re-initiate her diuretic regimen as well as her other
home medications.
ACUTE ISSUES:
#. GIB: the patient had dark emesis and a lavage done at OSH
revealed blood. On EGD, non-bleeding grade I varices are
appreciated so unclear if this is source of bleed. We treated as
for GIB but we did not continue octreotide and PPI. Treatment
with ceftriaxone and converted to po Cipro 500mg [**Hospital1 **] for 7 days,
Nadolol 20mg daily. Patient's hematocrit remained stable around
33-35 and she remained hemodynamically stable
.
#. Autoimmune Hepatitis c/b cirrhosis, recurrent ascites.
Abdominal pain may be [**1-19**] ascites. Continued on home dose of
Lasix (of which she had missed 4 days of doses), Aldactone, home
dose of Imuran, Budesonide. Started on weekly vitamin D 50,000
on Wednesdays. The patient achieved relief of abdominal pain
with carafate and was also advised to use Tums for her pain. As
well, she was given tramadol for this pain.
.
#.Uncomplicated UTI: patient had asymptomic pyuria, urine
cultures show staph aureus coag positive. Sensitivities revealed
resistance to levofloxacin and so ciprofloxacin will not cover
her. She was given a 3 day course of Bactrim for UTI.
.
#Patient eloped with 2 IV's in arms. She left without receiving
discharge paperwork but Rx were delivered.
.
CHRONIC ISSUES:
#. Cirrhosis. MELD was 15 on day of discharge. Patient will
continue to follow in transplant hepatology.
.
TRANSITIONAL CARE ISSUES:
CODE: Full
CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 73008**], [**Telephone/Fax (1) 72764**]
PENDING STUDIES: none
PATIENT ELOPED WITH IV'S INTACT.
Medications on Admission:
Imuran 50 mg once a day,
budesonide 3 mg one p.o. t.i.d.,
vitamin D 50,000 units once a week,
furosemide 20 mg once a day,
spironolactone 100 mg once a day,
calcium with vitamin D is on hold due to kidney stones,
iron 325 one three times a day
Discharge Medications:
1. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
Disp:*30 Capsule(s)* Refills:*2*
2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. budesonide 3 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO TID (3 times a day).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
8. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day as needed for abdominal pain for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 1 weeks.
Disp:*15 Tablet(s)* Refills:*0*
11. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
gastrointestinal bleed
urinary tract infection
autoimmune liver disease
Cirrhosis
SECONDARY DIAGNOSIS:
hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
***patient eloped prior to delivery of paperwork***
Dear Ms. [**Known lastname 3321**],
It was a pleasure taking care of you. You were admitted to the
hospital for a gastrointestinal bleed. You did not receive a
transfusion and your blood levels are stable. You were also
found to have a urinary tract infection while you were in the
hospital. You received an esophagogastroduodenoscopy while you
were in the hospital which did not reveal a source of your
bleeding.
Please note the following changes to your medications:
Please keep all of your follow up appointments.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: Wednesday [**2180-6-21**] at 10:45 AM
Location: [**Hospital3 **] PRIMARY CARE
Address: [**State **], 4TH FL, [**Location (un) **],[**Numeric Identifier 73009**]
Phone: [**Telephone/Fax (1) 4688**]
Department: TRANSPLANT
When: WEDNESDAY [**2180-6-21**] at 3:20 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: MONDAY [**2180-7-3**] at 1:40 PM
With: XMR [**Telephone/Fax (1) 327**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT
When: WEDNESDAY [**2180-8-30**] at 1:20 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"714.0",
"070.54",
"456.1",
"571.5",
"789.59",
"599.0"
] |
icd9cm
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[] |
icd9pcs
|
[
[
[]
]
] |
7920, 7926
|
4553, 6116
|
283, 312
|
8104, 8104
|
3306, 3311
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|
232, 245
|
6265, 6443
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340, 1759
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8069, 8083
|
7966, 8048
|
3325, 4161
|
8119, 8231
|
6132, 6239
|
1781, 2147
|
2163, 2465
|
3164, 3287
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
94,987
| 193,169
|
37083
|
Discharge summary
|
Report
|
Admission Date: [**2172-4-23**] Discharge Date: [**2172-5-4**]
Date of Birth: [**2117-2-7**] Sex: F
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55 year old woman s/p L4-L5 laminectomy and fusion on [**2172-4-7**],
discharged [**2172-4-12**], who presented to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Hospital **] hospital with 3
days of SOB on [**2172-4-23**]. Pt states that she developed SOB three
days prior to admission. She denies CP, palpitations, but does
endorse DOE with recent difficulty reaching the top of her
stairs. Following dinner on [**4-22**] the pt developed worsening SOB
at rest and the pt called EMS. En route to hospital pt was
initally bradycardic, hypotensive and with low sats, BP improved
with non-rebreather and the pt became tachycardic in the low
100's. At OSH pt was given 3L NS and 1u pRBCs for tachycardia
and anemia (OSH hct 26), and pt had a CTA PE protocol that
revealed a 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. The
pt was started on a heparin gtt and transfered to [**Hospital1 18**] ED for
further management. ABG at OSH showed: 7.46/30/53/21.
.
In the [**Hospital1 18**] ED, initial vs were: T 98.6 P 88 BP 135/88 R 28 O2
sat 91% NRB. Patient was given morphine and ondansetron and
heparin was continued. Patient was admitted to ICU for further
management.
.
On the floor, patient appears comfortable but tachypnic on NRB.
Reports that she is thirsty.
.
Review of systems:
(+) Per HPI
Also, patient endorses non-productive, non-bloody cough for
three days, constipation (no BM since she was discharged from
the hospital [**2172-4-12**]), and abdominal pain at the site of the
surgical incision.
.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Obesity
Gastric Bypass
s/p anterior L4-S1 fusion
Depression/Anxiety
Social History:
Lives with husband, runs food service.
- Tobacco: Denies.
- Alcohol: Denies.
- Illicits: Denies.
Family History:
Noncontributory.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R single lumen EJ in
place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, + ttp, non-distended, midline incision C/D/I
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2172-4-23**] 09:28PM PTT-54.2*
[**2172-4-23**] 02:37PM GLUCOSE-109* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11
[**2172-4-23**] 02:37PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.1
[**2172-4-23**] 06:17AM GLUCOSE-96 LACTATE-1.3 NA+-141 K+-3.2*
CL--102 TCO2-24
Iron: 20
calTIBC: 274
Ferritn: 64
TRF: 211
LE Ultrasound:
Grayscale and Doppler son[**Name (NI) **] of the bilateral common femoral,
superficial femoral, and popliteal veins were performed. Within
the right distal femoral vein, inferior to the bifurcation
(SFV), an echogenic clot is seen. Flow was seen around this
clot. The remaining vessels demonstrate normal compressibility,
flow and augmentation.
Outside Hospital CTA Scan: massive b/l PE
TTE [**4-23**]: 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.
CTA Chest [**4-30**]: IMPRESSION:
1. Minimally increase in large pulmonary artery clot burden on
the right
since 1 week prior. The pulmonary artery remains almost the same
diameter as the aorta suggesting mild pulmonary hypertension.
There are no other signs to suggest right ventricular strain.
2. Left upper lung ground glass opacities may represent
infectious etiology, asymmetric ventilation from pulmonary
embolus or foci of hemorrhage.
3. New small, left greater than right pleural effusions.
4. No RP bleed.
5. Small splenic infarct.
Brief Hospital Course:
55 y/o F with hx of gastric bypass and recent spinal fusion on
[**2172-4-7**] who presents with acute pulmonary embolism.
# Pulmonary embolism (provoked): Per reports from OSH, and per
discussion with radiologists at [**Hospital1 18**] and review of the images,
pt has diffuse PE's bilaterally, with very little lung
perfusion. Pt was started on oxygen and a heparin drip (with
which there was initially some difficulty in obtaining
therapeutic PTT) as well as coumadin. Upon admission she was on
a nonrebreather, but was weaned to facemask and then to nasal
cannula and, on discharge, was on room air during the day with
desaturations overnight requiring her to get home oxygen for
overnight only.
-could consider outpt sleep study
-pt discharged c therapeutic INR, will need close f/u
# s/p laminectomy (Dr. [**Last Name (STitle) 363**]: Midline incision healing well,
pt still having pain in abdomen, low back. She was initially
controlled with IV pain medication, but transitioned back to her
home regimen of PO oxycontin and oxycodone. Ortho recommended
A/P and lateral L-spine films during her admission. These were
obtained and showed no change in alignment.
-pt to f/u with Dr [**Last Name (STitle) 363**] as outpt
# Pain Management s/p laminectomy: Midline incision healing
well, pt still having pain in abdomen, low back. Ortho is
following along. Left back pain perhaps due to small splenic
infarct seen on chest CT. Pain service consulted. Tizanidine
continued. Started gabapentin and lidocaine patch.
# Depression/Anxiety: Pt. was very tearful during admission as
she was not expecting this and has had tremendous stress at home
(her son is in prison). Social work was consulted for support.
Home anxiety regimen continued. Seroquel increased to 50 qhs. Pt
able to discuss her anxiety and depression at length with this
provider. [**Name10 (NameIs) **] also states that she has never considered hurting
herself and that she believes she is here for a reason.
# splenic infact: unclear etiology
-recommend outpt heme eval
# anemia: iron studies c/w iron deficiency plus anemia of
chronic inflammation. Would recommend starting iron when pt on
less opiates (pt had issues c constipation during
hospitalization, did not want to start iron at this time).
- recommend start iron as outpt
Medications on Admission:
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
Discharge Medications:
1. oxygen
oxygen 2L per minute continuous for portability pulse dose
system
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clonazepam 1 mg Tablet Sig: [**2-8**] Tablet PO QHS (once a day (at
bedtime)).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): do NOT
take at the same time as oxycontin as it may make you sleepy. Do
NOT drive or operate machinery or drink alcohol while taking
this medicine.
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Put on
for 12 hours then MUST be removed for 12 hours (cannot wear 24
hours per day).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
12. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: take on Monday and Thursday only.
Disp:*30 Tablet(s)* Refills:*0*
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take
on Tue, Wed, Fri, Sat, Sun (take the other dose on Mon and
Thurs).
Disp:*30 Tablet(s)* Refills:*0*
15. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours.
Disp:*90 Capsule(s)* Refills:*0*
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain: do NOT take at the same time as oxycontin as
it may make you sleepy. Do NOT drive or operate machinery or
drink alcohol while taking this medicine.
Disp:*20 Tablet(s)* Refills:*0*
17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every six (6) hours as needed for shortness
of breath or wheezing for 2 weeks.
Disp:*1 inhaler* Refills:*0*
18. Mirapex Oral
Discharge Disposition:
Home With Service
Facility:
Homemakers of [**Location (un) 33810**]
Discharge Diagnosis:
Primary
Pulmonary Embolus
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You came to the hospital after having a blood clots in your
lungs (pulmonary embolus) in the context of recovering from back
surgery. You required intravenous heparin and coumadin was
started - when this drug reached a good level, the heparin was
discontinued. You will need to take coumadin for a year. You
will need to have your coumadin levels checked carefully so you
will see Dr [**Last Name (STitle) 10023**] on Wednesday. Please use your oxygen at
night while sleeping.
Please continue your medications with the following changes:
1. STOP percocet
2. STOP flexoril
3. START colace and senna and bisacodyl for constipation as pain
meds can be constipating
4. START oxycontin twice daily for pain
5. START oxycodone as needed for pain
6. START gabapentin
7. START lidocaine patch (12 hours on, 12 hours off)
8. START albuterol inhaler
9. START coumadin
Followup Instructions:
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: [**Last Name (LF) 2974**], [**2173-5-22**]:30 am
Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER
Address: [**Last Name (LF) **], [**First Name3 (LF) **] BLDG. [**Location (un) **]
Phone: [**Telephone/Fax (1) 3573**]
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
When: This Wednesday [**5-6**] 11:30a
Location: [**Location (un) **] INTERNAL MEDICINE
Address: [**Apartment Address(1) 83581**], [**Location (un) **],[**Numeric Identifier 62963**]
Phone: [**Telephone/Fax (1) 10026**]
Completed by:[**2172-5-6**]
|
[
"278.00",
"311",
"300.00",
"V45.86",
"453.41",
"289.59",
"280.9",
"564.00"
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icd9cm
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[] |
icd9pcs
|
[
[
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10247, 10317
|
4974, 7284
|
285, 291
|
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|
3067, 4951
|
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|
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|
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|
1805, 2366
|
226, 247
|
319, 1786
|
10402, 10511
|
2388, 2457
|
2473, 2572
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
97,164
| 109,302
|
44580
|
Discharge summary
|
Report
|
Admission Date: [**2134-11-26**] Discharge Date: [**2134-12-10**]
Date of Birth: [**2051-9-1**] Sex: F
Service: MEDICINE
Allergies:
Peanut / Chocolate Flavor / Codeine
Attending:[**First Name3 (LF) 9965**]
Chief Complaint:
CC:[**CC Contact Info 95464**].
Reason for MICU transfer: respiratory distress/COPD exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 2564**] is an 83 y/o F with HTN, COPD and RA who presented
to the ED with developing LLE erythema over 3 days duration.
Presented to PCP who suggested she go to the ED for further
eval. Denied any associated Sx including fever/chills or pain.
Does describe weeping from the lesion. In the ED she developed
afib with RVR and was treated with IV and oral metoprolol and
admitted to medicine for further work-up of new afib.
.
On the floor, she was continued on metoprolol for afib. She was
treated with ceftriaxone for cellulitis but blood cultures
turned positive for strep viridans. Thus, a TTE was ordered
which showed possible aortic valve vegetation. A TEE was
performed today to better characterize the vegetation but during
the procedure she became stridorous.
.
She was treated with nebulizers and IV steroids for presumed
COPD exacerbation. She also had magnesium, furosemide x1, and
metoprolol IV x 2. She was placed on a NRB with saturations in
the 90% and transfered to the MICU for further management of her
respiratory distress.
Past Medical History:
- Osteoporosis with T8-9 compression fracture
- RA
- COPD (no PFTs in OMR)
- HTN
Social History:
Not presently employed. Lives independently. Has a niece who is
[**Name8 (MD) **] RN. No EtOH, tobacco or other drug use.
Family History:
Father with [**Name2 (NI) **]
Physical Exam:
On Admission:
VS: afebrile, BP 114/70, HR 150s, RR 30s, O2sats 93-99% NRB
GA: AOx3, severe increased work of breathing with use of
abdominal muscles for respiration, no sentence dyspnea
HEENT: JVP elevated to 10-12 cm
Cards: irregularly irregular, S1 and S2, +[**1-31**] murmur best heard
over apex
Pulm: intermittent inspiratory stridor, expiratory wheezes
bilaterally, no crackles
Abd: soft, NT, +BS. no g/rt. neg HSM.
Extremities: erythema and flaking on skin over left tibia
extending down to foot. RLE with e/o venous statis changes.
On Discharge:
VS: 97.0 121/77 86 22 94%2L
Gen: Severely kyphotic, elderly female in NAD. Oriented x3.
Mood, affect appropriate.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi. Does have rhoncorous upper
airway sounds.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. Digital cap refill <2 sec. No C/C/E. Distal pulses
intact radial 2+, DP 2+, PT 2+.
Skin: venous stasis changes in lower extremity; cellulitis is
significantly improved
Pertinent Results:
On Admission:
[**2134-11-26**] 04:15PM BLOOD WBC-6.9 RBC-4.03* Hgb-12.6 Hct-38.9
MCV-97 MCH-31.3 MCHC-32.4 RDW-12.5 Plt Ct-428
[**2134-11-28**] 08:10AM BLOOD PT-12.2 PTT-22.6* INR(PT)-1.1
[**2134-11-26**] 03:30PM BLOOD Glucose-97 UreaN-13 Creat-0.6 Na-145
K-3.5 Cl-105 HCO3-32 AnGap-12
[**2134-12-4**] 08:32AM BLOOD ALT-28 AST-24 LD(LDH)-158 AlkPhos-80
TotBili-0.3
[**2134-11-27**] 06:00AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
On Discharge:
[**2134-12-10**] 05:45AM BLOOD WBC-10.4 RBC-3.35* Hgb-10.6* Hct-32.4*
MCV-97 MCH-31.5 MCHC-32.6 RDW-13.6 Plt Ct-236
[**2134-12-9**] 05:50AM BLOOD PT-14.5* PTT-30.7 INR(PT)-1.4*
[**2134-12-10**] 05:45AM BLOOD Glucose-102* UreaN-16 Creat-0.4 Na-139
K-4.0 Cl-100 HCO3-36* AnGap-7*
[**2134-12-10**] 05:45AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.1
Studies:
.
[**11-30**] TTE: IMPRESSION: Aortic valve mass, probably a vegetation.
No associated aortic regurgitation. Moderate mitral and
tricuspid regurgitation
.
[**12-1**] TEE Esophagus was successfully intubated with TEE probe.
Prior to the acquisition of any pictures the patient developed
stridorous breathing which resolved fully following removal of
the TEE probe. The procedure was aborted at that time. The
patient was closely monitored in the TEE room until sedation
wore off and she fully recovered back to baseline. There was no
further stridor noted.
.
[**12-4**] CT Head: IMPRESSION: No acute intracranial process; exam
limited by exclusion of the superior-most aspect of the brain.
.
[**12-5**] CT Chest: IMPRESSION: 1. No pneumonia. 2. Mild pulmonary
edema. Moderate right and small left pleural effusions,
moderately severe bibasilar atelectasis. New moderate
cardiomegaly. 3. New severe multilevel thoracic vertebral
compression fractures.
.
[**12-9**] CXR: PFI: Improved appearance of right lung with residual
right cardiophrenic consolidation with trace right pleural
effusion; unchanged retrocardiac consolidation with small left
pleural effusion.
Brief Hospital Course:
Assessment and Plan: Ms. [**Known lastname 2564**] is an 83 y/o F with HTN, COPD
and RA who presented with cellulitis and afib with RVR in the
ED. Found to be bacteremic on the floor and found to have aortic
valve vegitation.
.
# Strep viridans bacteremia - The patient initially presented
with cellulitis of her left leg and was treated with oral
antibiotics. On Day #3 of therapy, [**12-29**] blood cultures drawn at
admission returned (+) for Strep Viridans. She was started on IV
ceftriaxone on [**2134-11-29**]. The patient underwent TTE which
revealed an aoritc valve vegitation. Plan was for TEE however,
during the procedure, the patient became stridorous (as
described in detail below) and required intubation and MICU
transfer. In the MICU, the patient underwent TEE which again
demonstrated the aortic valve vegitation. On [**2134-12-8**], the
patient was HD stable and was able to return to the medicine
floor from the MICU. A midline was placed for long term
antibiotic therapy. The patient will be discharged to a rehab
center where she will continue antibiotic therapy for 1 month
and follow-up with ID as an outpatient.
.
# Respiratory distress: On [**2134-12-1**] a TEE was attempted
however had to be abandoned as the patient became stridorous
during the procedure. Following this event, the patient was
stable on the floor until ~6pm when she began to develop
respiratory distress. Despite agressive measures including IV
steroids, nebs, O2, lasix, and racemic epi the patient required
intubation and was transferred to the MICU. In the MICU the
patient was diuresed further and continued on
albuterol/ipratropium for COPD. Was also started on methylpred
60 mg q8h. Imaging showed a mild left effusion and atelectasis.
Extubated on MICU day #1 without event. During her ICU course,
the patient would intermittently develop respiratory distress
and stridor, with saturations dipping into the low 80s. She
underwent BiPAP intermittently overnight, then was changed to
nasal BiPAP after her respiratory status improved. On the floor,
the patient self-discontinued BiPAP due to discomfort. Seen by
ENT who scoped to the level of the vocal cords but found no
abnormality. Etiology of respiratory decompensation is unclear
although is believed to be related to possible upper airway
edema exacerbated by TEE/intubation. Also has poor reserve with
underlying COPD and severe kyphosis.
.
# Afib with RVR - The patient was noted to be in afib with RVR
while in the ED. No known h/o afib. In the hospital she was
initially controlled with IV metoprolol and loaded with orals.
Oral metoprolol titrated to 200mg daily and converted to long
acting. Given CHADS2 score of 2, anti-coagulation was
recommended and the patient was agreeable. Started on warfarin
without bridge and will continue warfarin on an outpatient
basis. Goal INR [**1-28**].
.
# Osteoporosis - In house, the patient was incidentally found to
have a number of new compression fractures on imaging. Is
writted for alendronate, vitamin D, and calcium at home although
reports not reliably taking the alendronate. She was maintained
on calcium and vitamin D in house. Received Alendronate on
Mondays per home schedule. She never complained of pain related
to compression fractures.
.
# COPD - The patient carries a history of COPD. This may have
contributed to respiratory decompensation described above. In
house she was continued on standing nebulizer therapy. Prior to
discharge, the patient continued to have a dry, hacking cough
and an increased oxygen requirement (2L NC to maintain sats
~94%). Given relatively clear imaging, a COPD exacerbation was
suspected and the patient was discharged with plans to complete
a steroid taper and a 5 day course of azithromycin.
.
# HTN - The patient has a h/o HTN and was on atenolol at home.
This was changed to metoprolol in house and she will be
discharged with plans to continue metoprolol.
.
# RA - Has a history of what is apparently rather severe RA. Not
on any medications to control disease at home. Attempted to
contact the patient's rheumatologist although he has apparently
recently retired.
.
# Transitional Issues:
1) Continue Ceftriaxone to complete a 1 month course and
follow-up with infectious disease clinic as scheduled.
2) Recommend referral to see a new rheumatologist (former
rheumatologist retired) and a pulmonologist.
3) Continue Metoprolol 200mg daily for atrial fibrillation
4) Continue coumadin daily and follow-up with [**State 95465**] [**Hospital 2786**] clinic
5) Complete steroid taper and course of azithromycin
Medications on Admission:
MEDICATIONS: (at home)
ALENDRONATE - 70 mg Tablet Weekly
ATENOLOL - 25 mg Daily
FLUTICASONE [FLOVENT DISKUS]
meloxicam 15 mg Tablet Daily
OXYCODONE-ACETAMINOPHEN [ROXICET] - 1 tab Q6H;PRN for pain
MULTIVITAMIN
.
MEDICATIONS: (on transfer)
Ipratropium Neb 1 NEB IH Q6H:PRN SOB/Wheezing
Acetaminophen 325-650 mg PO/NG Q4H:PRN pain or fever
Albuterol Inhaler [**12-27**] PUFF IH Q4H:PRN wheezing/shortness of
breath MethylPREDNISolone Sodium Succ 125 mg x1
Aspirin 81 mg PO/NG DAILY
Metoprolol Succinate XL 200 mg PO DAILY
Alendronate Sodium 70 mg PO QMON
Metoprolol Tartrate 5 mg IV x2
Metoprolol Tartrate 25 mg PO/NG ONCE
Benzonatate 100 mg PO TID
Magnesium Sulfate 2 gm IV ONCE
CeftriaXONE 1 gm IV Q24H day 1 [**11-26**]
MethylPREDNISolone Sodium Succ 125 mg IV Q6H start [**12-2**]
Docusate Sodium 100 mg PO BID
PredniSONE 40 mg PO/NG DAILY
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Racepinephrine 0.5 mL IH ONCE x2
Furosemide 20 mg IV ONCE
Senna 2 TAB PO/NG HS
Guaifenesin [**5-4**] mL PO/NG Q4H:PRN cough
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Monday.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime:
Please follow up with your [**Hospital 2786**] clinic for further
management of your dosing.
Disp:*30 Tablet(s)* Refills:*1*
4. multivitamin Tablet Sig: One (1) Tablet PO once a day.
5. ceftriaxone 1 gram Recon Soln Sig: One (1) Intravenous once
a day: Please continue on Ceftriaxone until instructed otherwise
at your infectious disease clinic follow-up.
6. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day:
Continue 4 pills daily for 3 days. Then 3 pills daily for 3 days
then 2 pills daily for 3 days then STOP.
Disp:*28 Tablet(s)* Refills:*0*
7. metoprolol succinate 200 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*
8. meloxicam 15 mg Tablet Sig: One (1) Tablet PO once a day.
9. azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
10. Flovent Diskus 100 mcg/Actuation Disk with Device Sig: Two
(2) Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Cellulitis, Atrial Fibrillation, respiratory failure
Cellulitis, Atrial Fibrillation, Endocarditis
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 at [**Hospital1 18**]!
You were admitted with a skin infection of your leg. In the
emergency room you were also found to have an abnormal heart
rhythym called atrial fibrillation. You were treated with
antibiotics for the skin infection with improvement. You were
also treated with a medication to slow your heart rate and were
started on a blood thinning medication to prevent stroke.
Additionally, you were found to have an infection of your
bloodstream and of your heart valve. For this you will be
discharged on a 4 week course of intravenous antibiotics.
See below for changes to your home medication regimen:
1) Please START Metoprolol 200mg once daily
2) Please START Warfarin 0.5mg in the evening. You will
follow-up with the [**State **] Square-[**Hospital1 18**] office
[**Hospital 2786**] clinic for further changes to your dosing
3) Please CONTINUE Ceftriaxone until otherwise instructed by the
infectious disease clinic
4) Please START Aspirin 81mg DAilY
5) Please STOP Atenolol
6) Please CONTINUE Prednisone 4 pills daily for 3 days. Then 3
pills daily for 3 days then 2 pills daily for 3 days then STOP.
7) Please CONTINUE Azithromycin 250mg daily for 3 additional
days to complete a 5 day course
8) Please STOP Roxicet
See below for instructions regarding follow-up care:
Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2134-12-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please follow-up with your primary care phsyician ([**Doctor Last Name 2204**],
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**Telephone/Fax (1) 2205**]) within 7 days of discharge from your
rehabilitation facility.
Completed by:[**2134-12-13**]
|
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11794, 11866
|
4906, 9030
|
395, 402
|
12010, 12010
|
2934, 2934
|
13514, 14130
|
1763, 1794
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10547, 11771
|
11887, 11989
|
9498, 10524
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12161, 13491
|
1809, 1809
|
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258, 357
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430, 1502
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4298, 4883
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2948, 3359
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12025, 12137
|
9053, 9472
|
1524, 1607
|
1623, 1747
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,096
| 103,715
|
50969
|
Discharge summary
|
Report
|
Admission Date: [**2186-7-25**] Discharge Date: [**2186-7-27**]
Date of Birth: [**2122-12-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy with placement of 4 cecal clips [**2186-7-26**]
History of Present Illness:
63F with a history of HTN, HLD, and DCIS s/p bilateral
mastectomy who presents with hematochezia x 12 hours, DOE, and
significant malaise. She underwent a screening colonoscopy on
[**2186-7-18**] where she was found to have a 5mm x 10mm sessile polyp
in the cecum, 1 x 2mm sessile polyp in the cecum, and a 4mm
sessile polyp in the sigmoid colon as well as several small
AVMs, mild diverticulosis, and internal hemorrhoids. For a few
days after her colonoscopy she was feeling somewhat unwell but
denies abdominal pain or cramping, hematochezia, dark stool,
maroon stool, DOE, or orthostatic symptoms. She fully recovered
and felt fine for a week. The evening prior to admission she
suddenly developed crampy lower abdominal pain and an urge to go
to the bathroom. She have 4 bouts of diarrhea of brown stool as
well as bright red blood. She denies blood clots or maroon
stool. She felt weak after the BMs and could barely walk back to
her office. A colleague drove her home. That evening she had DOE
walking in the yard with her dog. She called the on call service
at [**Location (un) 2274**] and was advised to stay well hydrated and consider
coming to the ED, but refused. The following morning she
conitnued to feel tired and weak. her abdominal cramps returned
and she had 4 more bouts of diarrhea with bright red blood. She
felt so weak she could barely stand and was dizzy with sitting
up. Her son called 911 and she was transported to the ED for
further management.
.
In the ED initial vital signs were 97.9 72 140/90 20 100% on RA.
Initial labs were notable for a H/H of 9.8/28.9 from a baseline
of 14.5/42.8 in 11/[**2184**]. Two 18G PIVs were placed and an ECG
showed no ischemic changed. She received NS 2000mL and was seen
by GI who recommended ICU admission and a PPI. She was
transfered to the ICU for further management.
.
In the [**Hospital Unit Name 153**] she is tired but denies and CP, chest pressure, SOB,
palpitations, or HA. She reports dizziness when she sits up and
some stomach grumbling, but no cramps. She denies any history of
bleeding problems, GIB bleeding, clotting problems, GERD, heart
burn, or jaundice.
.
She was consented for ICU care.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denied nausea, vomiting.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. No feelings of depression or
anxiety. All other review of systems negative.
Past Medical History:
- DCIS s/p mastectomy
- Osteopenia
- Hypercholesterolemia
- Vulvodynia
- Hx of BCC and SCC
- Rhinitis
- Constipation
- Sciatica
- Cervicalgia
- HTN
- Osteoarthritis
- Blistering dermatitis NOS
Social History:
- Tobacco: Denies
- etOH: Social
- Illicits: Distant marijuana, no IVDU or other illicits
Family History:
- Mother: [**Name (NI) 2481**] dementia
- Father: CAD s/p CABG, melanoma
- Sister: Breast cancer
Physical Exam:
GEN: NAD, pale
VS: 97.0 87 supine: 153/93 sitting 133/88 17 99% on RA
HEENT: MMM, no OP lesions, JVP below the clavicle, neck is
supple, no cervical, supraclavicular, or axillary LAD, normal
geographic tongue
CV: RR, NL S1S2 no S3S4, II/VI low systolic murmur at the LUSB
PULM: CTAB
ABD: BS++, soft, nondistended, liver tender and palpable 3cm
below the costal margin in the mid clavicular line, no stigmata
of chronic liver disease
LIMBS: No LE edema, no tremors or asterixis, no clubbing, no
koilonychia
SKIN: No rashes or skin breakdown
NEURO: Strength 5/5 of the upper and lower extremities, reflexes
2+ of the upper and lower extremities
Pertinent Results:
Labs on Admission:
[**2186-7-25**] 11:51PM GLUCOSE-95 UREA N-11 CREAT-0.7 SODIUM-145
POTASSIUM-3.5 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13
[**2186-7-25**] 11:51PM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-2.3
[**2186-7-25**] 11:51PM WBC-6.6 RBC-2.48* HGB-7.9* HCT-22.8* MCV-92
MCH-31.8 MCHC-34.6 RDW-12.8
[**2186-7-25**] 11:51PM PLT COUNT-216
[**2186-7-25**] 05:01PM WBC-8.2 RBC-3.19* HGB-9.9* HCT-29.5* MCV-93
MCH-31.2 MCHC-33.7 RDW-11.9
[**2186-7-25**] 05:01PM PLT COUNT-277
[**2186-7-25**] 02:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2186-7-25**] 02:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2186-7-25**] 02:40PM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2186-7-25**] 12:30PM GLUCOSE-145* UREA N-23* CREAT-0.8 SODIUM-134
POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-26 ANION GAP-12
[**2186-7-25**] 12:30PM ALT(SGPT)-21 AST(SGOT)-30 LD(LDH)-222 ALK
PHOS-52 TOT BILI-0.4
[**2186-7-25**] 12:30PM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-2.9
MAGNESIUM-1.8 IRON-73
[**2186-7-25**] 12:30PM calTIBC-272 VIT B12-513 FOLATE-10.3
FERRITIN-72 TRF-209
[**2186-7-25**] 12:30PM WBC-7.6 RBC-3.23* HGB-9.8* HCT-28.9* MCV-90
MCH-30.4 MCHC-34.0 RDW-12.7
[**2186-7-25**] 12:30PM NEUTS-79.0* LYMPHS-17.1* MONOS-3.3 EOS-0.5
BASOS-0.2
[**2186-7-25**] 12:30PM PLT COUNT-249
[**2186-7-25**] 12:03PM GLUCOSE-167* UREA N-22* CREAT-0.8 SODIUM-133
POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13
[**2186-7-25**] 12:03PM estGFR-Using this
CTA-Ab [**2186-7-26**]:
No acute intra-abd or pelvic abnl. Patent mesenteric vasculature
and no e/o
active extravasation.
.
Ab US [**2186-7-25**]
1.3-cm predominantly hypoechoic lesion of the pancreas.
Though likely benign and possibly sequellae of processes such as
pancreatitis,
dedicated MRCP (on a nonemergent basis) of the pancreas
recommended for
further evaluation.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
# Lower GI Bleed: Admitted with a Hct of 29 from baseline 43 and
orthostatic by vital signs. She was aggressively volume
resuscitated with 5 L of crystalloid and transfused 2 units of
PRBCs after continuning to pass dilute blood with a Golytely
prep, which was then held the first night of the hospitalization
after completing half of the prep. On hospital day 2, she
underwent colonoscopy, which was remarkable for bleeding in the
cecum, the site of 2 of her polypectomies 9 days prior to
admission; 4 clips were placed with adequate hemostasis. Her
volume and hematocrit subsequently remained stable. She was
discharged home in stable condition.
# Tender hepatomegaly: The patient's liver was slightly tender
to palpation on admission, which prompted and abdominal
ultrasound, which subsequently showed that the liver was normal.
# Pancreatic cyst on US: On abdominal ultrasound a pancreatic
cyst was found incidentally described as a 1.3 x 0.6 x 0.6 cm
predominantly hypoechoic lesion in the pancreatic head/neck; it
is likely benign. This will be further evaluated on an
outpatient basis after discharge with an MRCP.
Medications on Admission:
- Simvastatin 60mg PO HS
- HCTZ 12.5mg PO HS
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: Three (3) Tablet PO at bedtime.
Tablet(s)
2. STOPPED: Hydrochlorothiazide 12.5 mg Capsule Sig: One (1)
Capsule PO once a day: Take in mornings; Restart in a week
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed from cecal polypectomy site
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a privilege to take care of you in the hospital.
.
You were hospitalized for a bleed in your colon caused by the
re-bleeding of one of your polypectomy sites in your cecum. You
were admitted to the ICU with a low blood count and low blood
pressures when sitting up and standing. We resuscitated your
volume and blood coutns with IV fluids and 2 units of packed red
blood cells. A CT of yoru abdomen did not show the bleeding
source, but a colonoscopy revealed the source, which was stopped
with clips. You also underwent an abdominal ultrasound because
your liver was slightly tender on admission, which showed a
normal liver but an incidental finding of a pancreatic cyst. We
recommend that you have this finding evaluated further as an
outpatient.
.
No changes were made to your home medications.
Followup Instructions:
Please schedule an appointment with Gastroenterology for
evaluation of your pancreas
|
[
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7710, 7716
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6270, 7395
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344, 405
|
7803, 7803
|
4253, 4258
|
8784, 8872
|
3468, 3569
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7490, 7687
|
7737, 7782
|
7421, 7467
|
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3584, 4234
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277, 306
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433, 2609
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4273, 6247
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7818, 7930
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3146, 3341
|
3357, 3452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
96,443
| 103,219
|
545808
|
Physician
|
CVI
|
TITLE:
CVICU
HPI:
64 y.o. F POD 8 from replacement of R-sided desc. thoracic aorta (26mm
gelweave graft), POD # 5 from Rt bronchial Y-stent placement,
complicated by RLL and RML pneumonia, ARDS and sepsis
PMHx:
CAD, bronchus compression, CVA ([**Doctor First Name 1463**] occlusion), CTD w features of
Sjogren's, SLE, raynaud's, interstitial lung dz, hypothyroidism, GERD,
R kidney cyst
PSH: CABGx1 (LIMA>LAD) [**2104**], L carotid-subclavian BP, amplatzer
plugging of aberrant L subclavian, R lung resection (wedge),
ccy/carcinoid tumor removal with colonoscopy
Current medications:
24 Hour Events:
UNPLANNED EXTUBATION (PATIENT-INITIATED) - At [**2109-12-27**] 09:00 AM
INTUBATION - At [**2109-12-27**] 09:03 AM
ARTERIAL LINE - START [**2109-12-27**] 09:07 AM
BRONCHOSCOPY - At [**2109-12-27**] 09:10 AM
BLOOD CULTURED - At [**2109-12-27**] 10:00 AM
SPUTUM CULTURE - At [**2109-12-27**] 10:00 AM
URINE CULTURE - At [**2109-12-27**] 10:00 AM
PICC LINE - START [**2109-12-27**] 11:54 AM
Post operative day:
POD#5 - S/P Rigid and flexible bronch with Y stent placement in
mainstem
24 hour events: picc line placed, aline placed, respiratory distress
intubated with difficulty oxygenating, hypotension with increased
pressor requirement
Allergies:
Quinine
"pass out
[**Doctor Last Name **]
Last dose of Antibiotics:
Ciprofloxacin - [**2109-12-27**] 01:01 PM
Vancomycin - [**2109-12-27**] 02:07 PM
Piperacillin/Tazobactam (Zosyn) - [**2109-12-27**] 06:00 PM
Fluconazole - [**2109-12-27**] 08:52 PM
Piperacillin - [**2109-12-28**] 04:26 AM
Infusions:
Midazolam (Versed) - 2 mg/hour
Norepinephrine - 0.14 mcg/Kg/min
Phenylephrine - 1.5 mcg/Kg/min
Fentanyl - 250 mcg/hour
Cisatracurium - 0.14 mg/Kg/hour
Other ICU medications:
Midazolam (Versed) - [**2109-12-27**] 12:30 PM
Fentanyl - [**2109-12-27**] 03:20 PM
Lorazepam (Ativan) - [**2109-12-27**] 03:28 PM
Other medications:
Flowsheet Data as of [**2109-12-28**] 10:16 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**13**] a.m.
Tmax: 38
C (100.4
T current: 38
C (100.4
HR: 111 (84 - 124) bpm
BP: 117/46(64) {78/36(49) - 117/55(74)} mmHg
RR: 30 (21 - 39) insp/min
SPO2: 82%
Heart rhythm: ST (Sinus Tachycardia)
Wgt (current): 73 kg (admission): 63.4 kg
Height: 67 Inch
CVP: 13 (13 - 16) mmHg
Total In:
2,290 mL
873 mL
PO:
Tube feeding:
IV Fluid:
1,290 mL
873 mL
Blood products:
1,000 mL
Total out:
840 mL
129 mL
Urine:
785 mL
129 mL
NG:
Stool:
Drains:
Balance:
1,450 mL
744 mL
Respiratory support
O2 Delivery Device: Endotracheal tube
Ventilator mode: PCV+Assist
Vt (Set): 330 (330 - 400) mL
Vt (Spontaneous): 299 (299 - 430) mL
PS : 18 cmH2O
RR (Set): 30
RR (Spontaneous): 0
PEEP: 12 cmH2O
FiO2: 100%
RSBI Deferred: PEEP > 10, FiO2 > 60%, Unstable Airway
PIP: 31 cmH2O
Plateau: 30 cmH2O
Compliance: 19 cmH2O/mL
SPO2: 82%
ABG: 7.33/57/107/31/2
Ve: 9.2 L/min
PaO2 / FiO2: 134
Physical Examination
HEENT: PERRL
Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)
Diastolic), Tachycardia
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
on R-base, Diminished: Throughout)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -
Dorsalis pedis: Diminished)
Right Extremities: (Edema: Absent), (Temperature: Cool), (Pulse -
Dorsalis pedis: Diminished)
Skin: (Incision: Clean / Dry / Intact)
Neurologic: Sedated, Chemically paralyzed
Labs / Radiology
251 K/uL
8.9 g/dL
92 mg/dL
1.1 mg/dL
31 mEq/L
4.2 mEq/L
31 mg/dL
102 mEq/L
139 mEq/L
29
11.0 K/uL
[**2109-12-27**] 07:51 PM
[**2109-12-27**] 10:00 PM
[**2109-12-27**] 10:43 PM
[**2109-12-27**] 11:46 PM
[**2109-12-28**] 01:04 AM
[**2109-12-28**] 01:18 AM
[**2109-12-28**] 03:08 AM
[**2109-12-28**] 04:34 AM
[**2109-12-28**] 06:39 AM
[**2109-12-28**] 09:41 AM
WBC
11.0
Hct
32
32
27.1
29
Plt
251
Creatinine
1.1
TCO2
34
33
34
33
33
32
32
32
31
Glucose
88
116
111
102
92
Other labs: PT / PTT / INR:15.4/33.6/1.4, ALT / AST:[**11-18**], Alk-Phos / T
bili:62/1.4, Amylase / Lipase:18/, Fibrinogen:183 mg/dL, Lactic
Acid:2.2 mmol/L, Albumin:3.0 g/dL, Ca:7.8 mg/dL, Mg:2.3 mg/dL, PO4:1.7
mg/dL
Assessment and Plan
Neurologic: Neuro checks Q 2 hr, Pain controlled, Fentanyl and versed
drip for sedation, paralyzed due to hypoxia and difficulty oxygenating
Cardiovascular: Aspirin, place [**Last Name (un) **] for hemodynamic monitoring Add
vasopressin and wean Levophed for SBP > 100, then attempt to wean neo
Pulmonary: Cont ETT, (Ventilator mode: Other), improved with PCV with
inverse ratio ? ARDS. Low TV ventilation. Optimal PEEP per esophageal
balloon is 12. wean Fio2 as tolerated
Gastrointestinal / Abdomen: No issues
Nutrition: NPO
Renal: Foley, Oliguria will attempt gentle diuresis with lasix drip -
Goal even to 500ml negative
Hematology: Serial Hct, Stable anemia. Monitor
Endocrine: RISS, Glucose well controlled. Keep < 150
Infectious Disease: Check cultures, RLL and RML pneumonia and (GPC GRN
in BAL), GPC in venopuncture and GNR in urine. On
Vanco/cipro/zosyn/fluconazole for coverage. Vanco level prior to 4^th
dose
Lines / Tubes / Drains: Foley, OGT, ETT, Chest tube - pleural
Wounds: Dry dressings
Imaging: CXR today
Fluids: KVO
Consults: PT, IP
ICU Care
Nutrition:
Glycemic Control: Regular insulin sliding scale
Lines:
Arterial Line - [**2109-12-27**] 09:07 AM
20 Gauge - [**2109-12-27**] 11:53 AM
PICC Line - [**2109-12-27**] 11:54 AM
18 Gauge - [**2109-12-27**] 11:22 PM
Multi Lumen - [**2109-12-28**] 08:24 AM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: PPI
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: Patient discussed on interdisciplinary rounds , ICU
Code status: Full code
Disposition: ICU
|
[
"038.49",
"414.00",
"710.2"
] |
icd9cm
|
[
[
[
204,
218
]
],
[
[
232,
234
]
],
[
[
326,
334
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
626, 5466
|
5478, 7390
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
97,582
| 166,145
|
34873
|
Discharge summary
|
Report
|
Admission Date: [**2185-8-6**] Discharge Date: [**2185-8-10**]
Date of Birth: [**2133-5-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
wound infection/hematoma
Major Surgical or Invasive Procedure:
drainage of hematoma
History of Present Illness:
52yoM with Hep C and h/o IVDA, POD#11
s/p right ilioprofunda bypass with Dacron tube graft after found
to have occluded right fem-AK popliteal bypass, now presents
from
[**Hospital3 8544**] hypotensive (sbp 80s) with erythematous wound
and
2.2x1.8x4.0cm fluid collection within right groin incision per
CT
scan. Reportedly, feeling well although noted groin incision
progressively "red" over past 2-3 days. He denies tenderness or
drainage from wound, fever/chills, nausea/vomiting,
numbness/tingling of extremities, or difficulty walking. On
presentation to OSH, found to be afebrile but hypotensive with
sbp 80s, with erythematous staple line, without dopplerable
right
lower extremity pulse, and reportedly with Cr 5.1. He was given
3L IVF, vancomycin and levofloxacin, and underwent CT lower
extremity prior to being transferred to [**Hospital1 18**] for further
evaluation and [**Hospital1 **].
Past Medical History:
PAST MEDICAL HISTORY: Hepatitis C, h/o CVA [**2180**], h/o adrenal
insufficiency, h/o IVDA, h/o tobacco use
PAST SURGICAL HISTORY: h/o fem-AK popliteal bypass, right
iliofemoral and profunda endarterectomy with Dacron patch
angioplasty ([**3-/2184**]), angiogram ([**2185-7-25**]) - occluded fem-AK [**Doctor Last Name **]
at proximal portion with reconstitution of flow at R profunda
femoris artery distally, s/p right ilioprofunda bypass with
Dacron tube graft ([**2185-7-26**])
Social History:
divorced
lives with mother and x-wife house
current tobacco use
former IV drug abuse, not at present- heroin
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline.
Nodes: No clavicular/cervical adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses.
Rectal: Abnormal: Guaiac positive.
Extremities: No RLE edema, No LLE Edema, No varicosities.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE DP: N. PT: D.
LLE DP: D. PT: D.
DESCRIPTION OF WOUND: right groin staple line intact; wound with
increased warmth, erythematous and tender with no drainage
expressible
Pertinent Results:
[**2185-8-6**] 02:15AM PLT COUNT-129*#
[**2185-8-6**] 02:15AM WBC-6.0 RBC-3.90* HGB-12.5* HCT-36.7* MCV-94
MCH-32.1* MCHC-34.1 RDW-13.9
[**2185-8-6**] 02:15AM ALT(SGPT)-240* AST(SGOT)-191* LD(LDH)-172 ALK
PHOS-72 AMYLASE-102* TOT BILI-0.5
[**2185-8-6**] 02:15AM GLUCOSE-115* UREA N-33* CREAT-3.7*#
SODIUM-133 POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-21* ANION GAP-15
Brief Hospital Course:
In the ED, patient was hypotensive after 2 L fluid bolus and was
subsequently started on Levophed and admitted to the SICU.
Cipro, Flagyl, and vancomycin were started. Staples were removed
from the groin site and the wound was packed with significant
serous drainage noted. Echocardiogram showed normal ventricular
function and was negative for effusion and vegetation. On
hospital day 2, Levophed was weaned off.Creatinine declined to
1.0. Blood cultures were positive for GPC in clusters. Wound
culture grew MRSA. On hospital day 3, patient remained
hemodynamically stable and was subsequently transferred out of
the SICU to the floor. A Wound-Vac was placed over the right
groin site. Metoprolol 25 mg [**Hospital1 **] was added for hypertension with
improvement.
The day of discharge, Vac was removed for transfer and wound was
found to be granulating well. Patient was ambulating and
tolerating a regular diet. Pain was well-controlled. Patient is
to be discharged on 2 weeks oral Bactrim/Cipro/Flagyl.
Medications on Admission:
lisinopril 10 mg daily, escitalopram 10 mg daily, colace 100 mg
[**Hospital1 **],simvastatin 10 mg daily, ASA 81 mg daily, plavix 75 mg daily
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
11. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a wound infection of your left groin with
presumed sepsis. The wound was incised and drained and you were
started on antibiotics. The wound culture suggested you were
infected with methicillin-resistant staph aureus (MRSA). We
started you on metoprolol 25 mg orally twice a day for
[**Location (un) **] of your blood pressure.
1) You should continue the antibiotics by mouth for 2 weeks.
2) A nurse will come to your home to change the dressing for the
Wound VAC. You should get daily wet-to-dry dressing changes
until the WoundVac arrives.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*Keep your groin incision clean and dry after WoundVac dressing
placement.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 8343**] to schedule an
appointment.
Follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of your
blood pressure.
|
[
"998.12",
"070.54",
"998.59",
"038.12"
] |
icd9cm
|
[
[
[
290,
297
]
],
[
[
399,
403
]
],
[
[
5518,
5532
]
],
[
[
5781,
5787
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5439, 5497
|
2983, 3992
|
338, 360
|
5557, 5557
|
2588, 2960
|
8255, 8481
|
1940, 1957
|
4186, 5416
|
5518, 5536
|
4018, 4163
|
5708, 7161
|
7955, 8232
|
1444, 1796
|
1972, 2569
|
7193, 7940
|
274, 300
|
388, 1290
|
5572, 5684
|
1334, 1421
|
1812, 1924
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
89,766
| 144,665
|
995
|
Discharge summary
|
Report
|
Admission Date: [**2136-2-19**] Discharge Date: [**2136-2-24**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
CC:[**CC Contact Info 6576**]
Major Surgical or Invasive Procedure:
[**2-20**] ORIF of Rt Hip
History of Present Illness:
HPI:[**Age over 90 **]F s/p mechanical fall from standing, no LOC, no syncope.
Transferred from OSH for small traumatic Lt occipital SAH and R
hip fx
PMx: CAD s/p CABG x3 in [**2112**], Systolic CHF, EF approx 30-40%,
Chronic AF, not on coumadin [**1-2**] fall w/SDH [**11/2134**]; Cardiac
valvular HD, moderate to severe MR [**First Name (Titles) **] [**Last Name (Titles) **], HTN, hyperlipidemia,
Restless legs syndrome, Hypothyroidism, PVD - L RAS, treated
medically; PVD s/p b/l revascularization w/ acute occlusion of R
LE s/p atherotomy w/stent [**2134**]
[**Last Name (un) 1724**]:
ATENOLOL 50'', CLOPIDOGREL 75', LEVOTHYROXINE 62.5' (125 mcg
[**12-2**] tab QD), LISINOPRIL 20'', SLN 0.3 PRN chest pain, KCl SR 10
mEq 2 tabs' ROPINIROLE 0.25' HS, SIMVASTATIN 10', TORSEMIDE -
20 mg 2 tab qAM, 1 tab q PM PRN SOB; tylenol 500 1 tab TID PRN;
ARTIFICIAL TEARS 0.4 % Drops - 2 qtt [**Hospital1 **] PRN, ASA', CALCIUM
CARBONATE 500', DOCUSATE SODIUM 100'', ERGOCALCIFEROL 400'',
MULTIVITAMIN '
Social Hx:no EtOH, no tobacco
Past Medical History:
1. Congestive heart failure (As above)
2. Hypertension.
3. Hypothyroidism.
4. Atrial fibrillation: Not on coumadin [**1-2**] fall risk
5. Hypercholesterolemia
6. Coronary artery disease
7. Gait disturbance
8. Subarachnoid hemorrhage.
9. Hearing loss, which has gotten worse since the torsemide.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
PE:
VS: 97.7 64 160/98 12 100% RA
HEENT PERRLA, EOMI, TMs clear, no evidence of facial trauma
CV: Irregular, 2+ femoral pulses
Resp: eaqual bilateral breath sounds, no crepitus or contusion
GI: Abd softt/NT/ND
GU: No blood at ureteral meatus
Musculoskeletal: RLE externally rotated and shortened, obvious
defomity, tender, sensation intact to light touch, good cap
refill
Pertinent Results:
[**2136-2-24**] 01:11AM BLOOD WBC-9.4 RBC-2.98* Hgb-9.9* Hct-28.0*
MCV-94 MCH-33.4* MCHC-35.5* RDW-15.0 Plt Ct-191
0
[**2136-2-24**] 01:11AM BLOOD Glucose-94 UreaN-25* Creat-0.8 Na-142
K-3.2* Cl-100 HCO3-35* AnGap-10
[**2136-2-21**] 01:41AM BLOOD CK-MB-8 cTropnT-0.14*
[**2136-2-21**] 09:22AM BLOOD CK-MB-9 cTropnT-0.26*
[**2136-2-21**] 06:20PM BLOOD CK-MB-7 cTropnT-0.23*
Brief Hospital Course:
The patient was transferred from OSH to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**]
[**Last Name (NamePattern1) **] Hospital, she was seen in the Trauma Bay by Trauma
Surgery, Neurosurgery and Orthopedic Surgery were also
consulted. Repeat CT demonstrated stable small SAH and plain
films of the pelvis confirmed Rt hip fracture. she was
transferred to the Trauma ICU in stable condition. The remainder
of her discharge will be done by systems:
Neuro: The patient had a repeat Head CT on [**2135-2-20**] which showed
stable SAH. Neurosurgery recommended holding her plavix for 7
days, no need for seizure prophylaxis. She was AOx3 with some
episodes of confusion likely [**1-2**] dementia. Her neurological exam
remained stable throughout the remainder of her hospital stay.
CV: The patient has a h/o chronic Afib, post operatively she
went into AF w/ RVR with a rate in the 120s, she was hypotensive
and required Neo for BP suppory She was ruled out for MI, her
troponins were mildly elevated 0.26 maximally. She was started
on a Dilt gtt for rate controlHer Hct was 27 and she reecieved 1
unit of PRBC. She has an ECHO which demonstrated EF > 55% w/
mild LVH, Rt ventricular cavity dilated with normal free wall
contractility and moderate TR. Cardiology was consulted and
felt that the troponin leak was likely [**1-2**] demand ischemia. They
recommended continuing on ASA, beta blockade, rate control, and
statin, restarting plavix when able. They did not recommend
anticogulation given her fall risk. The patient was weaned off
pressors, she was transitioned from Dilt gtt to a po regimen of
Dilt 45mg QID and Lopressor 75 TID with adequate rate control.
She is to restart her plavix on [**2136-2-25**]
Resp: The patient used incentive spirometer, and good pulmonary
toilette was give. She had nebulizer treatments as needed
GI: The patient's diet was slowly advanced, she was seen by
speech and swallow [**1-2**] to some difficulty swalloing. She was
cleared for a Soft (dysphagia); Thin liquid diet on discharge
GU: The patient had some low UOP in the setting of her AF w/ RVR
and hypovolemia. Her UOP improved and she was restarted on her
home regimen of Torsemide prior to discharge
Heme: The patient was placed on Lovenox for DVT prophylaxis
Endocrine: The patient continued on her home dose of
Levothyroxine
Prior to discharge the patient was doing well. She was
neurologically intact. Her heart rate was irregular, her lungs
were CTAB, her abdomen was soft/NT/ND, Her Rt hip incision was
clean dry and intact. She was tolerating a disphagia diet
without difficulty and her pain was well controlled. She was
discharged to extended care facility with plans for follow-up as
follows:
Please follow-up with Orthopedics Dr. [**Last Name (STitle) 1005**] [**Telephone/Fax (1) 1228**] in
2weeks for a follow-up appointment
Please follow-up with Neurosurgery Dr. [**Last Name (STitle) 6577**]
[**Telephone/Fax (1) 1669**] for a follow-up appt in 1 mos
Medications on Admission:
ATENOLOL 50'', CLOPIDOGREL 75', LEVOTHYROXINE 62.5' (125 mcg [**12-2**]
tab QD), LISINOPRIL 20'', SLN 0.3 PRN chest pain, KCl SR 10 mEq
2 tabs' ROPINIROLE 0.25' HS, SIMVASTATIN 10', TORSEMIDE - 20 mg
2 tab qAM, 1 tab q PM PRN SOB; tylenol 500 1 tab TID PRN;
ARTIFICIAL TEARS 0.4 % Drops - 2 qtt [**Hospital1 **] PRN, ASA', CALCIUM
CARBONATE 500', DOCUSATE SODIUM 100'', ERGOCALCIFEROL 400'',
MULTIVITAMIN '
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
14. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
16. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
17. Torsemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
18. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
19. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
20. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) inj
Subcutaneous Q24H (every 24 hours) for 4 weeks: 30mg SC Q24hrs
for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Multi trauma: Lt occipital SAH, Rt intertrochanteric fracture
Discharge Condition:
Stable
Discharge Instructions:
Please do not drink alcohol or operate heavy machinery while
takig this medication
You may weight bear as tolerated on your Rt leg
Please follow-up with your PCP regarding this admission, your
medications for your heart have been changed please be sure to
discuss these changes with your PCP
Please restart your Plavix tomorrow [**2136-2-25**]
Followup Instructions:
Please follow-up with Orthopedics Dr. [**Last Name (STitle) 1005**] [**Telephone/Fax (1) 1228**] in
2weeks for a follow-up appointment
Please follow-up with Neurosurgery Dr. [**Last Name (STitle) 6577**]
[**Telephone/Fax (1) 1669**] for a follow-up appt in 1 mos
Completed by:[**2136-2-24**]
|
[
"414.00",
"428.22",
"427.31",
"402.91",
"272.4",
"333.94",
"244.9",
"443.9",
"272.0",
"719.7",
"852.01",
"389.9",
"290.10"
] |
icd9cm
|
[
[
[
502,
504
]
],
[
[
533,
544
]
],
[
[
573,
574
]
],
[
[
726,
728
]
],
[
[
731,
744
]
],
[
[
747,
768
]
],
[
[
771,
784
]
],
[
[
819,
821
]
],
[
[
1540,
1559
]
],
[
[
1591,
1606
]
],
[
[
1611,
1634
]
],
[
[
1639,
1650
]
],
[
[
3444,
3451
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7901, 7998
|
2731, 5733
|
290, 318
|
8104, 8113
|
2333, 2708
|
8509, 8804
|
1841, 1923
|
6190, 7878
|
8019, 8083
|
5759, 6167
|
8137, 8486
|
1938, 2314
|
221, 252
|
346, 1380
|
1402, 1699
|
1715, 1825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
98,973
| 152,951
|
47887
|
Discharge summary
|
Report
|
Admission Date: [**2177-2-28**] Discharge Date: [**2177-3-18**]
Service: MEDICINE
Allergies:
Amiodarone / Lopressor / Aspirin / dofetilide
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
DC-CARDIOVERSION X 2
History of Present Illness:
Mrs [**Known lastname 4643**] is a pleasant 87F with hx of intermittent vertigo on
Meclizine, afib on coumadin, recent UTI tx'd with bactrim, now
presenting to the ED for vertigo. Pt states that 4 days ago she
noticed hematuria, which prompted her to go to her PCP, [**Name10 (NameIs) **] which
point she was given bactrim for a UTI. She never had dysuria or
frequency. Today she felt vertiginous and lightheaded and
therefore presented to the ED. Pt states that he vertigo comes
on out of the blue, is not positional or worse with changing
positions. She states that she feels thirsty but has had normal
PO intake over the last several days. Of note, her UA from 4 d
PTA showed leuks, blood, few bacteria, creatinine was 0.87.
Urine cx showed mixed gram positive flora.
In the ED inital vitals were 98.7 60 92/68 (b/l 120/80) 18 100%
10L Non-Rebreather, which was rapidly weaned. Venous gas showed
7.26/48/51. Triggered for hypotension (reportedly 50/30),
central line placed, pt given 500 ccs NS, bedside echo showed
adequate pump funx, no effusion. CVP reportedly 22. Labs were
notable for lactate of 5.3, creatinine 1.9, gap of 16. She was
given zofran, levofloxacin for possible PNA, and started on a
norepi gtt for hypotension. CXR showed central venous catheter
terminating at the cavoatrial junction, mild pulmonary vascular
congestion, l-sided pleural effusion. Line was pulled back.
BPs improved to 100s, no O2 requirement. VItals on transfer
were 98.7 64 17 97/67 100% on 2L NC.
On arrival to the ICU, pt is comfortable. She states that her
breathing is slightly labored however she denies SOB, cough, CP.
She does feel slightly nauseous and weak all over. She does
not currently feel vertiginous, however states that it comes on
suddenly and she was recently feeling nauseous.
Past Medical History:
- Paroxysmal atrial fibrillation on Coumadin.
- Echo in [**2176-8-2**]: LVEF of 60-65%.
- R septic knee: hospitalized from [**2175-2-5**] to [**2175-2-10**] during which
she underwent arthrocentesis then I&D and washout on [**2175-2-5**]
followed by 14 day-course of ceftriaxone
- Breast cancer status post lumpectomy in [**2162-7-4**], also
with six weeks of radiation therapy.
- Chronic low back pain followed at the Pain Clinic.
- History of asthma: Spirometry: Mixed obstructive and
restrictive ventilatory defect. Since [**2171-5-7**], there is no
significant change in spirometry. Since [**2166-12-18**] TLC has
decreased 1.33L (28%).
- Exercise treadmill test echocardiogram in [**2162-8-3**] without
evidence of angina or ischemia after four minutes,
mild-to-moderate mitral regurgitation.
- Sick sinus syndrome with a DDI pacemaker placed.
- Herpes zoster in [**2168-3-5**].
- Hypertension
- ? Alzheimer's dementia
- recent rib fractures
Social History:
Pt lives at home with sister who was recently placed in rehab,
has home health aids. Ambulates with a walker. Quit smoking 10
years ago after almost a decade of smoking, no ETOH, no
illicits. She has 6 children, she previously worked for the
phone company and at [**Last Name (un) 59330**]. One of her daughters is a nurse.
Family History:
Father died of heart disease.
Mother died of CVA.
Sister: Died of emphysema at age 59.
Physical Exam:
Admission Exam:
Vitals: T:94.4 BP:152/57 P:65 R:20 O2: 98% on 2 L NC
General: Aaox3, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: RIJ in place, fresh blood under dressing
Lungs: tachypnic, clear to auscultation bilaterally, mild
crackles in L base
CV: Distant heart sounds, irregular rate, unable to appreciate
any murmurs.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: cool ext, thready pulses, no clubbing, cyanosis or edema
Skin: no rashes, L nipple scarred
Neuro: CNs [**3-16**] intact, moves all ext freely
Discharge Examination:
VS: Tc 98.0 BP 107-128/49-57 HR 69-79 RR 18 O2 96% on RA.
Wt: 66.4<--69.4<--69.6<--70.4<--70.1<--69.1<--70.3 kg.
GEN: pleasant elderly woman, NAD, AOX3. Looks a bit tired and
described some dizziness
CV: nl s1 + s2. Systolic mumur, most loudly auscultated in LUSB.
RESP: pt has poor air entry; otherwise ctab. Some crackles in
left base.
EXTREMITIES: 2+ pulses in all 4 extremities. No peripheral
edema. Pt has a grade 1 stress ulcer on her left ankle.
Complaining of pain in ankle.
NEURO: AOX3, but does get confused intermittently. No neuro
deficits.
Pertinent Results:
Admission Labs:
[**2177-2-28**] 07:15PM BLOOD WBC-11.1* RBC-3.89* Hgb-11.6* Hct-35.9*
MCV-92 MCH-29.8 MCHC-32.3 RDW-13.8 Plt Ct-320
[**2177-2-28**] 07:15PM BLOOD Neuts-84.9* Lymphs-9.8* Monos-3.9 Eos-0.8
Baso-0.5
[**2177-2-28**] 07:15PM BLOOD PT-36.3* PTT-37.6* INR(PT)-3.5*
[**2177-2-28**] 07:10PM BLOOD Glucose-156* UreaN-31* Creat-1.9*#
Na-131* K-5.9* Cl-96 HCO3-17* AnGap-24*
[**2177-2-28**] 07:15PM BLOOD CK(CPK)-116
[**2177-2-28**] 07:15PM BLOOD CK-MB-2 proBNP-4420*
[**2177-2-28**] 07:20PM BLOOD cTropnT-<0.01
[**2177-3-1**] 03:57AM BLOOD CK-MB-2 cTropnT-<0.01
[**2177-3-1**] 03:57AM BLOOD Calcium-8.0* Phos-7.1*# Mg-2.1 Iron-44
[**2177-2-28**] 08:21PM BLOOD pO2-51* pCO2-48* pH-7.26* calTCO2-23 Base
XS--5 Comment-GREEN TOP
[**2177-2-28**] 07:26PM BLOOD Lactate-5.3*
Discharge Labs:
[**2177-3-18**] 06:35AM BLOOD WBC-8.4 RBC-2.96* Hgb-8.5* Hct-26.7*
MCV-90 MCH-28.6 MCHC-31.6 RDW-14.5 Plt Ct-589*
[**2177-3-18**] 06:35AM BLOOD PT-36.3* INR(PT)-3.5*
[**2177-3-18**] 06:35AM BLOOD Glucose-83 UreaN-13 Creat-1.5* Na-138
K-3.6 Cl-94* HCO3-36* AnGap-12
[**2177-3-18**] 06:35AM BLOOD CK-MB-3 cTropnT-<0.01
[**2177-3-17**] 02:06PM BLOOD CK-MB-3 cTropnT-<0.01
[**2177-3-18**] 06:35AM BLOOD Calcium-8.1* Phos-4.6* Mg-1.6
[**2177-3-16**] 10:00PM BLOOD Ret Aut-2.6
[**2177-3-16**] 10:00PM BLOOD PEP-NO SPECIFI
Micro:
Blood cultures: NGTD
Urine culture: NGTD
Stool: -ve
Imaging:
[**2177-3-1**] CXR: Persistent low lung volume. Pulmonary edema has
resolved. Pacer leads are in standard position. Right IJ
catheter tip is in the upper right atrium. There is no evident
pneumothorax. Bilateral pleural effusions are small. Bibasilar
atelectases have improved on the left.
[**2177-3-1**] TTE (Focused views): IMPRESSION: Limited transthoracic
echocardiography. Unable to assess regional wall motion
abnormalities due to limited study, but overall systolic
function of the left ventricle is probably normal. Severe
tricuspid regurgitation with failure of tricuspid leaflet
coaptation. Mild mitral regurgitation. Unable to fully assess
aortic valve.
Compared with the findings of the prior report (images
unavailable for review) of [**2173-4-12**], the tricuspid regurgitation
is now severe. If clinically indicated, a complete transthoracic
examination with Doppler is recommended.
[**2177-3-4**] Portable TTE: Compared with the prior study (images
reviewed) of [**2177-3-1**], estimated pulmonary artery systolic
pressure is now higher.
[**2177-3-2**] LIVER OR GALLBLADDER US (SINGLE ORGAN) :
1. Cholelithiasis without evidence of cholecystitis.
2. Patent portal vein. Prominent hepatic veins likely due to
vascular
congestion.
3. Possible right renal fullness seen on partial views of right
kidney. If
indicated, this could be evaluated with renal ultrasound.
Renal U/s [**2177-3-12**]: Somewhat limited study however both kidneys
are within normal limits with good cortical thickness, no
hydronephrosis or mass lesions identified. The bladder is fully
decompressed around the Foley catheter.
[**2177-3-17**] CXR: Central venous catheter and permanent pacemaker
remain unchanged in position allowing for positional differences
of the patient. Cardiac silhouette is enlarged, accompanied by
pulmonary vascular engorgement. Previously reported multifocal
pulmonary opacities have partially cleared with residual
opacities mostly in the perihilar regions. This likely reflects
improving pulmonary edema. More confluent opacity in left
retrocardiac region has only slightly improved and is likely due
to a combination of atelectasis and effusion. Small right
pleural effusion has decreased in size.
[**2177-3-17**] EKG: Atrial fibrillation with controlled ventricular
response. Intermittent pacer spikes which do not capture
non-specific anterior and inferior ST-T wave changes. Modest Q-T
interval prolongation. Compared to tracing #1 ventricular paced
beats are absent. Anterior ST-T wave changes are more
pronounced. Clinical correlation is suggested.
Brief Hospital Course:
HOSPITAL COURSE: Pleasant 87 yo female presenting with
dizziness, hypotension concerning for sepsis initially requiring
pressors in the ICU, who was then called out to the cardiology
service with volume overload, AFIB and severe TR w/ RV
dilation. Underwent DCCV but continued to be in afib and had to
be transferred to the CCU for respiratory distress where she was
diuresed and then transferred back to the cardiology floor. She
was discharged to [**Hospital1 **] (LTAC).
ACTIVE ISSUES:
# Septic Shock: The pt was hypotensive on admission requiring
pressors with signs of end organ damage including acute renal
failure and shock liver. Lactate was 5.3 on admission and rose
rapidly throughout her first day in the ICU peaking at 9. The
pt had a recent hx of UTI and there was a concern for urosepsis,
so she was started on broad antibiotics with vancomycin and
zosyn and receieved a 7 day course. On exam, however, she was
cold and clamped down peripherally, more concerning for a
cardiogenic process. Additionally, ECG was showing only
intermittent capture of pacemaker. Cardiology/EP was consulted,
and her pacemaker was interrogated and adjusted to improve
cardiac output in setting of shock and acidosis (see Atrial
Fibrillation below). Echo was then obtained, which showed severe
tricuspid regurgitation with complete lack of coaptation of
tricuspid leaflets. It was thought that this was likely the
cause of her shock, in addition to the infectious component that
had instigated her acute presentation (although no infectious
source was isolated during her hospital course). Therefore she
was gently diruresed with IV lasix back to her dry weight. She
continued to have intermittent respiratory difficulty likely [**3-6**]
COPD and fluid overload, which was alleviated with nebs and IV
lasix.
# Atrial fibrillation: On coumadin, supratherapeutic INR on
admission (see below). EKG initially showed intermittent pacing
with evidence of pacer spikes on t-waves. Cardiology/EP consult
was obtained, and on pacemaker interrogation was noted to have
elevated thresholds above programmed output of leads leading to
intermittent capture. PPM was reprogrammed with higher output
and higher HR to 80s with appropriate capture. HR was increased
to improve cardiac output to more closely match physiologic
demand in setting of shock. She was started on dofetilide, but
this was discontinued due to QT prolongation. She was then
started on amiodarone and metoprolol. In the ICU, verapamil was
increased to 60mg TID and metoprolol was maintained at 50mg [**Hospital1 **].
In this setting, home lisinopril was held to give blood
pressure room. However, the pt has a hx of not tolerating Amio
which was dc/ed and the pt underwent DCCV after transfer to the
floor. However, pt reverted back to AFIB and had to go to the
CCU for resp distress. QT prolongation prevented dofelitide from
being continued, and metoprolol was dc/ed as it was thought to
be worsening bronchospasm. At the time of discharge she was put
on a higher dose of verapamil (280 [**Hospital1 **]). DCCV was performed
again and she continued to be in afib. Flecainide was dc/ed due
to likely underlying CAD and was switched to digoxin 0.125 every
other day. However, dig was also dc/ed and the pt was dc/ed on
verapamil alone with HR in 70s and 80s. The pacemaker was
changed from DDIR to VVI w/ a lower HR threshold of 50 bpm.
