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92,873
| 142,321
|
683919
|
Physician
|
Cardiology Comprehensive Physician Note
|
TITLE:
Date of service: [**2155-7-26**]
Initial visit, Cardiology service: CCU
Presenting complaint: (Other: Hypotension, tachycardia)
History of present illness: In brief, Ms. [**Known lastname **] is a 73 year old woman
who has a history of coronary artery disease s/p a myocardial
infarction in [**2131**] and a large abdominal aortic aneurysm. Of note,
approximately two months ago, the patient was undergoing pre-op
evaluation and evaluation of chest pain prior to repair of a 6.6 cm AAA
when she was noted to have an abnormal office EKG. Following this, the
patient underwent dobutamine stress test and was found to have
upsloping ST segment depressions during the study, subsequently
undergoing cardiac catherization on [**2155-6-13**] that revealed 3VD (mid LAD
occlusion, 90% LCx, 100% Ostial RCA lesion). The patient proceeded to
CABG earlier this month but was unable to tolerate placement on bypass,
and therefore was not revascularized and was maintained on medical
therapy for her 3VD.
.
Two days prior to this admission, the patient presented to outpatient
cardiology clinic complaining of dyspnea, and worsening DOE, which was
felt to be an anginal equivalent. Given her symptoms, she was admitted
to [**Hospital1 5**] for further evaluation. On admission the patient was found to
have a large left sided pleural effusion which was drained and found to
be exudative. She then underwent repeat elective cardiac catherization
on [**2155-7-25**], however, cardiac catherization was complicated by a small
sprial dissection of the OM1. The patient was hemodynamically stable
following her intervention and returned to the floor. However, while
on the floor the patient was noted to be hypotensive down to a systolic
in the 70s and slightly more tachycardic to the low 100's (baseline
80's-90's). After an initial 500cc IVF bolus, the patient's SBP
improved to the 100's but one hour later she was noted to have an SBP
in the 70s once again. Given her recent cardiac catherization there
was concern for possible pericardial tamponade so a bedside TTE was
performed which showed no significant pericardial effusion. En route
to the CCU, the patient was given an additional 500cc IVF bolus with
improvement of her SBP to the low 100's and the patient continued to
feel well with no symptoms of chest pain or shortness of breath.
Past medical history: CAD, s/p MI in [**2131**]
CHF (EF 45-50%)
Diabetes
Hyperlipidemia
Neuropathy
Sciatica
Asthma
Bursitis of the right shoulder
Rotator cuff tear, right shoulder
Dry eyes
H/O recurrent bronchitis
Seasonal allergies
GERD
H/O Proteinuria in the past
Squamous cell ca of the lip s/p resection
Tonsillectomy
S/P uvula removal
Diverticulitis
CAD Risk Factors
CAD Risk Factors Present
Diabetes mellitus, Dyslipidemia
CAD Risk Factors Absent
Hypertension, Family Hx of CAD, Family Hx of sudden cardiac death
(Tobacco: Yes), (Quit: Yes), (Cigarettes: 1 packs / day x 80 yrs)
Cardiovascular Procedural History
PCI: Most recent: [**2155-7-25**]
There is no history of:
CABG: Grafts: Not tolerated
Pacemaker / ICD
Allergies:
Sulfa (Sulfonamide Antibiotics)
Unspecified [**Doctor First Name **]
Flagyl (Oral) (Metronidazole)
Diarrhea;
Current medications: MEDICATIONS ON TRANSFER:
Aspirin 81 mg PO DAILY Start: In am
Clopidogrel 75 mg PO DAILY Start: In am
Ciprofloxacin HCl 500 mg PO Q12H
Rosuvastatin Calcium 20 mg PO DAILY
Gabapentin 300 mg PO Q12H
Acetaminophen 325 mg PO Q6H:PRN pain
Duloxetine 30 mg PO DAILY Start: In am
Milk of Magnesia 30 mL PO Q6H:PRN constipation
Insulin SC (per Insulin Flowsheet)
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
Docusate Sodium 100 mg PO BID
Fexofenadine 60 mg PO BID
Heparin 5000 UNIT SC TID
Ranitidine 150 mg PO BID
Cardiovascular ROS
Cardiovascular ROS Signs and Symptoms Present
SOB, DOE
Cardiovascular ROS Signs and Symptoms Absent
Murmur, Rheumatic fever, Chest pain, PND, Orthopnea, Edema,
Palpitations, Syncope, Presyncope, Lightheadedness, TIA / CVA,
Pulmonary embolism, DVT, Claudication, Exertional buttock pain,
Exertional calf pain
Cardiovascular ROS Details: Pt w/symptoms of SOB/DOE on admission but
not currently
Review of Systems
Signs and symptoms present
Black / red stool, Myalgias
Organ system ROS normal
Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,
Hematology / Lymphatic, Genitourinary, Musculoskeletal, Integumentary,
Neurological, Psychiatric, Allergy / Immune
Signs and symptoms absent
Recent fevers, Chills, Rigors, Cough, Hemoptysis, Bleeding during
surgery, Joint pains
ROS Details: Pt with history of black stools while on iron
supplementation. Pt also complaining of left upper arm myalgias
Social History
(Alcohol: No), (Recreational drug use: No)
Family history: Non-contributory
Physical Exam
Date and time of exam: [**2155-7-25**]
Vital signs: per R.N.
BP right arm:
98 / 53 mmHg
supine
T current: 99.5 C
HR: 105 bpm
RR: 19 insp/min
O2 sat: 100 % on Supplemental oxygen: 2L NC
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: Dry), (Teeth, gums and
palette: WNL)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Jugular veins: Not visible), (Thyroid: WNL)
Back / Musculoskeletal: (Chest wall structure: Midline sternotomy
incision well healed but slightly tender to palpation)
Respiratory: (Effort: WNL), (Auscultation: Abnormal, Decreased breath
sounds 2/3 up lung fields on left and diminished at right lung base
without wheezes or crackles)
Cardiac: (Rhythm: Regular, Tachycardic), (Palpation / PMI: WNL),
(Auscultation: S1: WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (foley catheter in place)
Femoral Artery: (Right femoral artery: Groin site without hematoma,
minimal tenderness to palpation, No bruit), (Left femoral artery: No
bruit)
Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and
station: not assessed), (Edema: Right: 0, Left: 0)
Skin: ( WNL)
Labs
Outside / other labs: CT Abdomen/Pelvis [**2155-7-25**]:
Stable supra and infrarenal aortic aneurysms. Trace pericardial
effusion. No retroperitoneal bleed, free fluid, or free air. No
hematoma near right femoral vessels.
Tests
ECG: (Date: [**2155-7-25**]), Sinus tachycardia, Q waves in II, III, aVF, poor
R wave progression, no ischemic ST segment changes
Stress Testing: (Date: [**5-8**]), (Protocol: Dobutamine), The patient was
infused with 15 and 30mcg/kg/min of Dobutamine at infusion time of 4.75
minutes. The test was stopped due to reaching the target submaximal
heart rate. The patient reported a lower RLQ discomfort [**4-8**] during
infusion. This symptom resolved after the Dobutamine was terminated. In
the presence of baseline changes, between 0.5-1mm of slowly upsloping
ST segment depression was seen in the inferior leads and V2-V6 at peak
infusion and in early recovery period; returning to baseline later in
recovery. The rhythm was sinus with rare isolated APBs and VPBs. The
blood pressure response to infusion was flat with an appropriate heart
rate response.
Cardiac Cath: (Date: [**2155-7-25**]), Initial angiography with a calcified
tortuous OM1
lesion to 90% and a longer 90% diagonal lesion. Access was quite
difficult. We used a micropuncture set to get access in RFA but had to
use a Glidewire to negotiate the tortuous iliacs and aorta. We
ultimated were able to get into ascending aorta and exchanged for a
Amplatz wire and then put up a 6F 90cm Shuttle sheath.
2. Limited hemodynamics with BP 123/67 with HR 82 in sinus.
3. POBA of OM1 with 2.25mm balloon resulting in dissection with good
flow.
Assessment and Plan
73F c 3VD and AAA, as well as DM, COPD and MMP now p/w increasing DOE
after failed CABG. Likely this represents an angina equivalent which is
exacerbated by her other pulmonary issues (effusion, COPD, asthma). To
cath tomorrow.
.
# PUMP: Pt c systolic CHF c EF of 45-55% on TTE in [**5-8**], BNP this
admission 8434. While on the floor, pt with hypotensive episode and
SBP to 70's that responded to total of 1L IVF. EKG remained
unchanged. Given recent c.cath with small dissection to OM1,
hemopericardium or retroperitoneal bleed were of concern given relative
hypotension. In addition, on admission, pt underwent thoracentesis of
L sided pleural effusion and removal of 1.5L possibly causing fluid
shifts and relative hypotension. [**Name2 (NI) **] potential etiologies of
hypotension could include dehydration, or less likely medication effect
from meds received in the cath lab. Pt currently asymptommatic but
tachycardic to 115. Hct stable 32.2-->33.4 on the floor. CT
abdomen/pelvis without evidence of RP bleed or hematoma around femoral
vessels. Bedside echo without evidence of significant pericardial
effusion and no gross change in LV function from prior study.
- Holding metoprolol for now until BP improves
- Follow Hct Q8 hours
- Active T&C
- IVF boluses as needed to maintain SBP>90
- Monitor on tele
- F/[**Location **] CT abdomen/pelvis read
- Monitor femoral groin site for signs of hematoma
.
# CORONARIES: 3VD on cath from [**5-8**], s/p recent attempted CABG but pt
unable to tolerate bypass, now s/p c.cath with POBA to OM1
-to cath in the am
-continue asa/plavix post procedure for 6 weeks
-continue Rosuvastatin
.
# RHYTHM: sinus in the 100s while on the floor pre-procedure and now
slightly more tachycardic to 110's which may represent blood loss or
dehydration
- continue to monitor on tele for now
- resume beta blocker to keep HR closer to 80 if BP tolerates
.
# COPD and asthma: continue home meds -- fluticasone, salmeterol,
albuterol/atrovent nebs.
.
# Pleural effusion: consistent with exudate based on Light's criteria;
s/p drainage on admission with improvement in effusion visualized on
repeat CXR. Pt also with small apical post thoracentesis pneumothorax;
IP following patient on the floor and considering pleurex drain.
- f/u with IP in AM regarding possibility of drain if pt remains
hemodynamically stable overnight
.
# Anemia: improved from baseline on admission.
- Monitor Hct as above
.
# UTI: pt c 6-10 WBCs on UA s/p foley placement, started empirically on
Ciprofloxacin on floor for UTI.
- continue cipro 500 [**Hospital1 **] for now
- f/u UCx from [**7-24**]
.
# DM: d/ced rosiglitazone given CHF.
-RISS
-FS QAC/HS
.
FEN: Cardiac diet/Diabetic diet
PROPHYLAXIS: pneumoboots, Hep SQ on hold for now until bleed ruled out,
colace, MOM prn
-[**Name2 (NI) 222**] management with tylenol prn
CODE: full
DISPO: CCU
|
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99,322
| 113,980
|
608855
|
Physician
|
Intensivist Note
|
TSICU
HPI:
52yF with TBM s/p metal stenting and subsequent PNA admitted to TSICU
with significant respiratory distress. Respiratory status improved and
pt transferred to floors. Pt to OR [**2146-11-14**] for tracheostomy, bronch
and stent removal and admitted to TICU postop management.
Chief complaint:
TBM
PMHx:
dwarfism, glaucoma, asthma, CHF, COPD, OSA on CPAP 13cm H2O,
osteoporosis, severe TBM
PSH: TBM stented s/p trach stent removal and tracheostomy [**11-14**]
Current medications:
1. Benzonatate 2. Calcium Gluconate 3. Chlorhexidine Gluconate 0.12%
Oral Rinse 4. Dextrose 50% 5. Fluoxetine 6. Furosemide 7. Glucagon 8.
Heparin Flush (10 units/ml) 9. Heparin 10. Insulin 11. Ipratropium
Bromide Neb 12. Lidocaine 1% 13. Lorazepam 14. Magnesium Sulfate 15.
Montelukast Sodium
16. OxycoDONE-Acetaminophen Elixir 17. Potassium Chloride 18. Potassium
Phosphate 19. Sodium Chloride 0.9% Flush 20. Xopenex Neb
24 Hour Events:
INVASIVE VENTILATION - START [**2146-11-20**] 05:10 PM
TM during day, CPAP in afternoon.
Post operative day:
POD#7 - s/p flex bronch w/ stent removal and tracheostomy .
Allergies:
Codeine
Nausea/Vomiting
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Hydromorphone (Dilaudid) - [**2146-11-20**] 06:15 AM
Heparin Sodium (Prophylaxis) - [**2146-11-20**] 08:00 PM
Other medications:
Flowsheet Data as of [**2146-11-21**] 04:20 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**48**] a.m.
Tmax: 37.2
C (99
T current: 36.9
C (98.4
HR: 84 (79 - 116) bpm
BP: 104/65(72) {86/49(57) - 156/92(102)} mmHg
RR: 26 (19 - 51) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 67.7 kg (admission): 71.9 kg
Total In:
1,269 mL
330 mL
PO:
420 mL
Tube feeding:
459 mL
210 mL
IV Fluid:
100 mL
Blood products:
Total out:
700 mL
0 mL
Urine:
700 mL
NG:
Stool:
Drains:
Balance:
569 mL
330 mL
Respiratory support
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Spontaneous): 312 (312 - 1,801) mL
PS : 12 cmH2O
RR (Spontaneous): 21
PEEP: 8 cmH2O
FiO2: 60%
PIP: 21 cmH2O
SPO2: 100%
ABG: ///32/
Ve: 7.2 L/min
Physical Examination
General Appearance: No acute distress
HEENT: PERRL
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Wheezes :
bilateral)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Temperature: Warm)
Right Extremities: (Temperature: Warm)
Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities
Labs / Radiology
326 K/uL
9.4 g/dL
110 mg/dL
0.5 mg/dL
32 mEq/L
3.8 mEq/L
16 mg/dL
101 mEq/L
141 mEq/L
28.7 %
6.1 K/uL
[image002.jpg]
[**2146-11-15**] 08:00 PM
[**2146-11-16**] 02:00 AM
[**2146-11-16**] 02:08 AM
[**2146-11-17**] 02:20 AM
[**2146-11-18**] 02:00 AM
[**2146-11-18**] 02:38 AM
[**2146-11-19**] 02:51 AM
[**2146-11-19**] 02:00 PM
[**2146-11-20**] 02:04 AM
[**2146-11-21**] 02:42 AM
WBC
7.1
7.2
5.5
10.5
6.5
6.1
Hct
29.5
26.9
27.3
31.5
28.6
28.7
Plt
[**Telephone/Fax (3) 9718**]
Creatinine
0.6
0.5
0.4
0.5
0.5
0.5
TCO2
30
Glucose
112
115
101
101
105
122
127
137
110
Other labs: PT / PTT / INR:12.9/41.0/1.1, Lactic Acid:1.0 mmol/L,
Ca:9.2 mg/dL, Mg:2.2 mg/dL, PO4:4.9 mg/dL
Assessment and Plan
TRACHEOBRONCHOMALACIA (TRACHEOMALACIA, BRONCHOMALACIA), ANXIETY
Assessment and Plan: 52yF with TBM s/p metal stenting and subsequent
PNA admitted to TSICU with significant respiratory distress.
Respiratory status improved and pt transferred to floors. Pt to OR
[**2146-11-14**] for tracheostomy, bronch and stent removal and admitted to
TICU postop management.
Neurologic: AOx3. Moves all 4 extremities. PERLL. Ativan 1-2mg q2h prn
for anxiety. Restarted fluoxetine 40mg qd. Neuro checks Q: shift Pain:
Roxicet prn.
Cardiovascular: Hemodynamically stable. Hx of CHF, on lasix 20mg PO QD.
Pulmonary: Pt admitted with PNA and completed 7 day course of
levofloxacin. TBM s/p 3 stents and removal of 2 stents and Tracheostomy
placed [**2146-11-14**]. On trach collar, occasional coughing fits and spasms
with min desaturation. Placed back on CPAP at night. Cont xopenex nebs,
atrovent nebs. tessalon perles prn. Restarted singulair. Longterm plan
includes tracheobronchoplasty in few weeks.
Gastrointestinal / Abdomen: Video swallow [**11-18**] ok thin liquids, soft
solids, Dobhoff placed [**11-17**]. Pt c/o of trouble swallowing, S&S
reconsulted. Cycling TF at night to stimulate PO intake during the day.
Nutrition: Tube feeding at goal.
Renal: On home dose of lasix. Keep dry.
Hematology: Hct stable. Monitor Daily.
Endocrine: RISS, adequate control.
Infectious Disease: Currently not on ABX. Afebrile. S/p 10 day course
of levofloxacin for PNA. OSH cultures showed S.Areus sensitive to all
abx except PCN, as well as [**Female First Name (un) 444**]. S/p 7 day course of acyclovir for
herpes on gluteus.
Lines / Tubes / Drains: PICC (placed [**11-2**]), Trach, Dobhoff
Wounds:
Imaging: CXR today
Fluids: KVO
Consults: CT surgery, Pulmonology
Billing Diagnosis:
ICU Care
Nutrition:
Replete with Fiber (Full) - [**2146-11-20**] 09:30 PM 50 mL/hour
Glycemic Control:
Lines:
PICC Line - [**2146-11-14**] 06:50 PM
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: Not indicated
VAP bundle: HOB elevation, Mouth care
Comments:
Communication: ICU consent signed Comments: [**Hospital **] rehab screening today
Code status: Full code
Disposition: ICU
Total time spent: 31 min
|
[
"300.00"
] |
icd9cm
|
[
[
[
5239,
5245
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
325, 507
|
531, 4645
|
4657, 7100
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
94,987
| 193,169
|
1126209
|
Radiology
|
P BILAT LOWER EXT VEINS PORT
|
[**Last Name (LF) 7088**],[**First Name3 (LF) 7089**] MED SICU-B [**2172-4-23**] 11:55 AM
BILAT LOWER EXT VEINS PORT Clip # [**Clip Number (Radiology) 95139**]
Reason: MASSIVE PE, R/O DVT
Admitting Diagnosis: PULMONARY EMBOLUS
______________________________________________________________________________
[**Hospital 2**] MEDICAL CONDITION:
55 year old woman with massive PE
REASON FOR THIS EXAMINATION:
r/o DVT
______________________________________________________________________________
PFI REPORT
Subacute DVT within the right distal femoral vein inferior to the bifurcation.
|
[
"453.41"
] |
icd9cm
|
[
[
[
620,
680
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
486, 700
|
283, 455
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,538
| 105,088
|
37596
|
Discharge summary
|
Report
|
Admission Date: [**2146-3-10**] Discharge Date: [**2146-4-27**]
Date of Birth: [**2117-12-8**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents / Dilaudid
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, tachycardia.
Major Surgical or Invasive Procedure:
[**2146-3-10**]: Ultrasound-guided pancreatic pseudocyst drainage with
drain placement.
.
[**2146-3-18**]: CT-guided drainage of upper abdominal pseudocyst
.
[**2146-4-14**]: Ultrasound-guided fluid aspiration of a left flank
collection.
.
[**2146-4-14**]: Ultrasound-guided placement of left pleural pigtail
catheter.
.
[**2146-4-21**]: Ultrasound-guided left flank fluid collection
drainage with placement of a 8-French [**Last Name (un) 2823**] pigtail catheter.
History of Present Illness:
Patient is a 28M well-known to the West 2 surgical service. He
was discharged [**2146-3-9**] after a prolonged hospital course for
gallstone pancreatitis. This was complicated by DVT,
respiratory/renal failure requiring mechanical ventillatory
support and CVVHD, and pancreatic necrosis requiring
percutaneous drainage. He improved and was discharged yesterday
to a rehabilitation facility. Today, he returns with tachycardia
and increased abdominal pain. The patient states that he began
to experience abdominal pain yesterday afternoon while working
with PT. He states that this pain is similar to the epigastric
pain he has experienced all along only worse. He rated this as
an [**9-6**] though currently [**7-7**]. He states that he was able to eat
dinner (grilled chicken) without difficulty. He was eating
breakfast this morning and became nauseated while eating grapes.
He had several episodes of non-bilious emesis and was brought to
[**Hospital1 18**] for further care given increased abdominal pain and
tachycardia.
Past Medical History:
PMH: Gallstone pancreatitis as above, obesity, congenital
blindness in right eye, left common iliac DVT .
PSH: Laparoscopic cholecystectomy [**1-5**]
Social History:
Recently married. He lives with his wife and their dog. No kids.
Works as an investment manager. Never smoker. Rare alcohol.
Smokes marijuana, denies other drugs.
Family History:
Diverticulosis in both of his parents. DM in grandmother. HTN in
father. [**Name (NI) **] 2 sisters and one brother.
Physical Exam:
On Admission:
VS: 99.4 150 136/88 28 100%RA
General: awake and alert, diaphoretic and sweaty
CV: Tachycardic
Lungs: Tachypnic, CTA bilaterally
Abdomen: Obese, soft, (+) palpable phlegmon in RUQ, (+) diffuse
tenderness greatest in epigastrium, no rebound/guarding,
hypoactive BS
Ext: warm, no edema.
.
At Discharge:
VS: T 99.2 HR 93 BP 106/54 RR 18 SaO2 98% RA
GEN: Deconditioned in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: Slightly decreased at bases, otherwise clear.
COR: RRR
ABD: Protuberant. (L) LQ abdominal JP drain (into pancreatic
pseudocyst) patent/intact. (L)flank drain patent/intact. Both
drains with scant output. Prior sub-umbilical drain site clean,
healed without drainage. BSx4. Soft/NT/ND.
EXTREM: WWP; mild LE edema, no cyanosis, clubbing.
NEURO: A+Ox3. Very deconditioned. Requires assistance with gait.
Pertinent Results:
On Admission:
[**2146-3-10**] 08:28PM TYPE-ART PO2-138* PCO2-42 PH-7.55* TOTAL
CO2-38* BASE XS-13 INTUBATED-NOT INTUBA
[**2146-3-10**] 08:28PM freeCa-0.98*
[**2146-3-10**] 05:10PM OTHER BODY FLUID AMYLASE-[**Numeric Identifier **]
[**2146-3-10**] 05:10PM PT-20.2* INR(PT)-1.9*
[**2146-3-10**] 02:50PM WBC-22.5* RBC-3.31*# HGB-8.5*# HCT-28.0*#
MCV-85 MCH-25.7* MCHC-30.4* RDW-18.2*
[**2146-3-10**] 02:50PM PLT COUNT-511*
[**2146-3-10**] 02:07PM GLUCOSE-196* UREA N-19 CREAT-1.3* SODIUM-134
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-30 ANION GAP-15
[**2146-3-10**] 02:07PM CALCIUM-7.7* PHOSPHATE-6.2* MAGNESIUM-1.5*
[**2146-3-10**] 01:52PM PT-22.6* PTT-33.6 INR(PT)-2.1*
[**2146-3-10**] 07:29AM WBC-30.7*# RBC-4.67# HGB-11.7*# HCT-39.7*#
MCV-85 MCH-25.0* MCHC-29.4* RDW-17.4*
[**2146-3-10**] 07:29AM NEUTS-89* BANDS-3 LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2146-3-10**] 07:29AM PLT SMR-VERY HIGH PLT COUNT-818*#
[**2146-3-10**] 05:46AM GLUCOSE-149* LACTATE-2.5* NA+-136 K+-4.6
CL--99* TCO2-17*
.
Prior to Discharge:
[**2146-4-27**] PT/INR: 31.9/3.2
.
IMAGING:
[**2146-3-10**] AP CXR: Low lung volumes with LLL consolidation, could
reflect atelectasis, however, pneumonia cannot be excluded.
.
[**2146-3-10**] CTA CHEST W&W/O C&RECONS, ABD/PELVIC CT W/CONTRAST:
1. Minimal interval increase in size of right upper quadrant
pancreatic pseudocyst. Interval decrease in size of remaining
loculated fluid collections.
2. No pulmonary embolism present. Large bilateral pleural
effusions with associated compression atelectasis.
3. Increased amount of abdominal and pelvic free fluid.
.
[**2146-3-11**] BILAT LOWER EXT VEINS:
1. Persistent non-occlusive thrombus in the left common femoral
vein.
2. No right lower extremity DVT.
3. Small right popliteal cyst.
.
[**2146-3-15**] CXR:
Cardiomediastinal silhouette is unchanged as well as there is no
change in extremely low lung volumes and bilateral pleural
effusions, left more than right. There is mild prominence of the
vasculature that appears to be more pronounced than on the prior
study and might represent some degree of volume overload. The
right internal jugular line tip appears to be atleast at the
cavoatrial junction, but also may be present in the proximal
right atrium.
.
[**2146-3-16**] ABD/PELVIC CT W/CONTRAST:
1. Enlargement of the previously seen fluid collection and
appearance of the numerous new large collections in the
peritoneum. The drained collection has significantly decreased
in size.
2. Increase in pleural effusions: Left moderate and right
minimal size, findings are accompanied by compressive
atelectasis.
3. Minimal residual of the left common femoral vein and left
external iliac vein thrombus.
.
[**2146-3-17**] AP CXR:
In comparison with the study of [**3-15**], there is still extremely
low lung volumes. Hazy opacification at the left base is
consistent with pleural fluid. Obscuration of the hemidiaphragm
suggests volume loss in the left lower lobe. The right lung is
essentially clear and there is no evidence of pulmonary vascular
congestion. The tip of the right IJ catheter is difficult to see
but appears to be in the mid-to-lower portion of the SVC.
.
1. Markedly decreased size of drained collection anterior to the
stomach and surroiunding the left hepatic lobe. New extensive
stranding and fluid within the gastrohepatic ligament and porta
hepatis, possibly induced by leakage from one of the adjacent
collections or recurrent pancreatitis. Slight re-accumulation of
fluid within the previously drained collection in the anterior
abdomen, now measuring 14.3 x 1.6 x 5.4 cm. Otherwise, overall
decrease in multiple remaining peritoneal and extraperitoneal
fluid collections compared to the prior study.
2. Persistent bile duct dilation likely secondary to
pancreatitis. Increased attenuation of patent portal vein from
adjacent new inflammation. Persistent marked attenuation of the
splenic vein. Smaller splenic infarcts.
3. Unchanged bilateral pleural effusions and associated
compressive atelectasis.
4. Unchanged thrombus within the left external iliac and common
iliac veins.
.
[**2146-3-28**] CXR:
Stable size of left pleural effusion with associated
consolidation which likely represents atelectasis but
superimposed infection cannot be excluded.
.
[**2146-4-13**] ABD/PELVI CT W/CONTRAST:
1. In this patient with known history of necrotizing
pancreatitis, there is enhancement of the distal body and tail
of the pancreas with non visualization of the remainder of the
pancreas. Multiple extensive peripancreatic fluid collections
have decreased in size since the prior study.
2. A small fluid collection adjacent to the inferior edge of
right lobe of liver measuring 4.9 x 3.2 x 2.0 cm, is new since
the prior study.
3. Unchanged left femoral vein thrombosis. Infrarenal IVC filter
in place.
4. Mild interval improvement in the small-to-moderate left
pleural effusion. Compressive atelectasis of the left lower
lobe is unchanged.
.
[**2146-4-15**] CXR:
Status after withdrawal of a left-sided chest tube. Minimal
apical and lateral basal pneumothorax without evidence of
tension. Unchanged minimal atelectasis at the left lung base. No
other changes. Normal cardiac silhouette.
.
[**2146-4-18**] CXR:
1. Low lung volumes with left basilar subsegmental atelectasis,
likely related to the recent abdominal surgery and ongoing
intra-abdominal process.
2. No appreciable residual left pneumothorax.
3. Left-sided PICC likely at the junction of that axillary and
subclavian vein; this may need to be advanced into a more
central vein, depending on the indication for its use.
.
[**2146-4-20**] ABD/PELVIC CT W/O CONTRAST:
1. Slightly decreased size of dominant central abdominal fluid
collection with left drain in satisfactory position. Right
catheter has been removed.
2. Other fluid collections are little changed [**2146-4-13**].
3. Resolving left pleural effusion with pleural air secondary to
left thoracic drain placement and removal. No new peripancreatic
fluid collection.
4. Hypodensity of the blood pool relative to the ventricular
myocardium is suggestive of anemia.
5. Moderate biliary dilatation likely secondary to CBD
obstruction by pseudocyst is similar to [**2146-4-13**].
.
MICROBIOLOGY:
FLUID/WOUND CULTURES:
[**2146-4-21**] 10:15 am FLUID,OTHER LEFT FLANK ABSCESS.
**FINAL REPORT [**2146-4-25**]**
GRAM STAIN (Final [**2146-4-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2146-4-25**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2146-4-25**]): NO ANAEROBES ISOLATED.
.
[**2146-4-16**] 4:30 pm FLUID,OTHER LEFT JP DRAIN FLUID.
**FINAL REPORT [**2146-4-19**]**
GRAM STAIN (Final [**2146-4-16**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 10PM [**2146-4-16**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final [**2146-4-19**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
[**2146-4-14**] 9:51 am PERITONEAL FLUID
GRAM STAIN (Final [**2146-4-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO DR.[**First Name (STitle) **] [**Doctor Last Name **] ON [**2146-4-14**] AT
03:50 PM.
FLUID CULTURE (Final [**2146-4-17**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2146-4-18**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2146-4-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
.
[**2146-4-14**] 9:57 am PLEURAL FLUID
GRAM STAIN (Final [**2146-4-14**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2146-4-17**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-4-20**]): NO GROWTH.
ACID FAST SMEAR (Final [**2146-4-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
.
[**2146-4-5**] SWAB GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC
CULTURE-FINAL:
[**2146-4-5**] 3:09 pm SWAB PSEUDO CYST FLUID.
**FINAL REPORT [**2146-4-11**]**
GRAM STAIN (Final [**2146-4-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2146-4-7**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-4-11**]): NO GROWTH.
.
[**2146-3-28**] 9:25 am PERITONEAL FLUID
**FINAL REPORT [**2146-4-1**]**
GRAM STAIN (Final [**2146-3-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2146-4-1**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6976**] @ 1:20 PM ON [**2146-3-29**].
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
RARE GROWTH OF THREE COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2146-4-1**]): NO ANAEROBES ISOLATED.
.
[**2146-3-23**] 10:43 pm FLUID,OTHER DRAIN FLUID.
**FINAL REPORT [**2146-3-28**]**
GRAM STAIN (Final [**2146-3-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2146-3-27**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2146-3-28**]): NO ANAEROBES ISOLATED.
.
[**2146-3-10**] FLUID,OTHER GRAM STAIN-FINAL; WOUND CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL:
GRAM STAIN (Final [**2146-3-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2146-3-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-3-16**]): NO GROWTH.
.
BLOOD & URINE CULTURES:
[**2146-4-18**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-15**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-14**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-12**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-28**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-28**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-23**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-23**] URINE CULTURE-FINAL: NO GROWTH.
[**2146-3-23**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-19**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-19**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-18**] FLUID CULTURE: NO GROWTH - FINAL.
[**2146-3-17**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-17**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-10**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-10**] BLOOD CULTURE: NO GROWTH - FINAL.
.
RESPIRATORY/OTHER CULTURES:
[**2146-4-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL:
Upper respiratory contamination.
[**2146-4-13**] CATHETER TIP-IV WOUND CULTURE-FINAL: NO SIGNIFICANT
GROWTH.
[**2146-4-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL:
Upper Respiratory Contamination.
[**2146-3-10**] MRSA SCREEN MRSA: NEGATIVE.
Brief Hospital Course:
The patient was re-admitted on [**2146-3-10**] back to the General
Surgical Service for evaluation and treatment of abdominal pain
and tachycardia. Admission abdominal/pelvic CT revealed minimal
interval increase in size of right upper quadrant pancreatic
pseudocyst, but decrease in size of remaining loculated fluid
collections. Large bilateral pleural effusions with associated
compression atelectasis were noted, as well as increased amount
of abdominal and pelvic free fluid. He was admitted to the SICU,
made NPO, started on vigorous IV fluid rescusitation, a foley
was placed, and he received IV pain medication with good effect.
He had a very long, and complicated hospital course.
.
In the process of repairing his florid necrotizing pancreatitis
secondary to his history of severe gallstone pancreatitis, he
ultimately developed recurrent pseudocyts, which have plagued
him throughtout his hospital stays since [**48**]/[**2145**]. To date, these
pseudocyts have been managed largely with percutaneous catheter
drainage of the pseudocysts. Initially, during this admission,
this was the approach to managing the patient's recurring
pseudocyts. The patient underwent drainage of pancreatic
pseudocysts on [**2146-3-10**] and [**2146-3-18**], Ultrasound and CT-guided,
respectively. However, he developed an accumulating posterior
retroperitoneal cyst, which continued to progress, and there was
evidence of a disconnected pancreatic remnant within it. The
recent drainages of the other satellite lesions have dried them
up. The main retroperitoneal cyst continued to grow in size, and
became symptomatic for him. He was unable to eat full meals and
has a diminished capacity to keep food down, as well as a poor
appetite. He also repeatedly spiked temperatures.
.
Given his history of a left lower extremity acute deep venous
thrombosis, Vascular Surgery was consulted. In lieu of planned
surgical intervention on [**2146-4-5**] for treatment of the above
pseudocyst with adhesions, the patient underwent placement of a
Bard G2 inferior vena cava filter, which went without
complication. Then on [**2146-4-5**], the patient underwent external
drainage of pancreatic pseudocyst and extended adhesiolysis,
which also went well without complication (see Operative Note).
After a brief, uneventful stay in the PACU, the patient was
returned to the floor NPO with an NG tube, on IV fluids and TPN,
with a foley catheter and two JP drains in place (one in the
pseudocyst and one in the abdomen to drain ascites), he was
continued on a Fentanyl patch and was given a Morphine PCA with
good effect. He was hemodynamically stable.
.
NEURO: Upon admission, the patient received IV pain medication
PRN transitioned to a Morphine PCA with good effect and adequate
pain control. When tolerating oral intake, he was transitioned
to oral pain medications. After the surgery on [**2146-4-5**], the
Chronic Pain Service was consulted. His pain was controlled once
the Fentanyl dose was increased to 75mcg/72Hr plus the Morphine
PCA. When again tolerating a diet post-operatively, the PCA was
discontinued, and he was started on oral pain medication in
addition to the Fentanyl patch with continued good effect. He
remained neurologically intact.
.
CV: Upon admission, tachycardia responded to vigorous IV fluid
rescusitation and beta-blockade with Metoprolol 50mg TID.
Metoprolol was increased to 75mg TID with eventual excellent
rate and BP control. By discharge, the Metoprolol was decreased
to 50mg [**Hospital1 **]. The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
.
PULMONARY: Tachypnea on admission. Chest CTA revealed large
bilateral pleural effusions with associated compression
atelectasis. Tachypnea resolved with diuresis with Lasix and
supplemental oxygen. He was given Albuterol and Atrovent
nebulizer treatments, good pulmonary toilet and use of the
incentive spirrometry were encouraged, and the patient received
chest PT with improvement in overall respiratory status. Able to
wean off supplemental oxygen. CXR on [**3-17**] revealed still
extremely low lung volumes. Hazy opacification at the left base
is consistent with pleural fluid. Obscuration of the
hemidiaphragm suggests volume loss in the left lower lobe. The
right lung was essentially clear and there was no evidence of
pulmonary vascular congestion.
Starting on [**4-12**], he spiked a temperature to 103 PO and his WBC
increased from 13 to 23,000. He had a CT abdomen performed
which demonstrated a left pleural effusion
on the upper cuts of the abdomen. Thoracic surgery was consulted
for management of the pleural effusion. On [**2146-4-14**], he underwent
ultrasound-guided thorocentesis and placement of left pleural
pigtail catheter. Plural fluid for culture, gram stain,
cytology, chemistries, and AFB was sent. The pleural pigtail
catheter was removed on [**4-15**]; post-removal CXR revealed minimal
apical and lateral basal pneumothorax without evidence of
tension. Unchanged minimal atelectasis at the left lung base. A
follow-up CXR on [**2146-4-18**] showed continued low lung volumes with
left basilar subsegmental atelectasis, likely related to the
recent abdominal surgery and ongoing intra-abdominal process. No
appreciable residual left pneumothorax was seen. The patient
remained stable from a pulmonary standpoitn thereafter.
Respiratory toilet, incentive spirrometry, and frequent
ambulation was encouraged.
.
GU/FEN: On admission, the patient was made NPO and he received
vigorous IV fluid rescusitation. A foley catheter was placed.
Allowed clears on [**3-11**] and [**3-12**], but an NG tube was placed on
[**3-13**] for increased abdominal distension and emesis resulting
with 1400mL bilious output. After successful clamp trial
overnight, the NG tube was discontinued on [**3-15**] in the morning.
Given persistent problems with tolerating oral intake, a PICC
was placed, and TPN was started on [**2146-3-14**]. With the decision
to proceed to surgery, TPN was continued through [**2146-4-12**]. When
not NPO for procedures, his diet was advanced back to low fat
regular with good tolerability and intake. When the foley
catheter was removed after surgery, he was able to void without
problem. Patient's intake and output were closely monitored, and
IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
.
GI: Admission liver and pancreatic enzymes were elevated.
Shortly after admission, the patient underwent ultrasound-guided
pseudocyst drainage measuring 1.7 liters of fluid with a
drainage catheter left in place to gravity on [**2146-3-10**]. Liver
and pancreatic enzymes began trending down. Follow-up
abdominal/pelvic CT on [**3-16**] demonstrated enlargement of the
previously seen fluid collection and appearance of the numerous
new large collections in the peritoneum. The drained collection
had significantly decreased in size. On [**3-18**], the patient
returned to Interventional Radiology for drainage of an anterior
collection, and placement of a new drainage catheter to gravity.
The previous drain was removed, and upper abdominal pseudocyst
was succesfully drained with a catheter left in place to
gravity. Unfortunately, as noted above, he developed an
accumulating posterior retroperitoneal cyst, which continued to
progress, and there was evidence of a disconnected pancreatic
remnant within it. He underwent external drainage of pancreatic
pseudocyst and extended adhesiolysis as described above. A (L)
flank drain was left in place. After the surgery, his symptoms
improved.
.
ID: Admission blood cultures were negative. [**3-10**] fluid culture
had no growth. On [**3-17**] after receiving FFPs, the patient mounted
a fever with a Tmax 101.5 PO. Blood cultures were negative.
Fluid cutlure from the [**3-18**] drainage also revealed no growth.
The patient's white blood count and fever curves were closely
watched for signs of infection. Admission MRSA screen was
negative. After the [**2146-4-5**] surgery, cultures from the peritoneal
fluid on [**4-14**], the (L) JP on [**4-19**], and the flank drain on [**4-21**]
all grew out MRSA. The patient had been started on empiric IV
Vancomycin, Ciprofloxacin, and Flagyl when he spiked a
temperature on [**4-14**]. Fluconazole for empiric coverage after the
thorocentesis was started on [**4-15**]. Flagyl, Cipro, and
Fluconazole were discontinued on [**4-16**]. Cipro restarted on [**4-21**].
Infectious Disease was consulted for discharge antibiotic
recommendations; their input was greatly appreciated. Cipro was
discomntinued, and oral Levofloxacin and Flagyl started on [**4-26**]
with Vancomycin continued. At discharge, the patient was sent
home on a two week course oral Linezolid, and a total of four
weeks of oral Levofloxacin and Flagyl.
.
ENDOCRINE: The patient's blood sugar was monitored throughout
his stay when he was on TPN; sliding scale insulin was
administered accordingly. He did not require exogenous insulin.
.
HEMATOLOGY: Upon admission, Coumadin was stopped, and the
patient received 5 untis of Fresh Frozen Plasma (FFPs) prior to
fluid collection drainage in Intervention Radiology. On [**3-17**],
FFPs were again administered in preparation for IR drainage of a
large anterior abdominal fluid collection, but was stopped after
the patient experienced severe lower back pain after initiation
of the second unit of FFP. On [**3-18**], he received a total of 4
units of FFPs prior to IR drainage of the aforementioned
collection. Prior to [**2146-4-5**] surgery, the patient received 2
units of PRBCs for a HCT of 22.2. He did not require any further
blood products after this date. At discharge, his HCT was 23.7.
.
PROPHYLAXIS: History left common iliac DVT and HITs. Repeat
duplex ultra-sound on admission confirmed persistent
non-occlusive thrombus in the left common femoral vein; no right
DVT was seen. Chest CTA did not reveal a PE. On admission,
Coumadin stopped, and Agatroban started. After the drainage of
the collection on [**3-10**], Agatroban was stopped, and Coumadin
restarted. Coumadin also restarted after reversal for second
collection drainage. After the surgery on [**2146-4-5**], the patient
was restarted on Argatroban. He was again converted back to
Coumadin prior to discharge, at which time the INR was
therapeutic at 3.2 on a Coumadin dose of 2.5mg daily. INR goal
2.5 with a therapeutic range of [**3-2**].
.
MOBILITY: The patient worked with Physical and Occupation
therapy extensively. By discharge, he was able to ambulate
independently. He was discharge home with PT and OT services.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with minimal assistance, voiding without
assistance, and pain was well controlled. He was discharged
home with VNA and PT services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever.
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
7. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for back pain.
8. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. Methadone 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
10. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
sliding scale Subcutaneous ASDIR (AS DIRECTED).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for btp.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Adjust dose according to INR. .
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust daily dose according to INR.
17. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
[**Hospital1 **]:*60 Capsule(s)* Refills:*2*
3. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Over-the-counter.
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Hospital1 **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*11*
5. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO every 4-6 hours as
needed for pain.
[**Hospital1 **]:*120 Tablet(s)* Refills:*0*
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain.
[**Hospital1 **]:*10 Patch 72 hr(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours.
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
[**Hospital1 **]:*120 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 4 weeks.
[**Hospital1 **]:*84 Tablet(s)* Refills:*0*
12. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 weeks.
[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
13. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 14 days.
[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO daily in the
evening or as directed by PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO As directed by
PCP: **This Prescription should only be used if advised by your
PCP.**.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] homecare VNA
Discharge Diagnosis:
1. Necrotizing gallstone pancreatitis.
2. Multiple pancreatic pseudocysts.
3. Non-occlusive thrombus in the left common femoral vein.
4. Left Pleural effusion
5. Anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-6**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD (Hematology).
Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2146-5-18**] 2:00. Location: [**Hospital Ward Name 23**] 7,
[**Hospital Ward Name 516**].
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-5-26**] 2:45.
Location: [**Hospital Ward Name 23**] 4, [**Hospital Ward Name 516**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Infectious Disease). Phone:
([**Telephone/Fax (1) 6732**]. Date/Time: Friday, [**2146-5-27**] at 10:00AM. Location:
[**Last Name (un) 6752**] GB, [**Last Name (NamePattern1) 439**], [**Hospital1 18**] [**Hospital Ward Name 517**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:
Friday, [**2146-5-27**] at 11:30AM. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 84361**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 84362**] (PCP) in [**3-2**] weeks.
Completed by:[**2146-4-27**]
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1858, 2011
|
2027, 2192
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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icd9pcs
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[
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3850, 4271
|
323, 407
|
524, 1706
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1728, 3313
|
3329, 3600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,716
| 149,105
|
45001
|
Discharge summary
|
Report
|
Admission Date: [**2168-2-13**] Discharge Date: [**2168-2-17**]
Date of Birth: [**2104-8-29**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / Diphenhydramine
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stents x2 to the left
circumflex artery and the left main coronary artery
History of Present Illness:
This is a 63 year old man with a history of CAD s/p 2 vs 3v
CABG, HL who presented to the ED with chest pain while walking
his dog today. He reported that prior to walking his dog at
5:10pm he was showering and developed SOB and dizzyness.
Subsequently, while walking his dog he developed SOB, [**9-14**] SS
chest pain and paramedics were called. On the ride to [**Hospital1 18**], his
pain started radiating to his left arm. A 12-lead ECG
demonstrated inferior ST elevations and ST depressions in the
lateral and precordial leads.
In the ED, initial vital signs were the following: HR: 83 BP:
118/75 Resp: 18 O(2)Sat: 100 Normal. He was given ASA 325 mg,
Plavix 600 mg, heparin 5000 units IV, as well as 125 mg IV
solumedrol, and 50 mg IV famotidine (for contrast allergy) and
taken emergently to the cath lab where native coronary
angiography demonstrated a 70% ostial LM lesion, a totally
occluded mid LAD, a 95% thrombotic appearing mid LCX lesion, and
a totally occluded mid RCA. Graft angiography revealed a patent
SVG to RCA/PDA, and a patent LIMA to LAD. The third vein graft
was not found despite non-selective power injection of the
aortic root, and was thought to likely be a SVG to OM that was
occluded. Subsequent reports from [**Hospital1 2025**], revealed that he only had
a 2-vessel CABG (per cath report from [**2164**]). The LCX lesion was
thought to the the culprit given its appearance, and this was
opened with a BMS. After this lesion was opened the patient
converted into AIVR which lasted about 5 minutes. Given that LM
had a 70% ostial stenosis, it was decided that the patient would
benefit from increased coronary inflow, and a BMS was also
placed in the LM. After both interventions, the patient's chest
pain and prior ECG changes resolved. He was transferred to the
CCU for close monitoring in good condition.
Of note, the patient had significant confusion during the
cardiac cath, asking repetitively where was and how he had
arrived in the cath lab. The patient noted a prior history of
mental status changes with benadryl, and it was unclear if the
patient??????s mental status changes in the cath lab were the result
of the fentanyl and versed that he received.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
- CABG: LIMA to LAD, SVG to PDA
3. OTHER PAST MEDICAL HISTORY:
CAD s/p 2 vessel CABG, LIMA to LAD, SVG to PDA, [**2157**] at [**Hospital1 2025**]
Temporal lobe epliepsy
ADHD
Psoriasis
Appendectomy
Hyperlipidemia
Social History:
- Tobacco history: never
- ETOH: rarely
- Illicit drugs: never
Lives with wife, [**Name (NI) **], in [**Location (un) **]
Has 2 sons works as department head at [**Hospital3 **]
Family History:
- No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death
- Mother: lupus, cardiac disease died in 70's from MI
- Father: MI x2, died at age 55 from MI
- strong family h/o HL including both parents and eldest son.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T= 97.8 BP= 115/71 HR=82 RR=16 O2 sat= 97% on 2L
GENERAL: NAD. Oriented x3. anxious.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. old midline scar well healed
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB on anterior exam,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3,
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
GENERAL: 63 YO M in no acute distress
HEENT: no lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 2+. right groin with no ecchymosis
or hematoma, angioseal palpated.
NEURO: Speech clear. 5/5 strength in U/L extremities. gait WNL.
SKIN: no rash
PSYCH: alert, mildly anxious, appears tired, cooperative.
Pertinent Results:
LABS ON ADMIT:
[**2168-2-13**] 06:30PM BLOOD WBC-10.7 RBC-4.92 Hgb-15.0 Hct-41.4
MCV-84 MCH-30.4 MCHC-36.2* RDW-12.5 Plt Ct-194
[**2168-2-13**] 06:30PM BLOOD PT-10.2 PTT-29.5 INR(PT)-0.9
[**2168-2-13**] 06:30PM BLOOD Fibrino-292
[**2168-2-13**] 06:30PM BLOOD Glucose-103* UreaN-22* Creat-0.8 Na-142
K-4.2 Cl-104 HCO3-26 AnGap-16
[**2168-2-13**] 11:02PM BLOOD CK(CPK)-645*
[**2168-2-14**] 05:38AM BLOOD CK(CPK)-922*
[**2168-2-14**] 01:55PM BLOOD CK(CPK)-726*
[**2168-2-14**] 03:30PM BLOOD CK(CPK)-638*
[**2168-2-13**] 06:30PM BLOOD cTropnT-<0.01
[**2168-2-13**] 11:02PM BLOOD CK-MB-97* MB Indx-15.0* cTropnT-1.36*
[**2168-2-14**] 05:38AM BLOOD CK-MB-137* MB Indx-14.9* cTropnT-2.67*
[**2168-2-14**] 01:55PM BLOOD CK-MB-100* MB Indx-13.8* cTropnT-2.11*
[**2168-2-14**] 03:30PM BLOOD CK-MB-87* MB Indx-13.6* cTropnT-1.85*
[**2168-2-15**] 06:15AM BLOOD CK-MB-21* MB Indx-8.4* cTropnT-1.67*
[**2168-2-16**] 05:45AM BLOOD CK-MB-5
[**2168-2-13**] 06:30PM BLOOD Calcium-9.8 Phos-2.2* Mg-2.0
[**2168-2-13**] 11:02PM BLOOD Valproa-85
[**2168-2-13**] 06:41PM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-33* pH-7.51*
calTCO2-27 Base XS-3 Comment-GREEN-TOP
[**2168-2-13**] 06:41PM BLOOD Glucose-94 Lactate-2.3* Na-142 K-4.2
Cl-100
[**2168-2-13**] 06:41PM BLOOD freeCa-1.12
LABS on DC:
[**2168-2-17**] 06:45AM BLOOD WBC-8.8 RBC-4.38* Hgb-13.6* Hct-37.9*
MCV-87 MCH-31.0 MCHC-35.9* RDW-12.7 Plt Ct-178
[**2168-2-17**] 06:45AM BLOOD UreaN-19 Creat-0.8 Na-143 K-4.7 Cl-105
HCO3-30 AnGap-13
[**2168-2-15**] 06:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9
ECG [**2168-2-13**]:
Normal sinus rhythm. Intra-atrial conduction abnormality.
Diffuse ST-T wave abnormalities. Inferior ST segment elevation.
Anterolateral ST segment depression. Consider acute inferior
myocardial infarction.
CATH [**2168-2-13**]:
1. Selective native coronary angiography in this right dominant
system
demonstrated severe 3 vessel and left main coronary artery
disease. The
LMCA had a 70% ostial lesion. The LAD was totally occluded in
its mid
segment. The LCx had a 95% thrombotic appearing lesion in its
mid
segment. The RCA was totally occluded in its mid segment.
2. Selective venous conduit angiography demonstrated a patent
SVG to
distal RCA graft.
3. Non-selective arterial conduit angiography demonstrated a
patent LIMA
to LAD with a kink in its midcourse.
4. Supravalvular aortography did not demonstrate any additional
grafts.
5. Primary PCI was delayed due to difficulty in locating the
patient's
prior bypass grafts and therefore determining the culprit artery
(no
reports of the anatomy were available and the patient stated
that he had
3 grafts despite our ability to only locate 2), and because
patient
agitation due to a paradoxical reaction to fentanyl caused a
delay in
the ability to safely carry out the procedure.
6. Successful direct stenting of the Cx with a 3.0x12mm
INTEGRITY
stent. Final angiography revealed no residual stenosis, no
angiographically apparent dissection and TIMI III flow (see PTCA
comments).
7. Successful direct stenting of the LMCA with a 4.5x18mm ULTRA
stent.
Final angiography revelaed no residual stneosis, no
angiographically
aparent dissection and TIMI III flow (see PTCA comments).
8. Patient went into AIVR post stenting of the Cx lesion. Rhythm
lasted
five minutes, and patient remained hemodynamically stable
throughout.
9. Successful closure of the 6 French right femoral arteriotomy
site
with a 6 French Angioseal VIP device with good resultant
hemostasis.
11. Limited resiting hemodynamics revealed normal systemic
arterial
blood
pressure with a central aortic blood pressure of 126/77.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease with a 95%
thrombotic LCx
lesion thought to the cause of the patient's acute STEMI.
2. Patent LIMA to LAD.
3. Patent SVG to RCA.
4. No other grafts demonstrated on aortography.
2. Successful direct stenting of the Cx with a BMS.
3. Successful direct stenting of the LMCA with a BMS.
4. Successful closure of the right femoral arteriotomy site with
an
Angioseal VIP device.
8. Normal central aortic blood pressure.
ECHO [**2168-2-15**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No pathologic valvular abnormality seen.
SUBMAXIMAL STRESS [**2168-2-17**]:
No anginal symptoms with nonspecific ST segment changes.
Attaining a submaximal level of 7 METs indicates an average
exercise
tolerance for his age, however patient could have attained
higher level
of work. Appropriate hemodynamic response to exercise. Echo
report sent
separately.
STRESS ECHO [**2168-2-17**]:
The patient exercised for 9 minutes and 0 seconds according to a
Modified [**Doctor First Name **] treadmill protocol (7 METS) reaching a peak heart
rate of 125 bpm and a peak blood pressure of 134/40 mmHg. The
test was stopped because of fatigue. This level of exercise
represents an average exercise tolerance for age (submaximal
test obtained as the patient is s/p STEMI). In response to
stress, the ECG showed no diagnostic ST-T wave changes (see
exercise report for details). There were normal blood pressure
and heart rate responses to stress.
Resting images were acquired at a heart rate of 69 bpm and a
blood pressure of 104/59 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Doppler
demonstrated no aortic stenosis, aortic regurgitation or
significant mitral regurgitation or resting LVOT gradient.
Echo images were acquired within 45 seconds after peak stress at
heart rates of 120-97 bpm. These demonstrated appropriate
augmentation of all left ventricular segments.
IMPRESSION: Average functional exercise capacity (submaximal
workload as patient is s/p STEMI). No diagnostic ECG changes in
the absence of 2D echocardiographic evidence of inducible
ischemia to achieved workload.
Brief Hospital Course:
HOSPITAL COURSE: 63 year old man with a history of CAD s/p CABG
who presented to the ED with chest pain while walking his dog
and was found to have an inferior STEMI. Received BMS
implantation to native LCX and LM.
# Inferior STEMI: The patient presented with STE of II,III, and
avF and STD depression in V2-V5. In the cath lab, his native
coronary angiography demonstrated a 70% ostial LM lesion, a
totally occluded mid LAD, a 95% thrombotic appearing mid LCX
lesion, LM had a 70% ostial stenosis and a totally occluded mid
RCA. Graft angiography revealed a patent SVG to RCA/PDA, and a
patent LIMA to LAD. A BMS was placed to the LCX and LM. He had
several episodes of [**2165-12-8**] resting CP in the two days after the
intervention that were relieved with sublingual nitroglycerin. A
submaximal stress echo was performed which demonstrated no
evidence of ischemia by ECG or echocardiogram. Pt was discharged
on ASA, plavix, metoprolol, lisinopril, sl ntg, imdur and
rosuvastatin. Creatinine was stable despite contrast load.
# Hyperlipidemia: on rosuvastatin at home, switched to high dose
atorvastatin hwile an inpatient given STEMI. Changed to
rosuvastatin 40 at discharge.
# Hyperglycemia: BS moderately elevated on routine labs. Pt
states his blood sugar has been elevated at times but A1C has
been nl. A1c was normal on recheck.
# Temporal lobe epliepsy- per patient develops flushing,. We
continued depakote 250mg 5 times daily (qAM, qNoon, qPM, and 2
tabs qHS). He remained well controlled.
# ADHD: we continued venlafaxine and held strattera due to risk
of adverse cardiovascular outcomes.
TRANSITONAL ISSUES: Followup with PCP and cardiologist was
arranged. Dr [**Last Name (STitle) 96196**] was made aware of hopsital course.
Medications on Admission:
ASA 325
Crestor 10mg Daily
Depakote 250mg tablets 1 tablet qAM, 1 tablet qNoon, 1 tablet
qPM, 2tablets pHS
Effexor XR 150mg daily
Strattera 100mg daily
Discharge Medications:
1. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO qHS ().
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
5. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablet* Refills:*0*
8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
10. Outpatient Lab Work
Please check Chem-7 on Friday [**2168-2-19**] with results to Dr.
[**Last Name (STitle) 96196**] at Phone: [**Telephone/Fax (1) 96197**]
Fax: [**Telephone/Fax (1) 96198**]
11. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hyperlipidemia
Temporal Lobe epilepsy
Coronary Artery disease
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack and was brought to [**Hospital1 18**] for a cardiac
catheterization. The catheterization showed that your grafts
from the operation were open and had good blood flow but there
was a clot in your left circumflex artery that was causing the
heart attack. You received a bare metal stent but also needed a
bare metal stent in your left main artery to increase blood flow
to the area. You will need to take plavix for at least one year
and possibly longer to prevent the stent from clotting off. Do
not stop taking Plavix or aspirin or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr.
[**Last Name (STitle) 96196**] says it is OK. This is extremely important to prevent
another heart attack. An echocardiogram was done that showed
that your heart function is normal. You had some chest pain
after the cathererization which was treated with nitroglycerin
but this did seem to cause any damage to your heart. Your stress
test was negative. You will have nitroglycerin tablets to take
at home. Please take this for any chest pain that is similar to
the pain of your heart attack. You can take one pill, wait 5
minutes, then take another pill if you still have chest pain.
Call 911 if you still have chest pain after 2 [**Last Name (STitle) 4319**] of
nitroglycerin. Call Dr. [**Last Name (STitle) 96196**] if you use any nitroglycerin at
all. You can also call the heartline to talk to a cardiologist
or NP here who can help you with your symptoms.
You received a lot of contrast during your catheterization. This
can sometimes affect your kidney function. So far, you have not
had any changes in your kidney function but please get blood
drawn on Thursday to check again.
.
We made the following changes to your medicines:
1. Continue aspirin forever, talk to Dr. [**Last Name (STitle) 96196**] before you stop
the aspirin for any reason.
2. Increase the Crestor to 40 mg to lower your cholesterol
3. Start taking metoprolol to lower your heart rate and help
your heart recover from the heart attack
4. Start taking lisinopril to lower your blood pressure and help
your heart recover from the heart attack.
5. Start taking Clopidogrel (Plavix) to keep the stents from
clotting off and causing another heart attack. Do not stop this
medicine unless you talk to Dr [**Last Name (STitle) 96196**] first.
6. Start taking nitroglycerin as described above to treat chest
pain.
7. Stop taking Strattera, this is not good for your heart. You
can talk to your physician about an alternative.
8. Start taking imdur, this will prevent chest pain. Talk to Dr.
[**Last Name (STitle) 96196**] if the lightheadedness does not improve in a few days.
Followup Instructions:
Name: JUDGE,[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: AMBULATORY PRACTICE OF THE FUTURE
Address: [**Location (un) 96199**] [**Apartment Address(1) 12836**], [**Location (un) **],[**Numeric Identifier 10614**]
Phone: [**Telephone/Fax (1) 96200**]
Appointment: WEDNESDAY [**2-24**] AT 12PM
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern4) 4094**]: CARDIOLOGY
Location: [**Hospital6 **]
Address: [**Street Address(2) 12266**], YAWKEY CENTER 5800, [**Location (un) **],[**Numeric Identifier 18228**]
Phone: [**Telephone/Fax (1) 96197**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 96196**]
within 1 month. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**
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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
|
[
[
[
253,
255
],
[
1343,
1358
],
[
9955,
9972
]
],
[
[
317,
340
]
],
[
[
866,
868
]
],
[
[
1247,
1258
]
],
[
[
1260,
1271
]
],
[
[
1314,
1317
]
],
[
[
1319,
1328
]
],
[
[
1330,
1341
]
],
[
[
6008,
6030
]
],
[
[
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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
98,335
| 196,522
|
38962
|
Discharge summary
|
Report
|
Admission Date: [**2150-4-3**] Discharge Date: [**2150-4-7**]
Date of Birth: [**2081-6-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2150-4-3**] Coronary artery bypass grafting x3 with left internal
mammary artery to the left anterior descending artery, and
reverse saphenous vein graft to the distal right coronary artery
and the obtuse marginal artery.
History of Present Illness:
68 year old male with progressive, exertional chest discomfort
over the past 6 months. He reports that he underwent a cardiac
catheterization at [**Hospital 1474**] hospital approximately 8-9 years
ago. He is unclear on the specifics of why he had the procedure,
but does not believe that he underwent PCI.Over the past six
months he has been bothered by chest discomfort, dyspnea and
fatigue. This can occur with walking about one block. In
addition, he notices right calf
pain with similar amounts of walking.Denies edema, orthopnea,
PND, lightheadedness. Cardiac workup with his PCP showed an
abnormal ETT and he was referred for an elective cardiac
catheterization [**2150-3-26**], which revealed three vessel coronary
disease. Cardiac surgery was consulted for evaluation of
coronary revascularization.
Past Medical History:
hypertension
hyperlipidemia
Diabetes
[**2150-2-4**] ETT: 5 minutes 30 seconds [**Doctor First Name **] protocol, 89% max
PHR. + Anginal discomfort with exercise. EKG with anterolateral
ST depression. Imaging: moderate in size, severe in intensity
territory of inferior reversibility. LVEF 55%.
Chronic renal insufficiency, creatinine 2.4
Left eye laser surgery approximately one month ago
Social History:
Lives with spouse
[**Name (NI) 1139**]: None
ETOH: None in 30 years
Family History:
No family history of premature CAD. Father died when patient was
5 years old-unknown cause.
Physical Exam:
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []few scattered rhonchi
Heart: RRR [x] Irregular [] NO Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +1 Left:+1
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2150-4-7**] 05:10AM BLOOD WBC-7.3 RBC-3.67* Hgb-10.3* Hct-32.6*
MCV-89 MCH-28.1 MCHC-31.7 RDW-14.4 Plt Ct-310
[**2150-4-3**] 11:40AM BLOOD WBC-7.4 RBC-2.85*# Hgb-8.4*# Hct-24.8*#
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.6 Plt Ct-199#
[**2150-4-3**] 11:40AM BLOOD Neuts-75.3* Lymphs-20.1 Monos-2.7 Eos-1.5
Baso-0.3
[**2150-4-7**] 05:10AM BLOOD Plt Ct-310
[**2150-4-3**] 11:40AM BLOOD Plt Ct-199#
[**2150-4-3**] 11:40AM BLOOD PT-14.2* PTT-30.5 INR(PT)-1.2*
[**2150-4-3**] 11:40AM BLOOD Fibrino-173
[**2150-4-7**] 05:10AM BLOOD Glucose-99 UreaN-22* Creat-1.5* Na-141
K-4.9 Cl-103 HCO3-31 AnGap-12
[**2150-4-3**] 12:45PM BLOOD UreaN-18 Creat-1.3* Cl-114* HCO3-25
[**2150-4-7**] 05:10AM BLOOD Mg-2.2
[**2150-4-3**] 05:59PM BLOOD Mg-2.3
Radiology Report CHEST (PA & LAT) Study Date of [**2150-4-6**] 1:48 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2150-4-6**] 1:48 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 86421**]
Reason: please do in afternoon [**4-6**] - eval for effusion
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
please do in afternoon [**4-6**] - eval for effusion
Final Report
TWO VIEW CHEST, [**2150-4-6**]
COMPARISON: [**2150-4-5**].
INDICATION: Status post coronary artery bypass surgery. Pleural
effusion
assessment.
FINDINGS: Status post median sternotomy and coronary bypass
surgery with
similar postoperative appearance of cardiomediastinal contours.
Improving
multifocal atelectasis with residual linear atelectasis in the
mid and lower
lungs. Persistent small lateral left pneumothorax as well as
bilateral small
pleural effusions. Retrosternal gas, probably postoperative
considering
recent surgery.
IMPRESSION: Persistent small lateral left pneumothorax and small
bilateral
pleural effusions. Improving multifocal atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2150-4-6**] 3:36 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 5259**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86422**] (Complete)
Done [**2150-4-3**] at 10:08:02 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2081-6-4**]
Age (years): 68 M Hgt (in): 65
BP (mm Hg): / Wgt (lb): 160
HR (bpm): 65 BSA (m2): 1.80 m2
Indication: Intraop CABG Evaluate wall motion, aortic contours,
valves
ICD-9 Codes: 424.0
Test Information
Date/Time: [**2150-4-3**] at 10:08 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: aw2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.6 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.6 cm
Left Ventricle - Fractional Shortening: *0.14 >= 0.29
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 57 ml/beat
Left Ventricle - Cardiac Output: 3.71 L/min
Left Ventricle - Cardiac Index: 2.06 >= 2.0 L/min/M2
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.7 m/sec <= 2.0 m/sec
Aortic Valve - LVOT pk vel: 0.80 m/sec
Aortic Valve - LVOT VTI: 15
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *2.2 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 84 ms
Mitral Valve - MVA (P [**2-14**] T): 2.6 cm2
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 0.86
Findings
LEFT ATRIUM: Normal LA size. Elongated LA. No thrombus in the
LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Complex (>4mm)
atheroma in the aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
Conclusions
Post Bypass: Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion.
Post Bypass: Patient is A paced, on phenylepherine infusion.
Preserved biventricular function. LVEF 55%. MR is now trace.
Aortic contours intact. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician
Cardiology Report ECG Study Date of [**2150-4-3**] 2:08:28 PM
Sinus rhythm. Low QRS voltage. Non-diagnostic repolarization
abnormalities.
Compared to the previous tracing of [**2150-3-31**] QRS voltage is
diffusely reduced.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 162 104 372/387 84 0 -14
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. See operative report
for further details. He received cefazolin for perioperative
antibiotics. Post operatively he was transferred to the
intensive care unit for management. In the first twenty four
hours he was weaned from sedation, awoke, and was extubated
without complications. He continued to do well and was
transferred to the floor. His percocet was stopped due to
confusion which resolved. Physical therapy worked with him on
strength and mobility. He was ready for discharge home with
services on post operative day four.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth every morning
DILTIAZEM HCL - (Prescribed by Other Provider) - 300 mg
Capsule,
Sustained Release - 1 Capsule(s) by mouth every morning
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Solution - 34 units at bedtime
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - 14 units before breakfast, 8 units before
lunch, 14 units before dinner
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth every
morning
METFORMIN - (Prescribed by Other Provider) - 850 mg Tablet - 1
Tablet(s) by mouth twice a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth qam
QUINAPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth every morning
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth every morning
OLMESARTAN-HYDROCHLOROTHIAZIDE [BENICAR HCT] - (Prescribed by
Other Provider; OTC) - 20 mg-12.5 mg Tablet - 1 Tablet(s) by
mouth daily every morning
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): 1 drop in each eye twice a day .
Disp:*qs qs* Refills:*0*
5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
7. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
9. Insulin Glargine 100 unit/mL Solution Sig: Thirty Four (34)
units Subcutaneous once a day.
Disp:*qs qs* Refills:*0*
10. Humalog 100 unit/mL Solution Sig: per scale Subcutaneous
before each meal : 14 units before breakfast, 8 units before
lunch, 14 units before dinner.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Diabetes mellitus type 2
Hyperlipidemia
Chronic renal insufficiency baseline cr 1.9
Discharge Condition:
Alert and oriented x2 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2150-5-6**] 1:00
Please call to schedule appointments
Primary Care Dr [**First Name8 (NamePattern2) **] [**Name (STitle) 1057**] in [**2-14**] weeks [**Telephone/Fax (1) 14331**]
Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-14**] weeks [**Telephone/Fax (1) 8725**]
Completed by:[**2150-4-7**]
|
[
"403.90",
"272.4",
"250.00",
"414.01",
"585.9"
] |
icd9cm
|
[
[
[
1417,
1428
]
],
[
[
1430,
1443
]
],
[
[
1445,
1452
]
],
[
[
12831,
12853
]
],
[
[
12917,
12943
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12780, 12810
|
9629, 10275
|
329, 556
|
12983, 13073
|
2614, 3691
|
13613, 14076
|
1913, 2007
|
11531, 12757
|
3731, 3761
|
12831, 12962
|
10301, 11508
|
13097, 13590
|
2022, 2595
|
279, 291
|
3793, 9606
|
584, 1395
|
1417, 1810
|
1826, 1897
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,258
| 108,206
|
34858
|
Discharge summary
|
Report
|
Admission Date: [**2136-11-1**] Discharge Date: [**2136-11-8**]
Date of Birth: [**2057-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1. Intra-aortic balloon pump placement
2. Cardiac catheterization with left main coronary artery bare
metal stent placement
History of Present Illness:
The patient is a 79-year-old male with history of prior CVA,
hypertension, cirrhosis and prior NSTEMI which was treated
medically in [**2136-10-24**] who presents now as a transfer from OSH with a new NSTEMI.
He has been complaining of epigastric pain and "heart burn" for
5 days leading up to this admission. He had associated chest
pain radiating to his jaw and bilateral arms for several days,
almost continuously but waxing and [**Doctor Last Name 688**] in intensity. He
states that he felt better with burping, and his pain worsened
after eating food. He denies any shortness of breath, chills, or
sweats. The patient presented to OSH and was found to have
elevated Troponins to 2.0 with CK of 103. CXR showing mild
pulmonary edema. The patient was treated as an NSTEMI protocol
with heparin, [**Doctor Last Name **], [**Doctor Last Name 4532**] load and he was then transferred to
[**Hospital1 18**] for further management. Aditional review of his EKG at
[**Hospital1 18**] revealed normal sinus rhythm but prominent ST segment
depressions in I, II, aVL, V5-V6
and ST segment elevations in leads aVR and V1. After admission,
the patient was observed on telemetry in preparation for a
cardiac catheterization. He was given ongoing therapy with
[**Last Name (LF) 4532**], [**First Name3 (LF) **], Statin, beta-blocker, and IV heparin. Overnight, he
triggered for hypotension and was given fluid bolus of 500cc x2.
He remained chest pain free initially but had recurrent chest
pain in the early morning hours requiring IV morphine.
In the cardiac cath lab, a right heart catheterization
demonstrated RA Pressure of 19 mmHg,RVEDP 21 mm Hg, PASP 51 with
a mean of 39 mm Hg and PCWP 34 mm Hg. Fluids were discontinued
and Mr. [**Known lastname **] was given 40mg IV lasix. On left heart
catheterization, the LMCA had a distal 90% stenosis at the
trifurcation of the ramus intermedius, LAD, and LCX. The LAD had
mild diffuse disease with a large D1. The LCX had an OM1 with
diffuse 90% proximal stenosis. The RCA was totally occluded
proximally with faint left-right collaterals. Resting
hemodynamics revealed elevated right and left-sided filling
pressures consistent with cardiogenic shock. The cardiac output
was 4.2 l/min with an index of 2.0 l/min/m2 and left
ventriculography was deferred with plan to stabilize patient
with IABP and consider stent or CABG at later time. Ultimately,
the patient underwent stent placement on [**2136-11-2**] with stent
placed across LAD to distal left main coronary artery. Outcome
showed an improvement to 30% obstruction at trifurcation vs.
prior 90% blockage, with a TIMI 3 result.
.
On arrival to CCU, patient was chest pain free and had no
shortness of breath. He was lying flat in bed on 4L NC. He
denied any back, groin pain, LE pain. On review of systems, he
denied any prior history of deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, hemoptysis, black stools or red stools. He denied
exertional buttock or calf pain. All of the other review of
systems were negative.
Past Medical History:
NSTEMI ([**1-31**])
CVA
Gout
Cirrhosis - alcoholic, no biopsy, no known h/o varices or
complications from his liver disease.
Dementia
HTN
OSA
macular degeneration
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
Cardiac History: NSTEMI
Prior percutaneous coronary intervention: none
Pacemaker/ICD:None
Social History:
The patient lives in [**Location **] and is dependent in ADL's and IADL's and
is cognitively very intact. He denies any history of smoking,
current etoh use or any history of drug use.
Family History:
No premature cardiac disease in family, noncontributory family
history.
Physical Exam:
VS - afebrile, T 98.4, IABP Augmented Diastolic BP 105/50, HR
82, SaO2 95% 4L NC, RR 20
Gen: No acute distress, well-developed and well-appearing middle
aged male. Alert and oriented to person, place and time. Mood,
affect appropriate. Speech mildly slurred (without dentures) .
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma. PERRL, EOMI.
Neck: Thick neck, supine, 8cm JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, balloon pump on 1:1.
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use. CTA
anteriorly, decreased b/s at bases.
Abd: Soft, NTND. No HSM or tenderness. Abdominal aorta not
enlarged by palpation.
Ext: Slightly cool lower extemities with 1+ pedal pulses
bilaterally, no edema. No femoral bruits, R-groin w/o hematoma
or ecchymoses, IABP in place.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: dopplerable DP pulses, faintly dopplerable PT pulses
b/l.
Pertinent Results:
[**2136-11-1**] Admission EKG: sinus rhythm with nml axis, nml
intervals, ST depressions in V4-V6, I, AVL and ST elevation in
AVR. Borderline ST elevation in V1.
.
[**2136-11-2**] Cardiac Cath Report: 1. Successful PTCA and placement
of a 3.0x15mm Vision stent in the distal LMCA and origin LAD
were performed. The stent was postdilated proximally using a
4.5x8mm Quantum Maverick balloon and distally using a 3.5x12mm
Quantum Maverick balloon. Final angiography showed normal flow,
no apparent dissection, and a 30% residual stenosis at the
trifurcation site. (See PTCA comments.)
2. Left femoral arteriotomy closure was performed using an 8
French
Angioseal VIP. FINAL DIAGNOSIS:PTCA and placement of a
bare-metal stent in the distal LMCA to origin LAD.
.
[**2136-11-3**] ECHO :
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-15mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is
moderate global left ventricular hypokinesis (LVEF = 40 %).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. There
is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. Moderate (2+) mitral regurgitation
is seen. The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
pMIBI at OSH [**1-/2136**]: left ventricular dialtion with diffuse
hypokinesis and reduced EF to 35%. non-transmural inferior wall
perfusion defect on post-stress images. subendocarial ishemia
[**2136-11-1**] 10:42PM PTT-58.0*
LABS PRIOR TO DISCHARGE:
[**2136-11-8**] 05:55AM BLOOD WBC-8.1 RBC-3.14* Hgb-9.3* Hct-28.2*
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.6 Plt Ct-252
[**2136-11-8**] 05:55AM BLOOD Glucose-113* UreaN-45* Creat-1.7* Na-141
K-4.2 Cl-108 HCO3-24 AnGap-13
[**2136-11-5**] 07:00AM BLOOD ALT-26 AST-25 AlkPhos-73 TotBili-0.4
[**2136-11-8**] 05:55AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1
[**2136-11-2**] 01:00AM BLOOD CK-MB-48* MB Indx-11.4* cTropnT-4.06*
proBNP-[**Numeric Identifier 79816**]*
[**2136-11-5**] 04:14PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2136-11-5**] 04:14PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2136-11-5**] 04:14PM URINE RBC-10* WBC-9* Bacteri-FEW Yeast-NONE
Epi-0
Brief Hospital Course:
In summary, the patient is a 79-year-old male with history of
hypertension, s/p NSTEMI [**1-/2136**] who was transferred from OSH
after presenting with 5 days of unstable angina with associated
dyspepsia and found to have NSTEMI with transient ST elevations
in AVR and ST depressions inferolaterally concerning for
significant left
main/proximal LAD disease with relative hypotension.
:
CORONARY ARTERY DISEASE/NSTEMI and CARDIOGENIC SHOCK: The
patient presented to OSH and was found to have elevated
Troponins to 2.0 with CK of 103. The patient was treated as an
NSTEMI protocol with heparin, [**Year (4 digits) **], [**Year (4 digits) 4532**] load and he was then
transferred to [**Hospital1 18**] for further management. Aditional review of
his EKG at [**Hospital1 18**] revealed normal sinus rhythm but prominent ST
segment depressions in I, II, aVL, V5-V6 and ST segment
elevations in leads aVR and V1. CK peaked peaked at 400. Patient
continued [**Last Name (LF) 4532**], [**First Name3 (LF) **], statin and heparin therapy. Patient's
beta blocker held in the setting of severe cardiogenic shock on
admission to CCU. Admission TTE/ECHO [**2136-11-1**] showed moderate
global left ventricular hypokinesis (LVEF = 40 %) and Grade
III/IV (severe) LV diastolic dysfunction. The right ventricle
was mildly dilated with mild global hypokinesis as well. The
patient was stabilized with the assistance of a intra-aortic
balloon pump to help augment BP. The patient was initially
placed on IABP 1:1 and gentle diuresis was given with lasix.
Diagnostic coronary angiography showed 2 vessel and left main
coronary artery disease as patient was found to have 90% L-main
occlusion. Due to significant comorbidities, there was
reluctance to offer CABG as reasonable option. After discussion
with family and patient he elected to undergo an attempt at PCI.
He underwent PTCA and placement of a bare-metal stent in the
distal LMCA to origin of LAD and recovered well with no notable
complications post-procedure.
.
PUMP FUNCTION: ECHO revealed LVEF of 35%. The patient had
initial elevation in BNP of [**Numeric Identifier 79816**] given his acute NSTEMI and CHF
with poor cardiac output. He received post catheterization
diuresis with Lasix and his CXRs showed improvement in his
pulmonary edema throughout his hospital course. The patient's
oxygen saturations were improved to 96 % on room air by time of
discharge and he had no clinical complaints of shortness of
breath and only trace lower extremity edema which had improved
from his initial presentation.
.
RHYTHM : The patient was monitored throughout his stay and per
telemetry he remained predominantly in normal sinus rhythm after
his PCI procedure with very limited PVCs.
.
ANTICOAGULATION: The patient's most recent ECHO revealed
moderate global left ventricular hypokinesis (LVEF =35-40 %)and
the right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. Thus, he was started on IV heparin and
bridged while starting coumadin therapy to reduce his risk of
thrombus and CVAs. The end INR goal being [**2-26**]. At time of
discharge the patient's INR was slightly supratherapeutic at 3.5
and his evening warfarin dose was held prior to his discharge.
.
ACUTE ON CHRONIC RENAL FAILURE : The patient's initial CRF
history was further challenged by his relative hypoperfusion in
the setting of his ACS/NSTEMI and during his cardiogenic shock.
Based on limited OSH records it is unclear what the patient's
true BUN/Cr baseline is. His Cr peaked at 2.4 and came down to
1.6/1.7 by time of discharge. He was given mucomyst pre and
post-procedure and IVFs were given sparingly due to the
patient's CHF/cardiogenic shock.
.
CIRRHOSIS : The patient had a GI consult for pre-op risk
stratification. Unclear if patient has true underlying cirrhosis
but ultrasound revealed a nodular liver. The patient was cleared
for surgery and he had LFTs within normal limits at the time of
discharge. Per GI records the patient had a classification of
Child Class B w/ 30% cirrhosis secondary to alcohol history. He
had no appreciable RUQ tenderness, jaundice, HSM on exam and he
will plan to follow-up with his usual PCP after discharge
regarding his GI management. Hepatitis B/C panels were done and
were all negative.
RECENT PNA : The patient was noted to have had a fever at OSH
and he had recently completed treatment for PNA. He had no
dullness to percusssion on exam and he had no significant cough
or productive sputum during his CCU course. At time of discharge
he had WBC count of 8.1 and was afebrile. Mr. [**Known lastname **] did have
leukocytosis to 19 at OSH but only mildly elevated WBC to 12
here and CXR clear other than mild effusions initially which had
improved to near resolution by time of discharge.
.
DEMENTIA : For the patient's mild dementia he was continued on
his daily Donepezil therapy.
.
URINARY TRACT INFECTION: On [**2136-11-5**] the patient had a routine
UA which revealed bacteria and WBCs and labs were consistent
with a UTI so he was started on Doxycycline for a 7 day regimen.
Follow-up urine cultures were negative. He was through 4/7 days
therapy at time of discharge and had no complaints of dysuria or
frequency.
FLUIDS AND ELECTROLYTES: The patients magnesium and potassium
were repleted on an as needed basis during his hospital stay and
daily electrolytes were monitored. He was started on a full
cardiac diet once he stabilized and he did very well with his
oral input and had a good appetite. IVF were used sparingly in
the setting of CHF.
.
SACRAL DECUBITUS: The patient's sacral stage 1 buttock sore
remained in tact and he had protective cream applied to avoid
any breakdown. Patient stable at time of discharge and will plan
to follow-up with his PCP regarding further monitoring.
.
PROPHYLAXIS: The patient was on anticoagulation for NSTEMI and
thrombus coverage in the setting of his hypokinetic heart and
was therefore covered for DVT prophylaxis as well. PT also
helped the patient to do exercises during his stay to maintain a
fair level of mobility. He was also given 40mg PO daily
Protonix for GI prophylaxis.
.
The patient was maintained as a full code
status for the entirety of his hospital stay. He was asked to
please return to the emergency room or call his primary
cardiologist or PCP as soon as possible if he had any worsening
shortness of breath, chest pain, dizziness or lightheadedness
after discharge.
Medications on Admission:
Home Medications on arrival:
Reglaid
Flonase
Sudafed
Celexa
Colchine
[**Date Range **]
Lopressor
Allopurinol
Aricept
Recently completed levaquin for PNA
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 37**] House Rehab & Nursing Center - [**Location (un) 38**]
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Acute Systolic Congestive Heart Failure
Urinary Tract Infection
Acute Renal Failure
Discharge Condition:
Stable
Creat: 1.6
BUN: 47
K: 4.2
Hct: 27.9
Stage 1 sacral ulcer
Discharge Instructions:
You had a heart attack and required a bare metal stent to open
one of your heart arteries. You will need to take [**Location (un) **] every
day for the rest of your life. You had some damage to your heart
muscle and now your heart is weak. Because of this, you will
need to follow a low salt diet, weigh your self every day and
call the doctor if you gain more than 3 pounds in 1 day or 6
pounds in 3 days. We changed some of your medicines.