# Acute renal failure: Creatinine elevated to 1.9 on
presentation, up from previous baseline of 0.7-0.8 one year
prior. Etiology thought to be ATN vs hypotension/shock. Her
initial course was complicated by hyperkalemia with associated
widening of QRS and [**Last Name (LF) 5937**], [**First Name3 (LF) **] she was given kayexalate, insulin +
D50, and calcium gluconate. Creatinine peaked at 2.9 with
minimal urine output, however renal function improved with
continued fluid resuscitation and support with pressors. Towards
the end of her stay she had another Cr spike (1.8 from 1.1)
which improved with gentle fluid resusciation. Her Cr at dc was
1.5.
# Dyspnea: Patient became acutely dyspneic after cardioversion
from Afib. She was transferred to the CCU for closer
monitoring. In the CCU, she was placed on a nitro gtt and
diuresed with lasix boluses. Her SOB was however multifactorial
but primarily d/t fluid overload vs COPD vs severe thoracic
kyphosis as she responded to both lasix and nebs. She was also
started on Fluticasone-Salmeterol Diskus (500/50). Torsemide was
started for po diuresis as she failed po lasix diuresis.
Lisinopril was restarted at 5mg. Her 02 requirement went up to
3L but she was comfortable on RA on dc. At discharge she was
stable on RA but patient prone to having acute episodes of
dyspnea that were alleviated with duonebs and IV lasix 40mg (if
the pt appeared overloaded on exam).
# Fluctuating INR: Pt presented on coumadin for Afib (INR goal
[**3-7**]); INR 3.5 on presentation in the ED but rapidly rose to 6.2
upon arrival in the ICU. Peaked at 9.7. No signs of bleeding,
so she was not given any reveral agents. Etiology of acute rise
presumed to be liver dysfunction in the setting of
hypotension/shock. However, pt has a hx of labile INR. Recieved
Vitamin K in the CCU and had hematuria which persisted a few
days after resolution of supratherpeutic INR. She was bridged
back to therapeutic range with lovenox. INR managment remained
challenging throughout her stay. At the time of dc her INR was
3.5 so her coumadin of 0.5 mg was held.
# Hematuria: pt continued to have gross hematuria. Unrelated to
INR levels. Was worked up in the past w/ cystoscopy showing
bilateral diverticuli. She has been set up for follow up appt
with urologist for cystoscopy. Renal u/s done here was normal.
# Transaminitis: AST/ALT in the 400s on presentation, likely
due to acute injury from hypoperfusion (shock liver) vs.
congestive hepatopathy. Alkaline phosphatase and bili remained
within normal limits, supports this hypothesis. Transaminases
rose to the thousands prior to coming down after resolution of
sepsis.
# Anemia: Normocytic, near recent baseline of 34.3 on
presentation. Despite high INR, no signs of acute bleedn other
than known prior hematuria that continued intermittently
througout her stay. Likely [**3-6**] chronic hematuria vs low marrow
production. Her retic count was normal, and SPEP was also
normal.
INACTIVE ISSUES:
# Dementia: stable; contined home meds mirtazepine and aricept
# GERD: continue home ranitidine
TRANSITIONAL ISSUES: Patient has a variety of specialist appts
that need to be followed up with. In case that she develops
dyspnea and does not respond to duonebs, IV lasix 40mg should be
given. Verapamil dose can be increased to 240 [**Hospital1 **] if rate
control or blood pressure managment becomes problem[**Name (NI) 115**]. Pt's
INR on the day of DC was 3.5 so her warfarin dose of 0.5 mg was
held. Please restart warfarin at 1 mg after the INR is in
therapuetic range.
Medications on Admission:
-Sulfamethoxazole-Trimethoprim 800-160 mg Oral Tablet TAKE 1
TABLET TWICE A DAY FOR 10 DAYS
-Lorazepam 0.5 mg Oral Tablet TAKE 1 TABLET AT BEDTIME
-Mirtazapine 15 mg Oral Tablet TAKE 1 TABLET AT BEDTIME
-Verapamil SR 12 HR 240 mg Oral Tablet Extended Release [**2-3**] po
QAM, and 1 po Qpm
-Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation
HFA Aerosol Inhaler Take 1 to 2 inhalations every 4 to 6 hours
as needed; rinse mouthpiece at least once a week
-Donepezil (ARICEPT) 10 mg Oral Tablet Take 1 tablet daily at
bedtime
-Lisinopril 40 mg Oral Tablet Take 1 tablet daily
-Flecainide 100 mg Oral Tablet [**Hospital1 **]
-Metoprolol Tartrate 50 mg Oral Tablet QD WITH ONE 25 MG TABLET
[**Hospital1 **]
-Metoprolol Tartrate 25 mg Oral Tablet 1 TABLET WITH 50 MG
TABLET [**Hospital1 **]
-Fluticasone (FLOVENT HFA) 110 mcg/Actuation Inhalation Aerosol
Use 1 inhalation by mouth twice daily and rinse your mouth
thoroughly afterward
-Furosemide 20 mg Oral Tablet TAKE ONE TABLET DAILY
-Ranitidine HCl 75 mg Oral Tablet Take 1 tablet twice daily;
available over the counter
-Warfarin 1 mg Oral Tablet Take 1.5 tablets daily or as directed
-Tramadol 50 mg Oral Tablet [**2-3**] tab po qhs
-Loperamide (IMODIUM A-D) 2 mg Oral Tablet Take 1 tablet now,
then 1 tablet each 4 hrsfter each unformed stool as needed;
available over the counter
-? meclizine, dosage unknown
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
ATRIAL FIBRILLATION
ACUTE ON CHRONIC DIASTOLIC HEART FAILURE
HYPERTENSION
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
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94,255
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51877
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Discharge summary
|
Report
|
Admission Date: [**2139-7-28**] Discharge Date: [**2139-7-31**]
Date of Birth: [**2084-12-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Right pleural effusion
Major Surgical or Invasive Procedure:
[**2139-7-30**] Pleuroscopy, Right pleural effusion drainage with
PleureX catheter placment.
History of Present Illness:
54 year old woman with history of right breast DCIS in [**2130**] and
primary peritoneal carcinoma with recurrent malignant right
pleural effusion requiring multiple thoracentesis. She presented
this time with progressive dyspnea
and reports that she is more SOB at rest. She has also been
complaining of cough that has been significat to a point where
she vomited on one occasion. She denies any chest pain, fevers,
chills, night sweats, nausea, or vomiting.
Past Medical History:
1- Breast CA, DCIS ([**2130**]) status post radiation, lumpectomy,
and tamoxifen.
2- Asthma
3- Osteoporosis
4- GERD
5- Stage IV ovarian cancer status post TAH BSO, primary
peritoneal carcinoma
6- PE, on Lovenox
Family History:
Sister with a history of breast cancer at 61. She has another
sister with biliary cirrhosis and [**Doctor Last Name 17472**]
syndrome. She has another sister who is healthy. Her brother
died in his 40s of sepsis of unclear etiology. The patient's
aunt on her father side had a colon cancer in her 60s. Her
mother died of ALS, but had a renal cell carcinoma, which was
treated completely with nephrectomy. She has two uncles on her
mother's side, one of whom had bladder cancer, another had
esophageal cancer. She had an aunt on her mother's side who had
esophageal cancer as well.
Pertinent Results:
[**2139-7-31**] WBC-9.3# RBC-3.53* Hgb-10.7* Hct-32.2* Plt Ct-94*
[**2139-7-27**] WBC-4.4# RBC-2.96* Hgb-8.6* Hct-26.7* Plt Ct-257
[**2139-7-30**] Neuts-85.3* Lymphs-11.6* Monos-1.9* Eos-0.8 Baso-0.3
[**2139-7-31**] Glucose-140* UreaN-24* Creat-0.7 Na-137 K-4.3 Cl-111*
HCO3-17
[**2139-7-27**] Glucose-109* UreaN-21* Creat-0.7 Na-135 K-3.8 Cl-104
HCO3-23
[**2139-7-31**] CXR: The two right chest tubes, superior and inferior
are in unchanged location. The right basal atelectasis is
unchanged. There is no evidence of reaccumulation of pleural
effusion. There is no pneumothorax, although note is made that
multiple lines overlying the right apex and minimal amount of
pleural air can be undetected.
The Port-A-Cath catheter inserted through the left subclavian
vein terminates at the level of low SVC. The lungs are well
expanded and the
cardiomediastinal silhouette is stable.
[**2139-7-31**] Lower extremity doppler: There is normal spontaneous
phasic flow, compressibility, and augmentation in bilateral
lower extremities from the level of the common femoral veins
through the proximal calf.
IMPRESSION: No evidence of deep vein thrombosis in either lower
extremity.
[**2139-7-27**]: Chest CT:
1. No pulmonary embolus. No aortic dissection.
2. Mildly increased moderate right pleural effusion and
associated
atelectasis.
Brief Hospital Course:
Mrs. [**Known lastname 107418**] was admitted on [**2139-7-27**] for increased shortness of
breath. A chest CT was done and revealed a right pleural
effusion. No pulmonary embolism was noted. On [**2139-7-28**]
interventional pulmonary was consulted. They recommended a
pleuroscopy with pleur ex catheter placement. Her Lovenox was
held. On [**2139-7-30**] she underwent Rigid fluoroscopy.Right pleural
biopsies. Talc pleurodesis. Insertion of a 24-French right chest
tube. Insertion of a right PleureX catheter. A total of 1400 mL
of bloody fluid was aspirated. She was transferred to the PACU
and found to be hypotensive with blood pressure in the 70s/40s.
Despite 3L IVF boluses she continued to be hypotensive and was
transferred to the SICU. On [**2139-7-31**] she was tachycardia to the
130s despite IVF, episode of anxiety/desaturation with
increasing O2 requirements. An echocardiogram was done which
showed Markedly dilated RV with severe global systolic
dysfunction. Small and under filled LV with hyperdynamic syst
fxn. Moderate functional TR. Moderate pulmonary HTN. Bilateral
lower extremity Dopplers were negative for DVT. She went into
PEA arrest, she was coded without recovery.
Medications on Admission:
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth q
week take w/ 8 oz of water, do not eat for 30 minutes
afterwards,
and remain upright after taking medication
ENOXAPARIN [LOVENOX] - 100 mg/mL Syringe - 1 injection (100
units) once daily
MAGIC MOUTH WASH - (Prescribed by Other Provider) - Dosage
uncertain
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice daily
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
Q6
hours as needed for nausea
SCALP PROSTHESIS - - Please provide patient with one scalp
prosthesis. ICD-9 183.0.
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet
-
Tablet(s) by mouth
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (Prescribed by
Other Provider) - Dosage uncertain
IBUPROFEN - (Prescribed by Other Provider) - 200 mg Tablet -
Tablet(s) by mouth
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right pleural effusion
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2139-10-16**]
|
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[
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icd9pcs
|
[
[
[
396,
435
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5289, 5298
|
3137, 4340
|
344, 439
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5365, 5375
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5428, 5576
|
1179, 1761
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5260, 5266
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5319, 5344
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4366, 5237
|
5399, 5405
|
282, 306
|
467, 929
|
951, 1163
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,461
| 160,208
|
37383
|
Discharge summary
|
report
|
Admission Date: [**2113-1-15**] Discharge Date: [**2113-2-13**]
Date of Birth: [**2063-6-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
49 M healthy male at [**Location (un) **], found to have [**5-21**] blood cultures
with staphylococcus bacteremia. On TTE mitral valve vegetations
were seen along withs severe MR [**First Name (Titles) **] [**Last Name (Titles) **] leaflet. Patient being
transferred to [**Hospital1 18**] for CT surgery evaluation and further
management.
Major Surgical or Invasive Procedure:
[**2113-1-27**] Mitral Valve Replacement(29mm St. [**Male First Name (un) 923**] Mechanical
Valve) with Debridement of Aortic Valve
History of Present Illness:
49 M heavy smoker presented to [**Hospital3 7569**] ER with fever,
fatigue and malaise on [**1-13**] of 3 days duration. He was febrile
to 101.5 in ER with HR 140s, BP 104/44, RR 22, 90% RA.
On labs WBC 16 with 35% bandemia, plt 79, HCT 51. He was
admitted on Friday night and developed a fever to 101.6 and
visual changes which prompted a CT head which showed small
infarct in the anterior and posterior circulation suspicious for
septic emboli. During this time his blood cultures from the ER
came back with 4/4 bottles positive for staph aureus. He
underwent a TTE which showed large vegetation on the mitral
valve and [**Month/Year (2) **] leaflet with severe MR. [**Name13 (STitle) **] has been on
vancomycin, CTX, and levofloxacin. The patient was transferred
to the ICU on Saturday for hypotension, tachycardia and had a SC
triple lumen catheter placed under sterile conditions and is on
Levophed for support. He was ruled out for influenza.
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.
Echocardiogram showed severe MR [**First Name (Titles) 151**] [**Last Name (Titles) **] posterior leaflet.
Some hazy densities seen on the mitral valve, while not entirely
clear that they are vegetations,in the setting of his clinical
picture, most likely he has
endocarditis. Cardiac surgery consulted for Mitral Valve
Replacement/Aortic Valve debridement.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
*Note: Patient had not seen a physician for many years prior to
current admission
Social History:
Lives with wife
-[**Name (NI) 1139**] history: 1.5-2 PPD for last 30 years
-ETOH: 3-4 beers daily
-Illicit drugs: none
Family History:
Brother had myocardial infarct in 50s.
Physical Exam:
General Appearance: Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL, Cervical
adenopathy
Cardiovascular: (PMI Hyperdynamic), (S1: Normal), (S2: Normal),
(Murmur: Systolic), holosystolic murmur IV/VI heard best at apex
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 : r>l)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, petechiae and [**Last Name (un) **] lesions
Musculoskeletal: [**Last Name (un) **] lesion on upper ext
Skin: Warm, Rash: upper and lower ext, occ petechiae
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone:
Decreased
Pertinent Results:
ADMISSION LABS [**2113-1-15**]:
[**2113-1-15**] 04:22PM WBC-19.4* HGB-15.3 HCT-46.4 PLT CT-122
[**2113-1-15**] 04:22PM NEUTS-77* BANDS-10* LYMPHS-5* MONOS-2 EOS-1
BASOS-0 ATYPS-4* METAS-0 MYELOS-0 PLASMA-1*
[**2113-1-15**] 04:22PM GLUCOSE-130* UREA N-8 CREAT-0.4* SODIUM-131*
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-13
[**2113-1-15**] 04:22PM ALT(SGPT)-46* AST(SGOT)-49* LD(LDH)-593*
CK(CPK)-142 ALK PHOS-64 TOT BILI-0.5
[**2113-1-15**] 04:22PM CK-MB-7 cTropnT-0.28*
[**2113-1-15**] 04:51PM LACTATE-1.6
U/A:
[**2113-1-15**] 09:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2113-1-15**] 09:23PM URINE RBC-21-50* WBC-[**7-27**]* BACTERIA-MOD
YEAST-NONE EPI-0\
OTHER PERTINENT LABS:
Lipid Panel: Total Chol-92 TG-120 HDL-18 LDL-50
HbA1C 5.6
Fibrinogen 861 -> 650
Haptoglobin 217
D-Dimer 1765
TSH 1.3
Microbiology:
[**2113-1-15**]: 1 of 4 bottle: STAPH AUREUS COAG +.Sensitivities:
CLINDAMYCIN <=0.25 S; ERYTHROMYCIN <=0.25 S; GENTAMICIN <=0.5 S;
LEVOFLOXACIN <=0.12 S; OXACILLIN 0.5 S; TRIMETHOPRIM/SULFA <=0.5
S
[**1-15**] - [**1-23**]: Blood cx negative
[**1-18**]: R elbow bursa Cx negative
[**1-16**], [**1-18**], [**1-20**]: Urine Cx negative
[**1-18**], [**1-21**], [**1-22**]: Feces negative for C.difficile toxin A & B by
EIA.
Imaging:
[**2113-1-15**] CXR:
Severe emphysema, bilateral pleural effusions, and adjacent
atelectasis.
[**2113-1-15**] CT head w/o contrast:
Suboptimal study due to motion. Multiple bilateral and supra-
and infratentorial hypodense foci, of varying size and degree of
definition. In this setting, these very likely represent embolic
infarcts from a central source, of varying ages. There is no
evidence of hemorrhagic conversion
[**2113-1-16**] ECHO:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
There is no ventricular septal defect. 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) are
mildly thickened but aortic stenosis is not present. There is a
probable (very small) vegetation on the aortic valve. No aortic
regurgitation is seen. There is moderate/severe mitral valve
prolapse (predominantly posterior leaflet). There is probably
partial mitral leaflet [**Month/Day/Year **] of the posterior leaflet. There is
a probable vegetation on the mitral valve. An eccentric,
anteriorly directed jet of moderate to severe (3+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion
[**2113-1-16**] CT abdoman:
Bilateral wedge-shaped defects of the renal parenchyma
concerning for septic emboli in the setting of endocarditis. 3.o
cm lesion in the mid right kidney is likely a phlegmonous area.
Renal vessel patency cannot be assessed due to suboptimal bolus
timing and patient motion.
2. Unchanged bilateral pleural effusions and adjacent
atelectasis.
3. Ascites and anasarca.
4. Tiny foci of air in the urinary bladder, which may be due to
instrumentation.
[**2113-1-16**] R elbow Xray:
Elbow joint effusion, no radiographic evidence of osteomyelitis
[**2113-1-17**]: CTA head/neck:
1. Multifocal evolving infarcts, with the most significant
interval change representing a progressive large left posterior
cerebral artery infarct.
2. Slightly attenuated left posterior cerebral artery without
focal
abnormality or intracranial aneurysm or vascular malformation.
3. It should be noted that CTA is not an ideal method for
evaluation of
mycotic aneurysms. Minor vascular abnormalities of vessels
distal to the
circle of [**Location (un) 431**] can be better evaulated with conventional
angiography.
[**2113-1-19**] CT head:
No acute hemorrhage. Evolving multifocal infarcts. No new areas
of hypodensity to suggest a new infarct
[**2113-1-20**] CT abd/pelvis:
1. Limited study due to lack of intravenous contrast. The known
renal
parenchymal defects concerning for infarcts are not well
evaluated on this
study.
2. No evidence of intra-abdominal or pelvic abscess.
3. Increased bilateral effusion with underlying atelectasis.
Ascites and anasarca.
4. Nonobstructing 2-mm right lower pole renal calculus.
5. Air in the urinary bladder, which may be due to
instrumentation.
6. Distended, fluid filled rectum could this explain the
patient's symptoms
[**2113-1-23**]: TEE:
A patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. There is a small mobile mass (< 0.5 cm) on the
LV side of the aortic valve. Trace aortic regurgitation is seen.
There is a large mobile vegetation on the anterior leaflet at
the base of the MV (A1 scallop), [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] junction . This area is
opposite the aortic root. No mitral valve abscess is seen. An
eccentric, anterior directed jet of Severe (4+) mitral
regurgitation is seen.
[**2113-1-24**] Cardiac Cath:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
revealed single-vessel and branch vessel coronary artery
disease. The
LMCA, LCX, and LAD had no significant stenoses. The RCA had a
50%
mid-vessel stenosis. The first diagonal branch of the LAD had a
70%
mid-vessel stenosis.
2. Limited resting hemodynamics demosntrated normal central
aortic
pressures.
FINAL DIAGNOSIS:
1. Single-vessel and branch vessel coronary artery disease.
[**2113-1-25**] MRI Spine:
[**2113-1-25**] CTA head:
Brief Hospital Course:
49 M found to have staphlyococcus aureus bacterial endocarditis
with severe mitral regurgitation secondary to mitral valve
vegetations and [**Month/Day/Year **] leaflet. Hospital course complicated by
sepsis, multiple cerebral and renal infarcts.
# Mitral valve staphylococcus aureus endocarditis/ Sepsis [**3-21**]
staphylococcus aureus bacteremia: BCx grew out MSSA, c/x neg
since [**1-17**]. ECHO (TTE and TEE) showed large vegetation on
mitral valve and small vegetation on aortic valve. The patient
has been treated primarily with Nafcillin 2g q4h. Abx were
broadened briefly to Vanc/Cefepime/Flagyl, but discontinued as
there was no evidence of superimposed hospital acquired
infection. The patient had multiple emoblic events, with
neurologic deficits including left sided facial droop, right
sided neglect, right sided hemiparesis, expressive aphasia, some
of which have improved during hospitalization. The patient had
several teeth extracted by Oral Surgery. MR spine showed no
evidence of epidural abscess. CTA head showed no evidence of
mycotic aneurysms. Risk of hemorrhagic conversion is thought to
be significantly reduced after the first three days. Pt already
has multiple reasons for urgent valve repair and has been
preopoeratively optimized. He was taken to surgery on [**2113-1-27**]
and underwent Mitral Valve Replacement (# 29mm St.[**Male First Name (un) 923**]
Mechanical Valve)/Debridement of Aortic Valve with
Dr.[**Last Name (STitle) **]. Cross clamp time= 95 minutes. Cardiopulmonary
Bypass time= 112 minutes. Pt was transferred to the CVICU
intubated, sedated, in critical but stable condition requiring
Neo and Milrinone to optimize cardiac output and index. Drips
were weaned off and aspirin, beta-blocker started. Postoperative
paroxysmal atrial fibrillation was treated with Amiodarone and
anticoagulation. He was transfused packed red blood cells for
moderate anemia with a hematocrit of 24. Chest CT scan done
postoperatively to rule out bleed. Acute Renal failure preop
persisted postop. Lasix drip initiated for oliguria, with good
response and gradual resolution. POD# 3 Mr.[**Known lastname 84050**] was weaned to
extubation without difficulty. Lines and drains were
discontinued when criteria met. PICC line inserted for long term
antibiotics per ID. Postoperatively surveillance cultures were
monitored, ID,Neuro and Opthalmology continued to follow.
Nafcillin 2gram IV every 4 hours to continue until [**3-3**]
follow up with [**Hospital **] clinic. Physical therapy/Occupational therapy
was consulted for evaluation of strength and mobility.
Anticoagulation with Heparin and Coumadin was initiated for INR
goal 2.5-3.5 for mechanical Mitral Valve.
#Preoperative Loose stools: Pt had loose stools since admission.
Cdiff negative x3. The patient was treated empirically with IV
Flagyl and PO Vanc. Flagyl was discontinued, but pt was
continued on PO Vanc. Course completed at the time of
discharge. He was afebrile and WBC was within normal limits.
Diarrhea was improving at the time of discharge with the
addition of tincture of opium titratated to effect.
#Preoperative Neurological deficits ?????? Neurological deficits
continue to improve. Pt regained ability to move all four
extremities. Postoperative head CT scan showed no intracranial
hemmorrhage. Neurology signed off.
- Future MRI head, optic nerves recommended per Neuro.
#Preoperative Delirium ?????? Pt agitated,requiring standing dose of
Haldol. Psychiatry consulted preop-followed postop. Avoid
narcotics once extubated- avoid benzodiazapenes.
- f/u psych recs - cont standing po haldol with prn haldol
#Preoperative Respiratory Distress ?????? Intubated preop for Pulm
edema seen on CXR.Diuresis initiated preop and continued postop.
#Preoperative Acute Renal Failure - creatinine bumped >2.0
(baseline 0.4). Multifactorial etiology for ARF in setting of
multiple renal infarcts, gentamycin use, contrast load and low
CO from MR. Postoperatively his creatnine came down and is
currently 1.9.
#Preoperative Olecranon bursistis s/p washout ?????? no evidence of
infection as per OR report and initial gram stain. Wound vac in
place, changed [**2113-2-13**]. Well-healing wound as per Ortho.
# Preoperative Hypotension ?????? secondary to sepsis/ low cardiac
output. Pt weaned off levophed [**1-16**], but restarted on [**2113-1-25**].
Pt also given IVF and Milrinone to improve UOP.
#Preoperative Hypoalbuminemia ?????? poor nutrition. Dobhoff placed
[**1-22**], Tube feeds started. Postoperatively Mr.[**Known lastname 84050**] was NPO.
After extubation, POD# 4 speech and swallow evaluated for oral
and pharyngeal dysphagia.He was receiving assisted feeds until
his mental status prevented appropriate po intake and concern
for aspiration. POD #7 He failed a video swallow. Discussion
with wife and team to determine need for PEG placement. TPN
started until PEG placed. On POD # 10 he had a PEG placed for
nutrition. He was tolerating tube feeds at goal at the time of
discharge.
#On POD 17 He was ready for transfer to rehabilitation for
further increase in strength and mobility. All follow up
appointments were advised.
Medications on Admission:
None
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY
(Daily).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q4H
(every 4 hours) as needed for diarrhea.
13. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY
(Daily).
14. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization
Sig: One (1) Inhalation q6h prn as needed for dyspnea/wheezing.
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation q6h prn as needed for wheezing.
16. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours): Continue until [**Hospital **] clinic follow
up-appointment [**2113-3-3**].
17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP > 140.
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
19. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): PTT goal
50-70 or until INR therapeutic >2.5.
20. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
21. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
TID (3 times a day) as needed for agitation/delirium.
22. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day).
23. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1)
Intravenous PRN (as needed).
24. Magnesium Sulfate 4 % Solution Sig: One (1) Injection PRN
(as needed) as needed for mg <2.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
MSSA Septicemia
Mitral Valve Endocarditis/Mitral Valve Regurgitation
Septic Emboli
Acute Renal Insufficiency
Olecranon Bursitis
Clostridium difficile Colitis
Discharge Condition:
Ambulating, gait steady
Sternal pain managed with percocet prn
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**]
**Vac change to right upper extremity every 3-4 days at rehab,
vac suction to 125mmHg
**Weekly CBC with diff/BUN/Creatnine/LFTs-fax results to [**Hospital **]
clinic
Followup Instructions:
Please call to schedule appointments
-Surgeon Dr [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
-Primary Care Dr [**Last Name (STitle) 84051**] in [**2-19**] weeks
-Cardiologist Dr [**Last Name (STitle) 1911**]: in [**2-19**] weeks:#[**Telephone/Fax (1) 62**]
-Dr.[**Last Name (STitle) **], Opthalmology: in 2 weeks: #[**Telephone/Fax (1) 253**]
-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],NP-Orthopedics: in 2 weeks #[**Telephone/Fax (1) 1228**]
-Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]:[**Hospital **] clinic #[**Telephone/Fax (1) 7043**]
**Vac change to right upper extremity every 3-4 days at rehab,
vac suction to 125mmHg
**Weekly CBC with diff/BUN/Creatnine/LFTs-fax results to [**Hospital **]
clinic
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-2-13**]
|
[
"518.4",
"486",
"682.3",
"593.81",
"414.01",
"427.31",
"424.0",
"726.33",
"293.0",
"303.91",
"599.0",
"E878.8",
"401.9",
"584.5",
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"421.0",
"285.9",
"434.11",
"997.5",
"038.11",
"348.39",
"788.5",
"276.1",
"250.00",
"272.4",
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"449",
"787.22",
"522.4",
"997.1",
"008.45",
"518.81",
"995.92",
"287.5",
"273.8",
"424.1",
"428.0",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.19",
"39.61",
"43.11",
"96.04",
"96.72",
"99.15",
"88.56",
"88.72",
"35.24",
"96.6",
"38.93",
"35.11",
"37.22",
"83.5"
] |
icd9pcs
|
[
[
[]
]
] |
18065, 18112
|
9986, 15138
|
616, 750
|
18314, 18379
|
3909, 4657
|
19085, 19985
|
2905, 2946
|
15645, 18042
|
18133, 18293
|
15164, 15622
|
9847, 9963
|
18403, 19062
|
2961, 3890
|
238, 578
|
778, 2611
|
7897, 9830
|
4679, 7888
|
2633, 2752
|
2768, 2889
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,955
| 102,785
|
51331
|
Discharge summary
|
report
|
Admission Date: [**2201-1-7**] Discharge Date: [**2201-1-23**]
Date of Birth: [**2115-1-13**] Sex: M
Service: MEDICINE
Allergies:
Indomethacin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
SOB, obtundation
Major Surgical or Invasive Procedure:
Balloon valvuloplasty
History of Present Illness:
85 y.o. Male with a past medical history of medically-managed
CAD s/p MI x 2 in [**2179**], CVA, severe aortic stenosis seen on
cath [**7-22**] presenting to the ED with marked respiratory
distress. Per ED report and EMS sheet they were called for
someone in respiratory distress.. When EMS arrived on scene he
was noted to be in profound respiratory distress but was able to
talk to the paramedics. His BP was noted to be in the 220s and
he became obtunded enroute to the ED. He was intubated
emergently in the field and given nitropaste for his
hypertension.
.
In the [**Name (NI) **] pt's initial VS were noted to be HR 65, BP 133/62, RR
30, Sat 97%. His CXR showed ET and NG tubes positioned
appropriately. Diffuse pulmonary opacities raise concern for
pulmonary edema though a superimposed pneumonia cannot be
entirely excluded. Initial ABG was noted to be show
resp/metabolic acidosis. pH 6.84, pCO2 105, pO2 170, HCO3 20,
lactate 7.4. He was given propofol for intubation, IV Nitro gtt
as well as Furosemide 20mg x 1. His vent was changed to FiO2
100%, Rate 30, TV 450, PEEP 10 with a resulting pH of 7.08, pCO2
59, pO2 141, HCO3 19. Repeat lactate trended down to 6.6. His
BP then dropped to SBPs in the 70s, sedation switched to
fent/versed, and patient started on dopamine gtt given severe
AS. Nitropaste was taken off and patient bolused 500 cc NS.
His CBC was notable for a leukocytosis 12.5, Hct 35.1. CT Head
showed no acute process. ABG prior to transfer showed pH 7.29
pCO2 42 pO2 105 HCO3 21 with lactate now 1.1.
.
Of note, he was apparently scheduled to see Dr. [**Last Name (STitle) 10121**] in the AM
for AVR for his history of Aortic stenosis.
.
Review of systems unobtainable as patient intubated.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
CAd s/p 2 MIs
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- CVA [**2195**] without residual deficits
- Gastric Ca s/p Bilroth II ([**2177**])
- Recurrent hyperplastic polyps w/ high grade dysplasia
- HTN
- BPH
Social History:
Per prior d/c summary. No alcohol, or illicit drug use. Smoked
cigarettes for 40 yrs, quit 20 yrs ago. Moved from [**Country 10363**] to US
>25 years ago and speaks both Romanian and Russian fluently.
Lives with wife and has a daughter/son in law in the area.
Family History:
Non contributory
Physical Exam:
GENERAL: Intubated, sedated.
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
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: Diffuse ronchi and wheeze bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm, no edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
.
[**2201-1-7**] 07:10PM BLOOD WBC-12.5* RBC-3.63* Hgb-10.7* Hct-35.1*
MCV-97 MCH-29.4 MCHC-30.4* RDW-21.6* Plt Ct-193
[**2201-1-7**] 07:10PM BLOOD PT-13.9* PTT-29.3 INR(PT)-1.2*
[**2201-1-8**] 02:00AM BLOOD Glucose-157* UreaN-43* Creat-1.4* Na-143
K-4.7 Cl-111* HCO3-22 AnGap-15
.
ECHO [**2201-1-8**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF 75%). Right ventricular chamber size and free wall
motion are normal. There are focal calcifications in the aortic
arch. The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is no pericardial effusion.
.
ECHO [**2201-1-10**]:
Technically suboptimal study.
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are severely
thickened/deformed. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Mild to moderate ([**12-14**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
.
CXR [**2201-1-15**]:
IMPRESSION: Decreased bilateral pulmonary edema with resultant
right greater than left small pleural effusions and bibasilar
opacities likely reflective of compressive atelectasis.
.
VIDEO SWALLOW STUDY [**2201-1-15**]:
IMPRESSION:
Aspiration and penetration with puree and nectar-thickened
liquids.
.
VIDEO SWALLOW STUDY [**2201-1-20**]:
IMPRESSION: Aspiration with all consistencies of barium despite
head
maneuvers. Please see speech and swallow note for details.
.
MICRO:
BLOOD CX [**2201-1-7**]: NO GROWTH
BLOOD CX [**2201-1-8**]: NO GROWTH
BLOOD CX [**2201-1-12**]: NO GROWTH
.
SPUTUM CX [**2201-1-8**]: MODERATE GROWTH Commensal Respiratory Flora.
.
URINE CX [**2201-1-7**]: NO GROWTH
URINE CX [**2201-1-12**]: NO GROWTH
URINE CX [**2201-1-17**]: NO GROWTH
Brief Hospital Course:
HOSPITAL COURSE:
85 y.o. Male with a past medical history of medically-managed
CAD s/p MI x 2 in [**2179**], CVA, hypertension, hyperlipidemia,
severe/critical aortic stenosis presenting with hypertensive
emergency, respiratory distress s/p intubation, pulmonary edema.
Course complicated by delirium, and swallowing difficulty
post-intubation, requiring open j-tube.
.
ACTIVE ISSUES:
#. Aortic stenosis: Patient with critical-severe aortic stenosis
noted in [**Month (only) 216**]. On admission, patient was started on and
required additional pressure support with neo. He went into
AFib with RVR, started on amiodarone gtt, then taken off when he
spontaneously converted to sinus brady. He continued to be
dependent on pressors, and balloon valvuloplasty was done with a
goal to bridge to valve replacement once acute status improves.
He improved and was able to come off pressors and was eventually
extubated. He was evaluated by cardiac surgery, who felt he did
not require AVR at this time. ACEI was held initially given
hypotension. Plan for this to be restarted, but given BP
well-controlled without, this was not restarted during this
admission. His home Imdur was held given preload dependence.
.
# CAD: Pt has history of CAD with prior cath in [**7-/2200**] showing
2 vessel disease, he was managed medically. On aspirin, plavix;
held beta blocker initially, isosorbide while on pressors.
Plavix was discontinued on admission, as it was not thought to
be clinically indicated and pt had recent GIB. He was continued
on ASA 325mg daily. Imdur continued to be dc'd given critical AS
as above. He was started on captopril on HD 5. Captopril was
uptitrated, and then switched to Lisinopril 40mg daily
initially. However, after pt made npo as discussed below, this
was held, and not restarted at discharge. This may need to be
readdressed as an outpt.
He was started on IV metoprolol briefly given agitation and need
for more tight BP management. This was switched to po metoprolol
to continue on discharge.
.
# Respiratory Failure: Patient intubated in the field for
altered mental status. Respiratory distress likely secondary to
flash pulmonary edema. Evetually able to be extubated once
clinical status improved. He had intermittent hypoxia, thought
to be related to flash pulmonary edema when pt became
hypertensive with agitation.
.
# Afib with RVR: In setting of flash pulmonary edema. He was
treated with beta blockade and kept on ASA 325mg. However, given
recent GIB and history of gastric CA, he was not anticoagulated.
Pt and family understood the risks of holding anticoagulation.
.
# Delirium: The patient was noted to be confused, and difficult
to orient on admission. Likely multifactorial [**1-14**] hypoxia,
sundownwing, ICU delirium. He was initially started on seroquel
qHS, but this did not effective and was started on Haldol with
frequent re-orientation. Daily ECG's were checked for prolonged
QT, and were normal. Geriatrics was consulted, and helped to
dose Haldol. His delirium resolved somewhat and he is
intermittantly alert and oriented. He has had no further
agitation. Given that delerium waxes and wanes, would recommend
low dose Haldol PO if needed for agitation.
.
# HTN: His BP was difficult to control when he became agitated,
requiring nitro gtt initially. He was then transitioned to
captopril with uptitration and hydral. His BP improved as his
delirium and agitation improved. ACEI then later held as above.
He was started on metoprolol 5mg IV q6hrs. He was discharged on
po metoprolol.
.
# Hypernatremia: [**1-14**] hypovolemia and no po intake. As noted
below, pt had to be NPO for several days. He was treated with
free water, and his Na improved. His Na improved after pt was
able to have TPN. His Na was 142 on discharge.
.
# Aspiration, failed swallow eval: Pt's voice was hoarse after
extubation, and he repeatedly failed swallow evals, and eventual
video swallow on [**1-15**]. ENT was consulted, and recommended that
would like improve with time, with NTD acutely. TPN was briefly
started. He failed a second video swallow, and ACS was consulted
for j-tube placement. Given his anatomy, he had an open j-tube
placed, and tube feeds were started.
He will follow-up with ENT as an outpatient for further
evaluation.
.
#. History of Gastric cancer/GIB/Anemia: Patient with
transfusion of units during stay with inappropriate increase
after transfusion. Initial source was thought to be RP bleed
from valvuloplasty or GI as he has a history of gastrict cancer.
Hcts remained stable after transfusions, however, CT scan was
negative for RP bleed, but showed splenic infarct. Hct remained
stable.
He was discharged on his Lansoprazole (switched from aciphex),
Lipase-Protease-Amylase, and Hyoscyamine Sulfate per prior
regimen.
.
# Thrombocytopenia: Suspicion for HIT while on heparin subq.
PF4 antbodies and iptic density density sent. Patient started on
argatroban for DVT prophylaxis briefly. PF4 Ab's resulted as
negative. Heparin SC was restarted for PPx. Plts uptrended and
remained stable on discharge.
.
# Anemia: Hct was 35 on admission, and dropped to 25, without
s/s bleeding. He was transfused 2 units PRBC's on [**1-10**], with
appropriate increase. His Hct remained stable for the duration
of the admission. He had slight drop after surgery, but was
without other s/s bleeding.
.
# Acute renal failure: Likely pre-renal/poor forward flow in
setting of critical AS. Cr improved quickly s/p valvuloplasty.
.
.
INACTIVE ISSUES:
# BPH: Finasteride was held during admission, and restarted on
discharge. Started on Flomax on discharge.
.
# HLD: Continued on Atorvastatin 40mg daily.
.
# Gout: Allopurinol held during admission given changing renal
function. Restarted on discharge.
.
TRANSITIONAL CARE:
1. FOLLOW-UP: Dr. [**Last Name (STitle) **] (Cardiology), and ENT
2. Studies pending: none
3. CODE: FULL
Medications on Admission:
1. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
2. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) [**Last Name (STitle) **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. Allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
4. Finasteride 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual 1 tab prn ().
7. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aciphex 20 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
12. Ambien CR 12.5 mg Tablet, Multiphasic Release [**Last Name (STitle) **]: One (1)
Tablet, Multiphasic Release PO at bedtime as needed for
insomnia.
13. Ferrous Sulfate
14. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO q 4h prn () as needed for gas.
15. Loratidine
Discharge Medications:
1. atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
2. insulin lispro 100 unit/mL Solution [**Last Name (STitle) **]: 0-12 units
Subcutaneous every six (6) hours: see attached Humalog sliding
scale.
3. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day).
4. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
5. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
6. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
injection Injection TID (3 times a day).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) vial Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
9. multivitamin, stress formula Tablet [**Last Name (STitle) **]: One (1) Tablet
PO DAILY (Daily).
10. oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
11. acetaminophen 500 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID (3
times a day) as needed for pain/fever.
12. 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.
13. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) [**Last Name (STitle) **]: One (1) Cap PO every eight (8) hours:
Please remove from capsule and dissolve completely. .
14. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
twice a day.
15. allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
16. finasteride 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
17. Flomax 0.4 mg Capsule, Ext Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Ext Release 24 hr PO at bedtime.
18. hyoscyamine sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
tablet Sublingual four times a day as needed for gastric spasm.
19. simethicone 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO four times a
day as needed for indigestion.
20. Outpatient Lab Work
Please check chem-7, CBC on sunday [**1-25**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Critical Aortic Stenosis s/p Valvuloplasty
Hypertension
Coronary Artery disease
Hypernatremia
Delerium
Aspiration
Atrial Fibrillation
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had severe aortic stenosis and required a valvuloplasty to
open the stiffened artery. This worked well and the aortic
stenosis is better. You required a breathing [**Last Name (un) **] to help you
throught the acute breathing problems. We adjusted your
medicines to treat your fluid overload and help your heart work
better. You became delerious during your hospital stay and
required some medicine to help your sleep. We found that your
swallowing is very weak and you are aspirating food and fluid
into your lungs. We started intravenous feeding and placed a J
tube to use for tube feedings and medicines. You will be
re-evaluated by a speech therapist at the rehab and will
hopefully be able to eat and drink again in the next month. You
were not empyting your bladder and a foley catheter was placed.
The foley should be left in for 2 weeks, then attempt to d/c
again.
.
We made the following changes to your medicines:
1. Start Humalog sliding scale to treat high blood sugars while
getting intravenous nutrition
2. Start colace and senna to prevent constipation
3. Start Tamulosin to help your prostate shrink and help you
urinate. Please take this for 2 weeks, then the foley catheter
will be discontinued.
4. Start heparin injections to prevent a blood clot
5. Start a multivitamin with the tube feedings
6. Start oxycodone and tylenol as needed for pain
7. Stop taking Loratidine, ambien, Aciphex, Imdur, Plavix,
Lisinopril, Ferrous sulfate, and lasix.
Followup Instructions:
Otolaryngology:
Phone: [**Telephone/Fax (1) 2349**]
Address:
[**Location (un) **] (east bound side of Rt 9) [**Apartment Address(1) **]
[**Location (un) 55**], MA Dr. [**Last Name (STitle) 106472**] [**Name (STitle) **]
Date/Time: [**2-10**] at 11:00am
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Cardiology
Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 5768**]
Appointment: Tuesday [**1-27**] at 11:30AM
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56,796
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53620
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Discharge summary
|
report
|
Admission Date: [**2149-6-10**] Discharge Date: [**2149-6-16**]
Date of Birth: [**2098-4-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
complete heart block
Major Surgical or Invasive Procedure:
pacemaker placement
History of Present Illness:
Mr. [**Known lastname 56272**] is a 51M w/ hx of AS (unknown severity), HTN,
hypothyroidism, s/p Hodgkin's treatment w/ extensive radiation
therapy to chest at age of 4, who presents intubated from
outside hospital with bradycardia.
The patient fell yesterday approximately 10pm, felt dizzy
previously, struck head and was evaluated by outside hospital
with CAT scan which was reportedly negative, reported to be a
concussion, and went home to rest. At the time that the patient
struck head, he reportedly "turned blue" and was subsequently
numb on his right side. Later in the day, the patient felt
faint, and began to [**Last Name (LF) **], [**First Name3 (LF) **] EMS was called and the patient
returned to the same OSH ER. He was found to be hypotensive and
bradycardic at a rate in 30s-40s, thought to be a ventricular
escape rhythm. The patient was given atropine and epinephrine
with no change in HR or BP. Labs subsequently revealed WBC:
14.7, HCT: 46.2, Plt: 237, INR: 1.3, K: 6.9, BUN:27, Cr:2.8,
Tn-I: 0.05. The pateint's baseline Cr is unknown. Patient was
started on a dobutamine drip, transferred here for further
evaluation.
Upon arrival to the [**Hospital1 18**] ED the patient was in complete heart
block with narrow escape rhythm at approx 35-40 bpm. His
pressures were 100-110 on 5 of dopamine drip. Repeat K
demonstrated K of 6.0. He was given insulin and calcium
gluconate. Placement of temporary pacing wire deferred
secondary to poor access (secondary to radiation) and renal
failure. The patient had a FAST exam that was negative. CXR
demonstrated a large globular heart. Cspine showed no acute
abnormality and CT head non-con demonstrated no acute
intracranial abnormality. A femoral triple lumen central line
was placed. He received 3L IVF in the Emergency Department.
Repeat labs demonstrated K of 4.6, Cr of 2.5 and lactate of 6.4.
On review of systems (per sister [**Location (un) **], the patient had symptoms
of dyspnea and dyspnea on exertion for approximately 6-9 months.
The sister knew no other symptoms. Reportedly he had been
evaluated for AVR, and was denied both open and transcutaneous
minimally invasive procedures.
The patient was intubated upon arrival to the CCU, history was
obtained from sister [**Name (NI) **] and the medical record. Upon arrival
to CCU, patient's rate 25-30, with SBP 80s-90s. SBP originally
in 80s-90s, decreased to 70s-80s. Dopamine transiently
increased in an attempt to elevated SBP. Transcutaneous pacing
was initiated. Increased voltage of pacing to facilitate
capture. SBP increased to 150s with capture of external pacing.
Decreased dopamine and increased sedation (fentanyl, midazolam
gtts).
Past Medical History:
1. CARDIAC RISK FACTORS: HTN
2. CARDIAC HISTORY:
- Aortic stenosis (unknown valve area), CHF (unknown EF)
3. OTHER PAST MEDICAL HISTORY:
- hypothyroidism
- s/p thyroidectomy
- Hodgkin's lymphoma (at age 4) s/p Cobalt Radiation
Social History:
- Tobacco history: unknown
- ETOH: significant alcohol use, per sister
- Illicit drugs: negative, per sister
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 60 externally paced, 136/50, 95% on ventilator (CMV, FIO2
52%, rate of 16, minute ventilation 7.8)
Gen: intubated, sedated
NECK: Significant radiation scaring. JVP difficult to assess [**2-27**]
positioning and ETT. Normal carotid upstroke.
Chest: pectus excavatum deformity
CV: bradycardic and regular. Varying intensity S1, no S2. III/VI
late peaking systolic murmur loudest at the LUSB with radiation
to the neck. II/VI holosystolic murmur at the apex.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP, NO CCE. Full distal pulses bilaterally. L femoral
venous line C/D/I.
NEURO: Responds to painful stimuli. Intubated and sedated.
DISCHARGE EXAM:
Vitals Tm/Tc: 99.6/99 HR; 84-101 RR: 18 BP: 100-122/61-65 o2
sat: 95% RA.
I/O:
24h: 1389/2100
8h: NPO/300
Gen: comfortable, in no distress
NECK: Significant radiation scarring. JVP difficult elevated
16cm.
Chest: pectus excavatum deformity
CV: Varying intensity S1, no S2. III/VI late peaking systolic
murmur loudest at the LUSB with radiation to the neck. II/VI
holosystolic murmur at the apex.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP, NO CCE. Full distal pulses bilaterally.
NEURO: Strength and sensation globally intact. PERRL
Pertinent Results:
Admission Labs:
[**2149-6-10**] 02:27AM BLOOD WBC-10.5 RBC-4.36* Hgb-13.3* Hct-43.5
MCV-100* MCH-30.4 MCHC-30.5* RDW-13.5 Plt Ct-223
[**2149-6-10**] 02:27AM BLOOD Neuts-86.7* Lymphs-6.5* Monos-6.4 Eos-0.3
Baso-0.1
[**2149-6-10**] 02:27AM BLOOD PT-15.4* PTT-31.0 INR(PT)-1.4*
[**2149-6-10**] 02:27AM BLOOD UreaN-33* Creat-2.5*
[**2149-6-10**] 05:50AM BLOOD Glucose-152* UreaN-32* Creat-2.2* Na-136
K-6.5* Cl-102 HCO3-21* AnGap-20
[**2149-6-10**] 05:50AM BLOOD ALT-2040* AST-3327* LD(LDH)-PND
AlkPhos-78 TotBili-1.2
[**2149-6-10**] 02:27AM BLOOD cTropnT-0.05*
[**2149-6-10**] 02:27AM BLOOD Calcium-10.3 Phos-7.8* Mg-2.0
[**2149-6-10**] 05:50AM BLOOD Albumin-4.1 Calcium-9.3 Phos-5.6*# Mg-2.0
Studies:
CXR ([**2149-6-10**]): IMPRESSION: Moderate pulmonary edema.
ECHO ([**2149-6-10**]):
The left atrium is normal in size. Left ventricular wall
thicknesses are top normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal anteroseptal akinesis and inferoseptal
hypokinesis (overall left ventricular ejection fraction ?45-50%
but views are suboptimal for assessment of sytolic function).
Cannot exclude additonal wall motion abnormalities. 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.] The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild to moderate ([**1-27**]+) aortic
regurgitation is seen. The mitral valve leaflets are severely
thickened/deformed. There is severe mitral annular
calcification. There is mild functional mitral stenosis (mean
gradient 3 mmHg) due to mitral annular calcification. Mild to
moderate ([**1-27**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
[Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is
mild pulmonary artery systolic hypertension. The pulmonic valve
prosthesis is not well seen. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
CT C-spine non-con ([**2149-6-10**]):
IMPRESSION:
1. No fracture or subluxation.
2. Likely status post thyroidectomy.
CT head non-con ([**2149-6-10**]):
IMPRESSION: No acute intracranial process.
CXR ([**2149-6-12**]):
Transvenous right atrial lead curls anteriorly, its tip
projecting over the anterior wall of the mid portion of the
right atrium. The right ventricular lead passes to the mid
portion of the right ventricle. Pulmonary edema continues to
clear. There is no pneumothorax or mediastinal widening and
small right pleural effusion is probably unrelated. Severe
cardiomegaly has also improved.
Right upper extremity u/s ([**2149-6-13**]):
IMPRESSION:
1. Acute thrombosis of the right basilic and cephalic
(superficial) veins.
2. No evidence of right lower extremity DVT. Axillary vein not
imaged, due to overlying bandage.
LE DOPPLER: No evidence of deep vein thrombosis in the right or
left leg
DISCHARGE LABS:
[**2149-6-16**] 06:52AM BLOOD WBC-7.8 RBC-3.52* Hgb-11.1* Hct-34.4*
MCV-98 MCH-31.6 MCHC-32.4 RDW-13.7 Plt Ct-265
[**2149-6-16**] 06:52AM BLOOD PT-13.1* PTT-93.0* INR(PT)-1.2*
[**2149-6-16**] 06:52AM BLOOD Glucose-89 UreaN-18 Creat-1.0 Na-140
K-4.4 Cl-101 HCO3-28 AnGap-15
[**2149-6-16**] 06:52AM BLOOD Calcium-8.0* Phos-3.9 Mg-2.1
Brief Hospital Course:
51M with aortic stenosis, CHF and hx of Hodgkin's lymphoma who
presents with complete heart block in the setting of renal
failure and hyperkalemia. Patient also has significant aortic
stenosis. The patient had a pacemaker placed, with resolution of
bradycardia and hemodynamic instability. He was worked-up for a
Cor-Valve.
# Complete Heart Block: Pt was in CHB on admission with
bradycardia to 30s. He was started on a dopamine drip.
Hyperkalemia was treated with insulin and calcium gluconate. Due
to poor access, temp pacer could not be placed; instead, a
femoral triple lumen central line was placed and he was given
fluids in the ED and then transferred to the CCU. Transcutaneous
pacing was initiated and the voltage of pacing was increased as
needed to facilitate capture. SBP increased to 150s with capture
of external pacing. Decreased dopamine and increased sedation
(fentanyl, midazolam gtts). He was taken to EP suite for
permanent pacemaker placement after which he became stable and
was weaned off dopamine. etiology remained uncertain, but could
include hyperkalemia, though there was little e/o hyperkalemic
signs on EKG. Also considered hypothyroidism - TSH was elevated
at 10 but free T4 was normal so no adjustments to his
levothryoxine were made. Also considered progression of CHF
secondary to AS. Blood cultures were drawn to r/o endocarditis
(pt has abnormal valves so would be at risk) but were NGTD.
Patient adamantly denied having any medication changes and
reportedly did not take more of less of any of his home meds.
After pacer placement, he experienced a few limited episodes of
atrial tachycardia with normal AV node conduction, which was
unusual given his previous CHB. However, he intermittently went
back into complete heart block requiring pacing, most notably
after receiving large metoprolol load prior to CTA
torso/coronaries in order to bring heart rate down for coronary
imaging. Pt appears to be quite sensitive to nodal blockade.
However, at lower doses of BB he was tachycardic to 100s (pt
a-sensed on pacer with v-pacing set up to 130s). Spoke with EP
who preferred pt to be beta blocked into lower rate than
adjusting pacer lower. His metoprolol was increased to 50mg
daily (succinate) for better rate control.
# Aortic stenosis: pt w/ known severe/critical AS, w/out record
of valve diameter. Pt apparently has been evaluated for AVR but
due to his anatomy s/p radiation treatments as a child, he is
not a candidate for open repair. Also eval'ed at [**Hospital1 756**] for
percutaneous valve replacement but femoral arteries were too
narrow. This was in [**2147**]. Given that corevalve at [**Hospital1 18**] uses
smaller sheath, decision was made to eval pt again for
percutaneous valve. obtained echo which showed AoVA of 0.9 cm^2.
Peak gradient over valve was 91mmHg and mean gradient was
50mmHg. He was taken for CTA torso as well to eval femoral
arteries. Final results were pending at the time of discharge,
but preliminary read showed acute PE (see below). Pt taken for
cardiac cath on [**2149-6-16**], report also pending at the time of
discharge. He will follow up with Dr. [**Last Name (STitle) **] to discuss
eligibility for corevalve as an outpatient.
# Acute PE: wet read of CTA done for corevalve work up showed
incidental finding of "Acute emboli in right lower lobar and
segmental pulmonary arteries (4:21-28)." Pt was started on a
heparin drip and then switched to lovenox injections at a dose
of 70mg subcutaneously [**Hospital1 **] for at least 3 months. He refused
warfarin, opting for lovenox instead. bilateral LE dopplers were
neg for DVT and RUE doppler (side of entry for pacemaker) showed
"acute thrombosis of the right basilic and cephalic
(superficial) veins. No evidence of right lower extremity DVT.
Axillary vein not imaged, due to overlying bandage." Source of
PE unknown but could be in axillary vein that was unable to be
imaged. Can work up further as an outpatient.
# Hypothyroidism: patient s/p thyroidectomy at age of 19. on
synthroid 150mcg qd at home. The patient was initially continued
on synthroid IV 75mcg qd while intubated, and quickly changed
back to 150mcg qd home dose. Checked thyroid studies in the
setting of CHB. Results were TSH 10, T4 7.4, T3 70, Free T4 1.4
so no changes were made to home levothyroxine dose.
# HTN: The patient was initially on dopamine upon admission to
the CCU. Dopamine was quickly stopped after placement of the
pacemaker. The patient was started on metoprolol and lasix
after he was called out to the floor.
# Hyperkalemia: The patient was hyperkalemic to 6.5 upon
admission, without specific EKG changes appreciated, and was
given calcium gluconate, insulin, D50 and kayexalate. After
hospital day #1, the patient's hyperkalemia resolved.
# Renal failure: The patient had [**Last Name (un) **] with Cr of 2.5 upon
admission to the CCU, likely from poor forward flow from
cardiogenic shock secondary to profound bradycardia. After
pacemaker was placed, the patient's renal failure resolved, with
Cr improving to baseline of 0.9.
Transitional Issues:
1. Patient should have thyroid function tests followed up as
outpatient.
2. follow up final CTA torso/coronaries and cardiac cath report
for corevalve work up.
3. consider additional work up for source of PE if indicated
Medications on Admission:
-metoprolol 12.5mg [**Hospital1 **]
-lasix 40mg [**Hospital1 **]
-synthroid 150mcg qd
-kcl 20mg qd
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO once a
day.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
5. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
Disp:*60 syringes* Refills:*2*
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
complete heart block
pacemaker placement
severe aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you had fallen and become
unresponsive. You were found to have a heart rate in the 30s and
your blood pressure was low. You were given a pacemaker and your
heart rate and blood pressure improved. The cause of your
abnormal heart rate could be due to medications, abnormal
electrolytes, or your severe aortic stenosis worsening. If your
symptoms recur, your pacemaker will prevent your heart rate from
dropping low. You were evaluated for an aortic valve repair
while you were here and should follow up with Dr. [**Last Name (STitle) **] in the
next few weeks. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) 32655**] NP will be contacting you at home
regarding the next step.
.
We made the following changes to your medicines:
1. DECREASE lasix to once daily
2. CHANGE metoprolol to 50mg once a day (long acting version).
3. START taking lisinopril to help your heart pump better
4. START taking lovenox injections twice daily to prevent the
blood clots in your lungs from getting bigger.
Followup Instructions:
Department: CARDIAC SERVICES
When: Thursday [**6-19**] at 1:45pm
With: [**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 110143**]
.
Department: CARDIAC SERVICES
When: Monday [**7-7**] at 2:00pm
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"738.3",
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"426.0",
"584.9",
"428.23",
"244.0",
"415.11",
"453.81",
"427.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.59",
"37.23",
"37.83",
"37.72",
"88.56",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14559, 14565
|
8437, 13508
|
325, 347
|
14673, 14673
|
4784, 4784
|
15888, 16296
|
3462, 3471
|
13900, 14536
|
14586, 14652
|
13777, 13877
|
14824, 15865
|
8081, 8414
|
3511, 4180
|
3135, 3192
|
4196, 4765
|
13529, 13751
|
265, 287
|
375, 3064
|
4800, 8065
|
14688, 14800
|
3223, 3317
|
3086, 3115
|
3333, 3446
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,910
| 103,160
|
52477
|
Discharge summary
|
report
|
Admission Date: [**2106-8-27**] Discharge Date: [**2106-8-31**]
Date of Birth: [**2023-2-21**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 yo W with PMH of Type II DM, HTN presents with hypoglycemia.
Patient woke this morning and fell out of bed. She was unable to
get up. She had no head trauma or loss of consciousness. Son
found her and called EMS. In the field, her FS was in the 20's
associated with altered mental status. She received oral glucose
+ juice and both mental status and FS's improved. She also
reports epigastric/ substernal CP, nonradiating that lasted for
several hours and improved on arrival to the ED without
intervention.
.
On arrival to the ED, VS: T97.5 HR 76 BP 148/103 RR 17 100%RA.
FS was 29. She received 1 amp of D50, 50 ucg of octreotide and
was started on D5 infusion. There was a question of new
infiltrate in R base and received Levaquin x 1. Labs notable for
elevated CE's. Per notes, patient was seen by cards, but was
refusing heparin or ASA at this time Pt was refusing treatment
with heparin and ASA.
Past Medical History:
DM type II
Mild-moderate diabetic retinopathy
HTN
Arthritis
Cataracts
Social History:
Patient was born in [**Country **]. Moved to the United States in [**2075**].
Currently living with her daughter. Previously worked as a
housekeeper at [**Hospital 13128**]. Denies tobacco/EtOH.
Family History:
Son in good health.
Physical Exam:
Vitals Stable.
GEN: elderly female, pleasant, NAD.
HEENT: eomi, mmm.
RESP: CTA B. No wrr.
CV: RRR. No mrg.
Abd: benign.
Ext: No cee.
Pertinent Results:
[**2106-8-27**] 09:00PM BLOOD cTropnT-0.10*
[**2106-8-28**] 10:15AM BLOOD CK-MB-10 MB Indx-7.0* cTropnT-0.22*
[**2106-8-29**] 09:05AM BLOOD CK-MB-4 cTropnT-0.21*
[**2106-8-30**] 02:00PM BLOOD cTropnT-0.21*
.
[**2106-8-30**] 02:00PM BLOOD WBC-6.3 RBC-3.54* Hgb-10.6* Hct-31.4*
MCV-89 MCH-29.9 MCHC-33.8 RDW-15.0 Plt Ct-263
.
[**2106-8-30**] 02:00PM BLOOD Glucose-175* UreaN-37* Creat-1.3* Na-139
K-4.2 Cl-109* HCO3-20* AnGap-14
.
[**2106-8-27**] 09:00PM BLOOD ALT-15 AST-24 LD(LDH)-217 CK(CPK)-135
AlkPhos-87 TotBili-0.2
.
[**2106-8-28**] 10:15AM BLOOD CK(CPK)-143*
[**2106-8-29**] 09:05AM BLOOD CK(CPK)-73
.
[**2106-8-28**] 10:15AM BLOOD Triglyc-33 HDL-65 CHOL/HD-2.2 LDLcalc-70
.
[**8-27**] EKG:
Sinus rhythm. Poor R wave progression, probably a normal
variant. Compared to the previous tracing of [**2103-7-24**] there is no
significant diagnostic change.
.
CXR:
IMPRESSION: No acute cardiopulmonary abnormality
.
Cardiac Echo:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic dysfunction. Mildly thickened aortic valve leaflets
without stenosis and mild aortic regurgitation.
Brief Hospital Course:
83 yo W with PMH of Type II DM, HTN presents with hypoglycemia.
Patient woke and fell out of bed at home. She was unable to get
up. She had no head trauma or loss of consciousness. Son found
her and called EMS. In the field, her FS was in the 20's
associated with altered mental status. She received oral glucose
+ juice and both mental status and FS's improved. She also
reports epigastric/ substernal CP, nonradiating that lasted for
several hours and improved on arrival to the ED without
intervention.
.
On arrival to the ED, VS: T97.5 HR 76 BP 148/103 RR 17 100%RA.
FS was 29. She received 1 amp of D50, 50 ucg of octreotide and
was started on D5 infusion. There was a question of new
infiltrate in R base and received Levaquin x 1. Labs notable for
elevated CE's. Per notes, patient was seen by cards, but was
refusing heparin or ASA at this time Pt was refusing treatment
with heparin and ASA.
In the ICU she was found to have an NSTEMI with her troponin
peaking at 0.22 the am prior to transfer to the floor. Her care
in the ICU was complicated by her refusing labs and medications.
Thus they were not able to continue to cycle her enzymes.
Started on lovenox 60 mg SQ x 3 doses first one given at 1600 on
[**2106-8-28**] while asleep. She was initially on an insulin gtt and
this was changed to SQ insulin. Family is aware of her refusing
many interventions. She remains full code with full treatment.
.
Pt completed treatment with 3 days of SQ Lovenox, without
recurrance of chest pains. Pt remained off of her glyburide,
however metformin was restarted. Geriatrics consulted, and
recommended pt have VNA after discharge to assist with
medications at home, and recommended Geriatrics follow up as an
outpt for formal eval and treatment (if needed) of dementia,
with formal memory assessment. Appointments scheduled.
.
Pt also c/o some constipation which was relieved during
hospitalization. Pt discharged on standing colace and prn senna.
.
Pt discharged to home with VNA, feeling well.
Medications on Admission:
Acetaminophen
Amitryptiline 10mg PO qHS
Cozaar 100 mg q daily
glipizide 10mg PO bid
metformin 500 mg [**Hospital1 **]
pravastatin 40mg qHS
Colace
Discharge Medications:
1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
7. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
[**Hospital1 **] (2 times a day).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
# NSTEMI
# Hypoglycemia
.
Secondary diagnoses:
Type II Diabetes
Hypertension
Discharge Condition:
stable
Discharge Instructions:
Take all of your medications as prescribed. Keep your follow up
appointments as scheduled.
Please return to the Emergency Department if you develop new
chest pain, shortness of breath; otherwise contact your primary
care provider with concerns.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2106-9-7**] 8:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12898**], DPM Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2106-9-14**]
12:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2983**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2106-11-11**] 9:00
|
[
"294.8",
"372.30",
"365.9",
"250.80",
"410.71",
"715.90",
"357.2",
"293.0",
"E932.3",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6380, 6437
|
2933, 4933
|
288, 295
|
6558, 6567
|
1744, 2910
|
6860, 7347
|
1555, 1576
|
5130, 6357
|
6458, 6484
|
4959, 5107
|
6591, 6837
|
1591, 1725
|
6505, 6537
|
236, 250
|
323, 1231
|
1253, 1325
|
1341, 1539
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,347
| 124,573
|
42789
|
Discharge summary
|
report
|
Admission Date: [**2137-7-12**] Discharge Date: [**2137-8-1**]
Date of Birth: [**2072-4-13**] Sex: M
Service: MEDICINE
Allergies:
Iodine / IV contrast
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
fatigue, weight gain, lower extremity edema and increasing
abdominal girth
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic paracentesis
History of Present Illness:
65 male with a history of NASH cirrhosis s/p TIPS, CAD s/p
CABG, DM2 on insulin, PAD s/p bilateral iliac stenting presents
with a 6 week history of increasing abdominal distention,
fatigue and worsening lower extremity edema. The patient was
first diagnosed with cirrhosis [**8-/2136**] and underwent a TIPS
procedure [**2137-6-13**]. His cirrhosis has been complicated by
ascites requiring repeated LVP (past 7 months), encephelopathy,
SBP and HRS. He was recently admitted to the [**Hospital1 18**] from
[**Date range (1) 28235**] to the liver service for similiar complaints. During
that admission, he was treated for hepatic encephalopathy with
lactulose/rifaximin, and SBP with 5 day course of ceftriaxone.
Discharged on prophylactic ciprofloxacin 500mg daily. Course c/b
[**Last Name (un) **] with Cr rising to 1.4, and he was diagnosed with HRS type 2
after he did not respond to albumin administration. Plan was to
follow-up with Nephrology as outpatient. He has a history of
diuretic refractory ascites, and required 2 paracenteses during
the admission. Ultrasound showed TIPS patent. Was discharged off
diuretics given worsening renal function and concern for
electrolyte abnormalities. During the admission, his chronic
hyponatremia worsened with administration of Bumex and
spironolactone, and improved when these meds were held. Since
discharge, the patient has noted increasing abdominal girth,
weight gain, and worsening fatigue. 1 day PTA, he presented to
[**Hospital3 **] for repeat paracentesis. There, he was noted to
be more edematous on exam. Patient mentions that the edema has
been getting progressively worse for the past several weeks.
His labs at [**Hospital1 **] were notable for hyponatremia with Na 116, WBC
6.5, K 5.3, Cr 1.6, AST 36, ALT 35, Tbili 1.0, AP 212, TSH 3.98,
Albumin 3.1, lactate 1.4. Per report, ultrasound there did not
show any evidence of fluid ammenable to paracentesis. Was
transferred to [**Hospital1 18**] for further evaluation.
In the ED, initial VS were 99 81 107/36 14 96%. Labs notable for
Na 114 (recent baseline 120-127), K 5.6, Cr 1.7 (recently
1.4-1.5), ALT 39, AST 44, AP 197, Tbili 1.1, Alb 3.2, Hct 25.8
(baseline 24-25), WBC 6.1 with 81.5% neutr. No imaging done
here. Patient received zofran for nausea. Liver consulted, who
recommended fluid restriction. Recommended albumin if worsening
renal failure, but as Cr 1.7 (which is near recent baseline), no
albumin given. Was admitted for further work-up and treatment of
hyponatremia and cirrhosis. VS prior to transfer 97.8 76 103/36
15 95%.
On the floor, the patient reports significant fatigue. He denies
chest pain, SOB, abdominal pain, nausea or lightheadness.
Past Medical History:
- Recent diagnosis of cirrhosis in [**4-/2136**] in the setting of
increasing abdominal girth. Transjugular liver biopsy on
[**2136-9-13**] confirmed cirrhosis. Upper endoscopy [**2136-10-30**] negative
for esophageal varices. Cirrhosis complicated by recurrent
ascites requiring LVP every 2 weeks. Now s/p TIPS [**6-13**]. Also c/b
SBP, encephalopathy, HRS.
- CAD s/p CABG
- DM2
- PAD s/p iliac stenting
- Psoriasis
- s/p roux-en-y gastric bypass
Social History:
Married. Born in the US. No history of alcohol excess and quit
alcohol [**8-/2136**] (1 beer daily at most in the past). Previously
worked as a machinist (toolmaker). He has two children. Tattoos
self-administered. Quit tobacco in [**2114**], with a total of 20
estimated pack years. No history of IV drug use, no cocaine use,
no transfusions, no military service.
Family History:
1) Sister, history of depression, anxiety,
2) Mother, history of hypertension.
3) No known FHx of liver disease, liver cancer or autoimmune
illnesses.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: TMAX 98.2 Tcurr 97.8 BP98/50 HR 74 94%/RA weight 69.8 kg
GENERAL: Fatigued, chronically-ill appearing male, NAD, sleepy
but arousable to voice, oriented x3, NAD
HEENT: Scelare anicteric, PERRL, OP clear, NGT in place
NECK: No cervical LAD, supple
LUNGS: CTAB, no wheezing/rales/rhonchi with no use of accessory
muscles
HEART: RRR, S1-S2 no rubs, murmurs or gallops
ABDOMEN: Soft, non-tender, distended. Dull to percussion with
minimal fluid wave. Hyperactive bowel sounds. No guarding or
rebound. Spleen and liver not appreciated due to fluid
distention. 3x2 cm scar tissue lateral to umbilicus on the right
side attributable to chronic insulin injection
EXTREMITIES: Warm, well-perfused wih 3+ pitting edema
bilaterally. 2+ peripheral pulses.
SKIN: No evidence of jaudice with extensive ecchymoses on upper
extremities and chest. Multiple tattoos.
NEURO: Drowsy but arousable to voice, oriented x3. CNs II-XII
grossly intact. Normal muscle strength ([**3-23**]) throughout. No
evidence of asterixis.
LABS: See below.
DISCHARGE PHYSICAL EXAM:
VS: 97.3, BP 121/43, HR 87, RR 20, 98% RA
Gen: NAD, alert and interactive, cooperative
HEENT: scattered ecchymoses, L sclera with hemorrhage improving
very slightly, full EOMI, MMM, bitemporal wasting, dobhoff in
place
CV: RRR, NS1&S2, no MRG
Resp: CTAB rare crackles at bases
Chest: Wasted with bony protruberences and visible rib cage.