Continue daily [**Location (un) **] to keep the cardiac stent open. Continue
doxycycline for 3 remaining days of therapy for a urinary tract
infection and continue daily Warfarin as prescribed to avoid
blood clots and to decrease stroke risk.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Cardiology: Pt will need follow-up with a cardiologist in [**2-27**]
weeks as a new pt.
Completed by:[**2136-11-8**]
|
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233, 245
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|
3851, 4037
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,802
| 139,284
|
29370
|
Discharge summary
|
Report
|
Admission Date: [**2120-10-14**] Discharge Date: [**2120-10-28**]
Date of Birth: [**2057-12-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Hypoglycemia, hypoxemia, hypothermia
Major Surgical or Invasive Procedure:
endotracheal intubation
Arterial line placement
Central venous line placement
Peripherally-inserted venous catheter
History of Present Illness:
Ms. [**Known lastname 32496**] is a 62 yo wheelchair bound F with IDDM c/b
peripheral neuropathy with CHF 20%, s/p right BKA, daughter
nurse, picked her up at adult day care, noticed somnolence,
checked glu - 25. Went to local ER. Gave amp D50 and gave her
zosyn, but there is no documented temperature. She was noted to
desat to the 70s on RA, but she was asymptomatic. She was put
on nonrebreather. She was also noted to be bradycardic in 40s.
She was tx here for further management. Upon arrival, she was
again without complaints. She was noted to desat to 82 without
NRB.
Vitals in the ED: HR 60s. T 92-93 rectal. HR 60, BP 160/63, RR
19, 98%NRB. No other antibiotics. 1 blood and urine here. 2
bloods at outside ed. lactate 1.5. Cr 1.4 there, 1.8 here. No
CTA done, but she was placed on heparin out of concern for PE.
She was put on a warming blanket.
In the ICU, she endorsed cough x 2 days, atypical chest pain.
She denies abd pain, dysuria or increased frequency, diarrhea,
n/v. She subsequently developed hypotension with SBP 70s to
80s. Given her evolving sepsis picture, pulmonary edema,
possible benefit of better monitoring, and possible need for
pressors, an arterial line was placed and she was intubated.
Past Medical History:
#. Chronic Systolic CHF EF 20%:
- h/o hospitalizations for CHF exacerbation
- Echo [**10-17**]: Moderate symmetric LVH with severe global left
ventricular dysfunction (EF 20-25%) Moderate tricuspid
regurgitation. Moderate pulmonary hypertension. Small
pericardial effusion.
- MIBI [**2117**] with normal perfusion
#. DM II x 15 years - complicated by peripheral neuropathy;
retinopathy
#. HTN
#. CAD - h/o distant MI per family report, no PCI or CABG
#. History of Pancreatitis
- s/p pancreatic duct stent
#. CKD (baseline 1.1-1.3 per report, but was 0.7-0.9 in [**4-17**])
#. Anemia - Mixed iron deficient and anemia of chronic disease
#. Thrombocytopenia
#. h/o thickened endometrium per US
#. osteopenia
#. History of stroke
#. Dementia
#. ? Seizure disorder
Social History:
The patient was previously living in [**Location (un) **] with her other
daughter. She recently returned to [**Location 86**] to live with her
daughter [**Name (NI) 70555**] who is employed at [**Hospital1 18**] as a coworker
[**Name (NI) 1139**]: Quit 1 year ago, previously [**12-13**] PPD x 50 years
ETOH: Rare
Illicits: None
Family History:
Mother with DM, breast cancer, MI in her 70's. Brother has DM.
Sister with heart disease.
Physical Exam:
vitals: 92 axillary, HR 67 83/35-->121/84 RR20 O2 83-94% NRB
heent: ncat, mmm, eomi
neck: no lad
pulm: ctab, no w/r/r
cv: hrrr, no m/r/g
abd: s/nd, mild diffuse ttp, hypoactive bs
extr: s/p right BKA, multiple ulcers on left foot without
erythema. exudate between 3rd and 4th toes where there is an
ulcer.
neuro: ao x 1 (self)
Pertinent Results:
[**2120-10-14**] 11:06PM PO2-67* PCO2-35 PH-7.32* TOTAL CO2-19* BASE
XS--7
[**2120-10-14**] 11:06PM LACTATE-1.5
[**2120-10-14**] 10:55PM GLUCOSE-266* UREA N-23* CREAT-1.8* SODIUM-144
POTASSIUM-5.6* CHLORIDE-118* TOTAL CO2-19* ANION GAP-13
[**2120-10-14**] 10:55PM CK(CPK)-51
[**2120-10-14**] 10:55PM cTropnT-0.03*
[**2120-10-14**] 10:55PM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2120-10-14**] 10:55PM TSH-11*
[**2120-10-14**] 10:55PM TSH-11*
[**2120-10-14**] 10:55PM T4-8.7
[**2120-10-14**] 10:55PM PLT SMR-NORMAL PLT COUNT-122* LPLT-3+
[**2120-10-14**] 10:55PM PLT SMR-NORMAL PLT COUNT-122* LPLT-3+
[**2120-10-14**] 10:55PM PT-11.6 PTT-31.3 INR(PT)-1.0
CXR [**10-23**]:
FINDINGS: In comparison with the study of [**10-22**], there is
persistence of
diffuse bilateral pulmonary opacifications. Again, this is
consistent with
ARDS, though vascular congestion or diffuse pneumonia can
certainly not be
excluded radiographically. Various monitoring and support
devices remain in place. The left hemidiaphragm is not sharply
seen on the current study. This could reflect some pleural
fluid, atelectatic change, or even focal
consolidation at the left base.
ABD/PELVIS CT [**10-18**]:
1. Significantly limited CT examination without intravenous
contrast with no source of infection identified. If there
remains a high clinical concern for an occult infection, can
consider correlation with a dedicated tagged white cell scan.
2. Ground glass and interstitial opacities within visualized
lung bases in
conjunction with small bilateral pleural effusions, small
pericardial
effusion, and probable compression atelectasis. These all likely
relate to
fluid overload/CHF with no discrete pneumonia noted.
3. Diffuse anasarca.
4. Unchanged pancreatic parenchymal calcifications again
suggestive of prior episodes of pancreatitis.
Brief Hospital Course:
62 yo female with DM, HTN, CAD, dementia, who presented with
hypothermia, hypoxia, and hypotension.
# Sepsis: The patient's clinical picture was consistent with
sepsis, initially concerning for urosepsis based on her UA in
the ED. Early goal-directed therapy was initiated, with prompt
transfer to the ICU. However, no bacteria grew from the urine,
and nothing was grown from blood and sputum cultures. She was
covered broadly with vancomycin, zosyn, and levofloxacin and she
improved clinically. She was ruled out for respiratory viruses.
Podiatry was consulted and did not feel that her left foot was
infected, only colonized. Bronchoscopy was also not revealing.
CT abd & pelvis were also unremarkable for source. Given no
clear source and clinical improvement she was given a 10-day
course of empiric antibiotics with the last doses on [**10-25**]. She
remained afebrile during the latter portion of her hospital
course.
# Hypotension/Hypertension: The patient was hypotensive on
admission requiring agressive fluid resuscitation (11L in the
first 24 hours) and pressors. She became hypertensive after the
second or third day of her ICU stay and was gradually started
back on some of her home medications, metoprolol and amlodipine.
Hydralazine was started due to hypertension and wanting to hold
enalapril and HCTZ given her acute renal failure. As kidney
function improved enalapril was started and gradually titrated
upward, while Hydralazine was discontinued. Her
anti-hypertensive regimen will need further adjustment as an
outpatient.
# Respiratory Failure: While in the ICU, she developed
progressive respiratory distress requiring endotracheal
intubation, the etiology of which proved unclear. Serial CXRs
appeared most consistent with ARDS, but lung compliance proved
good on the ventilator. Fluid overload was also postulated. She
was diuresed with Lasix, and successfully extubated on [**2120-10-23**].
Her length of stay fluid balance was still +4 L at the time of
discharge but she was autodiuresing well so no diuretics were
initiated.
# Acute Renal Failure: Creatinine was elevated to 1.8 on
admission and peaked at 2.1 but returned to a baseline of 1.2.
The patient likely had ARF [**1-13**] hypoperfusion.
# Question of DIC: Concering because of thrombocytopenia and
coagulopathy. However, Heme was consulted and did not think her
presentation was consistent with DIC. She also ruled out for
HIT. Her platelet count was stable at the time of discharge.
# Chronic diastolic heart failure: Pt. was found to have a
normal EF on ECHO (>55%) and severe diastolic dysfunction. She
was restarted on an ACEi as described above, a beta blocker, and
aspirin.
# History of seizure: Patient has a history of a recent seizure
of unclear etiology. It may be related to a past stroke,
however. She was managed with keppra.
# DM: Patient was managed on an ISS while inpatient. At the
time of discharge, her daughter reported episodes of
hypoglycemia as an outpatient and requested a script for
glucagon pens, which were given.
# Foot ulcers/bullae: Podiatry evaluated the patient's foot
ulcers and made recommendations for wound care. Her ulcers grew
pan-resistant bacteria (including VRE) but they felt that the
ulcers were not the cause of her septic presentation, and that
they were instead colonized. She additionally improved
clinically in the abscence of directed antimicrobial therapy
against VRE. She was discharged with wound care recommendations
for at-home wound care.
# CAD/hx of stroke: Patient was discharged on ASA and a beta
blocker.
Medications on Admission:
Per D/C summary [**10-8**]:
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Levetiracetam 500mg PO bid
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Silvadene 1 % Cream Sig: One (1) Topical once a day: Apply
to the blister once dry and stops draining.
Disp:*1 * Refills:*2*
13. Glargine 7 Units qAM
Insulin SC Sliding Scale
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Disp:*120 Tablet(s)* Refills:*2*
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Lantus 100 unit/mL Cartridge Sig: Seven (7) U Subcutaneous
QAM.
13. Insulin Lispro 100 unit/mL Solution Sig: AS DIRECTED
Subcutaneous ASDIR (AS DIRECTED).
14. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for DIARRHEA.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Sepsis
2. Acute respiratory failure
3. Acute renal failure, resolved
4. Low-grade DIC
Secondary diagnoses:
1. Chronic diastolic heart failure, compensated
2. Hypertension
3. Diabetes mellitus type 2, controlled with complications
4. Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted because you had a serious infection in your
blood stream. We treated you with antibiotics to help clear the
infection. We also had to assist your breathing with a
breathing tube. Your condition improved gradually and we
discharged you home with physical therapy services.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Please call your doctor or return to the hospital if you
experience fevers, chills, sweats, chest pain, shortness of
breath or anything else of concern.
Followup Instructions:
Please schedule an appointment with your primary care doctor
within the next one to two weeks:
PCP: [**Name10 (NameIs) 70557**],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **] [**0-0-**]
We scheduled you for an appointment with a nurse practicioner at
[**Hospital1 18**] next week. To keep this appointment, you will need to
call the office (the number is below). If you would rather see
Dr. [**Last Name (STitle) **], please call his office to schedule an appointment
there.
Scheduled Appointments :
[**Hospital1 18**]--Provider [**Name9 (PRE) 10160**] [**Name9 (PRE) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2120-11-4**] 2:00
Please schedule an appointment with the podiatry clinic within
the next week:
Podiatry
[**Hospital1 18**], [**Location 70558**]
Office Phone: ([**Telephone/Fax (1) 4335**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2120-10-29**]
|
[
"250.80",
"357.2",
"V49.75",
"427.89",
"362.01",
"414.01",
"412",
"585.9",
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"290.10",
"V15.82",
"250.40",
"404.91",
"038.9",
"584.9",
"428.0",
"780.39",
"041.04",
"518.81",
"286.6",
"272.0"
] |
icd9cm
|
[
[
[
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[
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[
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597
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[
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625
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[
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[
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[
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[
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[
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[
[
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[
[
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5247
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[
[
5250,
5252
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[
11451,
11462
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],
[
[
5331,
5336
]
],
[
[
7297,
7315
],
[
11331,
11349
]
],
[
[
7722,
7752
]
],
[
[
7920,
7937
]
],
[
[
8444,
8446
]
],
[
[
11302,
11326
]
],
[
[
11364,
11376
]
],
[
[
11526,
11545
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11213, 11268
|
5228, 8812
|
357, 474
|
11570, 11577
|
3352, 5205
|
12173, 13175
|
2893, 2985
|
9791, 11190
|
11289, 11379
|
8838, 8866
|
11601, 12150
|
3000, 3333
|
11400, 11549
|
280, 319
|
502, 1743
|
1765, 2530
|
2546, 2877
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
"276.51",
"V10.46",
"401.9",
"427.31",
"282.49",
"V12.54",
"157.8",
"789.59",
"253.6",
"458.9",
"486",
"792.1",
"289.59",
"276.69",
"198.89"
] |
icd9cm
|
[
[
[
710,
720
]
],
[
[
1833,
1872
]
],
[
[
1877,
1888
]
],
[
[
1893,
1911
],
[
8234,
8237
]
],
[
[
1929,
1939
]
],
[
[
1944,
1961
]
],
[
[
5040,
5067
]
],
[
[
5100,
5106
]
],
[
[
5414,
5418
]
],
[
[
5621,
5631
]
],
[
[
6499,
6507
]
],
[
[
6697,
6718
]
],
[
[
6966,
6988
]
],
[
[
7297,
7310
]
],
[
[
7743,
7774
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8900, 8906
|
5014, 8612
|
299, 306
|
9066, 9075
|
2983, 4895
|
10004, 10323
|
2238, 2283
|
8738, 8877
|
8927, 9045
|
8638, 8715
|
9099, 9981
|
2298, 2964
|
229, 261
|
334, 1808
|
4904, 4991
|
1830, 1997
|
2013, 2222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,796
| 148,602
|
38520
|
Discharge summary
|
Report
|
Admission Date: [**2172-5-8**] [**Year/Month/Day **] Date: [**2172-5-14**]
Date of Birth: [**2091-10-3**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Quinolones
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80F with history of COPD on home O2 who was found to have a UTI
a week ago and started on Macrodantin by her urologist. She took
3 days of Macrodantin and felt very nauseated and dizzy. On [**5-7**]
while walking to the bathroom, she fell and started complaining
of hip pain. Four people at [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] rehab helped her up
and put her back into bed. She denied any loss of consciousness,
blurry vision, chest pain, shortness of breath. A CT scan done
showed multiple pelvic fractures, a question of a pulmonary
embolism in the RLL and a bladder pollyp. She had seen her
urologist one week prior for cystoscopy for hematuria. At [**Last Name (un) 1724**]
she had an IVC filter placed [**2172-5-7**] as well as a PICC line. Her
Urine Cx from [**2172-5-4**] was ESBL E.Coli for which she has been
treated with Imipenem/Cilistatin.
Past Medical History:
COPD, CO2 retainer on home oxygen 2 liters, GERD, DVT 6 years
ago, spinal stenosis, CHF, hypertension, osteoporosis, anxiety,
bladder cancer, UTI, and shingles.
PSH: varicose vein ligation, hysterectomy, IVC filter [**2172-5-7**]
Family History:
Noncontributory
Physical Exam:
Upon admission:
Afebrile, BP 111-141/48-70, HR 88-101, RR 19-29, Sat 89-98% on
4L
General: Elderly Caucasian Female with pursed lip breathing,
mild tacypnea
Pulmonary: Inspiratory crackles noted at the bases but overall
is markedly improved from yesterday.
Cardiac: RR, nl S1 S2, systolic ejection murmur noted over
sternum, no rubs or gallops appreciated
Abdomen: distended, soft, non-tender, tympanetic to percussion
Extremities: No edema noted in lower extremities
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact.
.
Pertinent Results:
[**2172-5-8**] 08:48PM GLUCOSE-108* UREA N-20 CREAT-0.5 SODIUM-140
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12
[**2172-5-8**] 08:48PM ALT(SGPT)-31 AST(SGOT)-21 ALK PHOS-60 TOT
BILI-0.4
[**2172-5-8**] 08:48PM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-2.2*
MAGNESIUM-2.2
[**2172-5-8**] 08:48PM WBC-18.2* RBC-3.51* HGB-10.4* HCT-31.7*
MCV-90 MCH-29.5 MCHC-32.7 RDW-15.1
[**2172-5-8**] 08:48PM NEUTS-93.8* LYMPHS-2.8* MONOS-2.3 EOS-0.9
BASOS-0.2
[**2172-5-8**] 08:48PM PLT COUNT-178
[**2172-5-8**] 08:48PM PT-11.7 PTT-27.5 INR(PT)-1.0
CT: 1. Pelvic fractures: comminuted fx of left sacrum extending
into the first sacral arch. A second nondisplaced fx in the
inferior right sacral ala. Proximal left superior pubic ramus fx
and a comminuted fx of the left ischiopubic ramus. 2. Possible
thrombus in two pulmonary vessels of the right lower lobe. It is
unclear if these vessels are arteries or veins. 3. Small
bilateral pulmonary effusions with adjacent consolidations. 4. 1
cm bladder polyp.
CXR:
FINDINGS: In comparison with the study earlier in this date,
there is little change in the appearance of the heart and lungs.
Again, there is
hyperexpansion of the lungs with coarse interstitial markings
that could
reflect chronic pulmonary disease, elevated pulmonary venous
pressure, or
both. Bilateral pleural effusions or scarring with probable
bibasilar
atelectasis. Again, the possibility of supervening pneumonia
cannot be
definitely excluded.
Brief Hospital Course:
She was admitted to the Trauma service. She required ICU
admission for tenuous respiratory status given her history of
COPD. She required IV Lasix for diuresis which improved overall
respiratory function. Her home medications, including her home
oxygen, for her COPD were continued.
Orthopedics was consulted for her pelvic fractures. These
injuries did not require operative intervention; her weight
bearing status was as tolerated by patient without restriction.
Her pain regimen includes standing Tylenol, Ultram and prn
Oxycodone. She is also on a bowel regimen.
She is currently continuing treatment of her UTI with Meropenem;
stop date is [**2172-5-18**].
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay.
Medications on Admission:
Advair 250/50 b.i.d., Spiriva INH, dilt 240 daily, Ativan 0.5
b.i.d. p.r.n., Neurontin 300 b.i.d., Protonix 40 daily, Tylenol,
Celexa 10 daily, Colace 100 b.i.d., prednisone 5 daily, Mucinex
600 b.i.d., calcium 600, vitamin D 400, omeprazole 20, MiraLax,
senna 2tabs q.h.s., bisacodyl suppository as needed, milk of
magnesia 30 mL
[**Month/Day/Year **] Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection [**Hospital1 **] (2 times a day).
14. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
15. K Phos Di & Mono-Sod Phos Mono 250 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
16. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
20. Oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q4H (every 4
hours) as needed for pain.
21. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours).
22. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) MG Recon
Soln Intravenous Q12H (every 12 hours): Stop date [**2172-5-18**].
23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] at [**Location (un) 1821**]
[**Location (un) **] Diagnosis:
s/p Fall
Pelvic fractures:
Left comminuted sacral fracture
Inferior right sacral fracture
Left superior pubic ramus fracture
Left comminuted ischiopubic fracture
Urinary tract infection
Secondary diagnosis:
COPD on home oxygen
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
You were hospitalized following a fall; you sustained multiple
fractures of your pelvis which did not require any operations.
The Physical therapists are recommending that you go to rehab.
You may weight bear as tolerated on your lower extremities.
Followup Instructions:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP orthopedics for
your pelvic fractures; call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
Completed by:[**2172-5-14**]
|
[
"E888.9",
"496",
"V46.2",
"599.0",
"530.81",
"V45.89",
"805.6",
"808.2",
"808.42"
] |
icd9cm
|
[
[
[
291,
296
]
],
[
[
391,
394
]
],
[
[
399,
405
]
],
[
[
431,
433
]
],
[
[
1324,
1327
]
],
[
[
1470,
1481
]
],
[
[
7370,
7390
]
],
[
[
7397,
7416
]
],
[
[
7443,
7462
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3645, 4415
|
337, 343
|
2157, 3622
|
8025, 8350
|
1528, 1545
|
4441, 7270
|
1560, 1562
|
7302, 7489
|
289, 299
|
7564, 7564
|
7750, 8002
|
371, 1258
|
7510, 7532
|
1576, 2138
|
7579, 7715
|
1280, 1512
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
95,474
| 188,695
|
461683
|
Physician
|
Physician Resident Progress Note
|
TITLE:
Chief Complaint: [**Age over 90 **] year old female with a history of AF on coumadin,
systolic HF, diverticulosis, and internal hemmeroids who presents with
complaints of LGIB.
24 Hour Events:
Received one unit of FFP
Allergies:
Amiodarone
Unknown;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Changes to medical and family history:
Review of systems is unchanged from admission except as noted below
Review of systems: No chest pain, shortness of breath, fevers, chills
Flowsheet Data as of [**2190-6-16**] 07:45 AM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.4
C (97.6
Tcurrent: 36.4
C (97.6
HR: 70 (70 - 71) bpm
BP: 128/58(75) {114/48(65) - 150/64(84)} mmHg
RR: 17 (15 - 21) insp/min
SpO2: 96%
Heart rhythm: A Flut (Atrial Flutter)
Wgt (current): 61.4 kg (admission): 61.4 kg
Total In:
305 mL
PO:
TF:
IVF:
Blood products:
305 mL
Total out:
0 mL
200 mL
Urine:
200 mL
NG:
Stool:
Drains:
Balance:
0 mL
105 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 96%
ABG: ///29/
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, No(t) Cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Not assessed), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Labs / Radiology
220 K/uL
9.4 g/dL
93 mg/dL
1.1 mg/dL
29 mEq/L
4.4 mEq/L
28 mg/dL
106 mEq/L
142 mEq/L
28.7 %
6.1 K/uL
[image002.jpg]
[**2190-6-15**] 11:01 PM
[**2190-6-16**] 03:01 AM
WBC
6.1
Hct
29.8
28.7
Plt
220
Cr
1.1
Glucose
93
Other labs: PT / PTT / INR:15.9/27.2/1.4, Ca++:8.0 mg/dL, Mg++:2.6
mg/dL, PO4:3.3 mg/dL
Assessment and Plan
[**Age over 90 **] year old female with a history of AF on coumadin, systolic HF,
diverticulosis, and internal hemmeroids who presents with complaints of
LGIB.
# BRBPR: Multiple possible etiologies for this patient with history of
LGIB. Has a known internal hemorrhoids and diverticulosis, and either
would be consistent with her presentation. No complaints of
fever/chills or abdominal pain to suggest more malignant abdominal
pathology. Has no visible external hemorrhoids, fissures, or cracks on
exam. No evidence of hemodynamic instability and hct is down four
points from baseline but repeat check is stable. Last colonoscopy in
[**2180**].
- check q12h hct unless evidence of bleeding
- holding warfarin
- GI reccs, though unlikely to undergo colonoscopy
# Atrial fibrillation: Prior history of poor rate control, now status
post AVJ ablation w/ PPM. On coumadin as an outpatient.
- hold coumadin in setting of potential bleed
- given high-dose vitamin K in [**Last Name (LF) 73**], [**First Name3 (LF) **] be resistant to anticoagulation
for some time.
# Systolic CHF: Patient currently euvolemic on exam.
- hold metoprolol in setting of bleed
- will hold diuretics until acute bleed is stabilized.
# HTN: hypertension at presentation. Will still hold BP meds in
setting of bleed. [**Month (only) 51**] need to optimize prior to d/c
# Hx of CVA: no residual deficits. Hold dipyradiole, and clarify need
while on coumadin prior to d/c.
# FEN: No IVF, replete electrolytes, NPO for now, will clarify w/ GI
need for prep.
# Prophylaxis: SCDs
# Access: peripherals
# Code: FULL CODE
# Communication: Patient
# Disposition: Call out to floor
ICU Care
Nutrition:
Glycemic Control:
Lines:
18 Gauge - [**2190-6-15**] 08:23 PM
Prophylaxis:
DVT: pneumoboots
Stress ulcer: None
VAP:
Comments:
Communication: Comments:
Code status: Full
Disposition:
|
[
"455.8"
] |
icd9cm
|
[
[
[
132,
150
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
416, 487
|
506, 2802
|
27, 397
|
2814, 4914
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
98,552
| 198,795
|
34501
|
Discharge summary
|
Report
|
Admission Date: [**2187-9-22**] Discharge Date: [**2187-9-27**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 year old Female with Alzheimer's dementia, Atrial
Fibrillation, moderate malnutrition, transferred from [**Hospital 1562**]
Hospital for emergent ERCP for presumed gallstone pancreatitis
and septic shock. The patient was at her nursing home when she
was noted to have an episode of vomiting of large amount of
undigested food at 2 AM on [**2187-9-21**]. She then vomited a large
amount of brown liquid that was reportedly hemocult positive.
The nursing home physician was made aware and referred to ED.
The patient's oxygen saturation was noted to be 85-88% on room
air and 2L of oxygen via NC brought her saturation to 92%.
At [**Hospital 1562**] Hospital ED, VS: BP 129/68 P 83 R 18 Temp 100.3
O2 sat 93% on RA. EKG reported to have sinus rhythm with ST
depressions in V3-V6 consistent with digoxin artifact without
comparison. The patient was given Flagyl 500 mg IV x 1 and
Levaquin 500 mg IV x 1. An ultrasound of the abdomen there
reportedly showed cholelithiasis, a slightly enlarged CBD, and
pancreatic inflammation. Thought to have gallstone pancreatitis
and would need an ERCP, so she was transferred to [**Hospital1 **].
In [**Hospital1 18**] ED, her vitals were T 98.9 BP 99/62 HR 101 RR 19 O2
sat 93% 2L NC
2 L NS given. Flagyl 500 mg IV x 1, Vancomycin 1 gram IV x 1,
and Ceftriaxone 1 g IV x 1 were given. RUQ ultrasound, CXR, and
CT abdomen with contrast were performed. her urinalysis was
noted positive for infection. Urgent ERCP consult was obtained
with a plan to continue IV fluids and IV antibiotics. She was
noted hypotensive in the ED, and was admitted to the [**Hospital Unit Name 153**] for
further management.
A conservative approach to the cholangitis was followed given
her comorbitidities and her response to fluids and antibiotics.
She was also noted with a pneumonia. She was continued on
Vancomycin, along with levaquin and flagyl. After stabilizing,
she was transferred to the medical floor.
She subsequently defervesced, and slowly improved to baseline.
After being afebrile for 48 hours, she was stable to return to
her [**Hospital1 1501**].
Past Medical History:
Dementia
Atrial Fibrillation
Moderate Malnutrition
Social History:
Lives in [**Hospital3 **] facility, [**Hospital 4542**] Nursing Home.
Family History:
non-contributory
Physical Exam:
ROS:
GEN: - fevers
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
PHYSICAL EXAM:
GEN: NAD
Pain: 0/0
HEENT: Dry, - OP Lesions
PUL: CTA B/L
COR: Irregular, S1/S2, 2/6 SEM
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: non-verbal, minimally responsive
Pertinent Results:
[**2187-9-26**] 05:30AM BLOOD WBC-12.0* RBC-3.03* Hgb-9.5* Hct-28.7*
MCV-95 MCH-31.4 MCHC-33.2 RDW-12.8 Plt Ct-251
[**2187-9-23**] 11:07AM BLOOD WBC-13.6*# RBC-3.28* Hgb-10.3* Hct-31.2*
MCV-95 MCH-31.5 MCHC-33.2 RDW-13.0 Plt Ct-230
[**2187-9-22**] 04:01AM BLOOD Neuts-84* Bands-7* Lymphs-5* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2187-9-22**] 04:01AM BLOOD PT-13.9* PTT-30.5 INR(PT)-1.2*
[**2187-9-26**] 05:30AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-144
K-3.0* Cl-110* HCO3-25 AnGap-12
[**2187-9-24**] 05:10AM BLOOD Glucose-82 UreaN-18 Creat-0.7 Na-144
K-3.3 Cl-111* HCO3-24 AnGap-12
[**2187-9-21**] 08:20PM BLOOD Glucose-133* UreaN-25* Creat-0.8 Na-146*
K-4.3 Cl-109* HCO3-27 AnGap-14
[**2187-9-25**] 05:35AM BLOOD ALT-14 AST-14 AlkPhos-67 Amylase-73
TotBili-0.5
[**2187-9-24**] 05:10AM BLOOD ALT-19 AST-14 LD(LDH)-236 AlkPhos-68
Amylase-101* TotBili-0.6
[**2187-9-23**] 05:15AM BLOOD ALT-30 AST-22 LD(LDH)-205 AlkPhos-62
Amylase-305* TotBili-0.6
[**2187-9-22**] 04:01AM BLOOD ALT-50* AST-41* LD(LDH)-279* AlkPhos-69
Amylase-1107* TotBili-0.5
[**2187-9-21**] 08:20PM BLOOD ALT-70* AST-55* AlkPhos-75 TotBili-0.6
[**2187-9-25**] 05:35AM BLOOD Lipase-35
[**2187-9-24**] 05:10AM BLOOD Lipase-32
[**2187-9-23**] 05:15AM BLOOD Lipase-92*
[**2187-9-22**] 04:01AM BLOOD Lipase-1175*
[**2187-9-26**] 05:30AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.9
[**2187-9-25**] 05:35AM BLOOD Albumin-2.5* Calcium-7.5* Phos-2.3*
Mg-2.0
[**2187-9-23**] 05:15AM BLOOD Hapto-229*
[**2187-9-27**] 06:05AM BLOOD Vanco-12.9
[**2187-9-21**] 08:20PM BLOOD Digoxin-0.9
[**2187-9-22**] 03:45PM BLOOD Lactate-1.3
[**2187-9-22**] 09:59AM BLOOD Lactate-2.2*
[**2187-9-21**] 08:41PM BLOOD Lactate-3.1*
[**2187-9-22**] 09:59AM BLOOD freeCa-1.06*
[**2187-9-22**] 08:59PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2187-9-21**] 10:40PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024
[**2187-9-22**] 08:59PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2187-9-21**] 10:40PM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2187-9-22**] 08:59PM URINE RBC-65* WBC-12* Bacteri-FEW Yeast-NONE
Epi-0
[**2187-9-21**] 10:40PM URINE RBC-[**12-13**]* WBC-[**12-13**]* Bacteri-FEW
Yeast-NONE Epi-0-2
[**2187-9-21**] 8:20 pm BLOOD CULTURE
**FINAL REPORT [**2187-9-27**]**
Blood Culture, Routine (Final [**2187-9-27**]): NO GROWTH.
[**2187-9-21**] 11:17 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2187-9-23**]**
URINE CULTURE (Final [**2187-9-23**]): NO GROWTH.
[**2187-9-23**] 6:03 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2187-9-23**]**
GRAM STAIN (Final [**2187-9-23**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2187-9-23**]):
TEST CANCELLED, PATIENT CREDITED.
ECG Study Date of [**2187-9-21**] 8:57:54 PM
Sinus rhythm. Non-specific ST-T wave abnormalities. Clinical
correlation is suggested. No previous tracing available for
comparison.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2187-9-21**]
8:51 PM
IMPRESSION:
1. Cholelithiasis/biliary sludge. No son[**Name (NI) 493**] findings to
suggest acute
cholecystitis.
2. Mild right-sided calyectasis without hydronephrosis.
CHEST (SINGLE VIEW) Study Date of [**2187-9-21**] 9:27 PM
1. No evidence of pneumonia, slightly limited film due to
patient
incooperation and rotation.
2. Extensive mitral annular calcification.
CT ABDOMEN W/CONTRAST Study Date of [**2187-9-21**] 11:14 PM
IMPRESSION:
1. Moderately distended gallbladder without any intrahepatic
ductal
dilatation and mild prominence of the extrahepatic CBD which
measures 10 mm. No focal filling defects were identified;
however, CT is insensitive for detection of choledocholithiasis.
2. Peri-inflammatory changes and free fluid within the abdomen
consistent
with acute pancreatitis. No regions of pancreatic necrosis
identified.
3. Scattered tree-in-[**Male First Name (un) 239**] opacities reflecting an infectious
bronchiolitis
within the right lower lobe in this patient with a complete
mucoid impaction of the lower lobe bronchi bilaterally.
4. Incompletely characterized small hypoattenuating right
hepatic and right renal lesions, likely benign cysts, but too
small to definitively
characterize.
5. Extensive mitral annular calcification and atherosclerotic
disease within the coronary vessel and aorta.
CHEST (PORTABLE AP) Study Date of [**2187-9-23**] 4:50 AM
IMPRESSION: Increasing density in the left lung and right lung
base
concerning for pneumonia. Clinical correlation is recommended.
CHEST (PORTABLE AP) Study Date of [**2187-9-25**] 11:16 AM
FINDINGS: Bilateral pleural effusions and moderate interstitial
edema have
increased, compared with the prior study. The left upper lobe
opacity has
improved. Opacity in the right lower lung has increased in the
interval. Left retrocardiac opacity remains present. There is no
pneumothorax.
Brief Hospital Course:
1. Acute Pancreatitis, Choledocolithiasis with Obstruction,
Septicemia
- Patient was kept NPO, and given agressive IV rehydration
- Amylase trended down from 1107 to 305, lipase from 1175 down
to 92 on discharge from ICU.
- ERCP team was consulted, who believed that she had passed the
stone, given her improving labs.
- Levaquin and Flagyl were initiated
- Patient was on Vancomycin in hospital for MRSA empiric
coverage, discontinued prior to discharge
- Feeds were reintroduced on the floor and tolerated well
2. Bacterial UTI with Indwelling Catheter:
- Levaquin/Flagyl
- Foley changed
3. Acute Blood Loss Anemia due to Hematemesis
- Resolved on admission
- Likely [**Doctor First Name 329**] [**Doctor Last Name **] tear vs. mild gastritis
4. Bacterial Pneumonia
- Levaquin/Flagyl given possibility of aspiration
- Afebrile x48 hours at time of discharge
- Some element of fluid overload, so intermittant lasix given
5. Atrial fibrillation
- continue digoxin
6. Alzheimer's Dementia:
- at baseline, per family.
- Geriatrics consult was obtained, concur with current
management
- There is a suggestion by the geriatrics team, for her primary
team at the [**Hospital1 1501**] to consider hospice discussions with the family
Medications on Admission:
Milk of Magnesia prn
Acetaminophen prn
Compazine 25 mg PR q 12 hour prn
ASA 81 mg daily
Digoxin 250 mcg daily
Colace 100 mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal every six (6) hours as needed for fever or pain.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]
Discharge Diagnosis:
Acute Pancreatitis
Choledocolithiasis with Obstruction
Septicemia
Bacterial Pneumonia
Bacterial UTI with Indwelling Catheter
Moderate Malnutrition
Atrial Fibrillation
Acute Blood Loss Anemia
Hematemesis
Alzheimer's Dementia
Discharge Condition:
Good
Discharge Instructions:
Return to the hospital with fever, chills, nausea/vomitting,
hypotension, agitation.
Followup Instructions:
Follow up as needed with the medical staff at the facility
|
[
"331.0",
"294.10",
"427.31",
"263.0",
"577.0",
"574.91",
"038.9",
"599.0",
"285.1",
"578.0"
] |
icd9cm
|
[
[
[
290,
309
]
],
[
[
302,
309
]
],
[
[
312,
330
]
],
[
[
333,
340
]
],
[
[
8455,
8472
]
],
[
[
8475,
8492
]
],
[
[
8512,
8521
]
],
[
[
8970,
8978
]
],
[
[
9048,
9070
]
],
[
[
9079,
9089
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10691, 10787
|
8452, 9686
|
232, 238
|
11054, 11060
|
3182, 8429
|
11193, 11254
|
2545, 2563
|
9867, 10668
|
10808, 11033
|
9712, 9844
|
11084, 11170
|
2999, 3163
|
180, 194
|
266, 2367
|
2389, 2441
|
2457, 2529
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,985
| 162,894
|
41456
|
Discharge summary
|
Report
|
Admission Date: [**2152-2-29**] Discharge Date: [**2152-3-5**]
Date of Birth: [**2093-9-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 2412**] is a 58 year old female with a medical history
significant for hypertension, diabetes, chronic back pain and
depression who presented to the ED today after a mechanical fall
at a train station. She hit her face after tripping while
carrying heavy bags. She did not lose consciousness. She scraped
her face, and otherwise felt fine per report.
On arrival to the hospital, the patient was unable to provide a
detailed history due to confusion. However, her granddaughter
was with her at the station and reported the patient was quite
confused before and after the fall. In conversations with her
husband, he mentions that Ms. [**Known lastname 2412**] has bad back pain and has
had multiple recent injections and medication changes for this.
Notably, she was started on methadone approximately 3 weeks
prior to admission. Her gabapentin was also recently increased.
In reviewing her medications with her husband, it was also noted
that she had pill bottles of both metoprolol 6.25mg twice daily
and Toprol 50mg daily at home. She had no recent illness or
infections.
In the ED, she was at times somnolent, and confused, lighting a
cigarette while in the ED. Her initial vs were: T 97.4 HR 50 BP
119/84 RR 18 Sa O2 95%. Patient was given 500cc of saline and a
Tdap booster shot. She had a head CT that showed no acute
hemorrhage and focal hypodensities at the right basal ganglia,
likely old ischemic foci. They were going to send her home, but
she was a little bit lethargic and somnolent. Chem 7 showed
sodium of 120. Vitals on transfer BP: 170/99 HR 48 RR 11 Sat O2
99%3L.
In the ICU she received 2 liters of IV fluids and her sodium
improved to 129. She was also noted to have a bradycardia to the
40s. All of her sedating medications were held and her mental
status slowly improved.
Past Medical History:
- Depression
- Chronic Back Pain requiring 3 previous back surgeries
- Hypertension
- Type 2 Diabetes
Recent Hospitalizations at Other Hospitals:
1. [**Hospital 1474**] Hospital ([**0-0-**])
- Admitted for syncope. Underwent head CT, echocardiogram,
carotid doppler ultrasounds that were all unrevealing. Her
symptoms were then attributed to Fentanyl patches and other
sedating medications.
2. [**Hospital 1474**] Hospital ([**0-0-**])
- Admitted after being found down in her home with vomit in her
mouth. Reuired Bipap for respiratory support. She had a normal
EEG during this admission. Her presentation was attributed to
pneumonia and a COPD exacerbation.
3. [**Hospital3 10377**] Hospital ([**2152-5-17**])
- Admitted for delirium. She underwent MRI/MRA (revealed old
lacunar infarcts), head CT, chest CT, RPR, TSH, B12, [**Doctor First Name **], RF,
and infectious work-up that were all negative. She was thought
to have delirium from opioids and bezodiazepines.
4. [**Hospital3 10377**] Hospital ([**0-0-0**])
- Admitted for delirium. She underwent a head CT and was
ultimately diagnosed with a UTI.
5. [**Hospital 1474**] Hospital ([**145-7-18**])
- Admitted for somnolence. Found to have an elevated ammonia
and underwent multiple imaging studies and serology tests for
liver dysfunction. She improved with lactulose and was diagnosed
with new crytogenic liver dysfunction.
Social History:
- Tobacco: 1.5 packs per day
- Alcohol: Social (3 drinks, once a month)
- Illicits: None
Family History:
Not relevant to the current admission.
Physical Exam:
EXAM ON ADMISSION:
Vitals: T: 97 BP: 163/72 P: 49 R: 11 O2: 94%
General: Lethargic, somnolent, awakes to loud voice and sternal
rub,
HEENT: Sclera anicteric, dry MM, oropharynx clear, bruising on
her nose, bilateral eyes, and chin
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation with scant soft crackkles, no
wheezes, rales, ronchi
CV: Bradycardic and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: Obese, 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
Neuro: PERRL, Lethargic, oriented to place, + asterixis,
hyporeflexive
Pertinent Results:
ADMISSION LABORATORY STUDIES:
[**2152-2-29**] 07:15PM BLOOD WBC-9.0 (Neuts-71.2* Lymphs-19.4
Monos-5.6 Eos-3.3 Baso-0.4) RBC-4.06* Hgb-12.1 Hct-36.4 MCV-90
MCH-29.9 MCHC-33.3 RDW-14.8 Plt Ct-203 Plt Ct-203
[**2152-2-29**] 07:15PM BLOOD Glucose-97 UreaN-8 Creat-0.6 Na-120*
K-3.9 Cl-85* HCO3-28 AnGap-11 ALT-19 AST-25 AlkPhos-52
TotBili-0.3 Calcium-8.4 Phos-4.0 Mg-1.6 Osmolal-246*
- [**2152-2-29**] 07:15PM BLOOD TSH-2.6 Free T4-0.86*
- [**2152-2-29**] 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABORATORY STUDIES:
[**2152-3-5**] 06:45AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-130*
K-3.7 Cl-94* HCO3-27 AnGap-13
[**2152-3-3**] 01:46PM BLOOD VitB12-[**2092**]*
[**2152-3-4**] 06:40AM BLOOD Ammonia-41
Imaging:
[**2152-2-29**] CT HEAD: There is no evidence of acute hemorrhage, large
acute territorial infarction, or large masses. There are focal
hypodensities, one near right caudate head nucleus (2:15) and
second within the anterior limb of the right internal capsule
(2:14) compatible with old ischemic events. There is associated
ex vacuo dilatation of the right frontal [**Doctor Last Name 534**] of the lateral
ventricle. The remaining ventricles and sulci are normal in size
and configuration. There is no shift of midline structures.
Osseous structures appear normal. IMPRESSION: No acute
intracranial process.
[**2152-3-1**] PA AND LATERAL VIEWS OF THE CHEST: Cardiac size is top
normal. There are low lung volumes. There is crowding of the
vasculature but no area of focal pneumonia. There is no
pneumothorax or pleural effusion. Mild degenerative changes are
in the thoracic spine.
[**2152-3-2**] CT HEAD: There is no evidence of intracranial
hemorrhage, edema, shift of normally midline structures,
hydrocephalus, or acute large vascular territorial infarction.
Again seen are lacunes in the right caudate head and anterior
limb of the right internal capsule. Ex-vacuo diliation of the
frontal [**Doctor Last Name 534**] of the right lateral ventricle is again noted. Mild
prominence of the sulci is consistent with age-related
involutional changes. The visualized portions of the paranasal
sinuses and mastoid air cells are well aerated. The imaged
osseous structures are unremarkable. IMPRESSION: 1. No evidence
of intracranial hemorrhage or acute large vascular territorial
infarction. If there is continued concerned for parenchymal
changes, MR could be performed if not contraindicated. 2.
Unchanged lacunes involving the right caudate head and anterior
limb of the right internal capsule.
Brief Hospital Course:
Ms. [**Known lastname 2412**] is a 58 F with chronic low back pain on multiple
different medications, notably methadone (recently started),
gabapentin (recently increased), and clonazepam. She was
admitted on [**2152-2-29**] with delirium, a mechanical fall with facial
injuries, bradycardia, and hyponatremia. Of note, this is her
6th hospitalization to various hospitals since [**3-/2151**] with
similar symptoms (see past medical history in this discharge
summary for details).
She was initially admitted to the ICU as she was somnolent and
bradycardic on arrival. She was not intubated and her mental
status slowly improved over the next 96 hours with supportive
care. Her bradycardia was from accidental ingestion of both
Toprol and metoprolol for hypertension and resolved with holding
Toprol. Her hyponatremia was thought to be from hypovolemic
hyponatremia and not thought to be causing her delirium. All of
her symptoms were attributed to drug-induced delirium. She
improved with holding Risperdal and methadone and decreasing her
gabapentin and clonazepam. At discharge she was ambulatory with
minimal back pain on reduced doses of gabapentin, ibuprofen, and
Tylenol.
Management of chronic medical problems outlined below:
1. Chronic low back pain
- discharged off methadone and on decreased doses of gabapentin
and clonazepam
- she will follow-up in her pain clinic for repeat epidural
steroid injections in a few weeks
- we arranged for visiting nurses to assist with medication
changes and to discard unprescribed medications
2. Hyponatremia
- thought to be from hypovolemic hyponatremia but still had a
low sodium at discharge
- this will be repeated on [**3-7**] and the results faxed to her
PCP
[**Name Initial (PRE) **] if hyponatremia persists she should have an evaluation for
SIADH and causes of SIADH given her smoking history
3. Nicotine abuse
- likely has undiagnosed COPD with an element of chronic
hypoxia (room air sats 95% while hospitalized)
- received smoking cessation counseling while here
4. Hypertension and Cerebrovascular disease
- blood pressure at goal <130/80 on lisinopril 40 and
metoprolol 6.25 twice daily. Toprol was discontinued given
bradycardia on arrival. The visiting nurses will discard her
Toprol to prevent accidental co-administration of these 2
beta-blockers.
- of note, she had evidence of lacunar infarcts on her head CT
and her blood pressure should be carefully monitored. She should
continue her statin and start an aspirin as an outpatient if she
has no contraindications.
5. Type 2 diabetes
- restarted on Januvia at discharge
6. Depression and Other medication changes
- continued on fluoxetine
- she reported being on risperidone for hospital-associated
delirium during one of her 6 recent admissions. She has no other
indication for antipsychotic medications and this was
discontinued given her problems with medication side effects.
To Do:
- repeat electrolytes on [**3-7**] and possible evaluation for
hyponatremia
- continued smoking cessation counseling and consideration of
evaluation of COPD
- recheck blood pressure and titrate up to goal <130/80
- start aspirin
She has follow-up arranged with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on [**3-13**].
There were no tests pending at discharge.
Medications on Admission:
Clonazepam 1mg at bedtime
Metoprolol 6.25mg twice daily and Toprol 50mg daily (has both
pill bottles at home)
Ibuprofen three times daily
Methadone 5mg three times daily (started approximately 2 weeks
ago)
Lisinopril 40mg daily
Pantoprazole 40mg daily
Fluoxetine 80mg daily
Simvastatin 40mg daily
Gabapentin 800mg four times daily (recently increased)
Risperidone 0.25mg twice daily
Januvia 50mg daily
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
2. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for back pain.
10. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Drug-induced delirium from methadone, clonazepam, and gabapentin
Bradycardia from accidental combination of metoprolol and Toprol
Hyponatremia
Fall
Chronic low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 2412**],
You were admitted with confusion and a fall. We think this was
all from your medications, especially your gabapentin
(Neurontin) and methadone. Please change your medications as
below:
- decrease clonazepam to 0.5mg at night
- stop risperidone
- decrease gabapentin to 400mg three times daily
- stop methadone
- stop Toprol XL
- restart metoprolol 6.25mg twice daily
The medications that we stopped/decreased are causing you to be
confused and fall. You can die from falls such as this and it is
important that you find other ways to treat your back pain.
You should also stop smoking. It is the most important thing you
can do for your health. Please follow-up with Dr. [**Last Name (STitle) **] to
review all of these medication changes. Your visiting nurses
will also check a sodium level on [**3-7**] and send the results to
Dr. [**Last Name (STitle) **].
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 1955**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Location (un) 58843**], [**Location (un) **],[**Numeric Identifier 90192**]
Phone: [**Telephone/Fax (1) 34002**]
Appointment: Monday [**2152-3-13**] 2:30pm
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icd9pcs
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307, 314
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3704, 3744
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,325
| 109,434
|
478121
|
Physician
|
Cardiology Comprehensive Physician Note
|
Date of service: [**2124-7-31**]
Initial visit, Cardiology service: CCU
Presenting complaint: Chest pain, Claudication
History of present illness: Patient is a 59yo male with multiple
cardiac risk factors presenting with chest pain during cath procedure
today. Balloon pump placed and pain resolved. Currently is
asymptomatic and stable.
.
He reports recent worsening of this "chest sensation" in the last
month. Said in the last week, he has used his nitro 4-5x/day. Up
until one month ago, he "never" used his nitro. Reports some
additional anxiety since he got the stress test results back and thinks
that is contributing to his increased use of nitro. Denies having any
chest pressure, just this sensation which is described as follows:
starts with a tightened sensation in his throat that progresses down to
his heart. Does not occur at rest. Denies any radiation of pain, jaw
claudication, syncope, shortness of breath, diaphoresis, or
palpitations. Says this is the same sensation he had while in the cath
lab today and when he got to the CCU. At this time, he is not having
any chest pain.
.
Admitted to CCU with plans to undergo CABG on [**8-1**].
Past medical history: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)
Dyslipidemia, (+) Hypertension
2. CARDIAC HISTORY:
-CABG: Planned for [**8-1**]
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
-Positive stress test
3. OTHER PAST MEDICAL HISTORY:
Peripheral vascular disease- b/l lower extremities
CAD Risk Factors
CAD Risk Factors Present
Dyslipidemia, Hypertension
CAD Risk Factors Absent
Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death
(Tobacco: Yes), (Quit: Yes), (Cigarettes: .5 packs / day x 30 yrs),
(Discontinue tobacco: yes)
Cardiovascular Procedural History
There is no history of:
PCI
CABG
Pacemaker / ICD
Allergies: NKDA
No Known Drug Allergies
Current medications: 1. simvastatin 40 mg daily
2. candesartan 32 mg daily
3. doxycycline 20 mg daily
4. chlorthalidone 25 mg daily
5. fluoxetine 40 mg daily
6. dicyclomine 10 mg daily
7. sublingual nitroglycerin 0.4 mg
8. Chantix
9. aspirin 81 mg daily
10. Prilosec 1 one tablet daily.
Cardiovascular ROS
Cardiovascular ROS Signs and Symptoms Present
Chest pain, Claudication
Cardiovascular ROS Signs and Symptoms Absent
Murmur, Rheumatic fever, SOB, DOE, PND, Orthopnea, Edema, Palpitations,
Syncope, Presyncope, Lightheadedness, TIA / CVA, DVT, Exertional
buttock pain, Exertional calf pain
Cardiovascular ROS Details: 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. Hhe denies recent fevers,
chills or rigors. He reports denies exertional buttock and calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain at
present, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Review of Systems
Organ system ROS normal
Constitutional, Eyes, ENT, Respiratory, Gastrointestinal, Endocrine,
Hematology / Lymphatic, Genitourinary, Musculoskeletal, Integumentary,
Neurological, Psychiatric, Allergy / Immune
Signs and symptoms absent
Recent fevers, Chills, Rigors, Cough, Hemoptysis, Black / red stool,
Bleeding during surgery, Joint pains, Myalgias
Social History
Social history details: He is currently laid off, but he used to work
inmodification of vehicles for people with disabilities.
Functional activity, he continues to go to the gym doing mostly
weight training because his claudication prevents him from doing
walking, running, or other aerobics. Intentionally lost 30 pounds and
3 inches of his waist line over the past three years. He follows a
low-fat diet.
.
-Tobacco history: Quit one week ago (1ppd x 30 years)
-ETOH: 4 glasses of wine/week
-Illicit drugs: None
Physical Exam
Height: 65 Inch, 165 cm
Vital sign details: VS: T= 97.7 BP= 107/64 HR= 78 RR= 12 O2 sat= 99% on
2L
GENERAL: WDWN man 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 no JVP.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
difficult to auscultate given balloon pump
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were
unlabored, no accessory muscle use. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: Slightly cool to palpation. Right cooler than left Pulses
dopplerable. No signs of erythema, ulcers. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Popliteal 2+ DP/PT Doppler
[**Name (NI) **]: Carotid 2+ Popliteal 2+ DP/PT Doppler
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and
palette: WNL)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Jugular veins: JVP, 8cm)
Back / Musculoskeletal: (Chest wall structure: WNL)
Respiratory: (Effort: WNL), (Auscultation: WNL)
Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1:
WNL, S3: Absent, S4: Absent), (Murmur / Rub: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (WNL)
Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:
No bruit)
Extremities / Musculoskeletal: (Gait and station: WNL), (Muscle
strength and tone: WNL)
Skin: ( WNL)
Labs
146
12.2
89
0.9
29
3.0
12
93
130
34.6
5.1
[image002.jpg]
[**2124-7-31**] 04:39 PM
Na+
130
K + (Serum)
3.0
Cl
93
HCO3
29
BUN
12
Creatinine
0.9
Glucose
89
CK
74
ABG: / / / 29 / Values as of [**2124-7-31**] 04:39 PM
Tests
ECG: (Date: [**7-31**]), EKG: Pre-cath [**7-31**] 10:26am- sinus rhythm, no
ischemic changes. rate of 78. left axis, normal intervals. No LVH,
BBB. T-wave inversion in aVL, V1-V5
Post-cath [**7-31**]- 15:25- isolated STE in V2. sinus rhythm, normal
intervals. PVCs. left axis. T-wave inversion in avL and V3
Echocardiogram: (Date: [**7-17**]), STRESS ECHOCARDIOGRAM: Non-specific ECG
changes with 2D echocardiographic evidence of prior myocardial
infarction without inducible ischemia to achieved workload. Hypotensive
response to dobutamine.
.
Dobutamine infusion terminated secondary to symptomatic
hypotensive blood pressure response with probable anginal symptoms in
the absence of ischemic ST segment changes. Echo report sent
separately.
Cardiac Cath: (Date: [**7-31**]), LAD: ostial 95%. Heavy Calcium mid vessel
95%, distal 50%, D1 and D2 with origin 50%.
LCX: mid vessel 50%. OM2 has total occlusion with collaterals from LAD
filling the distal vessel. LPLV has proximal 20% stenosis.
RCA: Total occlusion with collaterals from LCA.
Assessment and Plan
ASSESSMENT AND PLAN
.
# CORONARIES: Cath showed 3VD. patient now reports increased frequency
of his angina in the last week (using nitro [**3-19**]/day). EKG showed
isolated ST-elevation in V2. Currently asymptomatic on nitro gtt.
- nitro gtt
- hold home PO nitro
- simvastatin 40mg daily
- aspirin 81mg daily
- CT [**Doctor First Name 213**] following
- CABG- hopefully tomorrow
- NPO after midnight
- carotid ultrasound
- trend enzymes given new ekg changes s/p cath.
.
# PUMP: IABP placed in cath lab. Holding canbdesartan given marginal
blood pressures. Will not add beta blocker given marginal blood
pressure on balloon pump.
- continue IABP
- check platelets
- on heparin IABP protocol
- monitor pressures
.
# RHYTHM: Sinus rhythm with rate in the 80s, frequent PVC's.
.
# Anxiety: continue paroxetine, ativan prn.
.
# Impacted Wisdom tooth. Will continue home dose doxycycline.
.
FEN: NPO past midnight. heart healthy diet otherwise.
.
ACCESS: PIV's
.
PROPHYLAXIS:
-DVT ppx with IV heparin
-Pain management with
-Bowel regimen with colace, senna
.
CODE: full
.
COMM: [**Name (NI) 946**] [**Name (NI) 9507**] (brother)- [**Telephone/Fax (1) 9508**]
[**Name (NI) 8**] [**Name (NI) 9509**] (girlfriend)- [**Telephone/Fax (1) 9510**]
.
DISPO: CCU for now
|
[
"427.69",
"300.00",
"520.6"
] |
icd9cm
|
[
[
[
8393,
8397
]
],
[
[
8410,
8416
]
],
[
[
8462,
8482
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1357, 1484
|
2017, 8951
|
156, 1233
|
1518, 1996
|
1255, 1334
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
93,945
| 167,733
|
36252
|
Discharge summary
|
Report
|
Admission Date: [**2191-5-22**] Discharge Date: [**2191-5-24**]
Date of Birth: [**2159-12-1**] Sex: F
Service: MEDICINE
Allergies:
Protamine Sulfate / Bactrim / Amoxicillin
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
epistaxis
Major Surgical or Invasive Procedure:
Nasal Packing
History of Present Illness:
31yoF with hx ckd stage 4, hd-dependent [**2-14**] to childhood reflux,
presents with epistaxis and anemia. Pt had a spontaneous
nosebleed, which began yesterday, seen early at OSH yesterday
([**5-21**]), had packing placed. Bleeding continued over course of
day, returned to hospital 2 additional times for continued
bleeding. Hct dropped from 22->16 at OSH. Now sent from [**Hospital1 **]
to [**Hospital1 18**] for further management as no ENT available there.
.
In [**Hospital1 18**] ED, vital signs stable, sbp 140, hr 80s, on room air.
Packing in place, no active bleeding. Hct 16 on arrival here
(stable from OSH). Patient initially refusing blood
transfusions, [**2-14**] to "fear of blood products," vs. "religious
issues. ED resident discussed risk and benefits, pt agreed to
receive pRBCs. Two pIVs (20/18) placed. Blood transfusion
initiated in ED. Pt then had another episode of brisk nose bleed
in ED, seen by ENT who placed new merocel packing in L nostril.
Received DDAVP, ancef, ativan, and zofran. Pt was admitted to
the MICU for close monitoring.
Past Medical History:
-CKD stage4 - [**2-14**] reflux as child, HD M/W/F
-HTN
-Anxiety
Social History:
Fiancee of 5 years, unclear about other social history
Family History:
NC
Physical Exam:
VS: T 98.1, BP 133/73, HR 88, RR 16, SaO2 94% on RA
GENERAL: sleepy but arousable, NAD
HEENT: No scleral icterus. PERRLA/EOMI. packing in Left nostril
with evidence of dried blood, no active bleeding, OP clear, MMM.
Neck NECK: Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: sleepy, alert and oriented x 3, moving all extremities
Pertinent Results:
[**2191-5-22**] 02:19PM GLUCOSE-85 UREA N-148* CREAT-8.9* SODIUM-135
POTASSIUM-5.2* CHLORIDE-98 TOTAL CO2-19* ANION GAP-23*
[**2191-5-22**] 02:19PM CALCIUM-10.0 PHOSPHATE-5.1* MAGNESIUM-2.3
[**2191-5-22**] 02:19PM HCT-19.6*
[**2191-5-22**] 05:25AM HGB-5.5* calcHCT-17
[**2191-5-22**] 05:20AM GLUCOSE-95 UREA N-132* CREAT-8.0* SODIUM-135
POTASSIUM-5.3* CHLORIDE-95* TOTAL CO2-23 ANION GAP-22
[**2191-5-22**] 05:20AM CALCIUM-10.2 PHOSPHATE-4.1 MAGNESIUM-2.4
[**2191-5-22**] 05:20AM WBC-5.4 RBC-1.66* HGB-5.4* HCT-16.4* MCV-99*
MCH-32.8* MCHC-33.1 RDW-17.5*
[**2191-5-22**] 05:20AM NEUTS-44.2* LYMPHS-49.8* MONOS-2.5 EOS-3.0
BASOS-0.5
[**2191-5-22**] 05:20AM PLT COUNT-159
[**2191-5-22**] 05:20AM PT-15.9* PTT-29.4 INR(PT)-1.4*
Brief Hospital Course:
31yoF 31yoF with hx ckd stage 4, hd-dependant [**2-14**] to childhood
reflux, presents with epistaxis and anemia.
.
# epistaxis/acute blood loss anemia: Required short MICU stay
until bleeding stabilized. Etiology of her epistaxis unknown, no
longstanding hx of nosebleeds; no hx of vonWillebrand's or
hemophilia. Issue exacerbated by uremia. Baseline hct unknown
but likely low given ESRD. Seen by ENT who feel most consistent
with arterial spasm. Anterior packing in place with no further
active bleeding apparent. Received DDAVP in ED. Given 4 units
PRBC's, q6H hct check which was stable with transfusion and
epistaxis did not recur. Placed pt on keflex for staph coverage
and placed afrin at bedside. After the packing is removed, she
should start nasal saline, sprays TID x10 days and apply a very
small amount of bacitracin, to the left anterior nose [**Hospital1 **] x 7
days.
.
# ESRD: [**2-14**] to childhood reflux, HD-dependant. Significant
uremia, stable potassium, stable clinical mental status.
Dialysis dates are M/W/F. Getting blood products with volume and
K. Not currently volume overloaded.
Medications on Admission:
Atenolol 100mg PO BID
Procardia XL 60mg PO daily
Doxazosin 2mg PO BID
Renagel 800mg TID with meals
Guanficine 1mg PO QHS
Discharge Medications:
1. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
DAILY (Daily) as needed for epistaxis.
Disp:*1 bottle* Refills:*0*
2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for anxiety/agitation for 7 days.
Disp:*10 Tablet(s)* Refills:*0*
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 2 days.
Disp:*4 Capsule(s)* Refills:*0*
6. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
8. Guanfacine 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Epistaxis
.
Secondary:
Hypertension
End Stage Renal Disease on Hemodialysis
Discharge Condition:
Vitals signs stable, hematocrit stable, ambulating
Discharge Instructions:
You were admitted for a nose bleed that required you to have a
blood transfusion to keep your blood levels stable. You also
received dialysis as scheduled.
.
Nose bleed instructions: Do not manipulate the packing. No nose
blowing. Do not touch or manipulate the nose. Avoid long, hot
showers. Avoid drinking very hot liquids or eating spicy foods.
If active (bright red) bleeding is noted, spray copious amounts
of Afrin in and around the packing (which is like a sponge) and
hold pressure on the tip of nose for 15-20 minutes. If bleeding
continues after that, please go to the emergency room.
.
Medications: Please continue with all your home medications as
previously prescribed. The following additions were made to
your regimen:
ADDED Keflex 500mg my mouth twice a day
ADDED Afrin to be used in nose if bleeding develops
.
You have an appointment with Dr. [**Last Name (STitle) **] with ENT on Thursday
[**2191-5-26**] at 11:15. The office is located on [**Last Name (NamePattern1) **].
Suite 6E. Please arrive 15 minutes early to complete some
paperwork.
.
Also, please call to schedule an appointment with your primary
care doctor within the next week.
.
Continue with dialysis as scheduled on Monday, Wednesday,
Friday.
.
If you develop any of the following, nose bleeding, chest pain,
shortness of breath, cough, fevers/chills, headache, dizziness,
nausea, vomiting or diarrhea, please call your primary care
doctor or go to your local emergency room.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] with ENT on Thursday
[**2191-5-26**] at 11:15. The office is located on [**Last Name (NamePattern1) **].
Suite 6E. Please arrive 15 minutes early to complete some
paperwork.
.
Also, please call to schedule an appointment with your primary
care doctor within the next week.
.
Continue with dialysis as scheduled on Monday, Wednesday,
Friday.
Completed by:[**2191-5-29**]
|
[
"784.7",
"585.6",
"V45.11",
"285.9",
"403.91",
"300.00",
"530.81"
] |
icd9cm
|
[
[
[
262,
270
]
],
[
[
368,
378
]
],
[
[
381,
392
]
],
[
[
454,
459
]
],
[
[
1495,
1497
]
],
[
[
1500,
1506
]
],
[
[
2966,
2971
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5006, 5012
|
2896, 4011
|
311, 326
|
5141, 5194
|
2127, 2873
|
6709, 7141
|
1598, 1602
|
4183, 4983
|
5033, 5120
|
4037, 4160
|
5218, 6686
|
1617, 2108
|
262, 273
|
354, 1421
|
1443, 1510
|
1526, 1582
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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6845, 9566
|
345, 373
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11924, 11924
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|
12724, 13759
|
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|
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|
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3669, 4638
|
278, 307
|
401, 2864
|
11896, 11903
|
4673, 6822
|
11820, 11875
|
11939, 12031
|
2886, 3247
|
3263, 3605
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
96,577
| 138,443
|
37061
|
Discharge summary
|
Report
|
Admission Date: [**2176-12-16**] Discharge Date: [**2176-12-19**]
Date of Birth: [**2126-2-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Ciprofloxacin
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50M with h/o recurrent pancreatitis and multiple pancreatic
surgeries here with abdominal pain radiating to back, consistent
with previous pancreatitis flares. Pain has been going on for 3
weeks, getting worse. Per patient, he has not eaten or stooled
for 3 weeks. He tried small sips yesterday. Report that he is
passing gas but had significant weight loss, weak, and unable to
ambulation. He ran out of pain meds this week. Denies HA,
fevers/chills, N/V, chest pain, sob, cough.
.
In the ED inital vitals were, 99.4 106 122/94 20 100%. His labs
were notable for WBC of 14.3, ALT: 21 AP: 189 Tbili: 0.7 Alb:
4.2 AST: 18 Lip: 51 Ca: 8.9 Mg: 2.9 P: 5.9, Na: 121, Cl: 78, K
5.3, HCO3 18 BUN 27, Cr. 1.2, Gluc 707. He recieved dilaudid
x2, zofran, Insulin gtt with NS 2L. FSBS trended down to 335
then 301. He did not get an EKG. CT abd showed pancreatic
calcifications consistent with history of chronic pancreatitis,
no adjacent stranding or pseudocyst. Diffuse small bowel wall
thickening is nonspecific and may be related to infection or
inflammation. No free fluid. He was transferred to ICU for
further management. vitals prior to transfer: Vital Signs:
Pulse: 96, RR: 16, BP: 119/80, O2Sat: 100, O2Flow: rm air, Pain:
8.
.
On arrival to the ICU, he appears to be in good spirit.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
ADD
PANCREATITIS, CHRONIC
ABDOMINAL PAIN, GENERALIZED
NAUSEA
INTESTINAL MALABSORPTION, POSTSURGICAL
OSTEOPOROSIS
TOBACCO USE
PSHx:
CCY with lateral pancreaticojejunostomy and
Roux-en-Y(complicated by bile duct leak, partial CBD stricture
acute pancreatitis, and hernia) [**2168**]
re-op for biliary drain and transhepatic biliary stent
incisional hernia repair (complicated by stent abscess) [**2168**].
Social History:
Patient moved from VT to [**Location (un) 86**] with his husband last year seek
out better medical care. Used to work in manufacturing, unable
to work recently. No EtOH since pancreatitis diagnosis in [**2167**];
prior to that was drinking [**2-28**] drinks/day for a few years and
had been drinking less heavily before that time. Smokes 1.5
packs cigarettes/day. No history IVDU, remote history of
marijuana.
Family History:
Paternal grandmother and uncle with diabetes, maternal family
history unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: bowel sounds absent, notable tenderness with guarding
on light touch, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Exam:
GENERAL: [x] NAD [] Uncomfortable. Cachectic.
Eyes: [x] anicteric [] PERRL
ENT: [x] MMM [] Oropharynx clear [] Hard of hearing
NECK: [] No LAD [] JVP:
CVS: [x] RRR [x] nl s1 s2 [] no MRG [x] no edema
LUNGS: [x] No rales [x] No wheeze [x] comfortable
ABDOMEN: [x] Soft []nontender [x]bowel sounds present []No
hepatosplenomegaly. mild ttp epigastrum without guarding or
rebound. midline abd scar.
SKIN: [x]No rashes [x]warm []dry [] decubitus ulcers:
LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD
NEURO: [x] Oriented x3 [x] Fluent speech
Psych: [x] Alert [x] Calm [x] Mood/Affect: appropriate
.
Pertinent Results:
Admission Labs:
[**2176-12-16**] 02:00PM BLOOD WBC-14.3* RBC-5.61 Hgb-17.0 Hct-48.7
MCV-87 MCH-30.3 MCHC-34.9 RDW-13.0 Plt Ct-415
[**2176-12-16**] 02:00PM BLOOD Neuts-87.4* Lymphs-9.4* Monos-2.7 Eos-0
Baso-0.4
[**2176-12-16**] 02:27PM BLOOD PT-9.3* PTT-22.5* INR(PT)-0.9
[**2176-12-16**] 02:00PM BLOOD Glucose-707* UreaN-27* Creat-1.2 Na-121*
K-5.3* Cl-78* HCO3-18* AnGap-30*
[**2176-12-16**] 02:00PM BLOOD ALT-21 AST-18 AlkPhos-189* TotBili-0.7
[**2176-12-16**] 02:00PM BLOOD Lipase-51
[**2176-12-16**] 02:00PM BLOOD Albumin-4.2 Calcium-8.9 Phos-5.9*#
Mg-2.9*
[**2176-12-16**] 08:30PM BLOOD Triglyc-83 HDL-38 CHOL/HD-2.3 LDLcalc-33
[**2176-12-16**] 05:24PM BLOOD Type-ART pO2-68* pCO2-36 pH-7.37
calTCO2-22 Base XS--3
[**2176-12-16**] 06:05PM BLOOD Glucose-287* K-4.4
IMAGING:
[**12-16**] CXR:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Unchanged bilateral basal pleural scarring, more evident
on the right than on the left side of the thorax. No acute
pulmonary or cardiac changes, no pleural effusions. No
pneumothorax. No focal parenchymal opacities indicative of
pneumonia.
[**12-16**] CT abdomen/pelvis:
CT ABDOMEN: The visualized lung bases are clear. There is no
pleural or
pericardial effusion. Pleural thickening or atelectasis is seen
in the right lower lobe (2:7).
Patient is status post Puestow procedure with suture lines in
the jejunum, not well assessed on this study. Pancreatic
calcifications are consistent with known chronic pancreatitis.
There is no evidence of pseudocyst or acute pancreatitis. The
liver is normal without focal liver lesion identified.
Pneumobilia throughout the mildly dilated intrahepatic biliary
tree is re-demonstrated as seen on MRI. The patient is status
post cholecystectomy. The spleen and right adrenal gland are
normal. Mild thickening of the medial limb of the left adrenal
gland is similar to [**2175-1-30**]. The kidneys enhance symmetrically
and excrete contrast promptly without hydronephrosis.
Lack of intra-abdominal fat makes evaluation of the bowel
suboptimal. There is marked small bowel wall thickening to 9 mm
(2:42), which is nonspecific. There is no small bowel
obstruction. The large bowel are normal in course and caliber
without obstruction. There is no free fluid and no free air. No
pathologically enlarged mesenteric or retroperitoneal lymph
nodes are identified, although evaluation is limited by lack of
intra-abdominal fat. Main portal vein, splenic vein and SMV are
patent.
The proximal aorta is of normal caliber with a significant
amount of
atherosclerotic calcifications. There is luminal narrowing of
the distal aorta with eccentric intraluminal thrombus. There is
minimal to no flow in the right common iliac artery. The right
common iliac artery at the bifurcation of the internal and
external iliac arteries is patent. The right external iliac
artery is attenuated. The left common iliac and external iliac
arteries are patent. The bilateral internal iliac arteries are
not well assessed due to extensive atherosclerotic
calcifications.
CT PELVIS: The rectum, sigmoid colon, bladder and prostate are
normal. There is no free fluid and no inguinal lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or
malignancy is seen.
IMPRESSION:
1. Pancreatic calcifications consistent with known chronic
pancreatitis. No evidence of pseudocyst or acute pancreatitis.
2. Diffuse small bowel wall thickening is nonspecific and may be
related to hypoperfusion, infection, or inflammation. No bowel
obstruction, free
intra-abdominal fluid or free air.
3. Occlusion of the right common iliac artery as described
above.
Studies:
LE Arterial Duplex:FINDINGS: The ABI on the right is 0.71 and on
the left is 0.69. Doppler
demonstrates monophasic waveforms diffusely and bilaterally. The
volume
recordings demonstrate waveform widening and low amplitude
bilaterally,
symmetrically.
IMPRESSION: Findings consistent with CT of [**2176-12-16**].
Discharge/Notable Labs:
[**2176-12-19**] 08:00AM BLOOD WBC-6.3 RBC-3.81* Hgb-11.7* Hct-32.8*
MCV-86 MCH-30.8 MCHC-35.8* RDW-13.4 Plt Ct-282
[**2176-12-19**] 08:00AM BLOOD Glucose-248* UreaN-2* Creat-0.5 Na-132*
K-3.6 Cl-99 HCO3-27 AnGap-10
[**2176-12-16**] 08:30PM BLOOD ALT-19 AST-13 LD(LDH)-130 AlkPhos-135*
Amylase-62 TotBili-0.3
[**2176-12-17**] 12:34PM BLOOD Calcium-9.2 Phos-2.6* Mg-2.0
[**2176-12-17**] 04:55AM BLOOD %HbA1c-11.1* eAG-272*
[**2176-12-16**] 08:30PM BLOOD Triglyc-83 HDL-38 CHOL/HD-2.3 LDLcalc-33
Brief Hospital Course:
50M with chronic panceatitis and multiple pancreatic surgeries
including pancreaticojejunostomy c/b biliary leak and stricture
admitted with abdominal pain and DKA
#Diabetes complicated by diabetic ketoacidosis:
A1c of 11.1 suggests that patient has been hyperglycemic for
some time. The exact cause is unclear, but it is likely a
reflection of pancreatic destruction from pancreatitis as his
blood sugars were very sensitive to insulin during
hospitalization. He was initially admitted to the ICU where he
was treated with an insulin gtt and then transitioned to
subcutaneous insulin. He was seen by [**Last Name (un) **] Diabetes team and he
was discharged on Lantus 4units QAM. Given the patients erratic
food intake including during flares of his pancreatitis,
combined with his history of poor medical followup, there was
concern that insulin may be associated with increased risk of
hypoglycemia in the patient. However, he had finger sticks of
300-400 consistently during hospitalization after he resumed a
regular diet so the decision was made to discharge the patient
on a regimen of low dose Lantus insulin alone. Extensive time
was spent teaching the patient how to accurately and
appropriately check his finger sticks and administer his insulin
and when to call doctors and of the warning signs of hyper and
hypoglycemia. Patient was discharged with plan to be in close
communication with his PCP and [**Name9 (PRE) **] re: insulin titration.
#Acute on chronic pancreatitis:
Patient's abdominal pain was felt to represent acute on chronic
pancreatitis. Pain improved over hospitalization and patient was
discharged on home pain regimen tolerating a diet. He was
continued on Creon.
# Occluded/Stenotic common iliac artery: Seen incidentally on CT
scan on admission. Patient did endorse claudication. He was seen
by the Vascular Surgery service and will follow up in Vascular
Surgery outpatient clinic.
#Dispostion: Patient was discharged home to follow up with his
PCP, [**Name10 (NameIs) **], and Vascular Surgery
Medications on Admission:
OXYCONTIN 15 MG XR 1 tab po twice daily
OXYCODONE HCL TABS 15 MG po q3-4 hr prn
CREON [**Numeric Identifier 17514**] UNIT CPEP (PANCRELIPASE (LIP-PROT-AMYL)) [**1-26**] with
each main meal and [**11-25**] with snacks
Discharge Medications:
1. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Four (4)
units Subcutaneous once a day: Please take in the morning.
Please call your doctor to adjust the dose if you have morning
finger stick sugars >200 or have readings <70 during the day.
Disp:*1 Pen* Refills:*2*
2. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*28 Tablet Extended Release 12 hr(s)* Refills:*0*
3. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. One Touch UltraSoft Lancets Misc Sig: as directed
Miscellaneous with meals and at bedtime.
Disp:*120 lancets* Refills:*2*
5. One Touch Test Strip Sig: as directed Miscellaneous as
directed.
Disp:*120 strips* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Acute on chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with high blood sugars and diabetic
ketoacidosis. You were treated in the Intensive Care Unit with
IV insulin and then given insulin on the medical floor. You were
also found to have a flare of your pancreatitis which improved
over the course of your hospitalization and you were able to
tolerate a regular diet prior to discharge.
You were seen by the [**Last Name (un) **] Diabetes service and were taught how
to give yourself insulin injections and check your blood sugars
using finger sticks.
You should take your Lantus insulin in the morning and check
your blood sugars before meals and before bedtime. Please lower
your insulin dose if you are not eating or if your blood sugars
are low. You should also keep juice, or non-diet soda,
chocolates or sweets with you to take in case your finger stick
readings are less than 70 or if you feel tremulous, start
sweating, notice vision changes, or feel as if you are going to
pass out.
Please be in close communication with your PCP and the [**Name9 (PRE) **]
center regarding your sugars so that your insulin dosing may be
adjusted as needed.
Please call your 911 if your blood sugars are continually
elevated above 500 or if you have low blood sugars with symptoms
that do not improve with sugar containing compounds such as
juice, soda, chocolate, or sweets.
Followup Instructions:
1) Please make an appointment to see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within
the next week
2) Please follow up the Vascular Surgery service as noted below:
Department: VASCULAR SURGERY
When: FRIDAY [**2177-1-3**] at 11:15 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
|
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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**]
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[
[
913,
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],
[
[
962,
978
]
],
[
[
1271,
1325
]
],
[
[
6972,
6990
]
],
[
[
7139,
7155
]
],
[
[
7416,
7432
]
]
] |
[
"35.21"
] |
icd9pcs
|
[
[
[
301,
327
]
]
] |
8840, 8870
|
6392, 7320
|
301, 395
|
9191, 9372
|
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
|
[
[
[
1881,
1890
]
],
[
[
1905,
1907
]
],
[
[
4989,
5006
]
],
[
[
5368,
5376
]
],
[
[
5389,
5395
]
],
[
[
5767,
5783
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7920, 7926
|
4553, 6116
|
283, 312
|
8104, 8104
|
3306, 3311
|
8851, 9907
|
2481, 2559
|
6740, 7897
|
7947, 7947
|
6469, 6717
|
8255, 8749
|
4178, 4530
|
2574, 2588
|
8779, 8828
|
232, 245
|
6265, 6443
|
340, 1759
|
8069, 8083
|
7966, 8048
|
3325, 4161
|
8119, 8231
|
6132, 6239
|
1781, 2147
|
2163, 2465
|
3164, 3287
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,325
| 109,434
|
36640
|
Discharge summary
|
Report
|
Admission Date: [**2124-7-31**] Discharge Date: [**2124-8-5**]
Date of Birth: [**2065-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cath- [**7-31**]
CABG- [**8-1**]
History of Present Illness:
Patient is a 59yo male with multiple cardiac risk factors
presenting with chest pain during cath procedure today. Balloon
pump placed and pain resolved. Currently is asymptomatic and
stable.
.
He reports recent worsening of this "chest sensation" in the
last month. Said in the last week, he has used his nitro
4-5x/day. Up until one month ago, he "never" used his nitro.
Reports some additional anxiety since he got the stress test
results back and thinks that is contributing to his increased
use of nitro. Denies having any chest pressure, just this
sensation which is described as follows: starts with a tightened
sensation in his throat that progresses down to his heart. Does
not occur at rest. Denies any radiation of pain, jaw
claudication, syncope, shortness of breath, diaphoresis, or
palpitations. Says this is the same sensation he had while in
the cath lab today and when he got to the CCU. At this time, he
is not having any chest pain.
.
Admitted to CCU with plans to undergo CABG on [**8-1**].
.
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. Hhe denies recent fevers, chills or
rigors. He reports denies exertional buttock and calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain
at present, 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:
-CABG: Planned for [**8-1**]
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
-Positive stress test
3. OTHER PAST MEDICAL HISTORY:
Peripheral vascular disease- b/l lower extremities
Social History:
He is currently laid off, but he used to work inmodification of
vehicles for people with disabilities.
Functional activity, he continues to go to the gym doing mostly
weight training because his claudication prevents him from doing
walking, running, or other aerobics. Intentionally lost 30
pounds and 3 inches of his waist line over the past three years.
He follows a low-fat diet.
Family History:
His mother died at age 85. His father is 88 with heart disease
and lung cancer. Father had a CABG in his 70s
Physical Exam:
GENERAL: WDWN man 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 no JVP.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4. difficult to auscultate given balloon pump
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Slightly cool to palpation. Right cooler than left
Pulses dopplerable. No signs of erythema, ulcers. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Popliteal 2+ DP/PT Doppler
[**Name (NI) 2325**]: Carotid 2+ Popliteal 2+ DP/PT Doppler
Pertinent Results:
[**2124-7-31**] 02:15PM BLOOD %HbA1c-5.3
[**2124-7-31**] 02:15PM BLOOD Triglyc-162* HDL-69 CHOL/HD-3.1
LDLcalc-111
CARDIAC CATH: [**2124-7-31**]
LAD: ostial 95%. Heavy Calcium mid vessel 95%, distal 50%, D1
and D2 with origin 50%.
LCX: mid vessel 50%. OM2 has total occlusion with collaterals
from LAD filling the distal vessel. LPLV has proximal 20%
stenosis.
RCA: Total occlusion with collaterals from LCA.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82902**] (Complete)
Done [**2124-8-1**] at 9:09:21 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2065-2-23**]
Age (years): 59 M Hgt (in): 66
BP (mm Hg): / Wgt (lb): 190
HR (bpm): BSA (m2): 1.96 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 440.0, 410.92
Test Information
Date/Time: [**2124-8-1**] at 09:09 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Moderately
dilated LV cavity. Moderate regional LV systolic dysfunction.
Moderately depressed LVEF.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta 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. Trivial
MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No 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. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE BYPASS 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. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with mid-distal anterior, anteroseptal and
apical severe hypokinesis/akinesis. No apical thrombus is seen.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-35%%). The right ventricle displays
borderline normal free wall function. 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 but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion. An intra-aortic balloon (IAB) is seen with
its tip at the level of the distal aortic arch/proximal
descending aortic transition area. Dr. [**Last Name (STitle) 914**] was notified in
person of the results in the operating room at the time of the
study.
POST BYPASS The patient is receiving epinephrine by infusion.