GI: distended, flanks dull, BS+, No TTP, +fluid wave, no leaking
from paracentesis site
Ext: BLE 2+ edema to knees; BUE with ecchymosis, left arm with
multiple lacerations, dressings c/d/i; L PICC removed
Neuro: no asterixis, A+Ox3
Pertinent Results:
ADMISSION LABS:
[**2137-7-12**] 10:49PM PT-14.4* PTT-38.6* INR(PT)-1.3*
[**2137-7-12**] 09:40PM GLUCOSE-279* UREA N-96* CREAT-1.7*
SODIUM-114* POTASSIUM-5.6* CHLORIDE-85* TOTAL CO2-26 ANION GAP-9
[**2137-7-12**] 09:40PM estGFR-Using this
[**2137-7-12**] 09:40PM ALT(SGPT)-39 AST(SGOT)-44* ALK PHOS-197* TOT
BILI-1.1
[**2137-7-12**] 09:40PM ALBUMIN-3.2*
[**2137-7-12**] 09:40PM WBC-6.1 RBC-2.89* HGB-8.4* HCT-25.8* MCV-89
MCH-29.1 MCHC-32.7 RDW-15.4
[**2137-7-12**] 09:40PM NEUTS-81.5* LYMPHS-9.9* MONOS-6.0 EOS-2.4
BASOS-0.2
[**2137-7-12**] 09:40PM PLT COUNT-156
.
DISCHARGE LABS:
[**2137-8-1**] 04:31AM BLOOD WBC-4.9 RBC-2.61* Hgb-7.7* Hct-23.9*
MCV-92 MCH-29.7 MCHC-32.4 RDW-17.3* Plt Ct-154
[**2137-7-21**] 04:20AM BLOOD Neuts-83.5* Lymphs-7.1* Monos-8.5 Eos-0.7
Baso-0.2
[**2137-8-1**] 04:31AM BLOOD PT-15.2* INR(PT)-1.4*
[**2137-8-1**] 04:31AM BLOOD Glucose-256* UreaN-73* Creat-1.6* Na-133
K-3.7 Cl-97 HCO3-29 AnGap-11
[**2137-8-1**] 04:31AM BLOOD ALT-17 AST-26 AlkPhos-84 TotBili-1.0
[**2137-8-1**] 04:31AM BLOOD Albumin-3.5 Calcium-8.0* Phos-3.8 Mg-2.9*
.
EKG on [**7-9**]
Sinus rhythm. The tracing is of improved technical quality.
There is a marked decrease in the limb lead voltage while the
precordial lead appearance is similar. The axis is now leftward
and the tracing is similar to that recorded on [**2137-6-14**] but there
is variation in the precordial lead placement. Followup and
clinical correlation are suggested.
.
PERTINENT RESULTS:
[**2137-7-20**] 08:48PM BLOOD CK-MB-4 cTropnT-0.18*
[**2137-7-21**] 04:20AM BLOOD CK-MB-3 cTropnT-0.22*
[**2137-7-22**] 04:59AM BLOOD CK-MB-3 cTropnT-0.25*
[**2137-7-17**] 06:30AM BLOOD CEA-9.6* PSA-0.1
[**2137-7-17**] 06:30AM BLOOD HIV Ab-NEGATIVE
[**2137-7-17**] 06:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2137-7-30**] 03:20PM ASCITES WBC-15* RBC-620* Polys-19* Lymphs-55*
Monos-9* Mesothe-12* Macroph-5*
[**2137-7-15**] 04:20PM ASCITES WBC-20* RBC-336* Polys-9* Bands-1*
Lymphs-29* Monos-0 Mesothe-4* Macroph-57*
[**2137-7-17**] 06:30
Test Result Reference
Range/Units
CA [**43**]-9 13 <37 U/mL
.
PERTINENT MICRO:
[**2137-7-24**] 08:00
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE
.
[**2137-7-17**] 06:30
HERPES SIMPLEX (HSV) 1, IGG
Test Result Reference
Range/Units
HSV 1 IGG TYPE SPECIFIC AB >5.00 H index
HSV 2 IGG TYPE SPECIFIC AB <0.90 index
.
[**2137-7-17**] 6:31 am Blood (EBV) **FINAL REPORT [**2137-7-23**]**
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2137-7-18**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2137-7-18**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2137-7-23**]):
POSITIVE >=1:10 BY IFA.
INTERPRETATION: UNINTERPRETABLE EBV PATTERN.
.
[**2137-7-31**] 06:31
EBV PCR, QUANTITATIVE, WHOLE BLOOD
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
.
PERTINENT IMAGING:
[**2137-7-21**] liver ultrasound with doppler
IMPRESSION
1. Patent TIPS. Mild elevation of velocity in distal TIPS
stent to which
attention can be paid on follow-up.
2. Cirrhosis, no focal liver lesion.
3. Moderate volume ascites.
4. Left portal vein not well visualized. This could be
technical but is not further evaluated on this study.
.
[**2137-7-25**] MIBI stress test
IMPRESSION:
1) Ascites
2) No evidence of focal myocardial perfusion defects.
.
[**2137-7-25**] Stress EKG (pharmacologic)
IMPRESSION: No ischemic ECG changes. No anginal type symptoms.
Appropriate hemodynamic response to Regadenoson. Nuclear report
sent
separately.
Brief Hospital Course:
65 yo M w/ NASH cirrhosis h/o SBP and TIPS with recent revision,
refractory ascites, hepatic encephalopathy, who presented with
lethargy and hyponatremia. Course complicated by HRS and
malnutrition. Approved for transplant waiting list during this
admission.
# Hyponatremia: Presented with lethargy, sodium of 114,
concerning for an acute on chronic process, as his records
indicate a baseline sodium level of 125-130. Due to [**Last Name (un) **] on prior
admission at [**Hospital1 18**] discharged [**7-10**], patient has not been on
diuretics. Patient was started on hypertonic saline drip in the
ICU and improvement of Na to >120 was noted by hospital day 2
and hypertonic saline was discontinued prior to transfer to the
liver service. Renal was consulted, and he had a TSH and
cortisol check, both of which were normal. Patient was managed
with fluid restriction and salt restriction. Sodium on discharge
was 133.
- Continue to fluid restrict to 750cc/day, 2g Na restriction
- Continue to hold diuretics for [**Last Name (un) **]
#Renal Failure: Acute on Chronic renal failure from baseline Cr
of 1.4. Likely HRS type 2 chronically, now exacerbated by HRS
Type I. Renal was consulted. Creatinine finally improved with
aggressive albumin resucitation and maximum doses of midodrine
and octreotide. 24 hr urine collection showed CrCl 23 while
creatinine was still elevated. If renal function worsens again
and cannot recover, may need repeat creatinine clearance, as if
GFR <25 for 2 weeks he may be a candidate for combined
liver-kidney transplant. At time of discharge patient was back
to about baseline on midodrine alone.
- Continue to hold diuretics
- Continue midodrine 15mg TID PO
- Follow up in transplant clinic as scheduled
# Cirrhosis: NASH cirrhosis s/p TIPS, cirrhosis complicated by
HE, SBP, HRS, MELD on transfer from MICU was 20, decreased to
15 at time of discharge. Patient approved for transplant waiting
list during this admission.
- SBP: h/o SBP, neg diagnostic paracentesis x2 this admission,
on cipro ppx
- Hepatic Encephalopathy: on lactulose, rifaximin. AMS resovled,
no asterixis at discharge
- Varices: None on OSH EGD, not on nadolol
- Ascites: Off diuretics for HRS, fluid and Na restriction; TIPS
patent on US [**2137-7-21**]
- Patient will follow up in transplant clinic
#Malabsorption: Severe nutritional deficiency as evidenced via
physical appearance of cachexia, bitemporal wasting, and albumin
of 3.1. Pt currently on tube feeds [**12-20**] malabsorption in setting
of NASH cirrhosis, gastric bypass surgery. He will need to be on
tube feeds indefinitely. As pt has distorted anatomy due to
roux-en-y gastric bypass, and will likely have recurrent large
volume ascites, a PEG tube is not a viable option for tube
feeds, so must use dobhoff. Nutrition was consulted, patientn
was on nepro tube feeds for hyperkalemia early in the admission,
transitioned back to isosource prior to discharge as was
normo-hypokalemic.
- Continue tube feeds at home via dobhoff
#DM: Sugars were difficult to control during this admission
while on tubefeeds and octreotide was also likely contributing
factor. Was discharged on slightly increased basal insulin dose,
and octreotide was not continued at discharge.
- Instructed to follow up closely with PCP for diabetes
management
# Falls: Patient had right arm pain and edema, ecchymosis s/p
fall in transit to [**Hospital1 18**] from OSH. No indwelling CVC to increase
risk of upper extremity DVT, plainfilm of R should without
fracture or dislocation. Improved without intervention. Of note,
patient also had a mechanical fall during this admission without
loss of conciousness. He did not recall hitting his head but the
following day he was noted to have left eye scleral hemorrhage
in addition to several new ecchymoses and lacerations.
Ophtomology consult was deferred as patient had normal EOM and
no vision changes.
# Troponemia: Obtained for unclear reasons during MICU work up,
Trop-T 0.18 to 0.25 in setting of worsening renal function
however in patient with known CAD s/p CABG. EKG with no ischemic
changes from prior. Patient without chest pain and without
events on telemetry. Nuclear stress testing for transplant work
up did not show any evidence of ischemic changes.
TRANSITIONAL ISSUES:
- Cultures of peritoneal fluid from [**2137-7-30**] pending at discharge
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Aspirin 81 mg PO DAILY
2. Creon 12 1 CAP PO TID W/MEALS
3. Cyanocobalamin 50 mcg PO DAILY
4. Glargine 30 Units Bedtime
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Quinine Sulfate 324 mg PO HS
7. Rifaximin 550 mg PO BID
8. Tamsulosin 0.4 mg PO HS
9. Testosterone 4 mg Patch 1 PTCH TD DAILY
10. Ursodiol 300 mg PO TID
11. Vitamin D 400 UNIT PO DAILY
12. Vitamin E 400 UNIT PO BID
13. Lactulose 30 mL PO TID
Titrate to [**1-20**] BMs/day
14. MetFORMIN (Glucophage) 500 mg PO DAILY
15. Ciprofloxacin HCl 500 mg PO Q24H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Creon 12 1 CAP PO TID W/MEALS
4. Cyanocobalamin 50 mcg PO DAILY
5. Lactulose 30 mL PO TID
Titrate to [**1-20**] BMs/day
6. Rifaximin 550 mg PO BID
7. Tamsulosin 0.4 mg PO HS
8. Testosterone 4 mg Patch 1 PTCH TD DAILY
9. Ursodiol 300 mg PO TID
10. Vitamin D 400 UNIT PO DAILY
11. Vitamin E 400 UNIT PO BID
12. Midodrine 15 mg PO TID
RX *midodrine 5 mg 3 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Glargine 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. MetFORMIN (Glucophage) 500 mg PO DAILY
16. IsoSource
Isosource 1.5 Cal Full strength;
Goal rate: 55 ml/hr x24 hr (continuous)
Flush w/ 30 ml water q4h
No residual checks
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] care
Discharge Diagnosis:
Primary diagnosis:
Hyponatremia
Acute kidney injury
Secondary diagnosis:
NASH cirrhosis
Diabetes melitus
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 17025**],
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted
because your sodium was dangerously low and you were fatigued.
You were treated in the intensive care unit with fluids through
your veins. Once your sodium had normalized you were transferred
to the [**Doctor Last Name 3271**] [**Doctor Last Name 679**] liver service, where you were treated for
kidney injury, which had improved at the time of discharge.
During your admission you continued you extensive work up for
transplant evaluation and were approved for the liver transplant
waiting list.
Please follow up at the liver clinic as scheduled below. Please
follow up with your primary care doctor about your diabetes.
They may want to check your kidney function as well.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2137-8-7**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21927**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: LIVER CENTER
When: THURSDAY [**2137-8-8**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2137-8-12**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 92441**], MD
Specialty: Primary Care
When: Friday [**8-16**] at 2pm
Location: [**Hospital6 **]
Address: [**Last Name (un) 59485**], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 92440**]
Completed by:[**2137-8-3**]
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56,527
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Discharge summary
|
report
|
Admission Date: [**2151-11-30**] Discharge Date: [**2151-12-21**]
Date of Birth: [**2079-7-18**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
Hemodialysis
History of Present Illness:
72 year old male with h/o CVA with expressive aphasia, OSA, AS,
CAD, OSA on BiPap and chronic systolic CHF (EF30-35%) who was
sent in to the ED by his VNA for hypotension (SBPs in 80s),
slurred speech, lethargy/unresponsiveness.
The patient's son stated that although he was unsure of what led
to his hypotension in this situation, the patient has a history
of inappropriately taking his medications including doubling up
on his medications or taking the same medication repeatedly and
skipping other medications. Of note, the patient was recently
discharged home from a rehabilitation facility following an
admission at [**Hospital1 18**] for altered mental status and acute renal
failure. Since discharge from rehab the patient's son stated
that his father has had problems with his CPAP and was unsure
how frequently he was able to use it.
In the ED, initial vital signs were T:97.3, HR:92, BP:120/62,
SO2:100% on NRB. He was not responsive. Initial labs in the ED
revealed a sodium of 130, K of 7.4 without evidence of peaked T
waves on EKG, a BUN of 207, a serum creatinine of 7.0, a BNP of
[**Numeric Identifier 37155**], and a Troponin-I of 0.12. Initial ABG showed profound
acidosis: 7.01/90/135/25 which was persistent through the
afternoon. He was Bipap'ed with some improvement in mental
status. Subsequently received Calcium gluconate 6 gm IV,
Dextrose and Insulin, NaHCO3 50 mEq, and Kayexalate 60g. He also
received ASA 600 mg PR given his elevated troponins. He
additionally received Levaquin 250 mg IV and Vancomycin 1g IV
x1. He was eventually intubated and brought to the [**Hospital Unit Name 153**].
Of note, pt was recently admitted for AMS/unresponsiveness in
the setting of having taken Ativan for abdominal MRI. He was
admitted to MICU for acute on chronic respiratory acidosis
(thought to be due to Ativan o/d, obesity hypoventilation
syndrome, and diaphragm paresis); there he was weaned from Bipap
uneventfully, and was diuresed for volume overload. On the
floor, he was weaned to 2L NC (baseline at home), continued
Bipap 15/8 for goal O2 >92%, was initially diuresed with rise in
his Cr from 1.5 to 3.6. His creatinine had returned to
approximately baseline (1.3) by discharge. Before this, he's had
several admissions for HF exacerbations with documented weight
gains, HF symptoms, and was diuresed each time. Some notes
indicate poor ability to take care of self at home, med
noncompliance, Bipap non compliance, etc.
A complete ROS was unable to be obtained as the patient was
intubated by arrival to the floor but the patient's son stated
that his father had a cold over the last month with a productive
cough and rhinorrhea but no fevers (no further ROS was
obtainable as he had not seen his father in days).
Past Medical History:
- Coronary artery disease s/p stent (LCx, [**2145**] at [**Hospital1 882**])
- Chronic systolic and diastolic CHF (EF 30-35%)
- Aortic stenosis (1.2cm2)
- CVA [**2145**], left MCA with expressive aphasia, motor planning
deficits, right-sided neglect. On coumadin in the past, stopped
due to GI bleed
- GI bleed [**2146**], due to hemorrhoids. Also [**6-/2151**] due to
hemorrhoids and coumadin stopped.
- BPH
- Prostate CA, [**Doctor Last Name **] 3+3, s/p XRT [**2142**]
- Hyperlipidemia
- Hypertension
- Thalassemia trait
- G6PD, class I - severe
- History of tobacco abuse (20 years total)
- OSA on BiPap 16/13 at home at night. O2 sat 85% at rest, on 2L
home O2
- Moderate pulmonary hypertension
- Gout
- Chronic back pain and lumbar spinal stenosis
- Light eye blindess [**1-12**] trauma
- Burn to L shoulder as a child
- Osteoarthritis
- H/o colon polyp
- H/o pancreatitis
Social History:
Lives alone in [**Location (un) 686**]. He is able to cook for himself. Able
to walk [**12-12**] blocks without dypnea. Poor compliance with diet.
Uses bubble packs for his medications. Doesn't know the names of
any of his medications but states he manages them himself. Has
assistance of his son and daughter per review of [**Name (NI) 2287**] records.
EtOH: none. Tobacco: Former 20 pack year smoker, quit 20 years
ago.
Illicits: Denies.
Family History:
Mother deceased from MI at age 37. Father deceased with CVA and
lung cancer. Maternal aunts with DM. Brother deceased from
esophageal cancer
Physical Exam:
Admit Exam:
93 --> 95.5 p77 113/63 (sbp 83-113) rr 12-20 92-99% on
vent 28%
Obese, intubated sedated gentleman. L eye appears atrophic
compared to R. Short, stout neck, with difficult to assess JVP's
Lungs rhonchorous with bronchial vented breath sounds, no clear
crackles though
RRR with AS type murmur along precordium, with S2 audible along
LSB, disappears at apex. PMI along LLSB. Radial pulses
non-palpable
Abd obese, NT ND, soft, BS+
No BLE edema. Proximal extremities initially cool to touch, now
warm with Bair Hugger on
Discharge Exam:
Pertinent Results:
[**2151-11-30**] 12:00PM BLOOD WBC-7.1 RBC-3.99* Hgb-10.0* Hct-31.2*
MCV-78* MCH-25.0* MCHC-31.9 RDW-17.2* Plt Ct-157
[**2151-11-30**] 12:00PM BLOOD PT-14.1* PTT-32.3 INR(PT)-1.2*
[**2151-11-30**] 12:00PM BLOOD Glucose-158* UreaN-207* Creat-7.0*#
Na-130* K-8.4* Cl-94* HCO3-20* AnGap-24*
[**2151-12-7**] 06:45AM BLOOD Glucose-105* UreaN-14 Creat-1.0 Na-145
K-3.9 Cl-106 HCO3-34* AnGap-9
[**2151-12-13**] 09:20AM BLOOD Glucose-144* UreaN-77* Creat-6.8* Na-135
K-4.9 Cl-95* HCO3-24 AnGap-21*
[**11-29**] CT HEAD:
No evidence of an acute intracranial process. Large chronic
infarction in the left hemisphere.
[**11-29**] CXR
FINDINGS: Evaluation is limited due to low lung volumes and body
habitus. As
compared to the prior examination increased fullness of the hila
and
prominence of the vasculature could represent additional volume
overload.
Right apical opacity correlates with a distend right internal
jugular vein.
Linear and bibasilar opacities most likely reflect atelectasis.
No
pneumothorax is seen.
IMPRESSION: Findings compatible with chronic congestive heart
failure.
[**11-30**] TTE
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
1.0cm2). Mild to moderate ([**12-12**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild-moderate aortic regurgitation. Right ventricular
cavity enlargement with borderline normal free wall motion.
Compared with the prior study (images reviewed) of [**2150-4-22**],
global left ventricular systolic function is improved and the
gradient across the aortic valve is increased. The severity of
aortic regurgitation is similar.
CXR [**12-15**]:
FINDINGS: In comparison with the study of [**2151-12-9**], there are
continued low lung volumes, which enhances the prominence of the
transverse diameter of the heart. Some indistinctness of
pulmonary vessels is consistent with increased pulmonary venous
pressure. There are some areas of atelectasis at the bases. A
small area of asymmetry in the mid zone on the right could
conceivably represent a developing focus of consolidation,
though it could merely reflect
some crowding of engorged vessels. Central catheter is now in
place that extends to the lower portion of the SVC.
Brief Hospital Course:
72 year old male with h/o CAD s/p stent to LCx, s/dCHF (30-35%)
with AR/AS/MR/TR/pulmHTN, CVA with expressive aphasia, OSA on
BiPap and ? home 2L NC who presented with unresponsiveness and
hypoTN and found to have profound respiratory and metabolic
acidosis, ARF, hyperK, pancreatitis.
#. Hypercarbic respiratory failure: Thought to be secondary to
worsening metabolic acidosis from renal failure and was unable
to keep up respiratory rate to compensate and fatigued.
COmplicated by likely aspiration PNA. Intubated for 2 days,
extubated without difficulty. Continued CPAP in hospital
overnight with good effect. Patient then began to refuse
nocturnal CPAP. Completed a full course of vancomycin for gram
+ cocci in sputum. He should continue the use of overnight CPAP
or nasal cannula oxygen at 4L.
#. Acute renal failure: Initially pre-renal in nature with
hypovolemia on initial exam, FeNa < 1%, FeUrea < 35%. Received
fluid hydration with good recovery of renal function to baseline
and normalization of urea. Hyperkalemia that was present on
admission resolved as renal function improved. Cr initially
7.0, improved to 1.0 on [**12-6**]. However, on [**12-8**] developed
recurrent ARF with Cr bumping to 3 and peaking at 7.7. Renal
team reconsulted. Sediment consistant with ATN. We did not
find a trigger for this recurrent episode of ARF. Dopplers
showed no evidence of thrombosis. He was started on dialysis
for three sessions after he developed hyperkalemia, hypocalcemia
and possible uremia. After discontinuation of dialysis, his
creatinine clearance with Cr 2.9 on the day of discharge.
Several of the patient's nephrotoxic medications were
discontinued including allopurinol, lisinopril, spironolactone,
gabapentin and torsemide because of kidney failure. He needs a
repeat chem 7 in 5 days. If in 5 days his kidney function is
improved, he could restart renally dosed allopurinol. The
remainder of these medications should remain discontinued until
re-addressed at his primary care doctor's office and renal
clinics. The patient's PCP will assist in scheduling outpatient
renal follow-up in the near term.
.
#. Pancreatitis: Chemical pancreatitis noted on admission as
patient did not complain of abdominal pain. Lipase trended down
with fluids.
.
#. Mechanical fall: He fell out of bed on one occasion on [**12-16**],
while trying to get out, after closing the door. ABG showed
respiratory acidosis and hypercarbia. He had no injuries.
.
#. Aortic stenosis/diastolic CHF: He had evidence of volume
overload on exam, prior to dialysis. His volume was managed
with dialysis. He is preload dependent due to aortic stenosis.
He would benefit from low dose diuretic as an outpatient, though
this cannot be restarted currently because of renal dysfunction.
If his renal function is improved in 5 days, would recommend
starting a low dose torsemide for ongoing fluid balance
maintenance. He should continue on a low salt (<2g), fluid
restricted diet (<1500cc).
.
# Goals of Care: Palliative care consulted given medical
complexity and poor long term prognosis. Patient remains full
code for now.
Medications on Admission:
Allopurinol 100 mg PO bid
Lisinopril 10 mg po daily
omeprazole magnesium 20 mg qday
spironolactone 25 mg [**12-12**] tablet po qday
Gabapentin 100 mg PO TID
Endocet 5/325 1-2 tablets q4 hrs prn pain
Lorazepam 2 mg PO anxiety
Latanoprost 1 drop right eye qhs
timilol maleate 1 drop right eye qday
opthalmic gel forming solution
Home O2 2L NC
Advair `1 inh [**Hospital1 **]
Ferrous Sulfate 325 PO bid
Metoprolol Succinate 50 mg qday
senna [**Hospital1 **]
torsemide 20 mg 1 tab po qday
Goserelin 10.8 mg subq implant
ASA 81 mg qday
Docustate
albuterol inhaler
Ventolin inh
Folate 1 mg tab po qday
Flomax 0.4 mg q24hrs (2 tablets po daily)
Simvastatin 40 mg po qhs
Discharge Medications:
1. omeprazole 10 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
4. Overnight CPAP or oxygen at 4L NC
CPAP is preferred but patient sometimes refuses in which case
overnight O2 by NC can be used at 4L.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
wehezeing.
9. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care
Discharge Diagnosis:
Hypercarbic respiratory failure
Aspiration PNA
Acute renal failure - ATN
OSA
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted with respiratory failure, pneumonia and kidney
failure. You were initially treated in the intensive care unit.
Your kidneys initially recovered however, then began to fail
again. You were started on dialysis, but this was stopped and
your kidneys are improving.
Have your blood drawn in 5 days to evaluate the progress of your
kidney function.
Take all other medications as prescribed. Many of your home
medications were discontinued, including allopurinol,
lisinopril, spironolactone, gabapentin and torsemide because of
kidney failure. If in 5 days kidney function is improved, you
could restart an appropriate dose of allopurinol. Please discuss
with your primary care doctor about the remaining medications
prior to restarting.
Followup Instructions:
Follow-up with your primary care doctor within 2 weeks.
Please also follow-up with a kidney and heart specialist within
3 weeeks. Your primary care doctor can help you find a new
kidney specialist who can see you as an outpatient.
|
[
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"272.4",
"507.0",
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"438.11",
"327.23",
"585.2",
"278.00",
"577.0",
"396.8",
"348.31",
"276.2",
"403.90",
"276.7",
"491.21",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.95",
"38.97",
"96.04",
"38.91",
"38.95",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12989, 13043
|
8126, 11253
|
281, 334
|
13164, 13288
|
5220, 5723
|
14129, 14364
|
4490, 4632
|
11966, 12966
|
13064, 13143
|
11279, 11943
|
13351, 14106
|
4647, 5184
|
5201, 5201
|
230, 243
|
362, 3111
|
5732, 8103
|
13303, 13327
|
3133, 4014
|
4030, 4474
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,140
| 192,205
|
47606
|
Discharge summary
|
report
|
Admission Date: [**2151-4-7**] Discharge Date: [**2151-4-11**]
Date of Birth: [**2092-7-27**] Sex: M
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: Briefly, this is a 58 year old
gentleman, who is a psychiatrist, who has had increasing
shortness of breath and dyspnea on exertion for the past
year. He has been followed by a cardiologist who noted
mitral valve prolapse and an echocardiogram done during
workup showed 3+ mitral regurgitation and normal ejection
fraction.
PAST MEDICAL HISTORY:
1. Raynaud's disease.
2. Mitral valve prolapse.
3. Exercise induced asthma.
4. Gastroesophageal reflux disease.
5. Depression.
6. Benign prostatic hypertrophy.
7. Osteoporosis.
8. Status post appendectomy.
9. Status post right lower extremity vein ligation and
stripping.
10. Osteomyelitis of the left hip.
MEDICATIONS ON ADMISSION:
1. Lexapro.
2. Omeprazole.
3. Ativan p.r.n.
4. Amoxicillin for dental procedures.
ALLERGIES: Sulfa drugs.
PHYSICAL EXAMINATION: He was afebrile with stable vital
signs. His lungs were clear. His heart was regular,
however, he had a significant III/VI holosystolic murmur
heard best at the apex. Abdomen is soft, nontender,
nondistended. Bowel sounds are present. His extremities are
warm and well perfused. He had good radial palpable pulses
throughout.
LABORATORY DATA: His laboratories were all within normal
limits.
HOSPITAL COURSE: The patient was taken to the operating room
on [**2151-4-7**], for a mitral valve repair with an annuloplasty.
The patient did well postoperatively and was transferred to
the CSRU. He was weaned from his ventilator and extubated.
He continued to do well and was planned on transferring to
the floor. He was off all pressors at that time. He was
transferred to the floor postoperatively where he continued
to improve. Physical therapy was consulted for evaluation of
his function and he did well with physical therapy and was
cleared by physical therapy standpoint to go home. He
continued to do well, however, he had a slow rhythm and
required AV pacing for multiple days throughout his hospital
stay. He was able to be slowly weaned off his AV pacing on
[**2151-4-9**]. He did not require any further AV pacing and, on
[**2151-4-10**], his wires were removed. He continued to do well.
His laboratories were all within normal limits. On [**2151-4-11**],
the patient was discharged home tolerating regular diet. He
was started on Lopressor 12.5 mg p.o. twice a day for beta
blockade. He did have some mild orthostatic changes with the
lower dose, however, it improved through his hospital stay,
and therefore it was decided that he would continue on his
beta blockade for now. It could be decided whether or not
his beta blockade should be continued.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once daily.
2. Percocet one to two tablets p.o. q4hours p.r.n.
3. Colace 100 mg p.o. twice a day.
4. Protonix 40 mg p.o. once daily.
5. Lopressor 12.5 mg p.o. twice a day.
DISCHARGE STATUS: He is discharged to home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Mitral valve regurgitation, now status post mitral valve
repair.
2. Exercise induced asthma.
3. Gastroesophageal reflux disease.
4. Depression.
5. History of pneumonia.
6. Benign prostatic hypertrophy.
7. Osteoporosis.
8. Status post appendectomy.
9. Status post right leg vein stripping.
10. Status post left hip osteomyelitis.
FO[**Last Name (STitle) **]P: The patient is discharged to home in stable
condition and instructed to follow-up with his primary care
physician in one to two weeks and instructed to follow-up
with his cardiologist in three to four weeks and is to
follow-up with cardiothoracic surgery in four to six weeks.
He was also instructed to call with any questions to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office. The patient was discharged home in stable
condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2151-4-11**] 08:30
T: [**2151-4-11**] 10:42
JOB#: [**Job Number 100590**]
|
[
"424.0",
"733.00",
"600.00",
"443.0",
"311",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"37.78",
"89.64",
"99.02",
"38.91",
"38.93",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
3107, 4196
|
2805, 3052
|
862, 975
|
1416, 2779
|
998, 1398
|
171, 497
|
519, 836
|
3077, 3086
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,305
| 144,863
|
31501
|
Discharge summary
|
report
|
Admission Date: [**2173-7-28**] Discharge Date: [**2173-8-8**]
Date of Birth: [**2139-9-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
pancreatitis, hypercalcemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
33yo previously healthy female presents from OSH with severe
hypercalcemia, acute pancreatitis who is now POD #0 s/p
C-section delivery of healthy male. She reports that she has
had ongoing mid-low back pain x several months which became
worse over the past few days. She also noted increasing
epigastric pain associated with nausea and vomiting at home over
the past 1-2 days. She has not been tolerating PO. She denies
diarrhea, however. No fevers/chills. No sick contacts. She
reports that the pain became so severe ([**10-6**]) overnight that
she went to the local ED for further evaluation.
.
At the OSH ED, initial labs revealed significantly elevated WBC
count with neutrophils near 90% (no bands); she was afebrile.
Further noted was a serum calcium level of 18.5 and elevated
pancreatic enzymes as outlined below. She is a former heavy
EtOH drinker, but has been sober x8 years. She denies RUQ pain
currently nor colicky pain in the past and is w/o h/o
gallstones. She reports severe "heartburn" during her pregnancy
for which she's been taking 15+ tums daily (finishes an entire
bottle approximately every 1-2wks). She has also been taking
daily prenatal vitamin daily, but denies any additional
prescription nor OTC medications.
.
In the ED at OSH, she was evaluated by Ob/gyn who found
nonreassuring fetal heart tones on monitoring. She was taken to
the OR for emergent/urgent c-section at 35 weeks. Per records,
it appears that she was placed on cefoxitin perioperatively, but
no additional abx. She received NS and then LR at continuous
rate of 150cc/hour for unclear total amount. Per record it
appears she was placed on tums prn despite her critically
elevated calcium and received a one time dose this morning. A
CT scan was reportedly performed post c-section, but in
discussion with medical records at OSH, there is no report of
this.
.
ROS: No changes in weight, no fevers/chills/sweats, no CP/SOB,
no HA/changes in vision, no diarrhea, +constipation, no [**Month/Year (2) **] in
stool/dark stool, no dysuria/hematuria.
Past Medical History:
PMH:
Hepatitis C (pos Ab - [**2173-7-30**])
Hepatitis B (status unknown)
Chronic back pain, diagnosed with osteoarthritis, degenerative
dz
Polysubstance abuse
Social History:
Married w/ 5 children. +0.5-1ppd. Recovering alcoholic (sober
x 8.5yrs). Also w/ h/o polysubstance abuse including heroin,
but none x 8.5yrs.
Family History:
Parents alive, healthy; 5 siblings alive and well.
Physical Exam:
PE: T 97.1 HR 87 BP 138/95 RR 26 O2sat 95-97% 2L
Gen: Somnolent, but arousable,
HEENT: Mildly dry MM, PERRL
Neck: Supple
CV: RRR, no mrg appreciated
Resp: bibasilar rales
Abd: Diffusely TTP > epigastrium, no guarding, but +rebound,
+distention, tranverse pelvic surgical incision with staples in
place, CDI, no e/o drainage
Ext: Trace b/l edema
Neuro: Somnolent, arousable, oriented x3, CN 2-12, strength,
sensation grossly intact
Pertinent Results:
OSH EKG: NSR at rate of 82, LAD, TWI V1, biphasic T wave in V2
(no comparison).
.
OSH CXR: No acute cardiopulmonary process.
.
OSH labs:
Amylase 513
Lipase 3788
Glucose 205
Creatinine 2.5
Serum calcium 18.5
Triglycerides 488
AST 23
ALT 30
Alk phos 208 (nml 50-136)
Albumin 2.5
T.bili 0.4
WBC "20K with left shift"
D-dimer 2093
Fibrinogen 749
PT/INR 11.5/0.9
ABG 7.43/41/86/28/97% 4L NC
Tox screen (unclear [**Name2 (NI) **] vs. serum) negative
.
[**7-29**] head CT: No acute intracranial hemorrhage or mass effect.
[**7-29**] CT abd/ pelvis: 1. Peripancreatic edema and mild
enlargement of the pancreas, consistent with pancreatitis.
Complications of pancreatitis unable to be evaluated on
noncontrast scan. Extensive free fluid and mesenteric edema,
likely due to both pancreatitis as well as
postoperative/postpartum condition. 2. Enlarged, postpartum
uterus.
.
[**7-29**] serum and urine tox neg (except opiates - administered here)
.
[**2173-8-3**] CT abd/ pelvis: 1. Findings compatible with
non-complicated pancreatitis, not significantly changed from
prior, however the administration of contrast allows
visualization of a homogeneous, non-necrotic pancreatic
parenchyma and no significant pseudocyst formation or other
related complication. 2. Bilateral pleural effusions, right
greater than left. 3. Post-partum uterus with internal fluid
and debris, in keeping with recent C-section.
.
Micro:
UCx: neg on [**9-10**], [**8-1**], [**8-2**]
BCx: [**7-29**] x 2, [**7-30**] x 2 negative final; [**7-31**] , [**8-1**], [**8-2**], [**8-3**] all
NTD
.
sputum [**7-30**]: >25 PMNs and <10 epithelial cells/100X field. 2+
(1-5 per 1000X FIELD): GRAM POSITIVE IN PAIRS AND CHAINS. 2+
(1-5 per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X
FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE: YEAST.
MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
.
sputum [**8-1**], [**8-2**] and [**8-3**]: 1+ yeasts
[**2173-8-1**] SWAB abd incision: 1+ PMNs, no org
Brief Hospital Course:
33yoF presented to OSH with severe abdominal and back pain,
found to have acute pancreatitis and severe hypercalemia,
presenting POD 0 s/p cesarean section for nonreassuring fetal
heart tones, and transferred to [**Hospital1 18**] ICU for further
management. Course complicated by agitation and worsening
respiratory distress.
1. Pancreatitis: Given her significantly elevated calcium on
admission with report of significant Tums intake, this was felt
to be the likely cause of her pancreatitis. Her triglycerides
were elevated but not markedly so (488 at OSH, 273 here) and
seems less likely cause of her pancreatitis. By [**Last Name (un) 5063**]
criteria on initial presentation had WBC count of >16K, glucose
of 205 which correlates with <5% motality. CT abd/pelvis was
obtained which showed evidence of pancreatitis - fat stranding
and free fluid in abd. also small amount of intra-abd free air
c/w post-op, and lung base atelectasis and effusions. She was
placed npo, given aggressive IVF and placed on TPN with serial
following of abdominal exams and lipase.
-she clinically improved, was ultimately transferred to the
regular medical floor, with resolution of abdominal pain, and
tolerating a regular diet.
.
2. Respiratory distress: Patient failed pressure support trial
on [**7-30**], with agitation and frequent desats to the 80s. Pt was
then on AC requiring increased oxygen requirements (up to FIO2
0.7). CXR on [**7-30**] suggested increased pulmonary edema v. ARDS.
Fluids were held/minimized and diuresis was attempted with 20mg
IV lasix x2, with no improvement in O2 saturation. It was felt
the patient could meet the requirements for ARDS, with
hypoxemia, bilateral infiltrates, Pa)2/FIO2 <200 and clinically
not suspected to have CHF. She was successfully extubated and
diuresed with IV lasix. She was transferred to the floor and
gradually weaned off of supplemental oxygen.
-on the medical floor, she was ambulating freely without SOB, 02
sats remained 97% on RA with ambulation.
-she did have some residual hoarsness most likely due to
intubation which should continue to improve.
.
3. Agitation: on [**7-29**] the patient became increasingly tachypneic,
tachycardic, and hypertensive with evidence of desaturation
secondary to agitation. Pt was intubated for control of airway,
and exhibited agitation in waxing/ [**Doctor Last Name 688**] pattern on both
propofol and versed/fentanyl for sedation. Etiologies included
calcium or electrolyte abnormalities, drug withdrawal, pain.
Intra-cranial process ruled out by neg. head CT. serum and urine
tox neg (except opioids - administered here). Patient was
started on haldol IV standing and placed on a 1 to 1 sitter.
She was then transitioned to PRN haldol with an appropriate
response.
-she was transferred to a medical floor, not requiring any prn
medicines for agitation, she was seen by psychiatry, sitter was
dc'd.
-she remained behaviourly appropriate throughout the remainder
of her hospitalization
.
4. Leukocytosis: She had an elevated wbc count on admission and
was pan-cultured with all cultures negative to date as of this
dictation. Due to pancreatitis and respiratory failure, she was
placed on broad spectrum antibiotics for a 7 day course. The
patient defervesced in the ICU and has remained afebrile for the
rest of the hospitalization. Her antibiotics were stopped on
[**8-6**].
.
5. s/p c-section (healthy male at 35 weeks): OB/gyn followed
during the hospitalization. Her staples were removed and she is
healing well. There is no sign of infection at the incision
site.
.
6. Hypercalcemia: Calcium 15.3 corrected for albumin of 2.5.
PTH here is 7 (low) and thus would suggest not primary
hyperparathyroidism as etiology of her hypercalcemia. Given
excessive use of tums, may very likely represent milk alkali
syndrome and exogenous source would decrease PTH production.
Did have triad of hypercalcemia, renal insufficiency, and
metabolic alkalosis (albeit mild w/ upper end nml HCO3 of 30 on
presentation to OSH). Other possibilities include malignancy
and PTHrp, sarcoidosis, hypervitaminosis D, but given clinical
presentation and hx, these seem less likely. Hypercalcemia has
resolved on HD2 with IVF resuscitation
.
7. Acute renal failure: Creatinine elevated to 2.5 on
presentation to OSH, now resolved to 1.0 on initial labs.
Likely prerenal given N/V and risk for 3rd spacing in setting of
pancreatitis as well as probable diuresis with hypercalcemia as
well as [**1-29**] to direct toxicity of calcium. FENa 0.53% supports
pre-renal etiology.
.
8. DISPOSITION: She was transferred to the floor, remained
stable from a hemodynamic and respiratory standpoint. She was
tolerating a regular diet and ambulating on her own without
difficulty. Because she was transferred to our ICU from [**State 1727**],
she will be discharged and stay with family locally before
returning to [**State 1727**]. Home VNA will be arranged for post-op wound
check and to assess for any physical therapy needs. Mrs. [**Known lastname 74127**]
also states she will be visited by WIC as well.
Medications on Admission:
Tums
Prenatal vitamin
Adderal (d/c'd when found out she was pregnant)
Discharge Medications:
none
tylenol prn for pain
Discharge Disposition:
Home With Service
Facility:
Homehealth care VNA of [**State 1727**]
Discharge Diagnosis:
acute pancreatitis
hypercalcemia
respiratory failure
Discharge Condition:
improved, tolerating full diet, ambulating without difficulty
Discharge Instructions:
seek medical attention if worsening symptoms of abdominal pain,
fevers, concern about your surgical scar, or any other symptoms
or concerns
Followup Instructions:
follow up with your regular doctors [**Last Name (NamePattern4) **] [**12-29**] weeks after returning
home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2173-8-8**]
|
[
"275.42",
"669.34",
"288.60",
"251.1",
"V11.3",
"486",
"648.14",
"648.94",
"647.84",
"577.0",
"285.1",
"648.24",
"518.82",
"648.44",
"293.0",
"305.90",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"96.04",
"96.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10572, 10642
|
5320, 10402
|
341, 347
|
10739, 10803
|
3323, 3783
|
10991, 11257
|
2794, 2846
|
10522, 10549
|
10663, 10718
|
10428, 10499
|
10827, 10968
|
2861, 3304
|
274, 303
|
375, 2434
|
3792, 5297
|
2456, 2616
|
2632, 2778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,600
| 163,608
|
9609
|
Discharge summary
|
report
|
Admission Date: [**2129-8-26**] Discharge Date: [**2129-9-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Right subtrochanteric femoral fracture repair with
intramedullary nail
History of Present Illness:
86yoF with h/o tachy-brady syndrome s/p PPM, AFib on
Coumadin/Amiodarone, chronic systolic dysfunction (EF 40% in
[**2123**]), CRI who presents with acute onset of diarrhea.
.
Pt and family ate chicken fried rice last night and then Friday
1am had sudden onset diarrhea (yellow, watery, not foul
smelling, not bloody, not meleanotic, no f/c/sweats, no n/v, no
abd pain). She had 10 episodes of diarrhea through the day.
Similar complaints in her daughter who also ate the same meal,
but less severity--only 2 episodes of diarrhea. No recent ABx or
travel. She got 2 doses of Imodium from her daughter which
helped.
.
In the ED initial VS: 98.2 60 140/57 16 100. Her labs showed
WBC's 8.5, CBC o/w normal, lipase 22, LFT's normal except very
slight increase AST 49 (new), low HCO3 at 18 (new), BUN newly
mildly elevated 23, Cr 1.2 actually lower than her baseline. K
initially high but hemolyzed, repeated were normal.
.
In the ED she c/o R hip pain with ambulation x1 week, no pain
while seated or at rest, no trauma or falls, not red or swollen.
She was tender under R greater trochanter and R trochanteric
bursitis was suspected. She got Depomedrol 40mg in 1% Lidocaine
injection into R bursa. Of note, she is followed at [**Hospital1 18**] Rheum
and has gotten steroid injections in her bilateral knees for OA,
most recently this month.
.
She was started on her first L of NS in the ED and PO fluids
were encouraged.
.
Before transfer from the ED: temp 97, p70 120/72 16 99%RA. She
is admitted for rehydration. On the floor she is without R hip
pain.
.
ROS:
(+) Per HPI
(-) for SOB, CP, BLE edema, palpitations, otherwise denies any
other symptoms, negative for all other major organ systems.
Past Medical History:
1. A-fib on amiodarone, and Coumadin
2. HTN
3. Tachybrady syndrome s/p pacemaker [**2120**]
4. CHF (EF 40%) reportedly in [**2123**].
5. Hypothyroidism
6. OA
7. Osteoporosis
8. Gout
9. [**9-/2128**] admission for RLL CAP
10. CRI with baseline Cr noted to be 1.3-1.5
11. Unsteady gait
Social History:
Pt currently lives at home with her daughters. Endorses a past
tobacco history at the age of 30, she smoked for 10 years, 5
cigs x day. She denies any EtoH or recreational drug use.
Family History:
Non-Contributory
Physical Exam:
On admission:
98.1 162/65 65 20 96%RA
Well appearing elderly F in no distress, pleasant, daughter at
bedside translating. She does not appear ill.
EOMI, no scleral icterus
Mouth dry appearing, no apparent lesions
Jugular pulsations noted at earlobe
Bibasilar paninspiratory crackles, dry sounding, with good air
movement, CTAB otherwise
RRR with very slight systolic AS type murmur at USB's. Not
irregular. Bilateral radials and DP's easily palpable
Abd is soft NT ND, benign
No BLE edema noted. Extrems are slightly cool but not cyanotic
CN 2-12 intact, spontan. moving all extrems, mood/affect
appropriate
R hip is without swelling or tenderness, grossly normal
appearing, no TTP, good range of motion, straight leg test
negative, [**Doctor Last Name **] test negative.
Some minor skin tenting, likely age related
Pertinent Results:
[**2129-8-26**] 07:30PM WBC-8.5# RBC-4.40 HGB-12.2 HCT-38.1 MCV-87
MCH-27.7 MCHC-32.0 RDW-17.1*
[**2129-8-26**] 07:30PM NEUTS-89.1* LYMPHS-8.2* MONOS-2.0 EOS-0.7
BASOS-0
[**2129-8-26**] 07:30PM PLT COUNT-161
[**2129-8-26**] 07:30PM LIPASE-22
[**2129-8-26**] 07:30PM ALT(SGPT)-29 AST(SGOT)-49* ALK PHOS-48 TOT
BILI-0.3
[**2129-8-26**] 07:30PM GLUCOSE-115* UREA N-23* CREAT-1.2* SODIUM-135
POTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-18* ANION GAP-19
[**2129-8-26**] 09:31PM K+-3.9
Micro:
[**2129-8-29**] C. diff toxin negative
FECAL CULTURE (Final [**2129-8-29**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2129-8-30**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2129-8-29**]):
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.
FECAL CULTURE - R/O VIBRIO (Final [**2129-8-30**]): NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final [**2129-8-30**]): NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2129-8-29**]):
NO E.COLI 0157:H7 FOUND.
[**9-3**] Blood cultures- pending
[**9-3**] Urine culture- No growth
[**9-5**] Blood cultures- pending
[**9-5**] CVL tip culture- pending
Studies:
[**8-27**] CXR: Moderate cardiomegaly and elongated tortuous aorta are
stable. Left transvenous pacemaker leads terminate in standard
position in the right atrium and right ventricle. There is no
pulmonary edema. The lungs are clear. There is no pneumothorax
or pleural effusion.
[**8-28**] Right Hip U/S: 1. No focal collection or hematoma
identified at the site of palpable abnormality. 2. Small focus
of ecchymosis in the right upper thigh, with an oblong
hypoechoic structure seen directly subjacent to the ecchymosis,
likely reflecting a tiny hematoma presumably related to recent
injection.
[**8-29**] CT Pelvis: There is a proximal diaphyseal comminuted
fracture of the right femur, with varus angulation, proximal and
medial displacement of the distal fracture fragment. There is
approximately 9 cm overlap of the fracture fragments. The
proximal fracture fragment is laterally angulated, and likely
accounts for palpable findings. There is no underlying bone
lesion. No additional fractures are identified.
The osseous structures are diffusely demineralized, limiting
evaluation for
nondisplaced fractures.
There is multifactorial spinal canal stenosis at the L5-S1
level, incompletely evaluated on this non-dedicated study. There
are degenerative changes of both sacroiliac joints. There is a
tiny sclerotic density in the left iliac [**Doctor First Name 362**] (2:27), probably
representing a small bone island.
Mild degenerative changes are noted at both femoroacetabular
joints, with
osteophyte formation. There are mild degenerative changes at the
symphysis
pubis.
There is marked expansion of the right thigh's muscles about the
fracture
site, consistent with presence of an intramuscular hematoma in
the quadriceps group and adductor compartment. Additionally,
there is soft tissue stranding involving the right lateral
thigh, incompletely evaluated, but may represent hematoma.
Incidentally noted are extensive atherosclerotic calcifications
of the
abdominal aorta and iliac vessels, which are normal in caliber.
There is
calcification adjacent to the posterior uterus, likely
representing calcified fibroids. There is no free pelvic fluid
and no pelvic or inguinal
lymphadenopathy.
IMPRESSION:
1. Displaced comminuted right femoral proximal diaphyseal
fracture with
adjacent intramuscular large hematoma.
2. Generalized demineralization, limiting evaluation for
nondisplaced
fractures.
[**8-31**] Echo: Hyperdynamic left ventricular systolic function. Mild
aortic and mitral regurgitation. Moderate pulmonary artery
systolic hypertension. Diastolic function indices are equivocal,
but given the dilated left atrium and pulmonary hypertension,
diastolic dysfunction is likely.
[**9-4**] Knee plain films: In comparison with the study of [**2127-7-10**],
there is continued severe degenerative change primarily
involving the medial and femoropatellar compartments but with
substantial spurring laterally as well. No acute abnormality is
identified.
Brief Hospital Course:
86 yo F with h/o tachy-brady syndrome s/p PPM, AFib on
Coumadin/Amiodarone, chronic systolic dysfunction (EF 40% in
[**2123**]), CRI, HTN who presents with acute onset of diarrhea and R
hip pain x1 week. [**Hospital **] hospital course by problem is as
follows:
# Diarrhea- Patient was given IVF rehydration and given a
regular diet. She was afebrile and without a WBC while having
symptoms of diarrhea so antibiotics were not given. When the
diarrhea persisted on the second day, stool cultures and C. diff
toxin were sent, which returned negative. Patient's symptoms
gradually resolved on their own.
# Right Hip Fracture: Patient complained of persistent right hip
pain and received steroid and lidocaine injection in the ED for
presumed trochanteric bursitis. Given the manipulation in the
area and patient's anticoagulated status, there was concern for
possible hematoma in the right thigh. Per radiology recs, right
thigh ultrasound were pursued as first study and was negative
for significant hematoma. When pain persisted, we evaluated with
CT of pelvis/thigh which was remarkable for a displaced
comminuted right femoral proximal diaphyseal fracture with
adjacent
large intramuscular hematoma. Ortho was consulted and proceeded
with repair the fracture with a right trochanteric
intramedullary nail. Post-operatively, patient became
hypotensive with concern for continued bleeding in her hip. She
received 4 units NS and 2 units of pRBCs with stabilization.
Because of concern for instability, patient was transferred to
the MICU, where she remained stable without requiring pressor
support or further transfusions. Her anti-hypertensives were
held during this tenuous time period. Ortho continued to follow,
and felt there was no need to take her back to the OR as she
didn't develop a compartment syndrome in that leg. She was
taken her off of her systemic anticoagulation (for Afib) and her
lovenox (as DVT prophylaxis s/p hip repair). Once stabilized she
was transferred back to the floor (24 hour MICU stay) and
restarted on her DVT/PE prophylaxis with lovenox with subsequent
restarting of her coumadin. Pain was controlled with oxydone and
standing tylenol. INR was elevated on discharge, therefore
coumadin was held. This should be restarted for goal INR [**2-9**].
.
#) [**Last Name (un) **] on CRI: At the time of transfer to MICU, her Cr had risen
abruptly from 1.1 to 1.5, given bleeding hypotension likely due
to ATN. Patient subsequently auto-diuresed and creatinine
improved to better than baseline- 0.8.
.
#) A. Fib s/p pacemaker placement: Patient was initially paced
on admission. Cardiology was consulted in the pre-operative
period for further assessment of how to manage her risk factors.
They recommended echocardiography prior to tweaking her
pacemaker settings. After surgery, patient converted to AF with
rates in the 90s, no longer dependent on her pacer (VVI). She
was continued on her qOD amiodarone and restarted on her
coumadin once her hemodynamic status stabilized. Coumadin was
held since her INR was supratherapeutic at 4.1 on day of
discharge to rehab.
.
#) H/O CHF: EF 40% in [**2123**], initially appeared somewhat
overloaded on exam; Echo showed EF of 75%. Iron studies were
sent (pending on discharge)with anemia and hyperdynamic LV.
Restarted on home lasix 20 mg po qdaily on discharge on rehab.
.
#) Left knee pain: Was thought to be due to gout. Colchine was
started which resolved her left knee pain. Day #2 of 4 day
course of colchine on day of discharge. Will complete two more
days of colchine at rehab to be completed on [**2129-9-8**].
.
#) Hx hypertension: BP meds initially held on admission due to
hypotension. Atenolol restarted, however verapamil and diovan
were held on dc due to stable pressures and BP. Would recommend
re-starting as an outpatient if needed for hemodynamic control.
.
#) Hypothyroid: continued home synthroid dosing
.
#) Asympotamic bacteruria with a foley: Foley was replaced for
urinary retention and started on 7 day course of Bactrim DS once
a day to be completed on [**2129-9-12**]. Would recommend voiding
trial at discharge.
Medications on Admission:
1. Amiodarone 200 mg qod
2. ASA EC 81 mg daily
3. Atenolol 50 mg qpm
4. ATenolol 100 mg qam
5. Colace 100 mg daily
6. Diovan 320 mg daily
7. Fluticasone 50 mcg 2 sprays each nostril daily pt states not
taking
8. Lasix 20 mg daily
9. Levothyroxine 25 mcg daily
10. Lovastatin 20 mg daily
11. Omeprazole 20 mg daily
12. [**Name (NI) 32575**] HFA pt states not taking
13. Ventolin HFA pt states not taking
14. Verapamil 480 mg daily
15. Coumadin 1mg daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO QOD ().
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO daily ().
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for hip pain.
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) as needed for constipation.
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Terconazole 80 mg Suppository Sig: One (1) Suppository
Vaginal HS (at bedtime) for 3 days: STOP [**2129-9-9**].
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days: STOP [**2129-9-9**].
12. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 7 days: STOP [**2129-9-12**].
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
14. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE DO NOT START UNTIL [**Name6 (MD) 32576**] by MD/NP. Last INR was 4.3 on
[**2129-9-6**]. Target INR is [**2-9**].
15. Morphine 5 mg/mL Solution Sig: One (1) Injection Q3H (every
3 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) 86**]
Discharge Diagnosis:
Right subtrochanteric femoral fracture
Diarrhea
Atrial fibrillation
Hypertension
Tachybrady syndrome
Congestive Heart Failure
Hypothyroidism
Osteoarthritis
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with diarrhea and right hip
pain. CT scan showed a fracture of your right femur. This
fracture was repaired in the operating room with an
intramedullary nail. The surgery was complicated by a little bit
of bleeding- you were briefly transferred to the medical
intensive care unit to monitor your blood pressure.
Your diarrhea was evaluated with blood tests and cultures of
your stool. We found no signs of serious bacterial infection.
You were given IV fluids while you were in the hospital and your
symptoms resolved on their own.
.
You were found to have left knee pain which was thought to be
due to gout. Your pain resolved with colchicine.
.
You were found to have urinary tract infection. Your foley was
replaced as you could not urinate without a foley and started on
antibiotic called BACTRIM DS for total of 7 days to be completed
on [**2129-9-12**].
We have made the following changes to your medications:
STOP ATENOLOL 100 MG in the morning. Continue atenolol 50 mg at
night.
STOP DIOVAN 320 mg daily
STOP VERAPAMIL 480 mg daily
START BACTRIM DS once a day for total of 7 days to be completed
on [**2129-9-12**]
CONTINUE COLCHICINE 0.6 MG ONCE A DAY for two days to be
completed on [**2129-9-8**]
.
Please continue taking your other medications as you were
previously.
It was a pleasure taking care of you at the [**Hospital1 18**]. We wish you a
speedy recovery.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Orthopaedics in 2
months. You can call [**Telephone/Fax (1) 1228**] to make that appointment.
.
Please follow up with your primary care physician in six weeks.
Department: RHEUMATOLOGY
When: TUESDAY [**2129-11-22**] at 10:00 AM
With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Unit Name **] [**Location (un) 861**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
|
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icd9cm
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32,592
| 129,030
|
31816
|
Discharge summary
|
report
|
Admission Date: [**2137-8-31**] Discharge Date: [**2137-9-8**]
Date of Birth: [**2064-12-27**] Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Hot swollen right elbow
Major Surgical or Invasive Procedure:
Debridement of right arm
History of Present Illness:
The patient is a 72-year-old gentleman who presents with fevers
and swelling in his right elbow. The patient had recently fallen
and was now having fluid draining from the elbow. Concern on
x-ray for tracking of subcutaneous
emphysema and lactate of 2.2 worrisome for necrotizing
fasciitis. Surgical service consulted for debridement.
Past Medical History:
# HTN
# Hyperlipidemia
# Alzheimer's dementia
# Prostate CA
# B glaucoma
# B cataracts
# Chronic back pain
# GERD
Social History:
# Personal: Lives with wife in son's home
# Professional: Retired school custodian
# Tobacco: Never
# Alcohol: Never
# Recreational drugs: Never
Family History:
Pt was adopted and does not know his biological FH.
Physical Exam:
Per [**Doctor First Name **] consult note:
T103.2 HR127 BP97/91 RR17 O2sat: 93RA
Non verbal
Comfortable
RUE with large area of post forearm erythematous, indurated,
slight fluctuance near olecranon with small I&D site that
expresses slight amount of pus, no cloudy or grayish drainage.
Radial pulse 2+ bil. 2+peripheral edema. No palpable joint
effusion
Pertinent Results:
[**8-30**]: TWO VIEWS OF THE RIGHT ELBOW: There is subcutaneous
emphysema tracking along the dorsal soft tissues posterior to
the ulna. There is degenerative change within the elbow joint
itself. There is a suggestion of chondrocalcinosis. No definite
elbow joint effusion is noted.
IMPRESSION: Subcutaneous emphysema as described above. Please
clinically correlate.
[**2137-8-30**] 09:08PM LACTATE-2.2*
[**8-31**] Head CT
IMPRESSION:
1. Evolution of previously demonstrated right epidural and
subarachnoid hemorrhage. Stable appearance of probable
chronic/subacute left subdural hematoma.
2. Mild increase in ventricular size without overt
hydrocephalus. Continued surveillance is warranted.
[**8-31**] CX:
Group A Strep and MSSA
[**8-31**] Swabs: MRSA rectal and nasal
Brief Hospital Course:
The patient was admitted to the Platinum surgery service with a
swollen, indurated, and erythematous right elbow suspicious for
necrotizing fasciitis. He underwent an extensive right elbow
debridement and tolerated the procedure well. Please refer to
the operative report for further detail. Upon admission, the
patient was started on Vanc, nafcillin, levo, and flagyl. The
patient went to the unit post operatively and required a
neosynephrine drip. A head CT showed mild inc of ventricular
size without overt hydrocephalus and Neurosurgery was consulted
who recommended outpatient f/u. On POD#2, the patient was
transfered to the floor with a 1:1 sitter. Plastics was
consulted and recommended wound vac for a month with outpatient
follow up. An orthopedics consult viewed no joint involvement.
Diet was advanced, and cdiff precautions were intacted [**1-4**] many
loose stool. Cdiff toxins were negative. Foley was d/c'd in
the am and reinserted in the pm [**1-4**] urinary retention. On
POD#3, vac was placed and right arm splinted. On POD#4, abx
were changed to Nafcillin, picc was placed, and Geriatrics was
consulted to help manage the [**Hospital 228**] medical issues. The
patient required a 1:1 sitter until POD#5 for night time
agitation which was improved once the patient was swithced from
haldol to Zyprexa and given a standing dose. The patient also
had required periodic restraints to protect tubes and lines.
Wound Vac was changed on POD#6 ([**9-6**]) and the patient was set up
for rehab. Upon discharge, the patient is afebrile, with all
vitals stable, tolerating a regular diet, with pain controlled
on po pain medication, and at his baseline mental status. The
patient will be going to LTAC with a PICC for long term
nafcillin, wound vac x 1 month, and a foley.
Medications on Admission:
rivastigmine, HCTZ, lasix, simvastatin, megestrol, fenofibrate,
protonix, trazodone, MVI, vit B, C
Discharge Medications:
1. Timolol Maleate 0.5 % Drops [**Month/Day (1) **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
2. Acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q8H (every
8 hours).
3. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
4. Olanzapine 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day).
5. Olanzapine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
6. Loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO QID (4 times
a day) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Megestrol 40 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day).
9. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
10. Hydrochlorothiazide 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED): Please refer to the insulin
sliding scale.
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: One
(1) ML Intravenous DAILY (Daily) as needed. ML(s)
15. Nafcillin in D2.4W 2 g/100 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q6H (every 6 hours) for 4 weeks.
16. Rivastigmine 3 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO twice a
day.
17. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice
a day.
18. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
s/p debridement of right arm
Discharge Condition:
Stable with baseline mental status
Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Followup Instructions:
Please call your plastic surgeon to schedule a follow up
appointment to be done in 1 month
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2137-10-2**] 8:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2137-10-2**] 9:30
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
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6116, 6199
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2245, 4045
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290, 317
|
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|
1443, 2222
|
6791, 7114
|
998, 1051
|
4195, 6093
|
6220, 6251
|
4071, 4172
|
6333, 6768
|
1066, 1424
|
227, 252
|
345, 682
|
704, 819
|
835, 982
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,613
| 185,771
|
40325
|
Discharge summary
|
report
|
Admission Date: [**2152-12-17**] Discharge Date: [**2152-12-25**]
Date of Birth: [**2126-1-19**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
trauma transfer
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a 25 year old female who complains of MVC.
This patient was the restrained front seat passenger in a
car traveling 40 miles an hour involved in a severe MVC. The
precise mechanism is otherwise unknown. She was unresponsive
at the scene and went to [**Hospital **] Hospital. There she was
noted to be hypotensive and tachycardic. Scanning showed
some type of intra-cranial hemorrhage, small lacerations of
both the kidney and spleen, as well as a shattered left
kidney.
She was given 2 units of blood and transferred here.
Past Medical History:
PMHx:migaines, childhood corneal disorder (posterior polymorphic
dystrophy)
Social History:
Married, lives with husband and [**Name2 (NI) **], works in retail for J
Crew
- tobacco, - ETOH
Family History:
father side of family has pseudocholinesterase
deficiency
Physical Exam:
HR:110 BP:105/70 Resp:20 on the vent O(2)Sat:100 on 100%
Normal
Constitutional: The patient is intubated and on a
backboard. There is good color change on the endotracheal
tube
HEENT: Pupils are 3-1/2 mm and constrict
Collared; there is a left nasal abrasion
Chest: Breath sounds equal
Cardiovascular: Normal first and second heart sounds
Abdominal: Soft and flat
Rectal: No blood in the stool
Extr/Back: No step-offs in the back
Left buttock abrasion
There is a left elbow abrasion
Neuro: She is pharmacologically paralyzed
[**Doctor Last Name **] Grade:4
GCS: EO: 3, motor: 6, verbal: 1T=10T
Cranial Nerves:
I: Not tested
II: opens eyes to voice. Pupils equally round and reactive to
light, 6 to 3
mm bilaterally. Visual fields-unable to test
III, IV, VI: Extraocular movements appear grossly intact
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing grossly intact to voice.
IX, X: Palatal elevation unable to test
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius- patient unable to perform
exam
XII: Tongue midline- unable to test while intubated
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength: due to mental status patient unable to
perform
detailed motor exam. To command patient moves all four
extremities symetrically. She grips bilaterally to command.
Attempts to "show 2 fingers", wiggles toes on the bed and
attempts to bend her knees.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
No clonus
Coordination: unable to test
Pronator Drift: pt unable to left arms off the bed
Pertinent Results:
[**2152-12-17**] 06:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2152-12-17**] 06:26AM HGB-12.4 calcHCT-37
[**2152-12-17**] 06:26AM GLUCOSE-140* LACTATE-4.0* NA+-141 K+-4.2
CL--112 TCO2-15*
[**2152-12-17**] 07:30AM WBC-15.1* RBC-4.16* HGB-12.6 HCT-37.3 MCV-90
MCH-30.3 MCHC-33.8 RDW-14.2
[**2152-12-17**] 07:30AM PLT COUNT-127*
[**2152-12-17**] 07:30AM PT-15.5* PTT-26.5 INR(PT)-1.4*
[**2152-12-17**] CT Abd/pelvis :
1. Devascularized left kidney with only small amount of residual
perfusion. No evidence of active arterial bleed. Stable size of
retroperitoneal hematoma. Visualization of only the proximal
portion of the left renal artery and left renal vein near its
confluence with the IVC raise the question of vascular pedicle
injury.
2. Splenic laceration as previously seen.
3. Liver laceration as previously seen.
4. Horizontal (Chance) fracture through the L1 vertebral body
with a small
hyperdense focus, possibly representing extradural hematoma. MRI
recommended for further evaluation.
5. Left-sided rib fractures.
6. Nonvisualization of the medial limb of the left adrenal
gland, may
indicate injury.
[**2152-12-17**] Head CT :
1. Stable small left intraventricular hemorrhage.
2. Question of additional foci of hemorrhage in the subarachnoid
space,
notably in the left frontal lobe. Prior administration of
intravenous
contrast, however, limits full evaluation.
3. Orogastric tube with single coil in the oropharynx.
Additional findings as on the final wet read- small left
parietal SAH/SDH?
contrast related enhancement and left tentorial subtle
hyperdense appearance-? SDH/ prior contrast related enhancement
and some degree of cerebral edema.
[**2152-12-18**] Head CT :
1. Stable small left intraventricular hemorrhage with possible
additional
foci of left parietal subarachnoid/subdural hemorrhage. No
evidence of new
hemorrhage.
2. No fracture identified.
3. Findings suggestive of acute on chronic sinusitis.
12/1210 MRI Lumbar spine :
1. Chance fracture involving the body and the right pedicle of
L1, as
described above, better seen on the prior CT study.
2. Areas of increased signal intensity in the interspinous
region from
T11-L2, which may relate to edema/injury to the ligaments in
this location. To correlate clinically. Recommend spine consult
to decide on further management.
3. Multilevel mild degenerative changes as described above
involving the
discs
[**2152-12-20**] CXR :
Bilateral airspace opacities mid to lower lobes, possibly
infectious
[**2152-12-23**] CT Torso :
1. No evidence of intra-abdominal abscess.
2. Interval moderate bilateral pleural effusions with adjacent
atelectasis. Cannot exclude superimposed infection.
3. Hypoperfused left kidney, asymmetrically small, with no
evidence of urine excretion at the portal venous phase,
compatible with the known traumatic injury. Small amount of
perinephric fluid/hematoma.
4. New small contrast collection in the spleen, could represent
repeated
acute hemorrhage, the adjacent rib fracture now shows some
displacement.
5. Unchanged liver and splenic lacerations as previously noted.
6. Unchanged L1 Chance fracture.
Brief Hospital Course:
Mrs. [**Known lastname 916**] [**Known lastname 88468**] was evaluated by the Trauma team in the
Emergency Room and admitted to the Trauma ICU for further
management of her injuries as well as evaluation by the
neurosurgery service. She underwent serial hematocrits and
neurologic exams. As her hematocrit remained stable since her
transfusions in the Emergency Room, her sedatives were
discontinued for a good neurologic assessment and she was
eventually weaned and extubated from the respirator on [**2152-12-18**].
While in the ICU a small amount of drainage was noted from her
ear and confirmed to be CSF. For a short time she was on
Nafcillin and Gentamycin however the leak sealed very quickly.
She was measured for a TLSO brace as she had an L 1 [**Last Name (un) 46542**]
fracture and until that arrived she remained on log roll
precautions. She had no neurologic deficits from her small SAH
with IVH and a repeat Head CT done 24 hours after admission
showed no increase in the size of the bleed.
Following transfer to the Trauma floor she was evaluated daily
by Physical Therapy and Occupational Therapy. She was learning
to walk with the brace on but required much cueing and balance
training. Her mini mental status exam showed some deficits with
memory, attention span and delayed recall. She will need
continued OT as well as a referral to the Cognitive [**Hospital 878**]
Clinic.
She developed fevers during her hospitalization and was pan
cultures on 2 occasions. The most revealing change was a chest
Xray on [**2152-12-20**] which showed bilateral lower lobe opacities,
possibly consistent with pneumonia. She was then treated for
hospital acquired pneumonia along with pulmonary toilet and she
began to progress well. A PICC line was placed for IV antibiotic
therapy but she physically improved as did her chest xray and
she will complete her course on oral antibiotics.
After a long hospital stay she was discharged to home on
[**2152-12-25**] with VNA services. She was ambulating independently
with her TLSO brace and tolerating a regular diet. She will
follow up in [**2-9**] weeks in the Acute care Clinic.
Medications on Admission:
Topamax
OCP
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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]Hospice
Discharge Diagnosis:
S/P MVC
1. Devascularized left kidney
2. Grade 2 liver laceration
3. Grade 2 splenic laceration
4. L 1 Chance fracture
5. Left rib fractures
6. Pneumonia
7. Acute blood loss anemia
8. CSF leak
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (TLSO
brace).
Discharge Instructions:
* You were admitted to the hospital after your car accident with
multiple injuries.
* You are improving daily but must continue to wear your TLSO
brace for the next 8 weeks. At that time Dr. [**Last Name (STitle) **] will
examine you and give you further recommendations.
* Your accident caused 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
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**2-9**] weeks.
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 8 weeks with Dr. [**Last Name (STitle) **]. You will need flexion
and extension films of the lumbar spine prior to that
appointment. The secretary can arrange that for you.
Call the Cognitive Neurology Dept at [**Telephone/Fax (1) 1690**] for a follow
up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-9**] weeks.
Completed by:[**2152-12-25**]
|
[
"864.05",
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"866.00",
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"287.5",
"348.5",
"853.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8754, 8808
|
6013, 8159
|
321, 328
|
9045, 9045
|
2812, 5990
|
10707, 11309
|
1125, 1184
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8221, 8731
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8829, 9024
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8185, 8198
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9224, 10684
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1200, 1796
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266, 283
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356, 897
|
1812, 2793
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9060, 9200
|
919, 996
|
1012, 1109
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,011
| 140,275
|
36081
|
Discharge summary
|
report
|
Admission Date: [**2162-12-9**] Discharge Date: [**2162-12-11**]
Date of Birth: [**2098-6-21**] Sex: F
Service: MEDICINE
Allergies:
[**Year (4 digits) **] / Zocor
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
[**First Name3 (LF) **] desensitization and elective cardiac catheterization.