There is normal right ventricular systolic function. The focal
abnormalities of the apical, anterior, and anteropseptal walls
noted in the pre-bypass study are improved and now display mild
hypokinesis. The left ventricular systolic function is now in
the 40 to 45% range. Valvular function is unchanged. The
thoracic aorta appears intact. The IAB remains as noted in the
pre-bypass study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2124-8-1**] 13:39
Brief Hospital Course:
Angina- Patient experienced angina while undergoing cath
procedure on [**7-31**]. Cath showed 3VD. Intra-aortic balloon
placed to improved coronary flow. Upon admission to floor,
nitro gtt was restarted. Heparin IV as well as IABP heparin
protocol started. He had residual pain that resolved upon
resuming nitro gtt. EKG initially showed isolated STE in V2
with T-wave inversion in avL and V3. Enzymes trended. Denied
any chest pain overnight. Was seen and evaluated by CT [**Doctor First Name **].
Mr. [**Known lastname 2816**] was taken to the OR for CABG x4 (LIMA-LAD, SVG-diag,
SVG-OM, SVG-PDA)on [**8-1**]. IABP was removed post-opeeratively.
Immediately after surgery Mr. [**Known lastname 2816**] was admitted to the CVICU
intubated, sedated and on epi and levo. Mr. [**Known lastname 2816**] was
extubated on POD#1 and epi and levo were weaned off. Chest tubes
were removed and Mr. [**Known lastname 2816**] was transferred to the floor on
POD#2. He was started on diuresis, betablockade and stain
therapy. Pacing wires were removed on POD#3. He was evaluated by
physical therapy and cleared for d/c home on POD#4.
Medications on Admission:
simvastatin 40', candesartan 32', doxycycline 20', Imdur 30',
chlorthalidone 25', fluoxetine 40', dicyclomine 10', NTG-sl
.4/prn,
[**Last Name (LF) 82903**], [**First Name3 (LF) **] 81', Paxil 40'
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. [**First Name3 (LF) 82903**] Oral
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease
dyslipidemia
peripheral vascular disease depression
hypertension
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] 1 week
Dr. [**Last Name (STitle) **] [**1-18**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Sternal Precautions
No lifting greater than 10 pounds for 10 weeks
No driving for 1 month and off narcotics
Cardipulmonary Assessment
Wound Care
Medication Compliance
Follow up appointment compliance
[**Hospital1 **] INSTRUCTIONS:
Dr. [**Last Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr. [**Last Name (STitle) **] 3 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name (STitle) **],THEVERTHUDIYIL K. [**Telephone/Fax (1) 82904**] in 1 week
Dr. [**Last Name (STitle) 911**] in [**1-18**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2124-8-5**]
|
[
"414.01",
"276.7",
"443.9",
"401.9"
] |
icd9cm
|
[
[
[
11314,
11336
]
],
[
[
11338,
11349
]
],
[
[
11351,
11377
]
],
[
[
11390,
11401
]
]
] |
[
"37.61"
] |
icd9pcs
|
[
[
[
8986,
8989
]
]
] |
11244, 11293
|
8756, 9890
|
284, 318
|
11426, 11433
|
3694, 8733
|
12708, 13093
|
2674, 2786
|
10139, 11221
|
11314, 11405
|
9917, 10116
|
11457, 12443
|
2801, 3675
|
2057, 2172
|
234, 246
|
346, 1920
|
2203, 2255
|
1964, 2037
|
2271, 2658
|
12475, 12685
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
94,255
| 142,254
|
481667
|
Physician
|
Intensivist Note
|
SICU
HPI:
54F pediatric nurse [**First Name (Titles) 622**] [**Last Name (Titles) 9818**] adenoCA s/p primary [**Last Name (Titles) 9818**]
tumor resection [**1-5**], now presenting to SICU with hypotension s/p
pleuroscopy/pleural bx/tunneled CT/talc pleurodesis for right malignant
effusion (1.5L). Procedure was performed for increasing dyspnea/cough
and O2 requirements. Effusion has been drained multiple times in
past. Pt has been hypotensive to 70s/40s in PACU desipte 3L IVF
boluses. Recieved 350 mcg fentanyl in procedure and oxycodone, toradol
in PACU. Unremarkable CT drainage volume in PACU.
Also of note pt has had self-reported poor PO fluid intake and N/V on
evening prior to procedure.
Chief complaint:
Hypotension, dyspnea
PMHx:
Asthma, Osteoporosis, GERD, h/o multiple PE [**2-2**] on lovenox preop, [**2130**]
DCIS left breast s/p lumpectomy, XRT, adjuvant. Stage IV ovarian
cancer status post TAH BSO, primary [**Year (4 digits) 9818**] carcinoma
Current medications:
1. IV access: Indwelling port (Portacath), heparin dependent Order
date: [**7-30**] @ 1717 17. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
Order date: [**7-30**] @ 1744
2. IV access: Peripheral line Order date: [**7-30**] @ 1717 18.
HYDROmorphone (Dilaudid) 0.125 mg IV Q3H:PRN breakthrough pain Order
date: [**7-30**] @ 1744
3. IV access: Indwelling port (Portacath), heparin dependent Location:
Left Order date: [**7-30**] @ 1717 19. Heparin Flush (10 units/ml) 5 mL IV
PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL
Normal Saline followed by Heparin as above daily and PRN per lumen.
Order date: [**7-30**] @ 1717
4. 1000 mL NS
Continuous at 100 ml/hr for 1000 ml Start: After the current bolus is
done Order date: [**7-30**] @ 1717 20. Heparin Flush (100 units/ml) 5 mL IV
PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing
port, instill Heparin as above per lumen. Order date: [**7-30**] @ 1717
5. 1000 mL NS Bolus 1000 ml Over 30 mins Order date: [**7-30**] @ 1717 21.
Heparin 5000 UNIT SC TID Order date: [**7-30**] @ 1717
6. 1000 mL NS Bolus 1000 ml Over 30 mins Order date: [**7-30**] @ 1717 22.
Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL
Normal Saline followed by Heparin as above daily and PRN per lumen.
Order date: [**7-30**] @ 1717
7. 1000 mL NS
Continuous at 100 ml/hr for 1000 ml
Change to peripheral lock when taking POs Order date: [**7-30**] @ 1852 23.
Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing
port, instill Heparin as above per lumen. Order date: [**7-30**] @ 1717
8. 500 mL NS Bolus 500 ml Over 30 mins Order date: [**7-30**] @ 1717 24.
Insulin SC (per Insulin Flowsheet)
Sliding Scale Order date: [**7-30**] @ 1718
9. 500 mL NS Bolus 500 ml Over 30 mins Order date: [**7-30**] @ 1717 25.
Ketorolac 15 mg IV ONCE Duration: 1 Doses Order date: [**7-30**] @ 1717
10. Acetaminophen 500 mg PO Q6H:PRN Pain
Please give no more than 2gm per day Order date: [**7-30**] @ 1717 26.
Magnesium Sulfate IV Sliding Scale Order date: [**7-30**] @ 1718
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB Order date: [**7-30**] @
1717 27. Pantoprazole 40 mg PO Q24H Order date: [**7-30**] @ 1717
12. Benzonatate 100 mg PO TID Order date: [**7-30**] @ 1717 28. Potassium
Chloride IV Sliding Scale Order date: [**7-30**] @ 1718
13. Calcium Carbonate 500 mg PO BID Order date: [**7-30**] @ 1717 29.
Potassium Phosphate IV Sliding Scale
Infuse over 6 hours Order date: [**7-30**] @ 1718
14. Calcium Gluconate IV Sliding Scale Order date: [**7-30**] @ 1718 30.
Prochlorperazine 10 mg IV Q6H:PRN nausea Order date: [**7-30**] @ 1717
15. Cepacol (Menthol) 1 LOZ PO PRN cough Order date: [**7-30**] @ 1717 31.
Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.
Order date: [**7-30**] @ 1717
16. Docusate Sodium 100 mg PO BID:PRN Constipation Order date: [**7-30**] @
1717
24 Hour Events:
ICU consent obtained. Pt gently hydrated with 100cc/h NS and
encouraged po clears intake. BPs near baseline 90s/60s but borderline
UOPs ~30/h and D/W thoracic team
Post operative day:
0
Allergies:
No Known Drug Allergies
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Flowsheet Data as of [**2139-7-30**] 08:56 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since [**41**] a.m.
Tmax: 35.8
C (96.5
T current: 35.8
C (96.5
HR: 119 (104 - 119) bpm
BP: 91/62(68) {84/49(57) - 105/67(73)} mmHg
RR: 25 (20 - 31) insp/min
SPO2: 90%
Heart rhythm: ST (Sinus Tachycardia)
Total In:
3,420 mL
PO:
120 mL
Tube feeding:
IV Fluid:
300 mL
Blood products:
Total out:
0 mL
2,110 mL
Urine:
230 mL
NG:
Stool:
Drains:
Balance:
0 mL
1,310 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SPO2: 90%
ABG: ////
Physical Examination
General Appearance: No acute distress, Cachectic, Appears older than
stated age.
HEENT: PERRL, EOMI, MMs dry
Cardiovascular: (Rhythm: Regular), No appreciable M/R/G.
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA
bilateral : Mild coarse BS in right fields.)
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
Left Extremities: (Edema: Absent), (Temperature: Warm)
Right Extremities: (Edema: Absent), (Temperature: Warm)
Skin: Right CT to clean dressing
Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
Moves all extremities, Alert, pleasant and conversational
Labs / Radiology
134
11.7
105
0.8
23
5.2
19
108
136
35.7
5.3
[image002.jpg]
Other labs: PT / PTT / INR://1.2
Fluid Analysis / Other Labs: Pleural fluid WBC 517, RBC [**Numeric Identifier 9819**], PMN 57,
Lymph 26
Imaging: [**2139-7-30**] CXR: R CT at R apex, distal pleurx at R CPA. Improving
R effusion, L atelectasis, no PTX.
Microbiology: [**2139-7-30**] Pleural fluid GS no organisms, 3+ PMNs.
ECG: ST/105 on admission. No appearance of ST changes.
Assessment and Plan
HYPOTENSION (NOT SHOCK)
Assessment and Plan: 54F with advanced metastatic ovarian adenoCA with
hypotension s/p pleuroscopy procedures, resolving with hydration.
Likely hypovolemia-related. BPs near baseline and patient mentating
well at this time.
Neurologic: Follow mental status. Dilaudid/percocet po and IV for
breakthrough pain. Tylenol prn.
Cardiovascular: Monitor BPs. No pressors given thus far. IP contact[**Name (NI) **]
re: fluid restrictions/goals.
Pulmonary: Supplental O2, follow sats. CT to pleurivac, Albuterol nebs
prn for asthma. Repeat CXR. Follow CT outputs. Discuss
anticoagulation postop plan with Thoracic team, was on lovenox preop.
Gastrointestinal / Abdomen: Regular diet, compazine prn
Nutrition: Regular diet, Clear liquids, Advance diet as tolerated ,
Encourage PO, supplementation as appropriate. Consider albumin if
large proteinaceous effusion drainage / continued clinical hypovolemia.
Renal: Foley, Borderline UOPs, follow with volume resuscitation.
Hematology: Postop CBC, monitor hemorrhagic O/P from chest tube.
Endocrine: RISS
Infectious Disease: Check cultures, Follow effusion
studies--protein/glucose/LDH pending.
Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest
tube - pleural , L Portacath, PIV, tunneled R chest tube to pleurivac,
R pleurix catheter capped
Wounds: Chest Tube dressing in situ
Imaging: AM CXR
Fluids: NS, 100 cc/h
Consults: CT surgery, Interventional Pulmonary
Billing Diagnosis: Post-op hypotension
ICU Care
Nutrition:
Glycemic Control:
Lines:
Indwelling Port (PortaCath) - [**2139-7-30**] 05:00 PM
Prophylaxis:
DVT:
Stress ulcer:
VAP bundle:
Comments:
Communication: Comments:
Code status:
Disposition:
Total time spent:
|
[
"458.29",
"276.52"
] |
icd9cm
|
[
[
[
204,
214
]
],
[
[
7136,
7154
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
762, 1026
|
1050, 6536
|
6601, 8797
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
90,539
| 154,506
|
40990
|
Discharge summary
|
Report
|
Admission Date: [**2198-5-21**] Discharge Date: [**2198-5-26**]
Date of Birth: [**2160-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Palpitations and increasing fatigue
Major Surgical or Invasive Procedure:
[**2198-5-21**] Mitral valve repair (36mm CG future ring)
History of Present Illness:
37 year old gentleman, known to our service (please see H&P from
[**6-20**]) who is originally from [**Country 2784**] and was found to have a
heart murmur on exam 6 years ago. He was found to have mitral
regurgitation which was subsequently followed by serial
echocardiograms by multiple physicians as he moves frequently.
His echocardiogram last year showed moderate to severe mitral
valve prolapse with 3+ mitral regurgitation. A cardiac MRI was
obtained which showed bileaflet mitral valve prolapse with
moderate mitral regurgitation. The LVEF was mildly depressed at
48%. The effective forward LVEF was moderately depressed at 35%.
He is symptomatic with mainly fatigue however he does note
occasional palpitations.
When we saw him in [**2196**] surgery was recommended but cardiology
decided to postpone surgery and treat his ventricular ectopy in
hopes to improve his LV systolic function and dimensions. Holter
monitor study in [**2197-12-10**] still showed significant amount of
ectopy, and he has persistent symptoms due to this, albeit less
frequent. Recent Echo on [**2198-4-24**] revealed moderate/severe mitral
valve bileaflet prolapse involving all anterior segment and all
posterior scallops with moderate to severe (3+) mitral
regurgitation.
Past Medical History:
Mitral valve regurgitation s/p mitral valve repair
Past medical history:
- Hypertension
- Non-sustained ventricular tachycardia
- Anxiety
- ? syncopal event [**5-21**]
- + PPD [**2181**], negative CXR
Social History:
Race: Caucasian
Last Dental Exam: 6 months ago
Lives with: College roommate
Contact: [**Name (NI) **] [**Last Name (NamePattern1) 89423**] Phone # [**Telephone/Fax (1) 89424**]
Occupation: He is a CEO of a series of call centers called the
VTW Company. This involves a lot of both national and
international travel.
Cigarettes: Smoked no [X] yes [] last cigarette _____ Hx:
Other Tobacco use: None
ETOH: < 1 drink/week [] [**1-16**] drinks/week [X] >8 drinks/week []
Illicit drug use-none
Family History:
N0n-contrib for Premature coronary artery disease. Two older
brothers, one with hypertension, the other with no known cardiac
disease. His mother has asthma and his father died of cancer.
There is no family history of sudden cardiac death.
Physical Exam:
Pulse: 80 Resp: 16 O2 sat: 100%
B/P Left: 114/80
Height: 5'[**96**]" Weight: 225
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade 236 late systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2198-5-21**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is mild regional left
ventricular systolic dysfunction with basal to mid inferior and
inferoseptal hypokinesis. There is mild to moderate global left
ventricular hypokinesis. Overall left ventricular systolic
function is moderately depressed (LVEF= 35-40 %). 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 stenosis or aortic
regurgitation. There is moderate/severe posterior leaflet mitral
valve prolapse, worst at P2. The entire anterior leaflet
prolapses as well, but to a lesser degree than the posterior
leaflet. An eccentric, anteriorly directed jet of moderate to
severe (3+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time
of surgery.
POST-BYPASS: The patient is AV paced. The patient is on an
epinephrine infusion. Left ventricular function remains
depressed, with an LVEF = 35%. Lateral wall motion remains
unchanged from prebypass. Right ventricular function appears
mildly depressed. There is a mitral annuloplasty ring in place.
Trace mitral regurgitation is seen. There is a mean gradient of
4mmHg across the mitral valve at a cardiac output of 5.6 L/min.
There is no systolic anterior motion of the mitral valve and no
increased LVOT gradient. The aorta is intact post-decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] [**Known lastname 89425**] was a same day admit and brought directly to
the operating room where he underwent a mitral valve repair.
Please see operative note for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later this day he was weaned from sedation,
awoke neurologically intact and extubated. Post-operatively his
rhythm was junctional/brady requiring pacing. Nodal agents were
held. He subsequently developed atrial fibrillation with slow
ventricular response. He remained hemodynamically stable. He
was started on Sotalol and beta-blocker was held. Rhythm
converted to Sinus. He was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD #5 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
on POD#5 in good condition with appropriate follow up
instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Lisinopril 30 mg PO DAILY
2. Magnesium Oxide 400 mg PO DAILY
3. Sotalol 80 mg PO BID
Theragran-M premier 1 tab daily
Discharge Medications:
1. Lisinopril 30 mg PO DAILY
hold for SBP<95 and notify HO
RX *lisinopril 20 mg once a day Disp #*60 Tablet Refills:*1
2. Sotalol 80 mg PO BID
RX *sotalol 80 mg once a day Disp #*30 Tablet Refills:*1
3. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
4. Aspirin EC 81 mg PO DAILY Start: POD #1
RX *aspirin 81 mg once a day Disp #*30 Tablet Refills:*1
5. Furosemide 10 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg once a day Disp #*5 Tablet Refills:*0
6. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *hydromorphone 2 mg every four (4) hours Disp #*60 Tablet
Refills:*0
7. Ibuprofen 400 mg PO Q8H:PRN pain
RX *ibuprofen 200 mg every six (6) hours as needed Disp #*120
Tablet Refills:*1
8. Potassium Chloride 10 mEq PO DAILY Duration: 5 Days
RX *potassium chloride 10 mEq once a day Disp #*5 Tablet
Refills:*0
9. Magnesium Oxide 400 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Mitral valve regurgitation s/p mitral valve repair
Past medical history:
- Hypertension
- Non-sustained ventricular tachycardia
- Anxiety
- ? syncopal event [**5-21**]
- + PPD [**2181**], negative CXR
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Edema- none
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
Wound check at Cardiac Surgery office: [**2198-6-5**] 10:00 in the
[**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Surgeon: Dr. [**Last Name (STitle) **] [**2198-6-28**] at 1:00pm in the [**Hospital **] medical office
building, [**Doctor First Name **], [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2198-6-15**] at 10:20a
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-15**] 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:[**2198-6-5**]
|
[
"424.0",
"401.9",
"300.00",
"427.1"
] |
icd9cm
|
[
[
[
369,
373
]
],
[
[
1791,
1802
]
],
[
[
1846,
1852
]
],
[
[
7796,
7818
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7610, 7671
|
5242, 6461
|
346, 405
|
7916, 8077
|
3407, 5219
|
9000, 9829
|
2455, 2696
|
6727, 7587
|
7692, 7743
|
6487, 6704
|
8101, 8977
|
2711, 3388
|
271, 308
|
433, 1694
|
7765, 7895
|
1935, 2439
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,359
| 141,463
|
39430
|
Discharge summary
|
Report
|
Admission Date: [**2172-9-20**] Discharge Date: [**2172-9-23**]
Date of Birth: [**2090-11-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Doctor First Name 2080**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD [**2172-9-21**]
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 87132**] is an 81 year old man with a history of CAD
s/p CABG, Afib on coumadin, s/p CVA [**2171**], s/p PPM, and DM2 who
presents with anginal chest pain with exertion in the setting of
multiple melanotic stools. Patient lives in [**State 760**] and was
visiting his daughter in [**Name (NI) 86**] the week. During the last few
days he had several black stools. He also started becoming more
fatigued with exertion and developed right sided chest pressure
with activity that resolved at rest. He presented to urgent
care today who recommended ED evaluation.
.
In ED VS were T 98.4 HR 78 BP 131/62 RR 18 SpO2 99%. Patient
denied any symptoms on arrival. EKG showed diffuse TWI in II,
III, aVF, V1-6, and ST depressions II, V4-6. Labs were notable
for Hct 19.5, WBC 12, Trop 0.05. Melanotic guaiac positive
stools on rectal exam. NG lavage showed a few coffee grounds
concerning for UGIB. GI team was consulted. He was transfused 2
units FFP and 2 units pRBC prior to transfer to the MICU.
.
On arrival to the MICU, he again denies any active chest pain.
He reports some right sided chest pressure and fatigue with
exertion which resolves with rest. He denies any recent
lightheadedness, shortness of breath, palpitations, abdominal
pain, diarrhea, vomiting, nausea, fever, chills. He denies use
of any etoh, NSAIDS, steroids. He reports his last colonoscopy
was over 10 years ago and was negative. He denies any history
of upper endoscopy or known GI ulcers. He later admits to
having a GI bleed during an admission in the [**2152**] for cardiac
angioplasty in the setting of anticoagulation or high dose
aspirin.
.
Review of systems:
(+) Per HPI, nocturia, constipation
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied nausea,
vomiting, diarrhea, or abdominal pain. No recent change in
bladder habits. No dysuria.
Social History:
Social History: He lives in [**State 760**] and is currently visiting
a daughter in [**Name (NI) 86**] (who is the director of Atrius). He denies
tobacco, EtOH, drugs.
Family History:
non-contributory
Physical Exam:
Physical Exam: at time of discharge
VS: BP 145/64, HR 85, RR 20, O2 95% RA
General: Sleeping but arousable, appears well, no distress
HEENT: moist mucosa, oropharynx clear
Cards: irregularly irregular, no murmur, 2+ pitting LE symmetric
peripheral edema, no carotid bruit appreciated
Pulm: clear bilaterally, no w/r/c
Abd: soft, nontender, nondistended
Extremities: warm, lipoma on posterior neck, LE skin changes
consistent with chronic venous stasis, 2 healed ulcers on left
shin
Neuro/Psych: hard of hearing. CN II-XII intact. Strength 5/5
upper and lower extremites b/l. Gait stable.
Pertinent Results:
On admission:
[**2172-9-20**] 01:40PM WBC-12.3* RBC-2.53* HGB-6.3* HCT-19.8*
MCV-78* MCH-24.7* MCHC-31.6 RDW-20.4*
[**2172-9-20**] 01:40PM PT-35.5* PTT-30.6 INR(PT)-3.6*
[**2172-9-20**] 01:40PM GLUCOSE-330* UREA N-55* CREAT-1.2 SODIUM-142
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-28 ANION GAP-16
At discharge ([**9-23**])
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8.5 4.08* 10.6* 33.2* 81* 26.0* 32.0 17.7* 186
Glucose UreaN Creat Na K Cl HCO3 AnGap
164 22* 1.0 140 3.2* 103 29 11
EKG (no baseline comparision) EKG showed diffuse TWI in II, III,
aVF, V1-6, and ST depressions II, V4-6.
ENDOSCOPY ([**9-21**])
Findings:
Esophagus: Normal esophagus.
Stomach:
Mucosa: Small erosions of the mucosa were noted in the antrum.
Excavated Lesions A single 5 mm ulcer with visible vessel was
found in the antrum. There were stigmata of recent bleeding.
Three endoclips were successfully applied to the ulcer with
visible vessel at stomach antrum for the purpose of hemostasis.
Duodenum: Normal duodenum.
Impression: Ulcer in the antrum (endoclip)
Small erosions in the antrum
Otherwise normal EGD to third part of the duodenum
Recommendations: Please f/u hct closely and transfusion with
target hct>30, pt at high risk for rebleed
H.pylori serology: positive
Brief Hospital Course:
An 81 year-old man with HTN, CAD, DM and atrial fibrillation on
coumadin h/o pontine CVA s/p PPM in [**2171**] presented fatigue,
chest tightness, in setting of several dark, melanotic stools
and supratherapeutic INR.
# GI Bleed/acute blood loss anemia: Secondary to bleeding antral
ulcer in setting of supratherapetic INR (3.6), + H.pylori
serology. On presention HCT: 19.6. During hospitalization
received total of 7units pRBC, 6units FFP, 5mg of vit K PO. Both
coumadin and ASA held. PPI gtt started, transition to IV.
Endoscopy performed on [**9-21**] and antral ulcer clipped. Biopsies
sent and H. pylori serologies sent. After clipping, serial HCTs
obtain, Hct stabilized with no further transfusion requirement.
Extensive discussion regarding patients ongoing management of
his CAD/afib while weighing GU bleeding risk. His outpatient PCP
was [**Name (NI) 653**] and agreed to manage issue with plan to hold
coumdin until follow-up. Prior to discharge, GI recommended
repeat endoscopy in 8weeks, oral PPI treatment [**Hospital1 **] until repeat
endoscopy, and re-initiation of ASA 81mg, Patient to obtain GI
doctor on return to NJ.
.
#) H.pylori infection. H.pylori sent post endoscopy which
returned postive. Patient already on a [**Hospital1 **] PPI. Patient started
on Amoxicillin and Clarithromycin for 14day course.
.
#) Atrial fibrillation (CHADS: 5), h/o pontine stroke s/p PPM in
[**2162**]. Rate controlled on metoprolol and amlodipine. Coumadin
held. Patient informed of importance to follow-up with PCP next
week as his risk of CVA is high and anticoagulation is necessary
in future.
.
# CAD s/p CABG. Troponin bump to 0.08 likely represented demand
ischemia in the setting of poor oxygen delivery from anemia.
Troponin downtrended with repeat 0.05. Patient without anginal
symptoms while hospitalized. Repeat EKGs without appreciable
changes.
.
# DM2, controlled with complications: Home byetta and metformin
initially held and patient maintained on an insulin sliding
scale with good effect.
Medications on Admission:
Medications at home:
Aspirin 81 mg
glucovance 500/500mg [**Hospital1 **]
Actose 30 mg
Byetta 10 mcg [**Hospital1 **]
Amlodipine 10 mg
Metoprolol 75 mg [**Hospital1 **]
Lipitor 10 mg
Klorcon 20 meq
Benicar/HCTZ 40mg/25mg
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
2 months.
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) as needed for H.pylori for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
6. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) as needed for H.pylori for 14 days.
Disp:*112 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Upper GI bleed: bleeding stomach ulcer
H. pylori infection
SECONDARY DIAGNOSIS:
CAD
Atrial Fibrillation
Hypertension
Diabetes
Discharge Condition:
Mental status: clear and coherent
Ambulates without assistance
Discharge Instructions:
You presented to [**Hospital1 18**] with symptoms of fatigue, chest tightness
in setting of several dark, melanotic stools. On arrival your
blood counts were found to be low. Gastroenterologists were
consulted and they performed an endoscopy to look for a source
of bleed. During the procedure a gastric ulcer was found an
clipped. Biopsies were taken and testing was sent to look for an
infection known as H.pylori. Testing for H.pylori returned
positive and you were started on Antibiotics and a PPI to treat
infection. Infection should resolve with 2 weeks of treatment.
During the course of your stay you received several units of
blood and your counts improved and at the time of discharge
counts were stable.
Due to the bleed, your anticoagulation was held. At time of
discharge aspirin 81mg was restarted. However, warfarin was not
restarted at time of discharge due to risk of bleeding. However
due to your high risk for stroke you will need additional
anticoagulation in the future.
Of note, you will need to follow up with GI for repeat endoscopy
in 8weeks
Changes to your medications:
Start:
Pantoprazole 40mg PO, take one pill by mouth twice daily until
your endoscopy in 8weeks
Amoxicillin, take four 250mg pills by mouth twice daily for
14days
Clarithromycin take two 250mg tablets by mouth twice daily for
14days
Stop:
Coumadin
Followup Instructions:
Will follow-up with internist office on Tuesday [**9-28**]
Will need GI follow-up in 8weeks.
Completed by:[**2172-9-24**]
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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**]
|
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[] |
icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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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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[
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|
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|
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|
7818, 7930
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|
3357, 3452
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,397
| 106,307
|
42639
|
Discharge summary
|
Report
|
Admission Date: [**2172-12-8**] Discharge Date: [**2172-12-14**]
Date of Birth: [**2095-2-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2172-12-8**]
1. Aortic valve replacement with a 27 mm [**Company 1543**] Mosaic
Ultra aortic valve bioprosthesis model number 305,
serial number [**Serial Number 92202**].
2. Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary
artery; reverse saphenous vein single graft from aorta
to the ramus intermedius coronary artery; reverse
saphenous vein single graft from the aorta to the distal
right coronary artery.
3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
77 year old male presented to ED today after found to have
abnormal stress test. On day prior to admission, he reported
left anterior chest, shoulder and upper arm
pain/pressure/numbness for 9 hours. He reports chest pain
started while he was working at his computer and persisted until
he went to bed that evening. He also says that over last few
months he has had occasional dyspnea on exertion. He saw his PCP
who recommended that he undergo an ETT. His exercise stress test
showed ST depressions in inferior and lateral leads. He was then
referred to [**Hospital1 18**] for a cardiac catheterization. He was found to
have aortic stenosis and coronary artery disease and is now
being referred to cardiac surgery for revascularization and an
aortic valve replacement.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
Mild aortic stenosis
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Anemia, vitamin B12 deficiency
Erectile Dysfunction
seborrheic keratosis
ocular hypertension
GERD
hypothyroidism
CKD
Social History:
Lives with significant other. Previously worked in
sales/marketing.
-Tobacco history: never smoked
-ETOH: occasional
-Illicit drugs: denies
Family History:
Father had pacemaker placed when 60.
Mother with hx of HTN and CVA
family hx also notable for colon cancer and diabetse
No additional family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admission Physical Exam
Pulse:58 Resp:20 O2 sat:100/RA
B/P Right:182/72 Left:201/63
Height:6'2" Weight:170 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [III/VI]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none - muscle
bulge on right mid shin (present x 60 years)
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left:transmitted murmur B/L
Pertinent Results:
[**2172-12-12**] 05:52AM BLOOD WBC-9.4 RBC-2.50* Hgb-7.8* Hct-22.4*
MCV-90 MCH-31.2 MCHC-34.9 RDW-13.2 Plt Ct-244
[**2172-12-8**] 02:30PM BLOOD WBC-12.1*# RBC-3.52* Hgb-10.6* Hct-31.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.3 Plt Ct-177
[**2172-12-9**] 02:07AM BLOOD PT-11.1 PTT-26.8 INR(PT)-1.0
[**2172-12-8**] 01:30PM BLOOD PT-12.9* PTT-32.9 INR(PT)-1.2*
[**2172-12-12**] 05:52AM BLOOD Glucose-108* UreaN-39* Creat-1.7* Na-132*
K-5.1 Cl-100 HCO3-27 AnGap-10
[**2172-12-8**] 02:30PM BLOOD UreaN-28* Creat-1.3* Na-139 K-4.9 Cl-110*
HCO3-24
[**2172-12-14**] 04:32AM BLOOD Hct-27.2*
[**2172-12-13**] 04:57AM BLOOD WBC-7.7 RBC-2.39* Hgb-7.4* Hct-21.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.4 Plt Ct-269
[**2172-12-14**] 04:32AM BLOOD UreaN-36* Creat-1.6* Na-136 K-4.8 Cl-102
[**2172-12-13**] 04:57AM BLOOD Glucose-91 UreaN-38* Creat-1.6* Na-135
K-4.5 Cl-103 HCO3-27 AnGap-10
[**2172-12-14**] 04:32AM BLOOD PT-24.8* INR(PT)-2.4*
[**2172-12-13**] 04:57AM BLOOD PT-11.1 INR(PT)-1.0
[**2172-12-9**] 02:07AM BLOOD PT-11.1 PTT-26.8 INR(PT)-1.0
[**2172-12-8**] 02:30PM BLOOD PT-12.6* PTT-33.0 INR(PT)-1.2*
Echocardiographic: [**2172-12-10**]
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Left Ventricle - Stroke Volume: 77 ml/beat
Left Ventricle - Cardiac Output: 4.67 L/min
Left Ventricle - Cardiac Index: 2.67 >= 2.0 L/min/M2
Left Ventricle - Peak Resting LVOT gradient: 7 mm Hg <= 10 mm
Hg
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *17 < 15
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *3.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *44 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 19 mm Hg
Aortic Valve - LVOT VTI: 27
Aortic Valve - LVOT diam: 1.9 cm
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 1.09
Mitral Valve - E Wave deceleration time: *291 ms 140-250 ms
TR Gradient (+ RA = PASP): 25 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2172-12-1**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' >15,
suggesting PCWP>18mmHg. 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. No 2D or Doppler evidence of distal arch coarctation.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
leaflets move normally. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR. Prolonged (>250ms) transmitral E-wave decel time.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis leaflets appear to move normally. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Increased left ventricular filling pressure.
Well-seated, normally functioning aortic valve bioprosthesis
with borderline-elevated transaortic valvular mean pressure
gradients (19 mmHg). Normal pulmonary artery systolic pressure.
Compared with the prior study (images reviewed) of [**2172-12-1**], a
bioprosthetic aortic valve is now present. The pulmonary artery
systolic pressure has normalized.
CXR: IMPRESSION: [**2172-12-13**] Right apical pneumothorax is tiny and
unchanged. Small bilateral pleural effusions are stable and
bibasilar atelectasis has improved. Heart size is normal. Right
jugular line ends low in the SVC. No pulmonary edema.
Brief Hospital Course:
On [**2172-12-8**] Mr.[**Known lastname 23903**] was taken to the operating room and
underwent Aortic valve replacement(#27 mm [**Company 1543**] Mosaic Ultra
aortic valve bioprosthesis)/Coronary artery bypass grafting x3
(left internal mammary artery to left anterior descending
coronary artery; reverse saphenous vein single graft from aorta
to the ramus intermedius coronary artery; reverse saphenous vein
single graft from the aorta to the distal right coronary
artery) with Dr. [**Last Name (STitle) 914**]. Please see operative report for
further details.CARDIOPULMONARY BYPASS TIME: 144
minutes.CROSSCLAMP TIME: 123 minutes. He tolerated the
procedure well and transferred to the CVICU intubated and
sedated. He awoke neurologically intact and was extubated. He
weaned off pressor support and initially Beta-blocker was held
due to nodal rhythm. Statin/Aspirin and diuresis were
initiatited. All lines and drains were discontinued per
protocol. POD#1 he was transferred to the step down unit for
further monitoring. Physical Therapy was consulted for
evaluation of strength and mobility. POD#3 he went into rate
controlled atrial fibrillation/flutter. He was placed on
Beta-blocker and oral Amiodarone. Anticoagulation with Coumadin
was initiated. His INR went from 1.0->2.4->3.2 and he was given
0 mg Coumadin on [**2172-12-14**] with repeat INR on [**2172-12-15**] scheduled.
INR goal 2.0-3.0 - [**Hospital 2274**] [**Hospital3 271**] to provide
further Coumadin instructions. On [**2172-12-13**] he was transfused
with 2 units of PRBC for HCT of 21.8 which increased to Hct of
27.2. He was given Folic acid, iron and Vitamin C for post op
anemia. He continue to progress and on POD 6 he was cleared for
discharge to home with VNA services. All follow up appintments
were advised.
Medications on Admission:
Lisinopril 20 mg daily
Levothyroxine 50mcg po daily
Omeprazole 20mg po daily
Vitamin B12 1000mcg po daily
HCTZ 25mg po daily (sometimes halved dose or did not take)
Fish oil
Red yeast rice extract
Discharge Medications:
1. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. levothyroxine 50 mcg 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).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN/TEMP.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200 [**Hospital1 **] x 2 weeks then 200 mg daily x 1 month or seen by
cardiologist.
Disp:*60 Tablet(s)* Refills:*0*
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 2 months.
Disp:*60 Tablet(s)* Refills:*0*
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 months.
Disp:*60 Tablet(s)* Refills:*0*
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed for goal INR 2.0-3.0 - Take NO Coumadin on [**2172-12-14**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Severe critical aortic stenosis/Severe 3-vessel coronary
disease.
s/p AVR/CABG
Atrial Flutter
Secondary:
Dyslipidemia
Hypertension
Mild aortic stenosis
Anemia, vitamin B12 deficiency
Erectile Dysfunction
seborrheic keratosis
ocular hypertension
GERD
hypothyroidism
CKD (baseline Creat 1.3-1.5)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call 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) 914**] - the office will call you with an
appointment for 1 month
[**Location (un) 2274**] office to call with appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2920**] or Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**University/College **] [**Location (un) 2274**] Center for the next [**1-16**]
weeks
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2172-12-17**] at 10:00
in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 17528**],[**First Name3 (LF) 17529**] [**Telephone/Fax (1) 17530**] in [**3-18**] 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**
Coumadin for Atrial Flutter: INR Goal 2.0-3.0
[**Hospital 2274**] [**Hospital3 **] to call with further Coumadin
instructions
Next INR draw Tuesday [**2172-12-15**]
Phone: [**Telephone/Fax (1) 17530**]
Fax: [**Telephone/Fax (1) 6808**]
Completed by:[**2172-12-14**]
|
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"702.19",
"365.04",
"530.81",
"244.9",
"585.9"
] |
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[
[
[
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397
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[
[
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593
]
],
[
[
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661
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[
[
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]
],
[
[
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]
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] |
12227, 12276
|
8160, 9955
|
355, 908
|
12615, 12841
|
3255, 8137
|
13765, 14988
|
2241, 2487
|
10203, 12204
|
12297, 12594
|
9981, 10180
|
12865, 13742
|
2502, 3236
|
1818, 1914
|
304, 317
|
936, 1708
|
1945, 2064
|
1730, 1798
|
2080, 2225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,700
| 130,026
|
41672
|
Discharge summary
|
Report
|
Admission Date: [**2103-9-18**] Discharge Date: [**2103-9-21**]
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
SDH
Major Surgical or Invasive Procedure:
.
History of Present Illness:
This is an 89 year man with with a history of a subdural
hematoma who underwent a craniotomy with evacuation of bilateral
SDH with drains on [**2103-9-17**] at [**Hospital **] Hospital.
Originally Mr. [**Known lastname 46825**] [**Last Name (Titles) 50921**] and fell on [**2103-7-23**] while
gardening. This seemed to be related to his chronic right foot
drop. There was no LOC. He immediately ambulated. His family
noticed an altered mental status; however, he did not seek
medical attention until [**2103-8-2**] when he was found to have
bilateral SDH's on CT and MR [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]. He went on vacation for
a week, had increased headaches and returned to OSH for CT/MR of
the head which revealed no significant SDH change, but
evacuation was required and performed on [**9-17**] with placement of
bilateral subdural drains.
Per the outside records, he had postop abdominal pain relieved
in decubitus position. He became confused, diaphoretic,
hypertensive was intubated and sedated in the early am of POD
#1. Head CT showed increase in R subdural collection no change
in the left. Abdominal CT showed 18mm infrarenal abdominal
aortic dissection. He had SBPs in 200s, became bradycardic to
50s despite IV hydralazine. He was then transfered to the [**Hospital1 18**].
Past Medical History:
Hypertension (usually runs 140/80 per pt and family)
EF of 50% ([**2103**])
Left BBB
Nephrolithiasis
Osteoarthritis
BPH Chronic LBP
PSH:
B/l carotid endarterectomy (Dr. [**Last Name (STitle) 8521**], [**First Name3 (LF) **])
cataract surgery
utereral stone removal/cystoscopy
Social History:
lives alone and is independent, mobile, Tobacco: 50+ pack year
hx (quit 20 years ago), EtOH: family endorses at least
6oz/scotch/day, no known illicits
Family History:
NC
Physical Exam:
On Admission:
The patient was intubated.
T:97 BP:140/52 HR: 66 R 7 O2Sats: 97%
Gen: intubated
HEENT: atraumatic, normocephalic
Pupils: 2-1.5mm bilaterally
Neuro:
Patient is intubated
EO to noxious stimuli
follows simple commands on R UE (shows thumbs up)
wiggles toes bilaterally
w/d LUE to noxious
Bilateral subdural drains in place
L drain 100cc since admission
R drain minimal out put since admission
Pertinent Results:
[**2103-9-18**] 01:29PM PT-13.1 PTT-26.5 INR(PT)-1.1
[**2103-9-18**] 01:29PM PLT COUNT-151
[**2103-9-18**] 01:29PM NEUTS-92.5* LYMPHS-3.9* MONOS-3.1 EOS-0.4
BASOS-0.1
[**2103-9-18**] 01:29PM WBC-14.8* RBC-4.17* HGB-14.1 HCT-38.7* MCV-93
MCH-33.9* MCHC-36.5* RDW-13.9
[**2103-9-18**] 01:29PM CALCIUM-8.4 PHOSPHATE-2.9 MAGNESIUM-1.7
[**2103-9-18**] 01:29PM CK-MB-3 cTropnT-<0.01
[**2103-9-18**] 01:29PM CK(CPK)-21*
[**2103-9-18**] 01:29PM estGFR-Using this
[**2103-9-18**] 01:29PM GLUCOSE-175* UREA N-18 CREAT-0.4* SODIUM-140
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
ECHO [**2103-9-18**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is at
least 15 mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is probably mild global left ventricular hypokinesis (LVEF = 50
%) (the degree of bradycardia and conduction delay associated LV
dysynchrony make an accurate estimate of LVEF more difficult).
No masses or thrombi are seen in the left ventricle. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). 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
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. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
CXR [**2103-9-18**]
1. Progression of left perihilar and lower hemithorax opacities
may represent aspiration or consolidation.
2. Esophageal catheter with side port in the distal esophagus
and would need to be advanced 7 cm to ensure most proximal side
port within the stomach.
CT head [**2103-9-19**]
1. Marked reduction in size of a right subdural hematoma, with a
drain in
place, and some residual blood products, layering dependently.
2. Bifrontal pneumocephalus, increased on the left, following
removal of this drain.
3. No new focus of hemorrhage.
4. Partial sinus opacification, particular of the sphenoid air
cells, which may relate to intubation and supine positioning.
Brief Hospital Course:
Mr. [**Known lastname 46825**] was admitted to [**Hospital1 18**] TSICU. On arrival,
intubated, he was sedated with bradycardia to the 30s requiring
x1 atropine with good response. A right axillary arterial line
placed. Neurosurgery evaluated the patient and removed the L JP
drain. The right drain was less functional and was milked with
improved output.
A chest X-rays showed progression of left perihilar and lower
hemithorax opacities may represent aspiration or consolidation.
An ECHO was done showed
EF 50% (the degree of bradycardia and conduction delay
associated LV dysynchrony make an accurate estimate of LVEF more
difficult).
He was on a nitro drip at 1mcg/kg/min with SBP goal < 140. EPS
was consulted.
They agreed with the plan for Hydralazine PRN for BP control
and approved restarting home dose of lisinopril and amlodipine
when tolerating po's. He was extubated overnight.
Vascular surgery consulted and they felt that this abdominal
pain at OSH was likely not due to his 18mm dissection. There are
no plan for intervention at this point.
He was trasnfered to the Neurosurgery service under the care of
Dr. [**Last Name (STitle) 739**]. He was getting Dilantin 100mg TID with 1000mg
initial load. CT head on [**9-19**] showed improvement in right SDH
but the drain was left in place for further evacuation in the am
and this was removed in the pm. Orders for trasnfer to SDU were
written.
CT head in the am of [**2103-9-20**] showed...He had expiratory whezzing
and nebulizer treatment was started. SQH was started for DVT
prophylaxis. Foley cathter was discontinued. PT was consulted.
They recommended rehab. Now DOD he is set for d/c to rehab and
will f/u accordingly.
Medications on Admission:
Lisinopril 20mg qd
sertraline 50mg qd
atenolol 25 mg qd
doxazosin 4 mg qd
diclofenac 25 mg qd
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever: max 4g/24 hrs.
4. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): hold sbp<100.
Disp:*60 Tablet(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day.
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Bilateral SDH
Brain Compression
AAA
Bradycardia
Hypertension
COPD
Back pain
PVC
Ventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to see your Neurosurgeon at [**Location (un) **] on [**9-26**] for
removal of your staples. You may also have these removed at
rehab
??????Please call your Neurosurgeon at [**Location (un) **] for a one month follow
up appointment.
- Please follow up with your PCP as soon as possible
regarding you Abdominal Aortic Aneurysm
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2103-9-21**]
|
[
"432.1",
"441.02",
"427.89",
"401.9",
"426.3",
"715.90",
"600.00",
"338.29",
"V15.82",
"348.4",
"491.20",
"724.2",
"427.69",
"427.1"
] |
icd9cm
|
[
[
[
216,
218
],
[
8044,
8056
]
],
[
[
1446,
1483
],
[
8076,
8078
]
],
[
[
1514,
1524
],
[
5139,
5149
],
[
8080,
8090
]
],
[
[
1632,
1643
]
],
[
[
1708,
1715
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],
[
[
1733,
1746
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],
[
[
1748,
1750
]
],
[
[
1752,
1762
]
],
[
[
1975,
2010
]
],
[
[
8058,
8074
]
],
[
[
8105,
8108
]
],
[
[
8110,
8118
]
],
[
[
8120,
8122
]
],
[
[
8124,
8146
]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[
5108,
5116
]
]
] |
7909, 8023
|
5023, 6719
|
259, 262
|
8171, 8171
|
2549, 5000
|
10195, 10707
|
2095, 2099
|
6864, 7886
|
8044, 8150
|
6745, 6841
|
8354, 10172
|
2114, 2114
|
216, 221
|
290, 1610
|
2128, 2530
|
8186, 8330
|
1632, 1910
|
1926, 2079
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,790
| 128,026
|
429273
|
Physician
|
Physician Surgical Admission Note
|
Chief Complaint: Recurrent episodes of headaches,cranial nerve
dysfunction, and dysesthesias
HPI:
[**Known firstname 549**] 19 yo F with Hx of [**Doctor Last Name 4210**] Chiari I malformation s/p elective
decompressive posterior craniectomy. Pt initially evaluated for
development of a patch of pain (hyperpathia) and numbness in
approximately the left T5 or T6 dermatome region posteriorly, 1 mo ago.
Further involvement of V2 and V3 trigeminal branches was present,
mainly in the onset of bifrontal and throbbing longstanding headaches.
MRI finally confirmed AC 1 malformation, tonsils 8 mm below F magnum
and syringomyelia with syrinx cavities at T5, T7 and T8-T11 levels.
Based on recurrent episodes of headaches,cranial nerve dysfunction, and
dysesthesias, pt underwent elective repair.
Post operative day:
POD#0 - Decompressive suboccipital craniectomy for A.Chiari
malformation Type I
Allergies:
Macrodantin (Oral) (Nitrofurantoin Macrocrystal)
Rash;
Last dose of Antibiotics:
Infusions:
Other ICU medications:
Other medications:
Past medical history:
Family / Social history:
s/p tonsillectomy, bilateral reimplanted ureters forurinary reflux, hxo
tick bites with negative lyme serology ([**2119-10-11**] at [**Hospital1 19**]).
Social: College student. Originally from CT.
Flowsheet Data as of [**2120-1-10**] 05:20 PM
Vital signs
Hemodynamic monitoring
Fluid balance
24 hours
Since 12 AM
Tmax: 36.7
C (98.1
Tcurrent: 36.7
C (98.1
HR: 80 (80 - 92) bpm
BP: 112/67(86) {112/67(86) - 118/71(92)} mmHg
RR: 8 (7 - 8) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)
Total In:
994 mL
PO:
TF:
IVF:
94 mL
Blood products:
900 mL
Total out:
0 mL
1,420 mL
Urine:
120 mL
NG:
Stool:
Drains:
Balance:
0 mL
-426 mL
Respiratory support
O2 Delivery Device: Nasal cannula
SpO2: 99%
ABG: ////
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL, Non icteric
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): time, space and person, Movement: Purposeful,
No(t) Sedated, No(t) Paralyzed, Tone: Normal, Strengh [**5-6**]. No
dysmetria. Correct diadokokinesia.
Labs / Radiology
[image002.jpg]
Assessment and Plan
19 yo F with Hx of [**Doctor Last Name 4210**] Chiari I malformation and thoracic
syringomelia, currently s/p elective decompressive suboccipital
craniotomy.
Assessment And Plan:
Neurologic: Alert. Oriented. Refering headache. Will continue w/
dilaudid PCA, robaxan. CT tonight. Monitor SBP, goal < 160.
Cardiovascular: Hemodynamically stable. Not on pressors. Hydralazine
prn to keep SBP<160.
Pulmonary: Sat 100% with 4L NC. Will monitor.
Gastrointestinal: NPO for now, will start diet after CT scan results.
Renal: Will check chemistry and lytes.
Hematology: Stable with HCT 42 / Hgb 14.1 on OR ABG, EBL during case
only 150 cc and pt hemodynamically stable
will check repeat CBC in
AM.
Infectious Disease: Will continue with Vanc and Gent for prophylaxis.
Endocrine: no issues
Fluids: NS w/ K supps @ 85 cc/hr
Electrolytes: check chemistries, replete lytes prn
Nutrition: Currently NPO. Will advance diet as tolerated.
General:
ICU Care
Nutrition:
Glycemic Control:
Lines: Foley, 2 PIVs
Arterial Line - [**2120-1-10**] 04:00 PM
18 Gauge - [**2120-1-10**] 04:00 PM
Prophylaxis:
DVT: Heparin SQ, boots
Stress ulcer: PPI for now, d/c when taking po
VAP:
Comments:
Communication: Comments:
Code status: full
Disposition: ICU
Total time spent: 32 minutes
|
[
"336.0"
] |
icd9cm
|
[
[
[
3371,
3382
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17, 1108
|
1133, 4647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
93,560
| 135,479
|
38152
|
Discharge summary
|
Report
|
Admission Date: [**2156-8-28**] Discharge Date: [**2156-9-16**]
Date of Birth: [**2133-2-14**] Sex: F
Service: NEUROLOGY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 28082**] is a previously healthy 23-year old woman who was hit
by a drunk driver in [**State 531**] and sustained massive traumatic
brain injuries in [**2155-12-29**], s/p craniectomy, cranioplasty,
and VP shunt, who currently presents from [**Hospital3 **] with
fever. Per her parents, on [**2156-8-22**] she had a low grade
temperature of 100.0. On [**2156-8-25**] she had two episodes of
nonbloody emesis, and she started to have a dry, nonproductive
cough. Ms. [**Known lastname 85111**] parents also noted that the she had
diaphoresis and increased movements. On [**2156-8-26**] they noticed
that her left eye, which has a keratograft and tarsorrhaphy,
became red and injected, with a small amount of purulent yellow
drainage. Per her parents, she has had eye infections multiple
times but they have resolved with drops. During the last week,
her rehab reports that she has been arching her back with head
turning to the left, has had increasing tone in LUE and lower
extremities, with flexion of the right arm. These episodes last
about 30 seconds and don't appear to be in repsonse to anything.
For the past two weeks she has also had mottling on the lower
extremities, but this may be connected to their utilization of
the tilt table at rehab. At rehab on [**2156-8-28**], she had a
temperature of 101, and she may hvae had abdominal tenderness
per physician's exam (she grimaced with abdominal exam). She was
sent to the [**Hospital1 18**] ED and spiked to 102 while in triage at the
BED.
.
On arrival to the ED her initial VS were T99.4, HR 122, BP
122/71, RR 18, Sat 98%. On exam she was noted to have a
nontender abdomen, a maculopapular rash on her face (which her
parents said has been going on for weeks) and very cloudy urine.
Neurosurgery was consulted. Preliminary read of the CT scan of
her head (which was done with and without contrast at the
request of neurosurgery) did not show any clear focus of
infection in her head and was overall not significantly changed
from prior. Labs were notably primarily for a WBC of 11.9
(79%N), an LDH of 273 (no prior for comparison). Her UA was
relatively unremarkable and a CXR appeared to have no evidence
of a PNA although it was somewhat nondiagnostic.
.
Neurosurgery felt that she should be admitted to medicine for
workup of fever. They feel it is very unlikely that the cause of
her fever is her IC shunt given that she has had it for the
better part of a year, however if her workup remains negative
they could consider tapping it.
.
On the floor, she was tachycardic to 111, with a Tmax of 99.3
and BP of 133/69. She was nonverbal and therefore unable to give
history.
.
Review of systems:
(+) Per HPI
(-) Unable to assess. Parents confirm no diarrhea and no other
mental status changes. Other than HPI, she is at baseline.
Past Medical History:
1. L craniectomy and cranioplasty
2. Ventriculoperitoneal shunt
3. Traumatic Brain Injury
4. G-tube placement [**2156-1-29**]
5. Exposure keratopathy and keratitis of the L eye
6. s/p L tarsorrhaphy
7. Traumatic optic neuropathy of the left eye
8. Facial fractures, including Lefort III, b/l s/p open
reduction, internal fixation on [**2156-1-30**], type 2 nasal orbital
ethmoidal fractures.
9. L clavicle fracture s/p ORIF [**2156-2-4**]
10. Fracture of left coracoid process and inferior sternum
11. L medial malleolus fracture and left tibial plateau
fracture, s/p ORIF
12. Minimally displaced comminuted fracture of the L inferior
pubic rami and minimally displaced fracture of the superior
pubic ramus.
13. R transverse process fracture of L5
14. Vertical midling sacral fracture
15. Myositis ossificans of the R proximal quadriceps
16. B/L pulmonary contusions.
17. IVC filter placement [**2156-1-22**].
18. Hepatic laceration
19. Autonomic dysfunction
20. S/P L keratograft at Mass Eye & Ear in [**2-4**].
Social History:
Ms. [**Known lastname 28082**] was a previously healthy, fully functioning woman
prior to being hit by a drunk driver in [**Location (un) 7349**]. She is a graudate
of [**University/College 85112**] and was working as an aide for Mayor [**Last Name (un) 41364**]
prior to her accident. She is currently a resident at [**Hospital1 **]. She has a very supportive family and her parents are
quite involved in her care.
Family History:
non-contributory
Physical Exam:
Vitals: T: 99.3 BP: 133/69 P: 111 R: 20 O2: 98% on RA
General: In a vegetative state. Does not respond to voice,
sometimes withdraws from painful stimuli.
HEENT: Sclera anicteric, dried blood in oropharynx on tongue and
hard palate, along with a small amount of mcuous on tongue.
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, large
ecchymoses on lower quadrants b/l, PEG tube site looks clean,
dry, and intact, w/o erythema
GU: Foley
Ext: warm, well perfused, 2+ DP pulses b/l, mottled pattern
resembling livedo reticularis on both lower extremities.
Skin: no rashes or ulcers
Neuro: in a vegetative state, nonresponsive, nonverbal. R pupil
with sluggish response to light; unable to assess L pupil as not
visible due to opacity over left [**Doctor First Name 2281**] and pupil. Roving eye
movements horizontally. L arm flexed, with decortical
spontaneous movements of all extremities. Unable to elicit
reflexes in upper extremities, but right patellar reflex 2+, and
2-3 beats of clonus in Right foot.
Pertinent Results:
[**2156-8-28**] 04:05PM WBC-11.9* RBC-3.90* HGB-12.7 HCT-36.2 MCV-93
MCH-32.7* MCHC-35.2* RDW-14.3
[**2156-8-28**] 04:05PM NEUTS-78.9* LYMPHS-11.8* MONOS-7.1 EOS-1.4
BASOS-0.8
[**2156-8-28**] 04:05PM GLUCOSE-114* LACTATE-1.2 NA+-138 K+-4.0
CL--101 TCO2-28
[**2156-8-28**] 04:05PM ALT(SGPT)-22 AST(SGOT)-21 LD(LDH)-273* ALK
PHOS-80 TOT BILI-0.5
[**2156-8-28**] 04:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**1-30**]
[**2156-8-28**] 04:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2156-8-28**] 04:40PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
Imaging:
[**2156-8-28**] CXR:Nearly nondiagnostic study with no gross opacity
noted. If clinically feasible, consider repeat study. IVC
filter present. VP shunt visible.
.
[**2156-8-29**] CT head with and w/o contrast:
1. No significant interval change. Persistent stable
ventriculomegaly and hydrocephalus.
2. No interval change in position of the VP shunt.
3. No definite rim-enhancing fluid collection. Post-contrast
images degraded by motion
.
[**2156-8-29**] CXR: Prelim read: no pleural effusion, evidence of
pneumonia, no retrocardiac effusion, no pulmonary edema, no lung
nodules or masses, minimal retrocardiac effusion, normal cardiac
silhoutte. VP shunt visible.
.
[**2156-8-29**] CT Abdomen/Pelvis with and w/o contrast:
Normal intraperitoneal course of VP shunt with no kinking or
fracture
identified. Normal appearing adjacent fluid.
Trace of free fluid noted in both adnexae. The uterus and both
adnexa are normal with simple follicular cyst identified in
relation to both ovaries. No adenopathy. The rectum and sigmoid
colon are unremarkable.
Urinary catheter noted within the bladder.
Brief Hospital Course:
[**Known lastname 28082**] was admitted to the medicine service for fever of unknown
source. She is in a persistent vegetative state at baseline. A
full workup for fever remained negative. She was found on
[**2156-8-31**] to have a generalized seizure. Her oxygen saturation was
in the 80's at that moment and she was intubated and transferred
to the ICU. In the ICU she was placed on two AED's (dilantin and
Keppra). Her Shunt was tapped and adjusted per neurosurgery. One
of two bottles from the CSF grew out coagulase negative staph.
We believe this is a contaminate given the benign nature of the
CSF profile. Still she was started on empiric antibiotics which
were Vancomycin and Ceftazidime. This was written for a 7 day
course and completed. She was subsequently afebrile. She was
extubated on [**2156-9-2**] and observed in the ICU overnight. There
were no acute events. She was transferred to the floor for
further care.
On the floor her antiepileptic drugs were adjusted to ensure
control with oral agents. Dilantin was stopped and valproate
started. Keppra was continued. Tube feeds were increased with
two three hour pauses daily to give these medications (hold one
hour before and two hours after). She had no further seizures on
the floor. Occulopalatal myoclonus continued.
Medications on Admission:
MED Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
MED Acetaminophen 1000 mg NG Q6H:PRN fever
Do not exceed 4gm per day.
MED Adderall *NF* (Amphetamine-Dextroamphetamine) 10 mg OGT [**Hospital1 **]
please schedule for 0700, 1200
MED Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
MED Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **]
MED Dantrolene Sodium 75 mg PO TID
please give through G tube
MED Bisacodyl 10 mg PR QOD
MED Propranolol 30 mg PO/NG TID
MED Artificial Tear Ointment 1 Appl BOTH EYES HS
MED Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation
MED Calcium Carbonate 500 mg PO/NG TID
MED Vitamin D 800 UNIT PO/NG DAILY
MED Levalbuterol Neb *NF* 0.63 mg/3 mL Inhalation q2hrs wheezing
MED Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
MED Atomoxetine *NF* 80 mg OGT daily
MED Amantadine 200 mg PO/NG DAILY
please schedule for 0800, 1400
MED Multivitamins 1 TAB NG DAILY
MED Omeprazole 20 mg PO DAILY
please give through OGT
MED Ondansetron 4 mg IV Q8H:PRN nausea
IV 500 mL NS Bolus 500 ml Over 30 mins
Discharge Medications:
1. Keppra 100 mg/mL Solution [**Hospital1 **]: [**2145**] mg PO twice a day: Stop
feeds one hour prior and for two hours after instilling. Give
with valproate.
2. valproic acid (as sodium salt) 250 mg/5 mL Syrup [**Year (4 digits) **]: 750 mg
PO Q12H (every 12 hours): Liquid.
3. miconazole nitrate 2 % Powder [**Year (4 digits) **]: One (1) Appl Topical TID
(3 times a day).
4. docusate sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: 100 mg PO TID (3
times a day).
5. lorazepam 2 mg/mL Syringe [**Year (4 digits) **]: 1-3 mg Injection PRN (as
needed) as needed for seizure>5 min or >3 /hr.
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Year (4 digits) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for Wheeze.
7. enoxaparin 40 mg/0.4 mL Syringe [**Year (4 digits) **]: One (1) Subcutaneous
DAILY (Daily).
8. nystatin 100,000 unit/mL Suspension [**Year (4 digits) **]: Five (5) ML PO QID
(4 times a day) as needed for oral thrush.
9. amantadine 50 mg/5 mL Syrup [**Year (4 digits) **]: 100 mg PO BID (2 times a
day).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Year (4 digits) **]:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
11. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Year (4 digits) **]: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
12. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Year (4 digits) **]: One
(1) Appl Ophthalmic QID (4 times a day).
13. ciprofloxacin 0.3 % Drops [**Year (4 digits) **]: 1-2 Drops Ophthalmic Q4H
(every 4 hours): Continue until ophthalmology f/u.
14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
16. therapeutic multivitamin Liquid [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
17. dantrolene 25 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO TID (3
times a day).
18. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
QOD () as needed for constipation.
19. propranolol 10 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3
times a day).
20. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1)
PO DAILY (Daily) as needed for constipation.
21. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Last Name (STitle) **]: One
(1) Tablet, Chewable PO TID (3 times a day).
22. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
23. senna 8.6 mg Capsule [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary
- Seizures
Seconadry
- TBI ([**2155-12-29**])
Discharge Condition:
Discharge condition: stable and at baseline
Mental status: In a vegetative state at baseline, nonverbal, not
oriented, does not follow commands--all at baseline.
Ambulatory status: nonambulatory (baseline)
Discharge Instructions:
You were admitted to the [**Hospital1 69**] on
[**2149-8-28**] because at your rehabilatation facility, [**Hospital1 **], you
had a temperature up to 101. We performed multiple tests to
determine the cause of your fever, but your work up was
negative. You were found to have seizures. You were intubated
for a short period of time while your seizures were better
controlled. We started you on two medications for this (Keppra
and Dilantin). You were placed on antibiotics without a definite
source of infection, later discontinued. Dilantin was stopped
and replaced by valproic acid. You were discharged seziure-free
on oral keppra and valproate.
Followup Instructions:
You will be returning to [**Hospital3 **] and should follow up
with your physicians there.
1. You should follow up with your primary care physician at
[**Name9 (PRE) **].
2. You should follow up with an ophthalmologist in [**1-1**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"780.60",
"V44.1",
"780.39"
] |
icd9cm
|
[
[
[
234,
238
],
[
13599,
13603
]
],
[
[
5267,
5274
]
],
[
[
13085,
13092
],
[
13660,
13667
]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[
13679,
13687
]
]
] |
12984, 13054
|
7715, 9006
|
279, 287
|
13174, 13197
|
5924, 7692
|
14056, 14409
|
4619, 4637
|
10164, 12961
|
13075, 13132
|
9032, 10141
|
13385, 14033
|
4652, 5905
|
2997, 3133
|
234, 241
|
315, 2978
|
13212, 13361
|
3155, 4169
|
4185, 4603
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
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221, 252
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346, 1380
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
"038.9",
"427.31",
"V58.61",
"V10.3",
"338.29",
"724.2",
"493.90",
"427.81",
"294.20",
"V15.82",
"785.52",
"496",
"584.5",
"737.10",
"599.71",
"790.4",
"285.9",
"530.81",
"428.33",
"402.91"
] |
icd9cm
|
[
[
[
214,
219
]
],
[
[
405,
408
]
],
[
[
413,
420
]
],
[
[
2424,
2436
]
],
[
[
2524,
2546
]
],
[
[
2532,
2544
]
],
[
[
2588,
2593
]
],
[
[
2944,
2962
]
],
[
[
3059,
3066
],
[
15162,
15169
]
],
[
[
3219,
3233
]
],
[
[
9261,
9272
]
],
[
[
10505,
10508
]
],
[
[
12169,
12187
]
],
[
[
13125,
13132
]
],
[
[
14264,
14272
]
],
[
[
14514,
14526
]
],
[
[
14832,
14837
]
],
[
[
15226,
15229
]
],
[
[
17272,
17311
]
],
[
[
17313,
17324
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17159, 17231
|
8767, 8767
|
260, 283
|
17349, 17349
|
4786, 4786
|
3451, 3539
|
17252, 17328
|
15762, 17136
|
8784, 9243
|
5579, 8744
|
3554, 4767
|
15279, 15736
|
214, 222
|
9259, 15142
|
311, 2120
|
15160, 15258
|
4802, 5562
|
17364, 17643
|
2142, 3092
|
3108, 3435
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
89,134
| 123,984
|
2973
|
Discharge summary
|
Report
|
Admission Date: [**2164-7-21**] Discharge Date: [**2164-7-24**]
Date of Birth: [**2080-1-17**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Pravachol / Ciprofloxacin / Zoloft / Lipitor
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 84 yo F on longstanding steroids for PMR,
temporal arteritis, osteoporosis, spinal stenosis, anxiety,
anemia, HTN, hyperlipidemia who presents from [**Last Name (un) **] with N/V.
.
Of note, the pt saw her PCP [**7-17**] with a number of complaints incl
a request to be tests for UTI b/c, per her, she "hadn't been
tested in a while". Her u/a came back positive so she was
prescribed cipro. However, the pt has a h/o being allergic to
this so [**7-20**], it was switched to macrobid. On the evening of [**7-20**]
she took her first dose of macrobid. On the am of admission, she
woke up nauseous and had chills. T was 103. She called her PCP
and was referred to the ED.
.
In the ED, she was noted to have a lac on her L ant shin from a
fall at home 2 days ago which was noted to look clean w/o e/o
infxn. She received ceftriazone 1gm, tylenol for fever and 3L
IVF. CXR ruled out PNA. 2 18 guage IVs were placed. Vitals on
transfer 98.9 86 97/34 20 96% on 2L NC.
.
On arrival to the ICU, she states she has dry mouth, post nasal
drip.
.
Review of systems:
(+) Per HPI
(-) Denies fever, cough, shortness of breath, chest pain,
vomiting, diarrhea, constipation, abdominal pain. Denies rashes
or skin changes.
Past Medical History:
#. Temporal arteritis
#. polymyalgia rheumatica
#. HTN
#. Thyroid nodule
#. hypothyroidism
#. Dyslipidemia
#. Osteoporosis
#. sciatica
#. spinal stenosis
#. IBS
#. diverticulosis
#. h/o gastric ulcer
#. anxiety
#. glaucoma
#. anemia
#. ventral hernia
Social History:
Occupation: former 3rd grade teacher in [**Hospital1 392**]
Drugs: denies
Tobacco: denies
Alcohol:
Other: lives with sister
Family History:
Non-contributory
Physical Exam:
VS: Tmax: 37 ??????C (98.6 ??????F), HR: 78 (77 - 89) bpm, BP: 108/36, RR:
15 (15 - 31) insp/min, SpO2: 99%
General Appearance: Well nourished, No acute distress
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : [**1-14**] way up bilat, No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, e/o venous stasis. Left
shin with lac- healing well with minimal drainage
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone:
Normal
Pertinent Results:
Labs on Admission:
[**2164-7-21**] 03:00PM BLOOD WBC-22.4*# RBC-3.48* Hgb-10.6* Hct-32.0*
MCV-92 MCH-30.4 MCHC-33.0 RDW-14.6 Plt Ct-225
[**2164-7-21**] 03:00PM BLOOD Glucose-110* UreaN-30* Creat-0.9 Na-139
K-3.8 Cl-102 HCO3-28 AnGap-13
[**2164-7-22**] 02:38AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.9
[**2164-7-21**] 03:22PM BLOOD Lactate-2.9*
Labs on Discharge:
[**2164-7-24**] 07:35AM BLOOD WBC-8.4 RBC-3.44* Hgb-10.4* Hct-31.7*
MCV-92 MCH-30.3 MCHC-32.9 RDW-14.7 Plt Ct-226
[**2164-7-24**] 07:35AM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-144
K-4.1 Cl-107 HCO3-28 AnGap-13
[**2164-7-24**] 07:35AM BLOOD Calcium-9.7 Phos-3.0 Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname **] is a 84 yo F on longstanding steroids for
Polymyalgia Rheumatica and temporal arteritis, osteoporosis,
spinal stenosis, anxiety, anemia, HTN, hyperlipidemia who
presents from home with N/V after antibiotic tx for a UTI and
found to be hypotensive.
.
# UTI in context of hypotension: Patient with E coli sensitive
to ceftriaxone on culture. Of note, her hypotension is likely
[**2-14**] adrenal insufficiency in the setting of infxn and
long-standing steroid use rather than sepsis. Initially,
stress-dose steroids were held because patient has h/o
co-morbities with steroids. IVF were also held, as patient with
crackles to mid-lung field on pulmonary exam. Pt was started on
Ceftriaxone 1g daily. Patient was transitioned to PO
cefpodoxime before her discharge home. She tolerated the
medications well.
.
# Hypotension: Likely multifactorial, but given chronic steroid
use, pt probably not able to mount cortisol response to stressor
of infection. Pt received boluses of fluids in the ED to which
she was only partially responsive, but did not receive fluids in
the ICU because she was exhibiting crackles on pulm exam. SBP
goal > 95; MAP goal >60. Pt has not received any acute
treatment for hypotension in ICU.
.
# Polymyalgia Rheumatica and Temporal Arteritis: stable; pt
continued on her home dose prednisone
.
# Hypernatremia: pt noted to have Na 146 on ICU day 2;
encouraged PO intake and monitored electrolytes.
.
# Osteoporosis: Known history; cont home fosamax, calcium and
vitamin D
.
# Anxiety: Pt on home benzodiazepines, but held benzos for high
risk of in-house delerium
.
# Hyperlipidemia: cont home ezetimibe
.
# HTN: held home valsartan given hypotension
Medications on Admission:
ALENDRONATE 70 mg weekly
DIAZEPAM 2.5 -5mg Q 8 prn anxiety (usu takes several/wk)
EZETIMIBE 10 mg daily
HYDROCODONE-ACETAMINOPHEN - 7.5 mg-325 mg 1-2 tabs Q 6 prn pain
(recently taking about [**1-14**]/day)
LATANOPROST 0.005 %Drops - 1 drop in each eye once daily
LEVOTHYROXINE 25 mcg daily
OMEPRAZOLE 20 mg [**Hospital1 **]
PREDNISONE 4mg daily
VALSARTAN 80 mg daily
ACETAMINOPHEN 1000mg PRN pain (pt states she rarely takes)
BIOTIN 3mg daily
CALCIUM CARBONATE-VITAMIN D3 1200 mg-800 unit daily
DOCUSATE SODIUM
CENTRUM SILVER daily
Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
10. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. Hydrocodone-Acetaminophen 7.5-325 mg Tablet Sig: 1-2 Tablets
PO every six (6) hours as needed for pain.
12. Diazepam 5 mg Tablet Sig: 0.5-1 Tablet PO every eight (8)
hours as needed for anxiety.
13. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet Sig: Two
(2) Tablet PO once a day.
14. Biotin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
15. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Urinary Tract Infection
Secondary Diagnosis: Hypotension
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 low blood pressure and a
wrinary tract infection. Your blood pressure stabilized and you
were placed on an antibiotic for your urinary tract infection.
You were discharged home on oral cefpodoxime. Please take this
medication through [**7-28**].
Please ADD the following medication:
Cefpodoxime 100 mg, take 2 tabs by mouth twice per day for an
additional 3 days
Followup Instructions:
Please follow-up with your primary care provider as listed
below:
Department: [**State **] SQ
When: TUESDAY [**2164-8-7**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
|
[
"244.9",
"V12.71",
"365.9",
"725",
"446.5",
"733.00",
"041.49",
"255.41",
"276.0",
"300.00",
"272.4",
"401.9",
"599.0",
"458.9"
] |
icd9cm
|
[
[
[
1698,
1711
]
],
[
[
1804,
1820
]
],
[
[
1836,
1843
]
],
[
[
3786,
3807
]
],
[
[
3813,
3830
]
],
[
[
3833,
3844
],
[
5175,
5186
]
],
[
[
4040,
4055
]
],
[
[
4130,
4150
]
],
[
[
5069,
5081
]
],
[
[
5249,
5255
]
],
[
[
5341,
5354
]
],
[
[
5381,
5383
]
],
[
[
7308,
7330
]
],
[
[
7354,
7364
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7262, 7268
|
3718, 5426
|
318, 324
|
7389, 7389
|
3066, 3071
|
7969, 8345
|
2031, 2049
|
6009, 7239
|
7289, 7289
|
5452, 5986
|
7540, 7946
|
2064, 3047
|
1446, 1600
|
275, 280
|
3425, 3695
|
352, 1426
|
7354, 7368
|
7308, 7333
|
3085, 3406
|
7404, 7516
|
1622, 1874
|
1890, 2015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
94,987
| 193,169
|
731145
|
Nutrition
|
Clinical Nutrition Note
|
Diet: Regular
Meds: Senna, Warfarin, vitamin B12, multivitamin, colace, others noted
55 y.o. Female with hx of gastric bypass and recent spinal fusion on
[**2172-4-7**] who presents with acute pulmonary embolism. Patient is
tolerating a regular diet, just starting to eat small meals. Patient
ate oatmeal for breakfast and is eating macaroni and cheese and
carrots/celery for lunch. Will follow up with po intake and tolerance.
#[**Numeric Identifier 1312**]
01:00 PM
|
[
"453.41"
] |
icd9cm
|
[
[
[
197,
220
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
96,218
| 122,615
|
43312
|
Discharge summary
|
Report
|
Admission Date: [**2187-10-7**] Discharge Date: [**2187-11-2**]
Date of Birth: [**2127-7-22**] Sex: M
Service: SURGERY
Allergies:
Vicodin
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Confusion/lethargy
Major Surgical or Invasive Procedure:
[**2187-10-19**]: combined liver/kidney transplant
History of Present Illness:
60 yo M w/ PMH of cirrhosis, encephalopathy p/w lethargy,
vomiting and confusion. Pt. had a paracentesis (9.5L) on
thursday and afterwards had been feeling somewhat tired as
normal for him after a paracentesis. He continued to feel tired
until 0300 this am when he vomited, he went back to bed and then
began having dry heaves around 0600. At this time his wife
checked him for asterixis and she noted that he did have a
flapping tremor and she brought him to the ED. She noted that he
had had 4 BMs yesterday. He was admitted from the ED w/o workup.
On the floor he was lethargic but arousable and he was taken for
abdominal u/s w/ IR paracentesis. ON presentation he only
complains of thirst.
Past Medical History:
1) Etoh cirrhosis, diagnosed in '[**82**], transplant candidate (may
need liver-kidney), complicated by:
- variceal bleeding in '[**83**], controlled with medications
- ascites requiring periodic paracenteses
- ? HRS [**8-3**]
- last EGD [**8-3**]: esophageal varices, portal hypertensive
gastropathy
- last colonoscopy [**8-3**]: Two 3mm benign-appearing polyps
2) Recurrent ARF with admissions [**6-3**] and [**8-3**] (? HRS vs IgA
nephropathy). No renal disease known prior to these admissions.
3) Hx sepsis from dog bite in '[**82**] c/b multiorgan failure
4) L4-5 spinal fusion '[**78**] at [**Hospital **] Hospital
5) AS of uncertain severity - scheduled for LHC on Fri [**9-14**]
6) HTN - stable off medications
7) Hypercholesterolemia
8) hx aortic aneurysm, stable for last 20 yrs
9) L sided hernia repair
10) Depression
11) R knee arthroscopy and meniscus repair
12) L knee open meniscus repair
Social History:
Pt born in [**State **], lived in [**Male First Name (un) 1056**], then Mass for many
years. Retired school counselor and high school basketball
coach. Lives with wife and dog. Drank ~2 drinks/day for appx 40
yrs, last drink [**2187-1-21**] for wife's birthday. Used tob rarely for
8yrs, quit around [**2166**]. Walks [**12-27**] to [**2-27**] mi daily.
Family History:
Father had CABG in 40s, also had 2 heart valve surgeries and 2
CVAs. Mom died at age [**Age over 90 **]. No fhx of liver or kidney disease.
Physical Exam:
VS - Temp 96.2F, BP 117/82, HR 86, R 18, O2-sat 97 % RA
GENERAL - Drowsy but arousable to call, Flap +
LUNGS - Clear B/L
HEART - RRR Systolic murmur
Abd: soft umb hernia non tender non distended
Rectal neg Guiaic neg
Brief Hospital Course:
Initially treated for encephalopathy by the medicine team until
[**10-11**] when a liver and kidney donor became available. On
[**2187-10-11**] he underwent Orthotopic deceased-donor liver transplant
(piggyback); portal vein to portal vein anastomosis; common bile
duct to common bile duct anastomosis with no T-tube; celiac
patch (donor) with replaced right hepatic artery to a branch
patch (recipient for Alcoholic cirrhosis; portal hypertension;
ascites; chronic renal failure; aortic stenosis. Surgeon was Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Two JPs were
placed. There were no complications. He then underwent cadaveric
kidney transplant into the right
iliac fossa with placement of a 6-French double-J stent. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed in the
retroperitoneum. Please see both operative reports for complete
details. Standard immunosuppressive induction therapy was given
(solumedrol and cellcept).
Postop, he was transferred to the SICU for postop management.
Prograf was started on pod 1. He was extubated on [**10-14**] after
bronchoscopy for LLL atelectasis. Platelets trended down.
Heparin was stopped and a HIT was sent which was negative.
Multiple blood products were given over SICU stay to maintain
hemostasis. Platelet count stabilized. Creatinine and LFTS
trended down. Urine output was excellent. Diet was advanced and
tolerated. Glucoses were elevated from the solumedrol. An
insulin drip was initially used then sliding scale insulin was
initiated. [**Last Name (un) **] was later consulted and NPH with sliding scale
was used.
He was transferred out of the SICU to the Med-[**Doctor First Name **] floor on
[**10-15**] where he continued to do well. He was assisted to
ambulate. PT followed him. The foley was removed with incident.
The 2 JPs and the [**Doctor Last Name 406**] drain outputs were in the 20-60cc range.
Pain was well managed with oxycodone. Solumedrol was tapered,
cellcept was adjusted to 500mg qid for some GI complaints and
prograf was adjusted daily per trough levels.
On POD 7, the NEOB called to report that the donor had had an
E.coli bacteremia. Given this, blood cultures were drawn for
surveillance. These returned + for coag negative staph. IV Vanco
was started and continued for 2 days. Blood, urine and the RLQ
retroperitoneal [**Doctor Last Name 406**] drain fluid cultures were positive for E.
coli. Initially, cipro was started for the urine. Dapto was
started for a surveillance rectal swab that returned postive for
VRE. This was only given for two days, then stopped on [**10-23**].
Meropenum was started on [**11-23**] and continued thru [**10-26**]. ID was
consulted and recommended resuming Cipro. This was continued
until ID re-evaluated and felt that he should remain on IV
antibiotics for a 10 day course given h/o aortic valve stenosis,
immunosuppression. Ceftriaxone was started on [**10-29**] and continued
until [**11-2**]. A PICC line was inserted and the plan was for a 10
day course. Given known aortic stenosis and development of sinus
tachycardia, a TTE was done to assess for vegetations. This was
negative. He then had a TEE to definitively rule out any
vegetation. This was negative.
Around POD 6, the medial JP and the [**Doctor Last Name 406**] (kidney) drainage
increased requiring IV fluid replacements. The 2 JPs around the
liver were removed on POD 8 & 14. Creatinine of this fluid was
1.7. Serum creatinine was 1.1. On POD 11 ([**10-23**]), urine output
increased to 3 liters. IV fluid replacement was given. He
developed dizziness, orthostatic hypotension with tachycardia
and a sense that his heart was racing. He denied sob or chest
pain. This was initially treated with aggressive IV volume
resuscitation. He continued to have sinus tachycardia.
Cardiology was consulted and IV lopressor was started. Sinus
tach improved and lopressor was switched to Toprol 100mg qd.
During this time his only complaint was fatigue that improved as
heart rate was controlled.
On POD 11, an MRCP was done to evaluate elevated alk phos that
had been running in the 300-400 range. There was no evidence of
biliary dilatation. A small amount of ascites was noted. Alk
phos improved some with daily range between 240-280. Alt and AST
somewhat increased. A duplex of the liver was done showing
normal vascular flow, no biliary dilatation or peri-hepatic
collections. On [**11-2**], an US guided biopsy was done to evaluate
for rejection given persistent elevation of LFTS. The biopsy was
negative.
On [**11-2**], he was discharged home to complete the Ceftriaxone
course for 5 more day. VNA services were arranged. Blood
cultures were to be done 72 hours after completing the
Ceftriaxone.
Staples were removed from the subcostal incision as well as the
RLQ incision. These incisions were clean, dry and intact. Vital
signs were stable with HRs in the 70-80s. He was ambulatory and
tolerating a carb consistent diet.
Medications on Admission:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILy (Daily).
4. Pantoprazole 40 mg Tablet, Sig: One tab Q12
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every
4-6 hours: Titrate to >5 bowel movements daily.
6. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Discharge Medications:
1. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous once a day.
Disp:*1 bottle* Refills:*2*
2. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
Disp:*1 bottle* Refills:*2*
3. syringes Sig: One (1) box four times a day: insulin
syringes-lo dose. 25 gauge needle. U 100.
Disp:*1 box* Refills:*2*
4. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
13. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 5 days.
Disp:*5 gram* Refills:*0*
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous once a day as needed for line flush: after 10ml of
saline via the PICC line .
Disp:*20 syringes* Refills:*0*
15. Picc Line Supplies
pump, tubing, dressing supplies
supply: 1 week
refill: 1
16. Outpatient Lab Work
Blood cultures 3 days after antibiotics stop
fax results to [**Telephone/Fax (1) 697**]
17. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
18. Metoprolol Succinate 100 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Hepatorenal syndrome now s/p kidney transplant
Cirrhosis now s/p orthotopic liver transplant
aortic stenosis
Sinus tachycardia
E.coli bacteremia [**2187-10-22**]
UTI, E.coli [**2187-10-22**]
VRE, rectal swab [**2187-10-11**]
Discharge Condition:
Stable/good
Discharge Instructions:
Call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101,
chills, nausea, vomiting, "racing heart" or palpitations,
shortness of breath, chest pain, diarrhea or constipation.