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2162-12-10**]
History of Present Illness:
This 64 year old woman with hypertension, hyperlipidemia and
prior stroke x 2 underwent elective cardiac catheterization at
[**Hospital6 3105**] in [**Month (only) 359**] due to chest pain and an
abnormal stress test. This was significant for a 70% LAD lesion
and no other significant CAD. Her EF was 65%. She reports that
the pain occurs approximately once per week, both at rest and
with exertion. She take nitroglycerin with relief of her
symptoms after 1 tablet. She has slight dyspnea with exertion
that occurs when she walks quickly or climbs stairs. She denies
any dizziness, lower extremity edema, orthopnea or PND. She does
report leg discomfort with ambulation.
.
She is being admitted this evening for [**Month (only) 4532**] desensitization
for an allergy noted to be skin itching.
.
On review of systems, she denies any prior history of 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:
Hypertension
Hyperlipidemia
CVA [**8-2**] with left sided hemiparesis and decrease in left eye
peripheral vision
CVA [**2158**]
Renal calculi
CAD s/p cath at LGH in [**Month (only) 359**]
s/p left great toe osteotomy
AAA repair [**2161-11-4**] at LGH
Tubal ligation
Social History:
-Tobacco history: 40 pack year Quit smoking: quit [**2157**]
-ETOH: no ETOH
-Illicit drugs: no drugs
Family History:
Father died of a stroke at age 78. Sister had pacemaker placed
at age 45.
Physical Exam:
VS T97.1F BP 179/76, HR 44, 96% RA
General Appearance: Middle-aged female lying in bed in NAD.
Alert and mostly Spanish-speaking
ENT - supple, JVD not distended, supraorbital erythema
(unchanged for years)
Cardiovascular: PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Respiratory / Chest: CTAB
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: No edema present, 2+DP b/l
Pulses: 2+ throughout LEs.
On day of discharge:
VS 98.3F, BP 152/72, HR 52, RR 18 94-98%RA.
ENT - as above.
CV S1,2 nl, RR, no m/g/r
Pulm: CTA b/l.
Ext - warm, dry no edema, R groin TTP no bruit, 2+ femoral pulse
and 2+DP.
Pertinent Results:
Laboratory studies:
.
[**2162-12-9**] 07:53PM BLOOD WBC-7.3 RBC-4.33 Hgb-11.8* Hct-35.0*
MCV-81* MCH-27.3 MCHC-33.8 RDW-13.7 Plt Ct-228
[**2162-12-11**] 06:25AM BLOOD WBC-6.9 RBC-4.56 Hgb-12.4 Hct-37.1 MCV-82
MCH-27.2 MCHC-33.4 RDW-14.6 Plt Ct-209
[**2162-12-9**] 07:53PM BLOOD PT-12.8 PTT-27.8 INR(PT)-1.1
[**2162-12-9**] 07:53PM BLOOD Glucose-113* UreaN-21* Creat-1.1 Na-137
K-4.1 Cl-101 HCO3-28 AnGap-12
[**2162-12-11**] 06:25AM BLOOD Glucose-96 UreaN-15 Creat-1.3* Cl-99
HCO3-32
[**2162-12-9**] 07:53PM BLOOD Calcium-9.6 Phos-3.1 Mg-2.0
[**2162-12-11**] 06:25AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0
Studies/Imaging: [**2162-12-9**]
[**2162-12-9**]
Sinus bradycardia. Possible left ventricular hypertrophy with
secondary
repolarization abnormalities. No previous tracing available for
comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
44 166 102 546/518 51 55 106
Cardiac Catheterization:
1. Planned PCI with access via RFA. Patient had mid LAD
80% long stenosis with no flow limiting disease in other
vessels.
2. Limited hemodynamics with BP 162/74 with HR 55 in sinus.
3. Stenting of mid LAD with Cypher 3x23mm stetn.
4. Successful groin closure with Mynx device.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Stenting of mid LAD.
Brief Hospital Course:
64 yo female with HTN, hyperlipidemia, CVA x 2, found to have
CAD with 70% LAD lesion at OSH on diagnostic cath admitted here
for [**First Name3 (LF) 4532**] densitization prior to catheterization.
.
# [**First Name3 (LF) **] desensitization. Pt. completed a [**First Name3 (LF) **]
desensitization procedure per [**Hospital1 18**] protocol w/ starting dose of
0.025mg escalated to 75mg over 12 doses. She tolerated this
well, w/o complications. There was no angioedema, bronchospasm,
hives. She was given benadryl prn for pruritis. Pt. had an
episode of pruritis on day of discharge, lasting 6hrs, w minimal
erythema around left neck region which resolved w/o treatment.
Pt. underwent cardiac catheterization on [**12-10**] as described
below.
.
# CORONARIES. Pt. had a diagnostic cath with 70% LAD lesion
from OSH. She was continued on her home medications with
exception of aggrenox, including ASA, statin, BBk, ACEI at home
doses. After she completed [**Month/Year (2) **] desensitization, she
underwent a catheterization. This showed a mid LAD 80% stenosis
with no flow limiting disease in other vessels. She received a
stent to mid LAD with Cypher 3x23mm. Her groin was successfully
closed w/ Mynx device. There were no complications, she
received IVF and NaBicarbonate pre/post hydration as well as
18hr course of integrillin. Patient was continued on above
regimen as well as [**Month/Year (2) **] 75mg. Post catheterization at time of
discharge she did not have CP, SOB or other angina equivalents
with ambulation.
.
# PUMP. No ECHO in [**Hospital1 18**] system and no evidence of heart
failure on exam
.
# RHYTHM. Pt. was Bradycardic in NSR throughout her stay w/ HR
in the 50s on telemetry. PR interval was 160. She was on
atenolol for BP control at 50mg QD.
.
# Hypertension. On multiple medications at home including a PRN
minoxidil for SBP > 170. SBPs ranged between 125 - 161 during
admission. Her regimen included Felodipine 10mg QD, Clonidine
0.2mg [**Hospital1 **], Enalapril 40mg QD, Chlorthalidone 25mg QD and
Atenolol 50mg QD. Due to hypertension, her Felodipine was
increased to 20mg QD. She was advised to schedule follow up
with her cardiologist within a week to optimize antihypertensive
regimen given over 4 antihypertensive medications.
.
# ARF. Elevated Cr to 1.3, baseline unknown, but 1.1 on
admission. Pt. likely w/ baseline CKD given long standing HTN.
This was likely [**1-30**] pre-renal etiology vs. Contrast induced
nephropathy. Pt. did receive IV fluid prehydration with
NaBicarbonate. Pt. was advised to increase PO fluid intake at
home and obtain f/u labs.
.
# Hx of CVA. Pt. w/ hx of previous CVAs x2 admitted on aggrenox.
This was stopped as pt was started on ASA 325 and [**Month/Day (2) **] for
her DES. Pt. denied having a Neurologist and her CVA secondary
ppx is reportedly managed by PCP. [**Name10 (NameIs) **] alone is a sufficient
as secondary stroke prevention regimen per guidelines, however
patient required ASA in addition for [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]. Given
increased incidence of bleeding in patients receiving ASA and
[**Last Name (Prefixes) **] for secondary stroke prevention, pt was started on
Omeprazole 20mg EC QD.
.
# Hyperlipidemia. Pt. was continued on home statin.
.
FEN: Regular cardiac diet, no IVF.
.
PROPHYLAXIS:
-DVT ppx with hep sc
-pain management with acetaminophen
-Bowel regimen
.
Patient was discharged home in hemodynamically stable condition,
w/o new rash, CP or SOB. Her new medication regimen was
explained to her at length through a spanish translator and her
undrestanding checked. She was advised to f/u w/ PCP and
Cardiologist within 1-2 weeks and check her laboratory studies
by [**2162-12-16**] to be called in to PCP and Cardiologist.
Medications on Admission:
Enalapril 40mg [**Hospital1 **]
Felodipine 10mg daily
Clonidine 0.2mg [**Hospital1 **]
Aggrenox 200/25mg [**Hospital1 **]
Aspirin 81mg daily
Chlorthalidone 25mg daily
MVI daily
Minoxidil 2.5mg daily PRN for systolic BP over 170mmHg
Atenolol 50mg daily
Ferrous sulfate 325mg 1 tablet daily
Calcium
Nitroglycerin PRN
Discharge Medications:
1. Chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO twice
a day.
12. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for for Systolic Blood Pressure > 170mmHg.
13. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**6-6**]
hours as needed for itching.
14. Outpatient Lab Work
Please check Chem 7 blood work by [**2162-12-15**] and report results to
Dr. [**Last Name (STitle) 29070**] at ([**Telephone/Fax (1) 29073**] and Dr. [**Last Name (STitle) 81857**] [**Name (STitle) 29065**] at
[**Telephone/Fax (1) 29068**].
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 90 days.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. [**Telephone/Fax (1) **] Allergy s/p Desensitization
2. Coronary Artery Disease
3. Hypertesion
4. Hyperlipidemia
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital for [**Telephone/Fax (1) **] desensitization due
to your allergy to [**Telephone/Fax (1) **] and a cardiac catheterization. You
completed this and had a cardiac catheterization on [**2162-12-10**].
You had a stent placed to one of your coronary arteries that
supplies your heart (left anterior descending artery now with
drug eluting stent).
The following changes were made to your medications:
Start [**Date Range **] 75mg by mouth once a day.
Stop Aggrenox
Start Aspirin at higher dose of 325mg daily
Increase Felodipine to 20mg daily
It is important that you take all your medications as
prescribed.
You should call your doctor or come to the emergency room with
any fevers > 100.4, chills, night sweats, chest pain, shortness
of breath, palpitations, skin rash, swelling or other symptoms
that concern you.
You will also need to have your blood work checked by Wednesday,
[**2162-12-15**] and call in results to you PCP and your Cardiologist.
Followup Instructions:
Please see your primary care doctor, Dr. [**Last Name (STitle) 29065**] in [**12-30**] weeks after
discharge, please call [**Telephone/Fax (1) 29068**] to make an appointment.
Please see your cardiologist, [**Doctor Last Name **],[**Doctor First Name **] B. within 2 weeks
of discharge, please call [**Telephone/Fax (1) 37284**] to make an appointment.
Please obtain blood work as prescribed by [**2162-12-15**] and call in
results to your Dr. [**Last Name (STitle) 29065**] and cardiologist.
Completed by:[**2162-12-11**]
|
[
"584.9",
"V07.1",
"401.9",
"414.01",
"272.4",
"698.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"99.12",
"00.40",
"00.66",
"00.45",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10318, 10324
|
4510, 8303
|
369, 412
|
10484, 10519
|
3169, 4404
|
11553, 12080
|
2375, 2451
|
8669, 10295
|
10345, 10463
|
8329, 8646
|
4421, 4487
|
10543, 11530
|
2466, 3150
|
1868, 1941
|
252, 331
|
440, 1755
|
1972, 2240
|
1777, 1848
|
2256, 2359
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,889
| 171,855
|
35786
|
Discharge summary
|
report
|
Admission Date: [**2124-11-3**] Discharge Date: [**2124-11-8**]
Date of Birth: [**2054-4-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
balance difficulty and confusion
Major Surgical or Invasive Procedure:
3rd ventriculostomy
History of Present Illness:
This is a 70 yr old gentlman who has flown in from [**Male First Name (un) 36290**] this afternoon and was directly transported to [**Hospital1 18**] for
assessment of progressive LE weakness. The patient was last
seen
by his daughter in [**Month (only) 359**] who has found him bedridden, weak,
and
incontinent of urine. This is a change from [**2124-1-29**]. It is
not known when the progression of weakness occurred. The
patient
has a prior EtOH abuse history; his last drink was 5 months ago.
CT head in the ED was consistent with massive hydrocephalus.
Past Medical History:
EtOH abuse, ? gastric ulcer
Social History:
lives in [**Male First Name (un) 1056**], has 6 children, prior EtOH
abuse, 1ppd tobacco, no drugs
Family History:
non-contributory
Physical Exam:
Exam upon admission:
T: 97.8 BP: 189/84 HR: 106 R 18 O2Sats ?82 %RA
Gen: WD/WN, NAD. Spanish-speaking.
HEENT: Pupils: 6mm, non-reactive EOMIs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Initially the patient was somnolent, yet easily
arousable. After his daughter arrived, he was more
conversational, awake, and alert.
Orientation: Oriented to person, place, only.
Language: Spanish-speaking.
Cranial Nerves:
I: Not tested
II: Pupils 6mm non-reactive; Extraocular movements intact
bilaterally without nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Cachexic. No abnormal movements, tremors. Strength full
power 4+/5 UE, [**3-4**] LE.
Pertinent Results:
[**2124-11-2**] 07:45PM BLOOD WBC-10.8 RBC-4.16* Hgb-13.9* Hct-40.1
MCV-96 MCH-33.5* MCHC-34.7 RDW-13.8 Plt Ct-141*
[**2124-11-2**] 07:45PM BLOOD Glucose-207* UreaN-20 Creat-1.0 Na-139
K-3.9 Cl-103 HCO3-26 AnGap-14
[**2124-11-3**] 02:36AM BLOOD Albumin-3.2* Calcium-8.7 Phos-2.6* Mg-2.0
Iron-32*
[**2124-11-3**] 02:36AM BLOOD PT-14.5* PTT-26.9 INR(PT)-1.3*
[**2124-11-6**] 02:51AM BLOOD WBC-9.9 RBC-4.18* Hgb-14.0 Hct-38.7*
MCV-93 MCH-33.4* MCHC-36.1* RDW-14.1 Plt Ct-134*
[**2124-11-6**] 02:51AM BLOOD PT-13.9* PTT-27.2 INR(PT)-1.2*
[**2124-11-6**] 02:51AM BLOOD Glucose-138* UreaN-17 Creat-0.7 Na-139
K-3.6 Cl-105 HCO3-24 AnGap-14
[**2124-11-6**] 02:51AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.2
[**11-2**] Head CT: Acute severe noncommunicating hydrocephalus caused
by at least two posterior fossa masses causing edema and mass
effect on the fourth ventricle.
[**11-4**] Head CT: Status post ventriculostomy. Interval development
of hemorrhage along the right basal ganglia extending into the
mid brain. Hyperdense tract through the right frontal lobe,
likely related to prior ventriculostomy catheter placement.
Small amount of intraventricular hemorrhage. Persistent
hydrocephalus and tonsillar herniation. Multiple masses within
the posterior fossa.
[**11-5**] Head CT:
Marked increase in size of large right parenchymal hemorrhage,
which
extends into the thalamus, midbrain and pons. Marked increase in
intraventricular hemorrhage. New subarachnoid hemorrhage,
predominantly in
the basal cisterns. Increased hemorrhage along the right frontal
ventriculostomy track.
2. New compression of the third ventricle with enlargement of
the temporal
horns of the lateral ventricles, indicative of trapping.
Persistent
transependymal CSF flow.
3. Increased intracranial pressure with new right uncal
herniation, increased sulcal effacement, increased effacement of
the frontal [**Doctor Last Name 534**] of the right lateral ventricle, and new
leftward shift of the septum pellucidum.
4. Cerebellar masses with compression of the fourth ventricle
again noted.
[**11-4**] Chest/Abd/Pelvis CT:
Concentric thickening of the colon in the region of the cecum.
Direct
visualization is recommended with colonoscopy to exclude colon
carcinoma.
2. Severe emphysematous changes within the lungs with two
suspicious soft
tissue lesions within the left upper lobe. While these foci may
represent scarring, further evaluation recommended with CT PET
imaging to
evaluate for metabolic activity in these foci which may exclude
possiblity of carcinoma.
3. Moderate secretions within the distal trachea. Please
correlate with
recent intubation/extubation.
4. Minimal ascitic fluid surrounding the liver and gallbladder.
5. Cirrhosis witihout secondary evidence of decompensated liver
disease
aside from small amount of paragastric varices.
Brief Hospital Course:
The patient was admitted to the ICU for Q 1 hour neuro checks.
On [**11-3**] He was taken to the operating room several hours later
for a 3rd ventriculostomy because he had a cerebllar mass that
was compressing the 4th venticle. He went to the PACU post-op
and was oriented x1, MAE. With MRI showing large cerebellar mass
s/p 3rd ventriculostomy. On [**11-4**] he had a Head CT due to right
mydriasis and
left hemiparesis which showed hemorrhage along the right basal
ganglia extending into the mid brain. He also had CT torso
showing multiple mets throughout and continued to have decline
in MS. A family meeting was conducted on [**11-6**] and the decision
was made to make pt [**Name (NI) 3225**] due to pt condition and prognosis. On
[**11-8**] at 12:45p the pt was pronounced by palliative care.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
cerebellar mass
obstructive hydrocephalus
right basal ganglia hemorrhage extending into the mid brain
R uncal herniation
Discharge Condition:
Deceased
Completed by:[**2124-11-8**]
|
[
"784.2",
"342.90",
"599.0",
"331.4",
"997.02",
"431",
"571.5",
"707.03",
"E878.8",
"305.1",
"707.22",
"707.06",
"707.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
5964, 5973
|
5077, 5880
|
351, 373
|
6137, 6176
|
2223, 2928
|
1150, 1168
|
5935, 5941
|
5994, 6116
|
5906, 5912
|
1183, 1190
|
279, 313
|
401, 966
|
1751, 2204
|
3497, 5054
|
1204, 1456
|
1471, 1735
|
988, 1017
|
1033, 1134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,561
| 112,503
|
22323
|
Discharge summary
|
report
|
Admission Date: [**2158-9-11**] Discharge Date: [**2158-9-15**]
Service: [**Last Name (un) **]
Allergies:
Coumadin / Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
1. Casting of Left forearm for Colles fracture
2. Hinge casting of bilateral lower extremities for spiral
fracture of the right distal femoral diaphysis extending to the
supracondylar region and oblique fracture of the distal left
femur metaphysis
3. Placement of percutaneous left nephrostomy tube
4. Transfusion of 2U PRBC
History of Present Illness:
82 y.o. female nursing home resident who fell during transfer
from bed to wheelchair on [**2158-9-9**]. The patient landed on her
knees bilaterally and struck her nose on the bed. After this
event, she complained of bilaterally leg pain. On [**2158-9-10**] X-rays
were taken at the nursing home, showing bilateral femur
fractures. She was then transferred to [**Hospital1 18**] for treatment.
Past Medical History:
A fib
HTN
Depression
Non-insulin dependent DM
Chronic venous stasis w/ hx of foot ulcers
Bilateral hip fractures s/p bilateral hip replacement
Osteoporosis
Arthritis
Degenerative joint disease
Chronic UTI
Social History:
lives at [**Location 58139**] [**First Name9 (NamePattern2) 58140**] [**Doctor First Name 533**] center for extended care
has two goddaughters who both have POA: [**Name (NI) 58141**] [**Name (NI) 58142**] and
[**Last Name (un) **] [**Name (NI) 58143**]
Family History:
non-contributory
Physical Exam:
on arrival to the ED
vitals: Temp 101.6 rectal HR 138 BP 153/52 RR 23 Sats 100% on
NRB FSBG 280
GEN: awake, alert, able to answer yes and no to questions,
follows commands NAD
HEENT: PERRL, EOMI, right perorbital ecchymosis, midface stable,
no oral pharyngeal trauma
NECK: c-collar in place, trachea midline
CHEST: equal BS bilaterally
CV: irregularly irregular, no M/R/G
ABD: SNTND
PELVIS: stable to AP and lateral compression
RECTAL: normal tone, no gross blood, heme neg
BACK: no palpable step-offs, no visible abrasions
EXT: left wrist swelling and ecchymosis, Right leg in flexion,
no grossly apparent deformities of bilateral LE
Skin: warm, dry, intact
NEURO: CN II-XII intact, able to move all 4 ext, no apparent
motor or sensory deficits
Pertinent Results:
[**2158-9-10**] 10:11 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
IMPRESSION:
1) No evidence of acute traumatic intraabdominal injury.
2) 9 mm obstructing stone in the proximal left ureter with
moderate hydronephrosis. CT evidence of bilateral pyelonephritis
[**2158-9-10**] 10:11 PM CT C-SPINE W/O CONTRAST; CT
RECONSTRUCTIONIMPRESSION: Severe degenerative changes and
demineralization. No definite acute fracture seen.
[**2158-9-10**] 10:10 PM CT HEAD W/O CONTRAST IMPRESSION: Likely remote
right MCA distribution infarct. Subacute to chronic right PCA
distribution infarct, but exact timing is indeterminate without
a prior study. MRI could be performed for further evaluation, if
the patient is a candidate for MRI
[**2158-9-10**] 9:36 PM ELBOW (AP, LAT & OBLIQUE) LEFT; WRIST(3 +
VIEWS) LEFTIMPRESSION:
1. Suspicion for fracture of the radial head.
2. Colles' fracture.
[**2158-9-11**] 3:57 PM L-SPINE (AP & LAT); T-SPINE IMPRESSION:
1. Loss of height in multiple midthoracic vertebral bodies and
in the L1 vertebral body. These are of uncertain chronicity.
2. Grade I anterolisthesis of L4 on L5.
3. Diffuse demineralization. No acute fracture can be
identified, noting that evaluation is limited in the presence of
diffuse demineralization.
[**2158-9-11**] 12:52 AM FEMUR (AP & LAT) BILAT
There is a spiral fracture of the right distal femoral diaphysis
extending to the supracondylar region. There is an oblique
fracture of the distal left femur metaphysis. Neither of these
fractures appear to extend intraarticularly. There is posterior
displacement of the distal fracture fragments bilaterally. There
is diffuse demineralization. Degenerative changes are seen in
both knees. There is a dynamic compression screw in the proximal
right femur with extensive foreshortening of the femoral neck
region and associated heterotopic bone formation. A bipolar left
hip prosthesis is present without evidence of fracture.
[**2158-9-10**] 09:10PM BLOOD WBC-21.3* RBC-3.16* Hgb-9.9* Hct-29.0*
MCV-92 MCH-31.5 MCHC-34.3 RDW-13.9 Plt Ct-360
[**2158-9-11**] 08:50AM BLOOD WBC-17.6* RBC-2.44* Hgb-7.7* Hct-23.4*
MCV-96 MCH-31.7 MCHC-33.1 RDW-13.7 Plt Ct-329
[**2158-9-11**] 10:35PM BLOOD Hct-27.6*
[**2158-9-12**] 01:59AM BLOOD WBC-15.6* RBC-3.24*# Hgb-10.2*# Hct-29.4*
MCV-91 MCH-31.4 MCHC-34.5 RDW-15.3 Plt Ct-270
[**2158-9-12**] 03:47PM BLOOD WBC-14.0* RBC-3.22* Hgb-10.3* Hct-28.5*
MCV-89 MCH-32.1* MCHC-36.3* RDW-15.6* Plt Ct-250
[**2158-9-13**] 05:27AM BLOOD WBC-11.7* RBC-3.21* Hgb-10.3* Hct-28.9*
MCV-90 MCH-32.0 MCHC-35.5* RDW-15.2 Plt Ct-267
Brief Hospital Course:
[**2158-9-10**]: X-ray studies revealed bilateral femur fx and left
Colles' fx. CT of Abd/Pelvis also revealed obstructing 9mm
ureteral stone on left with bilateral hydronephrosis. The pt was
empirically started on Levofloxacin for treatment of presumed
pyelonephritis. The pt was initially admitted to the TSICU
because she was requiring Diltiazem IV for management of her
rapid a fib. Vascular and Ortho services were also consulted for
evaluation of the pt's injuries. Based on clinical exam, the
pt's fractures did not compromise blood flow to the lower
extremities. A confirmatory angiogram was deferred secondary to
the risks of the procedures and the [**Hospital **] medical comorbidities.
Close neurovascular surveillence of the pt's LE was continued
throughout her hospital course and no changes were noted.
Orthopedics performed a closed reduction of the pt's left
Colles' fracture with good success. Her left forearm was then
placed in a hard cast. Urology was also consulted for the pt's
obstructing ureteral stone. Their decision to place a diverting
percutaneous nephrostomy tube would be determined based on the
pt's urine culture.
[**2158-9-11**] to [**2158-9-15**]: The pt's C-spine was cleared after flex-ex
films were obtained. T/L spine films revealed old compression
fx. The pt's HCT dropped to 23 and she was transfused 2U PRBC.
After clearance of the pt's C-spine, she was switched to PO meds
and transferred to the hospital floor. Options for treatment of
the pt's bilateral femur fx were discussed and the POA's decided
on non-surgical management with casting under fluoroscopy. This
was performed by orthopedics and the pt tolerated the procedure
well. The pt's initial urine ctx came back with diffuse
contamination. Urology decided to place a percutaneous
nephrostomy tube due to the high likelihood of infxn. This was
performed by interventional radiology on [**2158-9-14**]. After the
procedure, the pt's foley remained in place and will be removed
at the nursing care facility at the request of the pt's health
care POA. She had no difficulty urinating and clear urine was
draining from the tube. She was tolerating PO without difficulty
and placed back on all of her home meds. The bilateral hinged
casts on her LE fit well with no evidence of pain, swelling, or
erythema of the skin or her toes. Physical therapy worked with
the pt in house to facilitate her rehab. On [**2158-9-15**] the pt was
discharged home to her previous rehab facility. She will be
continued on PO antibiotics for five days after discharge.
Medications on Admission:
1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO at bedtime.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Effexor 37.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
7. Isordil Titradose 40 mg Tablet Sig: 1.5 Tablets PO once a
day.
Disp:*45 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO at bedtime.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Effexor 37.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
7. Isordil Titradose 40 mg Tablet Sig: 1.5 Tablets PO once a
day.
Disp:*45 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) injection
Subcutaneous QD (once a day) for 6 weeks.
Disp:*30 injection* Refills:*2*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
1. Pyelonephritis
2. A fib
3. GERD
4. Degenerative joint disease
5. Bilateral hip replacement
6. Left Colles' fracture requiring reduction and casting
7. Spiral fracture of the right distal femoral diaphysis
requiring reduction and casting
8. Oblique fracture of the distal left femur metaphysis
requiring reduction and casting
9. HTN
10. Depression
11. Non-insulin dependent DM
12. Chronic venous stasis w/ hx of foot ulcers
13. Osteoporosis
14. Blood loss anemia requiring transfusion 2U PRBC
15. Obstructive nephrolithiasis requiring placement of
percutaneous nephrostomy tube in the left ureter
Discharge Condition:
Stable
Discharge Instructions:
You may resume your regular diet. Continue physical therapy as
tolerated to help improve your movement with the leg casts. Your
weight bearing status is: non-weight bearing on bilateral lower
extremities and non-weight bearing on left upper extremity. You
will be on the Lovenox injections for anticoagulation for a
total of six weeks. Please leave the foley catheter in place
until arrival at the health care facility, then it may be
removed.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) **] in the [**Hospital **] clinic
located in the [**Hospital Ward Name 23**] building on the [**Location (un) 1773**]. An
appointment has been scheduled for you on [**10-20**] @ 9:10
AM. Please call ([**Telephone/Fax (1) 58144**] if you have any questions or need
to change the appointment. Prior to this appointment, please
obtain AP and Lateral x-rays of bilateral femurs and an x-ray of
the pt's left wrist. Please have these transported with the pt
on the day of the clinic appointment so Dr. [**Last Name (STitle) **] may see the
films.
Follow up with Dr. [**Last Name (STitle) 770**] of Urology in 4 weeks. Call ([**Telephone/Fax (1) 58145**] to schedule an appt. The clinic is located in the
[**Hospital Ward Name 23**] building. If possible, you may want to schedule the appt
for the same day as your orthopedic visit.
|
[
"285.1",
"591",
"821.29",
"E884.4",
"592.1",
"590.80",
"821.22",
"427.31",
"813.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"79.02",
"55.03",
"79.05"
] |
icd9pcs
|
[
[
[]
]
] |
9740, 9875
|
4913, 7462
|
271, 597
|
10517, 10525
|
2334, 4890
|
11017, 11903
|
1534, 1552
|
8371, 9717
|
9896, 10496
|
7488, 8348
|
10549, 10994
|
1567, 2315
|
227, 233
|
625, 1019
|
1041, 1247
|
1263, 1518
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,683
| 113,533
|
53989
|
Discharge summary
|
report
|
Admission Date: [**2106-8-19**] Discharge Date: [**2106-8-25**]
Date of Birth: [**2066-11-7**] Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 16851**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain,
pulmonary, and hepatic mets. He underwent MRI this morning on
[**Hospital Ward Name 516**]. Shortly after receiving gadolinium contrast he
developed worsening RLQ abdominal pain, then developed shaking
of all 4 extremities. He reports that he was awake and alert
throughout the episode. He was noted to be alert and oriented x3
directly afterward. BP noted to be 70s/40s on machine and
manual recheck. He has had worsening RLQ pain for the last five
days.
Today he noticed his abdomen to be more distended than usual.
Approximately one week ago his oxycodone was increased. Last HD
session yesterday. Last round of chemotherapy was [**8-11**].
In ED, he received 2L NS but SBP still in 80s. Started
peripheral levophed at 0.09 with response to 100s-110s.
Initial VS in ED:
T 98.1 HR 105 BP: 104/68 RR 22 O2Sat 97 on 4L NC
In the ED, he started empiric vancomycin and cefepime for
broad-spectrum coverage. CT revealed significant progression of
his metastases (pulmonary, hepatic) but could not rule out
pneumonia. New ascites but no evidence of appendicitis or acute
abscess.
Initial VS in MICU:
T 98.5 HR 101 BP 105/72 RR 19 O2Sat 96% on 4L NC
Past Medical History:
Metastatic renal cell carcinoma:
-- [**2106-3-10**]: cough x 2 weeks
-- [**2106-4-15**]: Chest/Abd/Pelvis CT with pulm nodules, RUL mass,
mediastinal/hilar lymphadenopathy, retroperitoneal adenopathy
-- [**2106-5-3**]: Brain MRI with lesions in R choroid plexus, L
parieto-occipital junction, L frontal lobe
-- [**2106-5-5**]: VATS wedge resection of RUL mass; path confirmed
renal cell carcinoma with clear cell features as well as the
presence of a TFE3 gene fusion
-- [**2106-6-10**]: CyberKnife radiosurgery to brain met
-- [**2106-7-23**]: CyberKnife radiosurgery to brain met
ESRD - secondary to focal glomerulonephritis, on HD since [**2089**]
HTN
Anxiety
Past Surgical History:
-multiple AV fistula placements/repairs
-2 breast reduction procedures
-2 operations for undescented testes
-right orchiectomy
-kidney biopsy
-repair of a ruptured quadriceps tendon
Social History:
Mr. [**Known lastname **] is single. He is currently on disability. Smoked 1PPD
x 20yrs and quit approximately one month ago. Prior history of
alcohol dependence, but quit approximately four years ago. He
has been living with friends in [**Name (NI) 1110**].
Family History:
His mother is healthy at age 60. His father died at age 48 from
throat cancer (he consumed cigarettes and alcohol) and colon
cancer. His sister and brother are healthy but another brother
has the "gene" for colon cancer and gets yearly check ups
Physical Exam:
At [**Hospital Unit Name 153**] admission:
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. JVP flat.
Lungs: Shallow breathing with accessory muscle use. Distant
breath sounds, crackles at bilateral bases, no wheezes, rales,
ronchi. Posterior lung fields not examined due to patient's
pain attempting to sit up.
Abdomen: Distended, tense, diminished bowel sounds. Nontender
to palpation.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. AV fistula in RUE; scars of prior AV fistula in LUE. R
hand exquisitely tender to palpation.
Neuro: CNII-XII intact, 2+ reflexes bilaterally, gait deferred.
At discharge:
VS: 97.4 92/60 97% on 2L pain 3
GEN: nad, laying in bed
NECK: supple
HEENT: op clear, poor dentition
CHEST: faint wheezing anteriorly
CV: rrr no m/r/g
ABD: distended
EXT: feet tender (chronic) no edema
NEURO: AAOx3
PSYCH: appropriate, pleasant
Pertinent Results:
CT C/A/P on admission:
1. New enhancing hepatic mass and increased number and size of
pulmonary
nodules at the lung bases compatible with worsening metastatic
disease.
Several osseous metastatic lesions with soft tissue components
are not
significantly changed in the interval.
2. Worsening diffuse septal thickening, likely reflective of
worsening
pulmonary edema, though lymphangitic carcinomatosis is not
excluded. Small
bilateral pleural effusions, right larger than left.
3. New moderate volume ascites.
4. Atrophic kidneys with multiple cysts, likely related to
dialysis.
Dominant, peripherally calcified complex cystic lesion in the
right upper pole
of the kidney could reflect the patient's primary renal
carcinoma.
[**2106-8-24**] 09:36AM BLOOD WBC-4.3# RBC-3.18* Hgb-9.2* Hct-29.6*
MCV-93 MCH-29.0 MCHC-31.1 RDW-18.6* Plt Ct-204
[**2106-8-24**] 09:36AM BLOOD Glucose-95 UreaN-22* Creat-6.5*# Na-140
K-4.2 Cl-102 HCO3-26 AnGap-16
[**2106-8-24**] 09:36AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8
[**2106-8-20**] 10:53AM ASCITES WBC-2050* RBC-1475* Polys-80* Lymphs-3*
Monos-14* Atyps-0 Mesothe-3*
Brief Hospital Course:
Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain,
pulmonary, and hepatic mets admitted to the MICU with
hypotension after receiving gadolinium during MRI on day of
admission.
Active Issues:
---------------
# Septic shock: [**3-11**] SBP: He met SIRS criteria (HR, RR, WBC)on
admission and required levophed after 2L NS with most likely
etiology SBP. He was treated with ceftriaxone (see SBP for
further details). Hypersensitivity reaction to gadolinium has
been described but is rare, and he has previously received
gadolinium. He received HD to remove gadolinum once he was
hemodynamically stabilized. Adrenal insufficiency was ruled
out. His shock resolved and he was transferred to the general
medical floor without any further infectious issues.
# SBP: He completed a course of ceftriaxone and given albumin on
day 1 and day 3. He will continue on norfloxacin for
prophylaxis.
#New Onset Ascites: likely due to new hepatic mets and or
carcinomatosis. No portal or splenic vein thrombosis seen.
# ESRD: The patient received HD to remove gadolinum for MRI .
He then continued on a MWF HD schedule. He had difficulty
removing fluid during HD due to hypotension, which had been a
problem at his out patient facility as well and so he was
started on midorine.
# Pain: pt with groin, leg, feet, back and abdominal pain. Pain
regimen adjusted to increased home oxycontin dose, continued
home oxycodone, tramadol, started naproxen and tylenol around
the clock.
# HTN: pt remained normo-tensive with his baseline SBP in the
100s. He was not discharged on his previous anti-hypertensive,
nifedipine.
# Anemia: likely [**3-11**] chronic disease and chemo. No evidence of
bleeding.
- cont epo
# Metastatic renal cell CA: Pt had been followed by Dr. [**Last Name (STitle) 22658**] in
[**Location (un) 1110**]. Will establish care in [**Location (un) 86**] with Dr. [**Last Name (STitle) **]. His
records from Dr. [**Last Name (STitle) 22658**] were faxed to the new office on the day
of discharge. He was found to have progression of known brain
and pulmonary mets and new hepatic mets during admission.
Patient and mother are aware of this. Pt expressed wishes to be
resuscitated but not intubated. Explained that this was not
possible. Discussed his poor prognosis of weeks to months and
the likelyhood of suscessful resuscitation would be at most 5%.
Patient stated that he would remain full code for now and would
discuss it with his friends and mother.
Medications on Admission:
NIFEDIPINE 60 mg QSunday/Tues/Thurs
OXYCODONE-ACETAMINOPHEN PRN
TRAMADOL 50 mg TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Midodrine 5 mg PO TID
4. Naproxen 500 mg PO Q12H
5. Nephrocaps 1 CAP PO DAILY
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
hold for sedation
7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
hold for sedation or RR<10,
8. Polyethylene Glycol 17 g PO DAILY
Hold if patient having daily BMs.
9. Senna 1 TAB PO BID constipation
10. TraMADOL (Ultram) 50 mg PO TID
11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
12. norfloxacin *NF* 400 mg Oral daily SBP prophylaxis
Discharge Disposition:
Expired
Facility:
[**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **] Center
Discharge Diagnosis:
spontaneous bacertial peritonitis
new hepatic metastasis of renal cell carcinoma
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 due to an infection in your abdomen which has
been treated.You will require prophylactic antibiotics from now
on to prevent this infection from returning.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2106-8-31**] at 4:00 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
|
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icd9cm
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,479
| 141,061
|
49377
|
Discharge summary
|
report
|
Admission Date: [**2159-6-1**] Discharge Date: [**2159-6-12**]
Date of Birth: [**2079-5-13**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
Trauma: fall
small rigth pneumothorax with pulmonary contusion
Right rib [**11-27**] Fracture (3, [**4-27**] have segmental fracture)
Right scapula fracture
Right clavicular fracture
T2,T6,T7 transverse process fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 80 year old male who complains of S/P
FALL. Time seen was 6:15, upon arrival. The patient fell
15-20 feet. He is complaining of right-sided rib pain. The
pressure was 1:30 systolic. His heart rate was 70. He is
breathing at 32-36. He has right shoulder pain according to
the paramedics previous complaining of slight shortness of
breath. There was no loss of consciousness. He got up and
walked into his house.
Past Medical History:
1. Coronary artery disease status post CABG, MVR in [**2146**].
2. Peripheral vascular disease status post bilateral carotid
stenting
3. HTN
4. RCC s/p resection
5. DM
6. AAA
7. Hyperparathyroidism
Social History:
Married, Russian only speaking and lives with his wife who works
at [**Hospital3 328**] and translates for him. Has one daughter and two
granddaughters. His daughter will drive them to and from the
hospital.
Family History:
Father had CVA.
Physical Exam:
PHYSICAL EXAMINATION: upon admission: [**2159-6-1**]
Constitutional: Back board and collar
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact, right
occipital abrasion
Neck is nontender
Chest: Clear to auscultation, right chest wall tenderness
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Pelvic: Pelvis stable
Rectal: Rectal is normal tone normal sensory
Extr/Back: Back is nontender. There is no extremity
tenderness. Right shoulder is without deformity or
tenderness.
Neuro: A/O X 3, CN 3-12 intact, normal sensory, normal
motor, normal cerebellar function, normal gait, downgoing
toes, DTRs normal
Physical examination upon discharge:
[**2159-6-12**]
vital signs: t=97.6, hr=73, bp=152/47, rr 20, oxygen sat 90%
room air
General: Sitting in chair
CV: Ns1, s2, -s3, ,-s4, +grade 2 systolic murmur, 2nd ICS,
LSB, RSB
RESP: Diminished bs right base
ABDOMEN: Rounded, soft, non-tender
EXT: no calf tenderness bil.
Neuro: Speaking broken English, follows commands
Musculskeltal: Right sided rib tenderness, right arm in sling,
fingers warm, + radial pulse
Pertinent Results:
[**2159-6-9**] 01:25AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.0* Hct-30.0*
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.9 Plt Ct-211
[**2159-6-8**] 12:45AM BLOOD WBC-7.8 RBC-3.26* Hgb-9.9* Hct-29.6*
MCV-91 MCH-30.5 MCHC-33.6 RDW-14.7 Plt Ct-180
[**2159-6-1**] 07:45PM BLOOD WBC-13.6* RBC-4.33* Hgb-13.2* Hct-38.8*
MCV-90 MCH-30.5 MCHC-34.1 RDW-14.1 Plt Ct-188
[**2159-6-9**] 01:25AM BLOOD Plt Ct-211
[**2159-6-8**] 12:45AM BLOOD Plt Ct-180
[**2159-6-1**] 07:45PM BLOOD PT-10.7 PTT-26.4 INR(PT)-1.0
[**2159-6-1**] 07:45PM BLOOD Fibrino-257
[**2159-6-12**] 06:35AM BLOOD Glucose-211* UreaN-42* Creat-1.5* Na-139
K-4.1 Cl-97 HCO3-33* AnGap-13
[**2159-6-10**] 09:23AM BLOOD Glucose-86 UreaN-46* Creat-1.6* Na-142
K-4.0 Cl-99 HCO3-35* AnGap-12
[**2159-6-9**] 01:25AM BLOOD Glucose-121* UreaN-46* Creat-1.5* Na-145
K-4.5 Cl-103 HCO3-35* AnGap-12
[**2159-6-1**] 07:45PM BLOOD UreaN-36* Creat-1.7*
[**2159-6-5**] 01:15AM BLOOD CK(CPK)-224
[**2159-6-1**] 07:45PM BLOOD Lipase-52
[**2159-6-5**] 05:14PM BLOOD cTropnT-0.21*
[**2159-6-5**] 01:15AM BLOOD CK-MB-4 cTropnT-0.30*
[**2159-6-4**] 04:31PM BLOOD CK-MB-7 cTropnT-0.31*
[**2159-6-4**] 08:26AM BLOOD CK-MB-8 cTropnT-0.23*
[**2159-6-4**] 04:13AM BLOOD CK-MB-4 cTropnT-0.10*
[**2159-6-10**] 09:23AM BLOOD Calcium-10.3 Phos-2.9 Mg-2.2
[**2159-6-1**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2159-6-7**] 01:38AM BLOOD freeCa-1.40*
[**2159-6-1**]: EKG:
Sinus rhythm. Left bundle-branch block. Occasional ventricular
premature
beats. Prolonged P-R interval. Compared to the previous tracing
of [**2156-8-23**] no clear change.
[**2159-6-1**]: chest x-ray:
IMPRESSION:
Limited exam. Multiple displaced right-sided rib fractures with
adjacent
subcutaneous emphysema. Comminuted right scapular fracture.
Atelectasis
versus contusions in the right lung base.
[**2159-6-1**]: cat scan of abdomen and pelvis:
IMPRESSION:
1. Small right pneumothorax without evidence of tension. Right
upper lobe and right lower lobe pulmonary contusions.
2. Comminuted right scapular fracture with right subscapular
hematoma. No evidence of active extravasation.
3. Flail chest with right 6th-8th rib segmental fractures.
Multiple
additional minimally displaced rib fractures as detailed above,
with small associated extrapleural hematomas. Extensive right
posterolateral chest wall subcutaneous emphysema. Minimally
displaced right proximal clavicle fracture.
4. Multiple right thoracic vertebrae transverse process
fractures, as
detailed above.
5. Esophagus is fluid-filled and may predispose the patient to
aspiration.
6. Intact infrarenal aortobiiliac stent-graft without evidence
of endoleak.
Excluded aneurysm sac measures 5.9 x 5.4 cm.
[**2159-6-1**]: cat scan of the c-spine:
IMPRESSION:
1. No cervical spine fracture, acute alignment abnormality, or
prevertebral soft tissue abnormality.
2. Fractures of right T2 transverse process, right 1st, 2nd,
and 3rd
posterolateral ribs, right proximal clavicle, and right scapula.
Numerous other transverse process and rib fractures are not
imaged, seen on accompanying CT torso.
3. Irregular sclerosis in right aspect of C2 vertebral body.
Clinical
correlation with history of malignancy should be made and a bone
scan can be obtained for further evaluation.
[**2159-6-1**]: cat scan of the head:
IMPRESSION:
1. No intracranial hemorrhage or calvarial fracture.
2. Probable subacute to chronic infarct within the right
frontal lobe, with chronic infarcts in the left cerebellum and
right subinsular region as well.
If there is concern for an acute stroke, MR may be obtained for
further
evaluation
[**2159-6-1**]: right shoulder x-ray:
Comminuted fracture of the right scapula and displaced fracture
of the right proximal clavicle. Known right-sided rib fractures
are better seen on the previous CT. No dislocation.
[**2159-6-4**]: Echo:
IMPRESSION: Suboptimal image quality. Well seated mitral valve
bioprosthesis with high normal gradient and mild mitral
regurgitation. Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD. Pulmonary artery hypertension.
Pulmonary artery hypertension. Mild aortic valve stenosis.
Compared with the prior study (images reviewed) of [**2158-10-16**],
the severity of aortic stenosis has increased. The mitral valve
gradient, severity of mitral regurgitation, and the egional and
global left ventricular systolic function are similar.
[**2159-6-4**]: EKG:
Sinus rhythm with ventricular premature contractions. Variable
A-V conduction, possible dual A-V nodal pathways. Compared to
the previous tracing of variable A-V nodal conduction is seen.
The other findings are
similar.
[**2159-6-5**]: EKG:
Sinus rhythm with atrial ectopy. Left axis deviation.
Non-specific
intraventricular conduction delay. Non-specific ST-T wave
changes. Compared to the previous tracing of [**2159-6-4**] atrial
ectopy is new.
[**2159-6-6**]: x-ray of abdomen:
IMPRESSION: Nonspecific bowel gas pattern with no obvious signs
of ileus or obstruction
[**2159-6-8**]: chest x-ray:
Current study demonstrates that the patient has been extubated.
Heart size and mediastinum are stable. No pneumothorax is seen
on the current
examination. Bibasal atelectasis and bilateral pleural
effusions appear to be slightly improved as compared to the
prior study.
[**2159-6-10**]: chest x-ray:
Heart size and mediastinum are stable. There is interval
improvement in
pulmonary edema with also improvement of bibasal lung aeration.
Current study demonstrates no evidence of pneumothorax.
Bilateral pleural effusion is most likely present.
[**2159-6-3**] 5:00 pm SPUTUM Source: Induced.
**FINAL REPORT [**2159-6-6**]**
GRAM STAIN (Final [**2159-6-3**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS AND IN
SHORT
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2159-6-6**]):
MODERATE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
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.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. HEAVY
GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
The patient was admitted to the acute care service after falling
off a ladder and stricking a tree on the way to the ground. Upon
admission he was complaining of right shoulder and rib pain. He
was made NPO, given intravenous fluids, and [**Month/Day/Year 1834**] imaging.
Review of the imaging showed right sided rib fractures [**11-27**] (3,
[**4-27**] segmental fractures, right clavicle and scapular fracture,
and T2-7 transverse process fracture. He was also reported to
have a small right pneumothorax. He was admitted to the
intensive care unit for monitoring where he had an epidural
cathete placed for pain control with a resultant drop in his
blood pressure requiring additional intravenous fluids. The
epidural catheter was removed on HD #2.
On HD #4, he was intubated for increased work of breathing,
progressive hypoxia, and copious secretions. He was bronched
with minimal remaining secretions. Sputum cultures grew MSSA and
H. Flu and he was started on vancomycin, nafcillin, and
ceftriaxone. The vancomycin was discontinued within 24 hours and
he was maintained on nafcillin and cetriaxone. During this
time, he had an eppisode of blood pressure instability where he
required pressor support. He was also noted to have an irregular
heart rate which was controlled with metoprolol. His pulmonary
status worsened and on chest x-ray was found to have a right
lung collapse requiring placement of a chest tube with
re-expansion of the lung. With his hemodynamic instability,
cardiology was consulted for a mild elevation in the troponins
and an echocardiogram was done on HD # 4. The echo showed an
ejection fraction of 40% and an increase in the severtiy of the
aortic stenosis. His troponins were monitored and they gradually
decreased. Recommendations were made by cardiology for
resumption of his home medications. They recommended holding his
metoprolol because of progression on EKG to Type 1 second degree
heart block.
The patient self-extubated on #5, and required re-intubation.
He was reported to have periods of agitation and the weaning
process was delayed. On HD #8, he developed stridor and
difficulty ventilating. He was bronched and his pulmonary
status markedly improved. He was extubated on HD #8. At this
time his chest tube was removed and his pain medication was
changed to patient controlled analgesia.
On HD #9, after his pulmonary and cardiac status stabilized, he
was transferred to the surgical floor. His rib pain has been
controlled with oral analgesics. His vital signs have been
stable. He has resumed his home medications except for his
metoprolol. His intravenous antibiotics were discontinued on HD
# 12 and he will start a 10 day renal course of levofloxacin for
MSSA in his sputum. He has been tolerating a regular diet and
voiding without difficulty. He has been instructed in the use
of the incentive spirometer. He has been evaluated by physical
therapy and recommendations made for discharge to an extended
care facility where he can further regain his strength and
mobility.
Follow-up appoinments have been made with Orthopedic service,
acute care service, and with his Cardiologist.
Medications on Admission:
amlodipine 10', lipitor 80', HCTZ 25', lisinopril 40', metformin
850', glipizide 10', metoprolol 25'', ASA'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 10 mg PO DAILY
hold for systolic blood pressure <110, hr <60
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Calcium Carbonate 500 mg PO QID:PRN indigestion
6. GlipiZIDE 10 mg PO DAILY
please monitor blood sugar
7. Heparin 5000 UNIT SC TID
8. Hydrochlorothiazide 25 mg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD DAILY rib pain
apply to right posterior chest
10. Lisinopril 40 mg PO DAILY
hold for systolic blood pressure <110, hr <60
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Omeprazole 20 mg PO DAILY
13. OxycoDONE (Immediate Release) 5-15 mg PO Q3H:PRN pain
hold for increased sedation, resp. rate <10
14. Sarna Lotion 1 Appl TP QID:PRN itching
15. Senna 1 TAB PO BID
16. traZODONE 25 mg PO HS:PRN insomnia
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
wheezing/shortness of breath
18. Ipratropium Bromide Neb 1 NEB IH Q6H
19. MetFORMIN (Glucophage) 850 mg PO DAILY
ON HOLD...ELEVATED CREAT 1.5, resume when creat <1.5
20. Levofloxacin 750 mg PO Q48H Duration: 10 Days
started on [**6-12**]
21. Docusate Sodium 100 mg PO BID
hold for diarrhea
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Trauma: fall
small right pneumothorax with pulmonary contusion
Right rib [**11-27**] Fracture (3, [**4-27**] have segmental fracture)
Right scapula fracture
Right clavicular fracture
T2,T6,T7 transverse process fracture
Discharge Condition:
Mental Status: Clear and coherent ( Russian speaking, but speaks
broken English)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after falling from a ladder
and striking a tree. You were brought to the hospital. After
imaging, you were found to have several rib fractures, fractures
segments to your spine, clavicle and scapula fractures, and a
collapse to your lung. You were noted to have increased
difficulty breathing and required a breathing tube for
assistance. You were also noted to have an irregular heart rate
and mild increase in cardiac blood work. You were seen by
Cardiology and recommendations made for your care. Fortunately,
you did not require any surgery and you are slowly recovering
from your fall. Your vital signs and blood work have been
stable. You are now preparing for discharge to an extended care
facility where you can further regain your strength.
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD
Specialty: Primary Care
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: ORTHOPEDICS
When: TUESDAY [**2159-6-26**] at 1:20 PM
With: [**Year (4 digits) **] XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2159-6-26**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 16471**], MD
When: FRIDAY [**2159-6-29**] at 11:00 AM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment. Please arrive at
10:30am.
Completed by:[**2159-6-19**]
|
[
"807.4",
"585.3",
"805.2",
"486",
"V42.2",
"426.13",
"811.00",
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"424.1",
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"518.81",
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"810.00",
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"414.00",
"E912",
"250.00",
"285.9",
"403.90",
"V10.52",
"443.9",
"780.09",
"411.89",
"860.0",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.23",
"96.6",
"03.90",
"34.04",
"96.05",
"96.72",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
14410, 14480
|
9952, 13112
|
491, 498
|
14746, 14746
|
2690, 9929
|
15758, 17417
|
1452, 1469
|
13270, 14387
|
14501, 14725
|
13138, 13247
|
14943, 15735
|
1484, 1484
|
1507, 1509
|
229, 453
|
2241, 2671
|
526, 988
|
1524, 2224
|
14761, 14919
|
1010, 1210
|
1226, 1436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,276
| 171,108
|
51
|
Discharge summary
|
report
|
Admission Date: [**2118-7-10**] Discharge Date: [**2118-7-11**]
Date of Birth: [**2034-1-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
84M PMhx metastatic papillary thyroid CA (s/p resection,
radioactive iodine) c/b lung mets, found to have large cavitary
mass in RLL, recent admission with malignant effusion + for SCC
recently treated for presumed post-obstructive pna. Prior
hospitalization was also notable for PET scan that revealed
widely metastatic disease.
He presents today from rehab with acute respiratory distress.
Pt is [**Name (NI) 595**] speaking so history was obtained from family. At
baseline he is on 2L o2, yesterday he was doing well, but last
night he woke up in respiratory distress. The rehab reported
that he was sating at 80% on a non-rebreather mask. EMS was
called and he was transferred the the [**Hospital1 18**] ED. Prior to event,
pt denies any fevers or chills, nausea, vomiting. He has a
chronic cough secondary to his lung ca but the quality of the
cough did not change. he is not experiencing any pain.
Of note, pt's recent PMH is notable for rapid progression of
metastatic lung SCC. He started experiencing chronic cough and
hemoptysis in [**Month (only) 547**] and symptoms have progressed since. In [**Month (only) 596**]
he was noted to have a large cavitary mass in RLL with satellite
nodules suggestive of primary lung Ca.
At the end of [**Month (only) **] he was admitted to osh with fever,
leukocytosis and cough and treated with ctx. His symptoms did
not improve. At this time a CT showed cavitary lesion as above
and a new large r exudative pleural effusion. Effusion
reaccumulated resulting in supplemental O2 requirement. As such
a chest tube was placed and the cytology came back + for SCC.
He was started on vanc zosyn for obstructive pna and was
transferred to [**Hospital1 18**]. Hospital course was notable for r/o PE,
attempted pleurx catheter placement on [**6-27**] that failed due to
loculated effusions not amenable to pleurx. At this point a PET
scan was done that showed extensive metastatic dz.
In the ED, initial VS were: t 98.1 80 106/46 80s on [**Last Name (LF) 597**], [**First Name3 (LF) **] he
was started on bipap 60 15/5 and his sats improved to 96%. He
was noted to have bilaterally crackles throughout lung fields,
and a power picc was in place in right ac fossa.
CXR is consistent with prior xrays from earlier this month, but
RLL effusion appears to have expanded. Labs were notable for
wbc of 38k with 94% N, hct was 25 and platelets 504. He was
given vanc and cefepine and transferred to the unit.
On arrival to the MICU, pt is somnolent, on bipap and sating in
the low 90s. he is with his family and easily arousable. He is
answering questions appropriately. His family was concerned
that he has been over sedated since he last left [**Hospital1 18**]. The
report that he has been sleeping all day and are concerned that
he is receiving too much narcotics. Apparently he was recently
started on a fentanyl patch 50mcg at rehab.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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. Denies
rashes or skin changes.
Past Medical History:
- metastatic thyroid CA followed by Dr. [**Last Name (STitle) 574**]
- metastatic SCC of the lung
- Hypothyroidism
- Hiatal hernia
- Shingles
- Prostate Cancer
- metastatic primary lung NSCLC
- COPD
Social History:
Lives w wife in [**Name (NI) 577**], moved from [**Country 532**] in [**2094**]; 30pkyr
tobacco, no illicits or etoh
Family History:
no history of lung cancer
Physical Exam:
Admission:
Vitals: see metavision, on bipap [**3-31**] with 60% sating at 91
General: somnolent, but arousable. family reports that he is
aox3. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, distant heart sounds that are
obscured by rhonchorus lung sounds
Lungs: diffuse rhonchi throughout, decreased breath sounds
throughout the R lung field particularly at the base
Abdomen: soft, non-tender, slightly distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: cool 2+ pulses, no clubbing, cyanosis or edema
Neuro: moving all extremities spontaneously, awakens to voice,
no focal deficits
Discharge: N/A as expired
Pertinent Results:
I. Labs
[**2118-7-10**] 03:05AM BLOOD WBC-38.0*# RBC-2.91* Hgb-7.7* Hct-24.9*
MCV-85 MCH-26.3* MCHC-30.8* RDW-16.4* Plt Ct-504*
[**2118-7-10**] 03:05AM BLOOD PT-13.8* PTT-30.0 INR(PT)-1.2*
[**2118-7-10**] 03:05AM BLOOD Fibrino-698*#
[**2118-7-11**] 02:57AM BLOOD Glucose-124* UreaN-31* Creat-0.9 Na-131*
K-4.4 Cl-95* HCO3-28 AnGap-12
[**2118-7-10**] 06:08AM BLOOD Type-ART pO2-65* pCO2-46* pH-7.42
calTCO2-31* Base XS-4
[**2118-7-10**] 03:05AM BLOOD Glucose-157* Lactate-1.2 Na-132* K-4.6
Cl-97 calHCO3-28
II. Microbiology
[**2118-7-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY INPATIENT
[**2118-7-10**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2118-7-10**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2118-7-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2118-7-10**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; Anaerobic
Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
Brief Hospital Course:
84M history of metastatic papillary thyroid cancer (s/p
resection, radioactive iodine) complicated by lung metastases,
found to have large cavitary mass in RLL with recent admission
for malignant effusion positive for small cell lung cancer
recently treated for presumed post-obstructive pna that presents
with acute respiratory distress. His respiratory distress was
thought to be secondary to aforementioned metastatic disease. It
was discussed with family and patient that his disease was
terminal without many further options. He was stabilized on
biPAP. Goals of care discussion yielded to make the patient
comfort measures only. He expired at 11:55 AM on [**2118-7-11**] with
family at the bedside including his wife and son. [**Name (NI) 6**] autopsy was
declined. Given death was within 24 hours of admission, the
medical examiner was notified but declined the case for further
review. The etiology of death was respiratory distress from lung
cancer.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Terazosin 4 mg PO HS
3. Acetaminophen 1000 mg PO Q8H
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. Amlodipine 5 mg PO DAILY
6. Gabapentin 800 mg PO TID
7. Docusate Sodium 100 mg PO BID
8. Ibuprofen 600 mg PO TID
9. Ipratropium Bromide Neb 1 NEB IH Q6H dyspnea, hypoxia
10. Levothyroxine Sodium 225 mcg PO DAYS (SA)
11. Levothyroxine Sodium 150 mcg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR)
12. Lidocaine 5% Patch 1 PTCH TD DAILY
13. Mucinex *NF* (guaiFENesin) 600 mg Oral [**Hospital1 **] Reason for
Ordering: metastatic lung cancer and dysphagia to liquid
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 40 mg PO DAILY
16. Senna 1 TAB PO BID:PRN constipation
17. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
18. Benzonatate 100 mg PO TID:PRN cough
19. OxycoDONE (Immediate Release) 5 mg PO Q4H pain
Pt may refuse do not wake at 4 am. hold for over sedation or RR
< 12
20. OxycoDONE (Immediate Release) 5 mg PO Q2H:PRN pain
Hold for sedation or RR < 12.
fentanyl patch 50 mcg/hr
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
|
[
"V15.82",
"511.81",
"553.3",
"197.2",
"162.8",
"518.81",
"496",
"198.5",
"185",
"V10.87",
"244.0",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7907, 7916
|
5821, 6782
|
324, 332
|
7967, 7976
|
4820, 5798
|
4055, 4083
|
7875, 7884
|
7937, 7946
|
6808, 7852
|
8000, 8010
|
4098, 4801
|
3281, 3681
|
264, 286
|
360, 3262
|
3703, 3904
|
3920, 4039
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,269
| 157,868
|
36655
|
Discharge summary
|
report
|
Admission Date: [**2199-7-20**] Discharge Date: [**2199-9-17**]
Date of Birth: [**2143-3-14**] Sex: M
Service: SURGERY
Allergies:
Olanzapine / Ciprofloxacin
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
mandible fracture s/p fall
Major Surgical or Invasive Procedure:
1. Open reduction and internal rigid fixation of R and L
mandible
2. Extraction of teeth numbers 2, 12, 15 and 22
3. Tracheostomy.
4. Percutaneous endoscopic gastrostomy converted to open
[**Last Name (un) **] gastrostomy.
History of Present Illness:
56 yo male with h/o of HTN and ETOH abuse presented to [**Hospital1 18**] ED
from an area hospital with bimateral mandible fractures s/p
?syncopal episode and fall onto face from chair to concrete. +
LOC and no recall of event. Reportedly he consumes [**1-4**] pint of
alcohol daily and had been drinking normal amount when fell. No
history of seizures or alcohol withdrawal.
Past Medical History:
HTN
ETOH abuse
Social History:
smokes cigarrettes
alcohol abuse
no family or friends to sign for patient
Family History:
None known
Physical Exam:
Upon admission:
Vitals: 100.5 106 109/84 16 98%RA
Gen: unkempt older man in NAD
HEENT: PERRL, EOMI, +sceral icterus, no occiput injury or
tendernes, marked swelling and tenderness of lower jaw and lips
with bleeding from tongue and mouth with small lacertaion on
anterior surface of tonque, no teeth, unable to protrude toungue
from mouth, swallowing without difficulty, no stridor. Not able
to visualizeze L tympanic membrane secondary to wax; right
tympanic membrane with blood in canal and possible ruptured
membrane.
CV: RRR
Lungs: CTAB
Abd: soft, NT/ND
ext: no deformities, 2+ DP/PT b/l, no tenderness, no edema
neuro: alert and oriented x 2 (Got month wrong). CN II-XII
grossly intact
Pertinent Results:
[**2199-7-19**] 06:34PM GLUCOSE-124* UREA N-27* CREAT-1.2 SODIUM-141
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-17* ANION GAP-20
[**2199-7-19**] 06:34PM WBC-11.3* RBC-3.18* HGB-10.7* HCT-32.6*
MCV-103* MCH-33.5* MCHC-32.7 RDW-13.4
[**2199-7-19**] 06:34PM PLT COUNT-154
[**2199-7-19**] 06:34PM PT-12.0 PTT-23.3 INR(PT)-1.0
[**2199-7-19**] 06:29PM LACTATE-1.6
[**2199-7-19**] 06:34PM ASA-NEG ETHANOL-61* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2199-7-20**]
1. Head CT demonstrate no acute intracranial process. There is
mild atrophy,
and scattered lacunar infarcts. There is no hemorrhage, mass
effect, or
edema.
2. Cervical spine CT demonstrating no evidence for traumatic
injury,
including no fracture, subluxation, or prevertebral soft tissue
swelling.
3. Facial bones CT demonstrating comminuted right mandibular
condyle
fracture, with additional non-displaced fracture of the right
mandibular
angle, and comminuted, slightly displaced fracture of the left
mandibular
body extending into the left mandibular angle. There are no
other facial
fractures identified.
4. Incidental note of paraseptal emphysema, large tracheal
diverticulum, and dense atherosclerotic disease involving the
carotid bulbs and
supraclinoid/cavernous internal carotid arteries. There is a
small amount of fluid in the right mastoid air cells.
[**2199-8-28**] ECHO
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
LV wall thickness. Top normal/borderline dilated LV cavity size.
Severe global LV hypokinesis. Transmitral Doppler and TVI c/w
Grade III/IV (severe) LV diastolic dysfunction. No resting LVOT
gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Severe global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild (1+) MR. LV inflow pattern c/w restrictive filling
abnormality, with elevated LA pressure.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Large left pleural effusion.
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. There is severe global left
ventricular hypokinesis (LVEF = 15 %). Transmitral Doppler and
tissue velocity imaging are consistent with Grade III/IV
(severe) LV diastolic dysfunction. The right ventricular cavity
is mildly dilated with severe global free wall hypokinesis. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. Moderate [2+] tricuspid regurgitation is seen.
[**2199-9-2**] MRA Brain
IMPRESSION:
1. Study limited by motion artifact, however, no evidence for
infarction.
2. Relative paucity of distal M2 branches of right MCA likely
due to motion artifact. However if clinically indicated CTA can
be performed for further evaluation.
Brief Hospital Course:
He was admitted to trauma service for management of pain and
mandible fracture. His imaging from the outside hospital
included a head CT which demonstrated no acute intracranial
process with scattered lacunar infarcts; C-spine CT was negative
for acute injury and facial bone CT showed communi [**Male First Name (un) **] right
mandibular condyle fracture, displaced fracture of left condyle.
ECG on admission revealed sinus tachycardia and a left
bundle-branch block. This remained unchanged with serial EKG's
throughout admission.
Neurology was consulted to work up his possible seizures vs
syncopal event leading to his fall. It was felt that because of
lack of post-ictal fatigue that seizure was unlikely cause;
rather his alcohol intoxication was likely more of a factor. A
syncopal event could not be completely ruled out. The
recommendations were to check orthostatics, consider routine
EEG, continue to monitor on telemetry, check echocardiogram
(ECHO showed dilation of RA and LV and ventricular hypokinesis
(LVEF = 25%)) and not to rule out ETOH as cause of fall.
At 2200 on HD1 he was noted to be actively withdrawing from
alcohol with tachycardia, elevated blood pressure, agitation,
and tremors. He was transferred to the ICU for closer
monitoring and adjustment of his CIWA scale.
On HD3 he was intubated due to worsening oxygenation. He was
found to have RLL infiltrate possibly related to aspiration
pneumonia. He was cultured and put on vancomycin, cefepime, and
Flagyl. Fentanyl and versed drip were started. He required
transfusion with PRBC's for falling hematocrit. (Last Hct on [**9-5**]
was 29)
On HD6 patient had open reduction and internal rigid fixation of
an open comminuted left mandibular body fracture and closed
right mandibular angle fracture by Dr. [**First Name (STitle) **].
He was noted with intermittent fevers; cultures (sputum, blood,
urine) negative at HD8. Antibiotics were stopped and he
underwent a bronchoscopy to send BAL for culture. He was noted
with fever spike with stopping of antibiotics and so they were
restarted.
Multiple attempts were made to wean him from ventilator support
but were unsuccessful. Because there were no immediate family or
friends to give consent for tracheostomy guardianship was
pursued. Once this was obtained a tracheostomy and gastric tube
placement was performed. Tube feedings initiated on
postoperative day 1.
He was eventually weaned from ventilator; sputum cultures grew
out coag negative staph and enterococcus species for which he
was treated with vancomycin and cefepime for 7 days. A PICC line
was placed for this therapy. During this treatment, he WBC
normalized and he was transferred to the floor tolerating trach
mask.
Once on the nursing unit he was noted with what was thought to
be runs of ventricular tachycardia. Cardiology was then
consulted and upon further ECG examination it was felt that it
was more consistent with left bundle branch block. Several
recommendations were made pertaining to his medications which
included stopping antipsychotic which cause prolongation of QT
interval. He was continued on his ACE and beta blockade.
Electrolytes were monitored and repleted accordingly.
He underwent evaluation of Physical, Occupational and Speech
therapy during his stay. He was initially recommended for rehab
after acute hospital stay but because of insurance barriers he
was unable to get into a rehab facility and continued his rehab
here. He underwent a swallow evaluation due to dysphagia and was
found to initially be at risk for aspiration and so he was
placed on ground diet and thickened liquids. His diet was
eventually advanced and he was able to tolerate soft diet due to
absent teeth and thin liquids.
He was followed by Social work closely throughout his hospital
stay for counseling, emotional support and for assistance with
finding a suitable shelter for him to go to given his reports of
being homeless. A shelter in the [**Hospital1 487**] area was found and he
was discharged there with instructions for follow up.
Medications on Admission:
MVI
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) MG PO every 4-6 hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Fall
Bilateral Mandibular fractures
Respiratory failure
Left bundle branch block
Delirium tremors
Rib fractures (left 6,7)
Liver contusion
C. difficile colitis
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
headaches, drainage from your wounds, chest pain, shortness of
breath, nausea, vomiting, diarrhea and/or any other symptoms
that are concerning to you.
The wound on the front of your neck from the tracheostomy will
heal completely over the next 1-2 weeks. If you notice that it
is not closing after 2 weeks please call the Trauma clinic at
[**Telephone/Fax (1) 2359**] to be seen.
It is important that you do not drink or take illicit drugs.
Followup Instructions:
Follow up in [**3-6**] weeks with Dr. [**Last Name (STitle) **], Trauma Surgery, call
[**Telephone/Fax (1) 2359**] for an appointment.
Follow up in [**3-6**] weeks with Dr. [**First Name (STitle) **], OMFS for your mandible
fracture and postoperative evalaution. Call [**Telephone/Fax (1) 55393**] for an
appointment.
Completed by:[**2199-9-25**]
|
[
"807.02",
"041.19",
"425.5",
"426.3",
"303.00",
"518.5",
"291.0",
"V60.0",
"348.39",
"802.29",
"E935.2",
"507.0",
"802.38",
"263.8",
"041.04",
"285.1",
"305.1",
"521.00",
"571.3",
"V15.88",
"997.31",
"780.2",
"008.45",
"787.20",
"E884.2",
"401.9",
"V85.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.19",
"31.1",
"38.93",
"96.72",
"96.04",
"76.76",
"43.19",
"96.6",
"33.24",
"76.92"
] |
icd9pcs
|
[
[
[]
]
] |
10014, 10020
|
5392, 9447
|
313, 542
|
10252, 10332
|
1837, 5369
|
10888, 11238
|
1093, 1105
|
9501, 9991
|
10041, 10231
|
9473, 9478
|
10356, 10865
|
1120, 1122
|
247, 275
|
570, 948
|
1136, 1818
|
970, 986
|
1002, 1077
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,274
| 145,920
|
54928
|
Discharge summary
|
report
|
Admission Date: [**2123-9-7**] Discharge Date: [**2123-9-11**]
Date of Birth: [**2042-11-17**] Sex: M
Service: MEDICINE
Allergies:
Aleve / Gemfibrozil / Lescol / Motrin
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
OSH transfer for CHF/NSTEMI
Major Surgical or Invasive Procedure:
cardiac catheterization with drug eluting stents x2 to left
anterior descending artery
History of Present Illness:
80 y/o M with PMH of DMII, [**Hospital **] transferred from OSH for
management of NSTEMI and CHF. He originally presented to OSH
from [**Hospital3 **] facility with SOB. His symptoms started on
Saturday when he was moving from his home to an [**Hospital3 **]
facility. He started having chest burning heaviness lasting
about an hour associated with some SOB that eventually subsided.