Call if you are having difficulty taking foods, fluids,
medications
Drink enough fluids to keep the urine light yellow
Labwork every Monday and Thursday to be faxed to transplant
clinic at [**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, alk phos,
albumin, T bili, trough prograf level
Monitor incisions for redness, drainage or bleeding. Staples to
be removed at your clinic visit
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2187-11-7**]
10:00
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2187-11-7**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2187-11-14**]
11:00
Dr. [**First Name (STitle) 437**] (Cardiology)-[**11-21**] at 9:20 ([**Last Name (NamePattern1) **], LMOB [**Location (un) 3971**])
Completed by:[**2187-11-2**]
|
[
"401.9",
"272.0",
"311",
"553.1",
"585.9",
"572.4",
"571.2",
"424.1",
"785.0",
"041.49",
"790.7",
"599.0",
"V09.80"
] |
icd9cm
|
[
[
[
1774,
1776
]
],
[
[
1806,
1825
]
],
[
[
1902,
1911
]
],
[
[
2691,
2700
]
],
[
[
3232,
3252
]
],
[
[
10628,
10647
]
],
[
[
10675,
10683
]
],
[
[
10721,
10735
]
],
[
[
10737,
10753
]
],
[
[
10755,
10760
]
],
[
[
10762,
10771
]
],
[
[
10790,
10792
]
],
[
[
10819,
10821
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10552, 10607
|
2774, 7949
|
285, 338
|
10876, 10890
|
11516, 12108
|
2376, 2517
|
8576, 10529
|
10628, 10855
|
7975, 8553
|
10914, 11493
|
2532, 2751
|
227, 247
|
366, 1062
|
1084, 1989
|
2005, 2360
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
92,002
| 129,029
|
18185
|
Discharge summary
|
Report
|
Admission Date: [**2153-4-30**] Discharge Date: [**2153-5-6**]
Date of Birth: [**2081-10-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional dyspnea
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x2 with
left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft to the ramus
intermedius
History of Present Illness:
Patient presented with increasing
dyspnea, given multiple cardiac risk factors had ETT which was
positive
Past Medical History:
Coronary artery disease, Hypertension,
Diabetes mellitus type 2, hyperlipidemia, Gout
End stage renal disease on hemodialysis x2 years(M-W-F)Dr
[**Last Name (STitle) 11427**] is nephrologist. **Awaiting renal transplant**
Social History:
Lives with: wife
Occupation: retired from [**Company **]
Tobacco: cigar 1/wk
ETOH: none
Drugs: none
Family History:
Both parents w/MI Mother died @66, father died
@72. Sister colon CA, Sister-leukemia, Brother prostate CA,
[**Name (NI) 50273**]
Physical Exam:
Pulse: 72 Resp: 20 O2 sat:
B/P Right: 122/66 Left: deferred AV fistula
Height: 5'8" Weight: 125.2 Kg 258 lbs
General: NAD-obese
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft[x] non-distended[x] non-tender[x]
bowel sounds + [x]
Extremities: Warm [x], well-perfused [] Edema: none
Varicosities: None [] mild
Neuro: Grossly intact, non focal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Left AV fistula with thrill
Carotid Bruit Right: no Left: yes
Pertinent Results:
[**2153-5-4**] 05:22AM BLOOD WBC-10.7 RBC-3.49* Hgb-11.2* Hct-34.6*
MCV-99* MCH-32.1* MCHC-32.3 RDW-15.0 Plt Ct-274
[**2153-5-1**] 06:45PM BLOOD PT-13.3 PTT-28.3 INR(PT)-1.1
[**2153-5-5**] 09:20AM BLOOD Glucose-217* UreaN-47* Creat-7.0*# Na-136
K-5.0 Cl-94* HCO3-29 AnGap-18
[**2153-5-4**] 05:22AM BLOOD Glucose-136* UreaN-59* Creat-8.7*# Na-133
K-5.6* Cl-92* HCO3-26 AnGap-21*
[**2153-5-5**] 09:20AM BLOOD Calcium-9.7 Phos-6.4*# Mg-2.6
[**2153-5-4**] 05:22AM BLOOD Calcium-9.7 Phos-9.3*# Mg-2.5
Brief Hospital Course:
The patient was brought to the operating room on [**2153-5-3**] where
the patient underwent coronary artery bypass x 4. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Vancomycin was used for surgical
antibiotic prophylaxis. POD 1 found the patient extubated,
alert and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. He
was maintained on his regular M/W/F hemodialysis schedule. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. He
did have several episodes of rate controlled atrial
fibrillation. His beta-blocker was titrated and amiodarone was
initiated. Anti-coagulation was initiated with coumadin. By
the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions.
Medications on Admission:
Metoprolol 25", Lisinopril 40', Amlopidine
10', ASA 81', Clonidine 0.2 @HS/prn, Pravastatin 40',
Allopurinol
100', Colchicine 0.6', Actos 45', Nephrocaps 1', Phoslo 667''',
Hydrocortisone 12.5'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for acute gout flair.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day.
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Hydrocortisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily.
Disp:*120 Tablet(s)* Refills:*2*
15. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Dose
to change daily for goal INR [**1-10**] for atrial fibrillation. First
INR [**2153-5-8**] with results to cardiac surgery [**Telephone/Fax (1) 170**].
Disp:*30 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Serial PT/INR
dx: atrial fibrillation
goal INR [**1-10**]
Results to Cardiac Surgery [**Telephone/Fax (1) 170**]
1st draw Tues. [**2153-5-8**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease, Hypertension,
Diabetes mellitus type 2, hyperlipidemia, Gout
End stage renal disease on hemodialysis x2 years(M-W-F)Dr
[**Last Name (STitle) 11427**] is nephrologist. **Awaiting renal transplant**
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
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**]
**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:
Dr. [**Last Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6254**] in 3 weeks [**Telephone/Fax (1) 6256**]
Dr. [**First Name8 (NamePattern2) 12334**] [**Last Name (NamePattern1) 50274**] in 2 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**
**First INR draw [**2153-5-8**], results to cardiac surgery
[**Telephone/Fax (1) 170**]**
Completed by:[**2153-5-6**]
|
[
"305.1",
"427.31",
"414.01",
"403.91",
"250.40",
"272.4",
"274.9",
"585.6",
"V45.11",
"V49.83"
] |
icd9cm
|
[
[
[
955,
973
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],
[
[
3378,
3396
]
],
[
[
5864,
5886
]
],
[
[
5889,
5900
]
],
[
[
5903,
5926
]
],
[
[
5929,
5942
]
],
[
[
5945,
5948
]
],
[
[
5950,
5972
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],
[
[
5974,
5988
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],
[
[
6058,
6082
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[
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[
380,
441
]
],
[
[
444,
496
]
]
] |
5784, 5843
|
2400, 3741
|
340, 500
|
6109, 6265
|
1880, 2377
|
6964, 7581
|
1016, 1148
|
3986, 5761
|
5864, 6088
|
3767, 3963
|
6289, 6941
|
1163, 1861
|
282, 302
|
528, 636
|
658, 882
|
898, 1000
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,103
| 190,480
|
25513
|
Discharge summary
|
Report
|
Admission Date: [**2121-6-8**] Discharge Date: [**2121-6-10**]
Date of Birth: [**2090-10-22**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12722**]
Chief Complaint:
abdominal pain, vomiting - admitted to MICU for severe
dehydration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30 year old woman with history of alcohol abuse, pancreatitis,
depression/anxiety who presents in with two days of LLQ
abdominal pain, vomiting and inability to tolerate PO's. She
reports that symptoms are similar to episodes of pancreatitis.
Patient states she has been sober for 2 months and then relapsed
one week ago. States her last drink was 24 hours ago. Denies
fevers, diarrhea, HA, CP, SOB, vaginal bleeding, vaginal
discharge. Lives alone.
.
Of note patient was recently hospitalized for ETOH withdrawal.
During this admission, there was concern that she was not safe
to go home given multiple admissions to the hospital related to
ETOH use. A section 35 as filed and patient was ultimately
escorted by police to court, where she was determined to require
involuntary admission for treatment of ETOH abuse. Her 30 days
of treatment ended 2 weeks ago.
.
At the time of presentation to ED patient was hypotensive to BP
83/69. Documented initial vitals in ED were: T 98.1 HR 108 BP
94/52 RR 12 O2 sat 98% RA. Labs were sigificant for EtOH of 366
with otherwise negative serum tox. AST 73, ALT 30, lipse 26.
Bedside ultrasound of abdomen and heart showed no abnormalities.
The patient was given 1 amp of D50 for hypoglycemia, 5 L NS for
volume repletion. She received zofran, Thiamine 100mg, folate,
Reglan, ativan 2mg Pantoprazole 40.
.
On arrival to the MICU, patient is somnolent and unable to
provide meaningful history.
Past Medical History:
- EtOH dependence
- EtOH pancreatitis
- EtOH hepatitis
- EtOH gastritis
- Anxiety
- Depression
- Bulemia
Social History:
Social History Per OMR:
Pt reports that she has hx of bulemia. States that her mo was
bulemic and that is something she has dealt with since
childhood. States she did not start drinking until she was 21.
She successfully completed undergraduate degree in biochemistry
in [**Location (un) 11177**] State and was accepted to [**Hospital1 3278**] dental school.
Drinking gradually became a problem and she identifies etoh
becoming a more significant problem during a difficult
relationship with a boyfiend after she moved to [**Location (un) 86**]. She
describes bulemia as being less of a problem currently, although
something she continues to deal with. Pt moved to [**Location (un) 86**] to go
to dental school at [**Hospital1 3278**]. She actually walked in graduation in
[**2116**] but has not finished her degree. She does not have plans to
return to dental school. Pt cont to stay in Ma because she is
certified as a dental hygenist in the state. She feels that her
etoh abuse was related to her inability to complete dental
school.
.
Pt has been to several detox facilities and 2 rehab programs in
CA. Pt did feel that programs were helpful. She has a hx of
being sober through AA and with support of her church.Pt denies
she has ever tried any illicit drugs. She currently lives alone.
.
Pt is from CA. Her mother is a major support and continues to
live in CA. Pt is not close with father. Pt states that she
stays in MA because it is one of the few states she is able to
practice as a dental hygenist.
Family History:
Family History per OMR
Maternal grandfather with alcoholism
Maternal uncle with drug problem
Paternal aunt with alcoholism
Physical Exam:
ADMISSION:
Vitals: T:96 BP: 95/76 P: 86 R: 18 O2: 100RA
General: Somnolent, arousable to voice, following commands, no
acute distress
HEENT: Sclera anicteric, dry MM, 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 anteriorly, no wheezes,
rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley with clear light yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: following commands, moving all extremities
.
DISCHARGE:
Vitals: 97.5 100/84 80 18 100%RA
General: Alert, oriented, laying comfortably in bed
HEENT: Sclera anicteric, PERRL, MMM, OP without lesions; cheeks
prominent
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: following commands, moving all extremities
Pertinent Results:
ADMISSION
[**2121-6-8**] 03:37AM BLOOD Glucose-31* UreaN-7 Creat-0.9 Na-147*
K-3.7 Cl-96 HCO3-25 AnGap-30*
[**2121-6-8**] 04:51AM BLOOD Glucose-186* UreaN-6 Creat-0.5 Na-144
K-2.4* Cl-112* HCO3-16* AnGap-18
[**2121-6-8**] 03:37AM BLOOD WBC-7.7# RBC-4.70 Hgb-15.3 Hct-45.8
MCV-98 MCH-32.6* MCHC-33.4 RDW-13.3 Plt Ct-391
.
PERTINENT
[**2121-6-8**] 03:37AM BLOOD Albumin-4.5 Calcium-8.9 Phos-4.4 Mg-1.9
[**2121-6-8**] 03:37AM BLOOD ALT-30 AST-73* AlkPhos-70 TotBili-0.3
[**2121-6-8**] 03:37AM BLOOD Lipase-26
[**2121-6-8**] 03:37AM BLOOD ASA-NEG Ethanol-366* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2121-6-8**] 04:14AM BLOOD Glucose-19* Lactate-6.3* Na-148* K-3.4
Cl-104
[**2121-6-8**] 04:48AM BLOOD Lactate-4.8*
[**2121-6-8**] 06:49AM BLOOD Lactate-5.5*
[**2121-6-8**] 06:49AM BLOOD freeCa-0.86*
[**2121-6-8**] 04:51AM BLOOD TSH-0.17*
[**2121-6-8**] 12:43PM BLOOD Free T4-0.49*
.
DISCHARGE
[**2121-6-10**] 07:30AM BLOOD WBC-4.9 RBC-4.26 Hgb-13.4 Hct-42.8
MCV-101* MCH-31.4 MCHC-31.3 RDW-13.0 Plt Ct-229
[**2121-6-10**] 07:30AM BLOOD PT-9.5 PTT-35.7 INR(PT)-0.9
[**2121-6-10**] 07:30AM BLOOD Glucose-86 UreaN-2* Creat-0.6 Na-139
K-4.1 Cl-102 HCO3-28 AnGap-13
[**2121-6-10**] 07:30AM BLOOD ALT-20 AST-37 AlkPhos-61 TotBili-0.4
[**2121-6-10**] 07:30AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.2 Mg-1.7
.
CXR
No acute cardiopulmonary process.
.
EKG: SR at 99, normal axis, possible [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6192**], incomplete
RBBB, ST depression V3-V4, lead 2, 3, aVF new compared to prior
EKG.
Brief Hospital Course:
30 year old female with alcohol dependence admitted with alcohol
intoxication and abdominal pain, requiring brief MICU course for
hypotension.
.
# Hypotension: Patient presented with hypotension in the setting
of decreased PO intake, vomiting and significant ETOH use. She
received 6L of IV fluids in the ED prior to arrival to MICU with
resolution of hypotension, supporting a diagnosis of
hypovolemia. No source of infection was identified and the
patient maintained good urine output. Blood pressure remained at
home SBP of 90-110 for the remainder of admission, as the
patient had improved PO intake.
.
# Acidemia: On admission, patient had combined AG acidosis, NAG
acidosis and respiratory acidosis. AG acidosis likely lactate
(admission lactate of 6.3)/ETOH ketosis (trace ketones on u/a),
hyperchloremic NAG from NS volume resuscitation. Respiratory
depression likely related to hypoventilation in setting of
benzodiazepine administration while intoxicated with PCO2 of 44
on ABG. Patient's lactate and pH improved in MICU.
.
# Elevated Lactate: Likely in setting of significant
hypovolemia and EtOH consumption. Evidence of acidemia on ABG.
Improved with volume resuscitation.
.
# EKG changes: Pt presented with ST depressions in anterolateral
chest leads and inferolateral limb leads. Could represent
changes due to hypokalemia or hypoglycemia. Repeat EKG on HD #2
showed resolution of all ST depressions s/p correction of
electrolyte abnormalities.
.
# Hypoglycemia: Likely due to poor intake while drinking.
Patient initially given D5 in ED and quickly normalized.
Subsequent FS WNL.
.
# Alcohol Abuse: Patient with significant history of ETOH abuse
with evidence of end-organ damage, including pancreatitis and
hepatitis. At the time of presentation, the patient was
intoxicated with ETOH level of 366. Patient has had multiple
hospitalizations related to ETOH abuse. The patient was started
on folate, thiamine, and a multivitamin on admission. She was
monitored on CIWA with PO diazepam, did not score on CIWA
(likely because had only been drinking for max 6 days after 30
days of abstinence in rehab). She was evaluated by social work
and was recommended for an alcohol abuse partial day program to
prevent relapse. She will attend [**Hospital1 **] starting Wednesday,
[**6-18**]. The patient was also resumed on home naltrexone
prior to discharge. She will follow up with her PCP on
discharge regarding her alcohol abuse. Her behavioral health
group coordinator was also notified of her admission and
discharge date to further plan support groups for the patient.
.
# Abdominal pain: Likely secondary to gastritis related to ETOH
abuse. LFTs mildly elevated, but consistent with her baseline
as she has alcoholic hepatitis. Lipase returned normal and
abdominal exam remained clinically benign. No evidence of bleed
throughout admission. The patient was continued on omeprazole.
.
# Hypothermia: Pt hypothermic to 93 on admission, likely
secondary to wearing inadequate clothing in cold weather, poor
nutritional state and receiving unwarmed IVF in ED. TSH was
found to be low (0.17), free T4 elevated. The patient should
follow up with her PCP for repeat thyroid function studies. She
may require thyroid suppression therapy.
.
# Depression/Anxiety: Followed as outpatient at [**Hospital1 778**] for dual
diagnosis, EtOH abuse and depression. The patient's behavioral
health coordinator was [**Hospital1 653**] regarding admission with
planned close follow-up.
.
# Bulimia/malnutrition: Patient reported it was not a current
issue, but demonstrated binging and purging behavior with
ordering multiple meals and witnessed emesis in the MICU. The
patient also has a poor nutritional status due to ETOH use.
Patient was felt to be potentially at risk for refeeding. Her
electrolytes were monitored closely and repleted aggressively.
=======================================
Transitional Issues:
- Patient scheduled an appointment with [**Hospital1 **] Outpatient
Services in [**Location (un) 86**] on Wednesday, [**6-18**] at 10:30 AM. We have
strongly encouraged her to keep this appointment and call her
PCP with any concerns.
- The patient should undergo repeat check TSH/Free T4 on
discharge from the hospital, as she likely requires thyroid
suppression therapy
Medications on Admission:
Per recent d/c summary (not reconciled)
1. FoLIC Acid 1 mg PO DAILY
2. Thiamine 100 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Fluoxetine 40 mg PO DAILY
2. naltrexone *NF* 50 mg Oral daily Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
RX *naltrexone 50 mg daily Disp #*30 Tablet Refills:*0
3. Omeprazole 40 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol abuse, hypoglycemia, hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 1887**],
.
You were admitted to the hospital with alcohol relapse leading
to low blood pressure and low blood sugar. You were given IV
fluids and your blood pressure improved. You were able to
tolerate foods without difficulty, and your blood sugar remained
stable. You did not show any signs of withdrawal.
.
For prevention of further alcohol relapse, you were resumed on
your home naltrexone. You should follow up with your primary
care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 63733**] injection as previously planned.
You should also follow up for your psychiatry intake as
previously scheduled. You should follow up with [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 15131**]
for coordination of your substance abuse care. You were seen by
social work and recommended for a partial day program. You were
given this information and were strongly advised to call and
have this set up.
.
MEDICATIONS CHANGED THIS ADMISSION:
START naltrexone 50 mg daily
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Thursday [**2121-6-12**] at 4:00 PM
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BWD
|
[
"311",
"300.00",
"303.00",
"458.9",
"276.52",
"276.2",
"251.2",
"535.30",
"571.1",
"991.6",
"E901.0",
"263.9"
] |
icd9cm
|
[
[
[
471,
480
]
],
[
[
482,
488
]
],
[
[
6416,
6433
]
],
[
[
6522,
6532
]
],
[
[
6783,
6793
]
],
[
[
7002,
7057
]
],
[
[
7858,
7869
]
],
[
[
9021,
9037
]
],
[
[
9121,
9139
]
],
[
[
9303,
9313
]
],
[
[
9358,
9414
]
],
[
[
9897,
9908
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11313, 11319
|
6392, 10294
|
373, 380
|
11404, 11404
|
4841, 6369
|
12613, 13037
|
3517, 3642
|
10895, 11290
|
11340, 11383
|
10713, 10872
|
11555, 12590
|
3657, 4822
|
10315, 10687
|
266, 335
|
408, 1844
|
11419, 11531
|
1866, 1973
|
1989, 3501
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
91,739
| 184,265
|
34428
|
Discharge summary
|
Report
|
Admission Date: [**2186-1-15**] Discharge Date: [**2186-1-17**]
Date of Birth: [**2141-2-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
2 episodes of syncope in the setting of BRBPR s/p colonoscopy
with 2 hot snare polypectomies 5 days ago
Major Surgical or Invasive Procedure:
Colonoscopy [**2185-1-16**]
History of Present Illness:
This is a 44 year old otherwise healthy male who is presenting
for evaluation of 2 episodes of syncope in the setting of BRBPR
5 days after having a colonoscopy with 2 hot snare
polypectomies. The patient does not recall his syncopal
episodes, but his wife was present to witness them. She said
that he had multiple, brief syncopal episodes that occurred
around 12:30 AM in the setting of a large bloody bowel movement.
He remembers feeling lightheaded and dizzy, but does not
acutally remember passing out. His wife says that he fell into
her arms but did not injure himself.
The indication for the patient's colonoscopy on [**1-10**] was that
he was intermittently having blood coating his stools. He was
found to have a 6mm sessile polyp in his cecum and an 8mm
pedunculated polyp in his sigmoid which were both completely
removed with hot snare polypectomy. The patient did have 1
episode of nausea and vomiting immediately after his
colonoscopy, but otherwise did well until 5:30 PM on [**2186-1-14**] when
he began to have BRBPR. He had a total of [**7-21**] episodes of
watery, BRBPR before reporting to an OSH where his Hct was
measured to be 37. He was transferred to [**Hospital1 18**] because his
original GI procedure took place here and his Hct upon arrival
had fallen to 31.7. He has not had any further BRBPR since
arriving at [**Hospital1 18**].
.
In the ED, initial vs were: T=98.2, P=76, BP=106/65, RR=16, O2
sat=100%. In general the patient appeared well and his exam was
benign. He did not report any abdominal pain, fevers, or chills.
His Hct fell to 31.7 from 37 at the OSH but he did not have any
further episodes of BRBPR. His coags were normal. Two 18 gauge
peripheral IVs were placed for access and he was cross matched
for 2 units of blood but not transfused. He was given 2L of NS
boluses and GI and surgery were contact[**Name (NI) **] regarding his
admission. Upon transfer to the floor, his VS were P=78,
BP=107/66, RR=19, and POx=100% 2L
.
On the floor, the patient appeared well and has not yet had any
bowel movements since arriving to [**Hospital1 18**]. He denies any fevers,
chills, or abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
-atopic eczema
-s/p colonoscopy [**2186-1-10**] with removal of 2 adenomatous polyps
(6mm sessile polyp at the cecum and 8mm pedunculated polyp at
sigmoid)
Social History:
The patient lives at home with his wife and 4 kids. He is a
non-smoker and does not drink any EtOH. He works as a software
engineer at [**Company **] Systems.
Family History:
The patient has a maternal uncle with liver cancer and both of
his parents have HTN. No family history of thalassemia that he
is aware of.
Physical Exam:
Vitals: T: 98.9, BP: 126/73, P: 79, R: 13, O2: 100% 3L NC
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
Neuro: A+Ox3, CN II-XII intact, motor strength and sensory
grossly equal and intact bilaterally
Pertinent Results:
[**2186-1-15**] 02:45AM BLOOD WBC-9.7# RBC-4.67# Hgb-9.8*# Hct-31.7*#
MCV-68* MCH-21.0* MCHC-31.0 RDW-14.2 Plt Ct-214
[**2186-1-15**] 02:45AM BLOOD Neuts-83.5* Lymphs-11.6* Monos-3.4
Eos-1.2 Baso-0.2
[**2186-1-15**] 02:45AM BLOOD Glucose-119* UreaN-22* Creat-1.2 Na-141
K-4.7 Cl-109* HCO3-26 AnGap-11
[**2186-1-15**] 02:45AM BLOOD calTIBC-243* Ferritn-299 TRF-187*
HCT trend:
[**2186-1-17**] 07:25AM BLOOD WBC-6.9 RBC-4.61 Hgb-9.8* Hct-31.0*
MCV-67* MCH-21.3* MCHC-31.7 RDW-14.2 Plt Ct-212
[**2186-1-16**] 09:25PM BLOOD Hct-32.3*
[**2186-1-16**] 04:00AM BLOOD WBC-6.3 RBC-4.89 Hgb-10.2* Hct-32.0*
MCV-65* MCH-20.8* MCHC-31.9 RDW-14.4 Plt Ct-230
[**2186-1-15**] 08:15PM BLOOD Hct-31.0*
[**2186-1-15**] 01:26PM BLOOD Hct-33.6*
[**2186-1-15**] 05:20AM BLOOD Hct-30.6*
Colonoscopy [**2186-1-15**]:
Impression: Sigmoid colon polypectomy site visualized with clean
base but with red spot suggestive of visible vessel. No active
bleeding noted. (endoclip)Cecal polypectomy site clean based
with red spot suggestive of visible vessel. No active bleeding.
(endoclip)
Otherwise normal colonoscopy to cecum
Recommendations: Likely post polypectomy bleed from cecal and
sigmoid colon polypectomy site. S/p endoclip to each ulcerative
area x 2. Please remain in ICU, clear fluids, trend hct. No MRI
x 1 month.
Brief Hospital Course:
This is a 44 year old otherwise healthy male who is presenting
for evaluation of 2 episodes of syncope in the setting of BRBPR
5 days after having a colonoscopy with 2 hot snare polypectomies
admitted to the ICU for concern of post-polypectomy bleeding.
.
#. Post-polypectomy GI bleed. The patient is presenting with
BRBPR 5 days following colonoscopy with removal of 2 adenomatous
polyps. GI performed colonoscopy to evaluate for
post-polypectomy bleed which showed sigmoid colon polypectomy
sites visualized with clean base but with red spot suggestive of
visible vessels which were endoclipped. Hct was trended closely
after the procedure, and remained stable around 32 for 48 hours
prior to floor transfer on [**1-16**] and for the remainder of his
hospitalization. He was tolerating a normal diet prior to
discharge.
.
#. Microcytic anemia. The patient's MCV has consistently been 68
even dating back to [**2183**] when his Hct was 45.2. It is likely
that the patient has thalassemia. Iron studies were sent and
showed ferritin 299 (normal), iron level 49 (normal), TIBC 243
(low), and transferrin 187 (low).
Medications on Admission:
Vitamin D 3000 units daily
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 7.5 Tablets
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleeding
Acute blood loss anemia
Discharge Condition:
Hemodynamically stable, Hct 31, without pain or active bleeding,
tolerating po diet and medications.
Discharge Instructions:
You were transferred to our hospital after experiencing large
amounts of blood in your stools. A colonoscopy was performed to
evaluate the source of the bleeding. You were found to be
bleeding from the sites of your recent biopsies. Clips were
placed over the bleeding vessels and you had no further episodes
of bleeding. You were monitored closely overnight. Your vital
signs and blood counts remained stable and you were discharged
home.
.
No changes were made to your home medications. Please continue
all home medications as previously prescribed.
Followup Instructions:
Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] at the [**Hospital1 **] [**Last Name (Titles) 516**] at [**Telephone/Fax (1) 7703**] to schedule follow
up in the next few weeks.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2186-1-18**]
|
[
"780.2",
"211.3",
"578.9",
"285.1"
] |
icd9cm
|
[
[
[
278,
284
]
],
[
[
1214,
1218
]
],
[
[
6845,
6861
]
],
[
[
6863,
6885
]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6818, 6824
|
5515, 6633
|
407, 437
|
6910, 7013
|
4191, 5492
|
7616, 7970
|
3395, 3536
|
6710, 6795
|
6845, 6889
|
6659, 6687
|
7037, 7593
|
3551, 4172
|
2626, 3022
|
264, 369
|
466, 2607
|
3044, 3202
|
3218, 3379
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
94,255
| 142,254
|
51877
|
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**]
|
[
"158.8",
"V10.3",
"V15.3",
"493.90",
"733.00",
"530.81",
"V10.43",
"V88.01",
"V12.55",
"V58.61",
"511.81"
] |
icd9cm
|
[
[
[
537,
564
]
],
[
[
953,
963
]
],
[
[
983,
1003
]
],
[
[
1036,
1041
]
],
[
[
1046,
1057
]
],
[
[
1062,
1065
]
],
[
[
1070,
1092
]
],
[
[
1094,
1112
]
],
[
[
1147,
1148
]
],
[
[
1151,
1160
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],
[
[
5319,
5340
]
]
] |
[
"34.09"
] |
icd9pcs
|
[
[
[
396,
435
]
]
] |
5289, 5298
|
3137, 4340
|
344, 439
|
5365, 5375
|
1780, 3114
|
5428, 5576
|
1179, 1761
|
5260, 5266
|
5319, 5344
|
4366, 5237
|
5399, 5405
|
282, 306
|
467, 929
|
951, 1163
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,355
| 104,515
|
52105
|
Discharge summary
|
report
|
Admission Date: [**2180-5-10**] Discharge Date: [**2180-6-8**]
Date of Birth: [**2100-5-15**] Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Procainamide / Cephalosporins
Attending:[**First Name3 (LF) 31014**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
79-year-old male with ischemic CHF NYHA IV (EF 30%) BiV ICD,
pAFIB on coumadin, CKD (Cr 1.6-1.8), hx of LGIB (angioectasia
colonoscopy [**2179**]) with down trending Hct from the low 30s-> 27.5
with progressive fatigue, DOE with any activity.
.
Patient complained of dyspnea with minimal exertion that was
worsening over the last few weeks. He could only walk ~10 feet
before feeling short of breath. He stated that his lasix has
been increased over the last 2 weeks and he was on 160mg [**Hospital1 **],
without symptomatic relief or resolution of significant lower
extremity edema. He was also on spirolactone and metolazone. His
stated that his weight has been stable at ~205lbs. He also
complained of orthopnea.
.
He denied having any chest pain or other respiratory symptoms.
He had darker stools since he was started on iron pills, but
denied having any blood on stool or black tarry stools.
.
In the ED, initial vitals were 98.4 67 107/56 18 99% RA. He
overall appeared comfortable. His EKG showed a ventricular-paced
rythm, bigeminy with rate in the 70s. His labs were notable for
creatine at 1.8 (trending up for the last 2-3 months, but at his
baseline), proBNP: 765, Hct at 27.3. Guaiac +. His chest X-ray
showed pulmonary congestion. The patient was then admitted for
further evaluation.
.
On the arrival to the floor, pt appears slightly uncomfortable.
He states to have increased dyspnea on exertion.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CHF (NYHA class IV, ACC/AHA stage D)
- Atrial Fibrillation
- CABG: Yes
- PERCUTANEOUS CORONARY INTERVENTIONS: None.
- PACING/ICD: Cardiac defibrillator in place
3. OTHER PAST MEDICAL HISTORY:
- Peripheral vascular disease
- Long-term anticoagulation
- Anemia
- Obesity
- Sleep apnea
- Osteomyelitis - Ankle/Foot (Acute)
- Restless legs syndrome
- Colonic Polyp
- Gout
- Lumbar spinal stenosis
- Nephrolithiasis
Social History:
Occupation: Retired security guard, worked at a pharmaceutical
company with chemical exposure.
Family: Married
Tobacco history: Smoked from age 6-35; quit at 35.
ETOH: 1-2 drinks per month.
Illicit drugs: Denies.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam
GENERAL: 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 to Jaw
CARDIAC: RR, with + holysystolic loudest on LUSB.
LUNGS: Bil crackles up to mid lung fields. No chest wall
deformities, scoliosis or kyphosis. Resp w/ mild increase in
wOB, no accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: +3 pitting edema up to thigh w/ LE
hyperpigmentation
PULSES: + 1 on bil LE
Discharge Exam
Gen: alert, oriented, NAD
HEENT: supple, JVD at 5 sitting on edege of bed
CV: irreg irreg, 1/6 systolic murmur at RUSB,
RESP: No crackles or wheezes.
ABD: firm, NT, pos BS
EXTR: 1+ peripheral edema to 1/2 up calf, skin is wrinkled near
ankles.
NEURO: A/O
Extremeties: none
Pulses:
Right: DP 1+ PT trace
Left: DP 2+ PT trace
Skin: intact
Pertinent Results:
LABS ON ADMISSION
[**2180-5-10**] 12:40PM GLUCOSE-115* LACTATE-2.1* K+-3.6
[**2180-5-10**] 12:30PM GLUCOSE-122* UREA N-46* CREAT-1.8* SODIUM-138
POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-33* ANION GAP-14
[**2180-5-10**] 12:30PM ALT(SGPT)-14 AST(SGOT)-18 ALK PHOS-179* TOT
BILI-1.0
[**2180-5-10**] 12:30PM LIPASE-34
[**2180-5-10**] 12:30PM cTropnT-0.02*
[**2180-5-10**] 12:30PM proBNP-765
[**2180-5-10**] 12:30PM ALBUMIN-3.9 CALCIUM-8.4 PHOSPHATE-2.5*
MAGNESIUM-2.8*
[**2180-5-10**] 12:30PM DIGOXIN-1.5
[**2180-5-10**] 12:30PM WBC-6.6 RBC-3.00* HGB-8.6* HCT-27.3* MCV-91
MCH-28.8 MCHC-31.7 RDW-19.2*
[**2180-5-10**] 12:30PM NEUTS-79.0* LYMPHS-12.4* MONOS-6.5 EOS-1.4
BASOS-0.7
[**2180-5-10**] 12:30PM PLT COUNT-284
[**2180-5-10**] 12:30PM PT-27.3* PTT-38.5* INR(PT)-2.6*
.
LABS ON DISCHARGE:
[**2180-6-8**] 05:16AM BLOOD WBC-7.1 RBC-2.90* Hgb-8.3* Hct-25.9*
MCV-89 MCH-28.5 MCHC-31.9 RDW-19.5* Plt Ct-305
[**2180-6-8**] 05:16AM BLOOD PT-28.2* INR(PT)-2.7*
[**2180-6-8**] 05:16AM BLOOD Glucose-92 UreaN-46* Creat-1.8* Na-141
K-4.0 Cl-100 HCO3-33* AnGap-12
.
ECG ([**2180-5-10**] 12:27:36 PM)
Demand ventricular paced rhythm with frequent ventricular
premature beats.
Q-T interval prolongation. No previous tracing available for
comparison.
.
ECG ([**2180-5-15**] 2:30:34 PM)
Ventricular pacing with wide complex native beats, probably
ventricular in
origin. Since the previous tracing of [**2180-5-10**] the ventricular
bigeminal pattern is not seen but ventricular premature beats
persist.
.
CHEST (PA & LAT) ([**2180-5-10**] 1:33 PM)
IMPRESSION:
1. Ill-defined bibasilar opacities, possible aspiration or
pneumonia in the appropriate clinical setting. Underlying mild
interstitial lung disease is also possible.
2. Intact pacemaker/ICD leads in standard position.
3. Stable mild cardiomegaly.
4. Possible small effusions or pleural thickening.
.
CHEST (PA & LAT) ([**2180-5-14**] 9:26 AM)
IMPRESSION:
1. Probable background COPD.
2. Cardiomegaly, with sternotomy and ICD device.
3. Bibasilar opacities, ? infectious, inflammatory or
aspiration. Suspect
some background more diffuse interstitial abnormality. If there
is clinical concern for an infectious process, followup imaging
to confirm resolution is recommended. Chest CT may be useful to
evaluate the background parenchymal pattern.
4. Bilateral pleural thickening.
5. ?increased soft tissue density adjacent to right paratracheal
region, not fully assessed here. Attention to that area at the
time of CT scan is
recommended.
.
CT CHEST W/O CONTRAST ([**2180-5-14**] 4:32 PM)
IMPRESSION: Fibrotic lung changes with a pattern corresponding
to NSIP, of
overall mild-to-moderate severity. Further pulmonologic workup
is strongly
suggested. Mild-to-moderate mediastinal lymphadenopathy, with
partly calcified lymph nodes, that might suggest previous
exposure to granulomatous disease and also might be related to
the fibrotic lung changes. Status post CABG, left pectoral
pacemaker in correct position.
No evidence of pulmonary nodules or masses. Minimal bilateral
pleural effusions. No pericardial effusions, no osteodestructive
lesions.
.
Cardiac Cath ([**2180-5-15**])
1. Markedly elevated left and right heart filling pressures.
2. Severe pulmonary hypertension.
Video swallow study ([**2180-6-8**])
1. Aspiration of thin liquids with moderate residue
2. Barium reflux to nasopharynx
3. large osteophyte in C3
Brief Hospital Course:
79-year-old male with ischemic CHF NYHA IV (EF 30%) BiV ICD,
pAFIB on coumadin, CKD (Cr 1.6-1.8), hx of LGIB (angioectasia
colonoscopy [**2179**]) with down trending Hct from the low 30s-> 27.5
with progressive fatigue, DOE with any activity who was admitted
for CHF exacerbation.
# CORONARIES: Pt has hx of 3 vessel disease with CABG in [**2172**],
he denied having any chest pain on admission. ASA, BB, statin
were continued on admission. He was started on losartan but due
to his acute kidney injury in setting of diuresis, his [**Last Name (un) **] was
discontinued. It will need to be restarted as outpatient.
# Acute on Chronic Systolic CHF: Pt with hx of CHF last echo
showed EF of 30%, fluid overloaded on exam. He appears to not be
responding appropriate to home dose of lasix, spironolactone and
metolazone. He was treated with IV lasix/metolazone and assessed
for further diuresis on a daily basis. However, his BP was often
too low and his daily lasix was held on numerous occasions. On
[**2180-5-14**] he was transfused w 2 Units of blood over 4 hours each
(for dropping Hct) but his pressures remained low. On [**2180-5-15**],
he underwent a R-sided cardiac cath that revealed PCWP of 30 and
he was placed on lasix gtt but this was quickly stopped as SBPs
were in the 70s. He was transfered to the CCU for augemented
diuresis on a dopamine and lasix gtt. In the CCU patient with
brisk diuresis of greater than 5L with noted subjective
improvement of symptoms, and dopamine was stopped on [**5-17**]. He
was transitioned to torsemide 100mg PO daily and metolazone 2.5
mg PO daily was started. He was continued on Torsemide 100mg PO
daily on the floor for several days, however hypotension with
SBP in low 80s-90s prevented further increase in diuresis.
Patient was significantly orthostatic during this time with SBP
60s and lightheadeness while sitting up and an inability to work
with PT given his symptoms. Over this period, several doses of
metoprolol were held given his hypotension. He has worsened
volume overload in this setting with uptrending weight,
creatinine. His weight was 94kg and Cr. 3.3 prior to his
transfer to the CCU for augmented diuresis. In the CCU, he was
restarted on dopamine and lasix gtt and diuresed well with BPs
in the 90s-100s/50s-60s. From [**5-26**] to [**6-4**], he diuresed an
additional 19L. Dopamine was weaned off on [**6-3**] and the patient
was transferred to the floor on [**6-4**] with a lasix gtt. [**6-6**] Lasix
gtt was dced and pt was started on torsemide 80mg [**Hospital1 **]. Torsemide
was decreased to 80 mg po qdaily on [**2180-6-8**] as he was net
negative on qdaily dose. His dry weight upon discharge was 182
lbs and BNP was 1117.
# RHYTHM: Pt w/ biventricular pacer, v paced at this time. Hx of
A-fib on coumadin at therapeutic range. On dig and on
metoprolol. His coumadin was held for Cardiac cath on [**2180-5-15**]
(at which point it was 2.2). Given he was CHADS2 of at least 2,
ASA 81mg daily was started for AF anti-coag, considering
carefully the presence of concomitant GI bleed. He was then
briefly heparin gtt- bridged to coumadin with uptitrated dose of
coumadin, his INR was 1.7 prior to his transfer to the CCU, and
was therapeutic while in the CCU. His INR Was 2.7 on discharge.
His goal INR is 2.0-2.5. Counadin was held on [**6-8**] to decrease
INR slightly. [**Month (only) 116**] consider 1mg alternating wtih 0.5 mg dosing in
the future.
# Anemia: Likely contributing to symptoms of fatigue. Patient
with known hx of angioectasia to the mid jejunum. Guaiac
positive in the ED. Hct 3 points lower than baseline. Currently
taking iron. Last colonoscopy in [**2179**]. GI was consulted and
recommended clarifying cardiac situation prior to any GI
studies. They also recommended supportive care with blood
transfusions; patient was transfused 1 unit of pRBCs in the CCU
with appropriate Hct elevation. GI was reconsulted when the
patient returned to the floor and he underwent an enteroscopy on
[**5-22**] which showed "Normal esophagoscopy; Normal stomach. Normal
duodenum with bile present. The enteroscope was advanced to
120cm into the jejunum and there was no bleeding identified and
not AVM seen." GI signed off at that point and indicated that
they did not believe he was having a significant GI bleed and
that further workup should be defered to the outpatient setting.
His HCT downtrended to nadir of 23.4 on [**2180-5-26**] without
transfusion. He was transfused 1U PRBC on [**2180-6-2**]. His iron
studies were consistent with iron deficiency anemia. He was
startd on iron 325 mg po BiD. His hematocrit on [**2180-6-8**] was
25.9. Our transfusion threshold for him was adjusted to > 22.
# Dysphagia: He was noted to have dysphagia to solid food on
[**2180-6-7**]. Speech and swallow study noted obstructive pattern
due to large C3 osteophyte. He was encourage to regain his
strength and placed on soft liquid diet with protein shakes for
nutrition.
# Fibrotic Lung changes. Patient without h/o of known
restrictive lung disease. CT chest on [**5-14**] with extensive
fibrotic lung changes with a pattern corresponding to NSIP, of
overall mild-to-moderate severity. Pulmonary impression was that
he had underlying restrictive lung disease and severe pulmonary
hypertension, likely significant causative factors for his
progressive DOE.
# UTI: On [**5-29**], the patient complained of dysuria. Urine cx grew
> 100k E.coli. He completed 7 days of ciprofloxacin 500 mg [**Hospital1 **].
# Acute on Chronic Kidney Disease. Per report baseline
creatinine 1.6-1.8. In house elevated to 2.7 on admission.
FeUrea 27; consistent with pre-renal in setting of intravascular
volume depletion vs poor forward flow in setting of heart
failure. Creatinine improved in the setting of augmented
diuresis. Transitioned to carvedilol to aid in forward flow
(which was changed to low dose metoprolol on the floor). His
creatinine reached a nadir of 1.9 on [**2180-5-22**] in the CCU while on
pressors and then trended up to 3.3 over the next 4 days as
hypotension, orthostasis and inability to further diurese
limited his renal perfusion. With augmented diuresis with
dopamine, Cr improved to baseline and was 1.8 on discharge.
# RESTLESS LEGS SYNDROME: Continued on Mirapex
# SLEEP APNEA: Continued on home CPAP machine.
# Rehab issues
1. Please check hematocrit, creatinine and electrolytes on
[**2180-6-11**] and [**2180-6-14**] and twice a week if he stays longer than a
week. Please arrange for transfusion if HCT is less than 22.
Please call physician on call if creatinine > 2.5, sodium < 130
or potassium > 5.0
2. His dry weight is 182 lbs. Please check weight daily, if his
weight is greater than 185 lbs please give him extra dose of
torsemide.
OUTPATIENT ISSUES:
- Pulmonary follow-up needed with PFTs
- Consider surgical biopsy which is usually necessary for
confirmation of dx of NSIP
- Consider capsule endoscopy / EGD / Colonoscopy
- Will need daily swallow therapy with speech therapist
Medications on Admission:
MEDICATIONS (Home):
- Furosemide (LASIX) 80 mg Oral take 2 tablets (160mg) twice a
day
- Potassium Chloride 20 mEq Oral Tablet, ER 2 tablet daily
- Metolazone 2.5 mg Oral Tablet
- Betamethasone Dipropionate (DIPROSONE) 0.05 % Topical Cream
Apply twice daily to legs
- Digoxin 125 mcg Oral Tablet TAKE ONE TABLET DAILY EVERY
EVENING
- Lorazepam 1 mg Oral Tablet TAKE [**1-2**] TO 1 TABLET AT BEDTIME AS
NEEDED FOR INSOMNIA
- Ferumoxytol (FERAHEME) 510 mg/17 mL (30 mg/mL) Intravenous
Solution feraheme 510mg conc:30mg/ml=17ml=510mg delivered in
syringe
- Magnesium Oxide 400 mg Oral Tablet TAKE ONE TABLET DAILY EVERY
EVENING
- Metoprolol Succinate 25 mg Oral Tablet Sustained Release 24 hr
- Lorazepam 1 mg Oral Tablet TAKE 1 TABLET AT BEDTIME AS NEEDED
- Simvastatin 10 mg Oral Tablet 1 tablet every evening for
cholesterol
- Allopurinol 300 mg Oral Tablet TAKE ONE TABLET DAILY
- Spironolactone 25 mg Oral Tablet take [**1-2**] tablet DAILY
- Ferrous Sulfate 325 mg (65 mg Iron) Oral Tablet 1 tablet qd
- Warfarin 1 mg Oral Tablet None Entered
- Omeprazole 20 mg Oral CpDR TAKE 2 CAPSULE DAILY
- Fluocinolone 0.025 % TOPICAL CREAM 0.025 % Top Crea apply
TWICE DAILY to legs as needed
- Docusate Sodium Capsule 100MG PO takes one [**Hospital1 **]
- Mirapex tablet 0.125MG PO (PRAMIPEXOLE DI-HCL)
.
MEDICATIONS (on transfer):
- Metolazone 2.5 mg PO DAILY
- Allopurinol 100 mg PO/NG DAILY
- Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **], hold for SBP<100 and
HR<60
- Digoxin 0.125 mg PO/NG DAILY
- Pantoprazole 40 mg PO Q12H
- Docusate Sodium 100 mg PO BID
- Fluocinolone Acetonide 0.025% Cream 1 Appl TP [**Hospital1 **]
- Simvastatin 10 mg
- Furosemide 5-20 mg/hr IV DRIP INFUSION
- Senna 1 TAB PO/NG [**Hospital1 **]:PRN Spironolactone 12.5 mg PO/NG DAILY
- Lorazepam 1 mg PO/NG HS:PRN anxiety
- Pramipexole *NF* 0.625 mg Oral QHS Restless leg syndrome
- Losartan Potassium 25 mg PO/NG DAILY hold for SBP<100
Discharge Medications:
1. betamethasone dipropionate 0.05 % Cream [**Hospital1 **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
2. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 0.25 Tablet PO BID (2
times a day): may crush in applesauce.
3. torsemide 20 mg Tablet [**Hospital1 **]: Four (4) Tablet PO DAILY (Daily):
can crush in applesauce.
4. spironolactone 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily):
can crush in applesauce.
5. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Hospital1 **]: Five (5)
cc PO BID (2 times a day).
6. lorazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety: please give under tongue or crush
in applesauce.
7. simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily): crush in applesauce.
8. allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day:
please crush in applesauce.
9. Outpatient Lab Work
Please check hematocrit, creatinine, INR and electrolytes on
[**2180-6-11**] and [**2180-6-14**] and twice a week if he stays longer than a
week. Please arrange for transfusion if HCT is less than 22.
Please call physician or NP on call if creatinine > 2.5, sodium
< 130 or potassium > 5.0. INR goal 2.0-2.5.
10. acetaminophen 650 mg/20.3 mL Solution [**Month/Day/Year **]: Twenty (20) ml PO
Q6H (every 6 hours) as needed for pain.
11. aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable
PO DAILY (Daily): may crush in applesauce.
12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): do not crush, can
dissolve in mouth .
13. pramipexole 0.25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QHS (once a
day (at bedtime)) as needed for Restless leg syndrome: may crush
in applesauce.
14. senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) ml PO BID (2 times a
day) as needed for constipation.
15. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Five (5) cc PO BID (2
times a day).
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Primary:
acute on chronic congestive heart failure: ACE held because of
renal failure.
Acute Blood Loss anemia
interstitial lung disease
Acute on Chronic Kidney disease
Coronary artery disease
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 an acute exacerbation of your congestive heart failure
and needed to be admitted to the CCU twice for intravenous
diuretics and medicines to help your heart pump better.
Your discharge and "dry" weight is 182 pounds. This is your
ideal weight and you will need to increase or decrease the
torsemide to stay at this weight.
Weigh yourself every morning before breakfast, call [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 107826**] NP if weight increases more than 3 pounds in 1 day or 5
pounds in 3 days.
You also continued to have bleeding from the malformations in
your intestinal tract. You will need to have blood transfusions
on a regular basis and continue to take iron supplements to keep
your blood count more than a hematocrit of 22.
Your blood count this morning is 26.
Your kidneys worsened with the diuresis temporarily but have now
recovered.
You have a bony deformity on your spine that is impinging on
your throat and causing trouble with swallowing. We think that
weakness is making this worse and hope that it will improve with
swallowing therapy and general physical therapy. In the
meantime, we will give you only shakes to drink and liquid or
crushed medicines.
We made the following changes to your medicines:
1. Discontinue furosemide, metolazone, digoxin and magnesium
2. Change metoprolol to tartrate formulation so the medicine can
be crushed.
3. Start torsemide 80 mg daily to prevent fluid accumulation.
This will need to be titrated up or down to maintain a weight of
182 pounds
4. Decrease allopurinol to 100 mg daily
5. Increase iron to twice daily
6. change omeprazole to lansoprazole so that it can be given in
liquid form
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 107827**], MD
Specialty: Cardiology
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **]
within the next week. You will be called with the appointment.
Since you are going to an Extended Care Facility they will call
your home number to speak to your spouse but they also have the
phone number of your daughter. If you have not heard within 2
business days or have questions, please call the number above.
|
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1816, 1881
|
2331, 2545
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 133,210
|
42980
|
Discharge summary
|
report
|
Admission Date: [**2186-2-25**] Discharge Date: [**2186-3-2**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
[**3-1**] PORT line removal.
[**3-1**] PICC placement.
[**3-2**] PICC removal.
History of Present Illness:
This is a 37 y/o male patient with PMH Type I DM, HTN,
gastroparesis, ESRD on HD (last in [**2-7**] per patient) who
presents to MICU with hypertensive urgency unable from the ED.
The patient early this morning to the ED with his usual nausea,
vomiting, abdominal pain and was found to be hypertensive to
256/110, HR 102, T 99.2, RR 22, 92% RA. History is difficult to
obtain from patient d/t somnolence and lack of desire to
participate in interview, but per ED note he was diaphoretic and
'writing in pain', vomiting clear substance. He was given
ativan a total of 4 mg of ativan, 6 mg of dilaudid, labetolol 20
mg IV x 1 and hydralazine 10 mg IV x 1 without good response
(200/99). He recieved 2L NS and was started on labetolol gtt
and BP decreased to 161/79. Tranferred to MICU for further
management while on labetolol gtt.
.
Of note, the patient is admitted to hospital 3 times every month
for similar complaints with last admission [**Date range (1) 92781**]/07. At
that time BP was attributed to abdominal pain and inability to
take PO meds d/t nausea/vomiting. Also had labile blood sugars
with repeated episodes of hypoglycemia, and [**Last Name (un) **] recommended
sugars in the range of 150-200. He eloped prior to formal
discharge when his FS was found to be critically high -
recommended to patient that he stay for repeat, but left AMA
without signing any forms.
.
Upon transfer to the MICU the patient appears somewhat
uncomfortable, reporting nausea and abdominal pain, but when
questioned he was unable/unwilling to participate in HPI or exam
d/t sleepiness. He denied CP, SOB, HA, vision changes, neck
stiffness, dysuria, or other symptoms.
.
In the MICU he became hypotensive to SBP 80s. Labetalol was
stopped and he received a 500cc fluid bolus and his blood
pressure rose to SBP 90s. Cardiac and infectious sources of
hypotension were considered, but cardiac enzymes were not
changed from prior studies and he had no localizing signs of
infection; blood cultures were sent and a ultrasound of the L
arm AVF ordered to rule out abscess at the site. He received a
partial HD session, limited by hypotension. Over night, his
blood pressure trended up to 130s systolic. He was restarted on
his home blood pressure regimen. Renal consult team saw him
[**2186-2-26**] and plan to next dialyze him on [**2186-2-27**].
.
He was to be called out to the medical floor on [**2186-2-26**] but
became somnolent after receiving pain and anti-nausea meds, so
he stayed in the ICU for closer monitoring of respiratory
status, which spontaneously improved. His blood sugar at 10pm
was low at 22 and he was disoriented, which resolved with two
glasses of juice; he did not receive his standing dose of NPH
that evening. Blood cultures returned positive with GPC in pairs
and clusters, so a TTE and surveillance cultures were ordered
and vancomycin was started. He was then called out to the
medical floor on [**2-27**].
Past Medical History:
1. DM type I
2. ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat
3. Severe autonomic dysfunction with multiple hospitalizations
for hypertensive emergency, gastroparesis, and orthostatic
hypotension.
4. History of esophageal erosion, MW tear
5. CAD with 1-vessel disease (50% stenosis D1 in [**7-/2181**]), normal
stress
[**11/2182**]
6. hx of Foot Ulcer
7. h/o clot in AV graft x2 ([**Month (only) 958**] and [**2185-8-13**])
Social History:
Denies alcohol or tobacco use. Endorses occassional marijuana
use. Lives with his [**Hospital1 **] mother and their three children.
Family History:
His father recently died of ESRD and diabetes. His mother is in
her 50s and has hypertension. He has two sisters, one with
diabetes, and six brothers, one with diabetes.
Physical Exam:
Vitals: 97.4, 164/90, 102, 10, 97% 4L
General: sleepy, arouses to voice but limited participation with
physical exam
HEENT: PERRL, left pupil smaller than right, pt will not
participate in EOMI, sclera anicteric, MM dry, No OP lesions
Neck: Supple, no JVD
CV: RRR, nl S1, S2, 2/6 systolic murmur at LUSB
Lungs: CTAB post
Chest: HD line in place without erythema
Abd: Soft, ND, nontender, + BS, no guarding, no rebound,
multiple well healed scars
Ext: no c/c/e, left arm with fistula with good thrill
Skin: no rashes
Brief Hospital Course:
Pt admitted to medical floor in hemodynamically stable condition
without specific complaints.
.
# hypertensive urgency: Upon presentation it was unclear when
last time was that patient took meds, but hypertension likely
d/t inability to take meds in setting of N/V. Also contribution
of autonomic dysfunction. No evidence of active end organ
damage. Pt was treated with labetalol gtt in MICU which was
weaned off on [**2-26**]. carduac enzymes mildly elevated, felt [**3-17**]
demand ischemia in setting of hypertensive urgency, CK and MB
trended [**Last Name (un) 8636**] at time of admission to medical floor.
.
Pt's hypertensive urgency was resolved upon admission to the
medical floor. His SBPs ranged 140s-170s. He was restarted on
his home regimen of antihypertensives without difficulty
(metoprolol 75 tid, clonidine patch and oral, nifedipine 30 SR
qdaily). he was discharged home with change in his regimen.
.
.
# bacteremia: pt with 2/4 bottles [**Last Name (un) **] neg staph on [**2-25**] and
again on [**2-26**]. PORT was felt most likely source, and pt has had
at least 2 sets of +blood cultures since it was placed. TTE was
obtained which was not concerning for endocarditis. pt without
stigmata of SBE. ID consult obtained which recommended removal
of PORT, which was taken out on [**3-1**]. Pt will compelete a 2
week course of vancomycin at hemodialysis, which has been
arranged by renal service. A PICC was breifly placed, however
removed as it is unclear if pt can reliably flush this. PORT
will be replaced on [**2186-3-20**] per IR (Dr. [**Last Name (STitle) 380**] placed last PORT,
then removed it on [**3-1**]), ordered placed in OMR. Indication:
diabetic gastropathy causing inability to toleral oral
antihypertensive medication prompting repeated ED presentation
for hypertensive urgency. Pt with surveillance cultures and
port tip cultures showing NGTD on [**3-2**], he will have futher
surveillance cultures drawn at hemodialysis and followed by his
nephrologist.
.
.
# n/v/abdominal pain: pt with multiple admissions with similar
complaints, etiology [**3-17**] gastroparesis, improves considerably
with ativan, dilaudid, reglan, pt was tolerating PO meds/diet at
time of admission to medical service and was restarted on oral
reglan.
.
.
# DMI: Pt on sliding scale as inpatient and taking NPH 2 units
[**Hospital1 **] at home. pt with two episodes of hypoglycemia (FSBS 22 and
27), etiology unclear, pt followed by [**Name (NI) **], who recommend no
changes to current insulin regimen. will discharge pt with
instructions to continue NPH 2 UNITS [**Hospital1 **] as [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] recs.
.
.
# CAD - pt denied cp/sob throughout hospitalization. Troponins
rose at admission, however CK and MB trending [**Last Name (un) 8636**] wat time
of admission to medical service. Etiology felt most likely
demand ischemia in setting of original hypertensive urgency with
persistent elevation of trop [**3-17**] ESRD. Pt was continued on
aspirin, metoprolol, nifedipine.
.
.
# ESRD: etiology likely [**3-17**] DM and HTN, pt tolerating HD well,
and underwent dialysis without difficulty on [**3-2**]. pt will be
discharged home with plan to continue current dialysis schedule
(Tue/Th/Sat). In addition pt will be given vancomycin at
dialysis x 2 week course (last day [**2186-3-14**]) given his PORT line
infection. He will have levels drawn at dialysis and be dosed
with vancomycin as appropriate. Plan is for surveillance
cultures to be drawn at dialysis. If negative, pt is scheduled
for presumptively replacement of PORT on [**2186-3-20**] with
interventional radiology (dr. [**Last Name (STitle) **]). Pt continued on home
regimen of calcium acetate 667 mg, 3 capsules TID.
.
.
# AV fistula: pt with h/o numerous clots in AV fistula. No
signs of infection presently, and tolerating dialysis without
difficulty. Pt was subtherapeuticon INR on admission, thus
treated with heparin gtt. [**Last Name (STitle) **] held on [**2-28**] for PORT
removal, and restarted on [**3-2**]. Pt discharged with instructions
to continue [**Month/Year (2) **] 1.5mg po qdaily with goal INR [**3-18**].
.
.
# DISPO:
pt discharged home on [**3-2**] with instructions to compelte 2 week
course of vancomycin at hemodialysis for his PORT line
infection. an appointment was made with interventional
radiology on [**2186-3-20**] to replace his PORT, under the assumption
that his surveillance cultures from dialysis remain negative.
discussed this plan with renal service ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) who will
communicate with pt's outpatient dialysis service.
Medications on Admission:
Metoclopramide 10 mg PO Q6
Metoprolol Tartrate 75 mg PO TID
Calcium Acetate 1340 mg tid with meals
Anzemet 12.5 IV prn
Prochlorperazine 10 mg IV Q6H prn
Ativan 1 mg PO Q6H prn
Dilaudid 4mg PO Q3-4H prn
Insulin NPH 2 units Subcutaneous twice a day.
Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QTHUR
Clonidine 0.2 mg PO TID
Prochlorperazine 10 mg q 6 h
[**Last Name (NamePattern1) 197**] 1.5 mg PO QHS
Nifedipine 30 SR mg PO QD
Bisacodyl prn
Protonix 40 QD
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
3. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO q6h prn.
5. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO q3-4hr prn.
6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous QHD (each hemodialysis): 2 week course to be given
at dialysis, last day [**2186-3-14**].
Disp:*qs * Refills:*2*
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
14. Humalog 100 unit/mL Solution Sig: USE AS DIRECTED
Subcutaneous four times a day: please use attached sliding
scale.
Disp:*qs * Refills:*2*
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 2 UNITS
Subcutaneous twice a day.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
bacteremia [**3-17**] PORT line infection
hypertensive urgency
diabetic gastropathy
Discharge Condition:
stable.
Discharge Instructions:
please continue to take all of your medications as prescribed.
you were started on a 2 week course of vancomycin to be given at
hemodialysis for your line infection. you will have your PORT
replaced after 2 weeks of antibiotics if your blood cultures
remain negative.
.
if you have recurrent fevers, chills, naseau, vomitting, chest
pain, shortness of breath, or other worrisome symptoms, please
contact your primary care physician or the emergency department.
Followup Instructions:
please follow up with your primary care doctor within 4 weeks.
.
please follow-up with your dialysis physician regarding
replacing your PORT.
.
please follow-up with dr. [**First Name (STitle) **] [**Doctor Last Name **] in gastroenterology
within 1-2 weeks, an appointment has been made for on you [**2186-3-20**]
at 3PM. [**Telephone/Fax (1) **] ([**Hospital Unit Name **], [**Location (un) 453**], [**Location (un) **]).
.
upon arriving home please contact the [**Name2 (NI) 387**] and arrange to be
seen within 1-2 weeks.
|
[
"536.3",
"337.1",
"250.43",
"790.7",
"250.63",
"414.01",
"250.83",
"041.19",
"996.62",
"585.6",
"403.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"86.05",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11358, 11364
|
4729, 9406
|
334, 415
|
11501, 11511
|
12022, 12551
|
4002, 4173
|
9915, 11335
|
11385, 11480
|
9432, 9892
|
11535, 11999
|
4188, 4706
|
275, 296
|
443, 3378
|
3400, 3837
|
3853, 3986
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,050
| 108,409
|
32909
|
Discharge summary
|
report
|
Admission Date: [**2101-1-13**] Discharge Date: [**2101-1-29**]
Date of Birth: [**2039-1-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Fatigue, lightheadedness, CP, SOB and fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61 female with a h/o right Wilms tumor, s/p nephrectomy on the
R in [**2078**] and nephrectomy on the L on [**1-4**]/008 for a lower pole
renal mass with pending pathology who now presents with SOB, CP
and fever. The patient reports that she was suffering from
constipation and took a dulcolax which resulted in a large BM
this morning around 2am. She started to feel fatigued and
lightheaded afterwards. THen she developed a fever to 102 and
chest pain that was sharp and located over her R sternum and L
shoulder. It was pleuritic and non radiating. She also started
to develop mild SOB and was brought to the ED. Reportedly at
home her BP was high over the last days after she was discharged
from the hospital, ranging between 150 and 180 systolic.
.
Of note, she underwent L nephrectomy on [**1-4**] and has been doing
fine since. The operation and postoperative phase went without
complications. She has been doing well at home afterwards and is
able to ambulate a flight of stairs without complications. He
was dialyzed yesterday without complications
.
On arrival in the ED she was hypotensive with blood pressure of
106/52 which then decreased further to 76 over palp systolic.
Other Vitals 98.3 100 95%on 2LNC. CT significant for large
pleural effusions b/l and moderate to large pericardial
effusion. More focal opacity again seen in the right lower lobe.
Again findings are suspicious for endobronchial lesion with
post-obstructive pneumonia although infectious pneumonia and
aspiration cannot be excluded. Also large amount of
pneumoperitoneum, possibly post-surgical. The patient also
received Ceftriaxone, Azithromycin and Zosyn. She received one
dose of dexamethasone due to her absolute adrenal insufficiency.
She received Tylenol, Fentanyl 50mcg and Morphine 2mg for pain.
.
On ROS, she denies recent antibiotic use other than one
preoperative dose of antibiotics. Otherwise she denies abdominal
pain, changes in the color of her stool or urine. She denies any
sick contacts.
Past Medical History:
Wilms tumor
HTN
PSH:
Right nephrectomy [**2078**]
CCY-open
C-section x 2
Tubal ligation
Social History:
none
Family History:
none
Physical Exam:
Vitals
General Appearance
HEENT
COR
LUNG
ABD
EXT
Neuro
Pertinent Results:
[**2101-1-13**] 04:06PM PT-12.3 PTT-33.2 INR(PT)-1.0
[**2101-1-13**] 12:50PM LACTATE-2.0
[**2101-1-13**] 12:45PM GLUCOSE-106* UREA N-20 CREAT-5.6* SODIUM-134
POTASSIUM-3.6 CHLORIDE-92* TOTAL CO2-30 ANION GAP-16
[**2101-1-13**] 12:45PM estGFR-Using this
[**2101-1-13**] 12:45PM CK(CPK)-15*
[**2101-1-13**] 12:45PM CK-MB-2 cTropnT-0.03*
[**2101-1-13**] 12:45PM WBC-18.4* RBC-3.64* HGB-9.8* HCT-30.2* MCV-83
MCH-27.0 MCHC-32.5 RDW-14.4
[**2101-1-13**] 12:45PM NEUTS-85.8* LYMPHS-9.1* MONOS-3.6 EOS-1.4
BASOS-0.2
[**2101-1-13**] 12:45PM PLT COUNT-388#
.
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2101-1-13**] 7:39 PM
CTA CHEST W&W/O C&RECONS, NON-; CT ABDOMEN W/CONTRAST
Reason: LT NEPHRECTOMY, NOW RT PLEURITIC CP, FRVER.
Field of view: 38 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with recent L nephrectomy, now with R
pleuritic CP, fever, dyspnea.
REASON FOR THIS EXAMINATION:
evaluate for PE, evaluate for intraabdominal process.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 61-year-old woman with recent left nephrectomy, now
with right pleuritic chest pain, fever, dyspnea.
COMPARISON: CT of the chest [**2101-1-1**], CT of the abdomen
[**2100-11-30**].
TECHNIQUE: MDCT-acquired axial images of the chest, abdomen and
pelvis were obtained with IV contrast. Images of the chest were
also obtained without IV contrast. Multiplanar reformatted
images were also displayed.
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: There is a new
moderate-to- large pericardial effusion. The pericardial
effusion measures of simple fluid attenuation, no definite
enhancing wall is identified.
Multiple prominent mediastinal lymph nodes are again seen,
slightly larger compared to prior chest CT. Enlarged right hilar
lymph node (3A:37) measures 17 mm in short-axis dimension,
little changed from prior.
New large bilateral pleural effusions with associated
atelectasis are identified. A more focal consolidation is again
seen within the right lower lobe. Previously described multiple
pulmonary nodules are not well evaluated on the current study.
There is no evidence of pulmonary embolism.
CT OF THE ABDOMEN WITH IV CONTRAST: There is a large amount of
pneumoperitoneum, possibly post-surgical in nature. Free fluid
seen scattered throughout the abdomen and pelvis, also
presumably post-surgical. The liver, pancreas, spleen appear
unremarkable. Patient is status post bilateral nephrectomies. No
definite recurrent mass is identified within the nephrectomy
beds.
Visualized portions of bowel appear unremarkable. There is no
evidence of obstruction. Normal appendix is identified.
Surgical staples seen in the anterior left abdominal wall.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid, bladder
appear unremarkable. Heterogeneous enhancing uterus consistent
with fibroid uterus is noted. Free fluid seen tracking into the
pelvis.
BONE WINDOWS: No suspicious lytic or blastic lesions are
identified.
IMPRESSION:
1. New moderate-to-large pericardial effusion.
2. New large bilateral pleural effusions with associated
atelectasis.
3. Focal opacity again seen in the right lower lobe. Again
findings are suspicious for endobronchial lesion with
post-obstructive pneumonia although infectious pneumonia and
aspiration cannot be excluded. As previously recommended,
dedicated bronchoscopy could be helpful for further evaluation.
4. No evidence of pulmonary embolism.
5. Large amount of pneumoperitoneum, possibly post-surgical.
6. Free fluid in the abdomen, presumably post-surgical.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: FRI [**2101-1-14**] 1:15 AM
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2101-1-13**] 12:56 PM
CHEST (PA & LAT)
Reason: Evaluate for PNA
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with fever, R chest pain. Recently postop
REASON FOR THIS EXAMINATION:
Evaluate for PNA
INDICATION: Fever, right-sided chest pain.
COMPARISONS: [**2101-1-4**].
CHEST, PA AND LATERAL: A dual lumen left internal jugular
approach hemodialysis catheter tip is within the SVC in
unchanged position. There are new, patchy airspace opacities at
the left lung base with a left-sided pleural effusion. A small
right-sided pleural effusion is also likely. Pulmonary
vasculature is within normal limits. Numerous surgical clips
within the abdomen and surgical staples overlying the left flank
are again identified. Free intraperitoneal air is consistent
with recent postoperative status.
IMPRESSION: Interval development of patchy airspace opacity at
the left lung base concerning for pneumonia giving the history.
Left-sided pleural effusion and likely small right-sided pleural
effusion. No evidence of CHF.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Approved: [**Doctor First Name **] [**2101-1-13**] 4:11 PM
.
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2101-1-19**] 7:00 PM
CT HEAD W/O CONTRAST
Reason: ? intracranial bleed
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with hypertensive emergency, headache, blurry
vision.
REASON FOR THIS EXAMINATION:
? intracranial bleed
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Hypertensive emergency, headache and blurry vision.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There are hypodensities within the white matter
centered within both occipital lobes extending into the parietal
convexities. There is no evidence for intracranial hemorrhage.
There is minimal mass effect, no shift of normally midline
structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
The osseous structures are unremarkable. There is mild mucosal
thickening in the right maxillary sinus. The mastoid air cells
are clear.
IMPRESSION: Findings suspicious for PRES (posterior reversible
encephalopathy syndrome). MR is recommended for further
evaluation if clinically indicated.
Findings discussed with Dr. [**Last Name (STitle) 6499**] via telephone 8:30 p.m.
[**2101-1-19**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: [**Doctor First Name **] [**2101-1-20**] 9:13 AM
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2101-1-22**] 3:37 PM
CHEST (PA & LAT)
Reason: ? interval change
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with known PNA and bilateral pleural effusion.
Now developing some low-grade fevers.
REASON FOR THIS EXAMINATION:
? interval change
STUDY: PA and lateral chest, [**2101-1-22**].
HISTORY: 62-year-old woman with known pneumonia and bilateral
pleural effusions. Now with developing low-grade fever. Evaluate
interval change.
There is a left-sided dialysis catheter, unchanged. Cardiomegaly
is stable. There has been improved aeration of the left
retrocardiac region and left base. There is a left small pleural
effusion. Surgical clips are seen within the upper abdomen.
Brief Hospital Course:
# [**Hospital 76591**] Hospital Acquired Pneumonia and Hypotension:
The patient presented with fever, cough, and infiltrate. In
addition she was initially hypotensive in the context of rising
white count and fever, suggesting possible sepsis and adrenal
insufficiency. She was fluid resuscitated and placed on
vancomycin and ceftriaxone for additional coverage. A DFA for
influenza was negative. The patient was also started on
stress-dose steroids for presumed adrenal insufficiency. The
pneumonia resolved clinically and radiographically. On chest
CT, an endobronchial lesion was identified. Pleural effusion
tapping was transudative but cytology was concerning for
malignant epithelial cells. The patient went for a bronchoscopy
that was unable to biopsy the suspected lesion; endobronchial
washings and lymph node biopsies were obtained that were pending
at the time of discharge.
# Pericardial Effusions: The patient's pericardial effusions
were identified on initial imaging. The differential included
uremia, fluid overloaded, and postoperative cytokine release
syndrome. Serial echocardiograms and physical exam did not
reveal tamponade physiology. Given the resolution of the
effusion with volume removal, it was thought to be secondary to
fluid overload; the fluid was never tapped.
# Posterior reversible encephalopathy syndrome (PRES) with
malignant hypertension: The patient had elevated blood pressures
following transfer out of the ICU despite dialysis and
antihypertensive therapy. Twenty four hours later she developed
confusion, sharply diminished visual acuity, and headache. The
diagnosis of PRES was made based on occiptial lobe findings on a
head CT. The patient's blood pressure was subsequently
controlled with a combination of Toprol XL, ace inhibitors, and
hemodialysis. Her headache, confusion, and visual changes
resolved.
# S/P bilateral nephrectomies: The patient was continued on
hemodialysis during her stay.
Medications on Admission:
Docusate Sodium 100 mg [**Hospital1 **]
Epoetin Alfa ASDIR
Oxycodone-Acetaminophen 5-325 mg PO Q4H (every 4 hours) as
needed.
B Complex-Vitamin C-Folic Acid 1 mg DAILY
Sevelamer HCl 800 mg TID
Prednisone 5 mg 2 Tablets PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a
day).
Disp:*64 Tablet Sustained Release 24 hr(s)* Refills:*0*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*28 Tablet(s)* Refills:*0*
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA
Discharge Diagnosis:
Primary:
Lobar post-obstructive Pneumonia
endobrachial lesion noted on chest CT
bilateral pleural effusions with cytology concerning for
malignancy
pericardial effusion
hypertensive emergency/posterior reversible encephalopathy
syndrome
fevers of unknown origin.
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
you were found to have a pneumonia. You also had fluid around
your heart and lungs that decreased after hemodialysis. Your
blood pressures were also very high resulting in headache and
visual changes. These both improved once your blood pressure
was controlled with medications and additional hemodialysis.
You also had a period of fevers. We never identified a cause
for these fevers, but they were likely bacterial in origin.
They resolved with antibiotic therapy.
The results of your pleural fluid cell analysis demonstrated
cells that were suspiscious for malignancy. You had a
bronchoscopy to obtain a sample of the tissue but they were
unable to sample the actual growth. Instead, they sampled
nearby lymph nodes and did a washing to collect cells. The
results of that study are pending and you need to have your
physician contact the [**Hospital1 18**] for followup.
Please continue to take your medications as prescribed. You
should follow up with your physicians as directed below. If you
develop a headache with visual changes, fevers, shortness of
breath, or any other concerns please contact a physician
[**Name Initial (PRE) 2227**].
Followup Instructions:
Please make an appointment to see you primary care physician,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 53192**] after discharge. He and your
nephrologist will have to work together to coordinate your blood
pressure medications with your hemodialysis.
In addition you will need to call Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] arrange for a
urology follow up appointment.
Your primary care physician should also follow up on the results
of your bronchoscopy to arrange the appropriate follow up and
evaluation of the growth in your lung.
You will also need to return to your dialysis on Monday as
planned.
Completed by:[**2101-2-8**]
|
[
"348.39",
"485",
"423.9",
"518.82",
"995.92",
"785.52",
"403.01",
"038.9",
"511.9",
"585.6",
"255.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"39.95",
"40.11",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
13224, 13283
|
9945, 11906
|
359, 365
|
13590, 13599
|
2638, 3443
|
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|
2542, 2548
|
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|
9333, 9436
|
13304, 13569
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11932, 12162
|
13623, 14845
|
2563, 2619
|
276, 321
|
9465, 9922
|
394, 2390
|
2412, 2503
|
2519, 2526
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,192
| 181,814
|
20011+57105
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-5-20**] Discharge Date: [**2106-5-28**]
Date of Birth: [**2034-3-28**] Sex: F
Service: Thoracic surgery
HISTORY OF PRESENT ILLNESS: The patient is a 72 year-old
female who presents preoperatively for repair of
tracheomalacia, status post tracheostomy. The patient is
status post resection of larynx tumor. She has had a left
main stem stent removed yesterday and is returned to the
emergency department with mild shortness of breath and
inability to clear her secretions. She came to the emergency
department and had some improvement. She is also here for
improvement of her tracheomalacia and scheduled for elective
tracheobronchoplasty.
PAST MEDICAL HISTORY: Is significant for laryngeal cancer,
status post resection and x-ray and radiation treatment,
tracheomalacia, status post tracheostomy, hypothyroid.
MEDICATIONS AT HOME: Synthroid .75 mcg per day, Zantac 150
mg p.o. b.i.d., potassium chloride, Mucomyst neb treatments q
4 p.r.n., albuterol inhaler p.r.n., saline inhaler p.r.n.
Patient has no known drug allergies.
SOCIAL HISTORY: She is a prior tobacco use.
FAMILY HISTORY: Is noncontributory.
PHYSICAL EXAMINATION: Patient is afebrile, 97.4, heart rate
is 83, blood pressure 145/63, respiratory rate of 30, satting
96 percent on room air. Patient is alert and oriented, well
appearing female, regular rate and rhythm. Lungs are clear
to auscultation bilaterally, had minimal sputum secretions.
Trach site is without any erythema. Abdomen is soft,
nontender, nondistended. Extremities showed no edema.
Patient had a chest x-ray which showed clear lung fields
bilaterally.
ASSESSMENT AND PLAN: A 72 year-old female who is preop for
tracheobronchoplasty. Patient has a history of
tracheomalacia. Patient is preopped for the operating room
the following day.
On [**2106-5-21**] patient was brought to the operating room for
elective tracheobronchoplasty and bronchoscopy. Patient
tolerated the procedure well and was transferred to the CSRU
in stable condition. Patient was extubated on a trach mask.
Patient had epidural and Foley catheter in place and chest
tube. On postoperative day one patient was afebrile. Vital
signs were stable. Patient was on a trach mask satting 98
percent. Patient's postoperative laboratories showed a white
count of 11.9 and a hematocrit of 34.3 and a platelet count
of 207. Patient's other laboratory values were otherwise
stable. Patient's epidural was continued. Vancomycin
intravenous was continued. Postoperative day two patient was
afebrile with stable vital signs. Patient was satting 95
percent on 60 percent trach mask. Patient's laboratory
values were all stable. Patient's chest tubes were
discontinued. On postoperative day two after chest tubes had
been discontinued patient started to develop increasing
subcutaneous emphysema up to her right base. Patient denied
any shortness of breath but had palpable crepitus across the
chest and right base. This was discussed with Dr. [**Last Name (STitle) 952**].
Chest x-ray showed pneumothorax and massive subcutaneous
emphysema. Patient had a right chest tube replaced. Patient
tolerated the procedure well. Patient was transferred to the
floor. Patient was seen by physical therapy. Patient was
out of bed to a chair. On postoperative day number four the
patient was ambulating with physical therapy. Patient had
maximum temperature of 99.2. Otherwise vital signs were
stable. Patient was saturating 92 to 96 on 56 percent face
mask. Patient's chest tube was putting out minimal output.
Patient did not have an air leak. Patient had laboratories
redrawn. White count was 7.8, hematocrit was 33.9. Other
laboratory values were all within normal limits. Patient's
chest tube was kept to suction and then transferred later on
that day to water-seal. The patient's antibiotic was changed
to Nasalide because the patient was feeling those issues
having a reaction to Vancomycin. On postoperative day four
patient's epidural was capped. On postoperative day five
patient had no significant events, he was afebrile. Vital
signs were stable. Chest tube continued to put out nothing
and had no air leak. Patient's subcutaneous emphysema had
improved significantly. Patient went for bronchoscopy by
pulmonary. Bronchoscopy showed no secretions with good
surgical results. Patient was out of bed with physical
therapy. Patient was seen by case management on
postoperative day six and stated that she was going to go
home, felt she had enough support to help her. On
postoperative day six the patient was continued to do well on
Nasalide tolerating it well, was afebrile with stable vital
signs. O2 saturations were 92 to 99 percent, 92 percent on
room air. Chest tube was putting out minimal. The chest
tube was removed. Patient was out of bed with physical
therapy. On postoperative day number seven patient
complained of having increased requirements for albuterol.
However, patient's oxygen saturations were 99 percent on the
trach mask. Patient was felt to be anxious about possible
discharge home. Rehabilitation possibilities were discussed
with the patient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 10638**]
MEDQUIST36
D: [**2106-5-28**] 08:46
T: [**2106-5-28**] 08:58
JOB#: [**Job Number 53918**]
Name: [**Known lastname 10011**], [**Known firstname 1194**] B. Unit No: [**Numeric Identifier 10012**]
Admission Date: [**2106-5-20**] Discharge Date: [**2106-5-28**]
Date of Birth: [**2034-3-28**] Sex: F
Service:
ADDENDUM
HOSPITAL COURSE: In summary, the patient's discharge was
postponed because of patient anxiety regarding going home,
and a rehabilitation screen was done. The [**Hospital 1325**]
rehabilitation screen, because of finding a bed, was likely
longer because of her MRSA in the sputum and pneumonia.
Therefore, she is now postoperative day #1, on Linezolid for
the MRSA pneumonia of a 14-day course. She is now doing
well. She has had an oxygen saturation of 99-100% on a trach
mask, although she does required frequent nebulizer
treatments, mainly for comfort and wheezing.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Tracheomalacia status post tracheostomy.
2. Status post resection of larynx tumor.
3. Removal of left mainstem bronchi stent.
4. Shortness of breath and wheezes.
5. Tracheomalacia status post tracheobronchoplasty during
this admission, date of which was [**2106-5-21**], via right
thoracotomy incision.
6. Laryngeal cancer with resection and radiation therapy in
the past.
7. Hypothyroidism.
8. Anxiety.
DISCHARGE MEDICATIONS: Synthroid 0.7 mcg/day, Zantac 150
p.o. b.i.d., Mucomyst nebs p.r.n., Albuterol nebs q.[**3-5**]
p.r.n., saline inhaler.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
DISPOSITION: To rehabilitation facility.
FOLLOW-UP: She is the patient with Dr. [**Last Name (STitle) 384**], call the
office for the appointment. She was encouraged to see her
primary care physician regarding anxiety.
[**First Name11 (Name Pattern1) 904**] [**Last Name (NamePattern4) 1369**], M.D. [**MD Number(1) 1370**]
Dictated By:[**Last Name (NamePattern1) 799**]
MEDQUIST36
D: [**2106-6-1**] 11:11
T: [**2106-6-1**] 11:23
JOB#: [**Job Number 10013**]
|
[
"519.1",
"V10.21",
"496",
"244.9",
"519.02",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"33.48",
"31.79"
] |
icd9pcs
|
[
[
[]
]
] |
1144, 1165
|
6814, 7476
|
6374, 6790
|
5763, 6319
|
885, 1081
|
1188, 5745
|
178, 690
|
713, 863
|
1098, 1127
|
6344, 6353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,143
| 133,347
|
42611
|
Discharge summary
|
report
|
Admission Date: [**2116-1-10**] Discharge Date: [**2116-1-13**]
Date of Birth: [**2033-5-19**] Sex: F
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
bright red blood per ostomy
Major Surgical or Invasive Procedure:
[**2116-1-10**]: MESENTERIC ANGIOGRAM and Embolization of peripheral
branch of the inferior mesenteric artery
History of Present Illness:
Ms. [**Known lastname 92167**] is an 82 year old woman with diverticulitis s/p
partial colectomy in [**2111**] who presented with frank blood on [**1-9**].
She initially went to [**Hospital **] Hospital where her sbp was noted
to be in the 150s. Her troponin was 0.07 with flat CKs, Cr 1.4.
Reportedly had an additionsl 700 cc of blood in the ED in her
ostomy. She was given one unit of prbcs prior to transfer to
[**Hospital1 18**] ED.
.
In the [**Hospital1 18**] ED, initial VS were: 97.5 108 158/79 14 97% RA. She
continued to have bright red output putting about 200-300 cc in
total. NG lavage negative. Hct was 32.2 (unclear baseline, was
34.7 at OSH around 2200), Cr 1.3. She was given a second unit of
prbcs and 1 liter NS. CTA showed an active diverticular bleed in
the transverse colon. IR was also contact[**Name (NI) **] and placed four
coils in her colonic artery on [**2116-1-10**]. She had an episode of
rigors post procedure, but was afebrile (cultures sent). She was
given 3U of PRBC and 1U of platelets in the MICU. Her Hcts have
been stable since the procedure and she was transfered to the
floor. She was restarted on lasix and metoprolol prior to
transfer. Her vitals on transfer were VS: 98.5 70 153/49 RR20
sat97% on RA.
Patient denies any fatigue, light headedness, nausea, or
vomiting. She denies fevers, chills, or night sweats. Her ostomy
output is becoming more brown. She has no abdominal pain and has
no shortness of breath or chest pain. Tolerating clears well.
Past Medical History:
PMH: CAD, type 2 DM, diabetic retinopathy, chronic lower
extremity edema, CRI, hypercholesterolemia, spinal stenosis,
osteoarthritis, gout
PSH: left colectomy, end colostomy, hartmann procedure for
perforated diverticulitis; pacemaker, eye surgery, rotator cuff
surgery, trigger finger surgery, hammer toe surgery
Social History:
Ambulates with wheelchair intermittently
- Tobacco: denies
- Alcohol: denies
- Lives in own apartment
Family History:
NC
Physical Exam:
Admission Physical Exam:
T 97.5 P 108 BP 158/79 R 14 SaO2 97% RA
Gen: no acute distress
Heent: no scleral icterus
Lungs: clear
heart: regular rate and rhythm
abd: soft, nontender, nondistended; ostomy with bloody output
extrem: no edema
Discharge exam
Vitals: T:99.2, 97.3 BP:129-157/51-74 P:67 R:20 O2:98%RA
FSBG: 142, 274, 264, 179
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: obese abdomen, soft, non-tender, bowel sounds present,
colostomy bag in place with brown stool in bag
Ext: warm, well perfused, 2+ pulses, trace to 1+ edema in BLE.
Pertinent Results:
Admission Labs:
[**2116-1-10**] 02:00AM WBC-7.6 RBC-3.61* HGB-10.7* HCT-32.2* MCV-89
MCH-29.6 MCHC-33.2 RDW-15.2
[**2116-1-10**] 02:00AM PLT COUNT-158
[**2116-1-10**] 02:00AM NEUTS-68.8 LYMPHS-23.6 MONOS-4.5 EOS-2.6
BASOS-0.6
[**2116-1-10**] 02:00AM GLUCOSE-170* UREA N-20 CREAT-1.3* SODIUM-142
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-29 ANION GAP-12
Urine:
[**2116-1-10**] 02:05AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2116-1-10**] 02:05AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
[**2116-1-10**] 02:05AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
Coagulation:
[**2116-1-10**] 02:00AM PT-10.6 PTT-27.1 INR(PT)-1.0
Other pertinent labs:
[**2116-1-10**] 02:00AM CK(CPK)-110
[**2116-1-10**] 02:00AM CK-MB-4 cTropnT-0.06*
Discharge labs:
[**2116-1-13**] 05:00AM BLOOD WBC-6.0 RBC-3.28* Hgb-9.9* Hct-29.6*
MCV-90 MCH-30.1 MCHC-33.3 RDW-15.4 Plt Ct-129*
[**2116-1-13**] 05:00AM BLOOD Plt Ct-129*
[**2116-1-13**] 05:00AM BLOOD Glucose-149* UreaN-26* Creat-1.5* Na-138
K-3.9 Cl-104 HCO3-29 AnGap-9
[**2116-1-13**] 05:00AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1
CT abd [**2116-1-10**] 4:27 AM IMPRESSION: Status post left colectomy
and end-colostomy; diffuse colonic diverticulosis with
intraluminal arterial blush in the transverse colon and minimal
accumulation on the delayed phase, compatible with arterial
bleed.
MESENTERIC ANGIOGRAM [**2116-1-10**] 7:38 AM
IMPRESSION:
Active extravasation from the peripheral branch of the inferior
mesenteric
artery, which was successfully embolized. No active
extravasation in the digital subtraction angiography from the
superior mesenteric artery.
Brief Hospital Course:
82 yo F h/o HTN, diverticulitis s/p partial colectomy p/w bright
red blood per ostomy consistent with new diverticular bleed and
comfirmed on CTA.
ACTIVE PROBLEMS:
# GI BLEED: Confirmed with positive CTA. She was taken to
Interventional Radiology and 4 coils were placed to a small
branch of her left colic artery. She received one unit of prbcs
in the OSH and received a total of 3 units prior to her
intervention. Receieved another unit after. Patient with likely
diverticular bleeding based on the fact that she has had
perforated diverticulitis s/o left hemicolectomy with colostomy.
However the patient has never had a colonoscopy so other
etiologies of lower GI bleed can not be completely ruled
out. Following embolization, she has not had any further
bleeding. Currently her hct is stable and she has brown stool
in her ostomy bag. She should have a colonoscopy as an
outpatient to assess for other sources of bleeding (malignancy,
AVM, ulcerated polyps...) She has a colonoscopy scheduled in
[**2116-1-30**].
# HTN: Initially held blood pressure medications in setting of
active GI bleed. Pressures normalized and BP meds were restarted
upon discharge. Losartan was held due to [**Last Name (un) **].
# CONTRAST NEPHROPATHY: baseline cr 1.3, and was stable on
presentation. It elevated to about 1.8 48hr post contrast, and
then receded back towards baseline. Losartan was held and
allopurinol was reduced from 300 to 100mg daily. She will have
a creatinine rechecked as an outpatient.
INACTIVE PROBLEMS
# Diabetes: Insulin dependent diabetic. Changed levemir to
glargine as not on formulary and continued HISS with QACHS
finger sticks.
# Gout: Continued allopurinol at renal dosing.
PENDING TESTS AT DISCHARGE: none
TRANSITIONAL CARE ISSUES: will have a HCT and CR checked in 72
hours to be followed by PCP, [**Name10 (NameIs) 1023**] was notified.
Medications on Admission:
asa 81 mg daily
metoprolol 50 mg [**Hospital1 **]
isosorbide dinitrate
lasix 40 mg daily
losartan
gabapentin 300 mg qHS
clonazepam
allopurinol 300 mg daily
levemir 20 units SC daily
humalog 15-20 units SC TID with meals
timolol eye drops
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. insulin detemir 100 unit/mL Solution Sig: One (1) 20
Subcutaneous once a day.
9. Humalog 100 unit/mL Solution Sig: [**12-2**] 15-20 Subcutaneous
three times a day.
10. Outpatient Lab Work
Please check a CBC and Cr and fax results to Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 92168**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Colonic diverticular bleed
Acute Kidney Injury
Secondary Diagnosis
Diabetes
Hypertension
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:
Thank you for allowing us to take part in your care. You were
admitted to the hospital because you had blood loss that was
coming from your stoma. You had some blood transfusions and a
procedure to stop the bleeding and have been stable since. You
also had decrease in your kidney function that we treated with
fluids.
We made the following changes to your medicines:
-please hold aspirin until told to resume by your PCP
[**Name10 (NameIs) **] hold your losartan until you see your PCP due to your
kidney injury
-we decreased your allopurinol to 100mg daily until you see your
PCP due to your kidney injury
-no other medication changes were intended to be made
Please recheck your Hematocrit and Createnine in three days. We
are writing you a prescription for this which will be faxed to
Dr. [**First Name (STitle) **].
Followup Instructions:
We also scheduled you for the following appointments. You will
follow up with the GI doctor on [**2116-2-11**] for a colonoscopy. You
will be called with specific instructions. We are also working
on scheduling an appointment with your primary care doctor. The
doctor will contact you with the date and time.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Location: THE MEDICAL GROUP
Address: [**Last Name (un) 15488**] [**Apartment Address(1) 31103**], [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**Telephone/Fax (1) 10508**]
*We are working on a follow up appointment for your
hospitalization with your primary care physician [**Name Initial (PRE) 176**] 1 week
of discharge. The office will contact you at home with the
appointment information. If you have not heard within 2 business
days or have any questions please call the office.
Department: WEST PROCEDURAL CENTER
When: TUESDAY [**2116-2-11**] at 12:30 PM
With: WPC ROOM THREE [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: GI-WEST PROCEDURAL CENTER
When: TUESDAY [**2116-2-11**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"562.12",
"274.9",
"553.20",
"E947.8",
"V45.3",
"584.9",
"414.01",
"V45.01",
"V44.3",
"287.5",
"250.50",
"403.90",
"V58.67",
"585.9",
"285.1",
"362.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
8044, 8050
|
4941, 6660
|
366, 477
|
8202, 8202
|
3215, 3215
|
9233, 10766
|
2474, 2478
|
7105, 8021
|
8071, 8181
|
6842, 7082
|
8385, 9210
|
4070, 4918
|
2519, 3196
|
6674, 6679
|
298, 328
|
6706, 6816
|
505, 2000
|
3231, 3945
|
3967, 4054
|
8217, 8361
|
2022, 2339
|
2355, 2458
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
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icd9cm
|
[
[
[]
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[
"23.19",
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icd9pcs
|
[
[
[]
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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
| 120,375
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53620
|
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",
"V10.72",
"424.1",
"276.7",
"785.51",
"401.9",
"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
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,603
| 191,797
|
7530
|
Discharge summary
|
report
|
Admission Date: [**2196-4-1**] Discharge Date: [**2196-4-12**]
Date of Birth: [**2128-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD with epineprhine injection
History of Present Illness:
67 yo M with h/o HTN, AF on coumadin, dilated CM, EF 50%, CAD,
PUD s/p gatrectomy/Billroth II in [**2172**] p/w BRBPR with 15 pt drop
in Hct, hemodynamically stable in ED, +non clearing NG lavage
with red blood and clots (800cc). GI was consulted. Pt received
FFP and vitamin K for INR 2.4.
Pt had been fine until last night when he developed nausea with
vomiting X 1 with streak of blood per wife. [**Name (NI) **] drank about 2
liters of water per his wife. Overnight, he had a grossly
bloody bowel movement that he reported to his wife in AM. It
occurred again this AM- large volume with bright red blood. +
LH + dizziness -CP -SOB - abd pain -fever -dysuria
Past Medical History:
Past Medical History:
HTN
Smoking
Polycythemia [**1-20**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-20**] HTN
CAD: last cath [**6-20**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2
EF 50% most recently, down to 25% in 99
Atrial fibrillation on coumadin
medullary thyorid CA s/p thyroidectomy
parathyroid adenoma s/p partial parathyroidectomy
TURP [**9-/2191**]
BPH
PUD s/p gastrectomy/Billroth II [**2172**]
s/p CCY
ventral hernia
Raynaud's
hematuria with hx epidymitis
depression
[**Last Name (un) **] [**2193-8-20**] with grade I int hemorrhoids and polyp at hepatic
flexure ([**6-17**] normal except for erythema in rectum)
EGD [**2193-8-20**] with erythema of entire remaining stomach ([**6-17**]
with gastritis)
Social History:
tobacco *40 pack year hx, 1ppd now
rare EOTH
lives with wife in JP
former engineer, married
Family History:
NC
Physical Exam:
PE: no distress, well -appearing
VS: 97.1 87 178/81 [**12-10**] 99% RA
HEENT: EOMI, anicteric, PERRL, MMM
Neck: supple, -lad, JVP not elevated
lungs: CTA bilat
heart: irreg with reg rate - murmurs
abd: soft NT ND -hsm, + hyperactive BS
ext: -e/c/c, 2 + DP bilat
neuro: intact grossly,
Pertinent Results:
[**2196-4-1**] 09:13PM HCT-27.3*
[**2196-4-1**] 05:22PM GLUCOSE-85 UREA N-70* CREAT-1.5* SODIUM-143
POTASSIUM-4.4 CHLORIDE-112* TOTAL CO2-25 ANION GAP-10
[**2196-4-1**] 05:22PM CK(CPK)-71
[**2196-4-1**] 05:22PM CK-MB-NotDone cTropnT-<0.01
[**2196-4-1**] 11:10AM PLT COUNT-152
[**2196-4-1**] 11:10AM PT-20.7* PTT-33.8 INR(PT)-2.7
Admission Chest X ray: unremarkable
.
EGD: [**2196-4-2**] - [**Doctor First Name **]-[**Doctor Last Name **] tear (injection, thermal
therapy, ligation). Blood in the stomach. Recommendations: High
dose (double dose) PPI, Surgical consultation. There is no
further endoscopic treatment for this lesion if he rebleeds.
Serial HCT, continue to transfuse, reverse coagulopathy, ICU
care.
.
[**2196-4-6**] GI BLEEDING STUDY - IMPRESSION: No visible source of
GI bleed.
.
EKG: 76 afib, LAD, IVCD, strain pattern V4-6, AVL, I, V5-AVL
deeper than priors, V4 strain new.
Brief Hospital Course:
67 y/o M w/ CAD and AFib on Coumadin and ASA, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]
tear with BRBPR and NSTEMI
.
UPPER GI BLEED: Pt was admitted to the MICU. EGD on [**2196-4-1**]
without active bleeding, but f/u EGD [**2196-4-2**] with [**Doctor First Name **]-[**Doctor Last Name **]
tear s/p injection, thermal therapy, and ligation. He recieved a
total of 9U of PRBC's, the last on [**2196-4-2**] with stable Hct. He
was c/o of the MICU on [**2196-4-5**], and was noted to have several
episodes of BRBPR the following day. He was orthostatic to BP
60/p, and there was concern for re-bleeding of [**Doctor First Name **]-[**Doctor Last Name **]
tear. He was transferred back to the MICU. NGT lavage was
negative for blood, and f/u bleeding scan was negative. The
patient did not have any further episodes of melena or BRBPR,
and Hct remained stable throughout the remainder of his stay. He
will f/u with GI for repeat EGD and colonoscopy.
.
CARDIOLOGY - Pt was noted to have NSTEMI with increased troponin
of 0.63 and peak CK of 286, felt to be related to stress in pt
pt with known CAD and UGIB. His cardiac enzymes trended down. He
was continued on BB and statin. After cardiology consult,
patient will have oupt stress. He will restart ASA therapy [**4-13**].
He also has a history of afib and coumadin was held in the
setting of GIB. He will need to discuss restarting Couamdin as
outpatient.
.
HTN/orthostasis - Will hold OP meds given orthostatic
hypotension from hypovolemia. Restarted Carvedilol. Pt
aggressively hydrated and dizziness improved.
Endocrine - on levoxyl
CRI- stable with Cr 1.5. Likely secondary to HTN.
FEN- encourage po fluids
Medications on Admission:
MEDS on admission:
aspirin 81mg PO QD
celexa 20mg QD
nefidipine 60mg PO QD
TUMS/calcium 600mg
synthroid 150mcg PO QD
coreg 6.25mg [**Hospital1 **]
vitamin C [**Hospital1 **]
calcetriol 0.5mg [**Hospital1 **]
Coumadin
Lipitor 10mg PO QD
clonopin 1mg HS
Imdur 120mg HS
Discharge Medications:
1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 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*
3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
5. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
GI bleed
Orthostatic hypotension
Non ST elevation MI
HTN
OSA
atrial fibrillation
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You are still dehydrated. Please drink plenty of fluids and
water, at least 8 cups per day. Please notify your doctor if you
have any bleeding from your stools. Restart your aspirin
tomorrow. Do not take your coumadin, imdur or nifedipine until
Dr. [**Last Name (STitle) 3357**] tells you to.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3357**] in 2 weeks.
Follow up with the gastrointestinal doctors for a repeat EGD and
colonoscopy. Please call Dr. [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) 7307**] [**Telephone/Fax (1) 1954**] for an
appointment.
Please f/u with outpatient cardiac stress test.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2196-4-12**]
|
[
"458.0",
"530.7",
"428.0",
"V45.81",
"280.0",
"427.31",
"410.71",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"42.33",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6190, 6248
|
3243, 4954
|
322, 354
|
6373, 6381
|
2312, 3220
|
6823, 7274
|
1984, 1988
|
5272, 6167
|
6269, 6352
|
4980, 4985
|
6405, 6800
|
2003, 2293
|
274, 284
|
382, 1049
|
4999, 5249
|
1093, 1858
|
1874, 1968
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,512
| 106,200
|
54954
|
Discharge summary
|
report
|
Admission Date: [**2110-7-14**] Discharge Date: [**2110-7-21**]
Date of Birth: [**2043-3-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
adhesive tape
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2110-7-17**]
1. Urgent coronary artery bypass graft x3: Left internal
mammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal and posterior
descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
[**2110-7-16**]
Cardiac catheterization
History of Present Illness:
Patient is a 67yo M with PMHx of HTN and HLD who presented to
the ED from his PCP's office with complaints of CP found to have
positive stress test in the ED after being observed.
Patient reports that since watching the Celtics in the playoffs
he had noticed a chest discomfort in his chest that was relieved
when turning off the TV. Over the weekend, he had 2 episodes of
chest pain associated with exertion. He was walking [**2110-7-12**] for
[**3-7**] miles and started noting chest pain across the chest. The
chest pain was quantified as [**6-12**]. He did stop and after approx
5 minutes the pain resolved. He walked again on the day prior to
presentation (Sunday)and it was quantified as [**7-13**]. The patient
states that the pain resolved with rest. His pain is not
associated with diaphoresis, shortness of breath, abdominal
pain, nausea, vomiting, dizziness, or lightheadedness. The
patient saw his PCP regarding his symptoms, who then referred
him to the ED for further evaluation.
The patient had a stress test done at [**Location (un) 2274**] that was stopped due
to leg fatigue in [**2110-3-5**]. He had no symptoms during this test
and was noted to be hypertensive during his study. He was chest
pain free during this ETT with no EKG changes.
In the ED, initial vitals were 99.1 92 169/91 16 100% 3L. He
received 325mg ASA in the ED. The patient's troponins in the ED
were negative times 2. He was observed in the ED and had an ETT.
Exercise stress test was positive with ST-depressions
inferolateral leads, ST elevation in AVR, V1, and chest pain
with SBP drop from 190 to 160. Nuclear imaging showed fixed
perfusion deficits but no inducible ischemia. He was admitted to
cardiology for cardiac catheterization.
On arrival to the floor, patient is currently chest pain free.
REVIEW OF SYSTEMS:
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He reports exertional leg 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:
PRIMARY DIAGNOSIS:
Coronary artery disease
SECONDARY DIAGNOSIS:
Hypertension
Hyperlipidemia
Myocardial Infarction [**2088**]
Social History:
Originally from [**Location (un) 3156**]. Married.
# Tobacco: Former smoker. Quite 4 months ago. Prior to quitting
patient smoked [**2-3**] ppd; patient endorses a smoking history of
1ppd or more 20 years ago
# Alcohol: Drinks socially.
# Illicit: Denies
Family History:
Father with CAD, MI (age >60 years) and PVD. Mother with stroke
at age 82; HTN. Maternal grandmother CAD and PVD.
Physical Exam:
Admission physical exam:
VS: T 97.7, BP 160/100, HR 60, RR 17, SpO2 99% on RA
Weight: 82.3kg
GENERAL: WDWN sitting at the side of the bed in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Xanthalesma
present on the eyes.
NECK: Supple with no JVD.
CARDIAC: R, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Varicose veins appreciated on the LE
bilaterally.
NEURO: CN II-XII tested and intact, strength 5/5 throughout,
sensation grossly normal. Gait not tested.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Intra-op TEE [**2110-7-17**]:
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF = 65%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. There are complex (>4mm) atheroma in the aortic arch.
The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. 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. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results at time
of surgery.
POST-BYPASS: The patient is in sinus rhythm. The patient is on a
phenylephrine infusion. Biventricular function is unchanged.
Mitral regurgitation is unchanged. The aorta is intact
post-decannulation.
.
[**2110-7-21**] 04:30AM BLOOD WBC-6.1 RBC-3.64* Hgb-11.2* Hct-33.1*
MCV-91 MCH-30.7 MCHC-33.9 RDW-14.9 Plt Ct-161
[**2110-7-20**] 03:57AM BLOOD WBC-7.9 RBC-3.81* Hgb-11.9* Hct-34.1*
MCV-90 MCH-31.3 MCHC-34.9 RDW-14.9 Plt Ct-170
[**2110-7-21**] 04:30AM BLOOD Glucose-89 UreaN-28* Creat-0.9 Na-136
K-3.7 Cl-98 HCO3-30 AnGap-12
[**2110-7-20**] 03:57AM BLOOD Glucose-100 UreaN-26* Creat-1.1 Na-136
K-4.0 Cl-99 HCO3-32 AnGap-9
Brief Hospital Course:
Patient is a 67yo M with PMHx of HTN and HLD who presented to
the ED from his PCP's office with complaints of CP who was found
to have positive ETT after observation in the ED found to have
2-vessel coronary artery disease on cardiac catheterization.
CARDIOLOGY FLOOR COURSE
# 2-vessel coronary artery disease: Patient presented with
symptoms of angina; he was not started on a heparin drip upon
admission. Nuclear stress images show fixed moderate basal
inferior wall perfusion defect and a fixed moderate inferoapical
perfusion defect with normal ejection fraction. Patient
underwent cardaic catheterization [**2110-7-16**] showing extensive
disease in LAD and RCA. The patient was started on aspirin 81mg
daily and his home simvastatin was continued. Cardiac surgery
was consulted in light of cardiac catheterization findings, and
it was recommended that the patient undergo revascularization
surgery. Patient was taken for CABG [**2110-7-17**]. Chest tubes,
foley and pacing wires were removed in the usual fashio. PT saw
patient. Pt stable for home. No sequele from the procedure.
# Hypertension: Managed with hydrochlorathiazide 25mg daily as
an outaptient only; patient has not been taking atenolol as an
outpatient. Upon admission, patient's systolic blood pressure
was 160, with diastolic 100. The patient was started on
lisinopril 5mg daily, at the time of his CABGE this was [**Name (NI) 1788**] pt
currently on lopressor 50 TID. He is tolerating this dose. He
will arrange to see his PCP [**Last Name (NamePattern4) **] [**3-8**] weeks.
# Hyperlipidemia: Patient on simvastatin as an outpatient. Most
recent LDL of 95. Simvastatin 10mg daily was continued during
the hospitalization.
# Kidney function: Review of Atrius records shows that the
patient's serum creatinine has ranged from 1.1-1.4. Patient
received [**Doctor Last Name 1567**] hydration prior to catheterization and after
catheterization. This remained stable during this hospital stay.
.
POST-OP COURSE:
The patient was brought to the Operating Room on [**2110-7-17**] where
the patient underwent CABG x 3 with Dr. [**First Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD **** the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN fever, pain
3. Aspirin EC 81 mg PO DAILY
4. Bisacodyl 10 mg PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. OxycoDONE-Acetaminophen Elixir [**6-12**] mL PO Q4H:PRN pain
RX *Roxicet 5 mg-325 mg/5 mL every four (4) hours Disp #*300
Milliliter Refills:*0
7. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *Lopressor 50 mg three times a day Disp #*90 Tablet
Refills:*0
8. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg daily Disp #*30 Tablet Refills:*0
9. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Coronary artery disease
SECONDARY DIAGNOSIS:
Hypertension
Hyperlipidemia
Myocardial Infarction [**2088**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
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 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:
Wound Check at Dr.[**Name (NI) 11272**] office: Phone:[**Telephone/Fax (1) 170**], [**2110-7-29**]
10:15
Surgeon Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 170**], [**2110-8-19**]
1:00
Cardiologist -- the office will call you with an appt.
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 90382**] in [**5-8**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2110-7-21**]
|
[
"414.2",
"285.9",
"401.1",
"287.5",
"411.1",
"V15.82",
"272.0",
"414.01",
"412",
"V17.3",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"39.61",
"36.15",
"36.12",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10168, 10239
|
6176, 9227
|
290, 602
|
10409, 10579
|
4362, 6153
|
11367, 12135
|
3334, 3450
|
9443, 10145
|
10260, 10260
|
9253, 9420
|
10603, 11344
|
3490, 4343
|
2447, 2895
|
240, 252
|
630, 2428
|
10325, 10388
|
10279, 10304
|
2917, 2917
|
3061, 3318
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,317
| 108,406
|
28741
|
Discharge summary
|
report
|
Admission Date: [**2150-8-1**] Discharge Date: [**2150-8-5**]
Date of Birth: [**2096-5-5**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 y/o man with end stage liver disease c/b renal failure now on
HD who was recently admitted for same here, d/c'd supposedly for
hospice care who was also getting o/p HD Tu Th Sa. Today he was
supposed to get dialysis, but complains that this was not
possible b/c his HD cath was "clogged". He reportedly had a
"friend" bring him to [**Hospital1 **] for HD and further mgmt. On arrival in
the ED he is found to be AF and HD stable, but massively volume
overloaded, with sats in the 70's on RA, and with MS changes
concerning for SBP. He is admitted for urgent HD for volume
overload.
Past Medical History:
cirrhosis ([**1-1**] EtOH)
h/o hepatic encephalopathy
h/o SBP
h/o esophageal varices (EGD [**2148**])
C.diff positive (currently on Flagyl)
likely HRS
Diabetes
Social History:
h/o EtOH abuse (reports being sober x 6 months).
+ smoker (1ppd).
Divorced, has 2 children.
lives with female friend who helps take care of him
Family History:
alcoholism
Physical Exam:
VS: 97.5 87 105/48 20 96% on NRB
HEENT - icteric, jaundiced, disheveled, chronically ill
appearing
COR:RRR no MRG
PULM:diminished breath sounds on the right
ABD:Massively distended, + fluid wave.
EXT:4+ pitting edema with cellulitis lt shank
NEURO:somnolent but arrousable, oriented only to person and
place (not year or reason for admssion); moves all four.
Pertinent Results:
None
Brief Hospital Course:
54 year old man with end stage liver disease, not a candidate
for transplant, who was recently admitted for liver failure and
? HRS, now HD dependent who presents to the ED stating that he
couldnt get his usually scheduled HD today because his "line was
clotted", in volume overload, desaturating on room air, and with
altered mentation concerning for SBP. Pt initially went to the
MICU, but pt and family decided that he should be CMO and then
discontinued dialysis treatment. He was transferred to the floor
and treated with morphine prn for tachypnea and pain, lorazepam
prn for agitation and anxiety and scopolamine patch for control
of secretions. He expired.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"303.90",
"585.6",
"571.2",
"403.91",
"572.3",
"428.0",
"250.00",
"572.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2426, 2435
|
1708, 2374
|
291, 297
|
2487, 2497
|
1679, 1685
|
2550, 2678
|
1273, 1285
|
2397, 2403
|
2456, 2466
|
2521, 2527
|
1300, 1660
|
232, 253
|
325, 911
|
933, 1095
|
1111, 1257
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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21,501
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1672
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Discharge summary
|
report
|
Admission Date: [**2138-7-14**] Discharge Date: [**2138-7-28**]
Date of Birth: [**2059-4-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Difficulty swallowing.
Major Surgical or Invasive Procedure:
PEG placement.
History of Present Illness:
This is a 79 y/o male patient with multiple system atrophy
(aggresive form of Parkinsons), HTN, prostate ca s/p XRT who was
initially admitted to neurology service on [**7-14**] for dysphagia
secondary to rapid deterioration of MSA and PEG placement. PEG
placement successful but after patient had sudden Hct drop and
on CT scan was found to have right RP and thigh bleed hematoma,
unknown etiology, transferred to MICU. Vascular consulted and
felt surgery and angio no indicated at present time as patient
would require intubation. Patient was transfused a total of 9
units of blood while in the MICU. Patient last blood transfusion
was on [**2138-7-25**] in the am and Hct has been stable. For the past
few days patient neurologic function has become worse, where
patient very stiff. Neurology following patient for management
of MSA. Patient also noted to be hypernatremic in the MICU and
is being given free water bolus through PEG tube. During
hospital course patient had thrombocytopenia as well, HIT sent
which came back negative, plt count starting to improve. He
continue to spike low grade fevers, patient pan-cultured with no
source of infection found, CXR negative.
Past Medical History:
1.)Multisystem atrophy
2.)HTN
3.)Prostate CA s/p XRT
4.)Cervical radiculopathy
5.)Hypercholesterolemia
Social History:
Pt lives with wife and is cared for by multiple aides. He is
totally depedent for adl's. Quit tobacco 30yrs ago.
Family History:
No neuro disease
Physical Exam:
t 98.4, bp 112/59, hr 104, rr 19, spo2 97%ra
gen- chronically ill appearing elderly male in nad
cv- tachy but reg, no m/r/g
pul- moves air well, minimal bibasilar rales
abd- peg in place, soft, nt, nd, nabs
back- no sacral edema, no bruising
extrm- 1+ edema over shins bilaterally
nails- no clubbing, no pitting/color changes/indentations
neuro- awake, non-verbal, resting tremor, moves extremeties
Pertinent Results:
[**2138-7-24**] CT abd/pel: No change compared to the exam of two days
earlier. This includes the left-sided retroperitoneal bleed and
the more superior portion of the right lower extremity bleeding.
.
[**2138-7-23**] renal u/s: Ultrasound is compared with a CT scan
performed 1 day previously. Again, shown is bilateral
hydronephrosis with atrophic kidneys with marked cortical
atrophy. No perirenal fluid is identified. The retroperitoneal
hematoma surrounding the left kidney is not seen. Please note
that ultrasound is not a reliable imaging technique for
excluding the presence of retroperitoneal blood or for ongoing
active bleeding.
.
[**2138-7-22**] EKG:Baseline artifact
Rhythm uncertain - mostly regular/slight irregular tachycardia -
may be atrial tachycardia but baseline artifacttmad
Right bundle branch block
Nonspecific ST-T wave changes
Suggest repeat tracing
Since previous tracing of [**2138-7-16**], bradycardia replaced by
tachyarrhythmia
.
[**2138-7-22**] CT: 1. Large right thigh hematoma.
2. Large left posterior pararenal space hematoma, which appears
separate from the muscles associated with the left iliac [**Doctor First Name 362**] as
well as from the psoas muscle.
3. Pulmonary opacities in the right and left lower lobes,
suggestive of aspiration. Very small bilateral pleural
effusions.
4. Small pericardial effusion.
.
[**2138-7-27**] 03:31AM BLOOD WBC-28.6*# RBC-4.31* Hgb-13.3* Hct-39.3*
MCV-91 MCH-30.8 MCHC-33.8 RDW-15.4 Plt Ct-122*
[**2138-7-26**] 04:30AM BLOOD WBC-17.3* RBC-3.80* Hgb-11.6* Hct-34.3*
MCV-90 MCH-30.5 MCHC-33.8 RDW-15.6* Plt Ct-99*
[**2138-7-25**] 03:37AM BLOOD WBC-15.8* RBC-3.27* Hgb-10.0* Hct-29.5*
MCV-90 MCH-30.4 MCHC-33.7 RDW-15.5 Plt Ct-69*
[**2138-7-24**] 04:23AM BLOOD WBC-24.4* RBC-2.88* Hgb-8.7* Hct-25.3*
MCV-88 MCH-30.1 MCHC-34.2 RDW-15.8* Plt Ct-87*
[**2138-7-23**] 11:09AM BLOOD WBC-24.5* RBC-2.80* Hgb-8.3* Hct-24.7*
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.2 Plt Ct-80*
[**2138-7-17**] 12:55PM BLOOD WBC-9.5 RBC-3.71* Hgb-11.1* Hct-32.7*
MCV-88 MCH-30.0 MCHC-34.1 RDW-13.6 Plt Ct-142*
[**2138-7-14**] 04:46PM BLOOD WBC-12.4*# RBC-4.26* Hgb-12.3* Hct-37.4*
MCV-88 MCH-28.9 MCHC-32.9 RDW-13.7 Plt Ct-189#
[**2138-7-23**] 11:09AM BLOOD Neuts-78* Bands-2 Lymphs-9* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2138-7-14**] 04:46PM BLOOD Neuts-82.2* Lymphs-11.4* Monos-5.8
Eos-0.4 Baso-0.3
[**2138-7-27**] 03:31AM BLOOD Plt Ct-122*
[**2138-7-27**] 03:31AM BLOOD PT-13.0 PTT-23.9 INR(PT)-1.1
[**2138-7-27**] 03:31AM BLOOD Fibrino-490*
[**2138-7-24**] 08:56AM BLOOD FDP-0-10
[**2138-7-27**] 03:31AM BLOOD Glucose-133* UreaN-31* Creat-1.0 Na-146*
K-3.2* Cl-104 HCO3-28 AnGap-17
[**2138-7-23**] 05:00AM BLOOD Glucose-129* UreaN-31* Creat-1.2 Na-145
K-4.5 Cl-114* HCO3-23 AnGap-13
[**2138-7-17**] 12:55PM BLOOD Glucose-76 UreaN-24* Creat-1.0 Na-145
K-3.3 Cl-106 HCO3-22 AnGap-20
[**2138-7-14**] 04:46PM BLOOD Glucose-104 UreaN-35* Creat-1.3* Na-145
K-4.3 Cl-108 HCO3-24 AnGap-17
[**2138-7-27**] 03:31AM BLOOD CK(CPK)-932*
[**2138-7-23**] 05:00AM BLOOD CK(CPK)-1354*
[**2138-7-22**] 03:00PM BLOOD LD(LDH)-208 TotBili-0.4
[**2138-7-14**] 04:46PM BLOOD ALT-32 AST-29 TotBili-0.6
[**2138-7-27**] 03:31AM BLOOD CK-MB-12* MB Indx-1.3 cTropnT-0.17*
[**2138-7-27**] 03:31AM BLOOD Calcium-8.0*
[**2138-7-26**] 04:30AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.0
[**2138-7-25**] 03:37AM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.9 Mg-1.9
[**2138-7-15**] 05:30AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.2
[**2138-7-22**] 03:00PM BLOOD Hapto-159
[**2138-7-15**] 05:30AM BLOOD TSH-1.1
[**2138-7-27**] 02:31AM BLOOD Type-ART pO2-111* pCO2-48* pH-7.41
calHCO3-31* Base XS-5 Intubat-NOT INTUBA
[**2138-7-27**] 12:52AM BLOOD Type-ART Temp-38.8 pO2-92 pCO2-64*
pH-7.30* calHCO3-33* Base XS-2 Intubat-NOT INTUBA
[**2138-7-22**] 06:18PM BLOOD Type-ART pO2-175* pCO2-34* pH-7.42
calHCO3-23 Base XS--1
[**2138-7-27**] 02:17AM BLOOD Lactate-2.6*
[**2138-7-27**] 12:52AM BLOOD Lactate-1.5
[**2138-7-22**] 06:18PM BLOOD Lactate-4.3*
[**2138-7-27**] 02:17AM BLOOD Hgb-13.1* calcHCT-39 O2 Sat-84
Brief Hospital Course:
On [**2138-7-27**], the pt was seen by a Catholic priest and
administered last rights. A family meeting outlined the pt's
wishes, including that he not be intubated, resuscitated, fed
via tube (though the family did undergo an initial attempt with
the PEG tube), or CPR. The pt was transferred from the MICU to
the floor with the status of Comfort Measures Only. The family
remained with the patient. A family member awoke and the pt had
died. The night float resident was summoned to the room, and the
patient was pronounced dead at 0410 on [**2138-7-28**]. The primary
cause of death was respiratory arrest secondary to multisystem
atrophy. An autopsy was declined by the family. The death
certificate was filled out by [**First Name8 (NamePattern2) **] [**Name8 (MD) 4154**], MD, the night float
covering intern.
.
The [**Hospital **] medical issues are as below:
1.)Acute blood loss anemia:
Top source appears to be into right thigh, given physical exam.
Other possibilities include RP or intra-abdominal bleed from
peg. Pt has been guaiac positive, but only trace positive brown
stool, making GI bleed seem less likely. Pt has been discussed
with vascular.
The pt was evaluated with CT and transfused multiple unit of
blood. The pt was made CMO before this issue was resolved.
.
2.)MSA:
The pt was treated with mirapex and had a PEG in place, though
the tube feedings were stopped after the family meeting, in
concordance with the pt's wishes.
.
3.)HTN:
vital sign monitoring was stopped after pt made CMO.Prior to
that, the BP meds were held due to blood loss anemia.
.
4.)Leukocytosis:
Pt without fever, feel this is most likely a stress response.
No clinically obvious infection.
.
5.)Thrombocytopenia:
Pt appears to be chronically low but is now lower than usual.
No documentation as to etiology. Will transfuse to keep over
50.
.
6.)FEN:
Pt initially tube fed via PEG, then discontinued per family
meeting.
Medications on Admission:
CELEXA 40MG--One by mouth every day
CIPRO 250 mg--one tablet(s) by mouth twice a day
DARVOCET-N 100 100-650MG--One by mouth q8 as needed for pain
DDAVP 0.2MG--One by mouth at bedtime
TERAZOSIN 10MG--2 by mouth every day
IBUPROFEN 800MG--One by mouth three times a day with food
NYSTATIN [**Numeric Identifier 4856**] U/G--Apply twice a day to affected area
PLAVIX 75MG--One every day
ROBINUL 1 mg--1 (one) tablet(s) by mouth three times a day
.
transfer-
1.)Terazosin 2mg daily
2.)Citalopram 40mg daily
3.)Mirapex 0.5mg daily
4.)Lansoprazole 30mg daily
5.)SC heparin
Discharge Medications:
Pt deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
Deceased.
Discharge Instructions:
Not applicable.
Followup Instructions:
Not applicable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
|
[
"287.5",
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"584.9",
"591",
"401.9",
"276.0",
"998.12",
"285.1",
"599.0",
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icd9cm
|
[
[
[]
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[
"99.04",
"38.93",
"43.11",
"96.6"
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icd9pcs
|
[
[
[]
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8901, 8910
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6326, 8247
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338, 355
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8963, 8974
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2292, 6303
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1839, 1857
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8273, 8841
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276, 300
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383, 1563
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1585, 1690
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1706, 1823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,527
| 194,420
|
12250
|
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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icd9cm
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,206
| 130,563
|
7477
|
Discharge summary
|
report
|
Admission Date: [**2170-7-31**] Discharge Date: [**2170-8-7**]
Date of Birth: [**2098-5-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
non-healing ulcer 5th toe
Major Surgical or Invasive Procedure:
Right common fem endarterectomy with stenting of right common
iliac and external iliac arteries with additional endarterectomy
of right profunda femoris artery at its origin.
History of Present Illness:
This is a 72-year-old male with a nonhealing ulceration of his
right fifth toe. Subsequent work up including both angiogram and
CT angiogram demonstrated
significant disease of the right iliac system. The patient was
therefore consented for right common femoral artery
endarterectomy with placement of right common iliac artery and
right external iliac artery stents.
Past Medical History:
PMH: defib-pacer, CAD s/p MI, DM, CVA, PVD, HTN, HLipid
PSH: L-Fem:akPop c PTFE ([**10-5**]), CABG ('[**58**])
Social History:
Lives with wife.
Family History:
n/c
Physical Exam:
PHYSICAL EXAMINATION
VS: BP 148/84 HR 84 O2 97% on 2L
HEENT: RIJ central line in place, JVP at 7 cm
Chest: CTA b/l
Cardiac: RRR, paradoxically split S2, [**1-6**] blowing systolic
murmur
at apex
Abd: soft, ntnd
extremities: surgical wound C/D/I, ulcerated R pinky toe, no LE
edema, dopplerable LE pulses
Pertinent Results:
[**2170-8-7**] 05:19AM BLOOD
WBC-10.7 RBC-3.20* Hgb-10.4* Hct-29.8* MCV-93 MCH-32.4*
MCHC-34.9 RDW-14.5 Plt Ct-510*
[**2170-8-1**] 11:30AM BLOOD
Neuts-83* Bands-0 Lymphs-4* Monos-11 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-2*
[**2170-8-4**] 04:00AM BLOOD
PT-13.3 PTT-27.2 INR(PT)-1.1
[**2170-8-7**] 05:19AM BLOOD
Glucose-187* UreaN-16 Creat-0.8 Na-134 K-3.8 Cl-102 HCO3-21*
AnGap-15
[**2170-8-7**] 05:19AM BLOOD CK(CPK)-58
[**2170-8-1**] 10:34AM BLOOD CK(CPK)-388*
[**2170-8-1**] 04:09PM BLOOD CK(CPK)-1232*
[**2170-8-2**] 01:59AM BLOOD ALT-74* AST-214* LD(LDH)-574*
CK(CPK)-906* AlkPhos-44 Amylase-51 TotBili-0.5
[**2170-8-5**] 02:24PM BLOOD CK-MB-4 cTropnT-2.81*
[**2170-8-5**] 08:30PM BLOOD CK-MB-4 cTropnT-2.34*
[**2170-8-6**] 05:20AM BLOOD CK-MB-4 cTropnT-2.71*
[**2170-8-7**] 05:19AM BLOOD CK-MB-3 cTropnT-1.85*
[**2170-8-7**] 05:19AM BLOOD
Calcium-8.3* Phos-3.5 Mg-1.9
[**2170-8-4**] 12:34AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
URINE Blood-LGE Nitrite-POS Protein-75 Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
URINE RBC->50 WBC-[**2-2**] Bacteri-MOD Yeast-RARE Epi-1
CXR:
IMPRESSION: Homogenous density in the right hemithorax likely
represents a
combination of fissural fluid and right lower lobe
consolidation. Another
possible explanation would be asymmetric pulmonary edema
secondary to mitral valve disease, although this is less likely.
ECHO:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is top
normal/borderline dilated. There is severe global left
ventricular hypokinesis (LVEF = 25 %) with mid to distal septal
and inferior akinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. with moderate
global free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve 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 tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname **] was taken to the operating room on [**2170-7-31**] for right
common femoral endarterectomy with common iliac, external iliac
stents and right profunda endarterectomy at its origin. The
operation proceeded without complication and he was transferred
to the floor in stable condition.
Post operatively, in the morning of POD 1, he was found to have
a wide-complex tachycardia on telemetry, becoming hypertensive
to the 160s and hypoxic requiring a non-rebreather mask. He was
intubated on the floor and then transferred to the CVICU.
Troponin pos and CKMB pos. TTE did not show focal wall motion
abnormalities, and CXR and physical exam were not consistent
with acute systolic heart failure. He was thought to possibly
have a peri-operative NSTEMI over simple demand ischemia, per
cardiology. He was started on aspirin 325, a heparin drip,
low-dose metoprolol, loaded with plavix.
Pt extubated in the CVICU. It was decided that he would have a
cardiac catheter.
COMMENTS:
1. Coronary angiography in this right dominant system revealed
severe 3
vessel CAD. The LMCA was occluded distally. The LAD was
occluded, with
distal filling via a patent LIMA, with a diffusely diseased,
extremely
small, LAD after the anastomosis. The LCX was occluded, with
distal
filling via a patent SVG. The RCA was occluded proximally, with
distal
filling via a patent SVG.
2. Selective graft arteriography revealed a normal LIMA-LAD
graft.
3. Selective graft venography revealed a normal SVG-OM-rPDA
graft. The
SVG-Diag graft was occluded at the ostium, and had a chronic
appearance.
4. Resting hemodynamics revealed elevated left-sided filling
pressures,
with LVEDP of 30 mmHg. There was mild systemic hypertension,
with SBP
of 143 mmHg. There was no evidence of aortic stenosis detected
by LV
pullback technique.
FINAL DIAGNOSIS:
1. Severe three vessel coronary artery disease.
2. Patent LIMA and SVG-OM-RPDA grafts, with chronically occluded
SVG-Diag.
3. Elevated left-sided filling pressures.
4. Mild systemic hypertension.
He tolerated the procedure well no complications.
When patient was stabalized from the NSTEMI. he was transfered
back to the VICU.
Pt troponin, CKMB down trend.
Was then transferred to the VICU for further recovery. While in
the VICU, received monitored care. When stable was delined.
Diet was advanced.
When stabilized from the acute setting of post operative care,
was then transferred to floor status.
On the floor, remained hemodynamically stable with pain
controlled. Continues to make steady progress without any
incidents. Discharged home in stable condition.
Medications on Admission:
Amiodarone 200 [**Hospital1 **], Digoxin 250 mcg daily, Gabapentin 100 mg
[**Hospital1 **], Toprol 25 mg daily, Tamsulosin 0.4 mg HS, ASA 81 mg daily,
Clopidogrel 75 mg daily, Ezetimibe 10 mg daily, Metronidazole
500 mg TID, Ciprofloxacin 500 mg [**Hospital1 **], Acetaminophen 325 mg Q6
PRN, Ativan 0.25 mg [**Hospital1 **] PRN, Bactrim DS 800-160 mg Tablet [**Hospital1 **],
Rosuvastatin 20 mg Tablet daily, Synthroid 50 mcg Tablet daily,
Glipizide 5 mg Tablet daily, Lasix 20 mg daily, Zestril 5 mg
daily, Flomax 0.4 mg daily, Oxycodone 5 mg Tablet PRN,
Glucophage 500 mg daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): cont home med/dose.
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
4. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for discomfort.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a
day.
9. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
10. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Zestril 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: x
6 days, then 5 mg x 1 day. INR [**Hospital1 **] is [**1-3**].
13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: x 1
day, then 2.5 x 6 days. INR checked by PCP. [**Name10 (NameIs) **] is [**1-3**].
14. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
15. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a
day: prn for anxiety.
16. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day.
17. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
19. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO three times a
day: prn.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Right lower extremity ischemia with ulceration.
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:
Division of [**Location (un) **] and Endovascular Surgery
Lower Extremity Endarterectomy/Stent Discharge Instructions
Medications:
?????? If instructed, take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What 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 [**1-3**]
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 [**2-1**] weeks for
post procedure check and ultrasound
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)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
DR. [**Last Name (STitle) **] (cardiology)
[**8-21**] 240pm
** be sure to bring your discharge instructions and all of your
current medications with you to appt **
Dr [**Last Name (STitle) 23782**] office:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2170-8-22**] 11:15
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2170-8-22**] 11:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2170-8-22**] 12:45
Completed by:[**2170-8-7**]
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icd9pcs
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[
[
[]
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8679, 8747
|
3752, 5584
|
339, 516
|
8839, 8839
|
1448, 3729
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|
1100, 1105
|
7007, 8656
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5601, 6374
|
9022, 11041
|
11067, 11628
|
1120, 1429
|
274, 301
|
544, 914
|
8854, 8998
|
936, 1049
|
1065, 1084
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
|
[
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"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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,019
| 150,112
|
8694
|
Discharge summary
|
report
|
Admission Date: [**2157-2-6**] Discharge Date: [**2157-2-10**]
Service: MEDICINE
Allergies:
Cephalexin
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
cardiac catheterizaton with balloon angioplasty to OM2
History of Present Illness:
The pt is an 86-y/o M with a PMH of CAD s/p CABG, s/p PCI to LCx
([**2154**]), s/p bioprosthetic aortic valve replacement, systolic CHF
s/p ICD revision [**12-24**], now presenting with chest pain. The
patient presented to [**Hospital6 **] this am with
complaints of one hour duration, mid-sternal chest pain with
band-like, cramping quality. Pain [**4-24**] in severity. His pain was
intermittent and non-radiating. Denies associated symptoms of
jam, arm or back pain. No N/V, no diaphoresis. No precipitating
factors. No dyspnea. Vitals T 97.7, HR 61, BP 127/68, RR 16, O2
95%. He was started on nitroglycerin gtt 28mcg/min, pain
improved to [**1-25**] and gtt was increased to 56mcg/min with
eventual improvement in pain to 0.5/10. He was also given
aspirin 325mg, morphine 2mg IV and dilaudid 0.5mg IV X1. The
patient is now transferred to [**Hospital1 18**] for consideration of cardiac
cath.
.
On arrival to the CCU, the patient is chest pain free. Denies
dyspnea. Vitals: T 97.9, HR 61, BP 142/74, RR 10, O2 97% 2L
Past Medical History:
CAD
'[**54**] PCI LCx stent
'[**47**] CABG/AVR
Systolic heart failure
PAF
HTN
s/p appendectomy
Social History:
Widowed, lives alone. His son lives nearby and able to assist.
-ETOH -Tob
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION:
VS - Vitals: T 97.9, HR 61, BP 142/74, RR 10, O2 97% 2L
Gen: WDWN elderly male 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 elevated to earlobe
CV: RRR, normal S1, S2. II/VI SEM loudest at LLSB. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. + crackles R base with
dullness on percussion, LLL clear
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 1+
Pertinent Results:
[**2157-2-6**] 05:04PM BLOOD WBC-11.2* RBC-4.67 Hgb-14.3 Hct-41.6
MCV-89 MCH-30.6 MCHC-34.4 RDW-14.7 Plt Ct-202
[**2157-2-6**] 05:04PM BLOOD Neuts-79.4* Lymphs-13.0* Monos-6.8
Eos-0.6 Baso-0.2
[**2157-2-6**] 05:04PM BLOOD PT-42.0* PTT-34.6 INR(PT)-4.6*
[**2157-2-6**] 05:04PM BLOOD Glucose-116* UreaN-38* Creat-1.4* Na-139
K-4.2 Cl-99 HCO3-30 AnGap-14
[**2157-2-6**] 05:04PM BLOOD CK(CPK)-106
[**2157-2-10**] 05:55AM BLOOD ALT-16 AST-22 LD(LDH)-226 CK(CPK)-25*
AlkPhos-59 TotBili-0.5
[**2157-2-6**] 05:04PM BLOOD CK-MB-5 cTropnT-0.02*
[**2157-2-7**] 12:27AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2157-2-7**] 06:25AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2157-2-7**] 06:58PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2157-2-6**] 05:04PM BLOOD Calcium-9.1 Phos-3.5 Mg-2.3
[**2157-2-10**] 05:55AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.0 Cholest-265*
[**2157-2-10**] 05:55AM BLOOD Triglyc-196* HDL-44 CHOL/HD-6.0
LDLcalc-182*
.
Chest x-ray - [**2157-2-6**] - FINDINGS: As compared to the previous
radiograph, the size of the cardiac silhouette is unchanged.
Also unchanged are the relatively low lung volumes. There is no
evidence of focal parenchymal opacity suggestive of pneumonia,
no pneumothorax, and no signs indicative of overhydration.
Minimal blunting of the costophrenic sinuses suggests minimal
pre-existing pleural effusions. The pacemaker leads are in
unchanged position.
.
[**2157-2-7**] - ECHO: - The left atrium and right atrium are normal
in cavity size. The estimated right atrial pressure is
10-20mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is mildly dilated with moderate to
severe global hypokinesis (LVEF = 25 %). No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. A well-seated bioprosthetic aortic valve prosthesis is
present with normal gradient. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-17**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is at least mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
dilated cavity and global hypokinesis. Normal aorticc valve
bioprosthetic gradient with mild aortic regurgitation.
Mild-moderate mitral regurgitation. At least mild pulmonary
artery systolic hypertension.
.
EKG - Atrial and ventricular pacing. Compared to the previous
tracing there is no significant change.
.
Cardiac catherization - COMMENTS:
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had no angiographically apparent disease.
--the LAD was totally occluded after D1.
--the LCX had diffuse distal disease 50-60%, unchanged from
before. The
OM and LCX stents were patent. OM2 had a jailed origin 80%
stenosis.
--the RCA was known occluded and not injected.
2. Venous conduit angiography revealed the SVG-OM graft
occluded at its
origin. The SVG-LAD graft was patent.
3. Limited resting hemodynamics revealed mild systemic arterial
systolic hypertension, with SBP 149 mmHg.
4. Successful PTCA of the OM2 origin using a 2.5x12mm Quantum
Maverick
balloon. Final angiography showed normal flow, no apparent
dissection,
and a less than 20% residual stenosis. (See PTCA comments.)
5. The right femoral arteriotomy was successfully closed using a
Mynx
device.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG-LAD graft, occluded SVG-OM graft.
2. Mild systemic arterial systolic hypertension.
3. PTCA of the OM2 origin was performed.
Brief Hospital Course:
86-y/o M with a PMH of CAD s/p CABG, s/p PCI to LCx ([**2154**]), s/p
bioprosthetic aortic valve replacement, systolic CHF s/p
biventricular ICD who presented with stuttering chest pain that
resolved. Cardiac enzymes were negative. Patient underwent
cardiac catherization and had stent placed in the OM1.
.
#. Chest Pain - The pt has a significant history of CAD with
previous CABG and PCI to LCx and OM in [**2154**]. The pt presented
with 1 hour history of mid-sternal, band-like chest pain not
relieved by ntg. No associated symptoms, no clear precipitating
event. Cardiac enzymes were negative x3. No clear ECG changes
however the pt is paced with LBBB morphology on ECG.
Presentation concerning for unstable angina given long cardiac
history but notably with absense of ECG and CE changes. Patient
was admitted for cardiac catherization which was delayed
secondary to elevated INR. Once INR was < 1.8 patient was taken
to cardiac catherization which demonstrated Cath obstructed OM1
which was balooned as well as distal LAD and RCA complete
obstructions that were not intervened upon. Patient was started
on IV heparin drip and nitro drips. IV heparin was discontinued
after the patient had 3 sets of negative enzymes. Patient was
continued on Beta blocker, aspirin. Initially prior to cardiac
catherization patient was placed on plavix 75 mg PO daily
however this medication was discontinued prior to discharge.
Cardiac catherization demonstrated three vessel coronary artery
disease, patent SVG-LAD graft, occluded SVG-OM graft, mild
systemic arterial systolic hypertension. Patient had PTCA of the
OM2 origin was performed. As patient with extensive coronary
artery history and also with markedly elevated LDL patient was
started on statin. Given that already on amiodarone as
outpatient started atorvastatin 20 mg PO daily.
.
#. Systolic Heart Failure - pt with report of severe CHF, BiV
ICD placed [**12-24**]. EF On exam patient appeared euvolemic. ECHO
showed EF 25%, mild symmetric left ventricular hypertrophy with
dilated cavity, global hypokinesis; nml AS valve with mild AR,
mild MR, mild [**Last Name (un) 6879**]. Patient was continued on home regimen on
BB, spironolactone and Lasix 60 mg daily. Patient also on
aspirin and as above was started on statin. Patient with severe
systolic heart failure but not previously on ACE inhibitor so
will defer starting to outpatient cardiologist given recent
cardiac catherization and dye load.
.
#. Hx of NSVT s/p ICD - Continue outpatient regimen of
amiodarone 100mg PO daily and metoprolol.
.
#. PAF - Patient maintained on amiodarone and metoprolol which
were continued on admission. Patient on coumadin as an
outpatient. INR elevated on admission likely secondary to recent
levoquin use. Initially coumadin was held in preparation for
cardiac catherization and restarted on discharge.
.
#. Gout - Completed prednisone taper for gout flare. Patient
complained after completion of prednisone taper that his toe was
bothering him again. Toe base appeared red and inflammed.
Patient reports that he has never had toe tapped to look for
crystals and has not been on prophylactic medications such as
allopurinol or colchicine. Given acute nature of worsening
symptoms started patient on short course of colchicine to
complete 3 day course. Patient told to follow up as outpatient
with primary care doctor and to have toe tapped and begin
appropriate therapy.
.
#. Hx of recent PNA - Resolved. Pt recently completed six day
course of levaquin/flagyl for post-procedure PNA [**12-24**], currently
with decreased R sided breath sounds and wheezes. The
floroquinolone likely caused the suprathrapeutic INR. CXR this
admission with no evidence of PNA and WBC are WNL.
.
#. FEN - cardiac diet, fluid restrict 2L daily
.
#. Access: PIV
.
#. PPx: coumadin, bowel regimen
.
#. Code: Full
Medications on Admission:
Amiodarone 100 mg Tablet daily
Furosemide 40 mg Tablet daily
Metoprolol Succinate 25 mg po daily
Nitroglycerin 0.4 mg Tablet PRN
Spironolactone 25 mg Tablet po daily
Warfarin 2 mg Tablet daily
Aspirin 81 mg Tablet 1 Tablet daily
Prednisone 40mg daily X 5days - 3days remaining
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
4. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total 3 doses: If you still have
chest pain after 3 doses, call 911.
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
6. Outpatient Lab Work
Please check INR on Monday [**2-14**], call results to Dr.
[**Last Name (STitle) 1911**]
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Systolic Congestive Heart Failure
Coronary Artery disease
Acute Gout Flare
Discharge Condition:
stable.
Discharge Instructions:
You had chest pain that caused you to go to [**Hospital3 **],
then you were transferred here. You did not have evidence of
damage to your heart muscle (heart attack). You pacemaker was
evaluated and you did not have evidence of any irregular rhythms
that could cause the chest pain. You had a cardiac
catheterization that showed a blockage in one of the small
arteries near your heart. This was opened with a balloon but no
stent was placed. You had a gout flare after the prednisone was
stopped, colchicine was given to treat the pain and
inflammation.
New medicines:
2. Metoprolol: to slow the heart rate and help your heart pump
better
3. Atorvastatin: to keep your chelesterol low and prevent
further blockages
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1
day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
.
Please call Dr. [**Last Name (STitle) 26676**] if you have any further chest
pain, nausea, trouble breathing, cough or any other unusual
symptoms.
.
No pools or baths for one week, you may shower and cover the
groin site with a band-aid. No lifting more than 10 pounds for
one week. Please talk to Dr. [**Last Name (STitle) 30441**] about an exercise
program or cardiac rehabilitation.
.
Please resume your coumadin at your previous dosing and check
INR on Monday
Followup Instructions:
Cardiology:
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 11767**]
Date/Time:[**2157-2-28**] 10:00
Primary Care:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 30442**], MD Phone: [**Telephone/Fax (1) 27541**] Date/Time: Monday [**2-14**] at 2pm.
Completed by:[**2157-2-11**]
|
[
"V45.01",
"V45.81",
"414.01",
"V45.02",
"428.22",
"427.31",
"411.1",
"274.9",
"412",
"428.0",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"00.45",
"00.66",
"37.22",
"00.40",
"89.49",
"88.57",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11338, 11344
|
6193, 10037
|
227, 284
|
11471, 11481
|
2454, 5972
|
12845, 13179
|
1562, 1579
|
10365, 11315
|
11365, 11450
|
10063, 10342
|
5989, 6170
|
11505, 12822
|
1594, 1594
|
1616, 2435
|
177, 189
|
312, 1336
|
1358, 1454
|
1470, 1546
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,797
| 108,144
|
49892
|
Discharge summary
|
report
|
Admission Date: [**2131-12-29**] Discharge Date: [**2132-1-30**]
Date of Birth: [**2074-11-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
ICD firing
Major Surgical or Invasive Procedure:
Pacer interrogation
Cardiac catheterization (no intervention)
Central venous line placement in Coronary Care Unit
History of Present Illness:
57 yo M with non-ischemic dilated CMP (EF 20% in [**2-10**] with 4+
MR) secondary to Chagas disease, s/p PPM-ICD for cardiac arrest
[**2127**], multiple ED evaluations for orthostasis, presenting s/p
ICD discharges on [**12-27**] and [**12-29**]. Both shocks were preceded by
prodrome of dizziness without chest pain, palpitations, or SOB,
or syncopal event, and was shocked once. EP evaluation on [**12-27**]
revealed appropriate VT therapy on both occasions. On [**12-27**],
amiodarone was increased from 200 mg QD to 400 mg [**Hospital1 **] x2 weeks
for reloading. EP also adjusted anti-tachycardia pacing
threshold and RV pacing output (given increase in threshold).
Has not had ICD firing prior to these events since implant, but
has had ? regular fast palpitations in chest over past 2 weeks.
On ROS, only other symptom noted was recent URI, for which he
started started Zithromax on [**2131-12-28**].
Past Medical History:
1. Heart failure (EF 20%, 4+ MR) primary cardiologist Dr. [**First Name (STitle) 437**]
2. Chagas disease (travel history in [**Country 3992**], SE [**Female First Name (un) 8489**], S.
America)
3. TB exposure (in travel), +PPD s/p INH.
4. multiple ED evaluations for orthostasis in setting of
medications
Social History:
Does not smoke, drink, or use drugs. Previously worked as
sniper/anti-narcotics [**Doctor Last Name 360**] in [**University/College **], [**Country **], and [**Country 3992**].
Born in [**Country 35188**]. Past exposure to TB in colleagues, never had
active TB, was treated with INH x 12 months
Family History:
No history of CAD. Mother died of diabetes complications. Father
died from prostate CA
Physical Exam:
PE: VS: 100.2 (100.6) | 106/67 | 79 | 24 | 95% on RA; Wt. 205
lbs.
gen: NAD, resting comfortably in bed.
HEENT: PERRL/EOM intact, OP clear, MMM, no JVD, no carotid
bruit.
neck: no masses, no LAD.
CV: RRR, nl s1s2, no murmurs.
chest: CTA b/l, no crackles or wheezes.
abd: soft, nt/nd, +bs, no organomegaly.
extr: warm well perfused, 2+ dp pulses, no cyanosis, no LE
edema.
neuro: a&ox3, cn ii-xii intact; motor, sensory, coordination,
and language grossly non-focal
Pertinent Results:
Admission Labs:
===============
[**2131-12-29**] WBC-8.8 RBC-4.43* Hgb-13.6* Hct-39.8* MCV-90 Plt
Ct-211
[**2131-12-29**] PT-12.8 PTT-21.9* INR(PT)-1.1
[**2131-12-29**] Glucose-64* UreaN-21* Creat-1.5* Na-140 K-4.7 Cl-105
HCO3-25
[**2131-12-29**] Calcium-9.7 Phos-3.5 Mg-2.0
[**2131-12-29**] TSH-0.47
[**2131-12-29**] Digoxin-0.5*
.
Cardiac Enzymes:
===============
[**2131-12-29**] 06:30AM CK-MB-4 cTropnT-<0.01
[**2131-12-29**] 05:00PM CK-MB-4 cTropnT-<0.01
[**2131-12-29**] 09:00PM CK-MB-3 cTropnT-<0.01
[**2131-12-31**] 04:48AM CK-MB-4 cTropnT-<0.01
[**2131-12-29**] 12:00AM CK(CPK)-195
[**2131-12-29**] 06:30AM CK(CPK)-183
[**2131-12-29**] 05:00PM CK(CPK)-165
.
ECHO [**2131-12-31**]-
Conclusions:
===========
1. The left atrium is elongated. LA 6.6 cm.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated (diastolic dimension
8.9cm). Overall left ventricular systolic function is severely
depressed (EF 15-20%). Resting regional wall motion
abnormalities include lateral, inferolateral and apical
akinesis. The remaining left ventricular segments are
hypokinetic.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The mitral valve leaflets are mildly thickened. Severe (4+)
mitral
regurgitation is seen.
5.There is mild pulmonary artery systolic hypertension.
6.There is no pericardial effusion.
7. There is an echogenic density in the right ventricle
consistent with an AICD.
.
CXR [**2131-12-30**]
===========
There is a dual lead left-sided pacemaker, unchanged in
position. There is a new right-sided IJ central venous catheter
with the distal tip in the proximal right atrium. No
pneumothoraces are identified. There is marked cardiomegaly
which is unchanged. There has been interval increase in the
pulmonary vascular markings consistent with edema. There is
again seen a linear density within the right mid lung zone which
may represent atelectasis or scarring. This is unchanged. The
left CP angle has been cut off from the study. There is some
mild elevation of the right hemi-diaphragm and blunting of the
right CP angle which may be secondary to atelectasis, scarring,
or pleural fluid
.
CATH [**2132-1-2**]:
INDICATIONS FOR CATHETERIZATION:
1. Ventricular tachycardia
2. Dilated cardiomyopathy.
3. Severe mitral regurgitation
4. Pre-operative evaluation.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.11 m2
HEMOGLOBIN: 33.3 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 19/17/15
RIGHT VENTRICLE {s/ed} 67/19
PULMONARY ARTERY {s/d/m} 67/37/49
PULMONARY WEDGE {a/v/m} 32/38/30
LEFT VENTRICLE {s/ed} 98/32
AORTA {s/d/m} 98/50/69
**CARDIAC OUTPUT
HEART RATE {beats/min} 80
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 70
CARD. OP/IND FICK {l/mn/m2} 3.8/1.8
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1137
PULMONARY VASC. RESISTANCE 400
**% SATURATION DATA (NL)
SVC LOW 50
PA MAIN 52
AO 95
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 24
pO2 72
pCO2 50
pH 7.4
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DIFFUSELY DISEASED 10
2) MID RCA DIFFUSELY DISEASED 10
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA DIFFUSELY DISEASED 10
4) R-PDA DIFFUSELY DISEASED 10
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DIFFUSELY DISEASED 20
6) PROXIMAL LAD DIFFUSELY DISEASED 10
6A) SEPTAL-1 NORMAL
7) MID-LAD DIFFUSELY DISEASED 10
8) DISTAL LAD DIFFUSELY DISEASED 10
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX DIFFUSELY DISEASED 10
13) MID CX DIFFUSELY DISEASED 10
13A) DISTAL CX DIFFUSELY DISEASED 10
14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 10
15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 10
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
minimal luminal irregularities. The LMCA had mild plaquing up to
20%.
The LAD had minimal luminal irregularities with a distal
myocardial
"bridge" with systolic compression. The apical LAD wrapped well
around
the apex. The LCx had minimal luminal irregularities. The RCA
had
minimal luminal irregularities, it had a twin distal system with
rPDA
and RPL.
2. Hemodynamics demonstrated severely elevated left and right
heart
filling pressures, severely elevated pulmonary artery pressures
and
large V waves on the pulmonary capillary wedge pressure. Cardiac
index
was depressed. The arterial waveform demonstrated narrow pulse
pressure
with low normal systolic systemic arterial pressure. There was
no
gradient across the aortic valve on pull-back of the catheter
from the
LV to the aorta.
3. Left ventriculography was not done as the filling pressures
were too
elevated.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Severe mitral regurgitation.
3. Severe systolic and diastolic ventricular dysfunction.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2131-12-29**] andk initially
underwent device interrogation by EP, followed by IV amiodarone
loading over 24 hours. He subsequently experienced two episodes
of VT/VF the night during amiodarone loading at 12:30, then
subsequently at 7:30 the following morning, 30 min after IV
amiodarone was completed. Anti-tachycardia pacing failed on both
attempts and he was shocked into SR. Lidocaine was initiated
with 100mg bolus and 1mg/min maintenance infusion. He was
transitioned to oral mexilitine. One hour following mexilitine
dose, pt was found by care assistant c/o SOB, nausea, dizzy and
"looking poorly." Nurse found pt to be hypotensive, diaphoretic,
and non-verbally responsive, lidocaine infusion turned off, no
events noted on telemetry. Upon finding pt, vitals noted to be
BP 70/50s HR 70s. Code blue was initiated, pt was able to speak
minimally with femoral pulses present. BS 123. Placed on NRB
with good sats. Received atropine 1 mg and 1L NS without effect,
and was started on levophed gtt 1.0 mcg/kg/min, with improvement
in bp to MAP 60s. ABG noted 7.39/41/230, lactate 1.0. Pt was
tranferred to CCU for pressor management.
On [**12-30**], the patient was transferred to the CCU. Upon arrival to
CCU, all 3 peripheral IV access was lost, thus Levophed drip
held and pts MAP remained > 60 with no further symptoms. He was
transferred back to ther cardiology service the following day.
Amiodarone and Mexilitine were continued and he had no further
episodes of VT/VF. He did have episodes of lightheadedness and
nausea following mexilitine doses but no further hypotensive
episodes.
Patient went to cardiac catheterization and EP study on [**2132-1-2**]
for VT ablation and right and left heart catheterization for
pre-operative preparation for MVR, but EPS could not isolate
endocardial source. EP recommendation at that time was to treat
HF as a possible trigger of VT, discontinue mexilitine and
re-load amiodarone. At that time, his right-heart hemodynamics
revealed severe congestion, mitral regurgitation, and
cardiogenic shock [Fick CO=3.78/1.8, RA 15, RV 67/19, PA 67/37
(49), PCW 29, LV 98/32]. Cardiac surgery was consulted for
possible MVR given persistent HF in setting of MR, and preferred
minimally invasive MVR, without epicardial VT ablation (per EP).
Patient was transferred back to CCU post-procedure. Overnight on
[**1-2**], the patient had another episode of 30 beat NVST without
ICD firing. The patient was maintained on amiodarone and
diuretics for hypervolemic status. He was diuresed and evaluated
for surgery. On [**1-7**], the patient experienced an 18 beat run of
VT followed by ATP pacing and successful conversion to NSR. On
the morning on [**1-8**], the patient had recurrent VT and failed VT
therapy ATP and required external cardioversion by single 30J
shock. The patient was transferred back to the CCU on [**1-8**] and
remained asymptomatic in preparation for cardiac surgery.
On [**2132-1-11**], the patient was taken to the operating room, where he
underwent mitral valve repair with 28mm annuloplasty ring.
Please see operative note for full details. The patient
tolerated this procedure, and was taken to the cardiac surgery
recovery unit on epinephrine, levophed, vasopressin and
lidocaine drips. On post-op day #1, the patient was able to
self-extubate, and required emergent re-intubation. His
lidocaine drip was stopped, and his epinepherine drip was
increased. On post-op day #3, the patient experienced another 27
beat run of VT. An amiodarone drip was initiated, and his
pitressin drip was titrated up for hypotension. On post-op day
#4, the patient was briefly extubated, but was re-intubated for
hypercarbic respiratory failure. On post-op day #5, a palpable
cord was noted on the patient's left arm from an infiltrated IV
site. IV vancomycin was started. Blood cultures were drawn,
which resulted in one set positive for coag(-) staph. Subsequent
blood cultures were all negative. On post-op day #6, the patient
was diuresed with lasix, and tube feeding was initiated. On
post-op day #8, the patient suffered recurrent runs of VT with
unsuccessful ATP x2 along with one unsuccessful attempt at
external shock with 30J before final control with a second
external shock. A lidocaine drip was re-initiated. On post-op
day #9, heparin sc was started, and the patient was extubated.
EPS recommendations were to start PO amiodarone 400mg QD along
with mexilitine 200mg PO Q8h. Shortly after initiating these
changes, the patient again suffered VT, and the amiodarone and
lidocaine drips were restarted. Though the patient was
considered for ablation, these interventions were felt to be too
risky. Based on EPS recommendations, the lidocaine drip was
stopped. On POD#11, an infectious diseases consult was obtained
for ongoing fevers to 101.5F. His antibiotic coverage was
broadened, and he was pan-cultured, though these all failed to
show any causative organism. The patient was re-intubated for
respiratory failure, and he patient suffered another episode of
VT requiring defibrillation. On post-op day #12, his amiodarone
drip was increased, and his LFT's were checked. This revealed
normal transaminases but an amylase of 587. The patient was made
NPO. This was rechecked on post-op day #13 and was found to be
526. A right-upper quadrant ultrasound was performed, but failed
to visualize the gallbladder. No common bile duct dilation was
noticed. The patient's medication regimen was reviewed, and all
non-essential drugs with possible hepatotoxicity were stopped.
On post-op day #15, the amylasemia continued to rise to 724 with
a lipase of 827. A CT scan was performed, but this failed to
show any evidence of pancreatitis. The patient remained
clinically benign. On post-op day #16, a clear liquid diet was
initiated. On post-op day #17, the amylase and lipase continued
to rise slightly, and a GI consult was obtained. No specific
etiology was noted, and the patient was again made NPO. On
post-op day 18, the patient again suffered 3 rounds of VT. The
amylase and lipase continued to rise to the 800's and 1000's
respectively. He remained NPO. On post op day 19 his amylase
remained elevated at 780. GI medicine recommmended beginning the
[**Last Name (un) **] diet when the diet is restarted and t/c discontining the
NGT. He was transferred to [**Hospital1 2025**] for transplant consideration.
Medications on Admission:
1. Carvedilol 3.125 mg [**Hospital1 **]
2. Lasix 20 mg QOD
3. Aldactone 50 QD
4. Amiodarone 200 mg QD changed to 400 mg daily [**12-27**]
5. Digoxin 0.1 mg QHS
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Lidocaine in D5W 4 mg/mL Parenteral Solution Sig: One (1)
ml/min Intravenous INFUSION (continuous infusion).
3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 24H (Every 24 Hours).
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: Five (5) cc PO BID
(2 times a day). cc
6. Amiodarone 50 mg/mL Solution Sig: One (1) mg/kg/min
Intravenous INFUSION (continuous infusion).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours).
10. Bumetanide 0.25 mg/mL Solution Sig: One (1) mg Injection [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1129**]
Discharge Diagnosis:
Non-ischemic dilated cardiomyopathy, Chagas disease
VT with AICD
Cardiogenic shock
Discharge Condition:
Good
Discharge Instructions:
Please report chest pain, palpitations, AICD firing, shortness
of breath or other concerning symptoms to your primary
physician.
You have been started on two new medications called Amiodarone
and Mexilitine. Please continue to take these as scheduled until
otherwise directed by your cardiologist. Please follow-up with
Dr. [**First Name (STitle) 437**] as scheduled below.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2132-1-7**]
1:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2132-1-9**]
9:00
Completed by:[**2132-1-30**]
|
[
"416.8",
"790.5",
"424.0",
"785.51",
"795.5",
"086.0",
"593.9",
"427.31",
"428.41",
"999.3",
"427.1",
"V53.32",
"518.5",
"790.7",
"425.8",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"37.34",
"38.93",
"37.26",
"37.23",
"96.6",
"37.27",
"88.56",
"39.61",
"00.17",
"96.71",
"88.72",
"99.62",
"00.13",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
15181, 15228
|
7541, 13978
|
333, 449
|
15355, 15362
|
2634, 2634
|
15785, 16089
|
2045, 2133
|
14189, 15158
|
15249, 15334
|
14004, 14166
|
7393, 7518
|
15386, 15762
|
2148, 2615
|
2986, 4858
|
4891, 7376
|
283, 295
|
477, 1386
|
2650, 2969
|
1408, 1717
|
1733, 2029
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,440
| 159,681
|
43893
|
Discharge summary
|
report
|
Admission Date: [**2172-4-28**] Discharge Date: [**2172-5-8**]
Date of Birth: [**2099-5-13**] Sex: F
Service: MEDICINE
Allergies:
Gentamicin
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
weakness and lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 72 yo female with h/o MCA embolic stroke in [**1-13**],
HTN, tachy-brady syndrome, breast CA, PAF, DM II, Diastolic HF,
and UTIs who presented to her PCP's office yesterday with LE
edema and was called into the ED tonight when labs came back
pertinent for hyperkalemia. Her son picked her up at home and on
transport to the hospital she became weak and lethargic and
required being carried out of the car into the OR.
.
On arrival to the ED vitals were T97.2 HR77 BP137/61 RR17 o2
99% RA. She was found to have a UTI and given her previous cx
data was started on vancomycin and CTX. Her exam was noticle for
lethargy, but arousable, not speaking, and poor capillary
refill. Her CXR showed bilateral pleural effusions and ? of
old femur fracture. Her lab was notable for a lactate of 5.4,
WBC of 10.5, creatinine of 1.4 (recent baseline 1.2). EKG with
no evidence of hyperkalemia. While in the ED her SBPS remained
stable with lowest SBP in the 110s. She received a total of 2.5
L of fluid in the ED including abx). Vitals prior to transfer
were 97.2 77 137/61 17 99% on 2L.
.
On arrival she was somulent but arousable. Vitals on arrival
were 95.6 162/78 16 84% on RA. Her o2 sat improved to the high
90s on a non rebreather. Her gas on arrival to the floor was
ph7.19 pCO281 pO2 255 HCO3 32. She was placed on BiPAP and her
gas improved to pH7.30 pCO264 pO2 86 HCO3 33. She then dropped
her pressures to SBP to 80s which responded to IVF bolus. She
dropped her pressures 2 more times during her centralline
placement which responded to bolus. A left IJ was attempted and
a R IJ was ultimately placed.
.
Review of systems:
unable to obtain secondary to pt's mental status
Past Medical History:
1: MCA embolic stroke c/b hemorrhagic transformation on coumadin
[**1-13**]. (residual aphasia & R sided weakness)
2. Hypertension
3. Tachy-brady syndrome s/p pacemaker
4. Paroxysmal atrial fibrillation
5. DM2
6. Diastolic HF ([**2169**])
7. Enterrococcal bacteremia treated with Amp/Gent, suspected
source suspected RLE cellulitis
8. Breast cancer s/p axillary dissection and chemo/radiation
9. Depression
10. Endometriosis
11. Shoulder pain
12. Incontinence
Social History:
Russian-speaking.45 yr smoking hx. [**12-7**] PPD. No EtOH or illicits
per her son.
Family History:
Father died at stroke at 74.
Physical Exam:
95.6 162/78 16 84% on RA.
Gen: initially opening eyes, later no longer opening eyes to
command
HEENT: pupils equally round, periorbital edema, mmm, oropharynx
clear
Neck: supple, elevated JVD
Lungs: No breath sounds at bases, decreased air movement
throughout, no crackles, no rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +bs, soft, non-tender, non-distended, no rebound
tenderness or guarding
Ext: 1+ radial and DP pulses, 1+ pitting edema to the knees with
ulcers in the lower extremities with clean bases
Pertinent Results:
Labs on Admission:
[**2172-4-28**] 12:03AM WBC-12.3* RBC-3.78* HGB-10.7* HCT-35.1*
MCV-93 MCH-28.3 MCHC-30.5* RDW-15.4
[**2172-4-28**] 12:03AM NEUTS-56.9 LYMPHS-35.4 MONOS-4.6 EOS-2.5
BASOS-0.6
[**2172-4-28**] 12:03AM PLT COUNT-320
[**2172-4-28**] 12:03AM PT-14.8* PTT-25.4 INR(PT)-1.3*
[**2172-4-27**] 05:30PM GLUCOSE-116*
[**2172-4-27**] 05:30PM UREA N-40* CREAT-1.4* SODIUM-145
POTASSIUM-6.1* CHLORIDE-98 TOTAL CO2-35* ANION GAP-18
[**2172-4-27**] 05:30PM URINE HOURS-RANDOM CREAT-68 SODIUM-58
POTASSIUM-48 CHLORIDE-87 albumin-9.8 alb/CREA-144.1*
[**2172-4-27**] 05:30PM URINE OSMOLAL-493
.
Labs on discharge:
[**2172-5-8**] 04:06AM BLOOD WBC-8.2 RBC-3.41* Hgb-9.7* Hct-31.0*
MCV-91 MCH-28.3 MCHC-31.1 RDW-15.1 Plt Ct-397
[**2172-5-8**] 04:06AM BLOOD PT-19.2* PTT-34.3 INR(PT)-1.8*
[**2172-5-8**] 04:06AM BLOOD Glucose-193* UreaN-21* Creat-1.0 Na-140
K-4.2 Cl-103 HCO3-31 AnGap-10
[**2172-5-8**] 04:06AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.7
.
Micro:
blood culture: [**4-28**] MICROCOCCUS SPECIES
.
urine culture: [**4-28**] Proteus Mirabilis
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Imaging:
CXR: [**2172-4-27**]
This exam is limited due to patient's body habitus and low lung
volumes. There is left-sided pleural effusion with likely
adjacent atelectasis. There is also a right-sided small pleural
effusion causing blunting of the right costophrenic angle. Heart
is enlarged.
The aorta is calcified and tortuous. There is no pneumothorax or
evidence of congestive heart failure. Bones are severely
osteopenic. Likely prior left humeral fracture is seen.
IMPRESSION: New bilateral pleural effusions, left more than
right. Cardiomegaly. No overt pulmonary edema.
.
ECHO: [**2172-4-29**]
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). 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 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 systolic prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
CXR: [**5-1**]
Compared to yesterday, the fluid level on the right has
resolved. There is
unchanged mild pulmonary edema, unchanged large layering
bilateral pleural
effusions with an unchanged retrocardiac opacity, likely
atelectasis.
Unchanged left pacemaker terminating in the right atrium.
IMPRESSION: Unchanged hypervolemia with mild pulmonary edema and
moderate to
large bilateral pleural effusions.
.
CT head: [**5-2**]
There is no acute intracranial hemorrhage. Extensive
encephalomalacia in the left MCA territory, with gyriform
mineralization, is unchanged and compatible with a left MCA
infarct with pseudolaminar necrosis. Mild ex vacuo effect on
the left lateral ventricle is most pronounced in the left
temporal [**Doctor Last Name 534**]. There is no evidence of acute major vascular
territorial infarct. Periventricular white matter hypodensities
are again noted, compatible with chronic microvascular ischemic
disease. An opacified left ethmoid Haller cell is again noted.