He thought that this was d/t GERD and took some tums. On
Monday, he reported his sxs to the NP[**MD Number(3) 31663**] new [**Hospital3 **]
facility, who noted bilateral LE edema and advised him to sleep
on 2 pillows that night and she set him up for a EKG this
morning. However, Monday evening he noticed he was SOB around
12am when he got out of bed to turn on the air conditioner. He
went back to bed and at 3am he was still SOB, when his symptoms
persisted he called his daughter at 5am and took a baby aspirin.
[**Name2 (NI) **] activated the help code at his assisted facility who called
the ambulance for transport to the OSH. At OSH he was found to
have a troponin I of 0.38, CR 1.3, hyponatremia to 129, and CXR
showed infiltrative changes at both lung bases with minimal
fluid. EKG showed NSR with RBBB, non-specific ST changes and
some ST depressions. He was treated with DuoNebs, heparin gtt,
nitro gtt was transferred to [**Hospital1 18**] for further management.
.
In the ED, initial vitals were 97.1 79 154/74 18 90% 4L
Labs and imaging significant for worsening interstitial edema
compared to OSH CXR. Patient given Lasix 20mg IV with 900cc
urine output. He required bipap for RA sats in low 80s. EKG
showed RBBB and TWI precordially and <1mm STE in AVR. Repeat
troponin was 0.2.
Vitals on transfer were 96.6 ??????F (35.9??????C) (Axillary), Pulse: 54,
RR: 18, BP: 118/53,(nitro o.28mcg/kg)
On arrival to the floor, patient was resting comfortable in NAD.
He states that he endorses PND. He sleeps on 1 pillow, although
he slept on 2 pillows last night on the advice of a NP[**MD Number(3) 31663**]
[**Hospital3 **] facility. He has been using a cane to ambulate
over the last few weeks (more per his family) due to low back
pain and has a hx of arthritis. In addition, over the last year
he has assumed full care of his wife who has worsening dementia
and has been eating microwaved meals with high salt content
since that time.
Of note, EKG from PCP [**Last Name (NamePattern4) **] [**2122-7-14**] showed Sinus bradycardia (49),
normal axis, Q waves in II, III, aVF, and non-specific TWI,
RBBB.
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, 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, palpitations, syncope or presyncope.
Past Medical History:
PMH:
Unspecified Anemia
BPH w/o urinary obstruction
Carotid Artery Stenosis
Cervical Radiculopathy
Chronic Kidney Disease, Stage I
CAD
Dermatitis
Diabetes Mellitus, II
Esophageal Reflux
Essential Hypertriglyceridemia
Hearing Loss
Liver Enlargement
Hypertension
Murmur
Overweight
Proteinuria
RBBB
Sciatica
Vitamin D Deficiency
PSH:
Carpel Tunnel ~[**2118**]
Social History:
Retired Businessman. Recently moved to New [**Hospital3 400**] so
that his wife with Dementia can have 24hr care. Smoked 1PPD for
20 years, quit 25 years ago. Drinks 1 bourbon per day. Denies
illegal drug use.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **]:
home [**Telephone/Fax (1) 112180**] dtr
cell [**Telephone/Fax (1) 112181**]
Family History:
Son had MI at 52
Mom died in sleep at 83
Father - emphysema
Physical Exam:
ADMISSION:
PE: 97.9 134/58 71 22 93%5L
APPEARANCE: WDWN in 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 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use.
CTAB: b/L 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.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
DISCHARGE:
PE: 98.3 131/55 64 18 99%RA
I/O: 730/700
APPEARANCE: WDWN in 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 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur No thrills, lifts.
No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use.
CTAB: b/L 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.
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:
Admission Labs:
[**2123-9-7**] 10:50AM PT-12.6* PTT-150* INR(PT)-1.2*
[**2123-9-7**] 10:50AM PLT COUNT-270
[**2123-9-7**] 10:50AM NEUTS-85.5* LYMPHS-9.8* MONOS-3.3 EOS-0.9
BASOS-0.6
[**2123-9-7**] 10:50AM WBC-10.0 RBC-3.35* HGB-11.2* HCT-32.7* MCV-98
MCH-33.3* MCHC-34.1 RDW-13.8
[**2123-9-7**] 10:50AM HDL CHOL-53 CHOL/HDL-2.3 LDL([**Last Name (un) **])-64
[**2123-9-7**] 10:50AM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.9
CHOLEST-122
[**2123-9-7**] 10:50AM CK-MB-6
[**2123-9-7**] 10:50AM cTropnT-0.21*
[**2123-9-7**] 10:50AM CK(CPK)-145
[**2123-9-7**] 10:50AM estGFR-Using this
[**2123-9-7**] 10:50AM GLUCOSE-151* UREA N-27* CREAT-1.2 SODIUM-133
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-22 ANION GAP-21*
[**2123-9-7**] 11:10AM URINE MUCOUS-RARE
[**2123-9-7**] 11:10AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2123-9-7**] 11:10AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2123-9-7**] 11:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2123-9-7**] 05:40PM PT-13.2* PTT-150* INR(PT)-1.2*
[**2123-9-7**] 05:40PM %HbA1c-5.5 eAG-111
[**2123-9-7**] 05:40PM CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-1.7
[**2123-9-7**] 05:40PM CK-MB-5 cTropnT-0.25*
[**2123-9-7**] 05:40PM GLUCOSE-175* UREA N-26* CREAT-1.1 SODIUM-131*
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-22 ANION GAP-17
.CXR [**2123-9-7**]:
Bilateral perihilar and basilar opacities, compatible with
Preliminary Reportpulmonary edema or bilateral pneumonia in the
correct clinical setting.
DISCHARGE:
[**2123-9-10**] 07:40AM BLOOD WBC-7.7 RBC-2.98* Hgb-9.8* Hct-29.5*
MCV-99* MCH-32.8* MCHC-33.1 RDW-13.9 Plt Ct-268
[**2123-9-10**] 07:40AM BLOOD PT-11.9 PTT-28.3 INR(PT)-1.1
[**2123-9-11**] 07:40AM BLOOD UreaN-22* Creat-1.2 Na-134 K-4.2 Cl-97
Brief Hospital Course:
80 y/o M with multiple cardiac risk factors including
long-standing DM, HTN, HPL and CAD with prior hx of cardiac
ischemia presenting with 1 episode of chest burning and
heaviness and 3 day hx of worsening SOB found to have elevated
troponin and pulmonary edema likely new onset CHF in the setting
of an NSTEMI. Contributing factors include multiple cardiac
risk factors in addition to increased salt intake over the last
year and stress this past weekend in the setting of him moving
from his home to an [**Hospital3 **]. In addition, his wife has
been in and out of the hospital over the last 3 weeks which has
been a source of stress for him as well.
#NSTEMI: Pt was taken to to cath on [**9-8**], given high risk cad
decomp hf, low ef, potentialy viable vasculature - RHC show PA
sat 52%, CO 4.2, CI 2.3, wedge 35, PA pressure 66/34; LHC -
totally occluded RCA (old with collaterals), LAD 90% prox, 70%
mid lesion, very calcified - needed rota - and received 2 DES to
LAD. Post procedure he was hemodynamically stable with no
evidence of distal embolization.
We started Carvedilol 25mg PO BID, Atorvastatin 80mg PO daily,
plavix 75mg PO daily(after loading with 300mg pre-cath),
Lisinopril 40mg PO daily and ASA 325mg daily. We also added
back his home dose of Cardura at 8mg PO for both blood pressure
control and BPH. He will follow up Dr. [**Last Name (STitle) **] in cardiology on
[**10-1**] as an outpatient further management of post NSTEMI
medications.
#CHF: Echo on admission showed moderately depressed LV function
with EF 35-40%, with inferior/inferoseptal akinesis and
anterior/anteroseptal. He was diuresed with Lasix IV with good
response and goal urine output 100cc/hr. He was started on
Lisinopril 40mg PO daily and carvedilol 25mg PO BID with good
blood prssure control. He will follow up with cardiology as an
outpatient for further titration of HF medications.
#RESPIRATORY DISTRESS: likely [**2-11**] new onset CHF with pulmonary
edema on CXR. He wasa treated with Lasix IV for diuresis with
good response and urine output of 100cc/hr. Upon admission to
the CCU he was descalated from BIPAP to Nasal cannula and had
98-99% O2 saturation on RA by the day of discharge.
#DM: Controlled on Metformin alone, Last A1c 5.6% per patient
Metformin was held on admission. A1C checked on admission was
5.5%. His renal function remained stable during admission with
a creatinine ranging from 1.1-1.2. He was placed on insulin sc
during this admission and was instructed to restart metformin
upon discharge.
Transitional issues:
Mr. [**Known lastname 112182**] will followup with Dr. [**Last Name (STitle) **] in cardiology
([**2123-10-1**]) for repeat echo and further management of NSTEMI
long-term effects. In addition, he will be scheduled to see his
new PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as an outpatient for hospital follow-up.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient Outside records.
1. Aspirin 162 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Doxazosin 8 mg PO HS
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. melatonin *NF* 3 mg Oral HS
8. Multivitamins 1 TAB PO DAILY
9. Simvastatin 10 mg PO DAILY
10. Calcium Carbonate 500 mg PO BID
11. NIFEdipine 30 mg PO Q8H
12. Vitamin D [**2111**] UNIT PO DAILY
13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Lisinopril 40 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
8. Calcium Carbonate 500 mg PO BID
9. Doxazosin 8 mg PO HS
10. Fish Oil (Omega 3) 1000 mg PO BID
11. melatonin *NF* 3 mg Oral HS
12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Vitamin D [**2111**] UNIT PO DAILY
15. Outpatient Lab Work
Please check chem-7 on Tuesday [**9-14**] with results to Dr.
[**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 6662**]
Fax: [**Telephone/Fax (1) 13889**]
ICD 9: 428
16. Nitroglycerin SL 0.4 mg SL PRN chest pain
RX *nitroglycerin 0.4 mg 0.4 mg sublingually every 5 minutes for
3 [**Telephone/Fax (1) 4319**] Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] home care
Discharge Diagnosis:
Primary: Acute systolic congestive heart failure
Non ST elevation myocardial infarction
.
Secondary: Diabetes mellitus
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 112182**],
.
It was a pleasure taking care of you here at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You were admitted to [**Hospital1 18**] on [**9-7**] for
a heart attack and congestive heart failure. It is thought that
you had the heart attack a few days before you came to the
hospital and an echocardiogram shows an area of your heart that
is not moving well. Because your heart was weak, you had fluid
that backed up in your lungs and you needed some support for
your breathing until we were able to remove the fluid. A cardiac
catheterization showed a blockage in your left heart artery and
two drug eluting stents were placed to keep the artery open. You
will need to take aspirin and Plavix (clopidogrel) every day
without fail to prevent the stents from clotting off and cuasing
another heart attack. Do not stop taking aspirin and Plavix or
miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **], your new Cardiologist, says that
it is OK. You are now doing well and have been started on many
new medicines to help your heart recover from the heart attack.
.
You will need to watch yourself very closely to make sure the
fluid does not return. Monitor your breathing and any swelling
in your legs. Please weigh yourself daily in the morning before
breakfast and record the weight. Call Dr. [**Last Name (STitle) **] for any
symptoms of fluid return or if your weight increases more than 3
pounds in 1 day or 5 pounds in 3 days. Your weight at discharge
is 168 pounds and this should be considered your ideal weight.
.
We would like you to have labwork done on Tuesday to check your
salts and kidney fuction with all the the new medicine we
started.
Followup Instructions:
Department: ADULT SPECIALTIES
When: FRIDAY [**2123-10-1**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 21928**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Name: [**Last Name (LF) 1576**],[**First Name3 (LF) 1575**]
Location: BIDHC [**Location (un) **] SUBACUTE CARE EXTENDED COMMUNITY
PRACTICE
Phone: [**Telephone/Fax (1) 14405**]
*Your primary care provider will visit you at home within 72
hours of being discharged from the hospital. If you have any
questions or concerns please call the office.
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66,213
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Discharge summary
|
report
|
Admission Date: [**2136-1-6**] Discharge Date: [**2136-1-8**]
Date of Birth: [**2057-2-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / Sulfa (Sulfonamide Antibiotics) /
Cephalosporins / Macrodantin / Clindamycin / Hayfever / Ativan
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Altered Mental Status, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 year old female with history of chronic pain on narcotics,
lumbar spinal stenosis, L2 discectomy, chronic venous stasis
dermatitis, chronic R heel ulcer now healed, deconditioning and
recent admit for lower extremity edema, aspiration pneumonitis,
and UTI returning with generalized weakness and RUE swelling.
She was sent in from [**Hospital3 2558**] with nursing noting mental
status changes and lethargy. Notes point out right upper hand
swelling. BP at the time noted to be 90/55 with temp 98.5. Per
report this right hand swelling was of four days duration but
gradually worsened. Denies erythema, warmth, pain, or prior
swelling like this. Denies f/c, -n/v/d, -CP/SOB/cough, -abd
pain, -dysuria, -focal n/t/w. No trauma. No exacacerbating or
relieving factors.
.
In the ED, initial VS were: T 97 80 146/76 18 97% RA. Physical
exam with HDS, AAOx3, no evidence of lethargy, mild edema of the
right hand. Differential diagnosis for her decreased energy and
concern for lethargy in the ED was recurrent common infections
versus metabolic versus electrolyte abnormality. In regard to
swollen right hand, there are no features to suggest neuro,
motor, vascular deficits, no underlying bony tenderness; they
felt this may be a possible DVT. Right upper extremity
ultrasound: no dvt. Labs were notable for an elevated d-dimer
and a lactate of 2. CXR was done. CTA was obtained which
identified large right main pulm artery embolus. She was
started on a heparin gtt. UA was dirty and concerning for UTI.
Based on prior resistance to cipro and allergies she was given
gentamicin IV x1. Pt was admitted to the MICU based on the
extensive nature of the embolus.
Past Medical History:
HTN
Hyperlipidemia
Hypothyroidism
Chronic pain syndrome on narcotics
Spinal stenosis s/o lumbar fusion, L2 disectomy
Type II Diabetes, controlled w/o complications
Asthma with hospitalization in past, no hx of intubation
Chronic venous stasis
Chronic Anemia
Depression
Cervical spondylosis
Chronic shoulder pain/left rotator cuff tear
Chronic constipation
Metatarsal Fracture 3rd, 4th right
Social History:
Currently resides at rehab facility, was living in an apartment
with her husband prior to previous admission. Uses a walker to
ambulate. Has two children. No tobacco (quit 30 yrs ago), no
etoh or illicits.
Family History:
No known malignancies
Physical Exam:
Vitals: afeb 83 129/63 16 98% on RA
General: Alert, oriented, no acute distress, fatigued
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL 4mm
bilaterally
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM best heard
at RUSB, occaisional extra beats
Lungs: Clear to auscultation laterally and anteriorly, no
wheezes, rales, ronchi
Abdomen: soft, non-tender, distended, trympanetic, bowel sounds
present, no organomegaly
Ext: warm, well perfused, 2+ pulses, trace LE edema bilaterally,
right heel intact without breakdown
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
[**2136-1-6**] 04:50PM URINE RBC-0 WBC-61* BACTERIA-FEW YEAST-NONE
EPI-9
[**2136-1-6**] 05:15PM WBC-3.4* RBC-3.30* HGB-9.0* HCT-28.4* MCV-86
MCH-27.3 MCHC-31.7 RDW-15.8*
[**2136-1-6**] 05:15PM PLT COUNT-271
[**2136-1-6**] 05:15PM D-DIMER-3053*
[**2136-1-6**] 05:15PM GLUCOSE-157* UREA N-20 CREAT-0.7 SODIUM-136
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2136-1-6**] 09:10PM PT-11.5 PTT-23.5* INR(PT)-1.1
CT OF THE CHEST [**2136-1-6**]: A pulmonary embolism is noted within
the right main pulmonary vessel extending into the right upper
lobe pulmonary vessels. Bibasilar atelectasis is noted.
Mediastinal, axillary and hilar lymph nodes do not meet CT size
criteria for pathologic enlargement. The thoracic aorta shows no
evidence of acute aortic injury and dissection. There are
coronary atherosclerotic calcifications. No pericardial effusion
is noted. Mild interstitial changes are noted within the lungs.
The study is not optimized for subdiaphragmatic evaluation.
Within this
limitation, the upper abdominal structures appear unremarkable.
Visualized osseous structures show multilevel degenerative
changes with no
lytic or sclerotic lesions suspicious for malignancies.
IMPRESSION:
1. Right main pulmonary vessel embolus extending into the right
upper lobe
pulmonary vessels.
2. Bibasilar atelectasis.
3. Coronary artery calcifications.
Brief Hospital Course:
78 yo F hx chronic pain and multiple prior UTI's presents with
lethargy found to have a UTI and PE.
.
ACUTE
# UTI - Reported burning with urination and had a UA with 61
WBC, few bacteria, and 9 epis. Possibly dirty, but given her
history of recurrent E. coli UTIs in the past, decided to treat
it. She was initially given aztreonam but then switched to one
time dose of fosfomycin (she has extensive allergies and
fosfomycin has worked in the past). Her symptoms resolved.
# PULMONARY EMBOLISM - PE was likely an incidental finding on
CTA of the chest as she had no dyspnea, hypoxia nor tachycardia.
She remained completely asymptomatic in spite of her large R
main PE. No ECG changes were present. She was started on heparin
and warfarin then transitioned to lovenox and warfarin. She will
need followup of INR with cessation of lovenox once her INR is
therapeutic. The etiology of the clot is unclear but may be due
to malignancy given her age.
CHRONIC
# CHRONIC PAIN SYNDROME - continued oxycontin and oxycodone.
Continued bowel regimen incl colace, senna, miralax, lactulose
# DM: Metformin held while in house. Restarted no discharge.
Covered with ISS while in hour.
# HTN: continued lisinopril, metoprolol
# HL: continued rosuvastatin
TRANSITIONAL CARE
- INR should be monitored at least twice a week until
therapeutic between a range of [**2-3**]. Warfarin should be adjusted
accordingly. Lovenox should be discontinued when therapeutic.
- Unprovoked clot is concerning for malignancy, though she has
been somewhat sedentary given her chronic pain and
poly-pharmacy. If warranted, search for malignancy should be
pursued as an outpatient.
Medications on Admission:
1. metformin 750 mg Tablet ER 24 hr PO at bedtime, and 250mg at
5pm
2. fluticasone-salmeterol 250-50 mcg/dose 1 puff [**Hospital1 **]
3. levothyroxine 175 mcg Tablet PO 6 days/week: except on
saturday, with 100mcg on saturday.
4. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. iron 325mg daily
6. trazodone 100 mg Tablet PO HS
7. montelukast 10 mg Tablet PO DAILY
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler inh
q6h prn sob, wheezing
9. alprazolam 0.25 mg Tablet PO BID
10. docusate sodium 100 mg PO BID
11. senna 8.6 mg Tablet PO BID as needed for constipation.
12. Miralax 17 gram Powder in Packet PO once a day prn
constipation.
13. metoprolol tartrate 25 mg Tablet PO BID
14. fluticasone 50 mcg/Actuation Spray, Susp 2 sprays Daily.
15. gabapentin 300 mg Capsule PO Q12H
16. lidocaine 5 %(700 mg/patch) Adhesive Patch daily
17. rosuvastatin 5 mg Tablet PO daily
18. acetaminophen 500 mg Tablet 2 Tablet PO Q6H prn fever
19. lisinopril 10 mg Tablet PO DAILY
20. lactulose 10 gram/15 mL Solution 30ml PO once a day.
21. Vitamin B-12 1,000 mcg/mL 1000 mcg Injection once a month.
22. Vitamin D 50,000 unit Capsule PO once a week.
23. OxyContin 60 mg Tablet ER q8h
24. oxycodone 10 mg Tablet po q6h prn pain
Discharge Medications:
1. metformin 750 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO at bedtime: and 250mg at 5pm.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
3. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): except saturdays.
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO SATURDAYS
().
5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
7. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
10. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
15. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
16. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
18. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain.
20. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
21. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
22. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a month.
23. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
24. OxyContin 60 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO every eight (8) hours.
25. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
26. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
27. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
Pulmonary embolism
Urinary Tract Infection
SECONDARY:
Chronic pain
HTN
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 2405**],
You were admitted to the hospital with a urinary tract infection
and a clot in your lungs. We gave you antibiotics for your
urinary tract infection. We also gave you blood thinners to
treat your clot. You will likely need to continue on blood
thinners for 6 months.
Medication changes:
# START lovenox injections 80mg every 12 hours (blood thinner)
# START warfarin 5mg daily (blood thinner)
You will need to have your INR monitored twice weekly until we
can find the correct dose of warfarin for you.
Followup Instructions:
Please contact your primary care physician for followup in [**1-2**]
weeks.
|
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54,994
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3325
|
Discharge summary
|
report
|
Admission Date: [**2173-5-17**] Discharge Date: [**2173-6-4**]
Date of Birth: [**2107-3-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Worsening shortness of breathx 6 months
Major Surgical or Invasive Procedure:
Core valve placement
oropharyngeal laceration s/p 3 sutures
pulmonary intubation
History of Present Illness:
Mrs. [**Known lastname **] is a 66 year old woman with multiple medical
problems including CAD s/p DES to RCA in [**2172-11-28**], severe
aortic stenosis (valve area 0.5 cm2), recent DVT treated with
coumadin, and SLE who is transferred from [**Hospital3 3583**] CCU
for evaluation of severe aortic stenosis earlier this year.
.
Her cardiac history dates to [**2172-11-28**] for SOB when
diagnosed with severe CHF and aortic stenosis. She also
underwent a cardiac catherization at [**Hospital1 3278**] during that
admission, and had a DES placed to the RCA, which was
complicated by acute renal failure in the setting of contrast
load. She was deemed to be an
inoperable candidate by the cardiac surgeons at [**Hospital1 3278**].
.
She then presented to the [**Hospital3 3583**] ED on [**2173-2-20**] after
several days of increasing cough productive of sputum, fevers,
and worsening SOB. She was admitted to the CCU and treated for a
pneumonia with broad spectrum antibiotics,diuresed with lasix
gtt and developed acute renal failure (Cre1.9->3.3->2.3)renal
thought it was secondary to diuresis versus worsening aortic
stenosis and less likely lupus nephritis given negative
complement.
.
During her hospitalization in early [**Month (only) 547**], she was seen in
consultation with the [**Hospital1 18**] (Dr. [**First Name (STitle) **] cardiac surgery service
who deemed her an Extreme Risk surgical candidate due to
porcelain aorta. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] later concurred in his
findings.
.
She was re-admitted to [**Hospital3 3583**] on [**2173-3-21**] with
worsening of her shortness of breath and suspicion of pneumonia
secondary to her immunocompromised status. She was transferred
to the [**Hospital1 18**] for further evaluation and treatment of her CHF.
.
Due to her worsening renal function (creatinine = 3.3 mg/dl),
left and right heart diastolic heart failure, and shortness of
breath, balloon aortic valvuloplasty was performed on [**2173-3-25**] with a 22 mm and 23 mm aortic valvuloplasty balloons
without complications. The final aortic valve area was 0..86
cm2.
.
Following BAV, she symptoms improved and her creatinine fell to
1.8 mg/dL. She mobilized over 1 kg of fluid in a 24 hour
period. Her dyspnea is substantially improved. She was
discharged to home on daily furosemide.
.
She was readmitted [**4-12**] for CTA to complete her workup. Her
renal function remained stable.
.
She has continuted to have NYHA Class III symptoms with
exertion.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
Cardiac Cath at [**Hospital1 3278**] in [**11/2172**]: DES to RCA
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Severe Aortic Stenosis
Systemic Lupus Erythematosis
TIA
PVD (65% stenosis in carotid arteries)
HLD
L vocal chord dysfunction
GERD
COPD
MVR (mild)
DVT (s/p anticoagulation with coumadin discontinued
approximately three weeks ago in [**1-/2173**])
Carpal Tunnel Syndrome
CKD baseline Cre 1.2->1.7
Retrosternal calcification (chronic)
Social History:
Married. Retired hairdresser. Lives in [**Location 3320**].
-Tobacco history: 20 ppy smoking hx, quit 27 years ago
-ETOH: [**11-29**] EtOH drinks weekly
-Illicit drugs: denies
Family History:
Father died at 75 from CAD. Aunt died of MI at 49. Sister with a
pacemaker.
Physical Exam:
General: Alert pleasant cauc female in NAD at rest.
Skin: pale,tan. Upper ext. ecchymotic. Turgor poor.
HEENT: Normocephalic, edentulous. Anicteric, conjunctiva pale.
Neck: (+)JVD. (+)bilat carotid bruit vs. murmer.
Chest: No obvious deformity. Rales bilaterally one third way
up.
Heart: RRR. III/VI Murmer RSB, radiating throughout.
Abdomen:Soft,NT/ND, (+)BS x 4 quad.
Extremities: 2+ pitting lower extemity edema bilaterally, healed
scarring bilat calf ulcerations. Feet warm.
Neuro: A+O x 3, pleasant, repositions self. Gross FROM. Denies
pain.
Pulses: 1+ peripheral pulses.
.
On Discharge:
Gen: alert, oriented, NAD
HEENT: supple, bounding jugular veins bilat when lying down.
CV: RRR, no murmurs
RESP: clear bilat
ABD: soft, pos BS, NT, no tenderness
EXTR: left arm with extensive old ecchymosis extending down the
back, mild swelling and tenderness at left axilla. Stable L
groin hematoma with old ecchymosis along the medial thigh and
extending laterally along lower back. [**11-29**]+ pitting edema from
mid shins bilat L>R. Pt states edema always worse on left.
Skin: stage 1 on coccyx, skin tear as described above
Pertinent Results:
Admission labs:
[**2173-5-17**] 12:44PM BLOOD WBC-8.6 RBC-2.91* Hgb-8.4* Hct-26.2*
MCV-90 MCH-29.0 MCHC-32.1 RDW-18.0* Plt Ct-187
[**2173-5-17**] 06:00PM BLOOD PT-11.8 PTT-24.0 INR(PT)-1.0
[**2173-5-17**] 12:44PM BLOOD Glucose-103* UreaN-59* Creat-1.8* Na-140
K-4.4 Cl-109* HCO3-20* AnGap-15
[**2173-5-17**] 12:44PM BLOOD ALT-21 AST-21 CK(CPK)-22* AlkPhos-127*
TotBili-0.3
[**2173-5-17**] 12:44PM BLOOD CK-MB-2 proBNP-[**Numeric Identifier 15453**]*
[**2173-5-18**] 02:04PM BLOOD Calcium-6.6* Phos-8.6*# Mg-1.6
[**2173-5-17**] 12:44PM BLOOD %HbA1c-5.0 eAG-97
.
Discharge Labs:
[**2173-6-4**] 05:27AM BLOOD WBC-7.1 RBC-2.48* Hgb-7.6* Hct-23.5*
MCV-95 MCH-30.5 MCHC-32.2 RDW-17.8* Plt Ct-258
[**2173-6-4**] 05:27AM BLOOD Glucose-74 UreaN-53* Creat-1.8* Na-143
K-4.3 Cl-114* HCO3-22 AnGap-11
[**2173-6-4**] 05:27AM BLOOD PT-17.0* INR(PT)-1.5*
.
EKG [**5-17**]: Sinus rhythm. Left ventricular hypertrophy with
secondary repolarization abnormalities. Compared to the previous
tracing of [**2173-4-14**] the findings are similar.
.
[**5-18**]: ECHO Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. An aortic CoreValve prosthesis is present. The
prosthetic aortic valve leaflets appear normal. A mild to
moderate ([**11-29**]+) paravalvular aortic valve leak is present. The
mitral valve leaflets are mildly thickened. There is severe
mitral annular calcification. Moderate (2+) mitral regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: Normally-seated CoreValve aortic prosthesis with
mild to moderate paravalvular leak. Moderate mitral
regurgitation. Normal global and regional biventricular systolic
function.
Compared with the prior study (images reviewed) of [**2173-3-26**],
severely stenotic native aortic valve has been replaced with a
CoreValve prosthesis.
.
[**5-18**] CXR: In comparison with study of [**5-17**], CoreValve is now in
place in the aorta. No evidence of pneumothorax or acute
pneumonia or definite pulmonary vascular congestion. Right IJ
pacer extends to the region of the apex of the right ventricle.
.
[**6-3**] Gastric Motility Test: Normal esophageal motility, limited
study.
.
[**5-28**] LUE U/S 1. Resolution of previously visualized DVT in one of
the two brachial veins with no evidence of residual DVTs in the
left upper extremity. 2. Left axillary hematoma with expected
evolutionary changes.
.
[**5-21**] LUE U/S 1. Deep vein thrombosis seen within one of the two
brachial veins. Normal flow is seen in the remainder of the
veins of the left arm.
2. Left axillary hematoma, which appears slightly smaller on
today's exam,
although note is made that a different technique was used.
Brief Hospital Course:
66 year old female with critical aortic stenosis s/p coreValve
percutaneous aortic valve replacement with a 26 mm CoreValve
with course complicated by left arm and left groin hematoma,
hypopharyngeal laceration which was sutured and hypotension
requiring pressors.
.
ACTIVE ISSUES
.
# Critical aortic stenosis s/p CoreValve: Pt with hx of critical
AS (valve area 0.5) admitted for elective core valve placement
[**5-18**]. Pt with successful core valve placement as well as R
common femoral art PTCA (70% lesion). Transferred to the CCU
with R IJ w/ temporary pacing wire for 48 hours, L groin 8Fr
venous sheath which was removed after 24h. Pt received 190cc
contrast, 3 liters IVF, 4units PRBC??????s, 1Gm vancomycin, 2 doses
Kefzol, 100mg hydrocortisone and 50mcgs Fentanyl. Pt required
Neo 2mcg/kg/min for hypotension 2/2 L groin bleed. While in CCU
pt required two additional units of pRBC??????s for L thigh hematoma
and phenylephrine gtt to maintain SBP >110. Phenylephrine gtt
was weaned off [**5-19**] with light fluid boluses and continued
transfusions and fentanyl given for groin/abd discomfort related
to hematoma. Aspirin and plavix will need to be continued for 3
months after CoreValve placement.
.
# Hypotension: Intra-op and immediately post-op, pt was
hypotensive and pressor dependent. Etiology likely cardiogenic.
Differential also includes adrenal insufficiency in setting of
surgical stress in patient on chronic steroids. Pt given stress
dose steroids and tapered with IV methylprednisone to 50 mg q8,
then transitioned back to her home dose of 5 mg PO of prednisone
daily. She was successfully weaned off all pressors by [**5-19**].
.
# Hypertension: Pt's blood pressures remained elevated to the
160s for most of her stay, sometimes going as high as 190s. We
resumed all of her home medications and up-titrated her
hydralazine. Would recommend re-initiation of an ACE/[**Last Name (un) **] once
pt's kidney function as stabilized.
.
# Oropharyngeal laceration: Pt sustained oropharyngeal
laceration during intraoperative TEE. ENT placed dissolvable
sutures with resolution of bleeding -sutures have since
dissolved. Pt initially started on IV clindamycin but switched
to po amoxicillin when able to tolerate. Pt completed her course
of amoxicillin prior to discharge. Pt was evaluated by
speech/swallow and ENT and was given permission to wear her
dentures so that her diet could be advanced. Pt can follow up
with ENT if needed after discharge in clinic ([**Telephone/Fax (1) 41**].
.
# [**Last Name (un) **] on CKD: On admission, her baseline creatinine of 1.8
increased to 2.9, likely due to hypotension during the procedure
as well as the large load of contrast (190 mL) she received
without pre-cath mucomyst. Pt's creatinine continued to trend
upward, peaking at 4.8, so renal was consulted. They followed
the patient and temporarily initiated phosphate binders, sodium
bicarbonate and low potassium diet, but ultimately felt
initiation of HD was not required after pt had good response to
IV lasix. Pt's urine output remained robust and her creatinine
trended down steadily to 1.8 at the time of discharge.
.
# Left groin hematoma: Reversed in the OR with protamine
sulfate. Required 4u transfusions pRBCs. Initially, pt's left
thigh was large and quite tender with limited range of motion
though she had palpable pulses throughout. By discharge pt's
left thigh was still larger than her right though significantly
less tender than before and with improved range of motion.
.
# Left axillary hematoma: Pt's axillary arterial line was pulled
with subsequent development of a large hematoma under her left
arm, extending to her forearm and down the side of her back to
her waist. Pt began complaining of pain in the left arm on [**5-20**]
and ultrasound showed development of a hematoma at the site of
the line removal. On [**5-23**], she was noted to have enlargment of
her arm hematoma with increased pain, swelling and edema in
addition to a significant Hct drop to 20.8 from 28.6. Pt
continued to have good pulses so concern for compartment
syndrome was low. Pt remained hemodynamically stable and
responded well to pRBC transfusion, ultimately requiring 4u over
the next several days. The pain, erythema, and questionably
demarcated appearance of the hematoma, particularly over the
forearm raised suspicion for cellulitis so patient was started
on vancomycin for an eight day course, which she has completed.
The left arm hematoma and left flank ecchymoses seem to be
resolving at the time of discharge.
.
# Left arm DVT: Ultrasound of the L arm on [**5-21**] showed interval
development of a left-sided DVT, likely due to compression and
stasis from the neighboring hematoma. She was started on
anticoagulation with coumadin bridged with heparin. Pt's INR has
been difficult to regulate, going up to 5.6 on [**6-1**] with some
complaints of bleeding in her mouth, so pt received 0.5 mg
vitamin K. At discharge pt was subtherapeutic on coumadin.
Difficulty regulating her INRs likely due to her poor
nutritional status. Follow-up ultrasound on [**5-29**] ultimately
showed resolution of the left arm DVT but it is still
recommended that pt continue coumadin for a one month course.
.
# Nausea: Unclear etiology though likely related to a
combination of mood/anxiety, pain, and medication effect, as it
often happens in the setting of taking medication. Pt's nausea
better controlled now with IV Zofran three times a day prior to
meals and medications. It was also suggested that she drink
protein shakes prior to taking her medications. GI was consulted
to investigate potential causes of patient's nausea but LFTs
were within normal limits and barium swallow evaluation were
both negative. Nausea had been a limiting factor for quite some
time during patient's stay as she was not eating well and her
nutritional status was poor at baseline. On discharge, pt's
appetite had improved significantly with some relief of her
nausea though she was still receiving IV Zofran three times a
day. We would like for patient to be transitioned off of IV as
soon as possible and to PO Zofran medication for nausea, so her
PICC can be removed.
.
# Abdominal pain: Likely from left groin hematoma vs
musculoskeletal pain from lying down during the procedure.
Differential also includes mesenteric ischemia but unlikely with
improving lactate and abdominal pain. Also concerning for
pancreatitis vs gallbladder/liver etiology which are unlikely
with normal liver enzymes and lipase. Pt no longer complaining
of pain at time of discharge.
.
CHRONIC ISSUES
.
# Coronary artery disease s/p DES to RCA in 01/[**2172**]. Stable and
continued on metoprolol, aspirin, plavix and simvastatin.
.
# Iron deficiency anemia: Continued iron.
.
# Lupus: Stable on home dose prednisone.
.
# COPD: Stable on home albuterol/ipratropium
.
TRANSITIONAL ISSUES
Patient's nutritional status remains poor (albumin of 2.2)
though she seems to respond well to protein shakes. Nausea
remains an issue for her - currently she requires IV Zofran
three times a day. However, given pt's fragile vasculature and
her history of significant hematomas, would prefer that patient
will be transitioned to PO Zofran as soon as possible so her
PICC can be discontinued. Also, we recommend re-starting an
ACE/[**Last Name (un) **] once her creatinine can tolerate it as her blood
pressures remain difficult to control even on her current
regimen. Patient should follow-up after discharge with
cardiology, renal, and ENT (see above for office number for
ENT). Pt will need to be on coumadin for her DVT for a one month
course.
Medications on Admission:
Amlodipine 10 mg PO daily
ASA 81 mg PO daily
Prednisone 5 mg OPO daily
Metoprolol succinate 100mg q24h
Plavix 75 mg PO daily
Protonix 40 mg PO daily
albuterol sulfate 1-2puffs q4h prn SOB
Calcium acetate 667mg po tid
calciium carbonate-vitamin D3 600mg/400unit poqday
docusate sodium 100mg po bid
ferrous sulfate 325mg po qday
furosemide 40mg po qday
loratiadine 10mg po qday
simvastatin 40mg po qhs
tiotropium bromide 10mcg inh daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). Tablet
Extended Release 24 hr(s)
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
8. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a
day.
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
18. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
19. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
20. 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.
21. Ondansetron 8 mg IV TID W/MEALS
Please give 30 min prior to meals. [**Month (only) 116**] take with meds if not
taking meals
Discharge Disposition:
Extended Care
Facility:
Radius [**Hospital1 392**]
Discharge Diagnosis:
Critical Aortic Stenosis s/o percutaneous aortic valve
replacement (CoreValve)
Hypertension
Acute on chronic kidney disease
Extensive left upper arm and left groin hematoma
Left brachial vein DVT
Chronic nausea
Coronary artery disease
Iron defeciency anemia
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 had a percutaneous aortic valve replacement (CoreValve). The
procedure went well and the valve is functioning normally.
However, you had some complications that led to a prolonged
hospital stay. You had some bleeding in the upper palate of your
mouth that required stiches and has healed. You also had acute
kidney failure requiring filtration of your blood. Your kidney
function is now the same was [**Doctor Last Name **] your were admitted. You had an
extensive bleed in the left arm and left groin that is slowly
resolving. The swelling in your left arm led to a blood clot
that is now gone but you will need to be on coumadin for another
2 months to prevent a reoccurance. Your blood pressure has been
high and we have adjusted your medicines to better control your
blood pressure. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Stop Calcium acetate and loratidine
2. Increase calcium to twice daily
3. Increase lasix to twice daily, you may take the second dose
at 3pm
4. Start miralax and senna to prevent constipation
5. Start hydralazine to lower your blood pressure
6. STart warfarin to prevent another blood clot
7. STart lorazepam to take as needed for anxiety
8. Start Zofran intravenously as needed to treat nausea before
meals. You should try to wean this medication as you are able.
Once you no longer need the medicine, your PICC line can be
removed.
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2173-6-18**] at 9:00 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
Department: ECHO LAB
When: FRIDAY [**2173-6-18**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
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] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"88.72",
"88.56",
"88.42",
"39.64",
"37.23",
"38.93",
"27.61"
] |
icd9pcs
|
[
[
[]
]
] |
17834, 17887
|
7764, 15381
|
343, 425
|
18189, 18189
|
5030, 5030
|
19900, 20527
|
3790, 3868
|
15867, 17811
|
17908, 18168
|
15407, 15844
|
18365, 19877
|
5607, 7741
|
3883, 4464
|
3082, 3216
|
4478, 5011
|
264, 305
|
453, 2974
|
5046, 5591
|
18204, 18341
|
3247, 3580
|
2996, 3062
|
3596, 3774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,854
| 128,991
|
32055
|
Discharge summary
|
report
|
Admission Date: [**2185-12-7**] Discharge Date: [**2185-12-26**]
Date of Birth: [**2115-11-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
Endotracheal intubation
Arterial line placement
Central line placement
History of Present Illness:
This is a 70 yo M with a past medical history significant for
CAD s/p MI x 2 and CABG, cirrhosis with a history of variceal
bleeds s/p banding in [**8-13**], who is transferred to [**Hospital1 18**] from an
OSH after several episodes of large hematemesis. The patient was
feeling generally unwell when he saw his PCP for [**Name Initial (PRE) **] regularly
scheduled appointment today. He was sent to get some bloodwork
drawn, which he did, and then returned home. He reports being in
his bathroom around 4pm the day of admission, had one episode of
melena and then suddenly he became extremely nauseated and had
three episodes of hematemesis, described as projectile by the
patient. He felt paralyzed but does not endorse dizziness,
lightheadedness, LOC, blurred vision or pain. Paramedics found
the patient confused, bradycardic with systolics in the 70's. He
was taken to the OSH, where he received some IV fluid
resuscitation. Labs were notable for H/H [**9-2**] (labs drawn by pcp
earlier in the day 12/35), INR 1.5, Ammonia 136. In the OSH ED,
he remained hemodynamically stable with SBP's 100-120. He
received zofran for nausea, IV protonix and 1 unit pRBC's before
transport.
.
He was transferred directly from OSH ED to [**Hospital1 18**] MICU for
further work up and treatment. On arrival, the patient is
hemodynamically stable, mentating well and communicative. He
currently denies nausea, vomiting, abdominal pain,
lightheadedness, dizziness, chest pain, headache, confusion. He
denies EtOH and has never had an EtOH abuse history.
.
Of note, he was recently admitted here at [**Hospital1 18**] for hematemesis
on [**2185-8-14**], at which time he was evaluated by both GI and
hepatology. He was initially seen at an OSH for 3 episodes
hematemesis and epistaxis begining on the morning of [**2185-8-14**]. He
was severely hypotensive, put on pressors, and given blood and
FFP before being medflighted to [**Hospital1 18**]. Here, he was intubated
for airway protection during EGD [**8-15**], which showed a variceal
bleed which was rebanded. He was extubated successfully [**8-17**]. He
received blood transfusions to Hct goal of 28 and received IV
PPI and octreotide drip. He was to be discharged on nadalol at
that time. Work up to explore the etiology of the patient's
cirrhosis was negative at that time for SLA, [**Doctor First Name **] and the viral
hepatitides, but smooth muscle antibodies were positive.
.
Also of note on his last admission was the incidental finding on
chest xray of extensive pleural disease likely related to
asbestos exposure, which was followed up by a chest CT which
additionally noted a loculated effusion at the left base with no
pleural masses only plaques as well as a 15mm paraesophageal
lymph node. This was to be worked up as an outpatient
Past Medical History:
PMH:
-Cirrhosis-unclear etiology, no history of etoh or hepatitis.
-portal hypertension
-esophageal varices: s/p UGIB X 2. Banding twice (8 bands then
18 bands placed). Last EGD [**2185-7-26**] with extensive varices
beginning inside cricopharyngeus and extending all the way to
the GE junction. No normal mucosa and some scarred areas with
new varices on top. In the stomach there were large varices in
the cardia. Mucosa of body and stomach with portal hypertensive
gastropathy worst from last endoscopy. No banding done at this
time.
-Diabetes mellitus
-Hypertension
-Rheumatic fever x 2 and a "rheumatic heart"
-CAD s/p MI--s/p 3v CABG at [**Hospital1 2025**] (confusion per wife re: 3v vs
1v). Patient with chronic stable angina since procedure.
-Kidney stones s/p penile urethra surgery to remove the stone
-Migraine headaches
-Asbestosis
.
Social History:
married, no children, no tob, etoh, drugs. retired pipe fitter
and was involved with asbestos removal. He lives in [**Location 730**], MA
with his wife.
Family History:
mother died of MI at age 70, father died of MI at age 70. Sister
died of TB.
Physical Exam:
Physical Exam on admission to MICU:
VS: Temp: 97.5 BP: 108/56 HR: 101 RR: 19 O2sat 100% 3L NC
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, but sluggish, no nystagmus, anicteric,
+conjunctival pallor. MM dry, op without lesions, poor
dentition.
NECK: no supraclavicular or cervical lymphadenopathy, no jvd,
brisk carotid upstroke, no carotid bruits, no thyromegaly or
thyroid nodules
RESP: CTA but decreased breath sounds at the left base. In
general decreased air movement throughout.
CV: RR, S1 and S2 wnl, harsh III/VI SEM heard best at the LUSB,
louder with inspiration, nonradiating.
ABD: distended abdomen with +BS, +fluid wave. Nontender, soft.
EXT: no c/c/e, cool, 1+ pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact, except very sluggish EOM. [**4-10**]
strength throughout, but weakness of biceps/triceps secondary to
old injuries. No sensory deficits to light touch appreciated.
Downgoing babinski bilaterally. Very mild asterixis. No pronator
drift.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2185-12-23**] 04:39AM 10.0 2.48* 8.2* 25.9* 105* 33.3* 31.9
21.2* 120*
[**2185-12-13**] 04:08AM 9.8 3.02* 9.9* 29.4* 97 32.9* 33.8 17.4*
75*
[**2185-12-9**] 05:10AM 1.6* 3.24* 10.7* 30.3* 94 33.1* 35.4*
16.8* 65*1
[**2185-12-7**] 08:26PM 7.9 2.99* 10.2* 29.7* 99* 34.0* 34.3
15.8* 127*
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2185-12-23**] 04:39AM 105 114*1 1.9* 149* 3.6 121*2 23 9
[**2185-12-13**] 04:08AM 189* 47* 1.2 144 3.7 113* 22 13
[**2185-12-9**] 09:32AM 89 31* 1.6* 142 3.1* 112* 20* 13
[**2185-12-7**] 08:26PM 294* 28* 1.1 136 4.7 106 20* 15
.
.
CXR on admission [**2185-12-7**]: extensive pleural disease along the
lower right heart border and evidence of a LLL infiltrate vs.
effusion, perhaps slightly larger than prior study in [**8-13**].
.
EGD [**2185-8-14**]: 5 cords of grade III varices were seen in the lower
third of the esophagus. The varices were bleeding. There were
signs of previous banding, however there were grade 3 varices
distal to previous banding scars with 2 varices actively
bleeding. 5 bands were successfully placed. Portal Hypertensive
Gastropathy.
.
ECHO [**2185-8-22**]: The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and 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. 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. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CT Chest [**2185-8-17**]: IMPRESSION: 1. Asbestos related pleural
calcifications with a loculated effusion noted at the left base.
No pleural masses. 15mm paraesophageal lymph node as described.
2. Extensive coronary artery atherosclerotic calcifications
status post CABG. 3. Cirrhotic liver with ascites.
Brief Hospital Course:
ASSESSMENT/PLAN: 70 yo M with idiopathic hepatic cirrhosis,
esophageal variceal bleeding MICU callout, deteriorated
significantly with resp failure, hypotention, abd.compartment
syndrome, made CMO.
.
# Respiratory failure: Pt developed in the setting of recieving
blood, there was a question of TRALI, ARDS [**1-7**] infection,
hepatopulmonary syndrome and fluid overload - negative w/u for
TRALI here, aggressively diuresed, contaminated sputum and
bubble study significant for intracardiac shunt. Pt intubated as
hypoxic, however after discussion with family, made CMO and
extubated with goals of care mainly comfort. Also IV antibiotics
stopped. Pt was transferred to the medicine wards.
.
# Abdominal compartment syndrome: Chronic based on pt history,
bladder pressure remained elevated during admission. Pt had
several therapeutic thoracentesis.
.
# DM2: Initially started on insulin gtt for improved glycemic
control then converted to NPH [**Hospital1 **]. However, once decision was
made for CMO, fingersticks were stopped with goal of care being
pt's comfort.
.
# Hepatic cirrhosis: Unclear etiology, not transplant candidate
given his cardiac history. Didnot undergo a TIPS procedure
during admission, pt was treated with lactulose, rifaximin for
encephalopathy; ciprofloxacin for SBP ppx. Hepatology team
followed cloesly.After discussion with family, pt made CMO.
.
# AMS: Likely [**1-7**] hepatic encephalopathy initially but later
with midazolam/fentanyl for sedation. Head CT negative for ICH
or infarct; EEG demonstrated encephalopathy. After sedation
discontinued, took approximately 7 days to have marked mental
improvement, which is consistent with underlying organ
dysfunction decreasing ability to clear sedatives. See hepatic
cirrhosis above.
.
# Hypotension: Initially found to be hypotensive as well as
bradycardic when seen by paramedics. Pt required vasopressors,
however weaned off after aggressive fluid resusitation. Etiology
remained unclear during hospitalization, [**Last Name (un) 104**] stim equivocal, no
evidence of sepsis or cardiogenic shock.
.
# Leukocytosis: also with fevers during hospitalization. No
evidence of SBP, blood, urine and sputum cultures negative.
Received antibiotics for a short while, cipro for SBP
prophylaxis. Leukocytosis resolved.
.
# Thrombocytopenia: Likely [**1-7**] hepatic dysfunction or marrow
suppression with antibiotics (meropenum/vanc), PPI. Remained
stable during admission.
.
# Hematemesis: Known hx of variceal bleeding with banding in
09/[**2184**]. EGD on [**2185-12-7**] showed new variceal bleeding.
Received several units of FFP's as well as PRBC, also completed
octreotide infusion x 48hrs then stated on pantoprazole [**Hospital1 **].
Hematocrit remained stable after initial episode in MICU.
.
# CAD: Had an episode of chestpain during admission, however no
EKG changes or troponin rises consistent with acute ischemia.
Did not have any further episodes of chestpain during admission.
.
# Loculated effusion [**1-7**] asbestosis: Stable during admission. Pt
& family had refused further workup as LLL effusion was larger
and there was concern for mesothelioma given extensive pleural
plaques and history of asbestos exposure.
.
# Goals of care: After long discussion with family, pt was made
CMO with the goals of care being primarily comfort after which
pt was transferred to the medicine [**Hospital1 **]. No further labs were
drawn, also no more vital signs.
.
Pt expired on [**2185-12-26**]
Medications on Admission:
Spironolactone 75mg [**Hospital1 **]
Lasix 40mg Qdaily
Glipizide 10mg Qdaily
Famotidine 20mg [**Hospital1 **]
Colace
Protonix 40mg Qdaily
.
Allergies: penicillin (dizzy, n/v)
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
|
[
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"707.03",
"414.00",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"42.33",
"38.91",
"99.07",
"88.72",
"96.72",
"96.04",
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11148, 11157
|
7411, 10891
|
279, 351
|
11208, 11217
|
5329, 7388
|
11273, 11405
|
4231, 4309
|
11116, 11125
|
11178, 11187
|
10917, 11093
|
11241, 11250
|
4324, 5310
|
235, 241
|
379, 3172
|
3194, 4044
|
4060, 4215
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,211
| 162,691
|
45657
|
Discharge summary
|
report
|
Admission Date: [**2128-9-17**] Discharge Date: [**2128-9-20**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Dyspnea, Nausea/Vomitting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 83 y/o M with a PMH significant for Parkinsons,
DM, HTN, s/p CVA with R-sided weakness and hyperlipidemia who
presented from his NH this morning with nausea, vomiting and
SOB. Per the chart, at 4:45am this morning the patient awoke
and vomited a small amount of light green mucous material and
appeared flushed and clammy. Temp at the NH was 100.4, FS 154,
RR 24-28 BP 147/71 and )2 sat 84% on RA. He became SOB and
began coughing. He was placed on NRB and sent to [**Hospital1 18**] via EMS.
En route the patient received albuterol nebs x2 with
improvement. The patient reports that he was feeling in his
USOH until this morning when he vomited. He denies recent CP or
pleuritic pain. He notes a chronic non-productive cough that is
unchanged. He denies any recent fever, chills or URI symptoms.
He denies any unusual foods or recent travel. He also denies
abdominal pain. He notes that his appetite and energy level
have been normal until this morning.
.
In the ED VS were T 98.7 HR 115 BP 124/60 RR 24 91% 4L. He
was noted to have diffuse expiratory wheezes with use of
accessory muscles. He was given continuous nebs with
improvement. CXR showed a patchy RLL opacity and he was given
levo 500mg and flagyl 500mg IV x1. A CTA was not performed due
to ARF, however heparin gtt was initiated given concern for PE.
.
On arrival to the ICU the patient appeared comfortable and was
sating 96% on 4L NC. He denied nausea and reported that his SOB
was improved. He continued to deny CP and abdominal pain.
Past Medical History:
Parkinsons
s/p L MCA CVA with residual R-sided hemiparesis
Aphasia
Dysphagia
DM
HTN
Hyperlipidemia
Social History:
Patient currently resides in NH ([**Location (un) 582**]/[**Location (un) 583**]) since stroke.
Former saxon in a church. Prior smoking history, smoked 2ppd
x30 years, quit [**2091**]. Denies alcohol use.
Family History:
non-contributory
Physical Exam:
T 98.5, 122/67, 99, 22, 90
General: Well-appearing elderly man, NAD, speaking slowly
HEENT: EOMI, PERRL, MM dry, poor dentition with multiple missing
teeth
Neck: no carotid bruits, supple, JVP hard to assess
Heart: regular, no m/r/g appreciated
Lungs: mild diffuse expiratory wheezes
Abdomen: obese, soft, NT/ND, +BS, guaiac neg. in ED
Ext: trace edema b/l LE, no calf tenderness
Neuro: muscle strength 4/5 in R ext. and [**5-22**] in L ext
Pertinent Results:
[**2128-9-20**] 06:45AM BLOOD WBC-15.8* RBC-3.33* Hgb-9.8* Hct-29.5*
MCV-89 MCH-29.3 MCHC-33.1 RDW-14.8 Plt Ct-482*
[**2128-9-17**] 11:10AM BLOOD PT-13.4* PTT-26.2 INR(PT)-1.2*
[**2128-9-20**] 06:45AM BLOOD Glucose-114* UreaN-26* Creat-1.2 Na-140
K-4.3 Cl-102 HCO3-28 AnGap-14
[**2128-9-17**] 06:20AM BLOOD Glucose-183* UreaN-23* Creat-1.6* Na-137
K-4.5 Cl-97 HCO3-29 AnGap-16
[**2128-9-17**] 01:50PM BLOOD ALT-12 AST-15 LD(LDH)-227 CK(CPK)-99
AlkPhos-130* Amylase-42 TotBili-0.4
[**2128-9-17**] 07:04PM BLOOD CK-MB-5 cTropnT-0.06*
[**2128-9-20**] 06:45AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0\
CXR:
AP CHEST: The heart size and mediastinal contours are within
normal limits. There is normal pulmonary vascularity. There is
patchy opacity of the right lower lung concerning for pneumonia
or aspiration. The left lung is grossly clear. There is no
pleural effusion or pneumothorax. The bones are demineralized.
IMPRESSION: Right lower lobe airspace opacity concerning for
aspiration and/or pneumonia.
BILAT LOWER EXT VEINS PORT [**2128-9-17**] 2:43 PM
Grayscale, color flow and Doppler images of both lower
extremities are obtained. The common femoral veins, superficial
femoral veins and deep femoral veins demonstrate normal
compressibility, respiratory variation, venous flow and venous
augmentation. IMPRESSION: No evidence of DVT in both lower
extremities.
Brief Hospital Course:
Impression/Plan: 83 y/o M with a PMH significant for Parkinsons,
DM, HTN, s/p CVA with R-sided weakness and hyperlipidemia who
presented from his NH with Aspiration Pneumonia and COPD
exacerbation
.
1. Aspiration Pneumonia and COPD exacerbation:
- To ICU on [**9-17**]
- Rapid improvement on levofloxacin/flagyl
- steroid taper for COPD.
- O2 requirement 4 LPM on admit, now on RA.
- Called out to floor on [**9-18**] evening
- Continue levofloxacin/flagyl on discharge
- Of note, in ER and [**Hospital Unit Name 153**], placed on heparin transiently with
concern for PE. NO CTA obtained due to acute renal failure.
LENI's negative and given rapid improvement, heparin stopped
[**9-17**].
2. Nausea, vomiting:
- Unclear etiology. ? gastroenteritis. Now resolved. LFT's,
lipase within normal limits. Did not recur during admission.
3. Acute Renal Failure/CKD Stage III:
- patient's baseline Cr 1.1-1.2, 1.6 on admission
- Likely prerenal given recent vomiting and dry appearing on
exam, which returned to baseline with gentle hydration
- Captopril and lasix re-started [**9-19**] after initially being held.
4. Type 2 DM - Controlled:
- On metformin and insulin as outpatient.
- Continued outpatient NPH 20 units qAM and 8 units qPM inhouse
along with ISS.
- Re-start metformin on discharge.
- RISS
- FS qid
- Diabetic diet
5. Parkinsons:
- continued sinemet
6. Benign Hypertension:
- Metoprolol/captopril initally held and then re-started.
7. Hyperlipidemia:
- Zocor Continued
.
8. H/O CVA:
- Has residual R-sided weakness and dysphagia. Continued
aggrenox
- aspiration precautions
- pureed diet
Medications on Admission:
Tylenol prn
Thiamine 100mg daily
MVI daily
Lasix 40mg daily
Citalopram 30mg daily
Sinemet 25/100 tid
Duoneb qid
Senna 2 tabs qhs
MOM 30ml qod
Xalatan 0.005% 1 gtt OU qhs
Simvastatin 10mg qhs
Flomax 0.8mg qhs
Metformin 500mg daily
Hydroxyzine 25mg daily
Colace 100mg [**Hospital1 **]
Flovent 2 puffs [**Hospital1 **]
Captopril 12.5mg [**Hospital1 **]
Aggrenox [**Hospital1 **]
Lansoprazole 30mg [**Hospital1 **]
Metoprolol 25mg [**Hospital1 **]
NPH 20 units qAM and 8 units qPM
RISS
Discharge Medications:
1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Neb Inhalation Q2H (every 2 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Neb
Inhalation Q6H (every 6 hours).
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
4. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO DAILY
(Daily).
6. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: One (1) Tablet PO
TID (3 times a day).
7. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
8. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
hr [**Hospital1 **]: One (1) Cap PO BID (2 times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
13. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
14. Citalopram 20 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY (Daily).
15. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
16. Prednisone 10 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO daily ()
for 3 doses.
17. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily () for
3 doses.
18. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily () for
3 doses.
19. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
20. Levofloxacin 250 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q48H
(every 48 hours) for 5 days.
21. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day) for 5 days.
22. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
23. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
24. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: Twenty
(20) Units Subcutaneous QAM: Hold for FS < 100.
25. RISS
Glucose Sliding Scale Parameters:
Start at 0, Increment by 50 mg/dl
Ending Point: 400 mg/dl
When Glucose < or = 80 Give: 4 oz. Juice 4 oz. Juice
& 15 gm crackers [**1-20**] amp D50 1 amp D50
Notify M.D. if Glucose > 400
Glucose Value to begin administering insulin: 151
mg/dl
Starting Point: 2 Units
Increment By: 2 Units
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
1. Aspiration pneumonia
2. COPD Exacerbation
3. Acute Renal Failure
Secondary:
1. Parkinson's Disease
2. Chronic Kidney Disease
3. Hypertension
Discharge Condition:
Good
Discharge Instructions:
Follow up as below.
You are one 2 antibiotics, and you should complete the full
course. One of the antibiotics is Flagyl (Metronidazole), which
reacts badly to alcohol. Please make sure that you are not
consuming any products with alcohol, such as mouthwash, or
violent vomitting may result. This medication may also make you
more sun-sensitive
Followup Instructions:
With your PCP. [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48975**], [**Telephone/Fax (1) 97337**].
|
[
"250.00",
"438.89",
"507.0",
"403.10",
"491.21",
"332.0",
"585.3",
"584.9",
"276.51",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9063, 9140
|
4056, 5664
|
241, 247
|
9327, 9333
|
2671, 4033
|
9727, 9881
|
2176, 2194
|
6197, 9040
|
9161, 9306
|
5690, 6174
|
9357, 9704
|
2209, 2652
|
176, 203
|
275, 1812
|
1834, 1934
|
1950, 2160
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,086
| 111,187
|
40001
|
Discharge summary
|
report
|
Admission Date: [**2152-5-25**] Discharge Date: [**2152-5-29**]
Date of Birth: [**2127-1-27**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8250**]
Chief Complaint:
scheduled c/s for complete posterior placenta previa
Major Surgical or Invasive Procedure:
Primary lower transverse c-section for posterior previa, ICU
admission, transfusion blood products.
History of Present Illness:
Ms. [**Known lastname 1255**] is a 25yo G1P0 at 37+2WGA by LMP ([**2151-9-7**]) presents to
L&D for a scheduled c/s for complete posterior placenta previa.
Patient trnsferred her care from [**Country 651**] at 24 weeks. Prior to
that she reported a normal pregnancy.
Pregnancy review:
Dating: [**Last Name (un) **] [**2152-6-13**] by LMP ([**2151-9-7**]) c/w 2nd tri US
Prepregnancy weight: 128
Exposures: No TB exposures. No pets. No sick contacts.
*) [**Name2 (NI) **]
- AB+/Abs-/RI/RPRNR/VZI/HBsAg-/HCV-/HIV-/GC-/CT- / GBS positive
- normal 2h GTT
*) Ultrasound
- FFS 25wks nl anatomy, complete previa 4cm over os
- [**4-12**]: 1676g 46th% BPP [**9-4**], AFI 9.7cm, cephalic; complete
previa
- [**5-9**]: [**11-6**] BPP
- [**5-16**] ATU EFW: 2918g, 55%
*) Screening
- Normal hemoglobin electrophoresis
*) Issues
1. Previa
- Growth/placenta scans in ATU q3 weeks
- [**5-16**]: placenta is 1.3cm away from the os
- [**5-23**]: complete previa
2. Anemia - iron/colace rx, on PNV as well
3. Transfer of care from [**Country 651**]
- Do not have records, probably not necessary at this point (pt
says they were faxed from [**Country 651**] by her husband)
Genetic risk factors/ethnicity:
- Born in [**Country 651**] of Chinese background; no known chromosomal
problems/birth defects in family
- FOB's family Chinese, no known chromosomal problems/birth
defects
Past Medical History:
-Obstetrical History:
G1 current
-Gynecological History:
LMP [**2151-9-7**]. No abnormal Paps. No STIs. No known fibroids.
Regular menses, q 30-31 days
[**Hospital 87972**] Medical History: denies
-Past Surgical History: denies
Social History:
Lives with her father. Graduated from BU law school. Husband in
[**Name2 (NI) 651**], coming to US and buying [**Last Name (un) **] nearby.
Family History:
Pt denied family hx of Down syndrome, neural tube defects,
thalassemias, Huntingtons dz, mental retardation.
Physical Exam:
Physical Exam:
A&O, NAD
RRR, CTAB
No thyromegaly or neck mass
Abd soft, NT, gravid
Ext NT NE
Pertinent Results:
[**2152-5-27**] 07:15AM BLOOD WBC-9.3 RBC-2.66* Hgb-8.7* Hct-24.7*
MCV-93 MCH-32.9* MCHC-35.4* RDW-14.3 Plt Ct-218
[**2152-5-26**] 03:29PM BLOOD WBC-17.5* RBC-2.89* Hgb-9.5* Hct-26.7*
MCV-92 MCH-32.8* MCHC-35.6* RDW-14.3 Plt Ct-219
[**2152-5-26**] 04:50AM BLOOD WBC-14.7* RBC-2.79* Hgb-9.1* Hct-25.2*
MCV-90 MCH-32.6* MCHC-36.1* RDW-14.2 Plt Ct-186
[**2152-5-25**] 02:01PM BLOOD WBC-14.2* RBC-2.04* Hgb-6.9* Hct-19.4*
MCV-95 MCH-33.8* MCHC-35.6* RDW-13.1 Plt Ct-198
[**2152-5-25**] 11:17AM BLOOD WBC-19.6*# RBC-2.47* Hgb-8.3* Hct-23.7*
MCV-96 MCH-33.4* MCHC-34.9 RDW-13.0 Plt Ct-240#
[**2152-5-25**] 10:00AM BLOOD WBC-9.1 RBC-3.13* Hgb-10.6* Hct-29.8*
MCV-95 MCH-33.8* MCHC-35.5* RDW-12.7 Plt Ct-159
[**2152-5-25**] 06:21AM BLOOD WBC-9.9 RBC-3.75* Hgb-12.3 Hct-35.0*
MCV-93 MCH-32.8* MCHC-35.2* RDW-13.0 Plt Ct-251
.
[**2152-5-26**] 04:50AM BLOOD PT-12.5 PTT-25.5 INR(PT)-1.1
[**2152-5-25**] 09:54PM BLOOD PT-12.4 PTT-23.3 INR(PT)-1.0
[**2152-5-25**] 02:01PM BLOOD PT-12.7 PTT-24.8 INR(PT)-1.1
[**2152-5-25**] 11:17AM BLOOD PT-13.3 PTT-31.8 INR(PT)-1.1
[**2152-5-25**] 10:00AM BLOOD PT-12.4 PTT-31.0 INR(PT)-1.0
.
[**2152-5-26**] 04:50AM BLOOD Fibrino-412*
[**2152-5-25**] 09:54PM BLOOD Fibrino-384
[**2152-5-25**] 02:01PM BLOOD Fibrino-280#
[**2152-5-25**] 11:17AM BLOOD Fibrino-173
[**2152-5-25**] 10:00AM BLOOD Fibrino-220
.
[**2152-5-26**] 04:50AM BLOOD Glucose-68* UreaN-10 Creat-0.7 Na-136
K-3.7 Cl-105 HCO3-23 AnGap-12
[**2152-5-25**] 09:54PM BLOOD Glucose-108* UreaN-8 Creat-0.6 Na-139
K-3.3 Cl-104 HCO3-27 AnGap-11
[**2152-5-25**] 02:01PM BLOOD Glucose-94 UreaN-9 Creat-0.5 Na-141 K-3.5
Cl-107 HCO3-28 AnGap-10
[**2152-5-25**] 11:22AM BLOOD Na-139 K-4.3 Cl-109*
.
[**2152-5-25**] 02:01PM BLOOD LD(LDH)-429* TotBili-0.3
.
[**2152-5-26**] 04:50AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.9
[**2152-5-25**] 09:54PM BLOOD Mg-2.1
[**2152-5-25**] 02:01PM BLOOD Calcium-7.7* Phos-4.0 Mg-1.6
[**2152-5-25**] 11:22AM BLOOD Albumin-2.6* Calcium-7.1* Mg-1.5*
[**2152-5-25**] 02:01PM BLOOD Hapto-48
.
[**2152-5-25**] 02:13PM BLOOD Type-ART Temp-36.6 pO2-148* pCO2-52*
pH-7.32* calTCO2-28 Base XS-0
[**2152-5-25**] 02:13PM BLOOD Lactate-1.7
Brief Hospital Course:
Ms.[**Known lastname 1255**] presented for L&D at 37 weeks and 2 days gestational
age for a planned cesarean delivery given complete posterior
placenta previa. The patient had previously been counseled
about risk of potential accreta as well as the risk of
hemorrhage. She also understood the risk of prematurity, which
was outweighed by the risk of labor/hemorhage. The patient was
typed and crossed for 2 units, and the blood was available on
labor and delivery at the time of the cesarean section. Her
surgery was complicated by uterine atony after delivery and
hemorrhage, EBL for the surgery was approximately [**2141**] cc. Pt
received uterotonics and was transfused 2 units of PRBC, 4 units
FFP, 2 units of PLT, and 2 units of cryo. [**Year (4 digits) **] were trended to
ensure pt's stability. Please see Dr[**Doctor Last Name 87973**] operative for
details of the surgery. Pt was then transferred to the ICU after
the surgery for intense monitoring given fluid shifts. Pt was
extubated on the evening of post-op day#0. Pt was transferred
out of the ICU on POD#1 and received routine post-op/postpartum
care. Pt spiked a fever, and was likely due to endometritis. She
was treated with Ampicillin/gentamicin/Clindamycin for 48 hrs
afebrile. Pt was started on iron supplement for post-op anemia.
Pt recovered well and was discharged on post-operative day #4
in stable condition: afebrile, able to eat regular food, under
adequate pain control with oral medications, and ambulating and
urinating without difficulty.
Medications on Admission:
Calcium + vit D, PNV, Iron
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
Disp:*60 Capsule(s)* Refills:*2*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain: take medication with food.
Disp:*60 Tablet(s)* Refills:*0*
3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary cesarean section
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Nothing in the vagina for 6 weeks (No sex, douching, tampons)
No heavy lifting for 6 weeks
No driving while taking narcotics
Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
Do not take more than 2400mg ibuprofen in 24 hrs
Please call if you develop shortness of breath, dizziness,
palpitations, fever of 101 or above, abdominal pain, increased
redness or drainage from your incision, nausea/vomiting, heavy
vaginal bleeding, or any other concerns.
Followup Instructions:
-Postpartum appointment: Dr.[**Last Name (STitle) **] [**2152-7-4**] at 10:15 AM. If you
need to change this appointment, please call [**Telephone/Fax (1) 2664**].
Completed by:[**2152-5-31**]
|
[
"615.9",
"V27.0",
"666.12",
"285.1",
"648.22",
"615.0",
"641.01",
"692.9",
"276.61",
"670.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"75.8",
"75.52",
"74.1"
] |
icd9pcs
|
[
[
[]
]
] |
6862, 6868
|
4684, 6212
|
370, 472
|
6937, 6937
|
2531, 4661
|
7557, 7752
|
2291, 2402
|
6290, 6839
|
6889, 6916
|
6238, 6267
|
7073, 7534
|
2108, 2117
|
2432, 2512
|
278, 332
|
500, 1865
|
6952, 7049
|
1887, 2085
|
2133, 2275
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,924
| 189,701
|
48836
|
Discharge summary
|
report
|
Admission Date: [**2183-5-21**] Discharge Date: [**2183-7-17**]
Date of Birth: [**2108-10-24**] Sex: F
Service: MEDICINE
Allergies:
Celebrex / Nsaids / Morphine
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
??????Shortness of breath?????? and pancytopenia
Major Surgical or Invasive Procedure:
1. Open Cholecystectomy
2. Leukemia induction
3. Central line placement
History of Present Illness:
This is a 74 year-old woman with a history of breast and colon
cancer, hypertension, hypercholesterolemia, and anemia (Hct
31-33), who presented to her PCP at [**Name9 (PRE) 191**] with shortness of
breath, was put on supplemental oxygen, and then referred to the
ED. Of note, patient has a recent history of nose bleeds for two
months associated with dizziness and sweating that was diagnosed
as a sinus infection on [**5-7**]. Her PCP treated her with a course
of Amoxicillin that developed into diarrhea and abdominal
cramps. Patient consulted her NP[**Company 2316**] who said it was okay to
discontinue her antibiotic. Shortly after, she developed this
two-week episode of dyspnea.
.
Patient complains of dyspnea on exertion for the past couple of
weeks that is associated with chest tightness, dizziness, and
lightheadedness. She feels weak, barely being able to walk from
her chair to her kitchen. After walking up the stairs to her
bedroom, she feels like ??????plopping into bed?????? because she is so
exhausted. She experiences a dry cough, chest tightness, and
heart palpitations with walking but denies radiating chest pain
or dyspnea at rest. Patient has developed a low grade fever of
100.0F that is easily abated with Tylenol. She denies
dehydration, maintaining adequate fluid intake. Otherwise,
patient denies history of asthma/COPD, orthopnea/PND, MI,
hemoptysis, hematemesis, N/V, melena/BRBPR, hematuria, edema, or
falls. Patient made an appointment with her PCP today, but upon
getting off the elevator, she felt that she was ??????mustering all
her strength to keep from passing out.?????? Her PCP put her on
supplemental oxygen and referred her to the ED for further
evaluation.
.
Hospital course: In the ED, patient had a low grade fever of
100.4. Her labs revealed a 15-point Hct drop and she was
transfused 2 U PRBCs. Patient was transferred to the floor
saturating at 98% on 2L and feeling more comfortable, denying
shortness of breath.
Past Medical History:
1. Breast cancer ?????? diagnosed in [**2174**] and treated by right
mastectomy, chemo and XRT; she continues to be followed by her
oncologist, Dr. [**Last Name (STitle) 2036**], for annual check-ups. Treated with AC
2. Colorectal cancer ?????? diagnosed in [**2153**], s/p colectomy
3. Hypertension
4. Hypercholesterolemia
5. Anemia ?????? chronic Hct (31-33)
6. GERD
7. Osteoarthritis ?????? Low back pain
.
Allergies/Intolerance:
Celebrex ?????? causes stomach irritation,diarrhea
NSAIDS
Statins ?????? muscle aches, headaches
Social History:
Social History: Patient??????s father is from [**Name (NI) 6257**]/[**Country 3587**] and
her mother is Indian/Irish. She lives in [**Location 669**] in a community
home (cooperative), and her 30 year-old son resides with her.
She is the mother of 8 children with several grandchildren. She
is independent, performing all her ADL??????s and IDL??????s. She has a
significant 60 pack-year tobacco history and denies alcohol or
IVDU. Her [**Doctor First Name **] heritage plays an important role in her
life, serving as a Sunday School teacher.
Family History:
Father ?????? MI (88yo)
Father??????s side ?????? MI, htn, DM, asthma
Physical Exam:
PE: Tm 100.4 Tc 99.6 HR 90 BP 140/80 RR 14 O2 100% RA Wt 82.9
kgs
General: Well nourished, appearing stated age, in no acute
distress, breathing comfortably, speaking in full sentences, not
using accessory muscles.
Head: Normocephalic/atraumatic.
Eyes: PERRL, EOMI, sclera anicteric. No conjunctival pallor.
Ears: Tympanic membranes clear with light reflex.
Mouth: Moist mucous membranes. Clear oropharynx. Top dentures.
Neck: Supple with normal range of motion. No thyromegaly. No
lymphadenopathy.
Lungs: Clear to auscultation bilaterally. No wheezing, rhonci,
or rales.
+ right mastectomy
CV: Regular rate and rhythm, no murmur. Normal S1/S2. Normal
PMI. No carotid bruits or jugular venous distension.
Abdomen: Soft, nontender, normoactive bowel sounds, no masses,
no organomegaly.
DRE: FOBT negative.
Back: No costovertebral angle tenderness.
Extremities: No edema, cyanosis, or clubbing. Good dorsalis
pedis pulses.
.
Neurologic Exam:
Mental Status: Alert & Ox3, cooperative, attentive; fluent,
non-dysarthric speech..
Cranial Nerves: I- not tested. II-XII intact.
Motor: Normal bulk and tone, no fasciculations, tremor or
pronator drift.
Strength: [**4-11**] throughout.
Sensation: Intact to light touch, temperature (cold), and
vibration sense.
Reflexes: 2+ throughout. Toes were downgoing bilaterally.
Coordination: Normal on finger-nose-finger, finger tapping,
rapid alternating movements.
Gait: Not tested.
Pertinent Results:
Labs on Admission ([**2183-5-21**] 01:40PM):
WBC-1.9* RBC-1.61*# HGB-5.9*# HCT-16.4*# MCV-102* MCH-36.5*
MCHC-35.9* RDW-18.1* RET AUT-0.6* GRAN CT-390*
NEUTS-12* BANDS-4 LYMPHS-46* MONOS-6 EOS-0 BASOS-0 ATYPS-0
METAS-2* MYELOS-0 BLASTS-30*
PT-12.9 PTT-23.7 INR(PT)-1.1
PLT SMR-VERY LOW PLT COUNT-30*# LPLT-2+
HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+
POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL
LD(LDH)-298* TOT BILI-0.2
GLUCOSE-107* UREA N-16 CREAT-0.8 SODIUM-132* POTASSIUM-2.9*
CHLORIDE-97 TOTAL CO2-23 ANION GAP-15
ANC Values: 390 on [**5-21**] -> 10 on [**6-10**] -> 130 on [**6-20**] -> 560 on
[**7-4**] -> 1020 on [**7-13**] -> 1390 on [**7-15**] -> 720 on [**7-17**];
.
.
STUDIES:
1. CXR [**5-21**]: No pneumonia.
2. BONE MARROW BIOPSY ([**5-22**]): DIAGNOSIS: Acute myelogenous
leukemia (see note). Note: cytogenetic studies revealed that 20
of 20 cell analyzed have trisomy 11. Trisomy 11 is frequently
associated with internal tandem duplications of the MLL (ALL-1)
gene.
MICROSCOPIC DESCRIPTION
PERIPHERAL SMEAR
Smear quality is acceptable. Red cells show
anisopoikilocytosis, and include microcytes and pre-dacrocytes.
WBC count is decreased. Differential shows: 18% segmented
neutrophils, 37% lymphocytes, 45% blasts. Many of the
neutrophils are hypolobated and hypogranular. Platelet count
appears decreased; rare giant forms are present.
ASPIRATE SMEARS
The aspirate material is adequate for evaluation. M:E ratio is
30:1. Myeloid cells appear increased, comprised primarily of
blasts and microblasts, with moderately nucleoplasm, large
prominent nucleoli, and some with Auer rods.
.
Erythroid maturation cannot be assessed due to paucity of
erythroid precursors. Megakaryocytes are present in markedly
decreased numbers. Differential shows: Blasts 60%,
Promyelocytes 3%, Myelocytes 17%, Metamyelocytes 5%,
Bands/Neutrophils 5%, Plasma cells 2%, Lymphocytes 5%, Erythroid
3%.
.
BIOPSY SLIDES
The core biopsy contains periosteum on both ends indicating that
it represents a tangential biopsy of the subcortical marrow
space, which is frequently hypocellular and not representative.
The marrow space is comprised of fat and stromal cells and is
devoid of maturing hematopoietic elements. Marrow clot section
is not submitted. Touch prep is not submitted.
.
3. ECHOCARDIOGRAM ([**5-23**]): IMPRESSION: Preserved global and
regional biventricular systolic function. Minimal aortic
stenosis. Mild mitral regurgitation. Pulmonary artery systolic
hypertension.
.
4. CT SINUS ([**5-26**]) IMPRESSION: No evidence of acute sinusitis.
.
5. CT ABDOMEN/PELVIS ([**6-24**]): IMPRESSION:
-A. Multiple gallstones as well as gallbladder thickening and
possible stranding around the gallbladder. This represents acute
cholecystitis. These findings were conveyed to the clinical team
(Dr. [**Last Name (STitle) **]. If indicated, ultrasound or nuclear medicine
gallbladder scan could be performed.
-B. Ill-definition and stranding around the head of the pancreas
could represent pancreatitis. However, at this point, the
amylase and lipase are normal.
-C. Small fat-containing ventral hernia (image 2, 29).
-D. Mild thickening of the sigmoid colon and rectum with
stranding around it likely representing mild colitis.
.
6. ECHOCARDIOGRAM ([**7-2**]): Compared with the findings of the
prior study (images reviewed) of [**2183-5-23**], there is now a
small pericardial effusion. The left ventricular ejection
fraction is now somewhat reduced.
.
7. MRI HEAD ([**7-9**]): Sagittal T1 and axial T1 images were obtained
through the brain. Further imaging was not performed as the
patient declined completion of the examination. The gadolinium
portion of the examination was not performed. IMPRESSION:
Limited examination of the brain with pre-contrast T1-weighted
images only performed. No overt evidence of acute intracranial
hemorrhage or hydrocephalus. Diffuse marrow space signal
abnormality likely represents marrow replacement and may be
related to patient's AML.
.
8. CXR ([**7-9**]): IMPRESSION: No pneumonia. Stable bilateral pleural
effusions.
.
9. PLAIN FILM HIPS, BILATERAL ([**7-17**]): 1. Mild-to-moderate
degenerative changes of right hip and moderate-to-severe
degenerative changes of left hip. No acute fracture or osseous
lesions.
.
Brief Hospital Course:
Ms. [**Known lastname 15063**] is a 74-year-old woman with a history of breast
cancer s/p mastectomy, radiation and chemotherapy; colon cancer
s/p hemicolectomy; and HTN who initially presented with SOB and
was found to have pancytopenia (WBC 1.6, Hct 16.4, Plt 30) with
a subsequent bone marrow biopsy consistent with AML. Her
hospital course for this admission is as follows:
.
1. AML. She initially presented with SOB and pancytopenia (WBC
1.6, Hct 16.4, Plt 30, ANC were 390) to the medicine team on
admission. Peripheral smear showed 30% blasts. Given this
finding, hem/onc service was consulted. After evaluation,
patient was transferred from the medicine service to the BMT
service. A bone marrow aspiration showed Acute Myeloid Leukemia
with trisomy 11.
.
On admission to BMT, allopurinol was started. After explaining
different therapeutic options and the risk involved, patient
decided to go for chemotherapy with MEC. A central line was
placed on [**2183-5-27**], although it had to be repositioned by IR on
[**2183-5-28**] before before use. Echocardiogram was done that showed
normal LVEF >55%, minimal aortic stenosis, mild mitral
regurgitation and Pulmonary artery systolic hypertension.
Induction chemotherapy with MEC was administered per protocol,
with Day 0 on [**2183-5-28**]. She was closely monitored for tumor lysis
syndrome, but this never developed. Allopurinol was
disccontinued on [**2183-6-10**] because of a new rash. The day 14 bone
marrow biopsy was not done since it was determined that the
results would not change her management. She was treated with
GCSF 480mcg SC daily beginning on [**6-11**] and continuing through
[**7-15**]. Her ANC response was slow despite GCSF, and in fact, it
started coming down again shortly after stopping GCSF; ** this
should be followed up in the outpatient follow-up. **
.
2. Neutropenic Fever. She was found to be neutropenic on
admission. Given her fever of 100.4 in the ED, cefepime was
started. She continued to have temperatures up to 100.5. No
source was identified. By [**2183-5-26**], with continued temperatures
in this range, vancomycin was initiated to broaden coverage. She
also was complaining of sinus congestion and mild frontal
headache at that time. CT of the sinus was done which came back
negative for sinusitis. All blood cx and urine cultures remained
negative. Vancomycin was discontinued after 72 hours and given a
lack of other focal signs for infection, it was thought that her
fevers might be related to her underlying hematologic
malignancy. Throughout her hospital course, she had intermittent
low grade fevers. She was started on multiple different abx and
would defervesce intermittently. Cefepime was used initially but
was switched to meropenem for worsening mucositis; Vanc was used
intermittently. Acyclovir was added for a herpetic ulcer in her
mouth. Fluconazole was given for approximately one week.
Meropenem was discontinued on [**7-4**] for a worsening rash and
Cefepime was re-started. Caspo was used for three weeks but was
also stopped ([**6-29**]) for worsening rash. Flagyl was started
for diarrhea on [**6-24**], but stopped for her rash on [**7-2**].
.
3. Acute cholecystitis. Ms. [**Known lastname 15063**] developed diarrhea on [**6-23**] along with mild upper abdominal pain. A CT showed acute
cholecystitis. Surgery was consulted and they performed an open
cholecystectomy on [**6-24**] under Dr. [**Last Name (STitle) **]. She tolerated the
procedure well and was transferred back to BMT from the SICU on
[**6-27**]. Bowel movements began on [**7-1**] and she was advanced to a
regular diet. The suture staples were removed on [**7-10**] and the
wound healed nicely after that. Her pain was well controlled
with oxycodone and acetaminophen.
.
4. Rash. A rash developed on [**6-10**], which disappeared after
discontinuing ambisome. However, a new rash developed on [**6-27**];
it is presumed that this was a reaction to ibuprofen, which she
got in the SICU despite an NSAID allergy. However, the rash
continued to worsen over all four extremities. Dermatology
recommended starting triamcinolone cream 0.1% [**Hospital1 **], which was
done. Caspofungin, Flagyl, and Meropenem were each stopped on
[**6-29**], and 28 respectively. The rash gradually began
improving and had nearly resolved by the time of discharge.
.
5. Mucositis. After her MEC chemo, she developed mucositis. Pain
was adequately controlled PCA dilaudid. She was also given
Acyclovir for a herpetic ulcer on her right buccal muccosa.
Supportive care with Magic mouthwash, Gel [**Last Name (un) **], and viscous
lidocaine was given. The PCA was discontinued on [**6-21**] as her
pain had decreased and WBC and ANC had increased.
.
6. Non gap metabolic acidosis. On hospital day 3, her
bicarbonate went down to 18. After reviewing possible causes, it
was concluded that it may have been related to her continuous
NS. IV fluids were stopped. Slow recovery was obtained.
However, given a persistently low bicarb, and a urinary GAP with
low K+, it was more likely related to a renal tubular acidosis.
However, this resolved over the subsequent week with no further
electrolyte abnormalities.
.
7. Hyponatremia. This was a euvolemic hyponatremia. Urine
osmolality was 364 and plasma osm 268. Given that she was on
hydrochlorothiazide and given the potential for SIADH, this
medication was discontinued. Betablocker was started for blood
pressure control. Her sodium slowly recovered.
.
8. GERD. This remained asymptomatic on pantoprazole 40mg PO
qday.
.
9. SOB. On admission, SOB was secondary to anemia (hct 16.4)
admission, which improved after transfussion in the ED. Initial
set of enzymes was negative. EKG normal on admission. No
evidence of heart failure on physical exam. Further SOB on [**6-15**]
was likely due to fluid overload; she got IV lasix 20mg x 1, and
albuterol neb.
.
10. LE edema. This developed on [**6-20**], with the left greater
than the right. A LE Ultrasound was negative for DVT. This
slowly resolved as the rash resolved.
.
11. Hypertension. This was controlled. As noted above, she was
switched from HCTZ 25mg PO to metoprolol 25mg [**Hospital1 **] in the setting
of hyponatremia. Nifedipine was started on [**2183-5-30**] for further
BP control.
.
12. Epistaxis. This was controlled by compression and platelet
transfusion.
.
13. Hip pain. On the morning of [**7-17**], she awoke with sharp left
hip pain. Although there was concern for pathologic fracture or
osseous involvement, plain films revealed only degenerative
changes consistent with her known osteoarthritis with no acute
fracture, dislocation, or osseous lesion. Oxycodone was given
for pain.
.
14. Anxiety. She was increasingly anxious over the course of her
hospitalization. On [**7-15**], she was switched from Ativan to
Klonopin 0.5 mg tid. This helped her some, although anxiety
remains an issue for her and should be followed as an
outpatient.
.
15. Access. A central line was placed by surgery on [**2183-5-27**]. It
was subsequently changed over a wire on [**2183-5-28**] by IR for proper
placement into the IVC. CXR on [**2183-6-4**] for a fever incidentally
showed that the central line migrated back to the
brachiocephalic vein. However, since she was not getting TPN, we
continued to use the line for her other medication.
.
16. Code: Full.
.
.
Medications on Admission:
Medications on Admission:
HCTZ 25mg PO qday
Pantoprazole 40mg PO qday
Ativan 1 mg PO qhs
Tylenol #3
Glucosamine 1 capsule [**Hospital1 **]
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8
hours).
Disp:*90 Capsule(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*0*
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*90 Capsule(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 MDI* Refills:*3*
7. [**First Name5 (NamePattern1) 4886**] [**Last Name (NamePattern1) 12106**] Sig: One (1) Miscell. once a day: Dispense
1 [**Last Name (NamePattern1) **], ICD 205.
Disp:*1 [**Last Name (NamePattern1) **]* Refills:*0*
8. Aquaphor Ointment Sig: One (1) application Topical three
times a day.
Disp:*1 tube* Refills:*2*
9. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) application
TP Topical twice a day for 2 weeks: to the affected area, avoid
face, axilla and groin area .
Disp:*1 tube* Refills:*0*
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary:
1. Acute Myeloid Leukemia, type M2
2. Cholecystitis, now s/p open cholecystectomy
Secondary:
1. Osteoarthritis
2. GERD
Discharge Condition:
Good condition, vital signs stable, discharged to acute rehab
facility.
Discharge Instructions:
You have been evaluated and treated for acute myeloid leukemia
(AML), as well as cholecystitis. Please take all medications as
directed. Please keep all follow-up appointments.
.
Call the BMT fellow on call if you develop fever greater than
101 degrees, shortness of breath, pain in the chest,
nausea/vomiting, or any other symptom that is concerning to you.
Followup Instructions:
An appointment will be made for you to see Dr. [**Last Name (un) 5561**] on
Thursday, [**7-24**]; you will be contact[**Name (NI) **] with the exact
time.
.
An appointment has been made for you to follow-up with Dr. [**Last Name (STitle) **]
([**Telephone/Fax (1) 6439**]) on Thursday, [**7-31**], at 3:00 pm.
Completed by:[**2183-7-17**]
|
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26,691
| 165,460
|
27668
|
Discharge summary
|
report
|
Admission Date: [**2145-5-19**] Discharge Date: [**2145-6-14**]
Date of Birth: [**2092-5-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p Rollover motor vehicle crash
Major Surgical or Invasive Procedure:
[**5-19**] Bilateral chest tubes; decompressive laparotomy; ICP
bolt placement
[**2145-5-21**] Abdominal wound closure
[**2145-5-27**] ORIF left humerus fracture
[**2145-5-28**] Percutaneous Tracheostomy; Scalp advancement and wound
closure
7/1306 Percutaneous Gastrostomy placement
[**2145-6-14**] s/p Decannulation of tracheostomy
History of Present Illness:
55 yo female s/p rollover MVC, restrained rear passenger. Trunk
pinned over patient's head with prolonged extrication time. In
field patient apneic and was intubated; SBP en route dropped
from 117 to 70's. She was taken to an area hospital where found
to have scalp laceration which was sutured; right SDH, SAH;
frontal contusions; open book pelvis fracture; fractures of left
humerus and left 6th rib. She received 4 units blood; bilateral
chest tubes placed. She was trnasferredto [**Hospital1 18**] for continued
management of her injuries.
Past Medical History:
None
Social History:
Married
Family History:
Noncontributory
Physical Exam:
VS upon admission to trauma bay:
BP 72/palp HR 122
Gen: intubated
HEENT: spont eye opening PERRLA 3->2; 6 cm lac forehead
Neck: c-collar
Back/spine: no stepoffs
Chest: bilat chest tubes
Cor: tachy
Abd: FAST negative
Rectum: decreased tone; guaiac negative
Extr: LUE deformity
Pertinent Results:
[**2145-5-19**] 11:34PM LACTATE-3.5*
[**2145-5-19**] 09:51PM GLUCOSE-182* UREA N-11 CREAT-0.7 SODIUM-144
POTASSIUM-3.4 CHLORIDE-114* TOTAL CO2-16* ANION GAP-17
[**2145-5-19**] 09:51PM ALT(SGPT)-37 AST(SGOT)-91* CK(CPK)-895* ALK
PHOS-43 AMYLASE-122* TOT BILI-0.3
[**2145-5-19**] 09:51PM CK-MB-21* MB INDX-2.3 cTropnT-0.13*
[**2145-5-19**] 09:51PM ALBUMIN-2.5* CALCIUM-5.4* PHOSPHATE-4.4
MAGNESIUM-0.9*
[**2145-5-19**] 09:51PM WBC-5.4# RBC-4.70# HGB-14.1# HCT-40.7# MCV-87
MCH-29.9 MCHC-34.5 RDW-13.9
[**2145-5-19**] 09:51PM PLT COUNT-24*
[**2145-5-19**] 09:51PM PT-17.3* PTT-37.5* INR(PT)-1.6*
[**2145-5-19**] 09:51PM FIBRINOGE-230#
CT HEAD W/O CONTRAST
Reason: eval ich, mass effect
[**Hospital 93**] MEDICAL CONDITION:
56 year old woman with MVC, known skull fx, humeral fx, open
pelvic fx
REASON FOR THIS EXAMINATION:
eval ich, mass effect
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 56-year-old in motor vehicle accident with known
skull fracture and multiple other fractures, assess for
intracranial hemorrhage.
TECHNIQUE: MDCT images of the brain without IV contrast. No
prior studies.
FINDINGS: Numerous intraparenchymal contusions are seen in the
right frontal lobe, superior left frontal lobe, right temporal
lobe, and along the region of the right petrous apex. There is a
right subdural hematoma extending along the convexity of the
frontal and parietal lobes and extending inferiorly along the
anterior temporal lobe probably into the middle cranial fossa.
Subdural hematoma is also seen extending along the posterior
aspect of the falx and over the tentorium. There is a mild
degree of subarachnoid hemorrhage, best seen in the
interpeduncular fossa and within the interfolial spaces of the
cerebellum. Blood is also seen within the Sylvian fissures and
in the right temporal [**Doctor Last Name 534**] of the lateral ventricle.
Mass effect from the hemorrhages and injury produces compression
of the body of the right lateral ventricle and mild shift of
midline structures towards the left. Additionally, cerebral
sulci and the suprasellar space appear somewhat narrowed.
There is a fracture of the left parietal bone, which appears to
extend inferiorly into the lambdoid suture on the left, where
there is sutural diastasis. Small amount of fluid is seen within
the left mastoid air cells and a small amount of air in the deep
soft tissues of the upper left neck inferior to the mastoid air
cells. Findings are related to the inferior aspect of the
fracture extending through the mastoid air cells. High-density
fluid is seen in the sphenoid sinus consistent with hemorrhage.
There appears to be a somewhat irregular fracture through the
clivus. There is a large scalp laceration with a significant
hematoma and subcutaneous air seen overlying the left parietal
fracture. Soft tissue laceration and skin staples are also seen
overlying the right frontal bone, though no frontal bone
fracture is seen.
There is minimal mucosal thickening within the ethmoid air
cells. The patient is intubated, and an OG tube is also seen
curling within the posterior oropharynx.
IMPRESSION:
Multiple cerebral contusions. Subdural hemorrhage extending
along the convexity of the right frontoparietal region and
probably extending into the middle cranial fossa. Subarachnoid
hemorrhage and intraventricular hemorrhage. Narrowing of the
suprasellar space is concerning for early cerebral edema.
Continued close followup is recommended.
Fractures through the left parietal bone extending into lambdoid
suture causing diastasis. There is also a fracture of the
clivus. Findings were communicated to the ED immediately via the
ED dashboard.
[**Numeric Identifier 4176**] PERC PLCMT GASTROMY TUBE [**2145-6-4**] 7:23 AM
Reason: please assess for percutaneous G-J placement
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman with recent decompressive laparotomy, closure,
head injury
REASON FOR THIS EXAMINATION:
please assess for percutaneous G-J placement
INDICATION: Status post MVA, high residuals with orogastric
tube, need for nutrition.
RADIOLOGISTS: Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 3175**], the Attending
Radiologist, present and supervising the entire procedure.
PROCEDURE/FINDINGS: After the risks and benefits of the
procedure were discussed with the patient's family, written
informed consent was obtained. A preprocedure timeout was
performed to confirm patient identity and the procedure to be
performed.
Utilizing an indwelling NG tube, the stomach was insufflated
with air under fluoroscopic guidance. A suitable spot for
percutaneous gastrojejunostomy tube placement was then chosen.
Under local anesthesia with 1% lidocaine, gastropexy was
performed using three T fasteners. Gastric puncture was then
performed using an 18-gauge needle advanced into the stomach
under fluoroscopic guidance. An 0.035 [**Last Name (un) 7648**] wire was then
advanced into the stomach and the wire was then introduced
across the pylorus into the duodenum and then into the proximal
jejunum. The [**Last Name (un) 7648**] wire was exchanged for an Amplatz wire. The
patient's indwelling NJ tube was then removed. The percutaneous
tract was then sequentially dilated and a peel- away introducer
sheath placed. A 14- French [**Doctor Last Name 9835**] gastrostomy tube was then
advanced into the proximal jejunum and the peel- away sheath
removed. The retention pigtail loop was formed and positioned in
the proximal duodenum. The position of the tube was confirmed
and documented with injection of contrast. The catheter was then
secured using a flexitrack device.
The patient tolerated the procedure well without immediate
complications.
MEDICATION: Moderate sedation was provided by administering
divided doses of fentanyl (100 mcg total) throughout the total
intra-service time of 1 hour and 20 minutes during which the
patient's hemodynamic parameters were continuously monitored.
IMPRESSION: Successful placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 9835**] percutaneous
gastrojejunostomy tube with the tip in the proximal jejunum.
BILAT LOWER EXT VEINS
Reason: Edema
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman with fever in ICU
REASON FOR THIS EXAMINATION:
Edema
INDICATION: Fever. Edema.
COMPARISON: [**2145-6-2**].
[**Doctor Last Name **]-scale and Doppler son[**Name (NI) 867**] of the right and left common
femoral, superficial femoral, and popliteal veins were
performed. Normal flow, augmentation, compressibility, and
waveforms are demonstrated. No intraluminal thrombus is
identified.
IMPRESSION: No evidence of DVT in the right or left lower
extremities.
Date: [**2145-6-11**]
Signed by [**Last Name (NamePattern4) 57715**] [**Last Name (NamePattern1) 15102**], CCC-SLP on [**2145-6-11**]
Affiliation: [**Hospital1 18**]
PASSY-MUIR VALVE EVALUATION/DISPENSE
HISTORY:
Thank you for referring this 53 yo female transferred here
[**2145-5-19**] s/p a high speech rollover MVA, in which she was a
restrained, rear passenger with prolonged extrication, apneic x2
requiring intubation in the field. The pt had multiple
orthopedic
and intracranial injuries and was transferred here from OSH for
further management. Issues include: open book pelvic fx, left
humerus fx, right sacral ala, right pubic bone fx with
retroperitoneal and intraperitoneal blood. Head CT revealed:
"multiple cortical contusions in both frontal lobes and the
right
temporal lobe, subdural hemorrhage extending along the convexity
of the right frontoparietal lobes and probably extending along
the right temporal lobe into the middle cranial fossa, subdural
hematoma also over the posterior aspect of the falx,
subarachnoid
hemorrhage and intraventricular hemorrhage as
described, apparent narrowing of the suprasellar space and
midline shift concerning for cerebral edema, fractures through
the left parietal bone extending into lambdoid suture causing
diastasis, a fracture of the clivus, questionable fracture
through the left mastoid air cells".
Pt has had multiple surgical interventions including: [**2145-5-19**]:
exploratory laparotomy for retroperitoneal hematoma with intra-
abdominal compartment syndrome, [**Last Name (un) **] bolt placement,
percutaneous skeletal traction pin placement and closed
reduction
of pelvic ring fracture dislocation with manipulation, [**2145-5-24**]:
open reduction and internal fixation for right vertical shear
pelvic fracture with complete sacral fracture and anterior and
posterior ring disruption, [**2145-5-28**] tracheostomy placement. Pt has
also had interventions to close open head lacerations. On
[**2145-6-4**], a J tube was placed. On [**2145-6-6**] trach mask trials
began.
We were consulted to evaluate the pt for a Passy-Muir Speaking
Valve (PMV) and for swallowing. RN reports the pt has only been
minimally responsive and when awake has only been able to move
the right side of her body (hand/arm and toes). However, RN
indicates that she has frequently been lethargic, and only has
intermittent periods of wakefulness. RN has not observed
mouthing
or attempts at verbal communication. The pt has had some
improvement in her secretions, which were previously very thick
and yellow, but are no white/clear and thinning out somewhat
with
aerosol/nebulizer treatments.
TRACH TYPE: [**Last Name (LF) 67572**], [**First Name3 (LF) **]-fit, DIC, #7, cuffed, trach tube
SECRETIONS / ABILITY TO HANDLE CUFF DEFLATION: Pt had been
suctioned by respiratory therapy prior to the evaluation. O2
saturation prior to cuff deflation was at 99% on trach mask, and
with cuff deflation and suctioning, decreased to 96%, but
increased to 99% within 1 minute. There was only a minimal
amount
of secretions noted with cuff deflation, and the pt did not
demonstrate any s&s discomfort, or secretion interference,
distress with cuff deflation.
PMV TOLERANCE / VOCAL QUALITY / O2 SATS:
The pt was able to tolerate the PMV with O2 saturation at 99%,
tracheal pressures between -2 to +7 cm H20 (normal range between
-10 to +10 cm H20), and without any evidence of respiratory
distress or secretion interference.
However, her MS was quite limited during the examination, as the
pt was only intermittently/alert awake. After several minutes of
stimulation and attempting to rouse the pt, she was able to say
"good". Vocal quality was hoarse/breathy with limited volume. No
other verbal communication could be elicited.
SUMMARY:
The pt is able to tolerate the PMV at this time, though her MS,
TBI is limiting her ability to engage in verbal communication
attempts. Discussed with the RN that for today, we could monitor
her O2 saturation, leaving the valve in place to determine if
she
can tolerate the valve for a period of time, which may encourage
her to cough out her mouth, develop increased airflow and
sensitivity to the oropharynx, and may 'catch moments in time'
when the pt may attempt to communicate verbally. It was noted
that when the pt actually spoke, she had very little mouth
movement, making the likelihood of lip [**Location (un) 1131**] unfeasible. If,
however, she is unable to tolerate the PMV today for a period of
time, then the plan can be changed to only place the valve on
when family/visitors, and/or staff interactions appear to
stimulate the pt.
With regards to swallowing, the pt's MS is too depressed/limited
at this time to even to attempt to engage the pt in a swallowing
assessment. However, we can continue to follow the pt to
determine when she may be appropriate for that assessment.
RECOMMENDATIONS:
PMV:
1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE!
2. Monitor O2 Sats / respiration while valve is in place.
3. Do not allow the patient to sleep with the valve in place.
4. If the patient is taking PO's, please deflate the cuff
and place the PMV for eating and drinking.
5. PMV wear schedule is up to the discretion of the
nurse and/or respiratory therapist.
SWALLOWING:
1. Remain NPO with J-tube feeding.
2. Will follow the pt's MS to determine when she may be
appropriate for a swallowing assessment.
Brief Hospital Course:
Patient admitted to the trauma service. Orthopedics, Plastics,
Neurosurgery were consulted because of her injuries; and
admitted to the Trauma ICU for close monitoring.
Neurosurgery placed [**Last Name (un) **] ICP bolt; she was loaded with
Dilantin and serial head CT scans were performed. She will
follow up with Neurosurgery in [**2-25**] weeks for repeat head
imaging. Her Dilantin has been discontinued.
Plastics consulted because of her extensive scalp wound; she was
eventually taken to the operating room on [**6-9**] for scalp
advancement and wound closure; her scalp sutures are to remain
in place for 3-4 weeks at which time she will follow up with
[**Hospital 3595**] clinic. Bacitracin will need to be applied to scalp
wound as directed on page 1.
Orthopedics was consulted for her multiple injuries; her pelvic
fracture was stabilized with closed reduction and fixation; she
was later taken to the operating room on [**2145-5-24**] for ORIF. Her
humerus was repaired on [**2145-5-27**].
She remained in the Trauma ICU vented; she was eventually
trached and a PEG was placed for nutritional support. Her trach
was eventually downsized and removed on [**2145-6-14**]. Her PEG remains
in place and she is receiving tube feedings. Nutrition services
followed patient during her hospitalization.
She did require intermittent intravenous antibiotics for
positive sputum and wound cultures; a PICC was placed secondary
to poor venous access; this line was removed on [**2145-6-14**]. She is
no longer on any antibiotics; most recent WBC on [**6-13**] was 9.5.
She was evaluated by Speech and Swallow for Passy Muir valve
(see pertinent results section).
Physical and Occupational therapy have been consulted and have
recommended a rehab for patients with traumatic brain injuries.
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
6. Metoprolol Tartrate 50 mg Tablet Sig: 1 [**11-23**] Tablet PO BID (2
times a day): hold for HR <60 and/or SBP <110.
7. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Topical TID (3 times a day): Apply to scalp incision.
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
9. Colace 150 mg/15 mL Liquid Sig: One (1) PO twice a day: hold
for loose stools.
10. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
11. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed) as needed for hemorrhoidal
pain/discomfort.
12. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ML's PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
s/p Rollover Motor Vehicle Crash
Right Temporal Subdural Hematoma
Subarachnoid Hemorrhage
Intraventricular Hemorrhage
Right Frontal/temporal Contusions
Diffuse Axomal Innury
Left Parietal Skull Fracture
Right 1st Rib Fracture
Left Pneumothorax
Open Book Pelvic Fracture
Right Sacral Ala Fracture
Bilateral Superior/Inferior Rami Fracture
Left Humerus Fracture
Discharge Condition:
Good
Discharge Instructions:
Plastic Surgery - keep head sutures in place for 3-4 weeks.
Apply Bacitracin to head wound three times a day.
Followup Instructions:
Follow up with Neurosurgery in [**2-25**] weeks; call [**Telephone/Fax (1) 1669**] for
an appointment. Inform the office that you will need to have a
repeat head CT scan for this appointment.
Follow up in [**Hospital 5498**] Clinic in [**12-25**] weeks; call [**Telephone/Fax (1) 1228**]
for an appointment.
Follow up in [**Hospital 3595**] Clinic in 3 weeks, call [**Telephone/Fax (1) 5343**] for
an appointment.
Follow up in Trauma Clinic in 4 weeks; call [**Telephone/Fax (1) 6439**] for an
appointment.
Completed by:[**2145-6-14**]
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50,863
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41359
|
Discharge summary
|
report
|
Admission Date: [**2139-5-19**] Discharge Date: [**2139-6-5**]
Date of Birth: [**2064-3-14**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
[**2139-5-21**] R colectomy w/ primary ileocolonic anastomosis
History of Present Illness:
75M with previous history of LGIB in setting of known
diverticulosis who presents with dark red lower GI bleed.
Patient first noticed profuse and spontaneous "darkish red
blood" around 9 am on Tuesday ([**5-19**]). He experienced another
3-4 episodes precipitating visit to ED at 2pm. Reports
dizziness with some mild chest pain at the time of his bleeding.
He denied any abdominal pain, nausea, vomiting/hematemesis,
fever, coughing, or changes in bowel movements.
He notes that he did not eat much on the day of presentation,
other than some bananas in the morning. Patient denies taking
any over the counter medications to ease the bleeding. His last
colonoscopy was in [**2133**] and the patient believes he was told
that he had diverticulosis.
At time of consultation, AFVSS, 2u pRBC without appropriate
hematocrit response, CTA without active extravasation,
hemodynamically appropriate, GI consultation pending.
Past Medical History:
MGUS, COPD, Asthma, Epilepsy (with 3-4 "grand-mal seizures"
in the past. Most recent was 18 mos ago), Aortic Aneurysm, and
Acid Reflux
Social History:
The patient smokes about 2 pipes/day. He used to smoke about
[**5-29**] pipes per day before gradually reducing the amount. He has
been smoking for over 40 years. Patient denies
alcohol/recreational drug use. The patient is a physicist who
used to work for Crystal System before retiring. He is
currently separated from his wife.
Family History:
father, grandfather and great grandfather all died of MI at 52
Physical Exam:
On admission:
VS: in the ED initially: 98 110 121/80 18 98% on RA
Gen: AAOX3, on nonrebreather, but otherwise in NAD< appears very
comfortable, speaking in full sentences.
HEENT:atraumatic
Neck:supple
Lungs:cta bilaterally no r/w/r
CV:RRR s1s2 no m/r/g
Abd.:soft protuberant, nt/nd +bs no HSM no stigmata of chronic
liver disease
Ext:no erythema or edema
Neuro: CNii-xii grossly intact
Rectal exam: on presentation to the ED was having bright red
blood per rectum
On discharge:
VS: T 97.9 P 80 BP 107/70 R 20 O2sat 98% RA
GEN: A&O, NAD
HEENT: Small laceration and echymosis to left foreheard, suture
in place.
PULM: Breath sounds diminished at RLL, no crackles/wheezes.
CV: RRR
ABD: Soft, appropriately tender at incision, nondistended.
Midline surgical incision open with dry dressing in place.
EXTR: 1+ edema bilaterally to LE, no edema upper extremities.
Warm, pink and well perfused.
Pertinent Results:
[**2139-5-19**]: ECG:
Sinus tachycardia. Non-specific repolarization abnormalities.
Compared to the previous tracing of [**2139-5-14**] the rate has
increased. Otherwise, findings are similar.
[**2139-5-19**]: CHEST PORT. LINE PLACEMENT
IMPRESSION: Right internal jugular central venous catheter tip
in the mid SVC. No pneumothorax.
[**2139-5-19**] CTA ABD & PELVIS:
IMPRESSION:
1. No definite evidence of active extravasation to localize the
patient's GI bleeding. Small internal hemorrhoid. Focal area of
increased enhancement in proximal transverse colon at hepatic
flexure is likely from a contracted bowel segment as it is
symmetric.
2. Asymmetric prostate enhancement with prostatic enlargement.
Correlate with PSA and physical examination.
3. Diverticulosis without diverticulitis. Cholelithiasis
without
cholecystitis.
4. Bilateral renal cysts.
5. Moderate-to-severe atherosclerotic disease in the coronary
arteries and abdominal aorta and major branches.
6. Sub-4 mm left lower lobe nodule for which follow up in 1
year is only
required if high risk for malignancy, [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] society
guidelines
[**2139-5-20**] GI BLEEDING STUDY:
IMPRESSION: Active large bowel GI bleed originating at the
region of the hepatic flexure.
[**2139-5-20**]:
PROCEDURES:
1. Selective superior mesenteric artery angiogram.
2. Selective inferior mesenteric artery angiogram.
3. Superselective contrast injections of second and third order
branches of the middle colic artery.
4. Superselective injections of the three branches of the
superior mesenteric artery supplying the sigmoid colon.
5. Sidearm angiogram of the right common femoral artery
bifurcation.
6. Hemostasis by deployment of 6 French Angio-Seal closure
device.
CONCLUSIONS:
1. Selective superior mesenteric artery DSA angiogram, inferior
mesenteric DSA angiogram and multiple supraselective DSA
injections of the second and third order branches of the
superior mesenteric artery disclosed no active arterial
bleeding.
2. Hemostasis by deployment of 6 French Angio-Seal closure
device in the
right common femoral artery.
[**2139-5-22**]: ECG:
Sinus tachycardia. Premature ventricular complexes. Non-specific
repolarization abnormalities. Compared to the previous tracing
of [**2139-5-19**]
no significant difference.
[**2139-5-22**]: ECG:
Sinus rhythm. Probable left atrial abnormality. Non-diagnostic Q
waves
in leads III and aVF. Compared to the previous tracing of [**2139-5-22**]
ventricular ectopy is absent
[**2139-5-22**]: ECG:
Sinus tachycardia with frequent and multifocal ventricular
premature beats. Non-specific lateral ST-T wave changes.
Compared to tracing #1 ventricular ectopy is seen and lateral ST
segment changes are new. Clinical correlation is suggested.
TRACING #2
[**2139-5-22**]: CHEST (PORTABLE AP):
There are lower lung volumes. Aside from linear atelectasis in
the left lower lobe, the lungs are clear. There is no evident
pneumothorax or pleural effusion. Cardiac size is top normal
and stable
[**2139-5-22**]: CHEST (PORTABLE AP):
FINDINGS: The right IJ line has been removed. Lung volumes are
slightly low. There is mild cardiomegaly and mild pulmonary
vascular redistribution. There is volume loss at both bases,
but no definite infiltrate.
[**2139-5-23**] ECHO:
IMPRESSION: Normal regional and global biventricular systolic
function. Mild calcific aortic stenosis. Mild mitral
regurgitation. Compared with the prior study (images reviewed)
of [**2138-10-14**], mild aortic stenosis is seen on the current
study. The severity of mitral regurgitation has increased
slightly. Pulmonary artery systolic pressures have increased.
[**2139-5-23**]: ECG:
Sinus rhythm with ventricular premature beats. Compared to
tracing #2
the heart rate is slower and lateral ST segment changes are less
prominent. TRACING #3
[**2139-5-24**]: CHEST (PORTABLE AP):
FINDINGS: There are small bilateral pleural effusions. There
continues to be volume loss/infiltrate in the right lower lobe,
although there has been some interval partial clearing. Upper
lungs are clear.
[**2139-5-25**]: ECG
Sinus tachycardia with occasional ventricular premature
contractions that are multifocal. Compared to previous tracing
dated [**2139-5-23**], there is no change.
[**2139-5-26**] CT ABD & PELVIS WITH CONTRAST:
IMPRESSION:
1. Collection of extraluminal air and fluid adjacent to the
anastomotic site and extension of fluid from the site to the
pericolic gutter. Findings are concerning for an anastomic leak.
Repeat scanning could be considered after oral contrast has
passed the anastomosis to evaluate for extraluminal contrast.
2. Cholelithiasis without any evidence of cholecystitis.
3. Extensive diverticular disease in the rectosigmoid colon.
4. Air- and fluid-filled distended small bowel consistent with
postoperative
ileus.
[**2139-5-26**] CT ABD & PELVIS W/O CONTRAST:
IMPRESSION:
1. While oral contrast is yet to reach the ileocolic anastomosis
there has
been an interval increase in the amount of surrounding free
intraperitoneal air and extensive mesenteric free fluid which
raises the concern for anastomotic leak. Upstream dilatation of
the small bowel seen is relatively uniform throughout and may
reflect postoperative ileus.
2. Moderate hiatal hernia.
[**2139-5-26**] CHEST (PORTABLE AP):
IMPRESSION: AP chest compared to [**5-24**], 9:40 a.m.:
Tip of the endotracheal tube is in standard position.
Nasogastric tube is
looped in the mid esophagus and would need to be advanced at
least 15 cm to move all the side ports into the stomach. Mild
pulmonary vascular congestion is new but there is no pulmonary
edema. Focal opacification in the infrahilar right lower lobe
has improved since [**5-23**], suspicious for pneumonia.
[**2139-5-27**]: ECG
Normal sinus rhythm with frequent ventricular premature
complexes in couplets. Intra-atrial conduction abnormality.
Possible inferior myocardial infarction of indeterminate age.
Non-specific diffuse ST segment abnormalities. Compared to the
previous tracing of [**2139-5-25**], ventricular premature complexes
persist as
do the ST segment abnormalities.
[**2139-5-27**]: ECG
Normal sinus rhythm. Intra-atrial conduction abnormality.
Frequent
ventricular premature complexes, some in couplets. Non-specific
ST segment
abnormalities, most marked in the lateral precordial leads.
Compared to the previous tracing, there is no significant
change.
TRACING #2
[**2139-5-27**]: CHEST (PORTABLE AP):
Vascular congestion on low lung volumes persist. Residual right
lower lobe consolidation has not worsened. Heart size is
normal. Pleural effusion is small, on the left if any.
Nasogastric tube is still looped in the midesophagus. ET tube
in standard
placement.
[**2139-5-27**]: CHEST PORT. LINE PLACEM
IMPRESSION: Right-sided PICC line tip now in the right atrium.
It should be pulled back 5 cm for more optimal placement at the
cavoatrial junction.
[**2139-5-28**]: CHEST (PORTABLE AP):
FINDINGS: As compared to the previous radiograph, the
nasogastric tube and the right PICC line are still seen. The
right PICC line has been pulled back by approximately 2 to 3 cm
and its tip now projects over the mid-to-low SVC. In the
interval, there has been development of bilateral areas of
atelectasis and minimal increase in diameter of the pulmonary
vasculature, potentially caused by mild fluid overload.
Unchanged moderate cardiomegaly. No parenchymal opacity
suggestive of pneumonia.
[**2139-5-29**]: CHEST (PORTABLE AP);
IMPRESSION: AP chest compared to [**5-27**] through 7. Dependent
edema and atelectasis have worsened since [**5-28**]. Moderate
cardiomegaly is more pronounced and small bilateral pleural
effusions are presumed. Right PIC line passes to the low SVC.
[**2139-5-30**]: CHEST (PORTABLE AP):
FINDINGS: Comparison is made to prior study from [**2139-5-29**].
There is a right-sided central line with distal lead tip in the
distal SVC. There are small bilateral pleural effusions. There
is atelectasis at the lung bases. However, the opacity at the
right lung base is more apparent and may be due to developing
infiltrate. Continued attention to this area is recommended on
subsequent exams. There are no pneumothoraces.
[**2139-5-31**]: CHEST (PORTABLE AP):
FINDINGS: Comparison is made to prior study from [**2139-5-30**].
The right base opacity seen on the prior study is less well
seen. There is a persistent left retrocardiac opacity. There
are no pneumothoraces. There is a right-sided central venous
line with distal lead tip in the distal SVC. There are low lung
volumes. There are small bilateral pleural effusions, stable.
[**2139-6-3**] CT HEAD W/O CONTRAST:
1. No intracranial hemorrhage or fracture.
2. Age-appropriate global atrophy.
3. Chronic left maxillary sinus inflammatory disease; correlate
clinically.
[**2139-6-3**] CHEST (PA & LAT):
IMPRESSION: Small left greater than right pleural effusions,
with improvement in aeration compared with [**5-31**].
[**2139-6-3**] EEG (prelim read):
no epileptiform discharges, occasional L posterior slowing,
otherwise normal.
Labs on admission:
[**2139-5-19**] 05:00PM WBC-8.5 RBC-4.53* HGB-10.8* HCT-34.0* MCV-75*
MCH-23.9* MCHC-31.7 RDW-18.4*
[**2139-5-19**] 05:00PM NEUTS-67.6 LYMPHS-23.5 MONOS-5.0 EOS-2.9
BASOS-1.1
[**2139-5-19**] 05:00PM PLT COUNT-279
[**2139-5-19**] 05:00PM PT-11.1 PTT-25.7 INR(PT)-1.0
[**2139-5-19**] 05:00PM GLUCOSE-95 UREA N-19 CREAT-1.0 SODIUM-137
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
[**2139-5-19**] 10:44PM HCT-32.7*
Labs at discharge:
[**2139-6-4**] 04:44AM BLOOD WBC-10.7 RBC-3.55* Hgb-9.6* Hct-30.2*
MCV-85 MCH-27.1 MCHC-31.8 RDW-19.6* Plt Ct-564*
[**2139-6-4**] 04:44AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-131*
K-4.7 Cl-98 HCO3-31 AnGap-7*
[**2139-6-4**] 04:44AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.8
[**2139-6-3**] 01:45AM BLOOD Prolact-13
Brief Hospital Course:
Pt is a 75 year-old with history of seizure disorder, COPD,
GERD, abdominal aortic aneurysm, presenting with multiple
episodes of painless BRBPR and admitted on [**2139-5-19**] under the
medical service. Medical course is as follows:
Patient was initially transferred to MICU for management of GI
Bleed. Patient underwent CTA evening of admission which did not
localize bleed. Surgery and GI consulted on patient and
recommended bleeding scan should patient rebleed. Patient
received one unit of pRBCs in ED and one additional until of
pRBCs on arrival to ICU.
Patient's bleeding stopped the evening he arrived to ICU ([**5-19**])
and he remained hemodynamically stable overnight. On the
morning of [**5-20**], patient started having BRBPR and systolic BP
dropped to 80s. He went for bleeding scan which localized
bleeding to hepatic flexure. Patient went to angio for
embolization, but could not be embolized. He was transferred to
surgical service for right hemicolectomy with primary
anastamosis overnight into [**5-21**].
Post-operatively, he was observed in the surgical ICU and was
transferred out to the floor a few hours later in the morning
hemodynamically stable.
On the floor pain management was difficult to achieve. He
failed to pass flatus initially believed to be caused by opiate
use, which was also contributing to delirium. Over the course
of the following days he failed to advance his bowel function,
had increasing distension and pain, to the point that on a
repeat CT scan was done on [**5-26**] which was highly suspicious for a
leak at the anastamosis. He was then transferred back to the ICU
on [**2139-5-26**] due to increasing abdominal distention, pain and
worsening confusion. He was subsequently taken back to the OR
that same day for revision and creation of a diverting loop
ileostomy. Please see Dr.[**Name (NI) 1863**] operative note for
additional details.
His post-operative course, by system:
Neuro: He was extubated one day after the takeback. He was
initially placed on a dPCA and then intermittent IV then PO
dilaudid and tylenol. He did show initial confusion/delerium in
the postoperative period, agitated and combative at times and
striking the nurse. Psych consult was obtained recommending
haldol for agitation. His confusion gradually improved and by
[**5-31**], day of transfer to the floor, he was markedly improved,
AAOx3 and no longer combative/agitated. However, following
transfer to the floor, the patient was triggered for
hallucinations after receiving intravenous hydromorphone.
Overnight, he again became agitated and combative requiring
bilateral wrist restraints; hydromorphone usage minimized.
Geriatric consulted was obtained who recommended standing
oxycodone dosing and seroquel qhs, which was started on [**6-2**].
However, his confusion and agitation continued and overnight on
[**5-21**] he sustained a fall while trying to get out of bed on
his own to use the urinal. Pt struck his head and had a small
laceration but no LOC. A head CT was obtained with was negative
for any acute injury. On [**6-3**] his medications were again changed
and he was started on tramadol for nonnarcotic pain management
and zyprexa for agitation. A neurology consult was also
obtained at that time who recommended an EEG which was performed
which was negative. Neurology felt the patient was stable from
their perspective to be discharged to rehab and recommended
follow up in one month with Dr. [**Last Name (STitle) 623**], the patients
primary neurologist. His home keppra was continued throughout
his hospitalization.
Psychiatry was consulted during his hospital course for given
his delirium. At the time of discharge it was concluded that the
was ongoing slow resolution of delirium, likely secondary to
complex medical comorbities, including malnutrition, pain,
post-op status, and anemia. His agitation and confusion seemed
to be much improved.
CV: His troponins were trended perioperatively peaking and
stabilizing at 0.20. He did not have EKG changes suggesting
infarct and was hemodynamically stable. Cardiology was asked to
reassess and recommended continuing current management with
metoprolol given presumed demand ishemia. He was continued on
aspirin 81.
Resp: Extubated postop. Showed signs of fluid overload
(crackles on exam) and was therefore diuresed with furosemide
intermittently to good effect. Satting in the mid to high 90s
on 3LNC on transfer to floor. Diuresis with prn furosemide was
continued and his supplemental oxygen was weaned, with oxygen
saturations remaining in the mid to upper 90's on room air.
Incentive spirometry and pulmonary toileting were encouraged,
prn albuterol sulfate per patient's home regimen was continued.
Patients lung sounds remained diminished at right lower lobe but
chest xray on [**6-3**] showed improvement in prior pleural
effusions.
GI: Ileostomy looked slighly dusky immediately post-operatively
but improved. He had ostomy output two days after his
takeback/diverting ileostomy and was progressed to sips then
clears, and ultimately to a regular diet on [**6-1**] which he
tolerated without difficulty.
GU: Foley catheter. UOP was good and accentuated with the use
of lasix to diurese (see resp section above). His foley was
removed on [**6-1**] at which time he voided without difficulty. ON
[**6-2**] he was noted to have urinary frequency and a u/a was
obtained which was negative. Again on [**6-5**] he complained of
dysuria and a u/a was negative. He was voiding adequate amounts
of concentrated yellow urine.
Heme: He was transfused 2 units of PRBC on [**2139-5-29**] for a Hct that
was trending down (23.3) in the setting of known demand
ischemia. His post-transfusion Hct responded appropriately (30)
and remained stable throughout the remainder of his hospital
course.
ID: Maintained on cipro/flagyl post-operatively for 14 days.
Afebrile but wound showed some slight drainage 2-3 days from the
takeback with increasing erythema and WBC increasing to 13.9
then 11.1 (from [**7-30**]). A few staples were removed in the area of
increased drainage on [**2139-5-31**] and packed with gauze with [**Hospital1 **]
dressing changes. However, on [**6-2**] his wound showed continued
errythema with induration and all staples were removed and the
wound was opened to allow drainage. [**Hospital1 **] dry dressing changes
were performed, with plan for patient to return to [**Hospital 2536**] clinic 1
week from discharge for possible vac placement.
Musk: Physical therapy was consulted to evaluate the patient's
mobility postoperatively who recommended discharge to rehab when
the patient was medically cleared.
On [**2139-6-5**] Mr. [**Known lastname 90043**] is afebrile and hemodynamically stable.
He is tolerating a regular diet and having output via his
ileostomy. His delirium is improving and he is neurologically
stable. He is being discharged to rehab with ACS follow up as
well as neurology follow up in place.
Medications on Admission:
albuterol sulfate 90 mcg QID PRN sob/wheezing
ipratropium bromide 17 mcg HFA 1 puff Q4 - 6 hrs PRN
sob/wheezing
levetiracetam 500 mg [**Hospital1 **]
aspirin 81 mg daily
latanoprost 0.005 % 1 drop qHS
ferrous sulfate 300 mg [**Hospital1 **]
omeprazole 20 mg [**Hospital1 **]
Discharge Medications:
1. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation QID (4 times a day).
4. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
5. levetiracetam 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
6. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
9. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours).
10. olanzapine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
11. olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
12. metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H
(every 8 hours) for 5 days: Total 14 day course [**Date range (1) 90047**].
13. ciprofloxacin 500 mg Tablet [**Date range (1) **]: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: Total 14 day course [**Date range (1) 90047**].
14. nystatin 100,000 unit/mL Suspension [**Date range (1) **]: Five (5) ML PO QID
(4 times a day).
15. tramadol 50 mg Tablet [**Date range (1) **]: One (1) Tablet PO QID (4 times a
day).
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 246**] Nursing Center - [**Location (un) 246**]
Discharge Diagnosis:
Right colonic bleed and severe pancolonic diverticulosis.
Anastomotic leak.
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 with lower gastrointestinal
bleeding from diverticulosis. You subsequently underwent a
right colectomy and were recovering in the hospital and
developed abdominal pain related to an anastamotic leak. This
required a second operation resulting in creation of and
ileostomy. Again, you recovered in the hospital, received
teaching for ileostomy care, and are now preparing for discharge
to rehab with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of 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 in 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.
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 [**4-30**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
Dressing changes will be performed by the nurses at the rehab.
When you come back to your clinic appointment we will likely
place a wound vac to help your incision heal, depending on how
the incision looks at that time.
*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, but
you may shower.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: FRIDAY [**2139-6-12**] at 8:30 AM
With: ACUTE CARE CLINIC/ Dr [**Last Name (STitle) 853**]
Phone:[**Telephone/Fax (1) 90048**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
We are working on a follow up appt with Dr. [**Last Name (STitle) 5560**] in the
1 month. You will be called at rehab with the appointment. If
you have not heard or have questions, please call [**Telephone/Fax (1) 7773**].
Completed by:[**2139-6-5**]
|
[
"311",
"428.31",
"273.1",
"998.59",
"E849.7",
"873.42",
"280.9",
"493.20",
"416.8",
"560.1",
"411.89",
"E878.2",
"E888.9",
"338.18",
"567.29",
"997.1",
"285.1",
"263.9",
"997.49",
"424.1",
"041.7",
"568.0",
"349.82",
"428.0",
"293.0",
"305.1",
"345.10",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.01",
"45.73",
"54.59",
"45.79",
"45.62",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
21818, 21909
|
12757, 19732
|
280, 344
|
22029, 22029
|
2815, 11959
|
24960, 25570
|
1825, 1889
|
20058, 21795
|
21930, 22008
|
19758, 20035
|
22180, 24090
|
24105, 24937
|
1904, 1904
|
2385, 2796
|
232, 242
|
12424, 12734
|
372, 1299
|
11973, 12405
|
22044, 22156
|
1321, 1458
|
1474, 1809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,996
| 176,702
|
6224
|
Discharge summary
|
report
|
Admission Date: [**2153-10-3**] Discharge Date: [**2153-10-8**]
Date of Birth: [**2095-9-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
diabetic ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 6818**] is a pleasant 58M with diabetes x 30yrs, CAD sp MI
and stents x2, who was brought to the ED today by his wife for
poor po intake x weeks, dizziness and weakness for 4 days. The
patient is unable to recount much of the history but states that
he was fed up with his medications and and thought they were too
expensive so stopped taking all of them several months ago.
Denies fevers, cp, sob, abdom pain, N/V, dysuria, endorses
polyuria and polyphasia. Per his wife, he has had intermittent
abd pain, and decreased appetite, did not go to work on tuesday
because of fatigue. She also states that he had two falls
recently but does not know if he hit his head.
In the ED, inital vitals were 96.1 111 93/60 16 100%. Labs were
notable for a bicarb of 5, lactate of 7.1, gap of 42. Lipase
was elevated at 210. Gas showed pH of 6.97 12 151. Trops were
negative, WBC elevated to 11.2. He was given 4 L IVF, 7 units
insulin, and started on 7 u/hr drip, given 40 kcl. Lactate
improved to 5.0 with fluids. CXR was unremarkable. EKG was
performed and showed sinus tach, TWI and ST depressions
inferolaterally. Head CT was performed for unclear reasons,
likely AMS.
.
On the floor, pt states he is thirsty, but otherwise denies
symptomatology. Specifically no abd pain, CP, SOB.
.
Review of sytems:
(+) Per HPI, polyuria, polydipsia, constipation.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea or
abdominal pain. No recent change in bowel habits. No dysuria.
Denied arthralgias or myalgias.
Past Medical History:
DM, diagnosed in [**2119**]
CAD s/p MI with multiple stents placed 10 yrs ago
Depression
Social History:
Lives with wife. [**Name (NI) **] 2 grown children, ages 24 and 28. Works
as a custodian at a school. No tob, etoh, illicits.
Family History:
mother with diabetes. Denies any family hx of malignancy, heart
disease.
Physical Exam:
Vitals: T:97.6 BP:166/77 P:101 R:20 O2:100% RA
General: aao x 3 but somnolent, no acute distress
HEENT: Sclera anicteric, MM dry, 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, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Pertinent Results:
Admission labs:
[**2153-10-3**] 09:30PM WBC-11.2*# RBC-6.07 HGB-17.4 HCT-53.2*
MCV-88# MCH-28.7 MCHC-32.8 RDW-12.8
[**2153-10-3**] 09:30PM NEUTS-90.1* LYMPHS-5.9* MONOS-3.7 EOS-0.1
BASOS-0.1
[**2153-10-3**] 09:30PM PLT COUNT-331
[**2153-10-3**] 09:30PM PT-11.9 PTT-21.2* INR(PT)-1.0
[**2153-10-3**] 09:30PM GLUCOSE-714* UREA N-52* CREAT-3.2*#
SODIUM-132* POTASSIUM-5.1 CHLORIDE-85* TOTAL CO2-5* ANION
GAP-47*
[**2153-10-3**] 09:30PM ALT(SGPT)-27 AST(SGOT)-25 LD(LDH)-205 ALK
PHOS-110 TOT BILI-0.4
[**2153-10-3**] 09:30PM LIPASE-210*
[**2153-10-3**] 09:30PM cTropnT-<0.01
[**2153-10-3**] 09:38PM GLUCOSE-GREATER TH LACTATE-7.1* K+-5.1
[**2153-10-3**] 10:19PM PO2-151* PCO2-12* PH-6.97* TOTAL CO2-3* BASE
XS--28
[**2153-10-3**] 11:15PM GLUCOSE-484* UREA N-46* CREAT-2.4* SODIUM-137
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-6* ANION GAP-37*
Chemistry trend:
[**2153-10-3**] 09:30PM BLOOD Glucose-714* UreaN-52* Creat-3.2*#
Na-132* K-5.1 Cl-85* HCO3-5* AnGap-47*
[**2153-10-3**] 11:15PM BLOOD Glucose-484* UreaN-46* Creat-2.4* Na-137
K-4.4 Cl-98 HCO3-6* AnGap-37*
[**2153-10-4**] 03:01AM BLOOD Glucose-268* UreaN-42* Creat-2.1* Na-133
K-4.4 Cl-101 HCO3-9* AnGap-27*
[**2153-10-4**] 10:59AM BLOOD Glucose-137* UreaN-30* Creat-1.7* Na-136
K-3.6 Cl-106 HCO3-18* AnGap-16
[**2153-10-4**] 03:20PM BLOOD Glucose-210* UreaN-26* Creat-1.5* Na-136
K-4.0 Cl-105 HCO3-15* AnGap-20
[**2153-10-4**] 01:30PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-300 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Discharge labs:
[**2153-10-8**] 05:55AM BLOOD WBC-4.7 RBC-4.37* Hgb-12.8* Hct-35.2*
MCV-81* MCH-29.3 MCHC-36.4* RDW-12.5 Plt Ct-195
[**2153-10-8**] 05:55AM BLOOD Glucose-69* UreaN-16 Creat-1.0 Na-141
K-4.1 Cl-103 HCO3-31 AnGap-11
Micro:
[**10-4**] Urine culture negative
[**10-3**] Blood cultures pending (negative at time of d/c)
Imaging:
[**10-3**] EKG:
Sinus tachycardia. Diffuse T wave inversions in the inferior and
anterolateral leads. There is a suggestion of left ventricular
hypertrophy, although the voltage criteria are not met. Abnormal
tracing. Compared to the previous tracing sinus tachycardia is
new and the T wave and ST segment abnormalities are new. The
prior tracing was recorded on [**2140-4-23**].
[**10-3**] CXR: IMPRESSION: No acute cardiac or pulmonary process.
[**10-3**] CT Head: IMPRESSION: Carotid arterial atherosclerotic
calcifications. Otherwise normal study.
[**10-4**] EKG: Normal sinus rhythm. Diffuse non-specific ST segment
abnormalities. Abnormal tracing. Compared to the previous
tracing sinus tachycardia is no longer present and the T wave
inversions are much less marked.
Brief Hospital Course:
Pleasant 58 yo gentleman admitted for DKA in the setting of
medication non-compliance and found to have major depression
requiring inpatient psychiatric stay.
# Diabetic ketoacidosis: Patient arrived with large gap in the
ED. He had a severe metabolic acidosis with arterial pH 6.97,
bicarb 5, from both ketoacidosis and lactic acidosis. He was
started on fluids and insulin drip in ED. No infectious source
was found, but patient had been off of all of his medications.
Lactate improved rapidly with rehydration. He had aggressive K+
and fluid repletion with Q4hr labs and venous pH monitoring.
When his anion gap improved, he was taken off of the regular
insuling drip and transitioned to 27 units of lantus with a
humalog sliding scale. He was discharged back on his home
lantus regimen of 54 units with reduced sliding scale given his
poor appetite and low PO intake.
# ST depressions: While tachycardic, no symptoms of ACS, two
sets of troponins were negative. Likely due to fixed defect in
setting of tachycardia. He may benefit from an exercise stress
test as an outpatient.
# Acute renal failure: Creatinine up to 3.2 from baseline 1.1 to
1.2. Likely pre-renal in the setting of severe dehydration from
DKA, as his creatinine improved quickly with rehydration.
# Depression: Likely contributing to med non-complicance. Pt
denies depression currently but wife states he has been acting
depressed at home. Found to be severely depressed by our social
worker and then sectioned by psychiatry to require inpatient
treatment.
Medications on Admission:
Pt has not been taking any meds x 2 months.
- [**Company 4916**] [**Hospital1 **], MA med list:
#. Lantus 54units SC qhs (last [**7-5**])
#. Novolog - 20units @ breakfast, 18units @ lunch/snack, 36units
@ dinner (last [**7-5**])
#. Isosorbide mononitrate 60mg PO daily (last [**3-5**])
#. Amlodipine 10mg PO daily (last [**3-5**])
#. Clonidine 0.1mg PO BID (last [**3-5**])
#. Simvastatin 80mg PO daily (last [**11-3**])
---
additional meds on Atrius records:
#. Lisinopril 20mg PO daily
#. Atenolol 100mg PO Daily
#. Mirtazapine 15mg PO qhs
#. MVI 1tab PO daily
Discharge Medications:
1. insulin glargine 100 unit/mL Solution Sig: Fifty Four (54)
units Subcutaneous at bedtime.
2. Humalog sliding scale
Please continue the attached Humalog insulin sliding scale.
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. Cepacol Sore Throat 15-3.6 mg Lozenge Sig: One (1) lozenge
Mucous membrane twice a day as needed for sore throat.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital
Discharge Diagnosis:
Diabetic ketoacidosis
Major depressive disorder
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 with very high blood sugars
after stopping all of your medications including your insulin.
You had a condition called diabetic ketoacidosis which improved
with fluids and insulin treatment. We restarted your other home
medications as well. We felt you were depressed and you will be
transferred to a facility to help focus on your mood.
The following changes were made to your medications:
1. Adjusted your sliding scale as attached as you are not eating
much food right now. Please discuss adjusting this scale with
your doctors once [**Name5 (PTitle) **] get out of the hospital and your appetite
improves.
2. Reduced your simvastatin dose to 20mg daily as it can
intereact with your blood pressure medication amlodipine.
3. Stopped your mirtazapine while psychiatry is figuring out a
different medication regimen for you.
4. Stopped your clonidine as your blood pressure was controlled
without it.
Followup Instructions:
Please follow-up with your PCP after discharge from your
psychiatric facility.
|
[
"296.23",
"401.9",
"250.12",
"288.60",
"V15.82",
"414.01",
"794.31",
"276.51",
"V58.67",
"412",
"V45.82",
"584.9",
"V15.81",
"V62.84"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8668, 8719
|
5717, 7254
|
326, 333
|
8811, 8811
|
3062, 3062
|
9925, 10007
|
2355, 2430
|
7868, 8645
|
8740, 8790
|
7281, 7845
|
8962, 9902
|
4589, 5375
|
2445, 3043
|
265, 288
|
1690, 2081
|
361, 1672
|
5384, 5694
|
3078, 4573
|
8826, 8938
|
2103, 2193
|
2209, 2339
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,412
| 137,917
|
35131
|
Discharge summary
|
report
|
Admission Date: [**2128-11-9**] Discharge Date: [**2128-12-9**]
Date of Birth: [**2053-9-20**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Reglan
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Ischemic bowel
Major Surgical or Invasive Procedure:
[**2128-11-9**] - 1. Extended right colectomy.
2. Right hepatic laceration treated with an argon beam
coagulation and packing.
3. A [**Location (un) 5701**] bag closure.
[**2128-11-10**] - 1. Reopening of abdomen.
2. Argon beam coagulation of liver laceration.
3. [**Location (un) 5701**] bag closure of the abdomen.
[**2128-11-13**] - 1. Reopening of abdomen.
2. Cholecystectomy.
3. Ileostomy.
4. Removal of Port-A-Cath.
History of Present Illness:
75F with scleroderma, gastric dysmotility, receiving chronic
parenteral nutrition transferred from [**Hospital **] hospital after
presenting with fevers and chills. During her hospitalization
there, she became hypotensive. She was started on Dopamine and
aggressively volume resuscitated, receiving 5L prior to
transfer.
While here, she has continued to be hypotensive and has received
an additional 2L of IVF. Her pressor requirement has increased,
as she now is requiring Levophed and Dopamine to maintain SBP
>90. Her ostomy output is now bloody.
She reports not feeling well this weekend. Last night she began
having fevers and chills. She denies any chest pain or shortness
of breath. She denies any dysuria or hematuria. She has diarrhea
at baseline, which has not changed in volume of late. She does
have a R-sided port in place, which she has had for the last 6
months to receive TPN. She denies any drainage or erythema
around
the port site. She does not receive any nutrition orally.