The bones are unremarkable.
IMPRESSION: No evidence of acute intracranial abnormalities.
Large chronic left MCA infarct. MRI would be more sensitive for
an acute infarct, if indicated.
.
Left upper extremity ultrasound [**2172-5-4**]: No evidence of DVT of
the left upper extremity.
Brief Hospital Course:
72 year old Russian speaking female with h/o stroke, HTN, DMII,
A fib, tachy/brady s/p pacemaker, breast CA, and diastolic heart
failure who presented with UTI, hyperkalemia, and severe sepsis.
1. Severe sepsis secondary to urinary tract infection: Presented
to ED with lactate of 5.4, leukocytosis to 12.3, intermittent
hypotension and low urine output. In the emergency department,
lactate decreased and hypotension resolved with IV fluid bolus.
Blood and urine cultures were drawn and placed empirically on
vancomycin and ceftriaxone (subsequantly broadened to zosyn).
CXR with no evidence of pulmonary infiltrate. Source of
infection attributed to urinary tract infection with grossly
positive urinalysis. Started on early goal directed therapy
with placement of arterial and central venous line for
hemodynamic monitoring. Although blood pressure required brief
support with levophed, hemodynamics normalized and patient
defervesced. 1 of 2 sets of blood cultures from the emergency
department grew micrococcus, which was thought to be a
contaminent so vancomycin was discontinued. Urine cultures
returned with proteus mirabilis (see above for sensitivities).
The patient's antibiotics were narrowed to ceftriaxone alone,
with a plan to treat for 14 days. The patient will complete her
course of ceftriaxone on [**2172-5-11**]. At that point, her midline can
be removed.
.
2. Hypoxia/Hypercarbia: Upon admission to the intensive care
unit, the patient was hypercapnic and in respiratory distress
with ABG of 7.19/81/255/32 on 100% NRB. Hypercapnia was
attributed to underlying lung disease with 45 yr smoking
history. The patient responded well to BiPAP with decreasing CO2
and was able to be transitioned quickly to 2-4L NC alone,
although she did subsequently require intermittent noninvasive
ventillation for hypercapnia. The patient was treated with
bronchodilators and diuresis. At the time of discharge, the
patient was breathing comfortably, with oxyggen saturations in
the low to mid 90s on 0-2 L/min O2 by nasal cannula.
.
3. Acute on chronic renal failure: Admitted to hospital with
hyperkalemia of 6.1 and acute renal failure with creatinine of
1.6 from baseline of 1.2 in [**10-13**]. EKG showed no changes
associated with hyperkalemia. Kidney injury was thought to be
prerenal in etiology, related to sepsis. The patient's kidney
function improved throughout her hospital stay and was 1.0 at
the time of discharge.
.
4. Urinary trace infection, complicated by sepsis: The patient
was found to have a urinary tract infection with proteus,
sensitive to ceftriaxone with a MIC of 4. The patient's sepsis
was thought to be caused by urinary tract infection.
.
5. Chronic atrial fibrillation: The patient has a history of
chronic atrial fibrillation. She is anticoagulated with
Coumadin, with her rate controlled by B-blockers.
The patient was admitted with a subtherapeutic INR, and placed
on heparin gtt with continuation of coumadin until INR > 2. INR
became supratherapeutic to 4.1 in setting of new antibiotics and
poor PO intake, so Coumadin was held. The patient's INR
subsequently became subtherapeutic, so she was started on a
heparin gtt, later transitioned to enoxaparin. The patient's INR
was 1.8 at the time of discharge. She should have her INR
checked daily until it is greater than 2.0, at which time
enoxaparin should be discontinued and warfarin continued at the
present dose of 4 mg daily. Thereafter, the patient's INR should
be checked twice weekly. Goal INR is 2.0 to 3.0.
The patient uses metoprolol for rate control. Beta blockade
was initally held due to hypotension. However, the patient had
intermittent tachycardia to the 120s requiring doses of IV
metoprolol. The patient's home dose of metoprolol tartrate was
restarted and then reduced to 100 mg in the morning and 75 mg at
night due to hypotension.
.
6. Ulcers on LE: The patient has ulcers on her lower extremity,
which are thought to be related to vascular insufficiency. There
was no evidence of active skin or soft tissue infection. The
wound care team was consulted and made recommendations for wound
care. These recommendations have been included in the patient's
page 1.
.
7. Acute chronic diastolic congestive heart failure: The patient
has a history of diastolic heart failure. Repeat echocardiogram
showed ejection fraction of 55%. The patient was aggressively
volume resuscitated, resulting in symptoms of volume overload.
In the ICU, the patient was diuresed with lasix 40mg IV. She
subsequently developed hypotension requiring a 250cc fluid
bolus. The patient was euvolemic at the time of discharge. Lasix
was discontinued given the patient's blood pressure of 100-140
and lack of edema. Consideration can be given to restarting this
in the outpatient.
.
8. Diabetes mellitus: Metformin was held given heart failure and
hypotension. The patient was initially treated with an insulin
sliding scale. Lantus 6 units at night was added to improve
glycemic control. The patient was discharge on Lantus 6 units at
night, plus Humalog insulin sliding scale.
.
9. Delirium: The patient developed waxing and [**Doctor Last Name 688**] mental
status that was thought to be related to delirium. The cause of
delirium was urinary tract infection. The patient's mental
status improved throughout her hospital course, and she was at
her pre-admission baseline at the time of discharge.
.
10. Hypertension: Stopped Lasix and lisinopril/HCTZ in the
setting of low blood pressures. Consideration can be given to
restarting these medications in the outpatient setting.
.
11. Depression: Continued venlafaxine.
.
12. Swallowing safety: The patient was evaluated by the speech
and swallow service, who recommended a diet of thin liquids and
soft consistency solids, pills crushed with puree, and strict
1:1 supervision when eating.
12. Code status: FULL CODE
Medications on Admission:
ATORVASTATIN 80 mg PO daily
FUROSEMIDE 10 mg PO every 2 days
GABAPENTIN 100 mg PO BID
LISINOPRIL-HYDROCHLOROTHIAZIDE - 10 mg-12.5 mg Tablet PO daily
METFORMIN 1,000 mg PO BID (breakfast and lunch)
Metformin 500 mg PO QHS
METOPROLOL TARTRATE 100 mg PO BID
OMEPRAZOLE 20 mg PO daily
VENLAFAXINE 37.5 mg PO BID
WARFARIN 4 mg tablets as directed (daily per most recent [**Company 191**]
anticoagulation sheet)
Humalin ISS
MAGNESIUM OXIDE 400 mg Tablet PO daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet [**Company **]: One (1) Tablet PO DAILY
(Daily).
2. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Company **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Venlafaxine 37.5 mg Tablet [**Company **]: One (1) Tablet PO BID (2
times a day).
5. Warfarin 2 mg Tablet [**Company **]: Two (2) Tablet PO Once Daily at 4
PM.
6. Metoprolol Tartrate 50 mg Tablet [**Company **]: Two (2) Tablet PO QAM
(once a day (in the morning)).
7. Metoprolol Tartrate 25 mg Tablet [**Company **]: Three (3) Tablet PO QPM
(once a day (in the evening)).
8. Insulin Glargine 100 unit/mL Solution [**Company **]: Six (6) units
Subcutaneous at bedtime.
9. Magnesium Oxide 400 mg Tablet [**Company **]: One (1) Tablet PO once a
day.
10. Enoxaparin 80 mg/0.8 mL Syringe [**Company **]: Eighty (80) mg
Subcutaneous [**Hospital1 **] (2 times a day).
11. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for wheezing.
14. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed for wheezing.
15. Outpatient Lab Work
Check INR daily until >2.0. Goal is 2.0 to 3.0. Stop enoxaparin
when INR > 2.0. INR should be checked twice weekly thereafter.
Please fax results to [**Hospital3 **] at [**Hospital1 771**] at [**Telephone/Fax (1) 3534**].
16. .
CeftriaXONE 1 gm IV Q24H. Last day = [**2172-5-11**].
17. Humalog insulin
Please see attached Humalog insulin sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
severe sepsis, caused by urinary tract infection
.
Secondary:
history of stroke
hypertension
diabetes mellitus, type 2
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because of a high potassium level. In
the emergency department, you were found to have a urinary tract
infection. You were admitted to the intensive care unit due to
low blood pressure and difficulty breathing. You were treated
with antibiotics, with improvement in your condition.
.
You had a special kind of IV called a midline placed in order to
administer antibiotics. You will need to continue to receive
daily antibiotic infusions through this line until [**2172-5-11**].
.
There are some changes to your medications:
START ceftriaxone and continue until [**2172-5-11**].
START Lovenox (enoxaparin) and continue for 1-3 days (until your
INR is >2.0). INR goal is 2.0-3.0.
START colace and senna as needed for constipation
START glargine 6 units at night. Talk to you primary care doctor
about when it will be okay to stop this.
STOP Lasix (furosemide)
STOP Neurontin (gabapentin)
STOP lisinopril-HCTZ
STOP metformin
CHANGE metoprolol to 100 mg in the morning and 75 mg in the
evening
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Follow up as indicated below.
Followup Instructions:
PLEASE FOLLOW-UP WITH Dr. [**Last Name (STitle) 1520**] on [**5-22**] at 10:30am at
[**Hospital3 **] / [**Hospital Ward Name 23**] [**Location (un) 895**] . Phone #[**Telephone/Fax (1) 250**].
This is for a post-discharge follow-up appointment until you can
get your next follow-up scheduled with Dr. [**Last Name (STitle) **].
.
Department: [**Hospital3 249**]
When: THURSDAY [**2172-5-28**] at 4:10 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital Ward Name 706**]
When: THURSDAY [**2172-6-25**] at 1:55 PM
With: [**Year (4 digits) 706**] [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital 2039**] CARE CENTER
When: THURSDAY [**2172-6-25**] at 3:15 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 2041**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
|
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"584.9",
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"518.81",
"599.0",
"403.90",
"250.00",
"428.33",
"305.1",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
15534, 15624
|
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|
292, 299
|
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|
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|
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|
2521, 2606
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,134
| 139,471
|
13474
|
Discharge summary
|
report
|
Admission Date: [**2139-10-25**] Discharge Date: [**2139-10-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Ventricular tachycardia ablation
History of Present Illness:
82F h/o CAD s/p CABG, HTN, DM, CRI, bilateral RAS s/p stenting,
h/o atrial flutter transferred from OSH after presenting with
chest pain and found to have stable wide complex tachycardia.
Had been feeling well until the morning of admission when she
developed diarrhea and nausea with emesis x 1. Began to
experience SSCP radiating to the back at 5pm that was unrelieved
by nitro. No associated SOB, diaphoresis. Has not had angina
since CABG. The patient called EMS who found her in stable wide
complex tachycardia with rate 200's. Given 2x lidocaine boluses
with resolution of the tachycardia and chest pain. Presented to
[**Location (un) 620**] ED where she again developed wide complex tachycardia
captured on ECG, likely VT. Given amiodarone boluses and placed
on amiodarone gtt with termination of arrythmia. Transferred to
[**Hospital1 18**] for further evaluation. Currently CP free. Denies resting
SOB, edema, PND, or orthopnea. Endorses DOE with 1 flight
stairs. No abdominal pain.
Past Medical History:
1. HTN
2. CHF (EF 50-60%)
3. CAD s/p CABG ([**2118**]; LIMA->LAD, SVG->OM1, SVG->RCA)
4. s/p MI ([**2105**])
5. DM2
6. bilateral RAS s/p stents ([**2134**])
7. right carotid stenosis
8. s/p appendectomy ([**2105**])
9. s/p cholecystectomy ([**2104**])
10. Spinal stenosis; s/p surgery ([**2134**])
11. Chronic renal insufficiency (baseline Cre 2.3)
12. Bilateral cataracts
13. s/p colonoscopy ([**2135**])
14. h/o atrial flutter
15. h/o chronic anemia (baseline Hct 30-32)
Social History:
The patient lives at home with her husband.
She has a 30-pack-year smoking history, but none currently.
She does not drink alcohol.
Family History:
NC
Physical Exam:
T 99.4 HR 60 BP 180/60 left arm, 180/72 right arm RR 23 SaO2 95%
on 2L NC Weight 193 lbs
General: WDWN, NAD, breathing comfortably on RA
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink, MM
moist
Neck: supple, trachea midline, no thyromegaly or masses, no LAD,
no carotid bruits
Cardiac: RRR, s1s2 normal, 2/6 systolic murmur @ apex, JVP 12 cm
Pulmonary: CTAB
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities
Pertinent Results:
Admission Labs:
* Hematology -
[**2139-10-24**] 10:23PM BLOOD WBC-15.6*# RBC-4.06* Hgb-13.3# Hct-37.5
MCV-93 MCH-32.8* MCHC-35.5*# RDW-13.6 Plt Ct-171
[**2139-10-24**] 10:23PM BLOOD Neuts-93.5* Bands-0 Lymphs-4.3* Monos-2.1
Eos-0.1 Baso-0
[**2139-10-24**] 10:23PM BLOOD Plt Ct-171
[**2139-10-25**] 03:22AM BLOOD PT-11.7 PTT-20.5* INR(PT)-1.0
[**2139-10-26**] 06:26AM BLOOD Ret Aut-1.6
.
* Chemisty -
[**2139-10-24**] 10:23PM BLOOD Glucose-438* UreaN-95* Creat-3.3* Na-142
K-4.2 Cl-107 HCO3-20* AnGap-19
[**2139-10-24**] 10:23PM BLOOD CK(CPK)-270*
[**2139-10-25**] 03:22AM BLOOD ALT-21 AST-35 LD(LDH)-293* CK(CPK)-323*
AlkPhos-112 Amylase-202* TotBili-0.4
.
Discharge Labs:
* Hematology -
.
* Chemistry -
.
ECG ([**2139-10-24**]): sinus, 89bpm, LAD, LVH, Q-waves III/AVf, STE's
III/AVf, new LBBB compared to [**2136-11-16**]
.
CXR, portable ([**2139-10-24**]): no acute process
.
Cardiac MR ([**2139-10-26**]):
.
Right
.
Prior studies -
.
Cath ([**11/2134**]):
COMMENTS:
1. Resting hemodynamics demonstrated systolic hypertension and
mildly
elevated biventricular filling pressures. The cardiac index was
normal at 3.8 L/min/m2.
2. Selective native coronary arteriography demonstrated total
occlusion of all coronary arteries proximally.
3. Selective graft angiography was performed. The LIMA to LAD
was
widely patent. The RCA filled well via collaterals from the
LAD. The SVG to OM1 was widely patent. The SVG to RCA was
totally occluded proximally.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease.
2. Patent LIMA to LAD and SVG to OM1.
3. Normal cardiac output.
4. Systolic hypertension.
.
TTE ([**1-/2135**]):
CONCLUSIONS:
The left atrium is mildly dilated. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is hypokinesis of the inferior and posterior
walls, but the overall ejection fraction is well-preserved
(50-60 percent). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is no significant aortic valve stenosis. 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 left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: left ventricular hypertrophy with preserved left
ventricular ejection fraction, inferior-posterior hypokinesis,
and probable diastolic dysfunction of the left ventricle.
[**2139-10-26**] 06:26AM BLOOD CK(CPK)-115 Amylase-28
[**2139-10-28**] 07:10AM BLOOD Amylase-100
[**2139-10-25**] 03:22AM BLOOD Lipase-194*
[**2139-10-26**] 06:26AM BLOOD Lipase-128*
[**2139-10-28**] 07:10AM BLOOD Lipase-109*
[**2139-10-24**] 10:23PM BLOOD CK-MB-27* MB Indx-10.0* cTropnT-0.33*
[**2139-10-25**] 03:22AM BLOOD CK-MB-39* MB Indx-12.1* cTropnT-1.92*
[**2139-10-25**] 11:15AM BLOOD CK-MB-27* MB Indx-11.0* cTropnT-1.43*
[**2139-10-26**] 06:26AM BLOOD CK-MB-10 MB Indx-8.7* cTropnT-0.92*
[**2139-10-24**] 10:23PM BLOOD Calcium-9.8 Phos-3.4 Mg-2.4
[**2139-10-26**] 06:26AM BLOOD calTIBC-242* VitB12-249 Folate-GREATER TH
Ferritn-133 TRF-186*
[**2139-10-25**] 03:22AM BLOOD TSH-1.6
Brief Hospital Course:
82F with CAD s/p CABG, CHF, DM2, CRI presents with SSCP and
stable VT. No more episodes VT or CP during admission. Unable to
induce VT on EP study but underwent empiric VT ablation based on
[**Month/Day/Year **] mapping.
.
# Wide complex tachycardia: likely VT based on OSH ECG given
left axis, atypical RBBB; thought to be originating from prior
inferior MI [**Month/Day/Year **] rather than new ischemia. at presentation, the
patient was asymptomatic and in sinus. transferred from OSH on
amiodarone gtt but discontinued to aide in ability to induce VT
at EP study. no more VT episodes during admission. underwent
cardiac MR [**First Name (Titles) **] [**Last Name (Titles) **] mapping. at EP study on [**10-27**], they were
unable to induce VT. the patient underwent presumptive ablation
of inferior/septal myocardial [**Month/Day (4) **]. f/u with Dr. [**Last Name (STitle) **] next week.
.
# CAD: s/p CABG with 2/3 grafts patent on [**2133**] cath. cardiac
enzymes positive in the setting of rapid sustained VT. concern
for ACS as may have new obstructing graft lesion however given
that symptoms of chest pain resolved when arrythmia terminated
thought to be less likely. she was contiued on ASA, plavix,
statin, beta blocker, and nitrate. heparin gtt was discontinued.
cardiac MR was performed (see above for results) for [**Year (4 digits) **]
mapping prior to ablation. no cardiac cath given less likely VT
from active ischemia and poor baseline renal function. she was
restarted on all of her home dose medications prior to
discharge.
.
# CHF: preserved EF on last echo, likely distolic dysfunction.
elevated JVP (possibly related to TR) but no edema or rales on
exam. she was given a low sodium diet, daily weights, strict
I/Os. lasix was initially held as thought slightly volume
depleted from vomiting and diarrhea prior to admission,
supported by exam and pre-renal indices. she maintained good
SaO2 and was restarted on lasix 40mg [**Hospital1 **] was restarted at
discharge.
.
# HTN: elevated BPs at admission in the setting of not receiving
her home medications. initially, clonidine and ACEi were held to
give room to up-titrate beta-blocker given VT and concern for
ACS. BPs remained slightly elevated at discharge (SBP 130-170).
She was restarted on home dose metoprolol, clonidine, isordil,
and ACEi.
.
# Acute on CRI: non-oliguric. Cre peaked at 3.3 (baseline of
2.3). Most likely etiology is pre-renal from either hypovolemia
(poor PO intake/vomiting), poor forward flow, although also
possible renal artery restenosis. indices supported pre-renal
etiology (FeNa 0.22%, Uosm 564) and improved to baseline during
admission with holding lasix. restarted on ACEi and lasix at
discharge.
.
# Abdominal symptoms: nausea, vomiting, and diarrhea the day of
presentation. no abdominal pain. afebrile but with elevated WBC
count. normal LFTs but elevated amylase and lipase (?[**1-29**]
vomiting) tjat then normalized prior to discharge. all symptoms
have resolved since admission. most likely viral
gastroenteritis.
.
# Anion gap metabolic acidosis: no ketones in urine. most likely
[**1-29**] renal failure, vomiting, diarrhea. delta-delta ~1 therefore
pure AG disorder. calculated serum osms 313. now resolved.
.
# DM: elevated blood glucose, minimal response to IV insulin
and was briefly on insulin gtt for tight glucose control, then
placed on home insulin regimen with good response.
.
# Anemia: Hct normal at presentation (likely due to
hemoconcentration), then decreased to 28 but remained table.
baseline Hct is approx 30. guaiac positive x1 during admission
but no melena / hematochezia. iron studies suggest ACD, likely
[**1-29**] renal failure. B12 and folate normal. was on epo in the
past, but no longer taking. continued aspirin, plavix for
cardioprotection. would recommend outpatient GI follow-up.
.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Lasix 120 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Forty (40) units Subcutaneous with breakfast.
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous with dinner.
10. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
12. Hydrocodone-Acetaminophen 7.5-750 mg Tablet Sig: One (1)
Tablet PO qhs: prn as needed for pain.
13. Niacin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Axid 150 mg Capsule Sig: One (1) Capsule PO once a day.
16. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Forty (40) units Subcutaneous with breakfast.
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous with dinner.
10. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
12. Hydrocodone-Acetaminophen 7.5-750 mg Tablet Sig: One (1)
Tablet PO qhs: prn as needed for pain.
13. Niacin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Axid 150 mg Capsule Sig: One (1) Capsule PO once a day.
16. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Ventricular tachycardia
.
Secondary:
1. HTN
2. CHF (EF 50-60%)
3. CAD s/p CABG ([**2118**]; LIMA->LAD, SVG->OM1, SVG->RCA)
4. s/p MI ([**2105**])
5. DM2
6. bilateral RAS s/p stents ([**2134**])
7. right carotid stenosis
8. s/p appendectomy ([**2105**])
9. s/p cholecystectomy ([**2104**])
10. Spinal stenosis; s/p surgery ([**2134**])
11. Chronic renal insufficiency (baseline Cre 2.3)
12. Bilateral cataracts
13. s/p colonoscopy ([**2135**])
14. h/o atrial flutter
15. h/o chronic anemia (baseline Hct 30-32)
Discharge Condition:
Stable
Discharge Instructions:
1)Please take all medications as prescribed, as listed in the
discharge instructions.
2)Please schedule follow-up with your primary care physician and
cardiologist upon discharge.
3)Please return to ED immediately if you experience worsening
chest pain, shortness of breath, nausea, vomiting, sweating,
fevers, chills, bleeding, or other concerning symptoms.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 40076**] Follow-up appointment should
be in 1 week
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2394**] Call to schedule
appointment in 1 week.
|
[
"250.00",
"276.2",
"428.0",
"008.8",
"584.9",
"403.90",
"276.50",
"427.1",
"V58.69",
"790.5",
"411.1",
"428.30",
"E879.8",
"285.21",
"585.9",
"442.3",
"412",
"997.2",
"V45.81",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.92",
"37.34",
"99.29",
"37.27",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
12239, 12297
|
5931, 9767
|
275, 310
|
12884, 12893
|
2595, 2595
|
13302, 13586
|
2016, 2020
|
10985, 12216
|
12318, 12863
|
9793, 10962
|
4067, 5908
|
12917, 13279
|
3268, 4050
|
2035, 2576
|
225, 237
|
338, 1331
|
2611, 3252
|
1354, 1851
|
1867, 2000
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,534
| 120,753
|
8948
|
Discharge summary
|
report
|
Admission Date: [**2124-2-4**] Discharge Date: [**2124-2-16**]
Date of Birth: [**2055-11-6**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 68-year-old female
with diabetes mellitus, IgG monoclonal gammopathy, who
presented to her primary care physician's office with a
complaint of an episode of chest pressure, recurrent episodes
of chest pain since [**2122**] relieved by rest. The patient
suffered a silent myocardial infarction in [**2120**]. The patient
had presented to her primary care physician's office for
worsening of symptoms.
PAST MEDICAL HISTORY: 1. IgG monoclonal gammopathy. 2.
Diabetes mellitus. 3. Osteoporosis. 4. Status post silent
myocardial infarction. 5. Status post total abdominal
hysterectomy for fibroids and menometrorrhagia in [**2101**].
MEDICATIONS ON ADMISSION: 1. NPH Insulin 18 and 6. 2.
Regular insulin 7 and 2.5. 3. Aspirin 81 mg q.d. 4. Vitamin
E 400 units q. day. 5. Zinc 50 units q. day. 6. Vitamin C
1,000 mg q. day.
SOCIAL HISTORY: The patient quit smoking six year prior.
PHYSICAL EXAMINATION: On admission the patient was afebrile,
vital signs were stable. Heart: Regular rate and rhythm.
Lungs: Clear to auscultation bilaterally. Abdomen: Soft,
nontender, nondistended.
LABORATORY DATA: White count was 6.8, hematocrit 39,
platelet count 259, electrolytes were within normal limits.
Cardiac enzymes were negative. Chest x-ray showed no acute
cardiopulmonary disease.
HOSPITAL COURSE: The patient was worked up with a
catheterization which revealed three-vessel coronary artery
disease with heavily calcified diffusely diseased vessels.
The patient underwent a coronary artery bypass grafting x 4
with left internal mammary artery to the diagonal, saphenous
vein graft to the diagonal left anterior descending coronary
artery, saphenous vein graft to the obtuse marginal and
saphenous vein graft to the posterior descending coronary
artery on [**2124-2-8**]. The patient tolerated the procedure
without any complications. The patient was extubated on
postoperative day number one and continued to do well. She
was transferred to the floor on postoperative day two and
continued to do well. She was a little slow to progress with
the physical therapist. On postoperative day five she was
noted to have some shortness of breath and some crackles at
the bases which improved with adjustment of the dosing to
intravenous Lasix. The patient continued to improve steadily
and by postoperative day number eight was felt to be ready
for discharge to home with [**Hospital6 407**].
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) **] in
four weeks and her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 31072**], in one
to two weeks, and her cardiologist in two to three weeks.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg b.i.d. x seven days.
2. Lopressor 50 mg b.i.d.
3. Ibuprofen 400 mg q. 6.
4. Percocet 1-2 tablets q. 4-6 hours p.r.n.
5. Tylenol 650 mg q. 4 hours p.r.n.
6. Enteric-coated aspirin 325 mg q. day.
7. Zantac 150 mg b.i.d. until follow up with the surgeon.
8. Colace 100 mg b.i.d.
9. Potassium chloride 20 mEq b.i.d.
10. Tums 500 mg t.i.d.
11. Multivitamins one q. day.
12. Milk of Magnesia 30 mL q.h.s. p.r.n.
13. NPH Insulin 22 units in the morning and 10 at night.
14. Regular Insulin 5 units in the morning and 2.5 at night.
15. Regular Insulin sliding scale to cover until follow up
with her primary care physician who will adjust her doses
according to her postoperative sugars.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To home.
DISCHARGE DIAGNOSIS:
Status post coronary artery bypass graft x 4.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2124-2-16**] 10:05
T: [**2124-2-16**] 10:22
JOB#: [**Job Number 31073**]
cc:[**Last Name (NamePattern4) 31074**]
|
[
"410.71",
"424.0",
"401.9",
"273.9",
"414.01",
"733.00",
"285.9",
"250.00",
"784.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"88.53",
"99.20",
"88.72",
"36.15",
"39.61",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
2880, 3576
|
3653, 4006
|
858, 1027
|
1511, 2606
|
2618, 2857
|
1109, 1493
|
183, 596
|
619, 831
|
1044, 1086
|
3601, 3632
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,544
| 180,659
|
490
|
Discharge summary
|
report
|
Admission Date: [**2124-1-20**] Discharge Date: [**2124-1-25**]
Date of Birth: [**2047-10-15**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit
Extracts / Nafcillin / cefazolin
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Renal Failure/pneumonia
Major Surgical or Invasive Procedure:
PICC line placement.
History of Present Illness:
76M complicated past medical history including CAD status post
CABG, s/p stents [**Month (only) **]/[**2122**] (on aspirin and plavix), status post
biologic AVR, CHF with EF 35-40 %, paroxysmal atrial
fibrillation on coumadin (now off secondary to recent epistaxis
requiring blood transfusion), history of strokes, CKD (baseline
Cr 2.5) with recent kidney injury thought to be secondary to AIN
from naficllin requiring hemodialysis, now off. He presented to
[**Hospital1 **] with lethargy. Patient states that he awoke this
morning feeling unwell. He had no specific or localizing signs.
He was recently discharged from [**Hospital3 4103**] on the [**Hospital **] Rehab
Facility 3 days prior to presentation. He had been there since
an admission to [**Hospital1 18**] for MSSA bacteremia complicated by what
appears to be acute kidney injury from acute interstitial
nephritis thought to be secondary to nafcillin. He also
developed diffuse skin vasculitis at that time. He had been on
steroids which had been tapered to off about 2 weeks ago. He
has also had intermittent delirium and volume overload. It
appears an NSTEMI also complicated his course.
He had an episode of epistaxis for which he was admitted to
[**Hospital1 **] from [**1-1**] to [**1-3**] with an INR greater than 10 at the
time. He is no longer on Coumadin but he is on aspirin and
Plavix. He has had no further bleeding. He has also had recent
transaminitis thought to be secondary to amiodarone and statin.
He had had a right upper quadrant ultrasounds which did not
reveal acute cholecystitis but did show gallstones in the
gallbladder. His amiodarone has been discontinued but it
appears he is back on his simvastatin.
At [**Hospital1 **], the patient complained of pain in his penis from
Foley catheter insertion in the emergency department.
He denies shortness of breath, fever, chills, abdominal pain,
nausea, vomiting, diarrhea, chest pain. He notes a mild
nonproductive cough over the last few days. He reports his
white blood cell count has been elevated intermittently in the
past. It was elevated at NewBridge; however, repeat was normal
and he was sent home.
Per his wife he had an episode of confusion in the morning with
some
urinary incontinence. He is now back at his baseline. He is
AAOx3.
It was also noted that he has had recent increase in lower
extremity edema which was thought to be secondary to his
prednisone. His lasix was increased to 80 mg PO BID from 40 mg
PO BID about a week and a half ago. His lower extremities have
improved in terms of swelling. He also reports improvement of
the vasculitic rash now scabbing.
For his diabetes, his lantus was recently increased from 22
units to 26 units as he has been having elevated blood glucose
which began at NewBridge on the [**Doctor Last Name **].
In the ER at [**Hospital1 **], he was found to have acute renal
injury with Cr of 3.1 (baseline ~ 2.5) as well as hyperkalemia
(K 6.1). He was treated with 8 units of IV insulin, Kayexalate,
and calcium gluconate. He was also given 2.5 L of IVF per
records.
CXR was felt to show possible left lower infiltrate. He was
given levofloxacin and vancomycin.
Studies were significant for:
Na 132 K 6.1, Cl 99, HCO3 26, BUN 71, Cr 3.1, Glc 355
WBC 16.6(H), Hct 30.6, Plt 376 MCV 81 with Diff N 77, M 13
INR 1.4
ALT 282, AST 533, ALP 618, Tbili 0.68, albumin 2.1
CK 56, Troponin 0.65 BNP 33,541
Lactate 2.7
UA: Blood moderate, nitrate, LE negative, RBC [**4-27**], WBC 0-2, Occ
epi
EKG: NSR at 77 bpm, PR prolongation, RBBB. No acute ST-T changes
CXR: Poor quality. Increased density in inferior portion of
chest on lateral view likely represents pleural fluid, probably
on the right, prominent cardiac silhouette
Head CT (prelim): Left maxillary sinus disease. No acute
intracranial pathology.
RUQ US (prelim): No [**Doctor Last Name **] sign. No pericholecystic fluid.
STones in neck of gallbladder. Gallbladder wall distended at 5
mm and had been 3 mm. No dilated ducts.
There was concern given leukocytosis and CXR showing ? pneumonia
and his new onset renal failure.
Given elevated LFTS, a RUQ US was performed that showed 5 mm
gallbladder wall (up from 3 mm two weeks ago) with stones in the
neck of the gallbladder. There was no son[**Name (NI) 493**] [**Name2 (NI) 515**] sign.
Flagyl was subsequently added for broader coverage. A surgery
consult was called in the ER for aforementioned findings. The
impression was that although the patient has no abdominal
tenderness that given his diabetes his clinical exam may be
altered. His leukocytosis may be secondary to ? developing
pneumonia; however, his gallbladder wall is thickened and the
patient will likely require percutaneous cholecystostomy tube.
His LFTs are difficult to interpret in context of acute illness,
and his CBD is not dilated.
He was transferred from [**Location (un) 620**] for ? cholecystitis for
potential surgical procedure.
VS on transfer were T 98.2, BP 126/68, HR 74, RR 17, pOx 98 % RA
Urine output 475 mL
.
In the [**Hospital1 18**] ED inital vitals were, 17:57 97.0 74 113/60 20 100%
2L Nasal Cannula.
Labs in [**Hospital1 18**] ER showed Na 137, K 5.4, Cl 104, HCO3 20, Lactate
2.6, Glc 271. Hgb was 10.
A general surgery consult was called in the ER. Impression was
admission to medicine with monitoring of LFTs and serial
abdominal exams. A percutaneous chole tube was not advised at
this time.
VS on transfer: AF, HR 74, BP 139/67, RR 22, pOx 100 % 3L
On arrival to the ICU, patient was initially sleepy, but then
awoke and wanted a piece of toast - which was given after
explaining that it would be optimal if he remained NPO given
concern for gallbladder process.
Past Medical History:
DM type II c/b neuropathy
HTN
HLD
CAD s/p CABG in [**2113**] and [**2119**] and multiple stents [**10/2123**]
s/p biologic AVR [**2119**] c/b transient heart block post-op treated
with pacer insertion ([**Company 1543**] Sensia dual-chamber pacemaker)
Paroxysmal Atrial Fibrillation (last pacer interrogation
demonstrated no episodes of AF)
Chronic Systolic Heart Failure (EF 35% to 40% in [**2119**])
BPH
Hypothyroidism
CKD stage III
Social History:
He lives at home with his wife. [**Name (NI) **] ambulates with a walker. He
has had multiple hospitalizations since the fall requiring a
stay at NewBridge on the [**Doctor Last Name **]. He was discharged 3 days ago.
He denies tobacco, alcohol, illicit drug use.
Family History:
Notable for a mother who died at 81 and had a brain tumor and a
sibling with Alzheimer disease. There is also thyroid, lung
cancer in other family members.
Brother: pancreatic and liver cancer in his brother.
[**Name (NI) **] family history of CAD or sudden cardiac death.
Physical Exam:
Vitals: T 97.9 BP 122/56 P 76 RR 17 Sat 99% on 2L NC
SBP 117-153
I/O +174 cc UOP 1000 cc since admission
General: Elderly male laying in bed in NAD. Alert and oriented
to person, place, and time.
HEENT: Sclera anicteric, MM dry, oropharynx clear
Lungs: Breathing comfortably, crackles at the left > right base.
CV: RRR, no MRG
Abdomen: +BS, soft NTND
Ext: warm, 1+ edema bilaterally
Pertinent Results:
[**2124-1-25**] 07:17AM BLOOD WBC-12.4* RBC-3.59* Hgb-8.5* Hct-29.3*
MCV-82 MCH-23.7* MCHC-29.0* RDW-15.9* Plt Ct-337
[**2124-1-24**] 07:19AM BLOOD WBC-12.8* RBC-3.54* Hgb-8.4* Hct-30.1*
MCV-85 MCH-23.8* MCHC-28.0* RDW-16.1* Plt Ct-326
[**2124-1-23**] 06:10AM BLOOD WBC-13.3* RBC-3.49* Hgb-8.5* Hct-28.0*
MCV-80* MCH-24.3* MCHC-30.2* RDW-16.7* Plt Ct-300
[**2124-1-22**] 06:30AM BLOOD WBC-20.8* RBC-3.96* Hgb-9.5* Hct-32.1*
MCV-81* MCH-24.0* MCHC-29.5* RDW-16.7* Plt Ct-423
[**2124-1-21**] 02:04AM BLOOD WBC-13.9* RBC-3.75* Hgb-9.2* Hct-31.9*
MCV-85 MCH-24.4* MCHC-28.8* RDW-16.3* Plt Ct-348#
[**2124-1-23**] 06:10AM BLOOD Neuts-79.0* Lymphs-14.0* Monos-5.9
Eos-0.8 Baso-0.3
[**2124-1-22**] 06:30AM BLOOD Neuts-85.4* Lymphs-8.0* Monos-5.9 Eos-0.5
Baso-0.3
[**2124-1-21**] 02:04AM BLOOD Neuts-83.7* Lymphs-10.4* Monos-5.3
Eos-0.4 Baso-0.2
[**2124-1-24**] 07:19AM BLOOD PT-15.2* INR(PT)-1.4*
[**2124-1-22**] 06:30AM BLOOD PT-14.5* PTT-29.8 INR(PT)-1.4*
[**2124-1-21**] 02:04AM BLOOD PT-16.2* PTT-31.1 INR(PT)-1.5*
[**2124-1-25**] 04:16PM BLOOD PT-17.3* PTT-33.8 INR(PT)-1.6*
[**2124-1-25**] 07:17AM BLOOD Glucose-69* UreaN-48* Creat-2.3* Na-143
K-3.9 Cl-107 HCO3-26 AnGap-14
[**2124-1-24**] 07:19AM BLOOD Glucose-75 UreaN-49* Creat-2.3* Na-139
K-3.7 Cl-104 HCO3-25 AnGap-14
[**2124-1-23**] 08:40AM BLOOD Glucose-185* UreaN-50* Creat-2.4* Na-137
K-4.4 Cl-103 HCO3-25 AnGap-13
[**2124-1-23**] 06:10AM BLOOD Glucose-88 UreaN-52* Creat-2.4* Na-140
K-4.4 Cl-106 HCO3-19* AnGap-19
[**2124-1-22**] 06:30AM BLOOD Glucose-196* UreaN-55* Creat-2.3* Na-136
K-4.1 Cl-100 HCO3-22 AnGap-18
[**2124-1-22**] 06:30AM BLOOD Glucose-200* UreaN-56* Creat-2.3* Na-136
K-4.1 Cl-100 HCO3-22 AnGap-18
[**2124-1-21**] 02:04AM BLOOD Glucose-378* UreaN-68* Creat-2.7* Na-135
K-4.5 Cl-100 HCO3-20* AnGap-20
[**2124-1-25**] 07:17AM BLOOD ALT-65* AST-27 AlkPhos-192* TotBili-0.4
[**2124-1-24**] 07:19AM BLOOD ALT-97* AST-43* LD(LDH)-325* AlkPhos-231*
TotBili-0.4
[**2124-1-23**] 06:10AM BLOOD ALT-130* AST-74* AlkPhos-273* TotBili-0.5
[**2124-1-22**] 06:30AM BLOOD ALT-201* AST-125* LD(LDH)-409*
AlkPhos-356*
[**2124-1-21**] 02:04AM BLOOD ALT-257* AST-313* LD(LDH)-382*
CK(CPK)-36* AlkPhos-408* TotBili-0.4
[**2124-1-21**] 02:04AM BLOOD CK-MB-5 cTropnT-0.04*
[**2124-1-25**] 07:17AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0
[**2124-1-23**] 06:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
[**2124-1-22**] 06:30AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0
[**2124-1-22**] 06:30AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9
[**2124-1-21**] 02:04AM BLOOD Albumin-2.4* Calcium-8.1* Phos-4.6*
Mg-2.0
[**2124-1-22**] 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2124-1-25**] 07:17AM BLOOD Vanco-10.5
[**2124-1-23**] 06:10AM BLOOD Vanco-9.7*
[**2124-1-21**] 02:04AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2124-1-22**] 06:30AM BLOOD HCV Ab-NEGATIVE
[**2124-1-21**] 02:26AM BLOOD Lactate-1.3
[**2124-1-20**] 06:33PM BLOOD Glucose-271* Lactate-2.6* Na-137 K-5.4*
Cl-104 calHCO3-20*
[**2124-1-20**] 06:33PM BLOOD Hgb-10.0* calcHCT-30
[**2124-1-22**] 06:30AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-PND
[**2124-1-21**] 02:05AM URINE Eos-POSITIVE
[**2124-1-21**] 02:05AM URINE Hours-RANDOM UreaN-555 Creat-64 Na-29
K-57 Cl-40
[**2124-1-21**] 02:05AM URINE Osmolal-395
[**2124-1-21**] 02:05AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
Microbiology-
[**2124-1-22**] 6:30 am Blood (CMV AB)
**FINAL REPORT [**2124-1-25**]**
CMV IgG ANTIBODY (Final [**2124-1-25**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
212 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2124-1-25**]):
POSITIVE FOR CMV IgM ANTIBODY BY EIA.
BORDERLINE POSITIVE.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
Greatly elevated serum protein with IgG levels >[**2111**] mg/dl
may cause
interference with CMV IgM results.
Interpret IgM result with caution; liver disease,
autoimmune and
lymphoproliferative diseases may cause false positive
results.
.
Urine legionella-negative
.
[**1-20**] EKG
Sinus rhythm. A-V conduction delay. Right bundle-branch block
with left
anterior fascicular block. Compared to the previous tracing
findings are
similar.
.
[**1-20**] EKG
Sinus rhythm. Right bundle-branch block with left anterior
fascicular block. Possible inferior myocardial infarction, age
inderminate. Non-specific ST-T wave changes. Diffuse low QRS
voltage. Compared to the previous tracing of [**2123-12-17**] the QRS
voltage has decreased.
.
HIDA [**1-21**]:
IMPRESSION:
1. Normal visualization of gallbladder.
2. Small bowel activity not visualized. Patient refused further
imaging.
.
[**1-21**] CXR:
Previous mild pulmonary edema has almost cleared. Substantial
consolidation persists at both lung bases, consistent with
pneumonia, particularly on the left. Small bilateral pleural
effusions are presumed. Moderate cardiomegaly is chronic, but
improved since [**1-20**]. No pneumothorax. Constellation of
external wires makes it impossible to determine if there is a
right PIC line in place. No pneumothorax.
.
[**1-22**] CXR-unchanged
.
[**1-24**] RUQ u/s:
IMPRESSION:
1. Cholelithiasis without specific signs of cholecystitis.
2. Normal flow and spectral analysis in the liver vasculature.
.
[**1-24**] CXR
IMPRESSION: Successful placement of right-sided PICC. Increase
in
cardiomediastinal widening and cardiomegaly probably a function
of cardiac
insufficiency.
[**2124-1-25**] 04:16PM BLOOD PT-17.3* PTT-33.8 INR(PT)-1.6*
Brief Hospital Course:
76M CAD s/p CABG and PCI with stents placed a few months ago,
systolic CHF, pAF, CKD III, and DM2, presenting with lethargy,
acute renal failure, pneumonia and possible cholecystitis.
.
# Acute toxic-metabolic encephalopathy
Patient had episode of brief confusion this AM. Per prior
medical records, patient can sometimes be confused. DDx includes
toxic-metabolic process in setting of renal dysfunction,
infectious process, or primary neurogenic process among others.
Latter unlikely given negative head CT and non-focal neuro exam.
Favor metabolic encephalopathy. On admission, patient AAOx3. His
mental status remained intact for the remainder of the
hospitalization.
.
# Leukocytosis/HCAP-
Patient presented with leukocytosis to 16.6 with neutrophilia on
differential. He was hemodynamically stable, afebrile, and
appeared to be perfusing well in the ICU. No adrenergic state or
recent steroids to explain elevated white count. There was
concern for infectious etiology given cough and evidence of PNA
with HCAP risk and initially ? cholecystitis in setting of
cholestatic LFTs (However, HIDA-limited study returned negative
and abdominal ultrasound showed cholelithiasis not
cholecystitis. Lactate was initially elevated at 2.7 initially
at BIDN s/p IVF with admission lactate 1.3. Initially, he was
treated with broad spectrum antibiotics including aztreonam,
flagyl, and vancomycin for both pulmonary and GI process.
Aztreonam was later switched to ciprofloxacin. The clinical
picture overall was consistent with HCAP but not acute
cholecystitis as pt did not have any abdominal pain. He
clinically improved and was transferred to the floor on [**1-21**]. He
spiked a temperature to 100.9 with leukocytosis to 20K.
Ciprofloxacin was switched to cefepime to optimize gram negative
coverage. He defervesced, leukocytosis improved, and oxygen was
weaned to room air for which he remained. Final antibiotic
regimen is IV vanco/cefepime/flagyl x8 total days. Vanco and
flagyl to end on [**1-28**] and cefepime to end on [**1-29**]. PICC line was
placed and can be removed after antibiotic course is complete.
.
# Transaminitis
He has had elevated LFTs in past thought to be drug-induced from
amiodarone and atorvastatin (which were held) in outpatient
setting. Pattern appeared to be both hepatocellular and
cholestatic concerning for aforementioned gallbladder process
with uncharacterized liver disease. Hepatitis viral serologies
were sent and were negative. HIDA scan was limited but,
unremarkable. RUQ US with doppler was negative. Off the statin,
the transaminases improved, and this was thought to be the most
likely etiology. Statin was not resumed during admission, but
this can be considered after further outpatient monitoring
especially given recent stent placement. Pt did not have any
abdominal pain while on the medical floor.
.
# Acute renal failure on CKD. New baseline appears to be ~2.3.
Range was 2.3-2.7 during admission.Attributed to increased lasix
dosage (80mg [**Hospital1 **] from 40mg [**Hospital1 **]) over past few weeks as well as
poor PO intake. FeUREA on admission 34%, also consistent with
pre-renal process. Recently, pt had AIN from nafcillin and had
to be temporarily dialyzed. He also received and completed a
course of prednisone therapy prior to admission. Cr ranged from
2.3-2.7 during admission and was 2.3 on day of discharge. Pt
should have his creatinine monitored daily while on antibiotic
therapy including vanco and cefepime. Of note, the renal team
monitored the patient closely during admission. His lasix was
restarted at 20mg daily on [**1-25**] given evidence of CHF seen on CXR
as well as slightly increased peripheral edema. Pt was not
hypoxic. Renal follow up arranged for 2 weeks after discharge.
.
# Chronic systolic heart failure: Compensated during admission.
BB dose was decreased to 50mg metoprolol [**Hospital1 **]. Lasix was
restarted on [**1-25**] at 20mg daily. Had been held recently due to
ARF. Pt is not on an ACEI presumable due to recent ARF/AIN. [**Month (only) 116**]
consider in the future should Cr stabilize. Would follow I/o's
and daily weights closely and uptitrate lasix prn pending
creatinine values.
.
# atrial fibrillation: Pt with pacemaker. Pt was placed on 50mg
[**Hospital1 **] metoprolol during admission with well controlled HR
(initially held given concern for sepsis). Pt with recent
history of significant epistaxis vs. hemoptysis [**12/2123**] per OSH
reports. Warfarin was restarted on 2.4 as his risk of CVA
currently outweighs risk of bleeding. Pt was given 2.5mg daily.
INR's remained subtherapeutic. INR 1.6 on day of discharge.
Warfarin can be continually uptitrated prn after discharge. He
was not given bridging therapy given the recent history of
bleeding.
.
# CAD, s/p prior CABG and DES x2 in [**Month (only) **]: stable. BB was
restarted with discharge dose of 50mg [**Hospital1 **] metoprolol. Pt was
continued on asa and plavix. Statin was held given
transaminitis. This may be able to be restarted in outpatient
setting after close monitoring of LFTs. An appointment with Dr.
[**Last Name (STitle) 4104**] of cardiology in [**Location (un) 620**] was made prior to discharge.
.
#HTN-continued BB.
.
# DM II uncontrolled with complications: Glucose was monitored
closely, and once he was taking good po on the medical floor, he
sometimes refused insulin and became markedly hyperglycemic.
Lantus insulin dose was increased to 30U, and he was maintained
on a Humalog sliding scale. See attached.
.
# Anemia: chronic disease, stable Hct. Pt can continue PO iron
[**Hospital1 **] as per outpatient regimen. HCT on discharge 29.3. Baseline
appears to be between 27-30. Further outpatient work up, such as
colonscopy, can be considered prn.
.
# BPH: stable on outpatient medications
# Hypothyroidism: continued synthyroid.
# ??History of strokes: resumed warfarin as noted above
# Skin impairment: Patient has notable skin impairment on
bilateral feet, also ? stage II decubitus ulcer. Wound care team
was consulted and made helpful recommendations.
# CODE STATUS: Was DNR/DNI on admission, but while in the [**Name (NI) 153**],
pt changed code status to Full Code. This can be continually
addressed upon discharge. Pt expressed frustration with frequent
admissions and rehab stays.
.
Transitional issues-
1.uptitrate lasix prn
2.consider restarting zocor prn
3.outpatient nephrology and cardiology follow ups
4.monitoring of INR and adjustment of coumadin prn
5.monitor of LFTs and creatinine to ensure stable/downtrending
Medications on Admission:
Patient unable to provide [**Name (NI) 4085**] list. This list from [**Hospital1 18**]
[**Location (un) 620**] list.
- Docusate 100 mg b.i.d.
- Aspirin 81 mg daily.
- Lasix 80 mg twice daily,recently increased 1-1/2 weeks ago.
- Plavix 75 mg daily.
- Metoprolol 100 mg b.i.d.
- Vitamin D 1000 units daily.
- Iron sulfate 325 mg b.i.d.
- Centrum Silver daily.
- Potassium 20 mEq twice daily.
- Protonix 40 mg daily.
- Zocor 80 mg daily.
- Glucosamine daily.
- Levoxyl 50 mcg daily.
- Amitriptyline 25 mg q.h.s.
- Flomax 0.8 mg q.h.s.
- Neurontin 300 mg q.h.s.
- Calcium acetate t.i.d.
- Lantus recently increased to 26 units daily.
- Insulin sliding scale.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
# health care-associated pneumonia
# acute renal failure
# elevated transaminases attributed to statin
# cholelithiasis
SECONDARY:
# chronic kidney disease stage III
# diabetes mellitus type II, uncontrolled with complications
# atrial fibrillation
# hypertension on coumadin
# CAD s/p CABG [**2113**] & [**2119**], s/p DES x2 [**Month (only) **]/[**2122**]
# chronic systolic CHF
# s/p biological AVR [**2119**]
# prior CVA
# hypothyroidism
# BPH
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were transferred from another hospital for further treatment
of kidney injury and pneumonia. In addition, there was initially
a question of whether you may have infection/inflammation of
your gallbladder but your tests were negative. You were
initially managed in the ICU, but your symptoms improved and you
were transferred to the medical floor. Your symptoms continued
to improve on antibiotic therapy. You will need to continue this
antibiotic therapy to complete a total of an 8 day course.
.
[**Year (4 digits) **] changes:
1.start IV vancomycin, IV cefepime and flagyl
2.restarted lasix at 20mg daily on [**1-25**]
3.restarted coumadin at 2.5mg daily on [**1-22**]
4.increased lantus to 30mg daily
5.stopped zocor due to transaminitis
6.decreased metoprolol to 50mg [**Hospital1 **] from home dose of 100mg [**Hospital1 **]
7.neurontin and calcium acetate not given
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Name: [**Last Name (LF) 4090**], [**Name8 (MD) 4102**] MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3637**]
When: Friday, [**2123-2-11**]:30 AM
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] [**Location (un) **]
CARDIAC SERVICES
Address:[**Street Address(2) **], [**Location (un) 620**], [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
When: Thursday, [**2-24**], 1:30 PM
|
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icd9cm
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
959
| 176,961
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9439+9440+56030
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-24**]
Date of Birth: [**2095-1-27**] Sex: F
Service: OME
CHIEF COMPLAINT: Fever.
Neutropenia.
Diarrhea.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old woman with
stage 3B gastric carcinoma originally admitted to the O-Med
Medicine Service. The patient is status post subtotal
gastrectomy, as well as 5-Fluoro Uracil two weeks prior to
admission. She presented with subjective fever, diarrhea and
found to be neutropenic. The patient had been diagnosed with
gastric carcinoma in [**2-/2151**] when a work-up for weight loss
and abdominal pain led to a gastrointestinal evaluation. The
patient had a subtotal gastrectomy in [**3-/2151**], which was
complicated by a difficult postoperative course including
sepsis with VRE incubation and small bowel obstruction. The
patient subsequently improved and then had a course of 5-
Fluoro Uracel from [**2151-5-25**] to [**2151-5-28**] as a preclude for
a possible chemoradiation one month later, but since during
the chemotherapy, the patient noted mouth sores with fatigue,
nausea and diarrhea with diarrhea increasing to the point in
the past few days prior to admission that was almost melanic
in color and "smells like blood". On the night prior to
admission, she had a fever of 101 with chills and electively
came to the hospital for further evaluation.
REVIEW OF SYMPTOMS: Positive for shortness of breath, as
well as nausea and upper respiratory problems since the 5-
Fluoro Uracil started, but denied any headache, chest pain,
lightheadedness, abdominal pain or lower extremity edema.
PAST MEDICAL HISTORY: Notable for gastric carcinoma, grade
TIMI Grade III-II with a subtotal gastrectomy in [**3-/2151**] and
a course of 5-Fluoro Uracil. She also had heparin-induced
thrombocytopenia. Positive history of hypertension. She has a
history of polycystic kidney disease and a history of chronic
renal insufficiency.
ALLERGIES: Penicillin which causes anaphylaxis and heparin-
induced thrombocytopenia, as well as nickel sensitivity.
MEDICATIONS PRIOR TO ADMISSION:
1. Atenolol 100 mg b.i.d.
2. Protonix 40 mg q day.
3. Hydralazine 25 mg t.i.d.
4. Compazine p.r.n.
5. Ativan 0.5-1.0 mg p.o. q six hours p.r.n.
6. Oxycodone 5-10 mg p.o. q 4-6 hours p.r.n.
SOCIAL HISTORY: The patient is a registered nurse who worked
at a rehabilitation facility and lives in [**Location 38**]. She has
five children. She denies any ETOH, but has a positive thirty
pack year smoking history. She only quit smoking this year.
FAMILY HISTORY: Negative for any history of malignancy, but
her father had polycystic kidney disease.
PHYSICAL EXAMINATION: Upon admission, her temperature was
98, pulse 58, blood pressure 142/75, respirations 20, 99
percent saturation on room air. General: She looked tired
but was in no apparent distress. HEENT: Notable for some
mild thrush, but moist mucous membranes. Neck had no jugular
venous distension. Lungs were notable for decreased breath
sounds at the bases. Cardiovascular examination was regular
with no murmurs, rubs or gallops. Abdomen was notable for
decreased bowel sounds, but was very soft and nontender. She
had a well healed midline scar. Extremities showed no
evidence of cyanosis, clubbing or edema.
LABORATORY DATA: Initial labs showed the patient's whites
were 6, hematocrit 33.3, platelets 43.
HOSPITAL COURSE: Throughout the course of the next few days
of the patient's hospitalization, her mental status began to
decline. A Neurology consult was called on [**2151-6-12**] after a
head magnetic resonance imaging scan done on [**2151-6-11**]
showed no evidence of any metastatic disease or infarcts;
only evidence of some minimal small vessel ischemic disease.
The patient had two lumbar punctures neither of which
revealed any obvious sources of infection. However, an
electroencephalogram performed was notable for the presence
of nonconvulsive status epilepticus. The patient was
transferred to the Fenard Intensive Care Unit on [**2151-6-14**].
The patient was loaded with both Dilantin, as well as
phenobarbital and Infectious Disease was consulted.
Ultimately, no organism grew out of any of her cultures,
including her cerebrospinal fluid, which was also sent off
for HSV PCR ultimately came back negative. The patient then
received a few days of empiric acyclovir treatment for
possible HSV, though that was discontinued once the results
came back negative. Blood, urine and cerebrospinal fluid
cultures, again, remained negative.
During the hospitalization, the patient was started on
empiric intravenous thiamine at 100 mg q day with possible
suspicion of a possible deficiency in dihydropyrimidine
dehydrogenase, which is an enzyme necessary for metabolism
with 5-Fluoro Uracil and in some published studies, the
patients became encephalopathic with this deficiency and
became encephalopathic after being treated with 5-Fluoro
Uracil. This was done empirically without any Western blots
or protein evidence or enzymatic activity evidence of this
patient to reveal this deficiency.
Over the course of the patient's hospitalization, she did
gradually improve on this treatment of thiamine, Dilantin and
5-Fluoro Uracil. The patient's code status was, after much
discussion with the family, made "Do Not Resuscitate" and "Do
Not Intubate". The plan as of this dictation now is for the
patient to be called to the regular hospital floor and to be
sent home with services. The family and patient indicate that
they do not want rehabilitation placement and would prefer
outpatient physical and occupational therapy via her home
situation. Discharge medications will be dictated as an
addendum to this Discharge Summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 18138**]
Dictated By:[**Doctor Last Name 12733**]
MEDQUIST36
D: [**2151-6-22**] 13:12:57
T: [**2151-6-22**] 14:01:28
Job#: [**Job Number 32195**]
Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-25**]
Date of Birth: [**2095-1-27**] Sex: F
Service: OME
HISTORY OF PRESENT ILLNESS: The patient is a 56 year old
woman with a history of locally advanced Stage 3B gastric
cancer status post subtotal gastrectomy who presents with
febrile neutropenia and diarrhea. The patient was initially
diagnosed in [**2151-2-14**] when her workup of weight loss and
abdominal distention led to a GI evaluation. She had a
subtotal gastrectomy in [**Month (only) 958**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3928**] postoperative
course including sepsis, intubation and small bowel
obstruction requiring several re-explorations. VRE infection
and HEPARIN INDUCED THROMBOCYTOPENIA, without clear evidence of
thrombosis.
Subsequently, she improved and started adjuvant 5- FU/LV
chemotherapy from [**5-25**] to 14 as a prelude to
chemo/radiation in approximately one month. Since starting
chemotherapy, the patient has noted worsening fatigue, nausea
and diarrhea. The diarrhea had gotten worse over the days
prior to admission and is dark and "smells like blood." The
night prior to admission, she spiked a fever to 101 with
chills and came in on the day of admission for further
evaluation.
REVIEW OF SYSTEMS: Review of systems was positive for
shortness of breath, nausea, URI symptoms since the 5-FU
started. It was negative for headache, lightheadedness, chest
pain, abdominal pain, lower extremity edema.
PAST MEDICAL HISTORY: Stage 3B gastric cancer. It was a
Grade 3, T3, N2 tumor with peri-neural lymphatic invasion.
She is status post subtotal gastrectomy in [**2151-3-15**] that
was complicated by sepsis and respiratory failure, small
bowel obstruction, encephalopathy and abdominal abscess.
Status post 5-FU/leucovorin chemotherapy.
HEPARIN INDUCED THROMBOCYTOPENIA without thrombosis.
Hypertension.
Polycystic kidney disease.
Chronic renal insufficiency.
Status post lower mandible resection with prosthesis several
years ago.
ALLERGIES: Penicillin which causes anaphylaxis, latex which
causes a rash, heparin and nickel.
MEDICATIONS ON ADMISSION: Atenolol 100 mg [**Hospital1 **], Protonix 40
mg qd, hydralazine 25 mg tid, Compazine 10 mg q6h, prn,
Ativan 0.5 to 1 q6h, prn, K/B/L and oxycodone 5-10 mg q4-6h,
prn for pain.
SOCIAL HISTORY: The patient is a former nurse who worked at
a rehab facility. She lives in [**Location 38**] with several of her
children. She denies alcohol use and has a 30 pack year smoking
history but quit this year. Her daughter [**Name (NI) **] is her HCP.
FAMILY HISTORY: Family history if negative for malignancy.
Father has polycystic kidney disease.
PHYSICAL EXAMINATION: On examination, the patient's
temperature was 98.8, pulse 58, blood pressure 142/76,
respiratory rate 20, sating at 99 percent on room air. In
general, she was tired but in no acute distress. Head and
neck exam showed mild thrush but moist oropharynx. Neck
showed no jugular venous distention. Lungs had decreased
breath sounds at the bases but no crackles or wheezes. Heart
was regular with no murmurs, rubs or gallops. Abdomen was
soft and nontender with normoactive bowel sounds. Extremities
had no cyanosis, clubbing or edema.
LABORATORY: White count was 0.6 with 40 percent polys, 50
percent lymphs, 4 percent eos and 6 percent atypicals.
Hematocrit was 33.3, platelets 43, sodium 140, potassium 2.8,
chloride 110, bicarb 19, BUN 17, creatinine 2.0, glucose 138,
calcium 2.6, ALT 10, AST 15, total bilirubin 0.8 and lactate
was 1.7. Her urinalysis was negative.
RADIOLOGY: A chest film showed patchy atelectasis of the
left base.
HOSPITAL COURSE: Febrile neutropenia: There was no clear
identifiable source. Given the patient's copious mucus
secretion and mucositis and neutropenia, she was covered
empirically with cefepime. She tolerated the antibiotics
without any complications. The patient was started on
Neupogen to increase her counts. After several days, her
absolute neutrophil count rose and she became afebrile and
there were no further infectious disease complications over
the course of her admission.
Diarrhea: The patient has a history of black stools that
were concerning but her stools were guaiac negative. After
several days, her diarrhea stopped and this was not a further
concern. The diarrhea was likely related to chemotherapy.
Altered mental status/neuro: Towards the end of the first
week of her admission, when her counts had recovered, the patient
became delirious. At first, she was inattentive and this
progressed rapidly to becoming very altered and nonresponsive.
Initially, the concern was for infection and so she had a torso
CT with contrast which did not show any evidence for abscess or
infection in her chest or abdomen. She then had a head MRI
which did not disclose any acute abnormality or explain her
altered mental status. There was no evidence for metastases.
The following day, the patient became rigid and was very
lethargic. A spinal tap was performed that showed 0 white
cells and 0 red cells with a protein of 71. At this point, a
neuro consult was obtained who thought the differential
diagnosis included paraneoplastic disease leading to altered
sensorium.
The following day, the patient became progressively more
unresponsive and so an EEG was performed. This showed
nonconvulsive status epilepticus. The patient was started on
Dilantin, while improving her EEG, did not improve her mental
status. At this point, it was decided that for the patient to
be better treated, she would require phenobarbital as well as
Dilantin. Given the concern for airway protection, she was
transferred to the ICU for close monitoring. At this point,
she had loading with Dilantin and phenobarbital which
achieved adequate levels after several days. There was no
evidence for further status epilepticus on the EEG and her
mental status slowly improved. She was able to become more
interactive and able to speak in short sentences. She is
significantly below her baseline but improved from when she
initially developed these symptoms. She is profoundly weak with
some cogwheeling suggestive of upper motor neuron damage. She
is at risk for aspiration.
As for the underlying etiology, it is completely unclear. One
possibility is that she had 5-FU toxicity, perhaps secondary
to dihydropyrimidine dehydrogenase deficiency, although one would
not have expected her counts to recover as they did. She was
started on thiamine empirically which may or may not have made a
difference, although its use has been reported (micromedex) in
similar situations. The remainder of the workup for the source of
the seizures was negative and she will need close outpatient
Neurology follow-up.
Hypertension: The patient has a history of hypertension. She
was initially continued on her outpatient medications of
atenolol and hydralazine. However, her blood pressure dropped
when she started on the Dilantin and so she was just
maintained on atenolol therapy.
Code status: The patient was admitted to hospital as a full
code. After further discussion with her oncologist, the
patient was made DNR/DNI. Once the decision was made to put
her on phenobarbital, however, the code status was
temporarily reversed. Once it became evident she would not
require intubation, it was changed back to DNR/DNI which is
where she is at this point.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To Rehab.
DISCHARGE DIAGNOSES: Gastric cancer.
Febrile neutropenia.
Nonconvulsive status epilepticus.
Hypertension.
DISCHARGE MEDICATIONS:
1. Dilantin 120 mg po q8h.
2. Colace 100 mg po bid.
3. Lactulose 30 cc po tid prn, constipation.
4. Phenobarbital 100 mg NG qd.
5. Lansoprazole 30 mg NG qd.
6. Atenolol 50 mg po qd.
7. Regular insulin sliding scale.
With respect to her nutrition, the patient was continued on
her tube feeds. These were increased once her PO intake
declined significantly.
FOLLOW UP: Follow up plans will be detailed in the addendum
to this dictation.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 150**], [**MD Number(1) 32196**]
Dictated By:[**Last Name (NamePattern1) 6997**]
MEDQUIST36
D: [**2151-6-25**] 08:17:05
T: [**2151-6-25**] 09:43:58
Job#: [**Job Number 32197**]
Name: [**Known lastname 5578**], [**Known firstname 5473**] Unit No: [**Numeric Identifier 5579**]
Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-28**]
Date of Birth: [**2095-1-27**] Sex: F
Service: OME
HISTORY OF PRESENT ILLNESS: This is an ADDENDUM to the
patient's discharge summary, dictated on [**6-25**].
HOSPITAL COURSE: Problem 1: Nutrition and swallow. The
patient was noted to be aspirating on her food and so a
swallow study was obtained. This confirmed that the patient
had moderate to severe oral mylopharyngeal dysphagia with
impaired orophage. She aspirated nectar, thin and thick
liquids. The patient was started on pureed solids and honey-
thick liquids. She tolerated that without any complications.
In the future, when her mental status clears, the patient
should have a repeat swallow study, so her diet can be
advanced. In the meantime, she was continued with increased J
tube feeds including free water boluses.
Problem 2: Thrush. Towards the end of her admission, the
patient developed oral thrush. She was initially treated
with Diflucan. This does interact with Dilantin and
Phenobarbital. These levels were checked and were normal.
By discharge, the patient no longer needed the Diflucan. At
rehabilitation, she should continue either with Nystatin
swabs that are soaked in Nystatin and brushed throughout her
mucosa or, if possible, Clotrimazole troches. This depends
on her degree of mental status.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES: Non convulsive status epilepticus.
Febrile neutropenia.
Gastric cancer.
5-FU toxicity.
DISCHARGE MEDICATIONS:
1. Phenobarbital 100 mg q. h.s. per J tube.
2. Pantoprazole 30 mg nasogastric q. Day.
3. Atenolol 50 mg twice a day per J tube.
4. Regular insulin sliding scale.
5. Phenytoin suspension, 120 mg q 8 hours nasogastric.
6. Nystatin 5 cc four times a day with a swab that is soaked
in Nystatin, brushing her oral mucosa.
FOLLOW UP: The patient will follow-up with Dr. [**Last Name (STitle) **] on
[**8-4**] for neurology follow-up.
She should contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5580**] office to schedule a
follow-up appointment [**Telephone/Fax (1) 5581**] within 2-3 weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5582**]
Dictated By:[**Last Name (NamePattern1) 5583**]
MEDQUIST36
D: [**2151-6-28**] 14:57:43
T: [**2151-6-28**] 16:24:07
Job#: [**Job Number 5584**]
|
[
"345.3",
"E933.1",
"288.0",
"780.6",
"V10.04",
"401.9",
"112.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"03.31",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8607, 8689
|
15880, 15972
|
15995, 16317
|
8146, 8324
|
14672, 15785
|
16329, 16878
|
2106, 2297
|
8712, 9653
|
7284, 7484
|
153, 186
|
14573, 14654
|
7507, 8119
|
8341, 8590
|
15810, 15858
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,980
| 117,582
|
22357
|
Discharge summary
|
report
|
Admission Date: Discharge Date: [**2144-9-21**]
Date of Birth: [**2074-2-10**] Sex: M
Service: CSU
.
HISTORY: Mr. [**Known lastname **] is a direct admission to the operating room
for coronary artery bypass grafting. He was seen in
preadmission testing prior to his scheduled admission to the
operating room. At the time of preadmission testing, the
patient's physical exam is as follows.
HISTORY OF PRESENT ILLNESS: 70-year-old Vietnamese speaking
man, with a history of coronary artery disease, presented to
an outside hospital one month ago, status post a syncopal
episode. He returned home and complained of fatigue and
chest pain with shortness of breath. On [**8-9**], the
patient had vomiting, lightheadedness and diaphoresis. He
then went to the emergency room via an ambulance. An EKG at
that time showed ST elevations in II, III and F with ST
depressions in V1 through V3 and V5 and six. The patient was
also found to be in complete heart block. Cath done at that
time. A transvenous pacing wire was placed and the
catheterization showed three-vessel coronary artery disease.
He had a stent to his RCA and was referred for coronary
artery bypass grafting.
PAST MEDICAL HISTORY: Significant for hypertension,
tuberculosis, treated over 20 years ago and angina. The
patient had a cath done on [**8-9**]. The cath at that
time showed a 70% mid RCA lesion and a stent was placed; 60
percent left main lesion and left circumflex, obtuse marginal
one and two diffusely diseased. An echo done also at that
time showed a mildly dilated RA with an ejection fraction of
55 percent and a mildly dilated descending aorta measuring
3.6 cm. The patient states no known drug allergies.
MEDS AT HOME:
1. Aspirin 81 mg every day.
2. Hydrochlorothiazide 50 every day.
3. Lisinopril 5 every day.
When seen in PAT, the patient was on aspirin 325 mg every
day, Plavix 75 every day, Colace 100 b.i.d., Lipitor 80 every
day, Captopril 12.5 t.i.d.
SOCIAL HISTORY: Lives with his daughter in [**Name (NI) 47**].
Fairly active man with current tobacco use, approximately
half pack per day times 60 years and occasional alcohol use,
a couple of drinks per week.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM: General: Sitting in bed, in no acute
distress. Neurologic: Alert and oriented x3. Moves all
extremities. Follows commands. Nonfocal exam. During this
period, the daughter was acting as an interpreter.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm, S1-S2. Abdomen is
soft, nontender, nondistended with normoactive bowel sounds.
Extremities: Warm, well-perfused with no edema and no
varicosities. Pulses radial two plus bilaterally. Dorsalis
pedis two plus bilaterally. Posterior tibial two plus
bilaterally. Carotids without bruits.
LABORATORY DATA: White count 6.2; hematocrit of 38.1,
platelets 191, PT 11.9, PTT 29.2, INR 0.9, sodium 141,
potassium 4.1, chloride 106, CO2 28, BUN 13, creatinine 0.6,
glucose 94, ALT 28, AST 32, LDH 38, alk phos 23, total bili
0.5. UA was negative.
Chest x-ray no acute cardiopulmonary processes.
HOSPITAL COURSE: As stated previously, the patient was a
direct admission to the operating room on [**9-17**]. Please
see the OR report for full details. In summary, the patient
had coronary artery bypass grafting times three with LIMA to
the LAD, saphenous vein graft to the diagonal and saphenous
vein graft to OM. His bypass time was 59 minutes with a
cross clamp time of 46 minutes. He was transferred from the
operating room to the cardiothoracic intensive care unit. At
the time of transfer, the patient was AV paced at 87 beats
per minute with a mean arterial pressure of 62 and a CVP of
five. He had Propofol at 20 mcg/kg per minute and Neo-
Synephrine at 0.5 mcg/kg per minute. The patient did well in
the immediate postoperative period. His anesthesia was
reversed. He was weaned from the ventilator and successfully
extubated. On postoperative day one, the patient continued
to be hemodynamically stable. He was begun on beta blockers
as well as diuretics. His chest tubes remained in because of
a fair amount of serosanguinous drainage and he was
transferred to the floor for continuing postoperative care
and cardiac rehabilitation. Once on the floor with the
assistance of the nursing staff and the Physical Therapy
staff, the patient's activity level was gradually increased
on postoperative day number two. He continued to be
hemodynamically stable. At that time, his Foley catheter was
removed as were his chest tubes and temporary pacing wires.
Over the next 2 days, the patient's activity level was
increased. He remained hemodynamically stable throughout
that period. On postoperative day four, it was decided that
the patient was stable and ready to be discharged to home.
At the time of this dictation, the patient's physical exam is
as follows. Temperature 99, heart rate 71 sinus rhythm.
Blood pressure of 108/70. Respiratory rate of 18. Oxygen
saturation 97 percent on room air. Patient's weight on the
day of discharge is 54.9 kg. Preoperatively, weight was 51
kg.
LABORATORY DATA: White count 7.9, hematocrit 27.3, platelets
153, sodium 139, potassium 3.8, chloride 104, CO2 26, BUN 12,
creatinine 0.6, glucose 112.
PHYSICAL EXAM: Alert and oriented. Moves all extremities.
Follows commands with family acting as interpreters.
Pulmonary lungs clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm, S1-S2. Sternum is
stable. Incision with staples open to air, clean and dry.
Abdomen is soft, nontender, nondistended with normoactive
bowel sounds. Extremities are warm and well-perfused with no
edema. Left saphenous vein graft harvest site incision is
clean and dry with Steri-Strips.
CONDITION AT DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: He is to be discharged to home with
visiting nurses.
He is to have follow-up with Dr. [**Last Name (STitle) **] in two to three weeks.
Follow-up with Dr. [**Last Name (STitle) 911**] in two to three weeks.
Follow-up with Dr. [**Last Name (STitle) **] in one month.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg every day times two weeks.
2. Potassium chloride 20 mEq every day times 2 weeks.
3. Colace 100 mg b.i.d.
4. Aspirin 325 every day.
5. Plavix 75 every day.
6. Lopressor 25 mg b.i.d.
7. Hydrocodone acetaminophen 5/500, one to two tablets every
four to six hours prn as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2144-9-22**] 17:29:10
T: [**2144-9-23**] 08:49:51
Job#: [**Job Number 58194**]
|
[
"411.1",
"V45.82",
"V12.01",
"410.72",
"414.01",
"441.2",
"401.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.62",
"36.15",
"39.61",
"99.04",
"89.61",
"99.05",
"99.07",
"36.12",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2218, 2236
|
6161, 6727
|
3164, 5316
|
5872, 6138
|
5332, 5823
|
5838, 5847
|
455, 1212
|
1235, 1988
|
2005, 2201
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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23,826
| 112,869
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45903
|
Discharge summary
|
report
|
Admission Date: [**2157-6-23**] Discharge Date: [**2157-6-27**]
Date of Birth: [**2099-5-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Intubated in medical ICU.
History of Present Illness:
Patient is a 58 y/o F w/ RA on prednisone, h/o GI bleed, and
recent admit to [**Hospital1 2025**] neuro ICU w/ meningo-encephalitis who
presents with hypotension. Patient presented to ED via ambulance
with SBPs in 70s-> 80s and a waxing and [**Doctor Last Name 688**] mental status
that corresponded to the blood pressure. Also there was some
report of diarrhea. Work-up included a CXR, UA, CT ABD, CT Head,
Surgery c/s that was relatively unremarkable. A right femoral
line was placed, 7 Liters IVFs given, Levophed and Decadron with
improvement in SBPs to 120s. Given Vanco, Levo, Flagyl. Patient
also intermittently hypoxic. An ABG was sent and was 7.10/75/112
and then 7.10/70/55. Patient then intubated for hypercarbic
respiratory failure. A CTA chest was then performed and was
negative for PE (preliminarily). When patient arrived in ICU she
was intubated, but awake and able to communicate appropriately.
She complained only of chronic back pain and naseau.
On further questioning, it is unclear what precipitated this
event. On one occasion, patient reports that she was walking
near her home when a stranger grabbed her and pulled her into a
car. She screamed and then they pushed her out of the car. She
was then brought in by EMS. On subsequent occasions, she claims
to have been in a meeting at work, became light-headed and then
awoke in the ICU intubated. She does not recall any further
details. She states that she has had diarrhea, nausea and some
emesis over the past month.
Past Medical History:
Meningo-Encephalitis (Neuro ICU at [**Hospital1 2025**], discharged [**2157-5-17**])
Anemia
Sleep apnea
Occult GI bleeding
Rheumatoid arthritis
Fibromyalgia
s/p right elbow replacement surgery [**9-6**]
Diverticulitis 25 years ago
Migraines
HTN
Hyperlipidemia
s/p lap cholecystectomy
Depression
Paraesophageal hernia with gastric ulceration s/p lap
paraesophageal hernia repair with Nissen fundoplication ([**12-6**])
Social History:
Denies tobacco, alcohol or drug use.
She is divorced. She has three daughters.
[**Name (NI) 1403**] as P.A. in adult primary care clinic.
She is lebanese/palestinian in background.
Family History:
Father died of MI at 85.
Mother had MI at 75.
There is family history of CAD and diabetes.
Physical Exam:
EXAM: T 98.9 BP 136/90 HR 84 RR 18 O2sat 96% on Room air
GEN: Awake in bed. Pleasant and comfortable. NAD
HEENT: PEERL, mild peri-orbital discoloration and swelling
NECK: Supple. No cervical lymphadenopathy.
CV: RRR. Normal S1 and S2. No murmurs, rubs, or gallops.
LUNGS: CTA bilaterally with no wheezes or decreased breath
sounds.
ABD: Soft with slight distention. Active bowel signs in all
four quadrants. Slightly uncomfortable on deep palpation.
EXT: No lower extremity edema. 2+ dorsalis pedis and radial
pulses.
Pertinent Results:
[**2157-6-25**] 08:00AM BLOOD WBC-7.8 RBC-3.31* Hgb-9.9* Hct-29.1*
MCV-88 MCH-29.9 MCHC-34.0 RDW-15.4 Plt Ct-208
[**2157-6-22**] 05:20PM BLOOD WBC-14.6*# RBC-3.96* Hgb-12.0 Hct-35.5*
MCV-90 MCH-30.4 MCHC-33.9 RDW-15.4 Plt Ct-264
[**2157-6-22**] 05:20PM BLOOD Neuts-80.2* Bands-0 Lymphs-11.3*
Monos-5.9 Eos-2.3 Baso-0.2
[**2157-6-22**] 05:20PM BLOOD Hypochr-NORMAL Anisocy-2+
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2157-6-25**] 08:00AM BLOOD Plt Ct-208
[**2157-6-22**] 05:20PM BLOOD PT-12.1 PTT-23.1 INR(PT)-1.0
[**2157-6-25**] 08:00AM BLOOD Glucose-95 UreaN-18 Creat-0.7 Na-142
K-3.9 Cl-107 HCO3-27 AnGap-12
[**2157-6-22**] 05:20PM BLOOD Glucose-134* UreaN-32* Creat-2.1* Na-138
K-4.6 Cl-102 HCO3-23 AnGap-18
[**2157-6-23**] 03:20AM BLOOD Glucose-213* UreaN-26* Creat-1.2* Na-139
K-4.6 Cl-109* HCO3-19* AnGap-16
[**2157-6-22**] 05:20PM BLOOD ALT-18 AST-23 CK(CPK)-48 AlkPhos-84
Amylase-77 TotBili-0.4
[**2157-6-22**] 05:20PM BLOOD Lipase-68*
[**2157-6-23**] 12:27PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2157-6-23**] 03:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2157-6-22**] 05:20PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2157-6-25**] 08:00AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2
[**2157-6-22**] 05:20PM BLOOD Albumin-3.4 Calcium-8.4 Phos-8.6*# Mg-2.4
[**2157-6-22**] 05:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2157-6-23**] 03:41AM BLOOD Type-ART pO2-159* pCO2-40 pH-7.30*
calHCO3-20* Base XS--5
[**2157-6-23**] 12:57AM BLOOD Type-ART Rates-12/ Tidal V-550 PEEP-8
pO2-219* pCO2-66* pH-7.14* calHCO3-24 Base XS--7 -ASSIST/CON
Intubat-INTUBATED
[**2157-6-22**] 10:08PM BLOOD pO2-55* pCO2-70* pH-7.15* calHCO3-26 Base
XS--5
[**2157-6-22**] 08:41PM BLOOD Type-ART pO2-112* pCO2-75* pH-7.10*
calHCO3-25 Base XS--7
[**2157-6-23**] 12:47PM BLOOD Lactate-1.3 K-4.5
[**2157-6-23**] 03:41AM BLOOD Lactate-2.7*
[**2157-6-22**] 06:10PM BLOOD Glucose-136* Lactate-1.8 Na-140 K-4.6
Cl-103 calHCO3-30
[**2157-6-23**] 03:42AM BLOOD Hgb-12.0 calcHCT-36 O2 Sat-64
[**2157-6-22**] 08:41PM BLOOD Hgb-11.3* calcHCT-34
[**2157-6-23**] 12:47PM BLOOD freeCa-1.16
Brief Hospital Course:
A/P: 58 year old female, with rheumatoid arthritis on daily
prednisone presented to ED with hypotension and
hypoxic/hypercarbic respiratory failure and transferred to the
floor with HTN.
.
1) Hypotension: Decreased blood pressure likely secondary to
sepsis and relative adrenal insufficiency, due to chronic
steroid use for treatment of RA. LLL PNA is possible source of
infection, but no elevated white count or sustained fever, so
unlikely. Broad spectrum antibiotics were initiated, but
discontinued after negative cultures.
.
2)Diarrhea: Patient reported episode of C. dificile following
admission to outside hospital. Treated with PO flagyl and
completed course 2 weeks before current admission. During this
admission, watery diarrhea developed. Sent two C. dificile
cultures and will discharge on prophylactic Flagyl. Duration of
antibiotic course will be determined by test results. Will send
3rd sample and test for C. dificile toxin-B.
.
3) HTN: Patient's blood pressure has remained elevated
throughout time after transfer to floor on [**2157-6-24**]. As there was
concern that regimen of ACE-I and BBlocker may have contributed
to hypotensive episode, caution was used to control BP. Patient
finally titrated to 100mg [**Hospital1 **] metoprolol and 40 mg [**Hospital1 **] of
lisinopril. Patient will be discharged home on this regimen.
(Of note, previous elbow fracture in her right elbow predisposes
to elevated HTN. Thus, measurements on this side may cause
spurious results).
.
4) Respiratory failure: Hypoxic and hypercarbic failure. LLL PNA
initially thought responsible due to possible hypoventilation
due to mental status/pain meds/OSA, but less likely. In the
MICU, broad spectrum antibiotics started and sputum culture
sent. Weaned FiO2 and good oxygenation saturation achieved on
room air.
.