Past Medical History:
Scleroderma
Gastric dysmotility
L colectomy and end transverse colostomy for presumed sigmoid
volvulus
R-sided port-a-cath for TPN
Gastostomy
h/o C. difficile colitis
prior prolonged hospitalization for ? sepsis
Social History:
Lives at home, has an aide that comes in daily. She is a
former smoker, quitting 8 months ago. Rare EtOH. She denies drug
use. She has one daughter and 5 grandchildren.
Family History:
Non-contributory to current situation.
Physical Exam:
PE: 96.8 104 95/67 (on 0.21 of Levo and 5 of Dopamine) 20
100% on 6L
NAD. A&Ox3. Ill-appearing.
Anicteric. Tacky mucosal membranes.
Trachea midline. No JVD, TM, or LAD.
Tachycardic. Regular.
Diminished bases. Fair aeration.
Soft. Distended. Hypoactive BS. NT. Dark/black blood in ostomy
bad. Stoma edematous/ischemic. Gastrostomy w/ benign, clear
output.
Clammy extremities. Cyanotic digits.
Moving all 4.
Pertinent Results:
[**2128-11-9**] 11:10AM PT-20.7* PTT-55.7* INR(PT)-1.9*
[**2128-11-9**] 11:10AM WBC-16.7* RBC-3.42* HGB-10.7* HCT-32.7*
MCV-96 MCH-31.3 MCHC-32.8 RDW-15.4
[**2128-11-9**] 11:10AM ALT(SGPT)-64* AST(SGOT)-193* CK(CPK)-335* ALK
PHOS-173* TOT BILI-3.1*
[**2128-11-9**] 11:10AM GLUCOSE-71 UREA N-25* CREAT-1.1 SODIUM-145
POTASSIUM-3.7 CHLORIDE-119* TOTAL CO2-10* ANION GAP-20
[**2128-11-9**] 11:20AM GLUCOSE-69* LACTATE-5.5* NA+-145 K+-3.8
CL--122* TCO2-10*
[**11-9**] CT AP: Extensive circumferential bowel wall thickening
extending from the colostomy affecting mainly the right colon,
highly concerning for ischemic bowel, with small amount of
extraluminal air. Infection and inflammatory processes are much
less likely.
Brief Hospital Course:
Operations/Procedures:
[**2128-11-9**]: TO OR
1. Extended right colectomy.
2. Right hepatic laceration treated with an argon beam
coagulation and packing.
3. A [**Location (un) 5701**] bag closure.
[**2128-11-10**]; TO OR
1. Reopening of abdomen.
2. Argon beam coagulation of liver laceration.
3. [**Location (un) 5701**] bag closure of the abdomen.
[**2128-11-13**]: To OR
1. Reopening of abdomen.
2. Cholecystectomy.
3. Ileostomy.
4. Removal of Port-A-Cath.
[**2128-12-7**] Tunneled R Central line (double lumen) Placed by IR.
Brief Hospital Course:
Pt was promptly taken to the operating room for an extended
right colectomy for ischemic colitis. [**Location (un) 5701**] bag was placed to
close the abdomen with the intention of taking the pt back to
the OR for a 2nd look. The following day, the pt was taken back
to the OR. The small bowel appeared to be viable. There was
oozing from a hepatic laceration and argon beam coagulation was
performed. Post-operatively, the pt remained critically ill. On
[**11-13**] she went back to the operating room with ? sepsis.
Currently patient is stable, white count has normalized. She
will be discharged to a rehabilitation facility with trach,
g-tube, ileostomy and foley. VAC changes to abdomen will be done
q 3 days.
Medications on Admission:
Lyrica 150'', Keppra 250', Prevacid 30', Iron 325', Flagyl 250'
x4d
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: per sliding
scale ml Injection ASDIR (AS DIRECTED).
2. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical QID
(4 times a day) as needed for skin folds.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Pregabalin 75 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO BID (2 times
a day).
5. Escitalopram 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO DAILY
(Daily).
7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml
Injection [**Hospital1 **] (2 times a day).
9. Outpatient Lab Work
Please follow LFT's, amylase and lipase, and when trending down
add fat back to TPN
10. TPN
See additional sheet with current TPN
11. Sodium Chloride 0.9 % 0.9 % Solution [**Hospital1 **]: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis: Ischemic bowel
Secondary Diagnosis: Sepsis
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.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on [**12-31**], Friday at
2:15. [**Hospital Ward Name 23**] Building [**Location (un) 470**].
Completed by:[**2128-12-8**]
|
[
"995.91",
"518.81",
"038.9",
"574.10",
"998.2",
"999.31",
"276.52",
"557.0",
"V44.3",
"710.1",
"998.11",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"86.05",
"51.22",
"50.61",
"33.22",
"45.73",
"38.93",
"54.12",
"99.15",
"86.22",
"46.21",
"33.21",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
6020, 6092
|
3985, 4707
|
295, 720
|
6198, 6207
|
2672, 3402
|
7041, 7218
|
2185, 2226
|
4825, 5997
|
6113, 6113
|
4733, 4802
|
6231, 7018
|
2241, 2653
|
241, 257
|
748, 1747
|
6168, 6177
|
6132, 6147
|
1769, 1982
|
1998, 2169
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,858
| 123,510
|
38288
|
Discharge summary
|
report
|
Admission Date: [**2175-8-19**] Discharge Date: [**2175-9-15**]
Date of Birth: [**2124-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Sore throat, coryza symptoms
Major Surgical or Invasive Procedure:
PICC placement
Bone Marrow Biopsy
History of Present Illness:
51 yo male presents with 1 week history of sore throat and URI
type symptoms. He presented to an OSH where he was noted to
have leukocytosis (WBC >70K) and given concern for hematologic
malignancy, he was transferred here for further care.
.
In the ED, initial vitals were: 98.2, 98, 138/67, 20, 94%.
Hematology evaluated the patient, and a peripheral smear was
consistent with likely AML. Bone marrow biopsy was performed,
and the patient was then initiated on leukopheresis prior to
admission. In the ED, he also received 3 gm hydroxyuria,
allopurinol, bicarb, as well as levofloxacin for ? PNA on his
CXR.
.
Currently, the patient feels better. He reports brownish
productive sputum. He saw his PCP on Wednesday, and since his
lungs were clear, he was told to continue on his OTC coricidin.
His symptoms continued to worsen which is why he presented to
the ED. He states he's also had nightsweats for the last week.
.
On ROS, he denies fevers, chills, weight change, visual changes,
headaches, nausea, vomiting, abdominal pain, constipation,
BRBPR, melena, dysuria, hematuria, frequency, urgency, numbness,
weakness, orthopnea, PND, or lower extremity edema. He does
report some increased dyspnea this past week as well as a few
episodes of diarrhea.
Past Medical History:
Hypertension
Seasonal Allergies
Social History:
Occasional ETOH. Previous smoker, none now (25pk/yr) quit 4 yrs
ago. No illicit drug use (prior use of marijuana)- no h/o IVDU.
Family History:
First cousin with leukemia
Physical Exam:
VITALS: 101.0 124/72 85 20 96%1L
GENERAL: WDWN male, NAD, appears comfortable
HEENT: NCAT, no cervical adenopathy; mucous membranes slightly
dry
CV: RRR, no M/R/G
LUNGS: few coarse BS in R base, otherwise clear without wheezes
rales or rhonci
ABDOMEN: soft, obese, non tender. normal BS. could not
appreaciate HSM due to body habitus
EXTREMITIES: no C/C/E
SKIN: no rash; few petecechiae around neck
NEURO: CN 2-12 grossly intact; [**6-14**] prox/distal strength BUE/BLE
extremities. no clonus.
PSYCH: A/O x 3; mood and affect appropriate
LYMPH: no cervical, suprclavicular, or axillary lymphadenopathy
appreciated
At discharge: same as above except:
HEENT: MM moist
SKIN: resolving maculopapular rash w/ excoriations on trunk,
single suture at site of skin biopsy on L side of abdomen;
minimal petechiae on B/L ankles
Pertinent Results:
Admission Labs:
[**2175-8-19**] 06:15PM WBC-70.2* RBC-3.90* HGB-13.6* HCT-36.5*
MCV-94 MCH-34.8* MCHC-37.2* RDW-15.2
[**2175-8-19**] 06:15PM NEUTS-4* BANDS-0 LYMPHS-8* MONOS-5 EOS-1
BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-1* OTHER-80*
[**2175-8-19**] 06:15PM PT-14.4* PTT-24.4 INR(PT)-1.2*
[**2175-8-19**] 06:15PM GLUCOSE-152* LACTATE-3.1* NA+-137 K+-3.1*
CL--92* TCO2-29
[**2175-8-19**] 06:15PM GLUCOSE-159* UREA N-13 CREAT-1.3* SODIUM-137
POTASSIUM-2.8* CHLORIDE-94* TOTAL CO2-26 ANION GAP-20
.
Discharge Labs:
.
Imaging:
ECHO [**2175-8-21**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. 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. 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. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
.
Cytogenetics [**2175-8-21**]
PML at 15q22
RARA at 17q21.1
ETO at 8q22
AML1 at 21q22
CBFB 5' at 16q22
CBFB 3' at 16q22
.
CXR [**2175-8-21**]: IMPRESSIONS: Unchanged bibasilar opacities.
.
CT Chest [**2175-8-24**]
IMPRESSIONS:
1. Diffuse right pleural thickening with sparing of the medial
pleural
surface together with tiny right pleural effusion likely account
for the CXR appearance. Together with shift of the mediastinum
towards the right,
fibrothorax is a possibility, especially if the patient has had
prior pleural disease. Comparison with older imaging may be
helpful in establishing chronicity. Otherwise, follow up CT in 3
months may be helpful to ensure stability.
2. Diffuse ground-glass attenuation of the lungs with smooth
septal
thickening can be seen in hydrostatic edema, but also in
atypical infections such as viral or pneumocystis pneumonia.
3. Borderline enlarged mediastinal and hilar lymph nodes may be
reactive
but attention at follow up CT suggested.
4. Splenomegaly with splenic infarct.
5. Possible left renal hypodensity, which may represent either
renal lesion or renal infarct. This could be evaluated by renal
US if warranted clinically.
.
CT sinus [**2175-8-26**]
IMPRESSION:
1. Mucosal thickening involving maxillary sinuses and sphenoid
sinus,
consistent with mucosal sinus disease.
2. No evidence of soft tissue infection or osseous erosion.
.
CXR [**2175-9-8**]
Cardiac size is normal. Bibasilar opacity is new on the left,
could be
atelectasis but superimposed infection cannot be totally
excluded. There is no pneumothorax or pleural effusion. Right
central catheters remain in place.
.
CXR [**2175-9-10**]
Cardiomediastinal contours are normal. Aside from minimal
atelectasis in the right base, the lungs are clear. Opacity in
the left lower lobe is no longer visualized. There is no
evidence of pneumonia, pneumothorax or pleural effusions.
Moderate degenerative changes are in the thoracic spine. Two
right central catheters remain in place.
.
[**9-11**] SKIN BIOPSY PATHOLOGY REPORT:
Superficial dermal hemorrhage associated with small vessel
thrombi and superficial to mid dermal perivascular lymphocytic
infiltrate (see microscopic description and comment).
No herpes virus identified (routine and immunostains).
Microscopic description. Sections show intact epidermis with
occasional dyskeratotic cells. No vesiculation is identified in
the multiple tissue levels examined. There is an area of red
blood cell extravasation in the superficial dermis which is
associated with thrombi in small vessels. No vasculitis is
seen. In addition, there is relatively [**Name2 (NI) 15410**] superficial to mid
dermal perivascular and predominantly lymphocytic infiltrate,
with some admixed histiocytes. No herpes virus cytopathic effect
is seen on routine stains. No immunoreactivity for herpes
simplex or varicella zoster is seen on specific immunostains. No
bacterial or fungal organisms are identified on Gram or GMS
stains, respectively.
Comment. No infectious agents are identified in this sample on
routine or infectious stains, and specifically, no herpes viral
cytopathic effect is seen. If there is continuing clinical
concern for herpes virus, culture may prove more sensitive than
tissue based stains. The combined findings of apparently
localized superficial dermal hemorrhage, small vessel thrombi
and perivascular mononuclear cell infiltration are unusual and
are not specifically diagnostic in this biopsy. The histologic
differential diagnosis includes trauma, an adjacent lesion or
excoriation, a hypersensitivity reaction, and possibly an
occlusive vasculopathy. Clinical correlation is necessary
Brief Hospital Course:
The patient is a 51-year-old man with newly diagnosed AML who
was hospitalized to undergo 7+3 induction
1. AML
Patient underwent 7+3 induction and tolerated the chemotherapy
well. On [**2175-9-1**], the patient's bone marrow demonstrated
"Markedly hypocellular marrow with chemoablation effects. No
morphological evidence of residual leukemia is seen." Pt.
underwent repeat bone marrow biopsy on day of discharge ([**2175-9-15**])
w/ aspirate taken but unable to obtain core sample. Acyclovir
started for prophylaxis.
.
2. Febrile neutropenia
Following a fever on [**2175-8-20**], the patient was started on
cefepime on [**2175-8-21**] and vancomycin on [**2175-8-23**]. Micafungin and
levofloxacin were added on [**2175-8-25**] after CT chest showed ground
glass attentuation. He was also ordered for CT sinus (pt uses
fluticasone at home). The patient developed a non-pruritic
maculopapular rash on his upper right arm. Derm was consulted,
since rash appeared concomitantly with fever, and were very much
convinced that the rash is a drug rash. For pruritus treatment,
Derm recommended clobetasone. Cefepime was changed to meropenem
on [**2175-8-26**] due to likely drug hypersensitivity. The patient
also has an intertriginous rash on his right groin; has
miconazole powder to use. On [**9-1**], with the patient having more
itching and rash, meropenem was switched to aztreonam and
flagyl.
On [**2175-9-7**], the patient again began to have fevers. CXR showed
perhaps a new opacity at base of left lung. Patient was
continued on an antibiotic regimen of aztreonam, flagyl,
vancomycin, and micafungin. Repeat CXR showed no evidence of
PNA. His fevers resolved on this regimen and flagyl, vancomycin,
micafungin d/c'ed on [**2175-9-14**]. Aztreonam d/c'ed on [**2175-9-15**]. ANC
improved from 0 to 2647 on day of discharge.
.
3. Rash, likely hypersensitivity reaction to drug
Patient has maculopapular rash that developed on extremities and
torso. Cefepime and meropenem were both stopped following
outbreak of rashes. Patient received sarna and diphenhydramine
for pruritus. The rash persisted after discontinuation of
antibiotics and derm was consulted for possible viral
etiologies. A punch biopsy was obtained and sent for pathology
which showed superficial dermal hemorrhage associated with small
vessel thrombi and superficial to mid dermal perivascular
lymphocytic infiltrate with no evidence of HSV or VZV. The
patient had a suture at the site of biopsy in place at time of
discharge with instructions to remove around [**9-26**]. He was
discharged with Sarna and clobetasol creams prn.
.
-f/u w/ Dr. [**Last Name (STitle) 410**] in clinic on [**2175-9-19**] at 11am
-f/u BM aspirate results
-Skin biopsy suture should be removed around [**9-26**]
Medications on Admission:
HCTZ 25 mg daily
Fluticasone nasal spray
Discharge Medications:
1. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical four times a day as needed for itching.
Disp:*1 bottle* Refills:*0*
2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
3. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*0*
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
puff each nostril Nasal once a day.
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 20 doses.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Acute myelogenous leukemia
SECONDARY:
Neutropenic fever
Rash, likely in reaction to cefepime
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 with a sore throat and
symptoms of an upper respiratory infection. You were found to
have a high white blood cell count and were diagnosed with acute
myelogenous leukemia. You had multiple bone marrow biopsies. You
underwent induction chemotherapy which you tolerated well. Your
counts went down as expected and you developed a fever which was
treated with antibiotics. Your fevers resolved and your counts
have gone back up. You also developed a rash which may have been
related to antibiotics and it was determined that there was no
virus causing the rash. The rash improved prior to discharge.
.
Some of your medications were changed during this admission:
START Acyclovir
START Oxycodone as needed for pain
.
You should continue to take your other home medications as
prescribed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2175-9-19**] 11:00 [**Hospital Ward Name **] [**Location (un) **]
|
[
"E933.1",
"288.00",
"205.00",
"787.01",
"401.9",
"V15.82",
"786.8",
"285.3",
"695.89",
"693.0",
"E930.5",
"528.00",
"E849.7",
"486",
"787.91",
"780.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.72",
"41.31",
"99.25",
"86.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11406, 11412
|
7871, 10635
|
344, 380
|
11559, 11559
|
2778, 2778
|
12552, 12755
|
1890, 1918
|
10726, 11383
|
11433, 11538
|
10661, 10703
|
11710, 12529
|
3306, 7848
|
1933, 2554
|
2568, 2759
|
276, 306
|
408, 1671
|
2794, 3289
|
11574, 11686
|
1693, 1727
|
1743, 1874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,032
| 133,972
|
17399
|
Discharge summary
|
report
|
Admission Date: [**2108-6-7**] Discharge Date: [**2108-6-22**]
Date of Birth: [**2031-1-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Fever, respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 year-old woman with a medical history of HTN, DM, CKD, who
was transferred to the ED from [**Hospital1 100**]-MACU for fever to 102.
She recently had a prolonged stay at [**Hospital1 **]-[**Location (un) 620**].
She was previously independent until [**2108-5-17**], when she was found
down in her apt in feces for an unclear amount of time (max
1-1/2 days). She was initially unresponsive and hypothermic and
after being warmed she was conscious but incoherent. Her blood
cultures from [**5-17**] grew pneumococcus (4/4 bottles) and MRSA ([**1-16**]
bottles). Subsequent Cx ([**5-20**], [**5-21**], [**6-2**]) were negative.
Sputum Cx on [**5-17**] grew MRSA and Pneumococcus; subsequently sputum
grew MRSA on [**5-22**]. She was treated with a two and a half week
course of Vanco for the MRSA. Vanco levels were mainly [**10-26**]
over her treatment course. It is unclear for how long she was
treated with ceftriaxone but she was not discharged on it, so
max of two and a half weeks. TTE on [**5-18**] and [**5-23**] were without
endocarditis.
Given her respiratory distress and acid base status she was
intubated in [**5-22**] and extubated on [**6-2**]. She was given frequent
nebs and placed on a steroid taper.
She also was found to have rhabdomyolysis from being down for an
unclear time. Her CK trended from 3396 to 168 ([**5-23**]). She was
treated with fluids.
Her creatinine was also elevated during the last admit. She was
given aggressive IV hydration (also for rhabdo) and although her
Cr initially improved it trended up again to 4.1. She became
volume overloaded and developed anasarca and thus underwent 4
sessions of HD. Her last HD sessoin was on [**6-4**] and her Cr was
2.4.
Given her change in mental status a CT Head was done which was
unrevealing. Neuro was consulted and felt it was a metabolic
encephalopathy. An MRI was limited by motion, but did not reveal
anything and an EEG did not show a seizure focus. Her mental
status improved with resolution of her PNA and HD but she was
still not oriented or able to verbalize.
Per report from the patient's sons, her NGT was pulled out last
pm, unclear if TF were running at the time. Then, the morning
of admission, the patient was found to have a fever of 100.8 and
was tachypneic with an O2 sat of around 87% on 2L NC (per ED
report, not noted in transfer paperwork). She was therefore
transported to the ED for further assessment.
In the ED, initial vs were: 102 76 190/70 30 100 on NRB. Her
labs were notable for WBC count of 11, Cr of 2.4, Na of 148. An
ABG was done on NRB: 7.43/44/150. Patient was given Vanco,
Zosyn, Levoflaoxacin.
On the floor, the patient is non-conversant, but is occasionally
able to nod appropriately. She is having occasional myoclonic
jerking. She is on a NRB and appears to be in no acute
distress.
Review of systems: Unable to obtain. Denies pain.
Past Medical History:
Diabetes mellitus x 10 years
Hypertension
Hyperlipidemia
Chronic obstructive pulmonary disease
Spinal stenosis
Lower extremity claudication
Hypothyroid
Chronic kidney disease stage III
Social History:
Prior to [**2108-5-17**] [**Location (un) 620**] admit she was living alone,
independent and functional with all her ADLs. She was still
driving. She was independent of her shopping, accounting,
cooking and cleaning her house. She did not have any memory
problems. She had difficulty walking long distances secondary to
her neuropathy. She did not walk with a walker or cane.
After her admit she was discharged to [**Hospital1 100**]-MACU
Tob: few cigs per day. She first started when she was a
teenager. She used to smoke a pack per day.
EtOH: she drank alcohol socially.
No rec drug use.
She was a homemaker at first but then went back as an
administrator at the treasury and retired in her sixties. HSG.
Health-care Proxy: [**First Name8 (NamePattern2) **] [**Known lastname 48652**] (oldest son)
NEXT OF [**Doctor First Name **]: [**Last Name (LF) **], [**First Name3 (LF) **], PHONE: [**Telephone/Fax (1) 48653**]
Family History:
Her mother lived to be 98 and died of natural causes. Her father
died of ?MI in his 60s. One brother died in his early 60s from
an MI. Her other brother died of pancreatic cancer at age 76.
Physical Exam:
Exam when transferred out of ICU
T 99.7, BP 149/58, HR 71, RR 13, 98% on non-rebreather
General Appearance: Well nourished, No acute distress
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bases, R>>L)
Abdominal: Soft, Tender: throughout
Skin: Warm
Neurologic: Attentive
Pertinent Results:
Admission labs:
[**2108-6-7**]
WBC-11.1* RBC-3.56* Hgb-9.7* Hct-32.0* MCV-90 RDW-18.9* Plt
Ct-212
Neuts-94.9* Lymphs-3.1* Monos-1.5* Eos-0.3 Baso-0.2
PT-12.7 PTT-26.8 INR(PT)-1.1
Glucose-363* UreaN-96* Creat-2.4* Na-148* K-3.8 Cl-108 HCO3-30
AnGap-14
ALT-59* AST-30 LD(LDH)-472* AlkPhos-60 TotBili-0.6
Lipase-112*
Albumin-2.6* Calcium-8.1* Phos-4.9* Mg-2.3
Triglyc-170*
Type-ART pO2-150* pCO2-44 pH-7.43 calTCO2-30 Base XS-4
Intubat-NOT INTUBA
Lactate-1.2
[**2108-6-7**]
URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011 Blood-MOD
Nitrite-NEG Protein-30 Glucose->1000 Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-MOD RBC-2 WBC-26* Bacteri-FEW
Yeast-MANY Epi-1
[**2108-6-9**] 08:59AM BLOOD Vanco-17.3
MICRO:
[**6-7**] BCx: STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY
[**6-7**] UCx: YEAST. >100,000 ORGANISMS/ML
[**6-7**] ULegionella: negative
[**6-8**] Lyme serology: negative
[**6-8**] Catheter tip Cx: negative
[**6-9**] C. diff: negative
[**6-9**] BCx: negative
STUDIES:
[**6-7**] ECG: Normal sinus rhythm. RSR' pattern in leads V1-V3 with
a QRS duration of 116 milliseconds. Moderate baseline artifact
but there is T wave flattening in leads V3-V5. Compared to the
previous tracing of [**2107-12-14**] this non-specific T wave change is
new. There is no other diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 146 116 442/447 46 12 55
[**6-7**] CXR: Left lower lung opacity may represent atelectasis
although
pneumonia cannot be ruled out; small bilateral pleural
effusions.
[**6-7**] LENIs: No evidence of deep venous thrombosis in the
bilateral lower extremities.
[**6-8**] TTE: Mild mitral regurgitation with normal valve
morphology. Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Pulmonary artrery systolic hypertension. No valvular pathology
or discrete vegetation seen.
[**6-8**] CT Chest (prelim):
1. Alveolar pattern of lung disease in right subpleural lung
zone compatible with infectious process. As far it can be shown
on a non-contrast examination, there is no evidence of
associated empyema. Bibasilar atelectasis.
2. Nodular opacity is unchanged in size since examination from
[**2103**], though has increased in density, and based on this
observation, malignancy cannot be excluded and delayed biopsy
should be performed after treatment of acute condition.
3. Relative distention of the gallbladder since prior
examination with
associated cholelithiasis. Correlation with ultrasound is
recommended to
exclude the possibility of cholecystitis.
4. Low-attenuation lesion within the right thyroid lobe, likely
nodule, and this can be correlated clinically, and if further
evaluation is deemed
necessary, a thyroid ultrasound on a non-emergent basis can be
considered.
[**6-8**] RUQ U/S: Distended gallbladder with intraluminal sludge and
gallstones without definite evidence of acute cholecystitis. If
clinical concern remains nuclear medicine hepatobiliary scan
could be performed.
[**6-9**] CXR, portable:
Heart is mildly enlarged. Aorta is calcified. There is patchy
focal density
in the right mid lung zone, which may represent aspiration or
pneumonia.
There is also left lower lobe atelectasis or infiltrate.
Findings are about
the same as the prior study. There is mild underlying
interstitial disease,
may represent mild congestive failure.
[**6-12**] CXR, portable:
The feeding tube is again seen and unchanged and within the
fundus of the
stomach. There is unchanged cardiomegaly. There is a left
retrocardiac
opacity. Small bilateral effusions are again seen. There is mild
atelectasis of the right mid lung field. Overall, these findings
are unchanged.
Brief Hospital Course:
77 year-old woman recently discharged from [**Location (un) 620**] ([**6-4**]) for
pneumonia/sepsis who presents from rehab with fevers and
respiratory distress. She spiked a fever following the removal
of her NG feeding tube which may have caused aspiration
pneumonitis v. pneumonia. It is possible that her previous
pneumonia may have been incompletely treated. Admission CXR had
LLL infiltrate and possible RLL infiltrate. Other possible
etiologies were thought to be wound infection, bacteremia,
endocarditis, C. diff infection. One set of blood cultures did
grow coagulase negative Staph. She was initially treated with
Vancomycin, Piperacillin/Tazobactam, and Levofloxacin. Her
antibiotics were narrowed to Vancomycin alone on [**6-9**], given her
prior known infection with strep pneumo and MRSA. TTE was
negative for valvular pathology. Aside from Urine with yeast, no
other cultures were positive.
The patient was stable to transfer to the floor. On the floor,
the patient's mental status was more alert. She was able to
engage in some mild conversation. Each day on the floor, the
patient would have one or more episodes of acute respiratory
distress that was attributed to secretions that blocked the
airway. Suctioning and good nursing care usually was able to
bring the patient back to her recent baseline.
The lack of meaningful physical improvement and seeing the type
of interventions that are required to suction secretions led to
a family meeting where goals of care were discussed. 3 of the
patient's 4 sons were able to meet. There consensus is that the
patient should only receive care that will add to her comfort.
They decided that a clogged NG feeding tube should not be
replaced so as to not subject the patient to another somewhat
uncomfortable procedure. The family ultimately decided to
transition the patient to hospice care. She was made comfort
measures only, and she passed away on [**2108-6-22**].
PROBLEM LIST
# Fever: aspiration pneumonitis vs transient bacteremia. One
set of blood cultures revealed coagulase negative Staph.
Antibiotics were narrowed to just Vancomycin (10-day course)
which would cover both Staph and Strep. CXR does not look worse.
# Respiratory distress: Difficult to determine how hypoxic she
was based on nursing home notes. SpO2 was 82% on RA in the ED,
then 100% on NRB. She has COPD and per her sons she was on O2 at
baseline (unclear how much). CT findings as above. She was
started on antibiotic therapy for pneumonia as above. She was
also continued on her steroid taper. Repeat CXR showed no
obvious worsening throughout the hospitalization. With her COPD
at baseline, her pulmonary function likely took a big hit during
her 3-wk bout of PNA at the OSH.
# COPD: The patient was treated with steroids, nebulizers,
antibiotics, and supplemental oxygen. Now only on steroids and
nebulizers.
# Altered mental status/Delirium: Per family, patient's mental
status improved slowly during her stay in the [**Hospital Unit Name 153**]. Possible
etiologies for delirium were felt to include infection, fevers,
uremia, hypernatremia, CVA. Now that patient has started
receiving as needed morhphine and ativan, the mental status is a
bit less attentive and less alert.
# CKD: Had 4 sessions of HD at [**Location (un) 620**] due to severe [**Last Name (un) **], now
with adequate urine output and off HD. Creatinine progressively
decreased to <2.0.
# Diabetes: On low dose Lantus and sliding scale insulin.
Increase as PO intake increases.
# Hypertension: On IV hydralazine and metoprolol. Can consider
Clonidine patch or crushed PO meds if taking some POs.
# Hypothyroidism: Synthroid PO vs IV.
# Nutrition/Fluids: IV fluids low rate, POs as tolerated. Speech
and swallow recommends pureed diet and nectar-thickened liquids.
Reassess as pt's mental status and physical condition improves.
# DVT Prophylaxis: Heparin subcutaneous
# CODE STATUS: The patient's DNR/DNI status was confirmed with
her HCP (son [**Doctor Last Name **] on [**6-7**].
Medications on Admission:
Prior to [**5-15**]:
Alendronate 70 mg Tablet weekly
Amlodipine 7.5 mg Tablet daily
Calcitriol 0.25 mcg daily
Epoetin Alfa [Procrit]
Fluticasone-Salmeterol 250 mcg-50 mcg/Dose 1 puff daily
Gabapentin 300 mg daily
Hydrocodone-Acetaminophen 5 mg-500 mg Q12 prn pain
Levothyroxine 25 mcg daily
Lisinopril 20 mg daily
Aspirin 81 mg daily
NPH Insulin Human Recomb [Humulin N] 16 U [**Hospital1 **]
Insulin Aspart Sliding scale
.
Medications from rehab:
Omeprazole solution 20 mg daily
Norvasc 10 mg daily
Aspirin 81 mg daily
Levoxyl 25 mcg daily
Ipratropium nebs TID
Albuterol nebs TID
Brovana nebs b.i.d. (per DC summary, not listed in NH meds)
Pulmicort nebs 0.5% b.i.d. (per DC summary, not listed in NH
meds)
Lantus 70 units daily (per DC summary, not listed in NH meds)
Heparin subcu 5000 units daily
Prednisone 30 mg daily tapering down by 10 mg every 3 days then
off
Metoprolol 25 mg t.i.d.
Epogen injection q.2 weeks
Lasix 40 mg every other day (per DC summary, though not listed
in NH meds)
NG tube with Nepro tube feeds at a goal of 33 mL/h
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"276.0",
"724.00",
"274.01",
"440.21",
"507.0",
"272.4",
"403.90",
"585.3",
"305.1",
"250.00",
"584.9",
"780.60",
"V58.67",
"790.7",
"786.1",
"293.0",
"244.9",
"041.19",
"496",
"349.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14022, 14031
|
8899, 12926
|
342, 348
|
14082, 14091
|
5161, 5161
|
14147, 14157
|
4424, 4615
|
14052, 14061
|
12952, 13999
|
14115, 14124
|
4630, 5142
|
3230, 3263
|
275, 304
|
376, 3211
|
5177, 8876
|
3285, 3471
|
3487, 4408
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,827
| 192,193
|
43296
|
Discharge summary
|
report
|
Admission Date: [**2197-1-18**] Discharge Date: [**2197-1-31**]
Date of Birth: [**2117-10-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
WOUND DRAINAGE
Major Surgical or Invasive Procedure:
wound washout x 2
TEE
blood transfusions
History of Present Illness:
HPI:79M recently discharged to rehab from the neurosurgery
service. He had a thoracic instrumented fusion with pedicle
screws and iliac crest bone graft on [**2197-1-11**]. The patient was
extubated the following day and his CT scan showed proper
placement of hardware. The patient was sent to rehab on [**1-16**]. He
is back in the ER today with an elevated WBC and reportedly has
had purulent drainage from the wound. The patient reports that
he is in pain but that it is not any worse today compared with
the last few days. He reports that it is difficult for him to
lie flat in the bed. The patient has been participating in
physical
therapy at rehab. He has no new weakness, numbness, tingling. He
has no bowel or bladder changes, no SOB, or chest pain.
Past Medical History:
PMHx:HTN,dislipidemia,TIA, ankylosing spondylitis, sleep apnea,
BPH s/p prostatectomy and removal of colon polyps.
Social History:
Social Hx:lives alone in [**Hospital3 4634**]
Family History:
Family Hx: widowed with 6 children
Physical Exam:
PHYSICAL EXAM:
T:99.3 BP:137/72 HR:105 RR:18 O2Sats:96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5- 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, propioception bilaterally.
Propioception intact
Toes downgoing bilaterally
Dressing changed: Wound had serosanguanous drainage. Dressing
had
some purulent drainage as well.
Pertinent Results:
1/28/09Labs:
Na 138 Cl 100 BUN 19 Glu 147
K 4.4 CO2 29 Cr 0.8
WBC 20.9 Hgb 10.3 Hct 29.4 Plts 546
N:92.7 L:3.8 M:2.5 E:0.9 Bas:0.1
Brief Hospital Course:
Pt was admitted to the hospital and went to OR for wound washout
with placement of VAC dressing. He was seen by ID and started
on antibxs and cultures followed. His vanco trough and
creatinine were also followed and adjustments to vancomycin made
- he will need weekly labs while on antibiotics - estimated
course - 6 weeks at minimum. VAC dressing was removed [**1-21**]. He
returned to the OR for second washout [**1-26**] and closed primarily.
He had drain placed which was removed on POD#4. The wound was
clean and dry. His hematocrit was followed and he received
transfusion [**1-30**] for hematocrit of 23 which came up to 28. His
motor exam remained full. He worked with PT/OT and was
recommended for rehab.
Medications on Admission:
simvastatin
metoprolol
lidoderm patch
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).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
11. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
13. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours).
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Wound infection
Bacteremia
post op anemia of blood loss
ankylosing spondylitis
Discharge Condition:
NEUROLOGICALLY STABLE
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ take daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks then increase as tolerated.
?????? Limit your use of stairs to 2-3 times per day
?????? Have your incision checked daily for signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
You will need to stay on vancomycin IV until seen in follow up
with ID - please have weekly labs: CBC with diff,
BUN,Creatinine, ESR, CRP and vanco trough and have results faxed
to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 432**]
Followup Instructions:
PLEASE HAVE YOUR SUTURES REMOVED AT REHAB [**2-9**] OR RETURN TO THE
OFFICE IF NEEDED
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Please follow up with ID: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2197-3-9**] 10:00AM
Completed by:[**2197-1-31**]
|
[
"427.31",
"V12.54",
"272.4",
"427.89",
"327.23",
"790.7",
"401.9",
"E878.4",
"V12.72",
"998.59",
"998.12",
"682.2",
"324.1",
"285.1",
"410.72",
"458.29",
"584.9",
"276.51",
"041.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.4",
"77.69",
"86.74",
"88.72",
"86.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4779, 4876
|
2389, 3112
|
288, 331
|
4999, 5023
|
2216, 2366
|
6555, 7012
|
1337, 1373
|
3200, 4756
|
4897, 4978
|
3138, 3177
|
5047, 6532
|
1403, 1649
|
234, 250
|
359, 1119
|
1664, 2197
|
1141, 1257
|
1273, 1321
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,027
| 131,105
|
48369
|
Discharge summary
|
report
|
Admission Date: [**2164-5-18**] Discharge Date: [**2164-5-24**]
Date of Birth: [**2099-3-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
right internal jugular central line placement
History of Present Illness:
This is a 65 y.o. Spanish-speaking male with a h/o paraplegia,
large sacral decubitus ulcer, stage IV, s/p recent abx course
for osteo who presents from [**Hospital **] clinic with hypotension and
chills.
.
Pt had recently been treated for sacral decub and osteomyelitis
for approx 11 weeks with vanco/Zosyn (until [**2164-5-7**]) without
resolution (no improvement in his ESR per ID call-in note). He
was seen by Plastics on [**2164-5-11**] and wound looked "good" (per PCP
[**Name9 (PRE) 7421**] note). He returned today to [**Hospital **] clinic complaining of
increased back pain in last 2 weeks. BP 85/60 in the [**Hospital **] clinic
(normal BP 130s/70s). Reported also increased dressing changes
at nursing home and subjective chills. Of note, pt has also
indwelling foley and had been on Vantin for ?UTI [**Date range (1) 101884**].
.
In the ED, his initial VS were T99.2, 87, 75/50, 15, 97%RA. He
remained hypotensive despite 4L IVF. Lactate was 1.2. WBC 9.2
without left-shift. ESR was 130. CXR unremarkable. UA cloudy and
positive for WBC and bacteria. ID was called and it was decided
to restart him on Vanc/Zosyn again. Pt received also 10 mg of
dexamethasone for presumed relative adrenal insufficiency. R IJ
was placed and pt was started on levophed gtt since still
hypotensive despite 4L IVF. Of note, trop was 0.17, cards was
called. EKG was unremarkable but cards recommended CTA to r/o
PE. Pt undergoing CTA prior to admission.
.
On arrival to the ICU, pt was still on low-dose levophed,
mentating fine, with good UOP.
.
On ROS, pt c/o chills, dysuria, recent flu-like symptoms with
cough, sputum (resolving), mild HA x3d (unchanged from prior).
Denies CP, SOB, abdominal pain, N/V.
Past Medical History:
1. Paraplegia (fell 13 years ago working on construction)
2. Depression
3. Frequent Urinary tract infections
4. GERD
5. Indwelling foley with persistent L sided hydronephrosis (per
last DC summary from [**1-/2164**])
6. Anemia (Hct baseline 28-30)
7. Sacral decubitus, stage IV, with recent osteomyelitis, s/p
approximately 11 wks of Vanc/Zosyn (completed [**2164-5-7**]), followed
by ID (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**])
Social History:
No smoking, no alcohol, no drug use. Currently at rehab.
Family History:
Mother: no history of MI, CA
Father: no history of MI, CA
Physical Exam:
VS: Temp: 95.4 BP: 113/62 HR: 76 RR: 13 O2sat 98% RA; CVP 3
GEN: pleasant, comfortable, NAD, cachectic
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, poor
dentition
NECK: no jvd, supple, RIJ in place.
RESP: CTA b/l anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice. Large sacral decub, stage 4, 5x5 cm
but clear margins, no purulent discharge. Also L lateral knee
ulcer, 1x1cm with clear margins.
NEURO: AAOx3. Moves UE b/l. Paraplegic.
Pertinent Results:
.
131 96 62
=========== 130
4.9 25 1.2
.
CK: 199 MB: 4 Trop 0.17
Ca: 10.1 Mg: 2.4 P: 3.8
ALT: 44 AP: 117 Tbili: 0.2 Alb: 3.4
AST: 31 [**Doctor First Name **]: Lip: 85
.
WBC 9.2 Hct 30.1 Plt 377
N:59.1 L:30.3 M:5.5 E:4.3 Bas:0.7
SED-Rate: 130
.
PT: 13.3 PTT: 28.8 INR: 1.1
.
UA: cloudy, 21-50 WBC, neg nitrite, moderate bacteria
.
EKG in the ED: NSR @ 79, nl axis, nl itnervals, no acute ST-T
wave changes. 3h later EKG with SB at 45 and Rsr' in V1 and V2.
.
Studies:
.
[**2164-5-18**] CXR: No acute cardiopulmonary process.
.
[**2164-5-18**] CTA: No evidence of pulmonary embolism or thoracic
aortic dissection.
.
[**2164-5-19**] MRI L spine:
1. Status post resection of distal sacrum and coccyx with a soft
tissue defect in the sacrococcygeal region.
2. The abnormal signal with enhancement of the S4 segment of the
coccyx could be due to osteomyelitis. Mild soft tissue changes
are seen surrounding the tip S4 segment of the coccyx.
3. No focal abscess is seen near the tip of the coccyx.
4. Slightly increased signal in the medial portion of the right
psoas muscle, in its lower portion, could be due to mild
inflammation. No abscess seen.
5. Small cysts within the right kidney, with prominence of the
right renal collecting system.
.
[**2164-5-20**] Renal U/S: Grossly unchanged exam with persistent
mild-to-moderate left hydronephrosis. Of note the left ureter
was not able to be identified on today's exam due to obscuration
from bowel gas. No renal or perirenal abscess is identified.
Brief Hospital Course:
65 y.o. Spanish-speaking male with a h/o paraplegia, large
sacral decubitus ulcer, stage IV, s/p recent abx course for
osteo who presented from [**Hospital **] clinic with hypotension and chills.
.
# Hypotension/sepsis: Hypotension most likely due to sepsis.
Given pyuria and history of frequent UTIs, most likely source of
infection is from the GU tract. Pt also has sacral decubitus
ulcer with recent osteomyelitis s/p abx; but no drainage and
clean margins. ESR has been rising from 100 since [**1-31**] to 130 on
this admission was concerning for recurrent osteo. Had low
baseline cortisol level but bumped appropriately after [**Last Name (un) 104**] stim
test, so relative adrenal insufficiency less likely. Hematocrit
remained stable, and there was no evidence of active bleeding.
The patient also ruled out for MI as noted below.
Pt was initially admitted to the MICU on a levophed drip, but
this was rapidly weaned off after fluid resuscitation. The
patient was then transferred to the floor and remained
hemodynamically stable off pressors. Vancomycin and zosyn were
continued to treat both UTI (given history of pseudomonas) and
skin flora. MRI of the L spine showed findings possibly
consistent with recurrent osteo. Wound care nurse and plastic
surgery were consulted who did not feel that the wound was
changed from baseline and not the source of his sepsis.
Renal ultrasound was done to rule out perinephric abscess given
the hisotry of recurrent UTIs; this was negative for abscess.
Prostate ultrasound was also done to rule out abscess given
history of elevated PSA; this showed no evidence of a prostatic
abscess or mass.
Infectious disease consult followed the patient during his
hospital course and recommended an antibiotic course of Zosyn
4.5g q8 to complete a 2 wk course for sepsis from presumed
urinary source. A PICC line was placed on [**2164-5-23**] and he was
discharged to complete a 14d course (d#5 on day of discharge).
.
.
# Chronic Sacral Decubitus Ulcer: Patient is paraplegic; ulcer
is stage 4, with exposed bone. Covered skin flora with vanco as
above. Wound care nurse and plastic surgery consult evaluated
the patient who did not feel this wound was infected and
Vancomycin was discontinued prior to discharge. A follow up
appointment was made with plastics clinic to consider a bone
biopsy once off antibiotics.
.
# Positive troponin: Initial cardiac enzymes were elevated in
the emergency room, but the patient was asymptomatic. Pt was
evaluated by cardiology in the ED. EKG without acute ST changes
and CTA without evidence of PE. Serial enzymes trended
downward, and the pateint ruled out for MI. Further workup
deferred to his PCP.
.
# Anemia - Recent baseline of 28-30. However, last Hct at rehab
from [**5-3**] was 35. Hct remained stable 26-30 during this hospital
course with no evidence of active bleeding.
.
# Elevated PSA: This was checked by urology as an outpatient,
and per OMR notes urology was unable to reach the patient to
follow up this result (possibly because the patient has been at
rehab). Prostate U/S done as above which did not reveal any
masses or abscess. Pt will need outpatient urology followup.
.
# Paraplegia: Has neurogenic bladder, indwelling foley. Foley
was changed on arrival due to positive UA. Foley will need to
be changed again midway through course of antibiotics. DVT ppx
was continued.
.
# Depression: continued venlafaxine
.
# DISPO - Full Code. Discharged back to [**Hospital3 2558**] to
complete a 2 wk course of Abx as above.
Medications on Admission:
Prilosec 20 daily
Trazodone 50 qHS
Tylenol prn
Venlafaxine 75 [**Hospital1 **]
Senna
Colace 100 [**Hospital1 **]
MoM 30ml daily prn
Bisacodyl prn
fleet enema prn
Vitamin C [**Hospital1 **]
Heparin sc TID
Oxycontin 20 qAM / 10 qPM
Zinc sulfate 220 mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
Sepsis, likely from urinary tract infection
Chronic stage IV sacral decubitus ulcer
.
Secondary Diagnoses: paraplegia, anemia
Discharge Condition:
Stable for discharge back to [**Hospital3 2558**]
Discharge Instructions:
You were hospitalized with low blood pressure, related to an
infection, likely from a bladder infection.
You should continue the antibiotics Zosyn for 9 more days.
Continue taking all of your other medications as prescribed.
Please have your blood drawn 1 week after discharge as
instructed below.
Please followup with your primary care physician, [**Name10 (NameIs) **] with your
infectious disease physician as scheduled below.
If you experience fevers, chills, shortness of breath, back
pain, abdominal pain, or any other concerning symptoms, please
call your doctor or return to the emergency room for evaluation.
Followup Instructions:
Please make an appointment to followup with your primary care
physician.
.
You have the following appointments already scheduled:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2164-6-8**] 2:00
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2164-6-15**]
11:00
Completed by:[**2164-5-23**]
|
[
"596.54",
"593.2",
"730.28",
"038.9",
"707.03",
"344.1",
"591",
"599.0",
"285.9",
"311",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8681, 8751
|
4839, 8375
|
327, 375
|
8940, 8992
|
3309, 4816
|
9662, 10059
|
2688, 2747
|
8772, 8877
|
8401, 8658
|
9016, 9639
|
2762, 3290
|
8898, 8919
|
276, 289
|
403, 2109
|
2131, 2597
|
2613, 2672
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,661
| 168,866
|
48717
|
Discharge summary
|
report
|
Admission Date: [**2179-9-23**] Discharge Date: [**2179-10-5**]
Service: MEDICINE
Allergies:
Penicillins / Lisinopril / Niacin / Meclizine / Ace Inhibitors /
Paxil
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Black Tarry Stools
Major Surgical or Invasive Procedure:
Push enteroscopy- [**2179-10-1**]
Placement of left nephrostomy tube- [**2179-10-1**]
History of Present Illness:
Ms. [**Known lastname 38758**] is a 86 y/o woman with recent history of low crit who
had swallow study today with GI at [**Hospital3 **] presenting for
melena and weakness.
The patient reports she has been experiencing melena and
weakness for the past 2 weeks in the setting of iron
supplementation. The patient also notes experiencing substernal
discomfort similar to heartburn which has been occurring for the
past week which was different in nature from her baseline
heartburn symptoms. She reports the pain occurred with laying
down or on exertion, but states the pain was different in that
it recurred intermittently in the past week which was different
from baselien. The day of presentation, the patient had
undergone a capsule endoscopy and got home, noticed 2 episodes
of black, tarry stool without any red blood. She again noted
weakness, lethargy, and nausea. She denies fevers, chills,
vomiting, abd pain or SOB. She presented to the ED. Of note
she had a large diverticular bleed in [**Month (only) **] of this year
which required 4 transfusions at [**Hospital6 **].
Colonocopy at the time showed diverticuli and EGD showed mild
antral gastritis and duodenitis. She had recently been
undergoing an outpatient workup for worsening anemia and was due
for initiation of aranesp shot tomorrow after having received IV
Iron supplementation recently. She denies NSAID use and denies
alcohol use.
In the ED, initial VS were 98.4 103 125/63 20 100%. Workup was
notable for a HCT of 21 (was 22.1 2 days prior, 26.2 one month
prior). EKG showed new ST depressions in the inferolateral leads
with Troponin of 0.06. Cardiology evaluated the patient and felt
that this was likely demand ischemia in the setting of GI bleed.
She was given Aspirin 325mg and and Nitroglycerin SL 0.4mg x1
with improvement of her heartburn-like pain. CXR showed possible
mild pulm edema, focal calcification R lower lung, likely
scarring/atelectasis. She was written for 2 units PRBC in
addition to 500cc of a 1L NS bag, a GI cocktail, and
Pantoprazole IV x1, and was admitted to the MICU for the
management of GI Bleed. VS prior to transfer were 116/64, 107,
17, 98% 2L.
On arrival to the MICU, the patient denied symptoms including
abdominal pain, nausea/vomiting, chest pain, heartburn, or
shortness of breath.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure, or
palpitations. Denies vomiting, diarrhea, constipation. Denies
dysuria, frequency, or urgency. Denies myalgias. Denies rashes
or skin changes.
Past Medical History:
Lower GI Bleed [**Month (only) **]/[**2179-3-9**] at [**Hospital **] Hospital. Thought to
be Diverticulosis. Required 4 units of blood. Had colonoscopy
with adenoma removed.
Normocytic Anemia: thought to be due to CKD/iron def
Iron Deficiency: S/P Ferraheme X 2 in [**2179-8-9**]
stage 4 CKD thought to be due to hypertension and possibly
diabetes.
Hypertension
hyperlipidemia
right knee arthritis
gastroesophageal reflux disease
mild aortic stenosis
mild mitral regurgitation
? mild type 2 diabetes (last A1C 6.2% not on any meds)
Social History:
Lives alone with sons very supportive. Uses Walker/Wheelchair
- Tobacco: Previously smoked, quit over 60 years ago.
- Alcohol: Denies
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 96.7 BP: 122/66 P: 100 R: 22 PO2: 98% 2L NC
General: Alert, oriented, no acute distress
HEENT: Pupils equal and round, sclera anicteric, MMM
Neck: supple
CV: Regular rate and rhythm, normal S1/S2, GIII
crescendo-decrescendo murmer at RUSB radiating across the
precordium, GII holosystolic murmer at the apex, no rubs or
gallops
Lungs: End inspiratory crackles at bases b/l, no wheezes or
ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Rectal: Guiac (+) with Black stool in ED
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
Admission Labs:
[**2179-9-22**] 09:10PM WBC-10.1 RBC-2.43* HGB-7.2* HCT-21.0* MCV-86
MCH-29.6 MCHC-34.3 RDW-16.6*
[**2179-9-22**] 09:10PM NEUTS-85.6* LYMPHS-10.3* MONOS-3.0 EOS-0.7
BASOS-0.3
[**2179-9-22**] 09:10PM PLT COUNT-241
[**2179-9-22**] 09:10PM FIBRINOGE-453*
[**2179-9-22**] 09:10PM CALCIUM-9.0 PHOSPHATE-4.3 MAGNESIUM-1.2*
IRON-38
[**2179-9-22**] 09:10PM cTropnT-0.06*
[**2179-9-22**] 09:10PM GLUCOSE-132* UREA N-77* CREAT-3.2* SODIUM-142
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-20
Reports:
.
ECG [**9-22**]: Sinus tachycardia and occasional atrial ectopy.
Increase in rate as compared with prior tracing of [**2170-5-21**].
There is new ST segment depression in leads I, aVL and V2-V6
consistent with active anterolateral ischemic process, in the
context of the increase in rate. Followup and clinical
correlation are suggested.
.
TTE [**9-23**]: Mild symmetric left ventricular hypertrophy. The
distal segments are not well seen but the distal inferior,
septal and lateral segments are probably hypokinetic. Moderate
calcific aortic stenosis. At least moderate mitral
regurgitation. Moderate to severe tricuspid regurgitation with
at least moderate pulmonary artery systolic hypertension.
.
CT Abd/Pelvis: [**9-24**]: 1. 6.8 cm abdominal mass, centered
anterior/inferior to the aortic bifurcation, abutting small
bowel loops anteriorly, and displacing the left ureter and left
iliac vessels posteriorly. Given the lack of associated bowel
obstruction, this most likely represents small bowel lymphoma.
Other etiologies such as a GIST could also be considered.
Adenocarcinoma is less likely. 2. Moderate left hydronephrosis
and hydroureter, secondary to compression from aforementioned
small bowel mass. 3. Small bilateral pleural effusions with
associated atelectasis. 4. Sigmoid diverticulosis. 5. Aortic
atherosclerosis, with 2.3 cm infrarenal aortic ectasia. 6.
Extensive lumbar degenerative change.
.
RENAL ULTRASOUND:FINDINGS: The right kidney measures 8.3 cm with
no evidence of hydronephrosis, stones, or masses within it.
Normal vascularity is seen within the right kidney.
The left kidney measure 9.5 cm. Moderate to severe
hydronephrosis is detected in the left kidney with preservation
of the left kidney cortex. No stones or masses are seen within
the left kidney. A simple cyst is seen within the upper pole of
the left kidney. The simple cyst has not changed from previous
examination. The left ureter was followed until its mid portion
where it disappeared. The bladder is within normal limits. No
jet sign was detected from the left side.
IMPRESSION: Moderate to severe hydronephrosis with hydroureter
of the
proximal and mid ureter. The renal cortex is preserved.
.
CXR: Portable AP chest radiograph was reviewed on [**2179-9-22**].
Heart size is enlarged. Mediastinal silhouette is unremarkable.
Lungs are
grossly clear except for minimal bibasilar atelectasis, but no
focal
consolidation is noted to suggest infectious process. Minimal
interstitial
changes, most likely chronic cannot be ruled out.
.
PUSH ENTEROSCOPY: Normal esophagus. Normal stomach. A few small
superficial nonbleeding ulcers at duodenal bulb. At the distal
jejunum, there was a large malignant appearing ulcerated mass.
It was >10 cm in length and involved the entire circumference
causing partially obstruction. The scope was able to traverse.
There was slight oozing of blood and heme within the mass.
Multiple biopsies were taken from the mass with a cold biopsy
forceps for histology. It was tattooed with the Indian Ink at
both ends. The capsule had passed distally and was seen on
fluoroscopy. Otherwise the limited exam of the rest of small
intestine was normal.
.
IR-GUIDED URETRAL STENT PLACEMENT:
.
Discharge labs:
.
.
Microbiology:
.
H. PYLROI SEROLOGY: NEGATIVE
Brief Hospital Course:
86yoF with history of gastric polyp, recent diverticular bleed,
progressive anemia, and CAD presenting for melena, anemia, and
demand cardiac ischemia.
.
#. GI bleed: She presented with black tarry stool and negative
[**Last Name (un) **]-gastric lavage in the ED. She had recently had a capsule
endoscopy that showed a possible necrotic bleeding mass in the
small bowel. She was given 3 units PRBCs with stabilization of
her hematocrit in the intensive care unit. She was also placed
on an IV PPI. A CT abdomen/pelvis was done that showed a 6.8cm
small bowel tumor consistent with malignancy. She remained
stable in the MICU with plans to have push enteroscopy for
biopsy after transfer to the medicine floor. On the floor, the
patient had episodes of melena. She received 2 units of pRBCs on
the floor and remained hemodynamically stable through her
admission on the medicine floor. The patient underwent push
enteroscopy [**2179-10-1**] which showed a malignant mass involving the
entire circumference of the distal jejunum causing partially
obstruction. A biopsy was obtained; the final pathology report
was pending on day of discharge, but prelim results showed
poorly differentiated carcinoma, unclear if adenocarcinoma or
lymphoid in origin. Oncology has consulted as an inpatient. Just
prior to discharge, prelim path results suggested poorly
differentiated lymphoma. Oncology has coordinated a PET/CT for
staging to be done in the next available slot on [**10-12**] at 2:45.
She will f/u on [**10-15**] with Dr. [**Last Name (STitle) 410**] & [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4027**]. Oncology
administrative staff have helped to notify her rehab, Colony in
[**Last Name (un) 33487**] [**Telephone/Fax (1) 102418**], of these appointments and patient
instructions for PET (NPO at least 4 hours before the test).
.
#. NSTEMI: She had ST depressions in the precordial and lateral
leads on EKG and ruled in for NSTEMI. It was felt this was
likely demand ischemia in the setting of GI bleed and she was
transfused to a hematocrit of 30. Her ST depressions normalized
with resolution of her anemia. Serial EKGs were performed that
showed stable Q waves in leads III and avF, with T wave
inversion in leads V4-V6. Her cardiac enzymes were trended
through her admission on the medicine floor. The troponin peaked
and then fell; the patient's CK-MB and CK remained flat while on
the medicine floor. Cardiology was consulted to determine if the
patient needed revascularization given the persistent T wave
inversions on EKG. Cardiology recommended no revascularization
at the present time, given the presence of the mass in the
patient's small bowel and that revascularization would delay
work-up of the small bowel mass. The patient was treated
medically with beta-blocker, aspirin, and statin. The patient
was monitored on telemetry through the admission. She had one
episode of 9 beats of non-sustained ventricular tachycardia. Pt
had no other significant events on telemetry.
.
#. Acute on Chronic Renal Failure: She had acute on chronic
renal failure with Cr 3.2 and recently 3.4 on [**9-20**] from baseline
of 2.4 on [**6-17**]. This was felt to be related to her recent GI
bleed and renal hypoperfusion. CT of the abdomen/pelvis showed
left hydronephrosis and hydroureter. The patient's creatinine
was trended through her admission on the medical floor. The
patient's creatinine continued to up-trend through the
admission. Urology was called, and they did not feel that stents
were warrented in this patient as there is a high risk of
stent-failure in patient's with an obstructive mass causing
hydroureter/hydronephrosis. Urine was negative for eosinophils
and the creatinine was unresponsive to fluid bolus. The
patient's worsening kidney function was thought to be due to
obstruction presumably from the small bowel mass. Renal
ultrasound showed moderate to severe left hydronephrosis with
hydroureter of the proximal and mid ureter. The renal cortex was
preserved on renal ultrasound. A renal consult was called, and
they attributed the patient's worsening renal function to
obstruction. The patient underwent nephrostomy tube placement on
the left. The patient's serum creatinine trended downward with
placement of the nephrostomy tube on the left, which initially
had bloody output that cleared to essentially normal urine with
trace bloody streaks by discharge. Pt has an appointment later
this week with Renal outpatient clinic.
.
#. Anemia: Patient presented with hematocrit of 26.8. Given
that the anemia is normocytic, it is more consistent with acute
or subacute blood loss rather than slow, occult blood loss
causing iron deficiency and microcytosis. The patient received a
total of 5 units of pRBCs. Her hematocrit was trended daily. The
patient had a transfusion threshold to transfuse if hematocrit
was less than 30 in light of the patient's NSTEMI. On day of
discharge, the patient's hematocrit was stable at ~ 29.
.
#. Aortic Stenosis: History of mild AS (valve area 1.2-1.9cm2)
in [**2170**], and Pt has 5/6 systolic murmur now. Repeat TTE on this
admission showed worsening of her AS with valve area of 1.0.
Cardiology did not feel that intervention was needed.
.
#. HTN: Her home hydrochlorothiazide, metoprolol, and losartan
were initially held in the setting of GI bleed. Upon transfer to
the floor, the patient's metoprolol had been restarted.
Metoprolol was continued through her admission on the medicine
floor. Her blood pressures ranged from 120s -140s / 60s-80s
while on the floor on metoprolol. Her Hctz was held, but her
losartan was restarted on discharge.
.
#. HLD: The patient's home atorvastatin was continued through
the admission, but the dose was increased in the setting of the
patient's NSTEMI per cardiology recommendations.
.
# Residual Capsule: Prior to admission, the patient underwent
capsule endoscopy. The patient had not passed the capsule prior
to admission and through the admission. KUB films showed that
the capsule was present in the right lower quadrant. The patient
was never obstructed through the admission. Push enteroscopy
showed that the capsule had passed the area of partial
obstruction. Per GI, there is no need to do any further imaging.
She will only need a KUB if she develops obstructive symptoms.
.
#Transition of Care:
- Follow-up with Oncology regarding the pathology report from
biopsies done at the push enteroscopy. Oncology has coordinated
a PET/CT for staging to be done in the next available slot on
[**10-12**] at 2:45. She will f/u on [**10-15**] with Dr. [**Last Name (STitle) 410**] & [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 4027**]. Oncology administrative staff have helped to notify
her rehab, Colony in [**Last Name (un) 33487**] [**Telephone/Fax (1) 102418**], of these
appointments and patient instructions for PET (NPO at least 4
hours before the test).
.
- Follow-up with outpatient nephrologist regarding nephrostomy
tube, continuation of aranesp and ferraheme, and chronic kidney
disease. They will also help with determining when to restart
hydrochlorothiazide and losartan.
.
- Follow-up with primary care physician regarding [**Name9 (PRE) 18290**]
hydrochlorothiazide and losartan in light of Pt's recent acute
renal insufficiency.
.
- Pt was prescribed ARANESP by unknown practitioner. Will need
to follow-up w/ heme/onc clinic about this.
.
Medications on Admission:
ATORVASTATIN 10mg PO Daily
CITALOPRAM - 20 mg PO Daily
FOLIC ACID 1mg PO Daily
HYDROCHLOROTHIAZIDE - 25 mg PO Daily
LOSARTAN - 100 mg PO Daily
METOPROLOL TARTRATE - 50 mg PO BID
PANTOPRAZOLE - 80 mg qAM and 40mg qPM
ARANESP
FERRAHEME
FERROUS SULFATE - 325mg PO BID
MULTIVITAMIN - PO Daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day as needed for constipation.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day: hold for sbp < 90 or HR < 55.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day: Take 2 tabs
qam and 1 tab qhs. Tablet, Delayed Release (E.C.)(s)
13. Aranesp (polysorbate) Injection
Discharge Disposition:
Extended Care
Facility:
Colony House Nursing & Rehabilitation Center - [**Location (un) 32775**]
Discharge Diagnosis:
Primary diagnosis:
-GI bleed
-poorly differentiated small bowel carcinoma
Secondary diagnosis:
Anemia
NSTEMI
Hypertension
Aortic stenosis
Acute on chronic kidney failure
Hyperlipidemia
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 38758**],
It was a pleasure taking care of your during your
hospitalization at [**Hospital1 69**]. You
were admitted with bleeding from your gastrointestinal tract and
were found to have a mass in your small bowel. You underwent
push enteroscopy to gather tissue samples. The final results
from these samples are still not available, but the preliminary
results show that you do have a cancer in your small bowel. You
spoke with our cancer experts, who will continue to see you as
an outpatient.
During this hospitalization you also suffered a very small heart
attack, known as an NSTEMI, because of anemia (low blood counts)
caused by the bleeding abdominal mass. You received blood
tranfusions to keep your blood counts stable.
Your creatinine also rose through the admission. You were found
to have an obstruction in your left kidney preventing the flow
of urine, which was causing worsening kidney function. You had a
nephrostomy tube placed in the left kidney to help drain urine
from this kidney.
Please take all medications as prescribed. Please note the
following medication changes:
*NEW:
- aspirin 81mg daily by mouth
- senna 1 tab orally twice a day
- docusate 100mg orally as needed for constipation
- polyethylene glycol 17g orally as needed for constipation
*CHANGED:
- metoprolol 25mg orally three times a day from metoprolol 50mg
orally twice a day
- increased the dose of atorvastatin to 80mg daily by mouth
*STOPPED:
- hydrochlorothiazide 25mg orally daily
- losartan 100mg orally daily
- pantoprazole 80mg in morning and 40mg in the evening
Please keep all follow up appointment as scheduled below. Please
arrange with your [**Hospital3 **] facility a hospital follow-up
appointment with your primary care doctor. You will also need to
have follow-up with an Oncologist regarding the results of the
biopsy from the mass in your small bowel.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2179-10-12**] at 4:00 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Specialty: Nephrology
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD
Specialty: Internal Medicine
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2205**]
Please discuss making a follow up appointment with Dr. [**Last Name (STitle) 2903**] with
the facility when you are ready for discharge. You will need to
discuss the results of your testing done while in the hospital.
*** You will need to have an appointment schedule with Oncology.
A doctor from our Oncology service will call you to schedule a
follow-up appointment for you once the pathology results are
finalized.
Completed by:[**2179-10-7**]
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8,196
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10944
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Discharge summary
|
report
|
Admission Date: [**2105-6-18**] Discharge Date: [**2105-7-16**]
Date of Birth: [**2034-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70M Cape-Verdean speaking with h/o DM, HTN, PVD s/p bilateral
BKA (Right [**2105-5-13**]) and ESRD s/p LUE fistula [**2105-5-22**], recent
admission for altered mental status presents with intermittent
CP and SOB x 3 days. The patient is a poor historian. He
describes the onset of palpitations 3 days ago, which on further
history reports as substernal chest pain. Denies any radiation,
SOB, nausea, or diaphoresis. The episode lasted 30-60 min and
resolved. He had repeat episodes yesterday and then today when
he was brought into the ED by his son. [**Name (NI) **] [**Name2 (NI) **], fever, chills,
SOB, HA, nausea/vomiting. Continues to make urine, perhaps
slightly increased amount recently but no dysuria.
.
Of note, the patient was recently admitted ([**Date range (1) 35542**]) for
altered mental status thought to be multifactorial from
medication confusion/noncompliance, severe hypertension at
presentation, and vomiting/minimal po intake; his confusion
improved prior to discharge. He also had bilious nausea/vomiting
with KUB and CT abdomen/pelvis negative for obstruction that
then resolved, hypertensive urgency, and isolated leukocytosis
(WBC 17) without obvious signs for infection and therefore not
treated.
.
In the ED, vitals: T 96.0 HR 84 BP 136/58 RR 16 SaO2 86 on RA ->
97% on 4.5L. Noted to be tachypnea intermittently to RR 32. ECG
nondiagnostic with LVH with repol changes, worsening ST
depressions laterally and positive troponin but normal CK. ABG
7.53/27/58; lactate 1.6; WBC 15.3; BNP [**Numeric Identifier 35543**]. CXR with ?left
infiltrate vs. pulmonary edema. Pt received Lasix 20mg IV, ASA
325mg, and Levaquin 500mg PO. He adamantly refused blood cxs
prior to antibiotics.
Past Medical History:
Insulin dependent diabetes mellitus-nephropathy, neuropathy,
retinopathy
Hypertension
Peripheral Vascular disease
s/p bilateral BKA
Coronary artery disease
End stage renal disease
BPH
Social History:
retired engineer, married, lives at home with wife. no [**Name2 (NI) **],
etoh, ivdu
Family History:
noncontributory
Physical Exam:
T 97.7 HR 72 BP 118/71 RR 22 SaO2 93% on 4.5L
General: WDWN, +acc muscle use, speaks in full sentences
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: RRR, s1s2 normal, no m/r/g, JVP ~12cm
Pulmonary: Bilateral crackles lower [**2-12**] lung fields with
decreased BS at the left base and dullness to percussion
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, bilateral BKAs with stumps c/d/i (staples on
left), no edema apparent
Neuro: Alert, speech clear and logical, CNII-XII intact, moves
all extremities
Brief Hospital Course:
70 y/o M with PMHx of DM, CRI, CAD, PVD s/p b/l BKA who was
initially admitted on [**2105-6-18**] for NSTEMI and CHF that was later
felt to be due to demand ischemia from CHF rather than plaque
rupture. While on the floor was refusing lab draws and
echocardiogram to assess resolution of NSTEMI. His hospital
course was then complicated by 2 embolic strokes on [**6-22**] (R
parietal and L frontal lesion) which caused him to become
aphasic and develop R sided weakness. He did not receive any
thrombolysis, and coumadin was held as felt risk on
anticoagulation outwayed the benefits. He has ESRD but not
getting dialysis yet as making urine, has a working fistula on R
arm. On [**6-28**] he was intubated and transfered to the ICU for
Urosepsis. He was treated with Meropenem, extubated, and
transfered out of the ICU and back to the medical floor. While
in the ICU a double lumen PICC was placed.
.
On the medical floor a PEG tube was placed and dispo planning
was in process until [**2105-7-11**] AM when he was found to be grunting
and coughing. At that time Lasix was given for fluid overload
and enzymes were cycled. His EKG showed suggestion of anterior
STEMI with no reciprocal changes, cardiology evaluated this and
felt it was most likely a NSTEMI. They felt that no further
intervention was warented. His troponin bumped to 1.49 and then
2.75 without an increase in his MB fraction. He was started on
Heparin for anticoagulation.
.
At 6:30 AM on [**2105-7-12**] a trigger was called for hypoxia and
tachypnia. Per the vitals sheet her O2 sat had dropped at 4:30AM
to 80s however he was due for transfusion which was started and
respiratory status worsened. The blood transfusion was stopped
and he was placed on 100% on shovel mask with sats recorded at
86%, he was then placed on NRB with sats up to 97%. He was given
100mg Lasix and 500mg Diurel. He was then transfered to [**Hospital Unit Name 153**] for
management of pulmonary edema.
.
On the evening of [**2105-7-12**] he again developed acute respiratory
failure. He was intubated. A family meeting was held [**7-13**], and
the decision was made to make the patient DNR, and to not pursue
any further escalation of care (no pressors, no dialysis). A
seconde family meeting was held on [**7-15**], and the decision was
made to make the patient comfort measures only. He was
extubated in the evening of [**7-15**]. He died at 0600 on [**2105-7-16**].
His son, [**Name (NI) **], was contact[**Name (NI) **] at the time of death.
Medications on Admission:
ASA 325mg daily
Sodium citrate-citric acid 500-334 30ml tid
Sevelamer 800mg tid
Docusate 100mg [**Hospital1 **]
Senna 8.6mg [**Hospital1 **]
Lactulose 30ml tid
Lantus 7 units qhs
ISS
Amlodipine 10mg daily
Isosorbide dinitrate 40mg [**Hospital1 **]
Simvastatin 20mg daily
Lopressor 100mg [**Hospital1 **]
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
1. Diastolic Heart Failure.
2. NSTEMI.
3. Acute Embolic Left Frontal and Right Parietal Stroke.
4. Acute Renal Failure
Secondary:
1. Chronic Kidney Disease Stage V.
2. Peripheral Vascular Disease.
3. Bilateral BKA.
4. Diabetes Mellitus Type II.
5. Peripheral Neuropathy.
6. S/P LUE fistula [**2105-5-22**]
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
|
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29,621
| 190,624
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4828
|
Discharge summary
|
report
|
Admission Date: [**2149-2-21**] Discharge Date: [**2149-3-29**]
Date of Birth: [**2083-12-3**] Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
hypoxia, hypotension
Major Surgical or Invasive Procedure:
Intubation
Placement of central lines
Thoracentesis
Tracheotomy
History of Present Illness:
65 yo male with DM, ESRD on HD 4x per week (T,TH,SAT,Sun), CHF
EF 35%, tachy/brady s/p PPM placement, Afib on coumadin, CVA w/
left-sided weakness, recent hospitalization with right shoulder
fx, norovirus infection, and pneumonia, who is admitted from an
outside hospital with hypoxia and hypotension
Pt was discharged from [**Hospital1 18**] in mid [**Month (only) 1096**] after right humerus
fracture fx and went into rehabilitation facility. He was then
admitted to the ICU for hypotension and was treated empirically
for HCAP with cefepime and vancomycin for a total of 8 days
ending on [**2148-12-15**]. He was doing well by the time of discharge
and was sent to a [**Hospital1 1501**] in [**Location (un) 3844**]. As per wife he developed
[**Name (NI) 20198**] 3 weeks ago and then developed a pneumonia for which
he was treated with levofloxacin x 2 weeks. She states that he
had a cough with increased amounts of secreation and was not
improving on antibiotics. Yesterday his sats were down in the
80s% and he was transferred from his [**Hospital1 1501**] to an outside hospital.
He was also found to be hypotensive w/ SBP in 80s. His recent
sputum culture obtained at the [**Hospital1 1501**] grew MRSA. He was a given
Levofloxain and Moxifloxacin in the OHS and then transferred
here for further care.
.
In the ED his vitals were: 98.6, 92/59 on 2mcg of norepi, 70,
20, 96% on 5L. Pt had increase resp distress with increase in
RR, increase in lethargy. He was then intubated in the ED. His
CXR showed a left effusion and bilateral pulmonary air space
opacities. His troponin is elevated from his baseline at 0.18
and his EKG showed new RBBB while paced. As per ED report the
EKGs were sent to the Cardiology for opinion. He was also given
vanco and cefepime 2gm IV x I. He had L IJ placed and placement
confirmed. His labs are notable for WBC of 22.5, no bands.
Electrolyte abnormalities with elevated K of 5.2, however is due
to be dialyzed tomorrow. He also received 2 L of fluids.
.
On arrival to the MICU, pt is intubated and non-responsive. Exam
significant for cold extremities. Vitals: T 101, HR in 90s, BP
90s/40s, Sat 98% on vent- AC with VT 400, RR 20, PEEP 10. Foley
with dark urine. L IJ in place and pt receving levophed.
Past Medical History:
Diastolic heart failure (LVEF > 55%)
Hypertension
ESRD on HD
Morbid obesity
Atrial fibrillation and h/o tachy-brady syndrome s/p pacemaker
placement
Diabetes Mellitus
DVT
CVA left frontal [**2136**] - L hemiparesis
Sleep apnea
Restrictive lung disease (thought [**2-19**] body habitus)
Gout
Chronic back pain
Hx of Subarachnoid hemorrhage
Social History:
The patient is married and has two children. He is a real estate
developer and lives in [**Location 5169**] NH. Denies tobacco or IVDA.
Consumes 1 alcoholic beverage every 2 weeks. Previously resided
in a [**Hospital1 1501**].
Family History:
Mother: died of MI at 77
Father: died age 80 [**2-19**] complication from renal disease
Physical Exam:
ADMISSION EXAM:
Vitals: T 101, BP 90s-80s/40s, HR 90s, RR 26-30, O2Sat 98% on
80% FiO2
GEN: Intubated, sedated and uresposive, ill appearing
HEENT: PERRL, no epistaxis or rhinorrhea, MM dry
NECK: No JVD, right tunneled line without erythema or purulence
or tenderness
CHEST: Pacer in place, RRR, no M/G/R, normal S1 S2
PULM: Rhonchi throughout
ABD: Soft, obese, non distended, (pt is sedated so difficult to
assess abd discomfort), +BS hypoactive, no HSM, no masses
EXTREM: Bilateral LE edema +2, cold extremeties + cyanotic
NEURO: Non-responsive, pupils reactive and slugish.
SKIN: Extremities are cool to touch, cyanosis on tips of fingers
and on foot, venous dermatitis on bil LE, stage II sacral decub
with no fluid fluctuation and no drainage. L heel wound. HD cath
intact with no drainage.
.
DISCHARGE EXAM:
Vitals: T 98.8, BP 80-116/40-60, HR 80s, RR 20s, O2Sat 100% on
40% FiO2
GEN: Alert and oriented, able to answer questions, NAD
HEENT: PERRL, no epistaxis or rhinorrhea, MMM
NECK: Supple, trach collar in place, no erythema or drainage
from site, no JVD
CHEST: Pacer in place, RRR, nml S1/S2, no M/G/R
PULM: Rhonchi throughout, decreased breath sounds at bases
ABD: Soft, NTND, NABS, no HSM, no masses
EXTREM: WWP, bilateral LE edema +2
NEURO: A&Ox3, CNs grossly intact, sensation intact, strength
diminished in all four extremities, unable to assess gait
SKIN: Chronic dermatitis changes over both shins
Pertinent Results:
ADMISSION LABS:
[**2149-2-21**] 07:00PM BLOOD WBC-22.5*# RBC-3.26* Hgb-9.8* Hct-31.0*
MCV-95# MCH-30.0 MCHC-31.5 RDW-15.5 Plt Ct-696*
[**2149-2-21**] 07:00PM BLOOD Neuts-90.6* Lymphs-5.9* Monos-3.0 Eos-0.1
Baso-0.3
[**2149-2-21**] 07:00PM BLOOD PT-28.9* PTT-45.8* INR(PT)-2.8*
[**2149-2-21**] 07:00PM BLOOD Glucose-153* UreaN-23* Creat-2.9* Na-132*
K-5.2* Cl-92* HCO3-25 AnGap-20
[**2149-2-21**] 07:00PM BLOOD ALT-17 AST-22 AlkPhos-124 TotBili-0.4
[**2149-2-21**] 07:00PM BLOOD Calcium-9.5 Phos-2.6* Mg-2.0
[**2149-2-21**] 07:21PM BLOOD Lactate-1.9 K-5.0
.
DISCHARGE LABS:
[**2149-3-29**] 03:59AM BLOOD WBC-14.9* RBC-2.60* Hgb-8.1* Hct-25.0*
MCV-96 MCH-31.2 MCHC-32.4 RDW-18.7* Plt Ct-802*
[**2149-3-29**] 03:59AM BLOOD Neuts-88.3* Lymphs-7.5* Monos-2.7 Eos-1.4
Baso-0.2
[**2149-3-29**] 03:59AM BLOOD PT-19.2* PTT-55.6* INR(PT)-1.8*
[**2149-3-29**] 03:59AM BLOOD Glucose-118* UreaN-16 Creat-1.7* Na-134
K-3.5 Cl-95* HCO3-30 AnGap-13
[**2149-3-29**] 03:59AM BLOOD Calcium-8.2* Phos-3.1# Mg-1.9
................................................................
MICRO:
[**2-22**] Sputum Cx: Staph aureus coag positive
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
.
[**2-23**] Respiratory viral screen: negative
.
[**2-24**] Sputum Cx: Staph aureus coag positive
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
[**3-2**] Pleural fluid: no growth
.
[**3-13**] Sputum Cx: Burkholderia (Pseudomonas) cepacia
SENSITIVE TO MEROPENEM MIC <=1 MCG/ML.
RESISTANT TO CHLORAMPHENICOL MIC >=32 MCG/ML.
RESISTANT TO TIMENTIN MIC >=128 MCG/ML
.
[**3-20**] Sputum Cx: Burkholderia (Pseudomonas) cepacia
CEFTAZIDIME----------- 16 S
LEVOFLOXACIN---------- R
MEROPENEM------------- 2 S
TRIMETHOPRIM/SULFA---- 2 S
.
**All blood, urine, and stool cultures negative**
................................................................
IMAGING:
[**2-21**] CXR: Bilateral pulmonary air space opacities concerning for
pneumonia.
Moderate left pleural effusion.
.
[**2-24**] CT Chest w/o con:
1. Bibasilar consolidations and multifocal ground-glass
opacities and
tree-in-[**Male First Name (un) 239**] opacities concerning for multifocal pneumonia. The
density of the lung parenchyma at the lung bases alternatively
could be explained by
amiodarone toxicity. Upon resolution of the patient's presumed
pneumonia, a repeat chest CT should be performed to assess for
possible pulmonary effects of amiodarone.
2. Bilateral effusions.
3. Large main pulmonary artery, suggestive of pulmonary
hypertension.
.
[**2-24**] ECHO: The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is mildly dilated. There is
moderate global left ventricular hypokinesis (LVEF = 30 %). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic root
is mildly dilated at the sinus level. 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. Moderate (2+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Compared with the prior study
(images reviewed) of [**2148-12-3**], the degree of pulmonary
hypertension detected has decreased.
.
[**2-27**] CT Torso w/o con:
1. Multifocal ground-glass and tree in [**Male First Name (un) 239**] opacities opacities
in both lower and right upper lobes likely represents infection.
Moderate left pleural effusion.
2. Cholelithiasis without evidence of cholecystitis. No discrete
abscesses were noted.
.
[**2-27**] RUQ U/S: Cholelithiasis with gallbladder wall thickening
and small amount of pericholecystic fluid. However, these
findings are equivocal for acute cholecystitis given the
underlying ascites. If there is continued concern for acute
cholecystitis, further evaluation with HIDA scan is recommended.
.
[**2-28**] Gallbladder Scan: Non-visualization of the gallbladder over
90 minutes with gallbladder visualized shortly after the
administration of 2 mg of morphine. Initial non-visualization
suggests gallbladder dysfunction, but visualization with
morphine demonstrates cystic duct patency. No evidence of acute
cholecystitic.
.
[**3-7**] CT Chest w/ con:
1. Stable multifocal ground-glass and tree-in-[**Male First Name (un) 239**] opacities
within both lungs and bibasilar consolidations consistent with
continued widespread infection. Interval decrease in size of
small left pleural effusion. No lung abscess.
2. Cholelithiasis without evidence of cholecystitis.
3. Pulmonary artery hypertension.
.
[**3-19**] ECHO: The left ventricle is not well seen. The left
ventricular cavity is dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is severely
depressed (LVEF=20-30%). The right ventricular cavity is
unusually small. with depressed free wall contractility. The
ascending aorta is mildly dilated. The aortic valve is not well
seen. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Severely depressed LV systolic function. Unable to
assess for dyssynchrony. Small, hypokinetic right ventricle.
Compared with the prior study (images reviewed) of [**2149-2-24**],
image quality is significantly more suboptimal. LV systolic
function appears similar. The right ventricle is not well seen
but is probably small and hypokinetic on the current study (was
dilated and hypokinetic on prior). Comparison of valvular
function could not be done.
.
[**3-28**] CXR: As compared to the previous radiograph, the patient
has received a nasogastric tube. The tube shows a normal course,
the tip of the tube is not visualized on the image. The other
monitoring and support devices are unchanged. Unchanged
appearance of the cardiac silhouette, the pre existing bilateral
parenchymal opacities and the pre-existing left more than right
pleural effusion. Unchanged aspect of the left pectoral
pacemaker.
.
[**3-29**] Left Shoulder XR: read pending
Brief Hospital Course:
65 yo man with DM, ESRD on HD, systolic CHF, tachy/brady
syndrome s/p pacemaker, atrial fibrillation on coumadin, h/o CVA
with residual left-sided weakness, who presented with hypoxic
respiratory failure and hypotension requiring intubation and
pressors.
.
# Hypoxic respiratory failure: He was treated in [**11/2148**] for
HCAP with 8 days of cefepime and vancomycin. He then developed
pneumonia in the [**Hospital1 1501**] and was treated with 14 days of
levofloxacin without improvement. OSH sputum culture from [**2149-2-19**]
was positive for MRSA. Repeat sputum at [**Hospital1 18**] from [**2-22**] also
growing MRSA. CXR showed bilateral infiltrates with a stable
left pleural effusion. He underwent a bronchoscopy with culuture
growing a small amount of yeast. Galactomannan negative. Beta
glucan >500 but likely related to recent zosyn. He was extubated
on [**2-26**]. IP performed a thoracentesis to drain the left-sided
effusion on [**3-2**], with fluid negative for growth. He temporarily
had a chest tube placed. He desatted secondary to increased
secretions, poor clearance, and mucus plugging, and was
re-intubated on [**3-5**]. He was briefly treated with ciprofloxacin
and cefepime and then completed a 14-day course of vancomycin
and meropenem which were completed on [**3-16**]. The patient was
unable to be weaned from the vent due to poor clearance of
secretions and absent gag reflex, therefore after two weeks he
and his wife decided to proceed with a tracheotomy. He is
currently requiring ventilator assistance at night (current
settings: 15 of pressure support, 8 of PEEP, 40% of FiO2), with
trach collar during the day. Trach tube is a #8 portex perc.
- Trach collar sutures will need to be removed
- Patient will need repeat CT chest in 1 month to ensure
resolution of pneumonia and to assess for amiodarone-induced
lung changes
.
# Septic shock/hypotension: The patient was initally hypotensive
requiring IV fluids and pressor support, thought to be due to
septic shock from his underlying MRSA pneumonia. An ECHO
revealed an EF 30%, similar to prior study, therefore
cardiogenic shock was felt to be unlikely. All blood cultures
were negative. In reviewing previous records, he was noted to be
chronically hypotensive which was thought to be due to autonomic
instability and improved with midodrine. He was treated with 7
days of stress dose steroids which completed on [**3-2**] and repeat
cortisol was normal. He was continued on midodrine and started
on fludricortisone. He continues to require small amount of
norepinephrine (0.02 mcg/kg/min) intermittently.
.
# Leukocytosis: Patient had persistent leukocytosis in the 60s,
despite treatment of the pneumonia. CT chest w/o evidence of
abscess or empyema. He has poor dentition, but no obvious
abscesses on exam and unlikely to account for such an elevated
WBC count. No evidence of endocarditis on ECHO. C. diff
negative. Repeat CT chest with stable left pleural effusion. He
underwent thoracentesis which was negative for growth. CT
abdomen with gallstones, but HIDA scan negative for acute
cholecystitis. He was evaluated by the hematology service who
felt that this was likely a leukemoid reaction, though could not
rule out a myeloproliferative process, especially considering
the patient's cachectic appearance and history of weight loss.
BCR-ABL was negative. His WBC trended down but remained elevated
around 14.
- Recommend through malignancy workup when patient is more
stable
- Patient should follow up with hematology/oncology at [**Hospital1 18**]
.
# ESRD on HD: The patient underwent CVVH throughout this
hospitalization as tolerated by his blood pressure. He was
continued on nephrocaps and sevelamer.
.
# Systolic CHF: LVEF=20-30%. Troponin peaked at 0.31 but CK-MB
was flat at 2-3. His EKG showed left axis deviation with new
RBBB with demand pacing. Cardiology was consulted and felt that
this may be due to digoxin toxicity, so the digoxin was held.
Lisinopril and metoprolol are being held in the setting of
hypotension. The pacer wires were replaced.
.
# Atrial fibrillation: Patient is currently on amiodarone and
anticoagulated with heparin gtt with bridge to warfarin. INR is
1.8.
- Recommend continuing the heparin gtt until INR is therapeutic
([**2-20**])
- Holding digoxin as mentioned above, in the setting of EKG
changes
- Holding metoprolol in the setting of hypotension
- Recommend cardiology follow up
.
# Tachy/brady Syndrome: Has pacemaker and had wires changed
during this admission.
.
# Humerus fx: S/p mechanical fall and underwent closed treatment
of his left proximal humerus fracture on [**2148-12-9**]. He should
continue with pendulum and passive range of motion, with active
assisted and active range of motion, though no resisted
exercises. He can wean out of his cuff and collar as he
tolerates. We obtained a repeat XR of the left shoulder on [**3-29**]
which orthopedics will review.
.
# Diabetes Mellitus: Patient has been receiving glargine 10
units QHS with an insuling sliding scale.
.
# Nutrition: Tubefeeds through Dobhoff; patient will need speech
and swallow evaluation to assess for safety and improved
swallowing function to determine if safe for oral feeding. If he
is not deemed safe for oral feeding he may require PEG tube
placement.
.
# Access: HD tunneled line, PICC
# PPx:
- DVT: Heparin gtt, warfarin
- GI: Lansoprazole
- Bowel: Docusate sodium, senna, miralax
# Code: Full Code
# Communication: [**Name (NI) 714**] (wife) ([**Telephone/Fax (1) 20199**]
Medications on Admission:
1. Albuterol 2 puffs Q6H
2. Allopurinol 100 mg QOD
3. Amiodarone 400 mg daily
4. Warfarin
5. Digoxin 125 mcg ([**1-19**] tab QMWFSat)
6. ASA 325 mg daily
7. Flovent 2 puffs Q12H
8. Insulin NPH 34 units QAM and 45 units QPM
9. Insulin HISS
10. Lisinopril 2.5 mg QMWFSat
11. Multivitamin
12. Metoprolol succinate 50 mg daily
13. Miralax daily
14. Percocet 1 tap Q3Pm/Q11pm
15. Pantoprazole 40 mg daily
16. Renagel 1600 mg TID
17.Senna 2 tabs QHS
18. Simvastatin 40 mg QHS
19. Tylenol 1500 mg Q3PM/Q11pm
20. Vitamin D 1000 units daily
21. Zinc sulfate 220 mg daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (2) **]:
Two (2) puffs Inhalation every six (6) hours.
2. allopurinol 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every other
day .
3. amiodarone 400 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
4. warfarin 1 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Once Daily at 4
PM.
5. aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
6. Flovent HFA 110 mcg/Actuation Aerosol [**Month/Day (2) **]: Two (2) puffs
Inhalation every twelve (12) hours.
7. insulin glargine 100 unit/mL Solution [**Month/Day (2) **]: Twenty (20) units
Subcutaneous at bedtime.
8. insulin lispro 100 unit/mL Solution [**Month/Day (2) **]: sliding scale
Subcutaneous four times a day.
9. Miralax 17 gram Powder in Packet [**Month/Day (2) **]: One (1) packet PO once
a day.
10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. sevelamer carbonate 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
12. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
13. simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
14. Tylenol 8 Hour 650 mg Tablet Extended Release [**Last Name (STitle) **]: One (1)
Tablet Extended Release PO three times a day as needed for fever
or pain.
15. Vitamin D 1,000 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
16. zinc sulfate 220 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
17. norepinephrine bitartrate 1 mg/mL Solution [**Last Name (STitle) **]: 0.01-0.4
mcg/kg/min Intravenous TITRATE TO (titrate to desired clinical
effect (please specify)) as needed for hypotension: map 55
(baseline BP high 80s-low 100s).
18. B complex-vitamin C-folic acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
19. midodrine 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times
a day).
20. fludrocortisone 0.1 mg Tablet [**Last Name (STitle) **]: 0.1 mg PO DAILY (Daily).
21. heparin (porcine) in D5W 25,000 unit/500 mL Parenteral
Solution [**Last Name (STitle) **]: 1600 (1600) units Intravenous per hour: Titrate to
goal PTT 60-100.
22. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN Pain
Hold for sedation, RR<12
23. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
Three (3) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
2 to left arm, 1 to right arm, 12 hours on/ 12 hours off. .
24. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
25. sodium citrate Solution [**Hospital1 **]: 1.2 MLs PO ASDIR (AS
DIRECTED) as needed for catheter not in use: for HD catheter.
26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
27. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary diagnosis:
- Pneumonia
- Sepsis
- Heart failure
.
Secondary diagnosis:
- End stage renal disease
- Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherant.
Level of Consciousness: Alert and interactive; able to mouth
words.
Activity Status: Out of Bed with assistance to chair.
Discharge Instructions:
Mr. [**Known lastname 20200**],
You were admitted with low blood pressure and low oxygenation in
the setting of pneumonia. We treated the pneumonia with
antibiotics. You required ventilator support for your breathing
and now have a tracheostomy. You are also on medications to help
with your blood pressure. You are being discharged to a rehab
facility where you can continue to get stronger and work with
the physical therapists.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
We have made the following changes to your medications:
- CHANGED insulin from NPH 34 units QAM and 45 units QPM to
glargine 20 units QPM
- CHANGED pantoprazole to lansoprazole
- CHANGED sevelamer from 1600mg TID to 800mg TID
- STOPPED digoxin, lisinopril, and metoprolol
- STOPPED percocet and STARTED dilaudid
- STARTED nephrocaps, midodrine, fludrocortisone,
norepinephrine, lidocaine patch, heparin gtt, chlorhexadine
gluconate oral rinse
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2149-4-7**] at 1 PM
With: [**Year (4 digits) **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: MONDAY [**2149-4-7**] at 2:00 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: CARDIAC SERVICES
When: MONDAY [**2149-4-7**] at 2:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2149-3-29**]
|
[
"518.81",
"812.20",
"428.20",
"E888.9",
"785.51",
"707.25",
"995.92",
"428.0",
"785.52",
"707.03",
"482.42",
"V45.11",
"425.4",
"403.91",
"250.00",
"584.9",
"707.07",
"V45.01",
"V58.61",
"585.6",
"427.31",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"39.95",
"38.95",
"33.23",
"96.72",
"34.91",
"96.04",
"31.1",
"00.51",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
21023, 21123
|
11699, 17205
|
288, 353
|
21294, 21294
|
4794, 4794
|
22468, 23439
|
3252, 3342
|
17817, 21000
|
21144, 21144
|
17231, 17794
|
21477, 22028
|
5367, 11676
|
3357, 4155
|
4171, 4775
|
22057, 22445
|
228, 250
|
381, 2629
|
21223, 21273
|
4810, 5351
|
21163, 21202
|
21309, 21453
|
2651, 2991
|
3007, 3236
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,286
| 141,332
|
51181
|
Discharge summary
|
report
|
Admission Date: [**2180-3-19**] Discharge Date: [**2180-3-25**]
Date of Birth: [**2105-9-27**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors / Angiotensin
Receptor Antagonist / Keflex
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 74yo M with history of myelofibrosis on
hydroxyurea, history of chronic c diff, and recent admission for
pneumonia discharged on [**3-14**] who presents with nausea, vomiting
and diarrhea. Today he reported feeling "like he was going to
die" so he came into the ER.
.
In the ED, initial vs were: T 97 P 80 BP 139/79 R 24 O2 sat
100%. CXR was significant for new R pleural effusion and
consolidation. He had a CT of his abdomen/pelvis which showed
new acute, possibly necrotizing pancreatitis. Patient was given
4L NS, vancomycin, flagyl, levaquin, zofran and morphine.
Surgery was consulted regarding questionable necrotizing
pancreatitis and felt he did not acutely require intervention as
he has had his gallbladder removed. Vitals on transfer were 70,
113/46, 19, 100% 2L.
.
In the ICU, patient is oriented to hospital and [**Location (un) 86**] but not
[**Hospital1 **]. He knows the month but not date or year.
Per HCP and patient, he has felt poorly since previous
discharge and never felt better despite PNA treatment. He has
had decreased PO intake for the past week with decreased, dark
urine output. He developed nausea and vomiting on Friday with
new abdominal pain yesterday. Patient has had chronic diarrhea.
.
Review of systems: Per HPI, otherwise difficult to obtain given
confusion
Past Medical History:
- Idiopathic myelofibrosis
- Anemia associated with CKD & Fe deficiency
- PVD with recurrent LE venous stasis ulcers
- PAF s/p [**Hospital1 4448**]
- CHF (EF 45% in [**4-9**])
- HTN
- Hyperlipidemia
- Hypothyroidism
- BPH
- Depression
- H/o chronic C. diff
- Diverticulitis
- recurrent delirium
Social History:
- Tobacco: Previously smoked, quit in [**2151**]
- EtOH: h/o heavy alcohol use, quit in [**2151**].
Currently lives in the [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Retired trial lawyer.
Married but currently seperated. Has 9 children.
Family History:
MI - father who died at 56y
CAD, Parkinson's disease, renal failure - brother
AS - mother
EtOH abuse - mother, brother
Bipolar d/o - daughter
.
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T: 94.7 BP: 111/39 P: 71 R: 13 O2: 100% 2L NC
General: Alert, oriented to person and year, no acute distress
HEENT: NC/AT, PERRL, sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally with decreased breath
sounds on right, no wheezes, rales, rhonchi appreciated
anteriorly
CV: Regular rate and rhythm, normal S1 + S2, [**2-6**] holosystolic
murmur over LLSB
Abdomen: soft, bilateral upper quadrant tenderness, worse at
RUQ, non-distended, bowel sounds present, mild guarding, no
rebound tenderness, no organomegaly appreciated
GU: foley
Ext: slightly cool feet, 1+ DP pulses bilaterally, no clubbing,
cyanosis or edema
.
DISCHARGE PHYSICAL:
Pertinent Results:
ADMISSION LABS:
.
DISCHARGE LABS:
.
MICRO:
.
STUDIES:
CXR [**2180-3-19**]: IMPRESSION:
1. Increased right middle and lower lobe opacities, reflecting
combined
pneumonia and pleural effusion.
2. Worsening congestive heart failure.
.
CTAP [**2180-3-19**]:
IMPRESSION:
1. Recurrent acute pancreatitis, with enlargement and
hypoenhancement of
pancreatic head and peripancreatic standing, suspicious for
necrosis. No
organized fluid collections.
2. Small amount of ascites.
3. Large right and small left pleural effusions, with right
lower lobe
collapse/consolidation.
4. Moderate cardiomegaly and pericardial effusion.
5. Hepatosplenomegaly.
6. Severe atherosclerosis.
.
KUB [**2180-3-19**]:
Single abdominal radiograph demonstrates air within dilated
small bowel
segments in the mid abdomen. If there is concern for
obstruction, then CT
would be helpful for further assessment.
.
MICRO:
UCx [**2180-3-19**]: no growth
[**Month/Day/Year **] Cx [**3-18**], [**3-19**], [**3-20**]: pending
Brief Hospital Course:
HOSPITAL COURSE:
Mr. [**Known lastname **] is a 74yo M with history of myelofibrosis and
recent PNA here with acute pancreatitis. Pt was treated
aggressively with IVF's and started on broad-spectrum abx
Vanc/Meropenem/Flagyl while in the MICU. His course was
complicated by hypercarbic respiratory distress, requiring
intubation. He continued to require IVF's, and required pressor
support. A family meeting was held on
# Acute pancreatitis: As evidenced by abdominal pain, elevated
lipase. CT scan was concerning for necrotizing component in the
pancreatitic head. The underlying cause of his pancreatitis is
unclear as he is s/p cholecystectomy and denies alcohol
ingestion. He recently had a lipid profile which showed
triglycerides of 84 which makes hypertriglyceridemia unlikely.
Medication effect is also a possibility and this could be due to
the levaquin he was discharged on or hydroxyurea as this is
listed as a possible side effect. Pt was treated with aggressive
IVF's, and started on broad spectrum abx with
Vanc/Meropenem/Flagyl. Surgery was consulted, and recommended no
acute surgical intervention. Patient was followed and treated
for 6 days with gradual deterioration and multisystem organ
failure. A family meeting was held and after careful
consideration he was made CMO. He passed on [**2180-3-25**] with his
family at his side.
Medications on Admission:
1. Lotemax 0.5 % Drops, Suspension Sig: One (1) left eye
Ophthalmic twice a day.
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as
needed for insomnia.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. oxycodone 15 mg Tablet Sig: One (1) Tablet PO once a day: in
the morning.
9. oxycodone 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. tobramycin-dexamethasone 0.3-0.1 % Ointment Sig: One (1)
Appl Ophthalmic HS (at bedtime).
11. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
12. Decubi Vite 400-50-500 mcg-mg-mg Capsule Sig: One (1)
Capsule PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. [**Year (4 digits) **] 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
18. Acidophilus Capsule Sig: One (1) Capsule PO twice a day.
19. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
20. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 3 days.
Disp:*11 Tablet(s)* Refills:*0*
21. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: to right side of chest.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
22. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"272.4",
"276.2",
"995.94",
"585.9",
"518.81",
"707.03",
"416.8",
"403.90",
"428.23",
"286.9",
"707.19",
"707.20",
"276.1",
"V45.01",
"459.81",
"560.1",
"238.76",
"285.21",
"584.5",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.72",
"57.94",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7648, 7657
|
4289, 4289
|
364, 370
|
7709, 7719
|
3277, 3277
|
7776, 7787
|
2355, 2501
|
7615, 7625
|
7678, 7688
|
5669, 7592
|
4306, 5643
|
7743, 7753
|
3313, 4266
|
2516, 3258
|
1680, 1737
|
311, 326
|
398, 1661
|
3294, 3296
|
1759, 2056
|
2072, 2339
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,683
| 126,886
|
50221
|
Discharge summary
|
report
|
Admission Date: [**2159-2-14**] Discharge Date: [**2159-2-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
CVL placement and removal.
History of Present Illness:
This is an 84 yo M with a past medical history significant for
multiple myeloma (gets care at DF), on dexamethasone, who
presents to the ED today with complaints of weakness and fatigue
for several days. He does not endorse any localizing symptoms,
but notes that he is "not feeling well" and feels weak. He
describes that he had a near syncopal event yesterday. He
describes that he was about to leave his home and suddenly fell.
He did not have his walker with him. He endorses a prodrome of
lightheadedness and felt "woozy" but denies loss of
consciousness. He did scrape his right knee and side of the
face a little bit. He saw his gerontologist the same day, but
felt better by that time. He describes possible fever/chills at
home, but did not measure his temperature. He denies any n/v/d,
sick contacts, myalgias, chest pain, palpitations or headache.
He is complaining about severe sweating that occurs at night
without any reason for which he had a work up at the VA that was
unrevealing.
Upon arrival to the ED, initial vital signs were 98.2 80 80/43
20 98% on room air. Tmx was 99.7. Exam was nonlocalizing with a
benign abdominal exam. His lactate was 1.3, but labs were
otherwise significant for a leukocytosis to 26,000 with a left
shift, acute renal failure with a creatine of 2.3. He had a
normal cxr, neg UA. Blood/urine cx were drawn and he was given
3L of NS with little improvement in his blood pressure. ECG was
without acute change, and a troponin was elevated at 0.44,
prompting a cardiology consult who advised that this was likely
in the setting of ARF and hypotension and was not ACS. He was
given an aspirin. At this time, the concern for relative adrenal
insufficiency was raised and he was given a dose of stress dose
hydrocortisone, with subsequent improvement in his BP to 88/39.
He was mentating clearly throughout.
He is being admitted to the MICU for hypotension. At time of
transfer to the MICU, his vitals were 73 88/39 20 96%ra, but he
subsequently dropped his pressures to the 60??????s. A CVL was
placed, he was started on levophed and given a dose of vanco,
CTX and flagyl. He now has a CVL and 2 18g PIV's for access, and
has been started on his 4th L NS.
Upon arrival to the ICU, the patient is alert and talkative. He
feels ??????better??????. He notes that he always has some amount of
shortness of breath, and although he appears somewhat
breathless, he will not endorse that this is any worse from his
baseline. He denies pleuritic chest pain, palpitiations.
Past Medical History:
Multiple Myeloma - treated at DF currently, on dexamethasone
DVT x 2, on coumadin
Valvular heart disease
Hyperlipidemia
BPH
Constipation
Hypertension
Plantar fasciitis
Severe leg pain
appendectomy and tonsillectomy as a child
a kidney stone removed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] in [**2146**]
cholecystectomy by Dr. [**Last Name (STitle) **] in [**2153-9-17**]
Social History:
He does not smoke nor drink. He is widowed, wife died approx 6
months ago, has a son and a daughter. [**Name (NI) **] used to run a
sportswear factory.
Family History:
His father died at 90 of cancer in the brain and his mother at
52 of breast cancer.
.
Physical Exam:
Gen: mild distress, mild dyspnea, states he feels comfortable
CVS: +S1/S2, no M/R/G, RRR
LUNGS: +crackles, no rhonchi
ABD: +BS, NT/ND
EXT: no c/c/e
Pertinent Results:
[**2159-2-14**] 07:18PM WBC-25.9*# RBC-3.97*# HGB-13.1* HCT-37.7*
MCV-95# MCH-32.9* MCHC-34.7 RDW-13.5
[**2159-2-14**] 07:18PM NEUTS-91* BANDS-1 LYMPHS-6* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-0
[**2159-2-14**] 07:18PM PT-19.1* PTT-25.1 INR(PT)-1.8*
[**2159-2-14**] 07:18PM GLUCOSE-90 UREA N-54* CREAT-2.3* SODIUM-134
POTASSIUM-5.3* CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
[**2159-2-14**] 07:18PM ALT(SGPT)-30 AST(SGOT)-35 CK(CPK)-96 ALK
PHOS-46 TOT BILI-0.6
[**2159-2-14**] 07:18PM cTropnT-0.44*
[**2159-2-14**] 08:44PM LACTATE-1.3
[**2159-2-14**] 09:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2159-2-14**] 09:33PM URINE RBC-0-2 WBC-[**3-22**] BACTERIA-MOD YEAST-NONE
EPI-0-2
.
CXR ([**2-16**]): Persistent CHF, slightly worse when compared to
[**2159-2-15**].
.
CT C/A/P:
1. Small bilateral pleural effusions, slightly larger on the
right, with adjacent compressive atelectasis.
2. No source for sepsis identified on CT of the chest, abdomen,
and pelvis.
3. Multiple renal cysts, measuring up to 11 cm on the right and
4 cm on the left, containing simple fluid. A smaller 14-mm
exophytic cyst along the upper pole of the right kidney, is
slightly hyperdense, possibly representing proteinaceous
material or blood products, although a solid lesion cannot be
excluded without administration of IV contrast.
4. Status post cholecystectomy.
5. Scattered colonic diverticula without evidence of
diverticulitis.
6. Mild prostatic enlargement.
7. Bilateral fat-containing inguinal hernias.
8. Multilevel compression fractures in the thoracolumbar spine
of indeterminate chronicity, status post kyphoplasty at two
levels. No associated soft tissue component is noted along the
spine.
9. Possible non-displaced acute/subacute lateral right 9th rib
fracture.
.
CARDIAC ECHO: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The number of aortic valve leaflets cannot be
determined. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. Mild to moderate ([**1-19**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: No valvular vegetations seen, but technical study
quality precludes definite asssessment of valvular morphology.
Mild aortic regurgitation. Mild to moderate mitral
regurgitation. Preserved biventricular systolic function. Mild
pulmonary hypertension.
Brief Hospital Course:
84 yo M with history of MM, DVT, admitted with hypotension and
ARF.
.
MICU COURSE: He was admitted to the MICU for hypotension. At
time of transfer to the MICU, his vitals were 73 88/39 20 96%ra,
but he subsequently dropped his pressures to the 60??????s. A CVL was
placed, he was started on levophed and given a dose of vanco,
CTX and flagyl. Upon arrival to the ICU, the patient was alert
and talkative. He received stress dose steroids out of concern
for AI in the setting of chronic dx use. He was started on
Vanc/Zosyn/Azithro for ? infiltrate in retrocardiac space. He
received volume resuscitation with 8 liters and subsequently
developed bilateral pleural effusions. He was briefly on bipap
overnight for 5 minutes because patient appeared uncomfortable,
but no clinical change. A CT c/a/p showed bilateral renal cyst,
for which he has urology f/u.
On transfer to floor, he felt better. He notes that he always
has some amount of shortness of breath, and although he appears
somewhat breathless, he will not endorse that this is any worse
from his baseline. He denies pleuritic chest pain,
palpitiations.
.
HYPOTENSION: Patient had mild fever and leukocytosis but no
localizing symptoms. Hypotension was originally fluid refractory
but responded to steroids. CT C/A/P showed no evidence of
infection. UA negative. Cardiac Echo did not point to a cardiac
[**Last Name (un) 68421**]. Cultures negative. Flu negative. Most likely cause is
mild viral vs. bacterial infection worse in setting of adrenal
insufficiency. In ICU, he was started on broad spectrum abx with
vanco, zosyn, azithro for planned 10 day course with goal stop
date [**2-23**]. His antibiotics were narrowed to Ceftriaxone/Azithro
to [**Last Name (un) 76271**] possible CAP. His stress dose steroids to prednisone
30mg daily and discharged on a [**Last Name (LF) 15123**], [**First Name3 (LF) **] his primary
oncologist.
.
# PULMONARY EDEMA: Patient flashed in setting of aggressive
volume repletion. Cardiac enzymes negative. No clear evidence of
heart failure. He responded well yo gentle diuresis.
.
# HEMATURIA: Patient with hematuria along with bilateral renal
cysts on CT scan. Urology consulted and have recommended
cytology, which was sent. Will f/u as outpatient.
.
#. ARF - likely prerenal azotemia.- Now resolved
.
#. Multiple Myeloma - multiple myeloma for which he takes
dexamethasone weekly on a regular basis. Per primary oncologist,
MM is in remission
.
#. History of DVT- continue coumadin
.
#. Depression - continue citalopram. SW consulted.
.
Code status: Full code
.
Communication: Daughter - [**Known lastname 104753**] [**Telephone/Fax (1) 104754**] (house)
[**Telephone/Fax (1) 104755**] (cell).
Medications on Admission:
ACETIC ACID - 2 % Solution - half cc in ears twice a day
AMOXICILLIN - 500 mg Capsule - 4 Capsule(s) by mouth once a day
as needed for for dental procedure
CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime
DEXAMETHASONE - 4 mg Tablet - 10 Tablet(s) by mouth once a day
every monday
FINASTERIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
GABAPENTIN - 100 mg Capsule - 1 Capsule(s) by mouth at bedtime
and then increase it up to 300 mg tid
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
OXYCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5
mg-325 mg Tablet - 1 Tablet(s) by mouth once a day as needed for
as needed for pain in legs
RANITIDINE HCL - 150 mg Capsule - 1 Capsule(s) by mouth twice a
day
TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg
Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - Dosage
uncertain - 5mg most recently per patient
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - Dosage
uncertain
ASPIRIN - (Prescribed by Other Provider) - Dosage uncertain
CALCIUM-CHOLECALCIFEROL (D3) [CALCIUM+D] - (OTC) - Dosage
uncertain
CHLORHEXIDINE GLUCONATE - 2 % Liquid - mouth wash twice a day
DOCUSATE SODIUM - 100 mg Capsule - 2 Capsule(s) by mouth twice a
day
FOLIC ACID - 0.4 mg Tablet - 1 Tablet(s) by mouth once a day
GUAR GUM [BENEFIBER (GUAR GUM)] - (Prescribed by Other
Provider)
- Dosage uncertain
MULTIVITAMINS WITH MINERALS [MULTI-VITAMIN W/MINERALS] -
(Prescribed by Other Provider; OTC) - Dosage uncertain
SENNA - 8.6 mg Tablet - 2 Tablet(s) by mouth once a day
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day
for 9 days: 4 tabs for 3 days;
then 2 tabs for 3 days;
then 1 tab for 3 days.
Disp:*21 Tablet(s)* Refills:*0*
2. Acetic Acid 2 % Solution Sig: One (1) half cc Otic twice a
day: in ears.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Dexamethasone 4 mg Tablet Sig: Ten (10) Tablet PO once a
week: on mondays. Do not resume for 3 weeks.
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
8. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. Calcitrate-Vitamin D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
16. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Primary:
HYPOTENSION
ADRENAL INSUFFICIENCY
PULMONARY EDEMA
HEMATURIA
ARF
Secondary:
Multiple Myeloma
History of DVT
Depression
Benign prostatic hypertrophy
Nutrition
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for low blood pressure. We looked for signs
of infection but did not observe any. You were treated in the
intensive care unit with medications to elevate your blood
pressure. These symptoms were likely due to a viral infection
in the setting of steroid use. Do not take your blood pressure
medications until your next appointment with your PCP this week.
You were started on prednisone, which you should [**Location (un) 15123**] slowly.
Please take decreasing doses over 9 days as directed. Following
this, you should not take your dexamethasone for 2 weeks.
If you have fevers, chills, feel week or lightheaded, or have
any other concerning symptoms. Please seek medical attention.
Followup Instructions:
You should follow up with your PCP, [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2159-2-22**] 9:30
You are scheduled to see urology for follow up with Urology.
You have an appointment scheduled on with Dr. [**Last Name (STitle) 770**] on [**3-26**] a 3:30PM, [**Hospital Ward Name 23**] [**Location (un) 470**].
You should keep your previously scheduled oncology appointment.
Completed by:[**2159-3-5**]
|
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26,212
| 114,328
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22769
|
Discharge summary
|
report
|
Admission Date: [**2188-10-1**] Discharge Date: [**2188-10-22**]
Date of Birth: [**2133-11-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Fever, chills
Major Surgical or Invasive Procedure:
Placement of new right tunneled catheter
Transfusion of 2 units of packed red blood cells in total
History of Present Illness:
54 cantonese only speaking male with CAD, HTN, DM, ESRD on HD
was found to be febrile after he had his hemodialysis on DOA. He
complained of chills and fevers since Friday. No n/v/diarrhea.
He did have some back pain for 1-2 days. Does not have any chest
pain, SOB, palpitations, dizziness. His fevers were most likely
from infected tunnelled RIJ. 2 sets of blood cultures were sent
and he was given Vanc 1 gm, Gent 60 mg.
Past Medical History:
HTN
DM
ESRD due to IgA nephropathy/DM
diabetic retinopathy- Blindness
R subclavian Thrombus history of coumadin (seems to have stopped
around [**12-9**])
Anemia of chronic disease
Hyperlipidemia
CAD - Cardiac catheterization from [**2188-2-4**] showed
three-vessel disease with a 30% left main, a diffusely diseased
LAD with 80% mid stenosis, 90% diagonal, 60% second diagonal,
and 90% OM1. No suitable for PCI
Social History:
Cantonese speaking with some English, immigrated to the US 10
yrs ago, currently lives with wife and 3 children, has been
blind for approx 3 years, has not worked recently; No history of
tobacco use, alcohol, or illicit drug use. Wife injects insulin.
Family History:
No DM, CAD, Stroke, HTN, or Renal Disease
Physical Exam:
98.6, 167/97, 79, 22, 94%/RA, FSG 198, Wt 128 lbs
Gen: Comfortable, intermittent hiccups
HEENT: NAD,
Neck: no JVD, tunnel catheter line nontender/ no erythema at
insertion site
Lungs: Lungs clear
Heart: RRR no m/r/g
Abd: +bs, soft, NTND, no palpable masses, no reboud, no guarding
Ext: wwp, no edema
Neuro: AOx3
.
Pertinent Results:
IMAGING:
.
CXRAY [**2188-10-1**]
Cardiomegaly. No evidence of CHF or pneumonia.
Hemodialysis catheter unchanged in position
.
MR L SPINE W/O CONTRAST [**2188-10-3**] 11:21 AM
At L2/3, there is a mild disc bulge, which is not causing canal
or foraminal stenoses.
At L4/5, there is a mild disc bulge eccentric to the left, which
is not causing canal stenosis, but is mildly narrowing the left
subarticular zone. There is no foraminal stenoses.
No paraspinal soft tissue abnormalities are noted.
IMPRESSION: Somewhat limited exam due to lack of gadolinium, but
no evidence of spondylodiscitis or epidural or paraspinal
abscess formation.
Minimal degenerative changes without canal or foraminal
stenoses.
.
CXR [**2188-10-14**]
IMPRESSION: Improvement of pulmonary congestive pattern since
previous examination four days earlier. Also, heart size has
decreased slightly. No evidence of new discrete infectious
pulmonary infiltrates.
.
CT CHEST W CONTRAST [**2188-10-15**]
1. Findings in the right middle lobe and right lower lobe are
consistent with multifocal pneumonia.
2. Mild CHF.
3. Small right pleural effusion and tiny on the left.
4. Small right internal jugular venous thrombus.
5. No evidence of pulmonary infarction.
.
CT HEAD [**2188-10-15**]
IMPRESSION: No intracranial hemorrhages or areas of abnormal
enhancement.
.
TTE ECHO [**2188-10-15**]
- compared with the findings of the prior study (images
reviewed) of [**2188-2-19**], a possible pulmonic valve
vegetation is now seen.
- moderate symmetric LVH
- overall left ventricular systolic function is normal (LVEF
60-70%)
- right ventricular pressure overload
- a small pericardial effusion with no echocardiographic signs
of tamponade
.
KUB [**2188-10-17**] done in context of abdominal pain, N/V
IMPRESSION: No evidence of ileus or obstruction.
.
Repeat CT head [**2188-10-17**]
IMPRESSION: No acute intracranial hemorrhage or mass effect.
.
TEE [**2188-10-20**]
IMPRESSION: Trace aortic regurgitation with normal valve
morphology. Normal pulmonic valve morphology with no evidence of
vegetation or abscess. Mild mitral and tricuspid regurgitation.
.
LABS
CHEM/CBC
[**2188-10-1**] 06:50PM BLOOD WBC-19.0*# RBC-4.04* Hgb-12.6* Hct-36.0*
MCV-89 MCH-31.2 MCHC-35.1* RDW-16.4* Plt Ct-255
[**2188-10-2**] 05:45AM BLOOD WBC-15.7* RBC-3.77* Hgb-11.4* Hct-34.8*
MCV-92 MCH-30.4 MCHC-32.9 RDW-16.4* Plt Ct-294
[**2188-10-10**] 12:00PM BLOOD WBC-6.8 RBC-2.90* Hgb-9.2* Hct-26.8*
MCV-92 MCH-31.6 MCHC-34.2 RDW-17.6* Plt Ct-244
[**2188-10-11**] 09:25AM BLOOD WBC-5.6 RBC-3.01* Hgb-9.4* Hct-27.6*
MCV-92 MCH-31.1 MCHC-33.9 RDW-17.6* Plt Ct-215
[**2188-10-1**] 06:50PM BLOOD Glucose-279* UreaN-11 Creat-3.6*# Na-135
K-6.8* Cl-95* HCO3-30 AnGap-17
[**2188-10-2**] 05:45AM BLOOD Glucose-221* UreaN-18 Creat-4.8*# Na-139
K-3.8 Cl-96 HCO3-33* AnGap-14
[**2188-10-10**] 12:00PM BLOOD Glucose-159* UreaN-31* Creat-4.4*# Na-138
K-3.8 Cl-100 HCO3-28 AnGap-14
[**2188-10-11**] 09:25AM BLOOD Glucose-190* UreaN-14 Creat-3.2*# Na-137
K-3.4 Cl-95* HCO3-33* AnGap-12
.
CARDIAC ENZYMES
[**2188-10-8**] 03:24PM BLOOD CK-MB-NotDone cTropnT-0.29*
[**2188-10-8**] 11:00PM BLOOD CK-MB-NotDone cTropnT-0.29*
[**2188-10-9**] 09:56AM BLOOD CK-MB-NotDone cTropnT-0.36*
.
OTHER LABS
[**2188-10-1**] 06:58PM BLOOD Lactate-1.0 K-5.0
[**2188-10-2**] 02:38AM BLOOD Lactate-0.9 K-3.7
[**2188-10-8**] 03:24PM BLOOD LD(LDH)-274* CK(CPK)-56
[**2188-10-9**] 09:56AM BLOOD CK(CPK)-73
[**2188-10-3**] 05:43AM BLOOD Lipase-21
[**2188-10-4**] 05:50AM BLOOD Lipase-23
[**2188-10-8**] 07:48AM BLOOD Lipase-31
Brief Hospital Course:
Assessment: 54 year old Cantonese-speaking male with DM and ESRD
on HD, and CAD s/p CABG, difficult to control HTN, who had a 3
week hospital course for MSSA septicemia from an infected
hemodialysis catheter, aspiration pneumonia, unstable
angina/demand ischemia with new ST depressions on EKG, and
co-management of other chronic medical issues.
MSSA septicemia from infected HD catheter -
54 year old Cantonese-only speaking male with CAD, HTN, DM and
ESRD on HD presented with fever and chills [**2188-10-1**]. He was found
to have a MSSA RIJ HD catheter infection by cultures on [**10-1**] and
[**10-2**]. He was given Vanc/Gent in the ED. The catheter was removed
and he had a temporary line placed. He was treated for the
infection with vancomycin, dosed with HD, per the renal
attending. The patient had a tunnelled HD catheter placed on
[**2188-10-9**] after dialysis. The patient was continued on vancomycin
on the floor, day# 1= [**2188-10-1**] to finish a 3-week course of
antibiotics the day of discharge. Daily vancomycin levels were
checked and he was dosed at HD ([**Month/Day/Year 766**], Wednesday, Friday) to
keep the vancomycin greater than 15. The patient was kept on
vancomycin for MSSA because the patient did not have good IV
access until an emergent midline was placed on [**2188-10-17**] at which
time the patient needed vancomycin coverage for
aspiration/nosocomial pneumonia. So, throughout the hospital
course, the patient was kept on vancomycin for MSSA instead of
switching to nafcillin. All surveillance blood cultures showed
no growth. The new tunnelled catheter had bleeding around the
site during the 24 hours that the patient was receiving heparin
gtt for possible NSTEMI with new ST depressions. Since then, the
catheter has had some oozing from the site when accessed by
hemodialysis during his sessions but has been controlled with
pressure at the site.
A CT scan of the chest revealed a RIJ thrombus around the site
of the new tunnelled catheter. Per the renal team, there was no
indication to change the catheter and patient will need to have
a follow-up CT scan of his chest in [**3-8**] months to assess this
clot.
Initially, he also complained of back pain in the setting of the
bacteremia and had an MRI and RUQ ultrasound to eval for other
possible source of septicemia, which were negative. The patient
also had a TTE that showed a possible pulmonary valve vegetation
on [**2188-10-14**] but a TEE done 6 days later on [**2188-10-20**] showed no
endocarditis.
The patient was discharged after finishing a 3 week course of
vancomycin per ID team recommendations, at hemodialysis for
septicemia from line infection by [**2188-10-22**], his day of discharge.
Aspiration pneumonia -
During the patient's course in the hospital, he had episodes of
vomiting with likely aspiration. He had both CXR and CT chest on
[**2188-10-15**] which showed areas in the right middle lobe and right
lower lobe consistent with multifocal pneumonia. The patient was
started on IV zosyn and placed on aspiration precautions. By the
day of discharge, the patient completed a 7 day course of zosyn
and was saturating well on room air, without cough or fever for
more than 72 hours.
New ST depressions in lateral leads on EKG [**2188-10-14**] -
On the AM of [**2188-10-14**], patient was found to have unretractable
vomiting, and EKG taken showed new 2-3mm ST depressions in leads
V4-6. His cardiac enzymes were slightly elevated at 0.2-0.4, but
his baseline troponins were also in the 0.2 range. The patient
had no complaints of chest pain, although he was a difficult
historian. Patient was started on a heparin gtt for concern of
NSTEMI, cardiology was consulted but no interventions were
recommended as the patient was with no areas amenable for PCI by
his last cardiac cath, and was not a good surgical candidate. By
his last cardiac cath, the patient had moderate to severe
disease in almost all his coronary arteries. The patient was
maintained on aspirin, plavix, and as the patient had concern of
septic emboli from presumed pulmonary valve endocarditis by TTE
at the time, concern for cerebral hemorrhage given acute change
in mental status, the patient's heparin gtt was discontinued
after 24 hours on [**2188-10-15**]. The patient's daily 12-lead EKGs
continued to have ST depressions, and some new ST elevations in
V3 throughout his hospital stay and no events on telemetry. The
patient was discharged on aspirin, plavix, beta blocker, [**Last Name (un) **],
and statin. He was also started on long acting nitrates with
good response. Cardiology consult team followed him as well and
recommended the above.
HTN/Acute pulmonary edema in the setting of hypertensive urgency
requiring transfer to the MICU on [**2188-10-10**]. Prior to HD, the
patient received, two (Hydralazine 50 mg and amlodipine 10 mg)
out of his five HTN medications. Initial BP 154/104, but HD RN
reported labored breathing and O2 sat 84-87%. Soon after
initiation of therapy his BP increased to 216/100. He was seen
by the renal fellow and medical team and adamantly refused
oxygen. His other oral BP medications were given with minimal
effect. He underwent 2.5 liter ultrafiltration but remained
hypertensive and hypoxic. He was given 10 mg IV Hydralazine X 2
and 10 mg IV Labetalol X 1 with minimal effect. O2 sat remained
85-90% RA. Several discussions via Cantonese interpreter and his
wife were done by the medical team and the patient adamantly
refused oxygen or ABG. BP remained 215/106 and 1 inch nitropaste
placed on patient. The patient was transferred to the MICU for
further management of acute pulmonary edema. 2.5 L
ultrafiltrate removed during HD on date of admission, with addn
2 L removed in CCU. He was transferred back to the floor on
[**2188-10-11**] with no oxygen requirements after removal of 4.5 liters
of fluid by HD. Throughout the rest of his hospital course, the
patient's blood pressure regimen was optimized on discontinuing
hydralazine and starting minoxidil and imdur. He was discharged
on minoxidil and imdur in addition to his home regimen of
maximum doses of metoprolol, amlodipine, and losartan. By
discharge, his blood pressures were ranging 120-140s SBP on this
regimen, with good O2 sat on RA. Blood pressure control was also
maintained by his M,W,F regimen of HD with fluid removal.
Acute on chronic anemia -
The patient had anemia with Hcts below his baseline of 33-34
likely due to chronic kidney disease with acute illness. Given
his acute coronary syndrome with the new ST depressions, the
patient received 2 units of PRBC transfusions during his
hospital stay with his Hct goal to be maintained above 30. He
also receives EPO at hemodialysis.
DM/CKD stage 5 -
The patient was followed by both the renal and [**Last Name (un) **] diabetes
teams during his hospital stay. His fluid status and ESRD were
maintained by hemodialysis three times a week on M,W,F, and his
diabetes was maintained on NPH 70/30 8units QAM, 6units QPM with
a regular insulin sliding scale. He was discharged with follow
up with his dialysis at [**Hospital1 336**] and new appointments were made for
him with Cantonese and Mandarin-speaking providers at [**Last Name (un) **] for
follow up on diabetes control and nutrition (both for diabetes
and diastolic CHF).
Small pericardial effusion found on ECHO - The patient remaied
without signs of HD compromise and no signs of cardiac tamponade
by ECHO. No JVD or hypotension. He will need follow up on this
with his PCP as an outpatient.
Code status -
Initially in the ICU, discussions with an interpreter found the
patient to be DNI but not DNR. Given his many chronic medical
problems and the patient's ongoing wish to go home and leave the
hospital, the palliative care team was consulted to have a
formal code status discussion and also goals of care discussion
with the patient and wife. The result of this discussion with a
Cantonese interpreter was the that patient and wife decided to
continue to pursue resuscitation in the event of a
cardio-pulmonary arrest, and be changed to Full Code status.
This was documented in the chart. The patient was discharged on
[**2188-10-22**] home with close follow up.
Medications on Admission:
- Metoprolol Tartrate 150 TID
- Atorvastatin 40 mg
- Pantoprazole 40 mg
- Amlodipine 10 mg QD
- Calcium Carbonate 500 mg TID
- Lisinopril 40 mg QD
- Sevelamer 800 mg TID
- Aspirin 325 mg QD
- Clonidine 0.3 mg/24 hr QSUN
- Losartan 100 mg QD
- Clopidogrel 75 mg QD
- Hydralazine 50 mg QID
- Insulin NPH 7 units QAM, 7 units QHS
- Folic Acid 1 mg QD
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once 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. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
10. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Erythromycin 5 mg/g Ointment Sig: 0.5 gm in OS Ophthalmic
QID (4 times a day).
13. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
subcutaneous per insulin sliding scale Injection QACHS.
17. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: One (1) 8 units Subcutaneous QAM, once a morning before
breakfast.
Disp:*qs * Refills:*2*
18. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Six (6) units subcutanous Subcutaneous QPM every night
before dinner.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Final diagnosis
Septicemia secondary to infection in hemodialysis catheter
.
Secondary diagnosis
Aspiration pneumonia
Unstable angina/ Non ST elevation Myocardial infarction
Pulmonary edema
Acute Diastolic congestive heart failure
Hypertensiion, malignant
Chronic kidney disease stage 5; on hemodialysis ([**Date Range 766**],
Wednesday, Friday)
Coronary artery disease, native
Hyperlipidemia
Anemia of chronic disease
Discharge Condition:
Good, good O2 sat on room air, no cough, new HD tunneled
catheter in place.
Discharge Instructions:
You were admitted for fever and chills at hemodialysis and was
found to have a bacterial infection in your bloodstream from an
infection in your dialysis catheter. To treat this, we removed
your infected catheter and are treating you with antibiotics at
hemodialysis treatment. While you were here, you were
transferred to the intensive care unit because you had a very
high blood pressure and had fluid in your lungs leading to
shortness of breath. After you had sessions of hemodialysis to
remove extra fluid, you improved and were transferred back to
the medical floor. We also placed a new hemodialysis catheter.
We made sure that you did not have other sources of the
infection in your spine and abdomen by a MRI of you spine and
ultrasound of your abdomen. However, you were found to have an
infection in your lung, so we started a second antibiotic to
treat this. We were also worried about a possible infection on
your heart valves and were treating you with antibiotics for
this, but the accurate ultrasound of your heart showed there was
no bacteria on your heart valves.
.
During your hospital stay, you were also found to have tracings
on your heart which showed that your heart was not getting
enough blood. The heart doctors were following [**Name5 (PTitle) **], but because
of your other medical problems and the severity of your heart
disease, you are not a good candidate for surgery of placement
of a stent in your heart. For this, we have been treating your
heart disease with medicine and monitoring your heart tracing.
You also received a total of two units of blood transfusion
during your hospital stay for your low blood counts. You were
also found to have a small clot at the end of your current
hemodialysis catheter which you will need to follow up with a
repeat CT scan of your chest in [**3-8**] months. There is no
indication to remove this catheter according to the kidney
doctors. [**First Name (Titles) 357**] [**Last Name (Titles) **] this with your primary care doctor.
.
On discharge from the hospital, you will be finished with a 3
week course of antibiotics for your catheter line infection, and
finished with a 1 week course of antibiotics for your pneumonia.
You will need to continue your hemodialysis on [**Last Name (Titles) 766**],
Wednesday, Friday at [**Hospital1 336**]. We also made the following changes to
your medications:
1. We started a blood pressure medication called minoxidil,
which you should take 2.5mg two times a day
2. We started a blood pressure medication called imdur 30mg
daily for your blood pressure
3. We stopped your hydralazine medication for your blood
pressure. Do not take this medication anymore.
4. We started you on a medication called nephrocaps (B
Complex-Vitamin C-Folic Acid) for your renal disease. Please
take one daily.
5. We adjusted your standing insulin dose to be 8 units of the
NPH insulin before breakfast and 6 units of the NPH at night.
.
Also, it is very important that you eat a low salt diet, less
than 2 grams per day, and restrict your fluid to 1,500ml per
day. You should weigh yourself daily and call your physician if
your weight changes by more than 3 lbs.
.
Please return to the hospital if you experience any fever,
chills, tenderness or pain at your hemodialysis catheter site,
uncontrolled nausea or vomiting, chest pain, shortness of
breath, or swelling in your legs.
Followup Instructions:
You have an appointment with your primary care doctor tomorrow
on [**10-23**] at 1:30pm. Provider: [**Name10 (NameIs) 32199**],[**Name11 (NameIs) 3078**] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 8236**]. You will need a follow up CT scan of your chest in
[**3-8**] months to follow up on the small blood clot around the tip
of your hemodialysis catheter.
.
You have an appointment with a dietician, [**First Name8 (NamePattern2) 8463**] [**Last Name (NamePattern1) 13260**] to work
on your nutrition. She is a Cantonese speaker. The appointment
is on [**10-30**], at 3pm. Please go to [**Hospital **] clinic on [**Last Name (un) 19749**] on the [**Location (un) **]. If you have any questions, call
[**Doctor First Name **], who is a Cantonese speaker, her telephone number is
[**Telephone/Fax (1) 58905**].
.
You have an appointment at the [**Hospital **] Clinic at [**Last Name (un) **] Diabetes
center on [**12-11**], Thursday afternoon at 4:30pm to follow up
on your diabetes control. The physician is [**Name Initial (PRE) **] mandarin speaker.
Please go to [**Hospital **] clinic on [**Last Name (un) 3911**] on the [**Location (un) **].
If you have any questions, call [**Doctor First Name **], who is a Cantonese
speaker, her telephone number is [**Telephone/Fax (1) 58905**].
.
Continue hemodialysis [**Telephone/Fax (1) 766**], Wednesday, Friday at [**Hospital 58906**]. [**Hospital1 336**] HD center: F ([**Telephone/Fax (1) 58907**]. T ([**Telephone/Fax (1) 58908**]
.
Your other appointments at [**Hospital1 18**] are as follows:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2188-10-30**] 9:20
Provider: [**Name10 (NameIs) **] PROCEDURE Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2188-10-30**]
10:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2188-12-30**] 9:40
|
[
"995.91",
"428.33",
"272.4",
"250.50",
"362.01",
"585.5",
"583.9",
"507.0",
"369.4",
"038.11",
"414.01",
"250.80",
"403.01",
"410.71",
"285.21",
"V58.67",
"V09.0",
"428.0",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04",
"38.95",
"97.49"
] |
icd9pcs
|
[
[
[]
]
] |
15960, 15966
|
5545, 13740
|
331, 432
|
16429, 16507
|
1999, 5522
|
19931, 21926
|
1606, 1649
|
14138, 15937
|
15987, 16408
|
13766, 14115
|
16531, 19908
|
1664, 1980
|
278, 293
|
460, 884
|
906, 1320
|
1336, 1590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,367
| 169,503
|
21124+57233
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-7-27**] Discharge Date: [**2121-7-29**]
Date of Birth: [**2063-6-10**] Sex: F
Service: MED
Patient is a 58-year-old female with a history of end-stage
renal disease and rapidly compressive scleroderma who
presents via Med Flight after being found acutely short of
breath, tachypneic with labored breathing. EMS unable to
obtain SAO2. Patient noted to be cyanotic appearing with
minimal breath sounds. Blood pressure at that time 194/128.
Patient was transferred to [**Hospital3 4298**] ED, emergently
intubated. ABG peri-intubation 7.13 with a PCO2 of 74, PO2
167. Was given Nitro paste, Versed. Chest x-ray showed
bilateral fluffy infiltrates. Was started on Nitro drip and
given Bumex then transferred to [**Hospital3 **] for further care.
PAST MEDICAL HISTORY: Scleroderma, Raynaud's, end-stage
renal disease, arthritis status post atrial myxoma removal,
questionable asthma, questionable hip fracture.
ALLERGIES:
1. Zestril
2. Verapamil
3. Latex
SOCIAL HISTORY: Lives in [**Hospital3 **].
MEDICATIONS ON TRANSFER:
1. Nitro drip
2. Diovan 325
3. Duragesic 150 mcg
4. Prilosec 28 b.i.d.
5. Prednisone 5 a day
6. Norvasc 2.5
7. Hydrochlorothiazide 25
8. Neurontin 100 b.i.d.
9. Ativan 1 mg t.i.d. p.r.n.
10. Aspirin
11. Nephro caps
12. Vitamin C
13. Tums
14. Oxycodone p.r.n.
15. Wellbutrin 100 b.i.d.
16. Quinine
PHYSICAL EXAMINATION AT TIME OF ADMISSION: Temperature 94,
blood pressure 157/90, was on AC 400 x 14 with an FIO2 of 50
percent. In general, is sedated, intubated. Skin appears
tight, grayish color; no rash. HEENT: Pupils are 2 mm, 1 mm
bilaterally. Neck is difficult to assess jugulovenous
pressure. Chest with decreased breath sounds anteriorly and
laterally at the bases with wheezing. Cardiovascular is
tachy; frequent ectopy; no murmurs; hyperdynamic. Abdomen is
soft, nondistended, positive bowel sounds. Extremities:
Sclerodactyly with ulcerations on the fingers and toes. No
lower extremity edema.
LABORATORY DATA: Chest x-ray showed bilateral diffuse
infiltrates, neurovascular redistribution.
EKG: Sinus at 140, normal axis, positive left ventricular
hypertrophy, lateral T wave inversion.
Chem-7 remarkable for a potassium of 5.9, BUN 31, and
creatinine 3.9, white count 11.9, hematocrit 39, platelets
192, LDH 267.
HOSPITAL COURSE BY PROBLEM: Respiratory failure: Patient
was intubated emergently at the outside hospital but after
discussion with the family which revealed the patient was Do
Not Resuscitate/Do Not Intubate and that she would not have
wanted to be intubated. Her sedation was lightened and, by
communicating through writing, patient stated that she wished
to be extubated and that she would not ever want to be
reintubated. Thus, on the evening of patient's admission on
[**2121-7-27**] she was extubated without event.
In terms of etiology of patient's respiratory failure, she
underwent a CTA which revealed no evidence of pulmonary
embolism, but there was evidence of large bilateral effusions
as well as extensive subcutaneous edema and ascites. It was
felt that fluid overload and congestive heart failure may
have been the cause of patient's decompensation. A
transthoracic echocardiogram was performed which revealed
severe global hypo/akinesis with an estimated ejection
fraction of approximately 20 to 25 percent.
Patient underwent hemodialysis to assist in fluid removal and
was started on afterload reduction with Hydralazine and nitro
paste. Patient has a questionable allergy to her ACE
inhibitor and also was having difficulty taking pills and
thus intravenous and transdermal medications were used.
Additionally, patient has an extremely low albumin due to
malnutrition and felt that this was contributing to her
anasarca and pleural effusions.
In terms of other possible etiologies, an induced sputum for
pneumocystis carinii pneumonia was sent and is pending at the
time of this dictation, and patient was treated with Levaquin
for a question of possible pneumonia.
Clostridium difficile colitis: Patient had extensive
diarrhea during her hospital stay. Was sent for Clostridium
difficile and came back positive. Patient was started on a
course of Flagyl.
End-stage renal disease: Patient was continued on
hemodialysis as per Renal and started on calcium carbonate as
a phos blanket.
Dysphagia: Patient had extensive difficulties with
swallowing food, liquid, and even pills. A Speech and
Swallow evaluation was ordered, but this is pending at the
time of this dictation. Patient's medications were given
intravenously as possible.
Pain control: Patient apparently is on 150 mcg Fentanyl
patch as an outpatient although arrived in the hospital with
only a 50 mcg patch. Due to the concern over the confusion
of the dose and the concern of possibly suppressing the
patient's respiratory drive, the Fentanyl patch was dosed at
75 mcg an hour, and breakthrough pain was managed through
intravenous Morphine given the patient's inability to take
POs.
Code status: Patient is confirmed a Do Not Resuscitate/Do
Not Intubate.
The remainder of this discharge summary, including patient's
discharge medications and discharge diagnoses will be
dictated as part of an addendum to this summary.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D.
Dictated By:[**Last Name (NamePattern1) 12327**]
MEDQUIST36
D: [**2121-7-28**] 18:28:31
T: [**2121-7-28**] 19:12:45
Job#: [**Job Number 56040**]
Name: [**Known lastname 10545**], [**Known firstname 739**] Unit No: [**Numeric Identifier 10546**]
Admission Date: [**2121-7-27**] Discharge Date: [**2121-7-29**]
Date of Birth: [**2063-6-10**] Sex: F
Service: MED
ADDENDUM: Transferred to [**Hospital 2653**] Hospital
Patient was previously prescribed Levofloxacin for sputum
that showed gram negative rods. Cultures came back as E.
Coli today on the day of discharge. Sensitivities showed
fluoroquinolone resistance to Cipro and Levofloxacin. She
was changed to P.O. Bacitracin. The antibiotic sensitivities
were as follows: Sensitive to ampicillin,
ampicillin/Sulbactam, cefazedone, cefepime, ceftazidime,
ceftriaxone, Gentamicin, Meropenem, piperacillin, pip/Tazol,
tobramycin, Bactrim. Intermediate resistance was noted to
cefuroxime. Resistance was noted to Cipro and Levo. The
patient during this admission was also found to be C. diff
positive and was put on Flagyl. She will need C diff
precautions at [**Hospital 2653**] Hospital.
The nurse noted during feeds that the patient had
intermittent difficulty with coughing while swallowing. A
bedside swallowing evaluation was done which could not rule
out aspiration. The patient will need a video swallow
evaluation at her new hospital but this evaluation did not
warrant delaying transfer.
Patient's albumin during this noted to be 2.7. She appears
cachectic and may benefit from calorie count and supplement
PPN/TPN to optimize nutritional status.
Patient is Do Not Resuscitate/Do Not Intubate.
[**Name6 (MD) 3354**] [**Last Name (NamePattern4) 5357**], M.D. [**MD Number(1) 7079**]
Dictated By:[**Last Name (NamePattern1) 10547**]
MEDQUIST36
D: [**2121-7-29**] 15:06:18
T: [**2121-7-31**] 13:21:23
Job#: [**Job Number 10548**]
|
[
"789.5",
"443.0",
"518.81",
"428.0",
"263.8",
"710.1",
"482.82",
"008.45",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"97.39",
"88.72",
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2384, 7343
|
1077, 2355
|
818, 1007
|
1024, 1052
|
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