5) ARF: Baseline creatinine is 1.1, but with ample fluids
repleted, Cr has continued to decrease. Likely pre-renal
etiology, as urine output has remained ample.
.
6) Guiaic positive stool: Has history of GI bleed [**2-3**] ulcers in
paraesophogeal hernia. HCT was stable throughout
hospitalization. Will continue PPI.
.
7) RA: Continue regimen of dolasetron. Pain was well
controlled with pain regimens.
.
8) Fibromyalgia: Hold Neurontin, Flexeril, Morphine for now. Use
Fentanyl/Versed for sedation and pain control.
.
9) Depression: Continue Effexor, Trazodone.
.
10) F/E/N: Appetite was good throughout admission. Placed on a
diabetic diet.
.
11) PPx: SQ heparin for DVT prophylaxis and PPI.
.
12) Comm: with patient and mother
PCP: [**First Name4 (NamePattern1) **] [**Name (NI) 1728**] -> [**Telephone/Fax (1) 96662**]
[**Hospital1 2025**]: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97764**] [**0-0-**], pager # [**Numeric Identifier **]. [**Hospital1 2025**] MR#
[**Medical Record Number 97765**]
Medications on Admission:
Prednisone 10 Daily
Metoprolol 150 mg TID
Atorvastatin 20 mg DAILY
Pantoprazole 40 mg Q24H
Cyclobenzaprine 30 mg TID
Trazodone 100 mg HS
Lorazepam 4 mg Tablet HS
Gabapentin 1200 mg TID
Morphine SR 30 mg Q8H
Oxycodone-Acetaminophen 5-325 mg Q4-6H prn
Venlafaxine 225 mg DAILY
Triamteren/HCTZ 37.5/25
Lisinopril 20
ASA
Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3)
Capsule, Sust. Release 24HR 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. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*42 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
Hold if HR<60 and systolic BP<100.
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension, hypoxic/hypercarbic respiratory failure.
Discharge Condition:
Good.
Discharge Instructions:
Please call your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1728**] ([**Telephone/Fax (1) **]) or come to
the emergency department if you develop any shortness of breath,
unexpected weakness, or any other concerning symptoms.
When at your visit with Dr. [**Last Name (STitle) 1728**], have him check the C.
dificile test results and discuss whether your metronidazole
(Flagyl) regimen should be continued.
Followup Instructions:
Please return home today and schedule an appointment with Dr.
[**Last Name (STitle) 1728**] for later this week.
|
[
"729.1",
"458.9",
"288.8",
"276.2",
"518.81",
"327.23",
"250.00",
"792.1",
"401.9",
"255.4",
"V58.65",
"780.2",
"276.52",
"714.0",
"311",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"00.17",
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9843, 9849
|
5348, 8211
|
306, 333
|
9946, 9954
|
3167, 5325
|
10432, 10548
|
2514, 2606
|
8578, 9820
|
9870, 9925
|
8237, 8555
|
9978, 10409
|
2621, 3148
|
255, 268
|
361, 1858
|
1880, 2300
|
2316, 2498
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,539
| 121,539
|
19545
|
Discharge summary
|
report
|
Admission Date: [**2112-2-8**] Discharge Date: [**2112-2-12**]
Date of Birth: [**2034-3-28**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
wound dehiscence
Major Surgical or Invasive Procedure:
wound revision
History of Present Illness:
77M w/ h/o prostate cancer with mets to spine who underwent
T9 laminectomy and fusion T7-11 on [**2112-1-15**] by Dr. [**Last Name (STitle) 548**]. He
had
had prior XRT x2. He was discharged to [**Hospital1 **] on [**2112-1-22**] and
was
seen in clinic [**2-3**] for staple removal. Upon removal he did
have
a couple areas of superficial dehiscence. He comes to ED today
with drainage from wound and temp to 101 ax yesterday, however
pt
was also diagnosed with bronchitis yesterday and begun on
levoflox
Past Medical History:
s/p T9 laminectomy and fusion T7-11 on [**2112-1-15**] by Dr. [**Last Name (STitle) 548**]
ONC HX:
Pt was initially diagnosed with localized prostate cancer in
[**2099**]. He was treated with external beam radiation until 04/[**2100**].
He did well until [**3-/2103**], when he was noted to have a rise in
his PSA. He was started on Eulexin and Zoladex. He had a very
good response, which lasted for 5-6 years. On [**2108-11-13**], he was
started on mitoxantrone and prednisone [**2-19**] rising PSA. He was
continued on this therapy for 5 cycles and then was started on
secondary hormonal therapy with ketoconazole and hydrocortisone.
[**10-20**] his PSA started rising, suggesting progression of disease
on hydrocortisone and ketoconazole. His PSA has continued to
rise this year going up to 98 [**2111-3-17**] and bone scan at the
time showed slightly increased uptake at T10, but no evidence of
mets. CT thorax showed stable lung nodules, adrenal adenoma, fat
stranding of left psoas muscles possibly c/w metastatic disease
and mildly enlarging infrarenal AAA. He was then admitted in
[**4-/2111**] for back pain and was found to have an L3 lesion
concerning for metastases and he was started on XRT. In the
interim, he was also continued on Zoladex. In [**7-/2111**], he was
restaged following the completion of his XRT. Between [**7-22**] and
the present he has been continued off of all therapies except
for Lupron and had been doing well including weaning himself off
of all pain medications. However, his PSA again began to
elevate, most recently 172 in 9/[**2111**].
PMH:
# CAD s/p MI x2 in [**2081**], [**2098**]
# CHF: EF 30% per Oncology notes from sometime in [**2109**], but no
study in the OMR
# h/o CVA in [**2098**]
# Hypertension
# Hypercholesterolemia
# s/p right CEA
# s/p left knee arthroscopic surgery
# A. Fib
Social History:
Lives in [**Location 3146**] with his wife, retired engineer. He has 4 grown
children. A former smoker, he quit in [**2081**] following a 60-80
pack a
year history. Rare EtOH currently, drank moderately in the past.
No IVDU.
Family History:
Non-contributory
Physical Exam:
Initial Exam:
T:99.8 BP: 122/ 54 HR:90 R 20 O2Sats94
Gen: WD/WN, comfortable, NAD.
HEENT: [**Last Name (un) **] EOMs
Neck: Supple.
Extrem: Warm and well-perfused. right boot
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:IP antigravity bilat
Sensation: Intact to light touch bilaterally.
Back: dressing on saturated with bloody serosang drainage.
Dressing removed, able to express fluid easily from lower
central
area of wound. Culture taken, redressed.
Pertinent Results:
[**2112-2-12**] 01:50AM BLOOD WBC-9.4 RBC-3.23* Hgb-9.9* Hct-28.3*
MCV-88 MCH-30.7 MCHC-34.9 RDW-17.6* Plt Ct-147*
[**2112-2-12**] 01:50AM BLOOD Plt Ct-147*
[**2112-2-12**] 01:50AM BLOOD Glucose-123* UreaN-30* Creat-0.9 Na-135
K-3.9 Cl-107 HCO3-19* AnGap-13
[**2112-2-9**] 11:35PM BLOOD ALT-52* AST-45* LD(LDH)-226 AlkPhos-137*
[**2112-2-12**] 01:50AM BLOOD Calcium-7.2* Phos-2.8 Mg-1.9
[**2112-2-12**] 09:55AM BLOOD Type-ART pO2-112* pCO2-35 pH-7.39
calTCO2-22 Base XS--2
Brief Hospital Course:
7M w/ h/o prostate cancer with mets to spine who underwent T9
laminectomy and fusion T7-11 on [**2112-1-15**] by Dr. [**Last Name (STitle) 548**]. He had
prior XRT x2. He was discharged to [**Hospital1 **] on [**2112-1-22**] and was
seen in clinic [**2-3**] for staple removal. Upon removal he did have
a couple areas of superficial dehiscence. He was admitted on
[**2-7**] with drainage from wound and temp to 101. During the first
24 hours of his admission he became hemodynamically unstable and
was transferred to the ICU for further monitoring. On hospital
day 2 he was take to the OR and found to have a very thin serous
fluid, clear evidence of infection, with fibrinous exudate
bordering on fascitis. He grew staph aureus coag positive
bacteria from his wound and blood. He was treated with IV
Vancomycin. He was unable to be extubated after his surgery his
family decided to make him CMO and he passed away.
Medications on Admission:
dig, lipitor, nifedipine,
valsartan, isorbide, simethicone,dulcolax, asa,
metoprolol, albuterol, citalopram,protonix,ssi
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
N/A
Completed by:[**2112-6-10**]
|
[
"518.5",
"412",
"038.11",
"584.9",
"998.32",
"998.59",
"729.4",
"V15.3",
"414.01",
"466.0",
"V10.46",
"682.2",
"428.0",
"995.92",
"198.5",
"427.31",
"599.0",
"285.9",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"96.6",
"96.71",
"99.04",
"83.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5239, 5248
|
4117, 5039
|
335, 351
|
5299, 5308
|
3620, 4094
|
5361, 5395
|
3007, 3025
|
5211, 5216
|
5269, 5278
|
5065, 5188
|
5332, 5338
|
3040, 3240
|
279, 297
|
379, 888
|
3255, 3601
|
910, 2748
|
2764, 2991
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,361
| 170,280
|
49549
|
Discharge summary
|
report
|
Admission Date: [**2125-10-14**] Discharge Date: [**2125-10-19**]
Date of Birth: [**2058-1-16**] Sex: F
Service: MEDICINE
Allergies:
Iodine Containing Agents Classifier / Losartan / perfume /
Amoxicillin / Penicillins / Atorvastatin
Attending:[**Name (NI) 9308**]
Chief Complaint:
right lower quadrant pain; hypertensive urgency
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 67 year-old Female with a h/o CAD (remote MI in [**2094**]'s
medically managed), diastolic heart failure, hypertension;
ascending aortic dissection, type A, s/p hemiarch aortic
replacement, resuspension of aortic valve commissures and
reapproximation of dissected aortic layers on [**2120-7-12**] by Dr.
[**Last Name (STitle) **] at [**Hospital1 112**], also with known descending aortic aneurysm, type
B, that has been folowed at the [**Hospital1 112**] radiographically since at
least [**2121**], who presented to the ED with a month of RLQ pain
that has been radiating to the groin, but now also to the lower
back. The pain is constant, improve with meals (leading her to
switch from eating 3 large meals a day to eating multiple small
meals throughout the day). She report h/o severe constipation
(been on colace, senna, dulcolax and enema). A new laxative was
given to her by PCP 3 days ago, which she has not had a chance
to use. She reports last BM about a day ago, passing flatus and
also some burping, with accompaning nausea. Denies any BRBPR or
melena.
.
The on [**2125-9-20**], she was evaluated in the ED for similar pain.
Patient had an ultrasound of the pelvis which showed fibroid
uterus. Ovaries were not visualized. She also had CT A/P non-con
on [**2125-9-20**] which only showed nonobstructing 4 and 6 mm right
renal stones. In comparison, today CT torso was obtained which
showed the descending type B aortic dissection extending from
just beyond the subclavian artery to iliacs. The great vessels
are not compromised. The true lumen feeds celiac artery,
superior mesenteric artery and right renal artery. The false
contain thrombus with dystrophic calcifications. The false lumen
feeds left renal and inferior mesenteric artery. In comparison
to the reports available to us, the dissection is unchanged from
prior. Prior images were not available for viewing from [**Hospital1 112**].
.
In ED, she c/o chest pain in the ER around 3PM, hypertensive to
sbp > 200. ECG was notable for NSR at 55 with Q's in III, F with
0.[**Street Address(2) 1755**] elevation and [**Street Address(2) 4793**] depression in I and L. Pain
improved with 2 SLNTG, Aspirin 325mg, Ondansetron and Morphine
Sulfate. BP at the time was elevated up to 180/90. She was also
started on a nitro gtt for BP control. She does get angina
occasionally, last time in [**2125-3-13**] which responds to SLNTG.
Repeat ECG after being pain free was similar. She was
premedicated (benadryl, solumedrol, famotidine) for the CTA as
she reports and allergy to IV constrast. Few hours later she
recieved Morphine Sulfate 4mg twice, Labetalol 100 mg, and
placed on nitro gtt for BP control. Patient was evaluated by
cardiology in the ED. Bedside TTE was done and did not show any
wall motion abnormalities, no pericardial effusion and no gross
valvular abnormalities. The coronary ischemia was rulled out by
cardiac markers and EKG. She was seen by Cardiology and vascular
surgery, who recommended admission to the medicine for BP
control.
.
CT imaging of the abdomen/pelvis non-contrast on [**2125-9-20**] which
only showed non-obstructing 4 and 6-mm right renal stones. A
non-contrast CT torso in the ED on this presentation was
reportedly consistent with reports from prior imaging at [**Hospital1 112**]
(actual images were not obtained). In the ED, she was
hypertensive, for which a Nitro gtt was initiated (with SBP >
200 mmHg). Her EKG was notable for NSR at 55 with Q's in III,
AVF with 0.5-mm ST elevation and 1-mm ST depression in I and
AVL. A bedside TTE was done and did not show any wall motion
abnormalities, no pericardial effusion and no gross valvular
abnormalities. Cardiac enzymes were negative. In the MICU, CTA
torso with contrast was performed and was also consistent with
written reports from prior imaging studies, with no acute
changes.
.
Nitro gtt was weaned off on [**10-15**] in the AM (8 am), with mean SBPs
in 100-130s systolic, HR 60-70s. She denies chest pain,
shortness of breath; no vision changes or headaches. Her AM dose
of Lisinopril of 5 mg was dosed this morning. Labetalol 200 mg
PO, Captopril 12.5 PO TID were initiated this AM.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. diastolic congestive heart failure
4. s/p MI
5. coronary artery disease
6. h/o TIA/stroke
7. type A aortic dissection (s/p repair [**2120**])
8. type B aortic dissection (medically optimized)
9. stage III chronic kidney disease (insult during repair of
aortic dissection bilaterally, creatinine 1.5-2.2)
10. NASH
11. atrophic left kidney
12. gout
13. right-sided nephrolithiasis
14. diabetes mellitus, type 2
15. diverticulitis
16. colonic polyps
17. obstructive sleep apnea
18. proximal aortic hemi-arch replacement (type A dissection,
re-suspension of aortic valve and re-approximation of dissected
aortic layers)
Social History:
Never smoker. She is a retired math and computer high school
teacher. Retired in the fall of [**2123**]. She is able to ambulate
around the house, but does not ambulate outside. Denies alcohol
use, denies recreational substance use.
Family History:
Father died of diabetic coma at 65, Mother [**Name (NI) **] and DM, died in a
car crash; all siblings with HTN, DM
Physical Exam:
ON ADMISSION
VITALS: 98.1 / 97.6 71 118/60 20 95%RA
GENERAL: Well-appearing African American women in NAD. Oriented
x 3. Mood, affect appropriate, cheerful.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of to base of clavicle.
CARDIAC: PMI located in 5th intercostal space, mid-clavicular
line. RR, normal S1, S2. No M/R/G. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: obese abdomen that is soft, NT/ND. No HSM or
tenderness. Abd aorta not enlarged by palpation. No abdominial
bruits. No CVA tenderness.
EXTREMITIES: No cyanosis, clubbing or edema. 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+
.
ON DISCHARGE:
VITALS: 98.5 / 98.5 57-70 115-178/62-107 16 97%RA
WEIGHT: 119.4 -> 119.1kg
I/Os: 950 / HLIV | 3700 (net -2.7L, this admission -5.7L)
GENERAL: Well-appearing African American women in NAD. Oriented
x 3. Mood, affect appropriate, cheerful.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of to base of clavicle.
CARDIAC: PMI located in 5th intercostal space, mid-clavicular
line. RR, normal S1, S2. No M/R/G. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: obese abdomen that is soft, NT/ND. No HSM or
tenderness. Abd aorta not enlarged by palpation. No abdominial
bruits. No CVA tenderness.
EXTREMITIES: No cyanosis, clubbing. 1+ bilateral pitting edema.
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:
[**2125-10-15**] 05:43AM BLOOD WBC-8.5# RBC-3.84* Hgb-12.1 Hct-35.4*
MCV-92 MCH-31.5 MCHC-34.2 RDW-14.1 Plt Ct-179
[**2125-10-14**] 03:15PM BLOOD Neuts-70.0 Lymphs-18.8 Monos-6.1 Eos-4.7*
Baso-0.4
[**2125-10-15**] 05:43AM BLOOD PT-14.4* PTT-20.3* INR(PT)-1.2*
[**2125-10-15**] 05:43AM BLOOD Glucose-137* UreaN-12 Creat-1.6* Na-138
K-4.4 Cl-102 HCO3-25 AnGap-15
[**2125-10-15**] 05:43AM BLOOD ALT-27 AST-20 CK(CPK)-113 AlkPhos-71
TotBili-0.4
[**2125-10-15**] 05:43AM BLOOD CK-MB-2 cTropnT-<0.01
[**2125-10-14**] 06:40PM BLOOD cTropnT-<0.01
[**2125-10-14**] 03:15PM BLOOD cTropnT-<0.01
[**2125-10-14**] 02:25PM BLOOD CK-MB-3 cTropnT-<0.01
[**2125-10-15**] 05:43AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.0 Mg-2.0
.
MICROBIOLOGY:
[**2125-10-15**] MRSA swab - negative
.
[**2125-10-14**] CTA CHEST, ABDOMEN, PELVIS - Type B aortic aneurysm
extending from just distal to the left subclavian artery through
the bilateral iliac arteries. No prior images are available for
comparison. In correlation with reports of study obtained at
[**Hospital3 103642**] in [**2123-5-12**], the extent
of dissection as well as features of the true and false lumens
appear similar. The dimensions do not appear significantly
increased, however, assessment of the acuity and progression is
limited in the absence of prior images. Prior repair of
ascending thoracic aorta. Cardiomegaly. No pericardial effusion.
.
[**2125-10-14**] CT CHEST, ABDOMEN, PELVIS - evidence of prior thoracic
aascending aortic repair. In region of arch and descending
aorta, eccentric calcification and heterogeneous appearance of
aorta could represent dissection or chronic findings (no priors
available) atrophic left kidney. Abdominal aorta appears normal
in caliber.
.
[**2125-10-14**] CXR - Difficult to assess for interval change given the
long interval between the most recent prior study and today.
There is increased tortuosity of the thoracic aorta and
therefore widening of the mediastinum. The mediastinum, however,
remains well defined. Additionally, complicating the comparison,
there has been interval median sternotomy surgery. If clinical
uspicion for dissection remains high, cross-sectional imaging is
warranted.
.
[**2125-10-14**] 2D-ECHO - the left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Left ventricular systolic function is hyperdynamic (EF =
70%). Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded, but on the views that were
obtained there does not appear to be any focal areas of
hypokinesis or akinesis. The descending thoracic aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Hyperdynamic LV with no
clear wall motion abnormalities seen on limited views.
Suboptimal image quality. Patient unable to cooperate with exam
due to severe andominal pain.
.
EKG ([**2125-10-14**]): NSR, lateral lead ST changes, lead III Q wave
Brief Hospital Course:
IMPRESSION: 67F with CAD (remote MI in [**2094**] medically managed),
diastolic CHF (EF 70%), HTN, ascending aortic dissection (type
A, s/p hemi-arch aortic replacement, resuspension of AV
commissures, [**7-/2120**]), known descending aortic aneurysm (type B,
radiographically followed since [**2121**]), who presented with HTN
urgency and chronic RLQ pain with stable imaging this admission.
.
# HYPERTENSION - The patient presented to [**Hospital1 18**] with evidence of
hypertensive urgency with SBP in the 200 mmHg range and
diastolic pressures in the 100s; she was asymptomatic
nonetheless with no evidence of end organ ischemia on admission.
The patient was admitted to the MICU and started on a
Nitroglycerin gtt on admission with adequate blood pressure
control. Her SBP improved to the systolic 100-120s mmHg with
transition to Labetalol and Captopril initially. She was
transitioned to a final regimen of Labetalol 400 mg PO TID with
Lisinopril 30 mg PO daily. Her creatinine was elevated on
admission and monitored closely (baseline unknown but likely in
the 1.3-1.7 range given her stage III chronic kidney disease,
per [**Hospital6 **] records). Her hypertension resolved
without issue after administration of the above oral agents. Her
goal blood pressure was less than 120-130 mmHg. She will be
discharged to rehab with blood pressure checks.
.
# TYPE B AORTIC DISSECTION - The patient was noted to have a
type B aortic dissection on prior imaging, which has been
monitored closely at [**Hospital6 1708**]. Her imaging
was repeated this admission given her atypical right lower
quadrant pain, and there was no notable progression. She was
seen by Vascular surgery given the clinical situation, who noted
no surgical intervention was warranted. We continued her
beta-blockade and kept her systolic blood pressure less than
120-130 mmHg to promote decreased shear forces in the aorta. She
will follow-up with Dr. [**Last Name (STitle) **] from [**Hospital6 **] Vascular
Surgery; this has been scheduled for her.
.
# RLQ PAIN - The patient presented with right lower quadrant
pain of approximately one month in duration. Give her history of
descending type B aortic aneurysm, this was investigated for
progression with CT imaging of the abdomen, pelvis and chest
which showed stable disease, no change from prior radiographic
images from [**Hospital6 **]. We also noted some
non-obstructing nephrolithiasis, but the patient had no
complaints of dysuria and had a negative urinalysis on
admission. It was thought that some constipation was
contributing to this and she was started on an aggressive bowel
regimen. She also was treated with Morphine SIR for pain control
and then transitioned to Tramadol for pain control, which
improved her symptoms. We also started Valium and Flexeril for a
possible back spasm component to her pain. Her radiology films
were reviewed and her appendix was deemed normal.
.
# ACUTE KIDNEY INJURY, ON CKD - The patient was admitted with a
creatinine of 1.3 with a reported baseline creatinine between
1.3 and 1.7 since her aortic dissection presentation in [**2120**].
She is noted to have stage III CKD, likely with some component
of hypertensive nephropathy. We avoided nephrotoxins and renally
dosed medications. Her creatinine was stable in the above range
this admission.
.
# CORONARIES - The patient has a history of coronary artery
diseaes noted in her records, but we have no record of cardiac
cath procedure. Her EKG on admission with was reportedly
unchanged from prior EKGs, but was notable for significant Q
waves in lead III, and lateral ST changes that were concerning.
She was without chest pain or dyspnea this admission and a
bedside TTE showed no wall motion abnormalities on admission. Of
note, her cardiac enzymes were negative x 4 this admission.
Given these findings, we continued medical optimization with
Aspirin 325 mg PO daily, Labetalol 200 mg PO TID, and
Pravastatin 20 mg PO daily.
.
# PUMP - The patient had a 2D-Echo showing EF 70% that is
hyperdynamic, this admission; there was no evidence of frank
wall motion abnormality, and history of diastolic CHF noted
previously. Review of her records showed a PET-CT from [**11/2124**]
which were documented as probably normal without evidence of
stress induced myocardial ischemia; she had a normal LV systolic
function. The patient's home dose of Lisinopril and Metoprolol
were discontinued and Captopril with Labetalol was used for oral
anti-hypertensive agents; thus beta-blockade and an ACEI were
continued. She was initially on Torsemide on admission, but this
was held given no evidence of volume overload and given her
acute renal insufficiency on CKD. Her goal diuersis was set at
even versus 0.5L/daily with electrolyte optimization, and her
I/Os were monitored closely with daily weights being monitored
as well. We eventually resumed her Torsemide 100 mg PO daily
with good effect.
.
# RHYTHM - EKG showing sinus rhythm; optimizing electrolytes and
continued telemetry monitoring without issues noted.
.
# DIABETES MELLITUS - Patient has been controlling her blood
glucose with insulin sliding scale at home; her HbA1c was 5.8%.
She was monitored with blood glucose monitoring and maintained
on her sliding scale.
.
# HLD - We continued her Pravastatin 20 mg PO daily.
.
TRANSITION OF CARE ISSUES:
1. Continue blood pressure medications with frequent blood
pressuring monitoring.
2. Continue to monitor back spasm and right lower quadrant pain;
if persistant, would consider GI consultation vs. Urology as an
outpatient.
3. Has outpatient follow-up scheduled with Dr. [**Last Name (STitle) **] from
cardiothoracic surgery at [**Hospital6 **] and with her
primary care physician.
4. She had no pending cultures or radiology reports at time of
discharge.
5. On discharge, she was having an acute gout flare of her right
toe, we continued her Allopurinol and recommended her to start
colchicine. She will follow-up with her PCP. [**Name10 (NameIs) **] avoided steroids
given her blood pressure and NSAIDs given her renal function.
Medications on Admission:
1. polyethylene glycol 17 gram (packet) PO daily
2. milk of magnesia 400 mg/5 mL oral suspension
3. mineral oil (rectal enema) PRN constipation
4. tramadol 50 mg 1-2 tabs PO Q6H PRN pain
5. lisinopril 5 mg PO daily
6. pravastatin 20 mg PO QHS
7. aspirin 325 mg PO daily
8. metoprolol succinate 100 mg ER PO daily
9. torsemide 100 mg PO daily (mid-day repeat dose if needed)
10. potassium chloride 40 mEq PO twice daily
11. allopurinol 500 mg PO daily
12. colchicine 0.6 mg PO daily (during active gout flares)
13. nitroglycerin 0.4 mg SL tab PRN chest pain
14. omega-3 fatty acid 1000 mg PO TID
15. fluticasone 50 mcg (2 sprays) INH daily PRN nasal symptoms
16. Advair 250/50 mcg twice daily
17. Ipratropium-albuterol 0.5-3 mg (2.5 mg)/3 mL INH Q4-6H PRN
wheezing
18. albuterol 90 mcg INH 1-2 puffs Q4-6H PRN wheezing
19. insulin sliding scale
Discharge Medications:
1. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. mineral oil Rectal
4. tramadol 50 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for gout symptoms.
8. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for SOB.
10. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*0*
12. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): [**Month (only) 116**] take extra dose in the PM (100 mg) for leg
swelling. Tablet(s)
13. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain.
15. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
16. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**2-11**]
sprays Nasal once a day as needed for allergy symptoms.
17. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
20. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back spasm, pain.
21. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back spasm, pain.
22. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever, headache.
23. insulin lispro 100 unit/mL Solution Sig: per sliding scale
per sliding scale Subcutaneous ASDIR (AS DIRECTED).
24. potassium chloride 20 mEq Packet Sig: Two (2) packets PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnoses:
1. Hyeprtensive urgency
2. Right lower quadrant pain of unclear etiology
3. type B descending aortic aneurysm (stable on imaging)
.
Secondary Diagnoses:
1. Hyperlipidemia
2. Diastolic congestive heart failure
3. Coronary artery disease
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:
Patient Discharge Instructions:
You were admitted to the [**Hospital1 1516**] Cardiology-Internal Medicine
service at [**Hospital1 69**] on [**Hospital Ward Name 121**] 3
regarding management of your heart issues. You initially were
admitted to the medical ICU for monitoring, given your very high
blood pressure. You were started on a Nitroglycerin infusion
which improved your blood pressure. You also had right lower
quadrant pain and imaging showed that your type B aortic
aneurysm was reassuring and showed no change from prior imaging.
Your right sided abdominal pain was attributed to
non-obstructing kidney stones on imaging that were likely
causing some colicky pain. You were given oral
anti-hypertensives to control your blood pressure, with good
effect. This will continue to monitored at rehab and your
aneurysm will be followed in clinic by Dr. [**Last Name (STitle) **]. You also had a
gout flare in your right toe and were given renally-dosed
colchicine with good effect. You were stable and improved on
discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* Worsening swelling in your legs or a weight gain of 3 lbs or
more, fatigue or excessive weakness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If 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 other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
* Upon admission, we ADDED the following medications:
You should START: Labetalol 400 mg PO three time daily
You should START: increase Lisinopril from 5 to 30 mg PO daily
You should START: Flexeril 10 mg PO TID PRN back spasm
You should START: Docusate sodium 100 mg PO twice daily and
Senna 8.6 mg PO QHS PRN constipation for a bowel regimen
You should START: Diazepam 5 mg PO Q6H PRN back spasm
You should START: Tylenol 325 to 650 mg PO Q6H PRN pain, fever
You should CHANGE: decrease you Allopurinol from 500 to 300 mg
PO daily
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Metoprolol
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Name: [**Last Name (LF) 67691**],[**First Name3 (LF) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appt: Wednesday [**10-22**] at 11:20 AM
.
Name: [**Last Name (LF) 11991**],[**First Name7 (NamePattern1) 177**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Location: B&W HOSP/CARDIAC SURGERY
Address: [**Doctor First Name 103643**] [**Hospital **] Clinic B, [**Location (un) **],MA
Phone: [**Telephone/Fax (1) 103644**]
Appt: [**10-31**] at 8:30am
|
[
"571.8",
"414.01",
"403.90",
"428.0",
"428.32",
"584.9",
"272.4",
"250.00",
"789.03",
"441.02",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20303, 20425
|
10920, 16979
|
403, 431
|
20724, 20724
|
7796, 10897
|
23773, 24348
|
5560, 5676
|
17873, 20280
|
20446, 20597
|
17005, 17850
|
20939, 23750
|
5691, 6678
|
20618, 20703
|
6692, 7777
|
316, 365
|
459, 4617
|
20739, 20883
|
4639, 5293
|
5309, 5544
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
|
[
"530.81",
"285.9",
"726.33",
"728.86",
"787.91",
"272.4",
"041.11",
"401.9",
"331.0",
"294.11",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"93.57",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6116, 6199
|
2245, 4045
|
290, 317
|
6272, 6309
|
1443, 2222
|
6791, 7114
|
998, 1051
|
4195, 6093
|
6220, 6251
|
4071, 4172
|
6333, 6768
|
1066, 1424
|
227, 252
|
345, 682
|
704, 819
|
835, 982
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,161
| 161,381
|
48777
|
Discharge summary
|
report
|
Admission Date: [**2181-4-18**] Discharge Date: [**2181-4-23**]
Date of Birth: [**2137-2-2**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Pericardial effusion s/p AF ablation
Major Surgical or Invasive Procedure:
Pericardiocentesis
Pulmonary vein isolation
History of Present Illness:
Patient is a 44 yo man with PMH long standing AFib, s/p PVI in
[**11-14**] at [**Hospital1 112**] which lasted 10 months, HTN, hypercholesterolemia,
who presented to [**Hospital1 18**] today for scheduled pulmonary vein
isolation/AF ablation. Procedure was noted to be technically
difficult with several attempts at transeptal puncture.
Ablation was carried out successfully, and on intra cardiac
ECHO, a pericardial effusion was noted (per notes approximately
1cm). It is unclear whether this effusion was present prior to
procedure. Therefore, a post-procedure ECHO was obtained that
per notes demonstrated pericardial effusion = 2.4cm (no report
online yet). Patient remained hemodynamically stable throughout
procedure and post-procedure. Currently patient feels "out of
it" from all the sedation medications, c/o mild chest pressure,
no other complaints.
Past Medical History:
1.) AFib s/p PVI in [**11-14**] at [**Hospital1 112**], lasted 10 months. Followed by
Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] and Alexi [**Doctor Last Name 13177**]
2.) HTN
3.) Hypercholesterolemia
4.) ?SSS
Per records, last ECHO in [**2-16**] demonstrated EF=37%
Social History:
SH: no tobacco, occasional EtOH, no drug use. Lives with wife
and 2 children (age 12 and 8) in [**Location (un) 5110**], currently unemployed
mechanic.
Family History:
noncontributory
Physical Exam:
Vitals - HR 74 NSR, BP 114/59, Pulses 7, RR 19, O2 100% 2L NC
General - Lying supine, appears lethargic but easily arousable,
NAD
HEENT - PERRL, MMM
Neck - Could not assess JVP as pt lying supine
CVS - RRR, nl S1, S2, no M/R/G
Lungs - CTA anteriorly and laterally
Abd - soft, NT/ND, no noted HSM, + BS
Groin - b/l groin puncture sites - R side covered with dressing
w/ some sanguinous drainage, no active bleeding noted, no
hematoma noted non-tender to palpation, no bruit ascultated. L
side same.
Ext - No LE edema b/l, 1+ DP pulses b/l, 2+ PT pulses b/l
Pertinent Results:
Pre-procedure EKG: AFib at 111, no other noted abnormalities
.
Post-procedure EKG: NSR @ 77, no other noted abnormalities
TTE [**2181-4-17**]
Conclusions:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is a
moderate sized, circumfirential pericardial effusion. There are
no echocardiographic signs of tamponade.
TTE [**2181-4-18**]
Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. There is a moderate to large sized
pericardial effusion (greatest posteriorly). There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2181-4-17**],
there is no
definite change (prior study had focused views and
underestimated the size of the effusion)
.
TTE [**2181-4-20**]
1. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
2. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
3.There is a large pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2180-4-18**], the effusion has grown in size.
.
Pericardiocentesis [**2181-4-20**]
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Pericardiocentesis: was performed via the subxyphoid approach,
using an
18 gauge thin-wall needle, a guide wire, and a drainage
catheter.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
COMMENTS:
1. Baseline hemodynamics demonstrated moderately elevated
right sided
pressures (mean RA 20 mmHg), pulmonary pressures (PAD 20 mmHg),
left
sided pressures (mean PCWP 20 mmHg) a pericardial pressure of 20
mmHg.
2. Pericardiocentesis was performed successfully and 650 ml of
bloody
fluid was drained.
3. Following pericardiocentesis, the RA pressure fell to 15
mmHg, and
the pericardial pressure fell to 1 mmHg.
4. Echocardiography performed following the procedure showed
only a small residual effusion (see echocardiography report).
5. A catheter was left in the pericardium to drain, and the
patient
left the catheterization laboratory in stable condition.
FINAL DIAGNOSIS:
1. Pericardial effusion.
2. Successful pericardiocentesis.
.
TTE [**2181-4-20**] post pericardiocentesis
Conclusions:
Focused study.
1.Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
2.There is a trivial pericardial effusion present.
.
TTE [**2181-4-21**]
Conclusions:
There is a trivial pericardial effusion. There are no
echocardiographic signs of tamponade.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2181-4-22**] 05:18PM 33.4*
[**2181-4-22**] 07:05AM 8.7 4.04* 12.2* 34.9* 86 30.1 34.8 13.8
268
[**2181-4-21**] 04:57PM 36.1*
[**2181-4-21**] 04:08AM 10.0 3.96* 12.2* 35.1* 89 30.7 34.6 13.8
182
[**2181-4-20**] 11:41PM 33.9*
[**2181-4-20**] 07:20PM 34.1*
[**2181-4-20**] 12:58PM 33.7*
[**2181-4-20**] 04:00AM 12.0* 3.58* 10.9* 31.2* 87 30.5 35.0 13.7
142*
ADDED RETIC [**2181-4-20**] 10:AM
[**2181-4-19**] 10:20PM 33.8*
[**2181-4-19**] 04:00PM 13.8* 4.03* 12.3* 35.3* 88 30.5 34.8 13.6
134*
[**2181-4-18**] 04:59AM 19.1* 5.04 15.1 43.6 87 30.0 34.7 13.8
210
[**2181-4-18**] 12:19AM 18.9* 5.24 15.6 45.8 87 29.9 34.2 13.7
240
Brief Hospital Course:
Patient is a 44 year old man with PMH long standing atrial
fibrillation, presented for elective Pulmonary vein
isolation/atrial fibrillation ablation.
.
Patient underwent Atrial fibrillation ablation on [**2181-4-18**] that
was initially successful in converting patient to NSR. However,
procedure was complicated by technical difficulties, including
new onset pericardial effusion thought to be due to perforation
of the posterior/septal wall of left atrium during the
procedure. Therefore the patient was admitted to the CCU for
monitering. The patient was initially in a lot of chest pain
following the procedure, which via evaluation was felt secondary
to his pericarditis from the procedure and the effusion. This
resolved quickly during his hospital course. His pulses and
hemodynamics were monitered closely and remained stable. Repeat
ECHO's initially demonstrated no change in the size of his
effusion, and with his stable hemodynamics, it was felt that his
effusion was stable.
.
However, 2 days following admission, the patient's clinical
status changed and he began having transient episodes of
hypotension. At this time, he was also noted to have a nearly
10 point Hct drop, and had returned again from NSR, which he had
been in since his pulmonary vein isolation, to Atrial
fibrillation/atrial flutter. EP was notified of the patient's
return to atrial fibrillation/flutter and opted to start the
patient on sotalol, which was titrated up to 120mg PO BID by
time of discharge. He was also intermittently given diltiazem
(PO and IV) for rate control.
To work up his Hct drop and associated transient episodes of
hypotension, a femoral artery ultrasound was performed on the
patient's femoral arteries bilaterally, which were negative.
His stool was guiaced for blood, which was negative. He had an
abdominal/pelvis CT scan to rule out a retroperitoneal bleed
which was negative. He also underwent another ECHO after this
Hct drop was noticed, which demonstrated a 25% increase in the
pericardial effusion, no evidence of tamponade, and patient's
pulses remained stable at this time. Therefore the patient was
brought to the cath lab for a pericardiocentesis with drain
placement, and successfully underwent drainage of 1 liter of
sanguinous fluid from the pericardial sac prior to removal of
his pericardial drain. His Hct was monitered TID during this
time, and remained stable with small amounts of fluctuation. A
repeat ECHO performed following removal of the
pericardiocentesis drain, prior to discharge, demonstrating no
re-accumulation of his pericardial effusion. The patient's
hemodynamics and pulses remained stable.
.
Therefore the patient was re-started on his coumadin with
lovenox bridge (given high incidence of clot formation following
pulmonary vein isolation) and discharged on sotalol 120mg [**Hospital1 **]
with instructions to follow up at his primary care physician's
office 1 day and 3 days after discharge for both Hct checks (to
ensure were stable) and INR checks, then follow up as his PCP
[**Name Initial (PRE) **]. He was also instructed to follow up with his
cardiologist 1 week following discharge.
.
Of note, the patient's blood sugars were noted to be elevated
throughout hospital course. Per patient, he stated that he was
told that his blood sugar was high prior, by his PCP, [**Name10 (NameIs) **] that
attempts at dietary and exercise modifications were made. Given
the patient's values of non-fasting glucose greater than 200,
the patient meets criteria for likely type 2 diabetes mellitus.
Management of this was deferred as an inpatient given the
patient's other medical conditions described above, but this
should be addressed in the outpatient setting, and consideration
should be made of starting an oral hypoglycemic [**Doctor Last Name 360**].
Medications on Admission:
Coumadin 7.5mg PO QD (last dose [**2181-4-12**])
Atenolol 25mg [**Hospital1 **]
Flexoril 10mg [**Hospital1 **] PRN
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day)
as needed for Aflutter.
Disp:*90 Tablet(s)* Refills:*2*
3. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 100 mg/mL Syringe Sig: One (1) injection
Subcutaneous [**Hospital1 **] (2 times a day): Please continue until advised
so by your primary care physician (once coumadin level is
therapeutic).
Disp:*30 injection* Refills:*2*
5. Outpatient Lab Work
Hematocrit, INR, PTT - Please check on Tuesday, [**4-24**]
6. Outpatient Lab Work
Hematocrit, INR, PTT - please check on Friday, [**4-27**]
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation status post pulmonary vein isolation
Atrial flutter
Hemopericardium
Pericarditis
Discharge Condition:
hemodynamically stable, no chest pain, good
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all follow-up appointments.
3. Please seek medical attention if you develop lightheadedness,
chest pain, shortness of breath, nausea, vomiting or have any
other concerning symptoms.
Followup Instructions:
1.) Please go to Dr.[**Name (NI) 102516**] office on Tuesday [**4-24**] and
Friday [**4-27**] after 9AM for blood draws to have your hematocrit
and INR checked.
2.) Please follow up with appointment with Dr. [**Last Name (STitle) 35833**]
[**Name (STitle) 35834**] ([**Telephone/Fax (1) 42311**]) on Tuesday [**5-1**] at 11AM. [**Month (only) 116**] call to
change appointment.
3.) Please follow up with Dr. [**Last Name (STitle) 13177**] in the next 1-2 weeks
([**0-0-**]). Please ensure Dr. [**Last Name (STitle) 13177**] is communicating
with Dr. [**Last Name (STitle) **], and you should probably also follow up with Dr.
[**Last Name (STitle) **] in the next 2-4 weeks (can discuss with Dr. [**Last Name (STitle) 13177**] whom
you should be following with)
|
[
"401.9",
"427.31",
"790.6",
"423.9",
"997.1",
"272.0",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
11275, 11281
|
6474, 10294
|
304, 350
|
11426, 11472
|
2361, 5201
|
11763, 12529
|
1752, 1769
|
10459, 11252
|
11302, 11405
|
10320, 10436
|
5218, 6451
|
11496, 11740
|
1784, 2342
|
228, 266
|
378, 1244
|
1266, 1565
|
1581, 1736
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,134
| 157,960
|
51258
|
Discharge summary
|
report
|
Admission Date: [**2156-3-24**] Discharge Date: [**2156-3-27**]
Date of Birth: [**2104-4-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Vaginal bleeding, abdominal pain
Major Surgical or Invasive Procedure:
Intubation
Mechanical Ventilation
History of Present Illness:
This is a 51-year-old woman with a history of schizophrenia,
lead poisoning, mental retardation, and type 2 diabetes who
presented to the emergency room on [**2156-3-24**] from her group home
with abdominal pain and vaginal bleeding. Per report she had
noted abdominal pain and was found to have blood on her sheets
and in the bathroom from the ngiht prior to admission. The
patient's last menstrual period was in the begining of [**Month (only) 956**].
On arrival in ED her initial vitals were T 97.1, HR 125, BP
144/73, RR 18, 100%RA. She was trace guaiac positive on rectal
exam but her abdominal exam was benign. She was noted to have
wheezing on lung exam and received nebulizers and
methylprednisolone 125 mg IV x 1. In this setting she became
agitated and resisted nebulizer treatment. She was unable to
undergo initial CT scan secondary to agitation and subsequently
dropped her oxygen saturations to the 80s on room air which
improved to the 90s on a non-rebreather. She received 1 mg
lorazepam and 2 mg haloperidol with no improvement in her
agitation and was subsequently intubated for airway protection.
Initial ABG post-inbuation was 7.14/67/383 which improved with
sedation to 7.29/51/187. She underwent CT torso which reavaled
a possible RUL pneumonia and a 3.7 cm adenexal cyst. Urine hcg
was negative. She received a total of 3L IVF. She was
subsequently admitted to the MICU.
While in the MICU she underwent pelvic [**Month (only) 950**] which showed a
2.8 cm simple left ovarian cyst and trace endometrial fluid.
She was started on ceftriaxone and azithromycin for community
acquired pneumonia. She was quickly extubated without
difficulty although she has had persistent tachypnea and
tachycardia without evidence of respiratory distress. She was
noted to have persistent vaginal bleeding which was felt to be
likely secondary to menstruation. She is being transferred to
the floor for further management.
Currently she has no complaints. She denies fevers, chills,
night sweats. No chest pain or difficulty breathing. No
palpitations. No nausea, vomiting, abdominal pain. No diarrhea
or constipation. No melena or hematochezia. She does endorse
vaginal bleeding. She denies having regular periods and the
bleeding is intermittent. No other vaginal discharge. No
dysuria or hematuria. No leg pain or swelling. She denies
visual or auditory hallucinations. All other review of systems
is negative in detail.
Past Medical History:
Type II Diabetes
Hypertension
Lead poison
Schizophrenia
Anxiety
Mild mental retardation
Hepatitis C
Social History:
Lives at group home. Currently smokes [**2-7**] pack per day. Has not
been drinking alcohol for many years. She denies a history of
IVDU.
Family History:
Her sister has schizophrenia. She has no known family history
of malignancy.
Physical Exam:
Admission Physical Exam:
VS: 97.0, HR 88, BP 113/76, RR 12, 99% intubated
GEN: middle-aged African-American woman intubated, looking
uncomfortable, responding to commands
SKIN: No rashes or skin changes noted
HEENT: No JVD, neck supple
CHEST: Lungs are clear from anterior, no wheezing
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES: no peripheral edema, warm without cyanosis
NEUROLOGIC: responding to commands
Discharge Physical Exam:
Vitals: T: 99.2 BP: 114/51 P: 116 R: 21 O2: 92% on RA
General: Alert, oriented to person, [**Hospital1 18**], not date, no acute
distress
HEENT: Sclera anicteric, MMM, poor dentition, 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
Pelvic: Blood coming from vaginal area
Rectal: Trace guaiac negative in ER
.
Pertinent Results:
Hematology:
[**2156-3-24**] 01:45AM WBC-5.4 RBC-4.83 HGB-11.6* HCT-38.3 MCV-79*
MCH-24.0* MCHC-30.3* RDW-16.2*
[**2156-3-24**] 01:45AM NEUTS-28.4* LYMPHS-44.4* MONOS-5.0 EOS-21.8*
BASOS-0.4
[**2156-3-24**] 01:45AM PLT COUNT-107*
[**2156-3-27**] 08:05AM BLOOD WBC-3.9* RBC-4.09* Hgb-10.4* Hct-32.6*
MCV-80* MCH-25.5* MCHC-32.0 RDW-16.8* Plt Ct-134*
Chemistries:
[**2156-3-24**] 01:45AM BLOOD Glucose-146* UreaN-9 Creat-0.8 Na-138
K-3.7 Cl-102 HCO3-25 AnGap-15
[**2156-3-24**] 01:45AM BLOOD ALT-11 AST-45* LD(LDH)-165 AlkPhos-95
TotBili-0.3
[**2156-3-27**] 08:05AM BLOOD Glucose-158* UreaN-8 Creat-0.7 Na-135
K-4.5 Cl-101 HCO3-29 AnGap-10
[**2156-3-27**] 08:05AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0
[**2156-3-24**] 05:31PM BLOOD CK-MB-7 cTropnT-<0.01
[**2156-3-24**] 01:45AM BLOOD Lipase-41
[**2156-3-25**] 04:05AM BLOOD calTIBC-455 Ferritn-13 TRF-350
Imaging:
CXR [**2156-3-24**]: The heart is normal in size. Bilateral hilar
adenopathy is longstanding. Small areas of new opacification in
the lingula and right base could be pneumonia, or lung
involvement of presumed sarcoidosis. There is no pleural
effusion or pneumothorax.
CT Chest/Abdomen/Pelvis [**2156-3-24**]:
1. Right upper lobe pneumonia versus sequelae of the patient's
known
sarcoidosis.
2. 6.8 cm left adnexal hypodense structure for which pelvic
[**Month/Day/Year 950**]
evaluation is recommended. Differential diagnosis includes large
adnexal/ovarian cyst, although underlying hydrosalpinx is not
excluded.
Multiple uterine fibroids and prominent endometrium which can
also be
evaluated on the recommended [**Month/Day/Year 950**].
3. 6 mm right breast nodular density; recommend correlation with
mammography.
4. Trace amount of right lower quadrant free fluid of uncertain
clinical
significance.
5. No evidence of pulmonary embolism.
Pelvic [**Month/Day/Year **] [**2156-3-24**]: 1. 2.8 cm simple left ovarian cyst
warrants followup to document resolution or improvement.
2. Endometrial fluid, a component of which is likely hemorrhage.
EKG [**2156-3-24**]: sinus tachycardia at 120, normal axis, normal
intervals, no acute ST segment changes, no priors for
comparison.
Microbiology:
Urine culture [**2156-3-24**]: Negative
Brief Hospital Course:
Assessment and Plan: 51-year-old woman with history of
schizophrenia, lead poisoning, type II diabetes and hypertension
who presented with abdominal pain and vaginal bleeding
subsequently intubated for agitation.
Vaginal Bleeding: Pelvic [**Month/Day/Year 950**] notable for simple ovarian
cyst and small amount endometrial bleeding. Patient continues
to have her menstrual periods regularly. Per her case manager
she had a pap smear and pelvic exam three weeks prior to this
admission which was unremarkable per report. Her hematocrit
decreased from 38 on admission to 33 although this was in the
setting of IV hydration. Her hematocrit was subsequently
stable. She had a pelvic [**Month/Day/Year 950**] which was notable for a
simple ovarian cyst which will require a repeat pelvic
[**Month/Day/Year 950**] in six weeks to confirm resolution.
Hypoxia/Shortness of Breath: Patient was noted to have hypoxia
in the setting of extreme agitation in the emergency and was
intubated. She underwent CTA which showed no evidence of
pulmonary embolism but did show evidence of sarcoidosis and a
possible pneumonia. She was treated initially with levofloxacin
and will complete a course of azithromycin for community
acquired pneumonia. She also was noted to have wheezing on exam
and was given a short course of inhaled corticosteroids and
bronchodilators. At the time of discharge she was breathing
comfortably on room air.
Anemia: Patient was noted to have a hematocrit on presentation
in the high 30s which decreased to the low 30s with IVF. Iron
studies were consistent with iron deficiency. She was started
on iron supplements. She should be referred for screening
colonoscopy as an outpatient given her age.
Abdominal Pain: Patient presented with abdominal pain. On
arrival the pain had resolved and her exam was benign. She had
a CT of the abdomen and pelvis which showed an ovarian cyst but
was otherwise negative. The ovarian cyst was confirmed by
pelvic [**Month/Day/Year 950**]. She did not require pain medications. It
was thought that her pain might be related to menstrual
cramping.
Breast Nodule: Patient was noted to have a 6 mm breast nodule
on CT scan. She is scheduled for mammogram as an outpatient at
which time correlation should be made.
Type II Diabetes: Her oral hypoglycemics were held given
contrast load for CT. She was managed with an insulin sliding
scale. Her home medications were restarted on discharge.
Hypertension: She was continued on lisinopril 2.5 mg daily.
Schizophrenia/Anxiety: She was continued on lamotrigine,
fluphenazine, risperidone and ativan.
Mild Thrombocytopenia: Platelet count stable. Attributed in the
past to medications versus hepatitis C.
Prophylaxis: She received subcutaneous heparin for DVT
prophylaxis.
Medications on Admission:
Albuterol inh 1-2 puffs qid
Benztropine 1 mg qhs
Fluphenazine 30 mg qday
Glyburide 5 mg qday
Lamotrigine 75 mg [**Hospital1 **]
Lisinopril 2.5 mg qday
Lorazepam 2 mg qhs
Metformin 1000 mg [**Hospital1 **]
Risperidone 4 mg qday
Acetaminophen prn
Aspirin 325 mg qday
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**2-7**] Inhalation four times a day as needed for shortness of
breath or wheezing.
2. Combivent 18-103 mcg/Actuation Aerosol Sig: [**2-7**] ih Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
3. Fluphenazine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Benztropine 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO twice a
day.
7. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Please restart this medication on Sunday [**2156-3-28**].
10. Risperidone 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
13. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
IH Inhalation twice a day.
Disp:*1 ih* Refills:*2*
15. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Abdominal Pain
Menstrual bleeding
Wheezing
Secondary:
Schizophrenia
History of lead poisoning
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were seen and admitted for your abdominal pain. You had an
extensive workup which included a CT scan and pelvic [**Month/Day/Year 950**]
which did not show a cause for your pain. You were diagnosed
with pneumonia and started on antibiotics.
You were diagnosed with a small ovarian cyst on pelvic
[**Month/Day/Year 950**]. You will need a repeat [**Month/Day/Year 950**] in six weeks.
Please make sure that this is done by your primary care doctor.
You were also noted to have a 6 mm right breast nodular density;
recommend correlation with mammography which is scheduled for
[**2156-4-20**].
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take Azithromycin 250 mg for four more days
2. Please take Advair 1 puffs two times a day
3. Please take combivent 1-2 puffs every 6 hours as needed for
wheezing
4. Please hold your metformin until Sunday [**2156-3-28**]
5. Please take iron 325 mg daily
Please keep all your follow up appointments as scheduled.
Followup Instructions:
Please keep the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2156-3-30**] 10:50
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-4-5**]
10:30
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2156-4-5**] 11:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2156-4-20**] 10:30
|
[
"317",
"276.2",
"620.2",
"909.0",
"401.9",
"518.81",
"218.9",
"280.9",
"785.0",
"070.70",
"486",
"300.00",
"295.90",
"280.0",
"305.1",
"493.22",
"E929.2",
"793.89",
"V65.5",
"287.5",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11250, 11256
|
6692, 9488
|
348, 384
|
11404, 11404
|
4465, 6669
|
12609, 13105
|
3167, 3247
|
9804, 11227
|
11277, 11383
|
9514, 9781
|
11551, 12586
|
3287, 3765
|
276, 310
|
412, 2870
|
11418, 11527
|
2892, 2994
|
3010, 3151
|
3790, 4446
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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**]
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31,657
| 148,281
|
7208
|
Discharge summary
|
report
|
Admission Date: [**2140-7-5**] Discharge Date: [**2140-7-19**]
Date of Birth: [**2084-1-3**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
[**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56yo M h/o MS (wheelchair bound), DM, HTN, hyperlipidemia,
h/o SDH who was found down at home in the bathroom on [**7-4**] and
admitted to [**Hospital3 3583**]. He was between the tub and sink
with
his head resting on the radiator and knees raised, "unresponsive
to all stimulation" but "eyes open and moving" per his ED note,
not able to verbally respond. He was being moved to a stretcher
and had "a grand mal [**Hospital3 862**]" and taken via EMS to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **].
There, he received narcan with no effect, as well as ativan and
etomidate and intubated for airway protection with concern for
status "asthmaticus" with all limbs "flailing" and
"unresponsive". CT showed "s/p L craniotomy w/o bleed or change
from prior scan [**2139-2-1**]" CT C-spine showed "cervical spondylosis
and cervical disc disease C4-C7". CXR negative for acute
infiltrates.
He was given dilantin 1200mg x 1, 2 doses of ativan, and then
propofol, and was admitted to the ICU.
Seen by neurology, there, who had followed the patient for
"break
through [**Month/Day/Year 862**]" and EEG had "suggested L TLE". Keppra was
started but discontinued due to "cognitive SE" and he was
maintained on "carbitrol 300mg [**Hospital1 **]". The consultant noted on
speaking to his RN that when propofol had been attempted to be
discontinued, he would have twitching of his "thigh and hand
(esp
R)" and pick at his clothes. It was unclear to the consultant
whether this represented [**Hospital1 862**] activity so the patient is
transferred here for taper off of propofol under continuous EEG
monitoring. He was given dilantin 1200mg IV on transfer.
Past Medical History:
Asthma
MS, since [**2119**]
DM
Osteoporosis due to steroids and hypoparathyroidism
HTN
Hyperlipidemia
h/o L SDH
b/l septic necrosis of hips
Chronic LBP
Social History:
SH: lives at home with HHA. Occasional EtOH, but not heavy.
Family History:
unknown
Physical Exam:
VS Tc 100.7/Tm 100.1 83-85 114-122/62-63 15-20 100%
Gen intubated, on propofol for my exam. Obese.
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no edema
NEURO
MS Intubated, lightly sedated on propofol. Grimaces and
localizes
to sternal rub.
CN
Pupils 3->2 b/l. EOM full to oculocephalics. b/l corneals
present
with no facial asymmetry.
Motor
Normal bulk and tone. Withdraws all limbs purposefully to
noxious
stimuli.
Sensory as above.
Reflexes symmetric, 2's in arms, 1's in legs. Toes down b/l.
Coordination unable to assess
Gait unable to assess
Pertinent Results:
[**2140-7-4**] 9am at OSH:
WBC 19.1 (82 poly's), hct 37.3 (MCV 89), plt 275
D-dimer 2.86 (H)
SMA remarkable for Cr 1.5, glu 152; lytes and LFTs normal
CK 565, trop-I 0.22 (high)
Tox screen negative
Carbamazepine level 5.27 ([**4-7**])
Theophylline level non-toxic at 3.8
UA cloudy, 0-2 wbc, 2+ bacteria, neg LE/nitrites
Imaging
Head CT and C-spine as above
[**2140-7-7**] 11:08AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-8
Lymphs-64 Monos-28
[**2140-7-7**] 11:08AM CEREBROSPINAL FLUID (CSF) TotProt-52*
Glucose-87
HSV 1 and 2 undetected.
HHV6 undetected.
[**2140-7-10**] 11:31AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.029
[**2140-7-10**] 11:31AM URINE RBC-[**2-29**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-<1
[**2140-7-15**] 06:35AM BLOOD WBC-7.5 RBC-3.32* Hgb-10.0* Hct-29.5*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.7 Plt Ct-538*
[**2140-7-7**] 05:30AM BLOOD Neuts-76.9* Lymphs-16.7* Monos-5.0
Eos-0.8 Baso-0.6
[**2140-7-15**] 06:35AM BLOOD Plt Ct-538*
[**2140-7-12**] 06:25AM BLOOD Ret Aut-2.2
[**2140-7-15**] 06:35AM BLOOD Glucose-128* UreaN-10 Creat-0.9 Na-143
K-3.9 Cl-106 HCO3-25 AnGap-16
[**2140-7-12**] 06:25AM BLOOD LD(LDH)-388* TotBili-0.3
[**2140-7-10**] 06:15AM BLOOD ALT-27 AST-31 LD(LDH)-445* AlkPhos-50
TotBili-0.3
[**2140-7-15**] 06:35AM BLOOD Calcium-8.8 Phos-3.6# Mg-2.0
[**2140-7-12**] 06:25AM BLOOD Hapto-424*
[**2140-7-7**] 09:55AM BLOOD VitB12-632
[**2140-7-7**] 05:30AM BLOOD Ammonia-54*
[**2140-7-7**] 05:30AM BLOOD TSH-0.67
[**2140-7-15**] 06:35AM BLOOD Carbamz-5.3
[**2140-7-5**] 03:44AM BLOOD Lactate-1.0
CT - torso- [**2140-7-8**]
IMPRESSION:
1. No cause for fever identified within the chest, abdomen, or
pelvis.
2. Extensive old traumatic injuries involving the ribs, pelvis
and vertebral column. Mild widening of the L3 vertebral body
anterior margin with soft tissue prominence is also likely
post-traumatic. However, an underlying destructive bone lesion
cannot be completely excluded. This is likely unrelated to the
patient's cause of fever and can be evaluated with a nonemergent
MRI.
3. Marked degenerative changes with near complete loss of joint
space involving the femoral heads bilaterally, likely related to
patient's history of avascular necrosis.
Brief Hospital Course:
Mr. [**Known lastname 26713**] is a 56-year-old man with a history of
long-standing MS [**First Name (Titles) **] [**Last Name (Titles) 862**] disorder transferred for the
question of continued [**Last Name (Titles) 862**] activity. His hosptial course by
problem is as follows:
1. NEURO: [**Last Name (Titles) **]. After admission to the ICU, he was quickly
weaned from propofol and was extubated. He had occasional
rhythmic beats of his ankle but remained alert. On the 4th day
of admission the patient had an episode of confusion/agitation
that resulted in a code purple (psychiatric code) in the middle
of which he had a brief [**Last Name (Titles) 862**] episode characterized by head
turning to the right and right shoulder clonus. Routine EEG
demonstrated initially demonstrated muscle artefact but a
subsequent study (on the 14th) revealed intermittent bifrontal
or generalized 4-7hz slowing. LP was performed by IR was notable
for slightly elevated protein at 52, normal glucose, no WBC, 1
RBC, negative HHV6 PCR, and negative HSV 1 and 2 PCR. Gram
stain and culture were obtained. CT from the OSH showed no mass
lesion or hemorrhage, which was confirmed here. His carbatrol
was increased to 800mg q12. He was initially started on
Dilantin, but this was stopped for fear that it was causing a
drug fever. He was subsequently started on Keppra 1000 [**Hospital1 **].
2. ID. He had fevers as high as 102.4 over several days. He was
cultured numerous times and numerous imaging studies were
obtained including chest x-rays and a CT-torso. No infectious
source found initially and thus the dilantin was implicated and
stopped. Subsequently enterococcus grew from a [**7-9**] urine
culture, but was felt to be a contaminant as the UA wa negative
and the number of colonies was low (4000). Also, his leg
wounds, likely sustained at the time of the fall were observed
to be infected. A wound care consult was obtained and they
suggested consulting the plastics service for debridement. They
performed some debridement and ultimately recomended against
antibiotics after suggesting them. Again the CSF did not
demonstrate an infection.
3. RESP: Asthma. Continued on prn nebs and his steroid taper was
continued for asthma exacerbation. The patient was also noted
to desat at night with sleep apnea. Pulmonary was consulted and
will arrange for an outpatient sleep study. Until that time the
patient should be maintained on nocturnal oxygen. He shouldn't
need this during the day.
4.Psych: Confusion. On the second night of admission, he became
acutely confused, requiring restraints and seroquel to keep from
jumping out of bed. He had another episode of confusion on the
8th day of admission, threatening to through his urinal/jug at
the nursing staff. No etiology could be identified despite the
toxic metabolic workup discussed above. An EEG performed on
[**2140-7-15**] was likewise unrevealing regading his aberrant
behaviour. His behavior was controlled with with PRN seroquel.
5. Cardiovascular: Patient was kept on aspirin, atenolol,
lipitor, and quinapril. Nifedipine was restarted prior to
discharge.
6. Anemia: This was present on admission with a HCT of 31.8,
normocytic. Fe studies revealed iron deficiency. He was
started on daily iron. B12 was continued as at home.
7. Back pain: this was controlled with baclofen, ibuprofen and
tylenol. Oxycontin was held.
8. Endo: Insulin sliding scale was maintained intiatlly.
Metformin and avandia restarted several days prior to dishcarge.
9. Contact was maintained with the patient's HCP [**Name (NI) **]:
[**Telephone/Fax (1) 26714**] (H); [**Telephone/Fax (1) 26715**] (W)
Medications on Admission:
Home meds:
Baclofen 10mg [**Hospital1 **]
Theophylline ER 300mg TID
Lipitor 80
Nifedipine 90mg ER daily
Carbatrol SA 300mg q12
Metformin ER 500mg TID
Avandia 8mg daily
Quinapril 40mg daily
Fosamax 10mg daily
Atenolol 25mg daily
Prednisone 10mg daily
Oxycontin 40mg 1-3 times a day PRN
omeprazole 20mg daily
Albuterol inh 2puffs q4
ASA 81
MVI
Calcium
Meds on transfer:
Propofol gtt
Tylenol q6 PRN
Atenolol 25
Baclofen 10mg [**Hospital1 **]
Carbatrol 300mg q12
Enoxaparin 30mg SC daily
RISS
Ativan 2mg IV q1 hr prn
Methylprednisolone 20mg IV q12
Morphine 1-2mg IV q8
PPI
Quinapril 40mg daily
Albuterol 5 puffs inh QID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for T>100.4.
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb treatment Inhalation Q6H (every 6 hours).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-29**]
Drops Ophthalmic PRN (as needed).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO twice a
day: Please use Keppra and not a generic substitute. .
Disp:*120 Tablet(s)* Refills:*2*
9. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Carbatrol - not generic (Carbamazepine 200 mg Cap),
Multiphasic Release 12 hr Sig: Four (4) Cap, Multiphasic Release
12 hr PO twice a day.
Disp:*240 Cap, Multiphasic Release 12 hr(s)* Refills:*2*
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
19. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
21. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
22. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
23. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
24. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
25. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO BID (2 times a day).
26. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
27. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
28. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
29. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Seizures - complex partial seizures.
delerium of uncertain etiology.
Discharge Condition:
Vital signs stable. No fever for greater than 48 hours. No
[**Location (un) **] for 4 days.
MS - Awake, alert, oriented, aware of current events. Speech is
characterized by urgency and nervousness. Nevertheless, he is
fluent and able to communicate effectively.
CN - EOMI, Facial expression symmetrical, facial sensation
intact to light touch.
Motor - decreased Lower extremity strength - chornic -
wheelchair at baseline.
Sensory - intact in the upper extremities.
Reflexes/Cereb/Gait - not tested.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your appointments as documented below.
.
Please note that you have a [**Location (un) 862**] disorder. Return to the
Emergency Room if you should have changes in your mental status,
if you notice having a [**Location (un) 862**], or if you awaken and think that
you may have had a [**Location (un) 862**]. Please take precautions not to hurt
yourself or others. You should not drive until you are [**Location (un) 862**]
free for six months. Don't swim unobserved.
.
Please note that the patient's theophyline and oxycontin were
discontinued.
Followup Instructions:
You have an appointment with your primary care doctor, Dr.
[**Last Name (STitle) 26716**], at 4:30pm [**7-26**], 1-[**Telephone/Fax (1) 26717**].
Completed by:[**2140-7-19**]
|
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|
296, 302
|
12656, 13162
|
3116, 5325
|
13824, 14001
|
2271, 2281
|
9690, 12423
|
12564, 12635
|
9048, 9399
|
13186, 13800
|
2296, 3097
|
233, 258
|
330, 2001
|
2023, 2177
|
2193, 2255
|
9417, 9667
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,451
| 150,121
|
45390
|
Discharge summary
|
report
|
Admission Date: [**2126-9-3**] Discharge Date: [**2126-9-14**]
Date of Birth: [**2044-12-15**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
pericardiocentesis with drain placement
History of Present Illness:
81 year old female with history of atrial fibrillation, AVNRT
s/p ablation, HOCM with marked diastolic dysfunction, AR, MR,
pulmonary hypertension, RCC s/p nephrectomy presenting w/ 3 days
of lightheadedness and palpitations. Reportedly bradycardic to
33 in our ED, however, EP interrogated PM and found that this
was not the case. Shortly after "bradycardic" she was in Afib
w/ [**First Name3 (LF) 5509**] to 133. EP recommended only PO lopressor. Recently
discharged on [**8-27**] after placement of pacemaker on both sotalol
80mg and lopressor 50mg. On the advice of PCP and pharmacist,
lopressor dose was halved b/c of concern of being on two
beta-blockers. Pt has not taken her Sotolol since last night.
Denies chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, syncope or presyncope.
.
However, patient endorses nausea/vomiting/diarrhea following PM
procedure. Unclear if in setting of sotalol versus keflex side
effect after pacer placement. However, in light of HOCM with no
resting gradient, likely that dehydration could have triggered
her afib.
In ED, patient was seen by EP. As per EP fellow, was in afib on
Thurs night (while feeling bad), then converted to sinus Friday
morning. Subsequently in afib since Saturday. Received IV
metoprolol 5mg x1 and PO 25mg Lopressor x1. Rate note
controlled prior to arriving on floor. HR 128 in ED.
On review of systems, she denies any prior history of stroke,
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. Does have
prior TIA. All of the other review of systems were negative.
Past Medical History:
HTN
HOCM-unclear if outflow obstruction
Mod MR, mild AR, cardiac MRI with EF 61%
AVNRT s/p ablation [**1-5**]
pAfib, symptomatic, every few weeks, d/c amio [**3-5**] DLCO, on
coumadin. has PFO on echo
TIA
recurrent syncope with negative w/u
RCC s/p right nephrectomy ([**2098**])
CKD II, baseline 1.1-1.3
hyperparathyroidism s/p parathyroidecomty
macrocytosis - eval by hematology unrevealing --> vitB12 started
despite normal levels
gout
OA
wrist/rib fracture [**1-5**]
diverticulosis
psoriasis behind ear
Social History:
Married. Nonsmoker. Drinks 1-2glasses of hard liquor drink
daily. No illicits. Normally very active, plays tennis 3X/week,
works out with trainer 1X/week, but nothing since 5 weeks prior
to PM placement.
Family History:
father died age 80s with CHF
mother died of diabetic complications
Physical Exam:
Gen: WDWN elderly female 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 no JVD
CV: PMI located in 5th intercostal space, midclavicular line.
irregularly irregular, normal S1, S2. II/VI systolic murmur at
apex, II/VI diastolic murmur heard best at LLSB. No thrills,
lifts. No S3 or S4. No pulsus.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation.
Ext: Trace non-pitting edema to ankles bilatereally. Bilateral
hands with nodules on MMPs/DIPs, non-painful.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2126-9-3**] 10:30AM BLOOD WBC-7.8 RBC-3.53* Hgb-11.8* Hct-35.6*
MCV-101* MCH-33.4* MCHC-33.2 RDW-14.8 Plt Ct-195
[**2126-9-3**] 05:17PM BLOOD WBC-8.3 RBC-3.41* Hgb-11.3* Hct-35.1*
MCV-103* MCH-33.2* MCHC-32.3 RDW-14.7 Plt Ct-193
[**2126-9-4**] 08:10AM BLOOD WBC-7.9 RBC-3.21* Hgb-10.7* Hct-32.8*
MCV-102* MCH-33.3* MCHC-32.5 RDW-15.1 Plt Ct-169
[**2126-9-5**] 05:28AM BLOOD WBC-7.9 RBC-3.07* Hgb-10.4* Hct-31.3*
MCV-102* MCH-33.7* MCHC-33.1 RDW-15.3 Plt Ct-186
[**2126-9-7**] 04:55AM BLOOD WBC-11.8*# RBC-3.04* Hgb-10.3* Hct-31.6*
MCV-104* MCH-34.0* MCHC-32.7 RDW-16.3* Plt Ct-186
[**2126-9-8**] 07:35AM BLOOD WBC-13.5* RBC-2.86* Hgb-9.7* Hct-29.3*
MCV-102* MCH-34.0* MCHC-33.2 RDW-15.6* Plt Ct-197
[**2126-9-9**] 06:25AM BLOOD WBC-10.1 RBC-2.86* Hgb-9.6* Hct-28.7*
MCV-101* MCH-33.6* MCHC-33.4 RDW-15.8* Plt Ct-179
.
[**2126-9-3**] 10:30AM BLOOD PT-26.9* PTT-29.4 INR(PT)-2.6*
[**2126-9-4**] 08:10AM BLOOD PT-29.8* PTT-30.3 INR(PT)-3.0*
[**2126-9-5**] 05:28AM BLOOD PT-36.4* PTT-31.5 INR(PT)-3.8*
[**2126-9-5**] 03:00PM BLOOD PT-22.9* INR(PT)-2.2*
[**2126-9-5**] 09:50PM BLOOD PT-16.7* PTT-25.4 INR(PT)-1.5*
[**2126-9-6**] 04:51AM BLOOD PT-14.1* PTT-24.4 INR(PT)-1.2*
[**2126-9-8**] 07:35AM BLOOD PT-15.0* PTT-35.7* INR(PT)-1.3*
[**2126-9-9**] 06:25AM BLOOD PT-15.8* INR(PT)-1.4*
.
[**2126-9-3**] 10:30AM BLOOD Glucose-188* UreaN-38* Creat-1.6* Na-133
K-4.7 Cl-96 HCO3-25 AnGap-17
[**2126-9-3**] 05:17PM BLOOD Glucose-133* UreaN-36* Creat-1.3* Na-135
K-5.5* Cl-102 HCO3-21* AnGap-18
[**2126-9-4**] 12:50AM BLOOD Na-136 K-4.0 Cl-104
[**2126-9-4**] 08:10AM BLOOD Glucose-130* UreaN-27* Creat-1.1 Na-138
K-4.2 Cl-103 HCO3-25 AnGap-14
[**2126-9-5**] 05:28AM BLOOD Glucose-124* UreaN-26* Creat-1.1 Na-136
K-4.2 Cl-104 HCO3-23 AnGap-13
[**2126-9-6**] 04:51AM BLOOD Glucose-131* UreaN-26* Creat-1.0 Na-138
K-4.5 Cl-104 HCO3-24 AnGap-15
[**2126-9-7**] 04:55AM BLOOD Glucose-121* UreaN-29* Creat-1.3* Na-134
K-4.7 Cl-100 HCO3-24 AnGap-15
[**2126-9-8**] 07:35AM BLOOD Glucose-99 UreaN-24* Creat-1.1 Na-130*
K-4.2 Cl-97 HCO3-24 AnGap-13
[**2126-9-9**] 06:25AM BLOOD Glucose-108* UreaN-23* Creat-1.1 Na-129*
K-4.2 Cl-97 HCO3-25 AnGap-11
.
[**2126-9-3**] 10:30AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0
[**2126-9-3**] 05:17PM BLOOD Calcium-8.8 Phos-4.6* Mg-1.9 Iron-60
[**2126-9-4**] 08:10AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
[**2126-9-5**] 05:28AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.1
[**2126-9-6**] 04:51AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
[**2126-9-7**] 04:55AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.0
[**2126-9-8**] 07:35AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.8
[**2126-9-9**] 06:25AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1
[**2126-9-3**] 05:17PM BLOOD calTIBC-313 VitB12-[**2045**]* Folate-GREATER
TH Ferritn-188* TRF-241
.
[**2126-9-5**] 03:00PM BLOOD T4-10.0
[**2126-9-3**] 10:30AM BLOOD TSH-5.0*
.
[**2126-9-3**] 10:57AM BLOOD Glucose-174* Lactate-3.2* Na-136 K-4.7
Cl-93* calHCO3-25
[**2126-9-4**] 08:14AM BLOOD Lactate-1.6
[**2126-9-3**] 10:57AM BLOOD Hgb-12.3 calcHCT-37
.....
IMAGING
CT chest wo con: [**9-3**] New pericardial effusion new from echo of
[**2126-7-2**]. Echo is recommended. There are small bilateral
pleural effusion. Opacities in the right lower lobe could be
atelectasis; aspiration, or superimposed infection cannot be
totally excluded. There is no evidence of interstitial fibrosis
in baseline study.
.
Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2126-9-4**] 11:08 AM
SPIROMETRY 11:08 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 1.83 2.57 71
FEV1 1.44 1.74 83
MMF 1.39 1.96 71
FEV1/FVC 79 68 116
LUNG VOLUMES 11:08 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 3.62 4.60 79
FRC 1.88 2.78 68
RV 1.32 2.03 65
VC 2.30 2.57 90
IC 1.74 1.83 95
ERV 0.57 0.74 76
RV/TLC 36 44 82
He Mix Time 2.50
DLCO 11:08 AM
Actual Pred %Pred
DSB 9.70 16.42 59
VA(sb) 3.21 4.60 70
HB 10.70
DSB(HB) 10.71 16.42 65
DL/VA 3.33 3.57 93
.
TTE [**9-4**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Diastolic function could not be
assessed. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, posteriorly directed jet of
moderate (2+) mitral regurgitation is seen. There is a moderate
sized pericardial effusion. The effusion appears
circumferential. There is sustained right atrial collapse,
consistent with low filling pressures or early tamponade. There
is right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology.
IMPRESSION: Moderate circumferential pericardial effusion with
compression of right atrium and ventricle. On the sub-costal
images the right ventricular free wall demonstrates diastolic
collapse, suggesting tamponade physiology. Moderate mitral and
mild aortic regurgitation. Pulmonary hypertension Compared with
the prior study (images reviewed) of [**2126-7-4**], pericardial
effusion is new. The degree of mitral regurgitation has
increased. The patient now has a pacemaker/defibrillator.
.
TTE [**9-5**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 60-70%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is moderately dilated. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a large pericardial
effusion. No right atrial or right ventricular diastolic
collapse is seen. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures. There
is significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling.
Compared with the findings of the prior study (images reviewed)
of [**2126-9-4**], the cardiac rhythm is now atrial fibrillation
with a rapid ventricular rate. The pericardial effusion is
unchanged. Significant respirophasic variation of right and left
ventricular filling is again noted, but frank cardiac tamponade
is not evident.
.
TTE [**9-6**]: There is a moderate to large sized pericardial
effusion. No right atrial or right ventricular diastolic
collapse is seen. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling.
Compared with the prior study (images reviewed) of [**2126-9-5**], the
findings are similar.
TTE [**2126-9-9**]: The left atrium and right atrium are normal in
cavity size. The right atrial pressure is indeterminate. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (?#)
appear structurally normal with good leaflet excursion. There is
mild pulmonary artery systolic hypertension. There is a moderate
circumferential pericardial effusion most prominent
inferolateral and inferior to the left ventricle (2.5cm) and
less lateral to the left ventricle (1.7cm) and anterior to the
right atrium (1.2cm). There is minimal (<0.5cm) around the left
ventricular apex and anterior to the right ventricle. There is
significant, accentuated respiratory variation in mitral valve
inflow with mild right atrial diastolic invagination, consistent
with impaired ventricular filling/elevated pericardial pressure.
TTE [**2126-9-10**]: Overall left ventricular systolic function is
normal (LVEF>55%). Initially there was a moderate to large
pericardial effusion seen in apical windows. Pericardiocentesis
needle location in the pericardial space was verified by
injection of agitated saline injection. Following
pericardiocentesis there was virtually no pericardial effusion
left (very small colletion seen adjacent to the superior aspect
of the right atrium).
TTE [**2126-9-11**]: Overall left ventricular systolic function is
normal (LVEF>55%). The mitral valve leaflets are mildly
thickened. There is a small to moderate sized pericardial
effusion. It measures ~.9 cm around the left ventricle and 1.6
cm around the right atrium. There are no echocardiographic signs
of tamponade.
TTE [**2126-9-12**]: Right ventricular chamber size and free wall motion
are normal. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2126-9-11**],
the pericardial effusion is smaller and is now located just
around the right atrium. There is no evidence of tamponade.
Cytology Report PERICARDIAL FLUID Procedure Date of [**2126-9-10**]
REPORT APPROVED DATE: [**2126-9-12**]
SPECIMEN RECEIVED: [**2126-9-11**] [**-1/2860**] PERICARDIAL FLUID
SPECIMEN DESCRIPTION: Received 350ml bloody fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: S/P pacer insert, presents with SOB and new
pericardial effusion.
PREVIOUS SPECIMENS:
[**2113-3-2**] 97-[**Numeric Identifier 96903**] PAP
[**2113-2-27**] 97-[**Numeric Identifier 96904**] URINE
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DIAGNOSIS: Pericardial fluid:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, macrophages and lymphocytes.
INDICATIONS FOR CATHETERIZATION:
Pericardial effusion
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Pericardiocentesis: was performed via the subxyphoid approach,
using an
18 gauge thin-wall needle, a guide wire, and a drainage
catheter.
A 4F sheath was placed into the right femoral artery for
hemodynamic
monitoring.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.61 m2
HEMOGLOBIN: 9.2 gms %
BASELINE POST PERICARDIOCENTESIS
**PRESSURES
RIGHT ATRIUM {a/v/m} 24/27/19 -/-/25
RIGHT VENTRICLE {s/ed} 59/24
PULMONARY ARTERY {s/d/m} 59/27/41
PULMONARY WEDGE {a/v/m} 35/37/33
AORTA {s/d/m} 180/83/121
PERICARDIUM {m} 25 5
**CARDIAC OUTPUT
HEART RATE {beats/min} 69 69
RHYTHM PACED PACED
O2 CONS. IND {ml/min/m2} 125 125
A-V O2 DIFFERENCE {ml/ltr} 48 59
CARD. OP/IND FICK {l/mn/m2} 4.2/2.6 3.4/2.1
**RESISTANCES
SYSTEMIC VASC. RESISTANCE [**2059**]
PULMONARY VASC. RESISTANCE 152
**% SATURATION DATA (NL)
SVC LOW 59
PA MAIN 54 46
AO 92 93
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**PTCA RESULTS
Pericardiocentesis COMMENTS:
Under echo ultrasound guidance, a micropuncture needle was
inserted into
the pericardium. Pericardial position was confirmed with
agitated
saline. A 5F pericardial drain was placed and transduced
waveform
confirmed pericardial waveform. A total of 520cc of pericardial
fluid
was removed. The pericardial drain was sutured in place. Echo
confirmed
near resolution of the effusion.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour6 minutes.
Arterial time = 0 hour56 minutes.
Fluoro time = 4.0 minutes.
IRP dose = 31 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 0 ml
Premedications:
Midazolam 0.5 mg IV
Fentanyl 75 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Lasix 20 mg iv
Nitroglycerin 40-80 mcg/min iv gtt
Lopressor 5 mg iv
Cardiac Cath Supplies Used:
- [**Company **], PERICARDIOSENTISIS SET
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
- MERIT, RIGHT HEART KIT
5FR COOK, MICROPUNCTURE INTRODUCER SET
7FR [**Company **], PULMONARY WEDGE PRESSURE CATHETER
COMMENTS:
1. Resting hemodyamics revealed elevated right and left sided
pressures
with rvedp of 24 mmHg and PCWP of 35 mmHg. There was near
equalization
of pressures consistent with tamponade physiology. There was
moderate
pulmonary hypertension. Pericardial pressure decreased from 25
mmHg to
5mmHg post procedure; however the RA pressure remained 25 mmHg.
There
was severe systemic hypertension.
2. Successful echo guided pericardiocentesis via lateral
approach with
removal of 520 cc of pericardial fluid.
FINAL DIAGNOSIS:
1. Pericardial effusion with equalization of pressures.
2. Successful echo guided pericardiocentesis with removal of
520cc of
fluid and improvement in pericardial pressures
Brief Hospital Course:
81 year old female with history of atrial fibrillation, AVNRT
s/p ablation, HOCM with marked diastolic dysfunction, AR, MR,
pulmonary hypertension, RCC s/p nephrectomy presenting w/ 3 days
of lightheadedness and palpitations found to have A-fib with [**Company 5509**]
that was responsive to Lopressor and Amiodarone.
.
#. A-fib with [**Company 5509**]: pt with h/o Afib now with [**Company 5509**] in context of
dehydration with BPs in high90s/low100s. She was given fluids
to maintain preload, and rate corrected to 70s with Lopressor IV
5mg x3, PO Lopressor 25mg x2, and amiodarone load 600mg x1. Pt
then maintained on Amiodarone 200mg daily, and Lopressor 37.5mg
QID. SBPs corrected themselves to 120s-130s, and patient
remained without CP, SOB throughout entirety of admission. She
was continued on her Coumadin until HD2 when she was noted to
have question of tamponade from pericardial effusion, and INR
was corrected with Vit K for potential procedure. Sotalol was
held given pt's renal failure and unclear etiology of diarrhea.
Diarrhea found to be related to C.difficile infection however
sotalol was still held. Patient had pericardiocentesis with
drain placement. Coumadin will be held at discharge pending
reevaluation of echocardiogram on [**2126-9-16**]. Patient did have
atrial fibrillation with [**Date Range 5509**] while in CCU; however, at discharge
patient had regular rate and rhythm with both A-V pacing and A
sensing and V pacing. Patient discharged on amiodarone 200mg PO
and metoprolol succinate 200mg daily.
.
#. Pericardial effusion: noted on CT thorax done as baseline
assessment of lung tissue prior to starting amiodarone
maintenance. Pt without pulsus and no hemodynamic instability
once rate corrected. [**Hospital1 **]-TID pulsus checks performed daily. No
complaints of SOB, even on deep inspiration. ECHO was done to
further assess ventricular functioning, and patient found to
have ventricular activity suggesting tamponade physiology. As
such, her Coumadin was held and INR corrected for potential
pericardiocentesis, and she was monitored for hemodynamic
stability in CCU. On [**2126-9-10**], with persistence of pericardial
effusion, patient was brought for cardiac catheterization, which
showed tamponade physiology. 520cc of fluid was removed from and
pericardial drain was placed. Drainage continued the following
day with another 550cc of drainage. There was some concern of
possible bleeding into the pericardial sac secondary to
pacemaker lead placement. Procedure was discussed for
manipulation of pacemaker lead; however, after drainage became
serousanguineous, the drain was pulled. Pulsus paradoxus was
check [**Hospital1 **] and were normal. Patient will have follow up
echocardiogram on [**2126-9-16**] for evaluation of any further fluid
accumulation.
.
#. Unclear reaction to amiodarone in past with decrease DLCL on
PFTs ([**2122**]): Baseline CT thorax as described above and PFTs.
pulmonary consulted with repeat PFTS and cleared pt to be on
amiodarone. Pt to follow-up with pulmonology as outpatient.
.
#. Acute on chronic renal failure with hyperkalemia: Cre
baseline 1.2, but elevated at 1.6 on admission. Urine lytes
indicated prerenal etiology. Cre corrected with IVF. Sotalol
was discontinued, Lisinopril and allopurinol were held. Chem
panel was trended. Patient was at baseline creatinine 1.1.
.
#. N/V and diarrhea in context of Sotalol and Keflex: unclear
whether adverse drug reaction or related to antibiotics.
Sotolal discontinued. C.diff positive and pt started on PO
Flagyl 500mg TID (renally dosed) x 14days. Patient did not have
symptoms at discharge.
.
#. HTN: well controlled with beta blockade that was also used
for A-fib [**Year (4 digits) 5509**]. Patient discharged on metoprolol succinate 200mg
daily.
Medications on Admission:
1. Allopurinol 100 mg daily
2. Amlodipine 2.5 mg Tablet [**Hospital1 **]
3. Warfarin 3 mg Tablet daily
4. Omeprazole 20 mg Capsule, Delayed Release daily
5. Cyanocobalamin 2,000 mcg Tablet SR daily
6. Metoprolol Tartrate 50 mg [**Hospital1 **] --> 25mg [**Hospital1 **]
7. Lisinopril 20 mg [**Hospital1 **]
8. Acetaminophen 325 mg Tablet q6PRN
9. Sotolol 80mg daily
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO BID (2 times a day).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*2*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 13 days: continue 14days from [**9-8**] (end [**9-22**]).
Disp:*39 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for chest pain.
Disp:*30 Capsule(s)* Refills:*0*
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Cyanocobalamin (Vitamin B-12) 2,000 mcg Tablet Sustained
Release Sig: One (1) Tablet Sustained Release PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Atrial Fibrillation (s/p pacemeker placement) with rapid
ventricular response
-Pericardial effusion
Secondary:
-HTN
-HOCM-unclear if outflow obstruction
-Mod MR, mild AR, cardiac MRI with EF 61%
-AVNRT s/p ablation [**1-5**]
-pAfib, symptomatic, every few weeks, d/c amio [**3-5**] DLCO, on
coumadin. has PFO on echo
-TIA
-recurrent syncope with negative w/u
-RCC s/p right nephrectomy ([**2098**])
-CKD II, baseline 1.1-1.3
-hyperparathyroidism s/p parathyroidecomty
-macrocytosis - eval by hematology unrevealing --> vitB12
started
despite normal levels
-gout
-OA
-wrist/rib fracture [**1-5**]
-diverticulosis
-psoriasis behind ear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with palpitations and a rapid heart rate that
was causing some dizziness/lightheadedness. In the hospital, we
gave you some medications to control your heart rate, and once
it was normal, you began to feel much better. We did a scan of
your chest while you were here because you were started on a new
medication (Amiodarone), and that scan noted some fluid around
your heart. So we did another scan of your heart (ECHO) and
were concerned about how well your heart was beating with the
fluid around it. For this reason, you were observed and a
decision was made to drain the blood from around your heart. The
drain was removed on [**9-12**] and you have been stable since. You
will need to have an Echocardiogram on Monday and will see Dr.
[**Last Name (STitle) **] on Wednesday to decide if you should restart your
coumadin. Do not take any coumadin until Dr. [**Last Name (STitle) **] tells you
to restart.
The following changes were made to your medications:
1) Sotalol was stopped
2) Decrease Amiodarone to 400mg daily
3) Stop Metoprolol Tartrate four times a day
4) Metoprolol Succinate was started at 200 mg daily
5) Stop taking Diphenhydramine, take Trazadone instead to sleep
at night
6) Start metronidazole until [**9-22**]
You should follow-up with your primary physician, [**Name Initial (NameIs) **]
pulmonologist, and your cardiologist. These appointments are
listed below. If the appointment times will not work for you,
please call to cancel or reschedule your appointments.
Followup Instructions:
Echocardiogram: Monday [**2126-9-16**] at 10AM, on [**Hospital Ward Name 517**]
Directions for Echo: Go to [**Hospital Ward Name 121**] Building Entrance, take the
[**Hospital Ward Name **] elevators to [**Location (un) 470**]. Echo reception desk: [**Telephone/Fax (1) 3312**]
.
Name: [**Last Name (LF) 2204**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: TUESDAY, [**9-10**], 11AM
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 2205**]
Department: CARDIAC SERVICES
When: TUESDAY [**2126-9-24**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**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: WEDNESDAY [**2126-9-18**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2126-10-22**] at 10:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES/ PULMONARY
When: TUESDAY [**2126-10-22**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
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) **] MD [**Doctor First Name 63**]
|
[
"584.9",
"V10.52",
"403.90",
"274.9",
"423.9",
"787.91",
"787.01",
"V45.01",
"745.5",
"276.7",
"427.31",
"396.3",
"416.8",
"425.1",
"V58.61",
"427.89",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
22328, 22334
|
17002, 20799
|
279, 320
|
23023, 23023
|
3882, 13713
|
24714, 26756
|
2884, 2952
|
21215, 22305
|
22355, 23002
|
20825, 21192
|
16804, 16979
|
23174, 24691
|
2967, 3863
|
15500, 16787
|
13746, 15481
|
227, 241
|
348, 2116
|
23038, 23150
|
2138, 2647
|
2663, 2868
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,860
| 124,162
|
4120
|
Discharge summary
|
report
|
Admission Date: [**2183-4-14**] Discharge Date: [**2183-4-16**]
Date of Birth: [**2125-3-19**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Prednisone
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
fever and altered mental status
Major Surgical or Invasive Procedure:
central venous catheter placement
History of Present Illness:
This is a 58 yo woman c MMP including morbid obesity, chronic
resp failure on home O2 Fio2 35 %, ESRD on HD, bedridden. Pt
was sent from [**Hospital1 11851**] NH today for fever and altered mental
status. Pt had been hallucinating and lethargic for the last 2
days . Pt c/o left flank pain which started last night and
worsening SOB.
.
In ED found to be febrile up to 101.4, HR 70- 80 BP 71/56
----160/61 after NS boluses and neo drip.ABG 7.22/48/132 At OSH
a fem A-line was placed, and in the ED at [**Hospital1 18**] a L subclavian
was placed, however, this did not cross midline.
Vanc/Unasyn/Clinda were started. Pt evaluated by surgery in ED
regarding L pannus which was exquisitely tender and
erythematous:no incarcerated hernia, most likely panniculitis.
Pt transfered to MICU d/2 concern of sepsis.
Past Medical History:
1. Hypertension
2. Obesity
3. Chronic obstructive pulmonary disease
4. History of methicillin resistant staphylococcus aureus
pneumonia
5. VRE urinary tract infections
6. ESRD on HD
7. Anemia of chronic disease
8. History of vaginal carcinoma, s/p TAH/BSO
9. Gastroesophageal reflux disease
10. Right heel ulcer with MRSA
11. status post tracheostomy in [**2178-10-10**]
12. Status post percutaneous endoscopic gastrostomy placement
in [**2179-6-9**]
13. Hypothyroidism
14. History of hypercalcemia
15. Status post cholecystectomy
[**93**]. Status post appendectomy
17. Depression
18. History of ARDS
Social History:
The patient was a resident of [**Hospital 18047**] Rehab Facility. Fifty
pack year smoking history, quit 10 years ago.
Family History:
Positive for [**Hospital 499**] cancer
Physical Exam:
T 100.4 HR 91-96 BP 71-160/56-61 Spo2 95% 100% FIO2.
CVP 12
.
GEN:Morbidly oibese lady, speaking trhough trachesostomy tube.
HEENT:trachesotomy in palce , no signs of erythema or exudate
CHEST:decreased BS in both bases, L subclavian line
CV: RRR no m/g/r
ABD: nt, nd except at left pannus which is exquisitely tender to
palpation c mild blanch erythema ?incarcerated hernia.
EXT:R LE heel ulcer granulating well, R tunneled dyalisis
catheter.
NEURO:sensation and mototr grossly nl.
Pertinent Results:
[**2183-4-14**] 10:25AM WBC-12.8* RBC-4.18*# HGB-11.5*# HCT-37.6#
MCV-90 MCH-27.6 MCHC-30.6* RDW-17.2*
[**2183-4-14**] 10:25AM NEUTS-63 BANDS-25* LYMPHS-3* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2183-4-14**] 10:25AM PLT COUNT-318
[**2183-4-14**] 11:04AM LACTATE-2.1*
[**2183-4-14**] 10:25AM GLUCOSE-99 UREA N-53* CREAT-5.1*# SODIUM-137
POTASSIUM-6.1* CHLORIDE-103 TOTAL CO2-17* ANION GAP-23*
[**2183-4-14**] 10:25AM CALCIUM-7.6* PHOSPHATE-7.6*# MAGNESIUM-1.5*
[**2183-4-15**] 05:52AM BLOOD Lactate-3.7*
[**2183-4-15**] 04:54PM BLOOD Glucose-144* Lactate-5.3*
[**2183-4-15**] 10:30PM BLOOD Glucose-467* Lactate-9.8*
[**2183-4-16**] 05:44AM BLOOD Glucose-815* Lactate-15.0*
[**2183-4-16**] 06:47AM BLOOD Glucose-857* Lactate-14.5*
.
[**2183-4-14**] AXR: This study is extremely limited secondary to
positioning and body habitus. From what can be visualized of the
abdomen there is increased density seen over the right
hemipelvis which may represent oral contrast versus bony
abnormality of the right pelvis. Contrast appears to be within
the rectum/sigmoid [**Month/Day/Year 499**]. There are no grossly dilated loops of
small bowel.
.
[**2183-4-14**] Abdominal ultrasound: Survey scans of the upper abdomen
show normal-appearing liver and normal forward flow in the
portal venous system.
The right kidney is seen to be rather small and atrophic. There
is no ascites noted.
Targeted scans of the left lower quadrant in the region of the
pannus demonstrate diffuse cellulitis, but no walled-off fluid
collections. A spot was marked for aspiration for purposes of
culture but no drainable abscess was identified.
CONCLUSION: Findings are consistent with panniculitis with
extensive edema in the left-sided pannus but no evidence of
walled-off fluid collection or abscess.
.
[**2183-4-14**] CXR: Bilateral lung opacities predominantly at lower lung
fields, which are concerning for pneumonia. A PA and lateral
radiograph would be helpful for more complete assessment, when
the patient's condition permits. Similar findings have been seen
on prior radiographs. Although possibly due to recurrent
aspiration pneumonia, a more chronic process such as
bronchoalveolar cell carcinoma cannot be excluded. If infectious
symptoms are absent, or, if this fails to resolve following
antibiotics, CT would be recommended.
Right central venous catheter whose tip is not well visualized.
No pneumothorax is seen.
.
[**2183-4-15**] CT of abdomen/pelvis: 1. Bilateral lower lobe
consolidation.
2. Diffuse subcutaneous tissue edema.
3. Gastric lipoma and numerous small bowel lipomas.
4. No intra-abdominal abscess identified.
5. The patient's fat pannus is incompletely imaged and the
apparent fluid collection seen on the ultrasound exam performed
on the same day is not well visualized on this study.
6. Enhancement in segment IV of the liver along the falciform
ligament with multiple chest wall collaterals is concerning for
SVC obstruction. This could be further evaluated with
contrast-enhanced chest CT.
Brief Hospital Course:
58 yo woman c MMP including morbid obesity, chronic resp failure
on home O2 Fio2 35 %, ESRD on HD, bedridden present c fever,
hypotension and worsening hypoxemia.
.
# Septic shock due to unclear etiology: Pt was given aggressive
IVF initially given sepsis and started on phenylephrine gtt.
Source of infection included the tunneled dialysis line vs.
panniculitis vs. PNA. She had an area of redness and
fluctuance in the LLQ of her pannus that showed a small fluid
collection in the ED. Surgery aspirated small contents and sent
the swab for culture. She was started on broad antibiotics.
Given her sepsis concern for line infection was high aswell and
patient needed to have the dialysis line removed. However she
was hypotensive and on a pressor and attempts to place a
temporary dialysis line were unsuccessful. She continued to
become progressively more hypotensive requiring additional
pressures. Given concern for intraabdominal infectin she
underwent CT scan. GIven her body habitus her full pannus was
not visualized in the CT scanner, however there were no obvious
source of infection in the intrabdominal cavity. Given her
increased pressor requirement family was called and after
discussion with brother goals of care were changed.
.
#Respiratory failure: Pt had bilateral infiltrates on CxR.
Unclear if she had PNA vs. fluid overload. She was given fluids
as part of her sepsis management. She was initially on trach
collar but given worsening hyposemia she was placed on
ventilator for assistance.
.
#Renal failure (acute on chronic): Patient with metabolic
acidosis and hyperkalemia on admission. She was total volume up
and disucssion was initiated with renal regarding CVVH as she
was still on a pressor. Renal service recommended dialysis
however her only dialysis access was the previous line where
there was concern for infection. Attempts to place new
temprorary dialysis catheter were unsuccessful. Given her
worsening sepsis and hemodynamic status further aggressive
measures to obtain access were deferred. Hyperkalemia treated
with insulin/glucose and improved from 6.1 to 4.0.
.
# FEN: Pt on gettting IV fluids. NPO initially.
# Prophylaxis: PPI , sc Heparin, pneumaboots.
# Communication: Health care proxy [**First Name8 (NamePattern2) **] [**Name (NI) **] was in close
communication thruout patient's stay. She was made DNR
initially and given her worsening clinical status goals of care
changed to comfort measures only. Patient was taken off
pressors and expired quickly.
Medications on Admission:
Insulin NPH 16 am and 12 pm
-Neurontin 100 [**Hospital1 **]
-Fosrenol 1500 qd
-Midodrine 10 tid
-Nexium 40
-Zinc
-Colace
-Amphogel 30 tid
-Nephrocaps
-MsO4 PRN
-Lactulose PRN
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Panniculitis
Renal failure
Respiratory failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2183-5-3**]
|
[
"682.2",
"250.40",
"403.91",
"682.6",
"496",
"427.32",
"530.81",
"286.6",
"278.01",
"038.42",
"486",
"276.2",
"585.6",
"518.83",
"785.52",
"995.92",
"707.07",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8355, 8364
|
5576, 8100
|
322, 357
|
8461, 8470
|
2535, 5553
|
8526, 8563
|
1975, 2016
|
8326, 8332
|
8385, 8440
|
8126, 8303
|
8494, 8503
|
2031, 2516
|
251, 284
|
385, 1197
|
1219, 1822
|
1838, 1959
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,676
| 167,303
|
52109
|
Discharge summary
|
report
|
Admission Date: [**2136-10-1**] Discharge Date: [**2136-10-12**]
Service: SURGERY
Allergies:
Penicillins / Aspirin / A.C.E Inhibitors
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
L great toe ulcer and L foot rest pain
Major Surgical or Invasive Procedure:
[**2136-10-2**] Left superficial femoral to peroneal artery bypass with
composite left cephalic and basilic vein and angioscopy.
History of Present Illness:
89 year old female with rest pain in the left foot secondary to
superficial femoral and above-knee popliteal occlusion and
diseased popliteal artery with disconnected runoff through the
distal peroneal artery and no foot vessels. She underwent two
attempts at recanalization of these vessels, both unsuccessful.
She was scheduled for bypass surgery on [**10-10**], but presented to
Dr.[**Name (NI) 5695**] office with worsening pain and a left great toe
ischemic ulcer. She was admitted on [**10-1**] for an earlier
operation.
Past Medical History:
PVD history:
-[**7-19**]: non-healing left great toe ulcer
-[**2135-6-28**]: right great toe ulcer excision, bone biopsy
-[**2135-6-22**]: right above-knee popliteal to DP bypass with NRSVG & R
[**Doctor Last Name **] aneurysm ligation for a critically ischemic right foot
-[**2136-5-8**]: right proximal SFA to DP bypass with L NRSVG c/b
dehiscence of RLE incision on POD7, requiring re-suturing.
1. Hypertension
2. Hyperlipidemia
3. Diabetes complicated by neuropathy
4. Status post total abdominal hysterectomy
5. Coronary artery disease
6. Cardiomyopathy (LVEF 30-35% by echocardiogram [**4-18**])
7. Peptic ulcer disease
8. Gastroesophageal reflux disease
9. Spinal stenosis
10. Cholecystectomy
[**40**]. Hypothyroidism
12. Subacromial bursitis
13. Chronic constipation due to puborectalis dysfunction
14. Arthritis
Social History:
She lives alone in elevator apartment building. Originally from
[**Location (un) 4708**]. She has 5 children. Has an aid to help with cleaning,
cooking etc 5 days/week. She has PT at home twice a week and VNA
services twice a week. She denies smoking, alcohol or drug use.
Family History:
Diabetes in mother. Hypertension in "everyone in the family". No
known history of stroke.
Physical Exam:
95.9 95 164/88 18 93%RA
Gen: NAD, A&O x 3
CVS: RRR, nl S1S2, +SEM RUSB
Pulm: CTA b/l
Abd: soft, NT, ND, +BS
Ext: 3+ pitting edema b/l; LLE with dry ulcer of great toe,
necrotic edges, warm foot
Pulses: LLE warm 2+ fem, [**Name (NI) **] PT & DP; RLE warm, 2+ fem, 2+ DP,
[**Name (NI) **] PT
Pertinent Results:
On admission:
[**2136-10-1**] 05:25PM BLOOD WBC-11.3* RBC-3.77* Hgb-11.2* Hct-33.5*
MCV-89 MCH-29.8 MCHC-33.6 RDW-14.0 Plt Ct-391
[**2136-10-1**] 05:25PM BLOOD PT-12.1 PTT-26.8 INR(PT)-1.0
[**2136-10-1**] 05:25PM BLOOD Glucose-121* UreaN-20 Creat-1.3* Na-141
K-5.2* Cl-100 HCO3-33* AnGap-13
[**2136-10-1**] 05:25PM BLOOD Calcium-9.5 Phos-3.3 Mg-2.2
[**2136-10-1**] 04:43PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2136-10-1**] 04:43PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2136-10-1**] 04:43PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-
WOUND CULTURE (Final [**2136-10-4**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
GRAM NEGATIVE ROD(S).
MODERATE GROWTH OF THREE COLONIAL MORPHOLOGIES.
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
CT HEAD W/O CONTRAST ([**2136-10-4**]): No acute intracranial hemorrhage
or mass effect.
Left foot three views([**2136-10-9**]): 1. Osteomyelitis involving the
distal tuft of the first distal phalanx worse since the previous
study. 2. Nonaggressive appearing periosteal reaction along
the second through
fourth metatarsal shafts, stable.
On discharge:
[**2136-10-9**] 06:33AM BLOOD WBC-10.5 RBC-3.78* Hgb-11.1* Hct-33.8*
MCV-89 MCH-29.3 MCHC-32.8 RDW-14.3 Plt Ct-437
[**2136-10-12**] 05:04AM BLOOD PT-14.4* PTT-129.2* INR(PT)-1.3*
[**2136-10-10**] 06:00AM BLOOD Glucose-115* UreaN-22* Creat-1.1 Na-137
K-4.3 Cl-99 HCO3-32 AnGap-10
[**2136-10-10**] 06:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
Brief Hospital Course:
Patient underwent left superficial femoral to peroneal artery
bypass with composite left cephalic and basilic vein and
angioscopy on [**2136-10-2**]. Intraoperatively, a left atrial
appendage thrombus was found on TEE. In the PACU, she required
sedation secondary to agitation and a nitroglycerin drip to keep
her SBP<170. Vanco, Cipro, and Flagyl were started empirically
for the toe ulcer.
On [**10-3**], she was stable off of the gtt and was transferred to
the VICU. She was arousable, but was not alert and oriented.
Her blood pressure continued to be an issue, rising to SBP 217
overnight. IV lopressor, Lasix, and labetalol were used with
good response. Her standing lopressor dose was changed from 50"
to 50'''. Her standing Lasix dose was then increased from 20'
to 20".
Dr. [**Last Name (STitle) **] was consulted on [**10-4**] regarding the L atrial thrombus.
He recommended anticoagulation when appropriate. Overnight, her
SBP again increased to the 170s. She was wheezing and her CVP
was 17. She was given Lasix, lopressor, and NTG paste to LCW.
Her lopressor dose was increased from 50''' to 75'''. She
continued to be confused and reported visual hallucinations.
On [**10-5**], Neurology was consulted to evaluate for possible
stroke, as she remained confused and had new dysarthria and left
facial droop. A head CT was negative for acute intracranial
hemorrhage or mass effect. Minimization of sedative and
analgesic medication use was recommended, as she had been
receiving morphine and Percocet. Anticoagulation was again
recommended. She was started on a heparin gtt. Haldol and
Zyprexa were were started for confusion/agitation. She
continued to be hypertensive, and her lopressor was increased
from 75''' to 100'''.
On [**10-7**], her mental status was noted to be much clearer.
Tylenol was used for pain with morphine for breakthrough pain.
Her blood pressure again increased to 200s systolic; it
responded to labetalol.
On [**10-9**], patient was made floor status. Lasix was decreased to
QD. She underwent metatarsal PVRs which demonstrated good
waveforms. Podiatry was consulted for her left great toe ulcer.
Foot XR demonstrated osteomyelitis. She was felt to be a poor
operative candidate given her [**Month/Year (2) 1106**] status, and Santyl
ointment with DSD QD and multipodus boots were recommended. She
is to follow up with Dr. [**Last Name (STitle) **] in his office.
Coumadin was started on [**10-10**]. She was deemed stable for
discharge on [**2136-10-11**]. PT evaluated her and recommended rehab.
A bed became available at [**Hospital1 **] on [**2136-10-12**].
Medications on Admission:
simvastatin 20', Cozaar 25', metformin 500", Lasix 20', Colace
100''', Levothyroxine 25 mcg', omeprazole 40', metoprolol 50'
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
11. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Ophthalmic [**Hospital1 **] ().
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-14**]
Drops Ophthalmic PRN (as needed).
14. Atropine 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
15. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
17. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
19. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
20. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
21. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a
day.
22. Morphine 15 mg Tablet Sustained Release Sig: 0.5 Tablet
Sustained Release PO Q6H (every 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
left first toe cellulitis/osteomyelitis, PVD, distal SFA
occlusion s/p left SFA-peroneal bypass with spliced arm vein
Discharge Condition:
good
Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-17**]
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
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? 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:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Please check INR qday and adjust Coumadin accordingly until
therapeutic.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2136-11-15**] 9:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2136-11-15**] 9:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2136-11-15**]
10:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2136-11-15**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 23733**], M.D. Date/Time:[**2136-11-27**] 11:00
Completed by:[**2136-10-12**]
|
[
"585.9",
"707.15",
"250.00",
"440.23",
"425.4",
"272.0",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
8964, 9034
|
4341, 6971
|
287, 418
|
9196, 9203
|
2546, 2546
|
12132, 12849
|
2130, 2221
|
7146, 8941
|
9055, 9175
|
6997, 7123
|
9227, 11626
|
11652, 12109
|
2236, 2527
|
3978, 4318
|
209, 249
|
446, 978
|
2560, 3964
|
1000, 1823
|
1839, 2114
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,902
| 101,588
|
2476
|
Discharge summary
|
report
|
Admission Date: [**2151-10-11**] Discharge Date: [**2151-10-15**]
Date of Birth: [**2075-9-22**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
pre-syncope, chest pain
Major Surgical or Invasive Procedure:
s/p dual chamber pacemaker placement
History of Present Illness:
76 yo female with ESRD, DM2, HTN, hyperlipidemia, diastolic
dysfunction, sarcoidosis presented to ED after waking up this am
with sharp, pleuritic chest pain and dizziness. CP improved with
sl ntg x2 but dizziness persisted. In ED, found to be
hypotensive to sbp 70s initially. However, 1 hour later pt
brady'ed to 30s with associated hypotension to 70's responsive
to 0.5mg atropine followed by dopamine drip to 10 mcg. EP
consulted with plan for possible pacer placement.
.
Pt was chest pain free in sinus brady with sbp to 200's on
dopamine. Dopamine drip weaned down, pt coded and given atropine
and dopamine. Seen by EP who felt it was sinus arrest.
.
ROS: She complained of abdominal pain with associated nausea but
this is baseline for her. Otherwise no CP, SOB, f,c,v.
.
Past Medical History:
ESRD on HD (MWF)
IgA nephropathy
DM2, diet controlled
HTN
hyperlipidemia
HTN
Persantine MIBI [**1-6**] with EF 59%, no defects
Echo [**11-4**] with mild PAH, trivial MR/TR
Sarcoidosis
Diastolic dysfunction
Gastritis
Hiatal hernia
Schatchi ring
Anemia
Glaucoma
Diverticulosis
Appendectomy
Social History:
Lives with husband and daughter
denies tobacco and ETOH
does IADL
Family History:
non-contributory
Physical Exam:
VS: t98.2, p56, 180/90, rr13, 100% 2Lnc
Gen: pleasane, A&Ox3
HEENT: MM dry, poor dentition, JVD to tragus
CVS: brady, regular, [**1-8**] sys murmur
Lungs: diffuse scattered crackles with poor inspiratory effort
Abd: sfot, ND, thin, NT
Ext: no edema, 1+ DP bilaterally, shiny skin
L UE fistula, R femoral line
Neuro: face symmetric, moves all extremities
Pertinent Results:
[**2151-10-11**] 04:15AM WBC-4.5 RBC-3.51* HGB-10.4* HCT-32.8* MCV-93
MCH-29.7 MCHC-31.8 RDW-14.7
[**2151-10-11**] 04:15AM PLT COUNT-324
[**2151-10-11**] 04:15AM NEUTS-60.0 LYMPHS-28.1 MONOS-6.4 EOS-4.5*
BASOS-1.1
[**2151-10-11**] 04:15AM PT-14.7* PTT-90.4* INR(PT)-1.4
.
[**2151-10-11**] 04:15AM GLUCOSE-144* UREA N-41* CREAT-6.1*#
SODIUM-135 POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-32* ANION GAP-17
[**2151-10-11**] 04:15AM CALCIUM-9.9 PHOSPHATE-3.7# MAGNESIUM-2.1
.
[**2151-10-11**] 04:15AM CK(CPK)-23*
[**2151-10-11**] 04:15AM CK-MB-NOT DONE cTropnT-0.14*
[**2151-10-11**] 09:30AM CK(CPK)-25*
[**2151-10-11**] 09:30AM cTropnT-0.13*
[**2151-10-11**] 04:00PM CK(CPK)-46
[**2151-10-11**] 04:00PM CK-MB-NotDone cTropnT-0.17*
.
[**2151-10-11**] 09:30AM ALT(SGPT)-43* AST(SGOT)-65* ALK PHOS-299* TOT
BILI-0.3
.
[**2151-10-11**]: EKG
Probable junctional escape rhythm, rate 34. Since the previous
tracing
of [**2151-9-11**] no P waves are seen. The rhythm appears to be a
junctional escape
rhythm. The Q-T interval is significantly prolonged.
Non-specific ST-T wave
abnormalities are noted.
.
[**2151-10-11**]: CXR
Comparison made to prior study of [**2151-9-11**]. The heart is
enlarged. There are prominent vascular markings. Linear
atelectasis is present in the left retrocardiac region.
.
IMPRESSION: Findings consistent with mild congestive heart
failure.
.
[**2151-10-11**]: TTE
Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal.
3. The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
5. There is mild pulmonary artery systolic hypertension.
6. There is a trivial/physiologic pericardial effusion.
7. Compared with the findings of the prior study of [**2149-11-21**],
there has been
no significant change.
.
[**2151-10-12**]: CXR
PA & LATERAL VIEWS OF THE CHEST: There has been interval
placement of a dual- chamber pacemaker seen overlying the right
upper chest with leads in satisfactory position. The heart is
enlarged. There is slight upper zone vascular redistribution. No
focal infiltrates identified. There is mild blunting of the
posterior costophrenic angles consistent with small pleural
effusions.
.
IMPRESSION: Interval placement of dual-lead pacemaker with leads
in satisfactory position. Slight upper zone redistribution and
small bilateral pleural effusions consistent with mild heart
failure.
.
.
Brief Hospital Course:
1. Rhythm: Pt admitted with symptomatic junctional bradycardia.
Pt evaluated by EP who felt this was an indication for pacer
placement. Pt had an urgent dual chamber pacemaker placed on
HD1. Procedure was complicated by a small groin hematoma, which
remained stable. Pacer site looked fine without signs of
infection. Pt was given vanco for a couple of days after the
procedure.
.
2. CAD: Pt has history of multiple admissions for rule out MI
without any history of MI. No prior cath. Had a MIBI in [**1-6**]
which was unremarkable. Pt was continued on home aspirin. Given
her multiple cardiac risk factors, she was started on bb, [**Last Name (un) **]
(does not tolerate ACE), and statin. Would consider repeat ETT
vs. cath. as an outpatient. Pt remained chest pain free and
hemodynamically stable throughout hospitalization.
.
3. Pump: Clinically, pt appeared euvolemic. Pt had mild CHF on
CXR. Pt was continued on usual hemodialysis schedule which
helped to remove volume.
.
4. [**Name (NI) 5964**] Pt was seen by renal and continued on her usual
hemodialysis schedule. Pt was continued on calcium carbonate.
She was given epo during dialysis. Electrolytes remained within
normal limits.
.
5. Mental status/Home safety: Pt was A&O x 3 during the day. Pt
would sundown in the evening, requiring a sitter. It was noted
by daughter (who flew in from out of state) that here mother
seemed more confused than baseline. We did not notice any acute
change in her mental status during this hospitalization. Pt was
evaluated by PT and OT who felt that pt was safe to return home
with home PT. Pt lives with her husband and her daughter.
6. Gastritis: Pt was continue protonix.
.
7. DM2: Diet controlled in house. Pt was put on SSI while
in-house.
.
8. Coagulopathy: Initially elevated PTT and INR. Most likely lab
error, as repeat labs were normal.
.
9.FEN: Pt was put on diabetic diet. Electrolytes were repleted
as necessary to K 4.0 and Mg 2.0
.
10.FULL CODE
Medications on Admission:
calcium carbonate 1.25g tid
colace [**Hospital1 **]
norvasc qd
folic acid qd
protonix qd
timolol eye drops
cosopt eye drops
asa 325 qd
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Junctional bradycardia s/p pacemaker placement
ESRD
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2151-10-19**] 11:30
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2151-10-21**]
9:45
|
[
"428.30",
"250.00",
"285.9",
"E878.1",
"428.0",
"427.81",
"998.12",
"135",
"272.0",
"403.91",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.95",
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
6757, 6814
|
4613, 6572
|
297, 335
|
6910, 6916
|
1961, 4590
|
7083, 7378
|
1554, 1572
|
6835, 6889
|
6598, 6734
|
6940, 7060
|
1587, 1942
|
234, 259
|
363, 1144
|
1166, 1455
|
1471, 1538
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,116
| 190,106
|
704
|
Discharge summary
|
report
|
Admission Date: [**2176-12-11**] Discharge Date: [**2176-12-16**]
Date of Birth: [**2121-12-5**] Sex: F
Service: MEDICINE
Allergies:
Lithium / Depakote / Neurontin
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
drug overdose, respiratory failure
Major Surgical or Invasive Procedure:
placement of right IJ
History of Present Illness:
55yo woman with psychiatric history and previous suicidal
ideation
presented to ED after being found unresponsive. Likely
overdose on ativan, seroquel and risperdol. On presentation to
the ED,
was unresponsive and unstable [**Company 5249**] 104.8, 148, 16, 88% RA. Glc
was 123.
She was intubated and given charcoal as well as dantrolene for
potential
NMS; NMS was felt to be unlikely given lack of rigidity on exam.
Labs
also significant for increased CK's; hydrated with fluids +
bicarb
for potential rhabdomyolysis.
Past Medical History:
1) schizoaffective disorder
2) bipolar
3) h/o suicide attempts
4) hyperlipidemia
5) TAH, h/o uterine CA
6) l. knee surgery
7) chronic bronchitis
Social History:
smoker 1.5 packs for years
divorced
Family History:
significant for FH of bipolar disorder
Physical Exam:
initially hyperthermic and hemodynamically unstable in ED.
On admission to [**Hospital Unit Name 153**], 98.0, 91, 140/70, 18, 100%
on AC (600 x 18, 0.4, 5)
intubated and sedated
pupils minimally responsie
rrr, no m/r/g
coarse breath sounds bilaterally
soft abdomen
neuro exam limited, but no evidence of rigidity on exam
Pertinent Results:
[**2176-12-11**] 10:49PM TYPE-ART TEMP-37.2 RATES-/15 PO2-161* PCO2-36
PH-7.24* TOTAL CO2-16* BASE XS--11 COMMENTS-QNS TO VRI
[**2176-12-11**] 09:27PM TYPE-ART TEMP-37.2 PO2-506* PCO2-46* PH-7.17*
TOTAL CO2-18* BASE XS--11 INTUBATED-INTUBATED
[**2176-12-11**] 09:27PM freeCa-1.01*
[**2176-12-11**] 09:27PM GLUCOSE-218* LACTATE-2.6* NA+-141 K+-3.6
CL--122*
[**2176-12-11**] 07:35PM URINE HOURS-RANDOM CREAT-183 SODIUM-69
[**2176-12-11**] 07:35PM URINE HOURS-RANDOM
[**2176-12-11**] 07:35PM URINE GR HOLD-HOLD
[**2176-12-11**] 07:35PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2176-12-11**] 07:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2176-12-11**] 07:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2176-12-11**] 07:35PM URINE RBC-[**3-1**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2176-12-11**] 07:35PM URINE AMORPH-MOD
[**2176-12-11**] 07:27PM GLUCOSE-181* LACTATE-3.5* NA+-144 K+-4.6
CL--110 TCO2-23
[**2176-12-11**] 07:25PM UREA N-30* CREAT-2.2*# SODIUM-145
POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-20* ANION GAP-19
[**2176-12-11**] 07:25PM ALT(SGPT)-84* AST(SGOT)-148* LD(LDH)-337*
CK(CPK)-4764* ALK PHOS-71 AMYLASE-40 TOT BILI-0.4
[**2176-12-11**] 07:25PM CK-MB-6 cTropnT-0.07*
[**2176-12-11**] 07:25PM ALBUMIN-4.6 CALCIUM-9.8 PHOSPHATE-0.9*#
MAGNESIUM-2.3 URIC ACID-5.9*
[**2176-12-11**] 07:25PM OSMOLAL-317*
[**2176-12-11**] 07:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2176-12-11**] 07:25PM PLT COUNT-152
[**2176-12-11**] 07:25PM PT-14.4* PTT-25.7 INR(PT)-1.3
[**2176-12-11**] 07:25PM FIBRINOGE-395
ECG: Sinus tachycardia, Modest right ventricular conduction
delay pattern
Diffuse ST-T wave abnormalities with right precordial lead
downslying ST
segment elevation - consider acute injury/ischemia or possible
"Brugada-type ECG" pattern Clinical correlation is suggested
Since previous tracing of [**2176-4-4**], sinus tachycardia and diffuse
ST-T wave abnormalities present
TTE: The left atrium is mildly dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF 60-70%). The
right ventricular cavity is dilated. Right ventricular systolic
function is borderline 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 mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
In ED:
Patient was intubated for airway protection, as she was
unresponsive
secondary to overdose.
Overdose:
she was given charcoal by NG and toxicology
was consulted. She was also given dantrolene due to concern for
NMS.
rhabdomyolysis:
managed with IVF hydration and alkalinization of the urine. She
did have acute renal failure, but FeNa was most consistent with
pre-renal
azotemia, likely secondary to hypotension.
increased anion gap acidosis:
this was likely secondary to both lactic acidosis and uremic
acidosis. Also
had acute respiratory acidosis secondary to hypoventilation.
The metabolic acidosis resolved with hydration, and the
respiratory acidosis resolved after mechanical ventilation.
acute renal failure:
Concern for ATN with rhabdomyolysis, but FeNa consistent
with pre-renal azotemia, secondary to hypotension. This
trended downward with IVF hydration. Potential
rhabdomyolysis was managed with aggressive ivf hydration
with alkalinization of the urine.
ID:
empirically started on levaquin/flagyl in ED with
fever and hypotension. Not continued in ICU; follow up
cultures.
Spiked to 102.2 on [**2176-12-14**]. Cultures sent, CXR with no
frank infiltrate, and central line removed with cath tip sent
for
culture. No empiric antibiotics started - awaiting culture
data.
CV:
Presented with new 2mm ST depression in 2,3,avF as
well as lateral pre-cordial leads. This was likely
a rate-related ischemia as she was tachycardic in the 140's on
presentation. These ST depressions trended back
to baseline with rate decreasing. She did have positive
troponins; felt to be demand ischemia. The EKG changes
resolved, and cardiac enzymes trended down.
Medications on Admission:
seroquel 25mg
risperdol 1mg
lorazepam 1mg
pravachol 10mg
ASA 325
MVI, vit C, folic acid
colace [**Hospital1 **]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
drug overdose
Discharge Condition:
To [**Hospital1 **] 4, resolving rhabdo/CK levels
Discharge Instructions:
1. Please follow up: Blood culture data
2. Please f/u HIT ab as outpt
3. Please follow-up with appointments as below
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2177-1-10**] 3:20
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5250**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5251**] Date/Time:[**2177-1-22**] 10:30
Provider: [**Name Initial (NameIs) **] PAIN MANAGEMENT CENTER Where: PAIN MANAGEMENT
CENTER Date/Time:[**2176-12-16**] 1:30
|
[
"276.2",
"491.9",
"728.88",
"E950.3",
"518.81",
"584.9",
"272.4",
"969.4",
"287.4",
"969.0",
"969.3",
"295.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6192, 6207
|
4343, 6030
|
327, 350
|
6265, 6316
|
1538, 4320
|
6483, 7032
|
1139, 1179
|
6228, 6244
|
6056, 6169
|
6340, 6350
|
1194, 1519
|
6361, 6460
|
253, 289
|
378, 902
|
924, 1070
|
1086, 1123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,347
| 125,606
|
49821
|
Discharge summary
|
report
|
Admission Date: [**2164-3-9**] Discharge Date: [**2164-3-15**]
Service: Trauma
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 4135**] is an 88 year old
female with a past medical history of chronic obstructive
pulmonary disease, hypertension, insulin dependent diabetes
mellitus, history of lung carcinoma, status post lobectomy
who presented to the [**Hospital6 256**] at
approximately 6:30 in the morning on [**2164-3-9**] after
suffering an unwitnessed fall from standing and being found
on the kitchen floor in her home. She had activated a
Medical Bracelet Life Alert and was seen by the emergency
medical services in her home in Southborn [**State 350**]. Her
initial [**Location (un) 2611**] coma scale was 15. She was complaining of
some mild headache and was transported by ambulance to the
[**Hospital6 256**] Emergency Department
with stable vital signs and an intact neurologic event. She
had had an obvious left supraorbital laceration which had
minimal bleeding. After she was initially transported there
was no evidence of hypoxia or hypotension noted. She was
seen by the Neurosurgical Service and thereafter a trauma
consultation was called.
PAST MEDICAL HISTORY: The patient's past medical history is
notable for coronary artery disease, history of hypertension,
history of hypercholesterolemia, history of peripheral
vascular disease, history of Type 2 diabetes, history of
gastroesophageal reflux disease, chronic renal insufficiency
chronic obstructive pulmonary disease, history of
adenocarcinoma of the lung, history of diverticulosis and
history of a small infrarenal stable 3.5 cm abdominal aortic
aneurysm.
PAST SURGICAL HISTORY: Notable for total abdominal
hysterectomy and bilateral salpingo-oophorectomy, history of
prior left lobectomy for adenocarcinoma of the lung in [**2153**].
It is unknown as to whether or not the patient continues to
drink. She had a history of previous tobacco use, greater
than 65 years of one to two packs per day, however, she has
quit since her lung surgery in [**2153**]. She has not imbibed in
any recreational drugs.
ALLERGIES: Penicillin, Phenobarbital and Ibuprofen.
MEDICATIONS ON ADMISSION: Albuterol, Beclomethasone,
Moexipril 15 mg b.i.d., Quinine sulfate 250 mg a day,
Fexofenadine 50 mg a day, Ambien, Cilostazol 200 mg p.o.
q.i.d., Zantac 150 mg q. day, Thiamine, Vitamin C, a full
Aspirin, Colace 100 mg p.o. b.i.d., Norvasc 5 mg p.o. q. day,
Neurontin 100 mg p.o. q.h.s. and Dextromethorphan.
PHYSICAL EXAMINATION: Her admission vital signs on
examination were significant for a temperature of 97.4
rectally, a blood pressure of 148/72 with a heart rate of 70,
respiratory rate 18 and she was sating 96% on 2 liters of
nasal cannula. Her initial examination was notable for [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 2611**] coma scale of 15. She had an obvious 2 cm left
supraorbital laceration with associated ecchymosis. There
was no active bleeding. Her pupils were equal, round and
reactive to light and accommodation, they were 4 to 2 and
brisk bilaterally. Her extraocular movements were intact.
Her tympanic membranes were clear. Her oropharynx was
negative. Her trachea was midline. She had an old
well-healed left neck incision from prior carotid surgery.
Her heart was regular, lungs clear but decreased throughout.
Her chest had no deformities or tenderness. Her abdomen was
soft, nontender, nondistended. There was no pulsatile mass,
no bruit. She had an old lower midline scar that was noted
without any evidence of hernia. Her pelvis was stable. Her
flanks were without any deformity. No costovertebral angle
tenderness. There was no ecchymosis. Her back showed no
deformities, tenderness or stepoff along her thoracolumbar
spine. Her extremities had palpable popliteals and femoral
pulses bilaterally, they were monophasic dorsalis pedis and
posterior tibial pulses on both feet. There were no obvious
skin ulcers.
LABORATORY DATA: Her admission laboratory data were notable
for a white count of 11,000, hematocrit 41, platelet count
303. Chemistries notable for a sodium of 137, potassium 5.2,
chloride 105, bicarbonate 22, BUN and creatinine 56 and 1.1
with a glucose of 194. Her coagulase panel was normal. She
had a urinalysis that was negative. Her toxicology screen,
urine and serum were otherwise unremarkable. Her lactate was
unremarkable. She had a Foley catheter placed by the
Emergency Department Services. She had had a chest x-ray
that was within normal limits. Pelvis film was normal. Her
computerized tomography scan of the cervical spine showed old
degenerative changes, no acute fracture or tissue edema. She
had a fast ultrasound examination within the Emergency
Department that was also normal. She had no evidence of free
fluid in the abdomen. She had had a computerized tomography
scan of the head performed which showed a small right
subdural hematoma, right frontal contusion as well as a left
frontal subarachnoid blood and question of left temporal
region, subarachnoid blood. There was no midline shift and
no collapse of the ventricles. She had had a TLS series
which showed no evidence of thoracolumbar or sacral spinous
process fracture or vertebral body fractures. She was
complaining of left wrist pain, however, the previous failed
to reveal any obvious injury. Bilateral knee films were
performed because of small scraps and cuts over the knees
which showed no evidence of fracture or dislocation.
After Trauma Consultation was called, three hours into her
hospital course in the Emergency Department, evaluation by
the Trauma Service found that her [**Location (un) 2611**] coma scale had
deteriorated 12. She was obviously confused and agitated.
Due to this she required an emergent repeat head computerized
tomography scan which showed no evidence of increased
bleeding or shift of midline structures. Thereafter she was
intubated for airway control. It became immediately obvious
that the patient was going to do somewhat poorly given her
age and multiple comorbidities and traumatic mechanism with a
head bleed.
HOSPITAL COURSE: She was admitted to the Trauma SICU Service
for further management and care. Over the ensuing 24 to 36
hours, the patient required minimal ventilatory support. She
was somewhat awake and following simple commands. She did
have a gag reflex and after approximately 24 hours on the
ventilator and after being evaluated by the Neurosurgical
Service and having had two follow up head computerized
tomography scans showing no significant changes, she was able
to be weaned and extubated without event. However, 24 hours
after her extubation she had increased work of breathing,
tachypnea a high degree of secretions that were somewhat tan
and purulent in nature. She was having a low-grade
temperature and ultimately required reintubation because of
respiratory failure. Over the ensuing three to four days she
required full ventilatory support. She did spike a
temperature intermittently as high as 102.6 and was
pancultured accordingly. She did have sputum that was
growing Staphylococcus aureus confirming likely that she did
have a Staphylococcus pneumonia. It should be noted that the
patient had previously been in a rehabilitation facility for
approximately two to three months during her recovery phase
of the previously treated pneumonia. She was not responding
much to commands. She had been loaded with Dilantin on her
admission and had no evidence of seizure activity. She was
being followed by the Neurosurgical Service who had evaluated
the patient's likelihood of functional recovery which was
minimal.
After prolonged discussions and multiple family meeting with
the health care proxy who is the son as well as the daughter
and two other sons, it was fully understood and decided that
the patient had made strong wishes that she did not want to
be supported on a ventilator. She had actually had a
pre-existing Do-Not-Resuscitate, Do-Not-Intubate order and as
a consequence the family opted to remove her from the
ventilator and to make her comfort-measures-only, knowing
that this was in keeping with the patient's prior known
wishes and legal wishes as in a prior Do-Not-Resuscitate,
Do-Not-Intubate order, as well as knowing that she would not
have a very good functional recovery and would likely acquire
at minimum prolonged ventilatory support with tracheostomy
and enteral feedings through a percutaneous ventral
gastrostomy tube. This was not in standing or compatible
with the patient's previous known wishes and the family was
quite accepting and expecting this for removal of care.
Thereafter, after several family discussions it was
determined that the patient would be removed from the
ventilator and be comfort-measures-only. This was done in
the afternoon of [**2164-3-15**]. She expired at 3:30 PM.
There was no evidence of cardiac or pulmonary activity, no
brain stem reflexes were noted. Her pupils were fixed and
dilated and she was pronounced dead. The medical examiner
did accept this case after hearing that she did have a
traumatic mechanism, so please refer to the final autopsy
results and publication per the medical examiner for further
details to elucidate whether there was any undue harm placed
on this patient or any other mechanism that lead to her
deterioration. The family was present at the bedside and was
quite aware of the outcome.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2164-3-15**] 16:35
T: [**2164-3-15**] 16:54
JOB#: [**Job Number 104118**]
|
[
"496",
"E888.9",
"790.7",
"518.81",
"873.40",
"276.2",
"E849.0",
"432.1",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2191, 2501
|
6150, 9730
|
1683, 2164
|
2524, 6132
|
120, 1183
|
1206, 1659
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,712
| 116,811
|
51568+59358
|
Discharge summary
|
report+addendum
|
Admission Date: [**2151-11-21**] Discharge Date: [**2151-12-2**]
Date of Birth: [**2084-11-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ambien
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
s/p redo sternotomy OPCABGx1 (SVG to PDA) on [**11-22**], MVR (#29
Medtroinc Mosaic), TV repair (#32 CE ring) via right thoracotomy
[**11-23**]
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a 67 year old gentleman who has had
multiple recent hospital admissions for congestive heart
failure. A subsequent work-up revealed severe mitral
regurgitation, severe tricuspid regurgitation, and 90% occlusion
of left main. He was therefore recommended for surgical
correction of his cardiac pathologies.
Past Medical History:
- CHF, EF 20%
- Hyperlipidemia
- Hypertension
- Severe Mitral valve disease.
- Severe Tricuspid valve disease.
- Chronic renal failure.
- Idiopathic thrombocytopenic purpura (ITP).
- Cholestatic jaundice.
- Pancreatic cysts s/p biopsy.
- Renal artery stenosis.
- Bilateral EEA approximately [**2147**].
- Coronary artery bypass graft (CABG) x 5.
- Pulmonary hypertension.
- Left inguinal hernia repair in [**2149**].
- Knee surgery.
- Cardiomyopathy.
- Atrial fibrillation.
- Congestive heart failure.
- Hypothyroidism.
Social History:
He used to drink alcohol excessively, but had his last drink
several months ago. He smoked a half pack to one pack per day
for 15 years until he quit in [**2113**]. He lives with his wife.
.
Family History:
His mother died of a heart attack. His brother died of a heart
attack at age 33. His father died with [**Name (NI) 2481**] disease. Pt's
maternal side of the family has marked hyperlipidemia. He has no
known family history of cancer.
Physical Exam:
On physical exam Mr. [**Name13 (STitle) **] was found to be awake, alert, and
oriented. On auscultation of his lungs, he was found to have
scattered rales. His heart was of regular rate and rhythm. His
sternum was stable and his incision was clean, dry, and intact
with no erythema or drainage. His abdomen was soft, non-tender,
and non-distended. His extremities were warm with no edema.
His lower extremity harvest site was clean and dry.
Pertinent Results:
[**2151-12-2**] 07:40AM BLOOD WBC-8.3# RBC-3.82* Hgb-11.4* Hct-36.5*#
MCV-96 MCH-29.9 MCHC-31.3 RDW-17.9* Plt Ct-195#
[**2151-12-2**] 07:40AM BLOOD Plt Ct-195#
[**2151-12-2**] 07:40AM BLOOD Glucose-76 UreaN-48* Creat-1.8* Na-147*
K-4.1 Cl-109* HCO3-28 AnGap-14
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 67 year old gentleman who has had multiple
recent hospital admissions for congestive heart failure. A
subsequent work-up revealed severe mitral regurgitation, severe
tricuspid regurgitation, and 90% occlusion of left main. He was
therefore recommended for surgical correction of his cardiac
pathologies.
He was taken to the operating room on [**2151-11-22**] with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] for a redo sternotomy and off pump CABGx1. He
tolerated the procedure well and transferred to the surgical
intensive care unit in critical but stable condition. On the
following day on [**2151-11-23**] he underwent the second stage of his
intervention, a mirtal valvereplacement with a #29 [**Company 1543**]
mosaic valve and a tricuspid valve repair with a 32 CE ring via
a right thoracotomy. He tolerated this procedure well and was
transferred in critcal but stable condition to the surgical
intensive care unit.
He was extubated on post-operative day 7 after multiple failed
attempts. He was weaned from his pressors, his chest tubes were
removed. His LFTs were found to be elevated early in his
post-operative course, but these lab values were trending toward
normal by the end of his stay.
By post-operative day 9 he was transferred to the step down
floor. His epicardial wires were removed. Mr. [**Known lastname **] was
ready for discharge to a rehab by post-operative day 10.
Medications on Admission:
protonix 40
toprol XL 25
lisinopril 2.5
lasix 80 TID
digoxin 0.125
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*qs qs* Refills:*0*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed.
Disp:*qs ML(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12414**] Healthcare Center - [**Location (un) 12415**]
Discharge Diagnosis:
CAD, severe mitral regurgitation, severe tricuspid regurgitation
s/p redo sternotomy OPCABGx1, MVR, TV repair
congestive heart failure
hypercholesterol
hypertension
chronic renal failure
ITP
pancreatic cysts
renal artery stenosis
s/p CEA
s/p CABG1984
pulmonary hypertension
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Followup Instructions:
Please see your primary care physician and your cardiologist in
[**1-26**] weeks.
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-28**] weeks. ([**Telephone/Fax (1) 11763**].
Call to make appointments.
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2151-12-22**] 3:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2152-3-7**]
10:20
Completed by:[**2151-12-2**] Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 17451**]
Admission Date: [**2151-11-21**] Discharge Date: [**2151-12-2**]
Date of Birth: [**2084-11-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ambien
Attending:[**First Name3 (LF) 674**]
Addendum:
Medications adjusted after discharge. Please add lasix 20 mg
[**Hospital1 **].
Medications on Admission:
lasix 20mg PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital 12776**] Healthcare Center - [**Location (un) 12777**]
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2151-12-2**]
|
[
"458.29",
"424.0",
"428.0",
"427.31",
"403.90",
"518.5",
"997.1",
"287.31",
"585.9",
"584.9",
"427.89",
"272.0",
"397.0",
"244.9",
"571.5",
"425.4",
"428.40",
"414.01",
"416.0",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"35.33",
"96.6",
"35.23",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7090, 7319
|
2601, 4078
|
295, 441
|
5782, 5789
|
2316, 2578
|
6067, 7022
|
1599, 1835
|
4195, 5348
|
5485, 5761
|
7048, 7067
|
5813, 6044
|
1850, 2297
|
236, 257
|
469, 830
|
852, 1374
|
1390, 1583
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,760
| 154,438
|
30020
|
Discharge summary
|
report
|
Admission Date: [**2181-5-18**] Discharge Date: [**2181-5-23**]
Date of Birth: [**2146-5-14**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6440**]
Chief Complaint:
R flank pain
Major Surgical or Invasive Procedure:
Right PCNL, Right chest tube placement, Right ureteral stent
placement.
History of Present Illness:
35-year-old male who originally
presented with gross hematuria and was found to have a large
approximately 2 cm right-sided upper pole caliceal calculi.
Given the upper pole nature of the stone as well as its size,
percutaneous nephrolithotomy was opted as the best treatment.
The patient did have access placed by interventional
radiology prior to the procedure.
Past Medical History:
GERD
Social History:
Pt smokes a pack a day for the last 18 years. Occasional ETOH
use.
Family History:
n/c
Physical Exam:
on admission:
A&Ox3, NAD
CTAB
RRR
abd soft, mild RUQ and R flank tednerness, ND, +BS
GU: wnl
Pertinent Results:
[**2181-5-18**] 11:45PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-500 KETONE-15 BILIRUBIN-LG UROBILNGN-2* PH-6.5 LEUK-LG
[**2181-5-18**] 09:18PM GLUCOSE-211* UREA N-15 CREAT-1.0 SODIUM-137
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
Brief Hospital Course:
Patient was admitted on [**2181-5-18**] and taken first to IR for R PCNL
access. He then went to the OR for a R PCNL. He had a
noncomplicated operative course until extubation. When the
patient was placed in the supine position in the
anticipation of extubation, he did have desaturation to the
upper 80s and upon auscultation unequal breath sounds were
heard in the right hemithorax with bronchial breath sounds
apparent. A chest x-ray was ordered which revealed a hydro
hemothorax. After consultation with various difficult
attending urologists, it was deemed that a chest tube needed
to be placed to decompress the pleural space. A second x-ray
confirmed correct chest tube placement as well as reinflation of
the lung and significant decrease in pleural fluid. He was then
kept intubated and taken to the PACU and then to the ICU in
stable condition. On POD1 his pulmonary function remained
stable, but his BP decreased into the 80s but responded to
hydration and a brief period of time on pressors. On POD1 he
also underwent removal of the nephrostomy tube and placement of
a ureteral stent. After this he remained hemodynamically stable
and was extubated on POD2 withour complication. His
hydro/hemothorax resolved on follow-up chest x-rays and the
chest tube was set to waterseal on POD 3 and taken out on POD 4.
On POD 3 he was also taken out of [**Hospital Unit Name 153**] to the regular floor.
He remained hemodynamically stable, afebrile, without pain for
the remainder of his stay. On POD 5 he was discharged for home
in stable condition, with a normal chest x-ray, with clear
discharge and follow up instructions. He is to follow up with
Dr.[**Name (NI) 6444**] clinic in 2 weeks for stent removal.
Medications on Admission:
excedrin, viagra
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
take for constipation while taking pain medications.
Disp:*60 Capsule(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain: do not drive
while taking this medication.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
right upper pole renal calculi
Discharge Condition:
good
Discharge Instructions:
Please call your doctor or come to the emergency room if you
notice wound redness, swelling, purulent discharge, have a fever
greater than 101.5, have severe pain not controlled by
medication, have any breathing difficulty or for any other
concerns.
You have steri strips over your chest tube wound. Those will
fall off on their own in about 7-10 days. You can shower with
them then blot dry after. Do not soak in a bath or swimming
pool.
Please resume taking your home medications as prior to your
operation.
Please do not drive when taking narcotic pain medications.
Followup Instructions:
Please call Dr.[**Name (NI) 6444**] office to schedule a follow up
appointment to see him in 2 weeks for stent removal. The phone
number is [**Telephone/Fax (1) 6445**].
Completed by:[**2181-5-23**]
|
[
"511.8",
"518.5",
"596.7",
"995.92",
"592.0",
"593.89",
"276.2",
"997.5",
"593.4",
"998.59",
"998.11",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"87.74",
"55.03",
"59.8",
"57.32",
"96.71",
"34.04",
"55.01"
] |
icd9pcs
|
[
[
[]
]
] |
3482, 3488
|
1331, 3057
|
327, 401
|
3563, 3570
|
1056, 1308
|
4190, 4392
|
923, 928
|
3124, 3459
|
3509, 3542
|
3083, 3101
|
3594, 4167
|
943, 943
|
275, 289
|
429, 794
|
957, 1037
|
816, 822
|
838, 907
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,436
| 130,432
|
45161
|
Discharge summary
|
report
|
Admission Date: [**2130-8-6**] Discharge Date: [**2130-8-31**]
Date of Birth: [**2060-11-1**] Sex: M
Service: MEDICINE
Allergies:
Flomax / Shellfish Derived / Fish Product Derivatives / Zolpidem
/ Ativan
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Back pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 69 yo man with a h/o multiple myeloma who was referred
from HD [**8-5**] with increasing back pain. He was discharged [**8-4**]
from [**Hospital1 18**] with pain well controlled but at rehab they did not
give him any dilaudid. Reportedly he was very histronic at rehab
so they referred him in. He denies any change in the pain and no
additional symptoms. He notes the pain is 0/10 after morphine in
the ED and is requesting it by name vs. dilaudid that he was
discharged on. He is also hungry but those are his only
complaints. Of note documents from [**Location (un) 582**] note dilaudid given
at least once on [**8-4**] and [**8-5**].
In the ED, initial vs were: T 99.5 HR 98 BP: 199/92 RR: 16 Sat:
95%. Initially he was given dilaudid 1mg iv which he did not
think worked, and then was given morphine SR 15mg po then 4mg iv
morphine which helped.
ROS: All other review of systems negative except as noted above.
Past Medical History:
IgA Multiple myeloma s/p 11 cycles velcade/dex
-- received first dose cytoxan on [**2130-7-3**] for disease progression
on velcade, also treated with rituxan
ESRD [**2-27**] to MM - Tu/Th/Sa; has last [**8-5**]
R PICA CVA [**5-27**] - ataxic @ baseline
PAF
PE [**9-2**]
Mild-mod AR
Mod MR
[**Name13 (STitle) **] TR
C. diff
Strep pneumo PNA
PCP PNA
HTN
Hyperlipidemia
Diverticulosis
H. pylori gastritis
Anemia of B12/Fe-deficiencies, CKD
Anxiety and depression
Social History:
Formerly worked at [**Hospital1 **] and [**Hospital6 **].
Married, 3 children. Son is HCP. Wife has [**Name2 (NI) 499**] CA. 20 pack-year
smoking hx. Drinks ETOH socially.
Family History:
Mother and father died of lung CA.
Physical Exam:
T 99.7 HR 107 BP 154/85 RR 20 Sat 96% RA
Gen: Elderly man in NAD
Eye: extra-occlar movements intact, pupils equal round, reactive
to light, sclera anicteric, not injected, no exudates
ENT: mucus membranes moist, no ulceratios or exudates
Neck: no thyromegally, JVD:
Cardiovascular: irregularly irregular and tachycardic, normal
s1, s2, no murmurs, rubs or gallops; HD catheter on right chest
clean, dry, intact, tract non-tender
Respiratory: Clear to auscultation bilaerally, no whezes, rales
or rhonchi anteriorly as unable to roll or sit up
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling.
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, asterixis absent, speech fluent,
DTR's 3+ patellar, babinski down-going bilaterally, strength 4/5
right lower extremity, 4-/5 left lower extremity
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
[**2130-8-6**] 12:07AM GLUCOSE-108* UREA N-19 CREAT-5.3* SODIUM-140
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-26 ANION GAP-23*
[**2130-8-6**] 12:07AM WBC-5.8# RBC-2.86* HGB-9.1* HCT-28.1* MCV-98
MCH-31.8 MCHC-32.4 RDW-19.3*
[**2130-8-6**] 12:07AM NEUTS-82.5* LYMPHS-11.2* MONOS-4.6 EOS-1.4
BASOS-0.3
[**2130-8-6**] 12:07AM PLT COUNT-132*
L spine xray wet read [**8-5**]: no acute fracture.
Brief Hospital Course:
Mr. [**Known lastname 69629**] is a 69 y.o. man with multiple myeloma and ESRD on
[**Known lastname 2286**] who presented with poor pain control. His
hospitalization was complicated by aspiration PNA which
necessitated transfer to the ICU. His hospitalization was
complicated by delirium.
Delirium: Multifactorial: end-stage myeloma, hypercalcemia,
pain, ICU stay, and pain meds. He had been was alert to person
and place prior to ICU transfer. He had a waxing and [**Doctor Last Name 688**]
mental status, that gradually cleared through his
hospitalization. A primary contributor to his mental status was
his elevated calcium, and with treatment of his calcium with
pamidronate and IV steroids, his mental status improved, and he
is now alert and oriented. The likelihood that he will again
become altered was discussed with the family. Currently his
calcium levels have been monitored daily and if they continue to
rise, can be treated with IV pamidronate, which he has received
in the past. On the day of discharge he is A&O x 3, alert and
conversant with a Spanish translator.
Pain control: The patient entered the ICU with poorly controlled
pain resulting from his metastatic multiple myeloma. The pain
consult team evaluated the patient and recommended a regimen.
This included a Fentanyl patch 50 mcg/hr, lidocaine 5% patch 2
patches, Dilaudid 2 mg PO q3 hr PRN and Acetaminophen 650 mg [**Hospital1 **]
ATC. He was then restarted on PO celebrex 100mg [**Hospital1 **]. His pain
currently has improved and is now on a stablized regimen.
Aspiration pneumonia: While in the ICU, the patient developed an
oxygen requirement. Currently on vanco (started [**8-11**]), cefepime
(started [**8-8**]) and flagyl (started [**8-8**]). Has not been febrile.
Antibiotics were discontinued after 5 days. He again developed
an oxygen requirement after several weeks into his
hospitalization. Chest CT revealed a dense RUL pneumonia.
Repeat cultures are negative. Repeat Chest imagine on [**8-28**] shows
progression of consolidation and the patient was empirically
started on Zosyn 2.25mg IV BID and on the day of discharge is on
d3/10. Repeat imaging could be considered after his course is
completed. His respiratory status is stable on 2L O2 by nasal
cannula.
Positive AFB: He was found to have AFB on his sputum culture
from [**7-21**] during his prior hospitalization. He was placed on
respiratory precautions and the ID service was consulted. The
DNA proble from the state returned postive for MAC and negative
of MTb. The possibility of treatment for MAC was considered and
the discussion occurred between the ID service and his
outpatient oncologist, who felt that it was not appropriate at
this time to treat the MAC infection. His respiratory isolation
was discontinued. Addtionally, one more induced sputum was
obtained and the ID team felt that further specimens should be
obtained if treatment would be considered. Furthermore, the ID
team also discussed the option of repeat bronchoscopy with
biopsy, but per the pulmonary service, the pt would need
intubation to perform the bronchoscopy. After discussion with
the pt's son, the decision was to avoid intubation and
bronchoscopy at that time given the risks/benefits of the
procedure.
Atrial fibrillation: The patient had episodes of atrial
fibrillation with RVR while in the unit. He was in NSR for
approximately 2 weeks, but then went back in to AF on [**2130-8-24**].
Chest CT revealed no PE but the pneumonia described above. His
metoprolol was titrated up to 100mg TID. He is not
anticoagulated due to prior discussions regarding risk/benefit
analysis with his family. On discharge, he remained in NSR at
the above dose.
Hypercalcemia: The patient has been receiving daily [**Date Range 13241**]
due to hypercalcemia. IV steroids and Pamidronate were
initiated. His calcium improved with these treatments. The
level was starting to rise again by [**8-24**], and he will need
repeat dosing of pamidronate, possibly as frequently as every 2
weeks. But, pamidronate should be administered when his calcium
level continues to rise.
Multiple myeloma: The patient has been followed by oncology.
Several family meetings were held to discuss the goals of care.
The patient's HCP, [**Name (NI) **] [**Name (NI) **]., has continued to ask for other
options for his father's care. As Mr. [**Known lastname 69629**] [**Last Name (Titles) 48752**] an
improved mental status, he again started to request further
chemotherapy. A meeting was held with the pt's primary
oncologist, his wife, and son who discussed that no further
chemotherapeutic options were appropriate now. They did agree
to continue decadron 20mg daily 4 days/week, every other week.
On discharge he is currently on d3/4 and should restart in 2
weeks.
ESRD on HD - stable. Renagel 800mg PO TID was added to his
regimen.
HTN - The pt was started on amlodipine 5mg PO daily for HTN in
addition to metoprolol 100mg TID
# Communication: Patient, son [**Telephone/Fax (1) 96530**] [**Known firstname **] jr.
Medications on Admission:
per d/c summary, pt unable to verify
Senna 8.6 mg PO BID as needed for constipation
Epoetin Alfa 10,000 unit at HD
Metoprolol Tartrate 100 mg PO three times a day.
Allopurinol 100 mg PO EVERY OTHER DAY
Folic Acid 1 mg PO DAILY
Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY
B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Cyanocobalamin 100 mcg PO DAILY
Fexofenadine 60 mg PO DAILY
Docusate Sodium 100 mg PO BID as needed for constipation.
Renagel 1600 mg PO three times a day.
Pantoprazole 40 mg PO Q24H (every 24 hours).
ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs
every 4-6 hours as needed for shortness of breath or wheezing.
Dilaudid 2 mg PO every four hours as needed for pain.
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical Q24H (every 24 hours):
apply for 12 hours on, 12 hours off, apply to each hip at point
of pain .
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day).
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
5. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
at bedtime as needed for constipation.
14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
15. Celecoxib 100 mg Capsule Sig: One (1) Capsule PO bid ().
16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
17. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
18. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
19. Dexamethasone 4 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily) for 4 days: please give 4 times weekly every other week.
20. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP < 100. Tablet(s)
21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): NTE 4g tylenol daily.
22. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q12H (every 12 hours): To continue for 10
days .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Multiple Myeloma
ESRD on HD
Hypercalcemia
AFB positive BAL
paroxysmal Atrial fibrillation
HTN
Hyperlipidemia
h/o PE in [**9-2**]
Discharge Condition:
Stable, 2L nasal canula
Discharge Instructions:
- Continue to monitor daily calcium levels
- Continue to montior respiratory status, pt needs to be
maintained on 2L NC
- Continue to monitor on telemetry given his paroysmal A fib
Followup Instructions:
- Follow daily calcium levels, had suffered from delirium
worsened by hypercalcemia
- Needs HD on Tuesday, thursday, Saturday
- F/u with oncology with Dr. [**Last Name (STitle) 410**]
|
[
"584.9",
"438.84",
"995.91",
"518.81",
"272.4",
"284.1",
"275.42",
"427.31",
"293.0",
"410.71",
"733.13",
"031.2",
"403.91",
"507.0",
"482.89",
"203.00",
"038.9",
"285.21",
"300.4",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11623, 11694
|
3536, 8596
|
344, 350
|
11867, 11893
|
3119, 3513
|
12123, 12310
|
1995, 2031
|
9381, 11600
|
11715, 11846
|
8622, 9358
|
11917, 12100
|
2046, 3100
|
294, 306
|
378, 1306
|
1328, 1790
|
1806, 1979
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,660
| 191,017
|
49327
|
Discharge summary
|
report
|
Admission Date: [**2134-7-1**] Discharge Date: [**2134-7-5**]
Date of Birth: [**2075-11-27**] Sex: F
Service: MEDICINE
Allergies:
Rofecoxib / Aspirin
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI (per [**Hospital Unit Name 153**] admit note): 58 yo woman with stage IIIb NSCLC
(treated with cisplatin/etoposide x2/XRT/RU lobectomy) most
recently 3 weeks s/p C1 docitaxel ([**6-15**]) w/ dyspnea, fever to
101 at home, fatigue over the past 3 days. She reports slowly
progressive DOE worse over the last 3 days, now with dyspnea at
rest. She feels that she is not able to take a deep breath, that
she is wheezy/tight/breathing through a straw. She feels
improved with albuterol inhaler which she has been using at home
every 5-6 hours (more than usual). She notes worsening cough,
not productive of sputum. She notes intermitent orthopnea and
PND last night only (at time of fever). She denies chest pain,
either exertional or pleuritic. She notes her right arm/shoulder
pain is improved from her [**6-20**] admit. Of note post-lobectomy was
on home O2 2L NC which was stopped on last admit ([**Date range (1) 20648**]).
She further notes feeling very fatigued, with low-grade fevers
and sweats (no chills). Highest temp was 101 this morning
(0200). She notes decreased PO/appetite with 2 lbs weight loss
over the past few days (40 lbs since diagnosis). She notes
baseline migraine HA (normal for her, for which she takes
fioricet) unchanged, sinus pain, sore throat, pain on
swallowing, nausea, vomitting, diarrhea, constipation, melena,
BRBPR, dysuria, vaginal discharge, leg pain, back pain. She
denies recent travel or ill contacts.
In the ED she was 84/61, HR 90, RR 20, 98% on 3L NC, afebrile.
She was given 2L NS, improved to 100/50, HR 80's (not on BB).
She was thought to have ? RUL [**Last Name (LF) 103346**], [**First Name3 (LF) **] given 750mg iv
levofloxacin, 1gm iv vanco, 600mg iv clinda. Her Hem onc fellow
did not want central line and BP stabilized. She was given 25mg
iv benedryl for ? phlebitis in left arm iv (? unclear
precipitant). Lactate 1.1. Random cortisol and blood cultures x2
sent. She was transferred to [**Hospital Unit Name 153**] for further management.
.
On arrival she feels much improved, ROS as above.
She was transferred to the medical floor on [**2134-7-2**]. Upon
arrival, she states she was feeling much better. Her breathing
was easier, though she did note some dyspnea while washing up in
the morning. She continues to have migraine symptoms, she has
some intermittent low back pain for which she's needed
breakthrough medication, but overall she is feeling much
improved.
.
Past Medical History:
ONCOLOGIC HISTORY: Initially presented with dyspnea on exertion
and found on CXR to have mass in the right upper lobe. CT showed
a 2.5 x 1.5 spiculated nodule in the right apex along with
emphysema and mediastinal lymphadenopathy. She underwent a
bronchoscopy, which confirmed non-small cell lung cancer. PET
scan on [**2133-10-8**] confirmed uptake in the spiculated right
upper lobe mass as well as lymphadenopathy in the right
supraclavicular node, peribronchial, mediastinal, and
contralateral mediastinal lymph nodes. Diagnosed with stage IIIB
nonsmall cell lung cancer and treated with two cycles of
cisplatinum and etoposide along with radiation complicated by
persistently low platelet count: completed [**12-2**].
Her cancer responded and she underwent RUL lobectomy [**2134-2-25**].
Pathology showed "very small amount" residual non-small cell
lung cancer as well as 0/4 lymph nodes involved. Follow-up
revealed left supraclavicular adenopathy and repeat PET scan
showed avid LAD in left supraclavicular, axillary and posterior
cervical nodes. Biopsy of her supraclavicular and axillary lymph
node on the left side revealed NSCLC. Taxotere chemotherapy was
started on [**2134-6-15**] for concern that her cancer is causing
lymphatic obstruction in her left axilla. She was admitted
[**Date range (1) 20648**] with back and neck pain, also with SOB, CTA negative,
thought to be [**1-29**] splinting from pain. Scheduled for admit for
taxotere/bronchoscopy [**7-5**].
..
COPD on home O2, Spirometry [**5-3**]: FEV1 1.18 liters (49%
predicted), FVC 2.08 liters (64% predicted), FEV1/FVC ratio
56.72 (77% predicted)
Hypothyroidism after thyroidectomy
CCY
Inguinal hernia
GERD and Barrett's esophagus
HTN
s/p knee cartildge repair
s/p hyesterectomy
ulcerative colitis, on asacol, no active symptoms
Social History:
She lives alone in [**Location 4288**], recently moved from [**Location 3615**]
to be near her brother. She is retired from the department of
Mental Retardation and has been on disability since [**2117**] due to
mental health issues and now cancer. She smoked 2 ppd for 45+
years and quit [**10-2**] though still smokes 10 cigarettes every 2
weeks. She drinks 2 drinks/year and smoked marijuana during her
chemotherapy, not currently.
Family History:
Mother: breast cancer, father: MI, brother: healty
Physical Exam:
Physical Exam on transfer:
Vitals: T 98.4 oral BP 110/83 HR 84 RR 20 Sat 92% RA wt 148.1
Gen: Thin, woman sitting up in bed, non-diaphoretic nad
HEENT: PERRL, EOMI, sclera anicteric, mmm, OP clear
Resp: crackles at bases bilaterally, otherwise clear
CV: sinus, no m/r/g
Abd: +BS, non-tender, non-distended, no masses or HSM
Back: no CVA tenderness, well healed right lateral surgical scar
Ext: no cyanosis, clubbing, edema; no calf tenderness
.
Pertinent Results:
.
Imaging:
portable CXR ([**2134-7-2**])IMPRESSION: PA and lateral chest compared
to [**3-26**] through [**7-1**]:
Left lung is fully expanded and clear. Postoperative right lung
is small and contains a large right suprahilar mass. Appearance
of the lower lung suggest some atelectasis and vascular
congestion but no strong evidence for pneumonia. Heart size
normal. Upper mediastinum shifted to the right contiguous with
apical pleural or extrapleural cap, of longstanding.
Brief Hospital Course:
58 year old woman with stage IIIb NSCLC s/p right upper
lobectomy, XRT, 2 cycles of cisplatinum and etoposide, then 1
cycle taxotere with acute worsening of dyspnea, fever and cough.
Also with anemia, hypertension, chronic pain, hypothyroid,
migraine headaches and depression. Following issues addressed
on this admission:
.
1. Dyspnea: Chronic dyspnea multifactorial including lung
cancer, copd and anemia. Worsened on admit, treated for
pneumonia (initial empiric cocverage with levaquin/vancomycin
until [**7-4**] with return of sputum cx which demonstrated
oropharyngeal flora only. Tailored to levaquin, for 10 day
course. COPD regimen of advair, tiotropium, albuterol nebs
continued. Dyspnea improved throughout course, at baseline on
discharge patient's oxygen saturation was inmid 90's on room
air.
2. Hypotension with history of hypertension: Likely related to
poor po as improved with 2L IVF and stable throughout although
noted history of hypertension on two agents.. No further
episodes of hypotension following IVF. Orthostatic on [**7-4**],
given one unit of prbc's and further ivf's. BP meds (lisinopril
and nifedipine held as of [**7-4**]). Patient remained normotensive
for the remainder of her stay and should follow up with her PCP
regarding reinitiating antihypertensive meds.
.
3.Fever: pulmonary infection possible vs drug fever.
Defervesced on vanc/levo as of [**7-4**]. Vanc d/ced on [**7-4**]. To
complete course of levaquin.
.
4 Anemia: Likely chemotherapy/malignancy related;hemolysis
indices negative. Given one unit pRBC's [**7-4**].
.
5. COPD: advair, tiotropium, albuterol, antibiotics as above.
.
6 NSCLC: Was to start C2D1 of taxotere [**7-5**], hem onc aware,
deferred at this time. She will follow up with oncology on
[**7-14**].
7. Right shoulder pain: ? hypersensitivity [**1-29**] taxotere,
improved significantly since last admit. Continued fentanyl
patch, held on lidocaine patch as currently well controlled and
can not continue this at home, continued neurontin.
.
8. back pain: continued fentanyl, oxycodone prn for
breakthrough
.
9. GERD: coontinued [**Hospital1 **] ppi per home regimen.
.
10. Hypothyroid: Continued home levothyroxine dose.
11. Depression: continued home venlafaxine with ativan prn.
.
12 Ulcerative colitis: no active symptoms, continued home
asacol.
.
.
13. Coagulopathy: Elevated PTT/PT/INR at admission, now normal
following one dose of vitamin K, continue to monitor
.
14 Migraine HA: continued home fioricet.
.
Medications on Admission:
Levothyroxine 150 mcg PO DAILY
Fluticasone-Salmeterol 500-50 mcg [**Hospital1 **]
Albuterol 90 mcg 1-2 Puffs Q6H prn->taking q5-6
Lorazepam 1 mg Tablet Q8H as needed for anxiety
Lisinopril 20 mg PO DAILY
Gabapentin 100 mg PO Q8H
Pantoprazole 40 mg PO Q12H
Acetaminophen 325 mg [**12-29**] PO Q6H as needed
Nifedipine 60 mg SR PO DAILY
Venlafaxine 150 mgSR PO DAILY
Butalbital-Acetaminophen-Caff 50-325-40 mg 2 PO Q4H
Fentanyl 50 mcg/hr Patch 72 hr
Oxycodone 5 mg 1-2 Tablets PO q4-6
Asacol 800mg po bid->recently changed from tid
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-29**]
Tablets PO Q4H (every 4 hours) as needed for head ache.
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days days: take one tablet daily.
Disp:*8 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
11. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
14. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing/dyspnea.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Respiratory failure
Pneumonia
non-small cell lung cancer
Discharge Condition:
good
Discharge Instructions:
Patient instructed to continue on the Levofloxacin for 8 more
days for a total of 10 days of treatment. She should return to
the ER if she develops worsening shortness of breath, cough,
fevers.
Followup Instructions:
Patient will follow up with oncology here for further
chemotherapy and reevaluation on [**7-14**].
|
[
"530.81",
"518.81",
"196.3",
"286.9",
"556.9",
"162.3",
"486",
"724.5",
"496",
"285.29",
"719.46",
"346.90",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11082, 11140
|
6087, 8585
|
287, 293
|
11241, 11248
|
5584, 6064
|
11491, 11593
|
5050, 5102
|
9165, 11059
|
11161, 11220
|
8611, 9142
|
11272, 11468
|
5117, 5565
|
240, 249
|
321, 2754
|
2776, 4581
|
4598, 5034
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,690
| 123,760
|
49770
|
Discharge summary
|
report
|
Admission Date: [**2105-7-13**] Discharge Date: [**2105-7-22**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F with h/o diverticultis, PVD presents with LLQ pain,
nausea, and leukocytosis. The patient states that her symptoms
started over one week prior at her nursing home where she lives.
She says that she developed acute episode of diarrhea, which
precipitated the pain. The patient says that she had fevers as
high as 103 around that time. She says that they began treating
her for diverticulitis with ABX, however, the pain continued.
She was given opioids which provided temporary relief. The
patient endorses nausea but no vomiting. She has no appetite due
to the pain. The patient states that she has a h/o constipation
and that she hasn't had a bowel movement in [**3-19**] days. The
patient denies hematochezia or melena. No recent travel or food
exposures.
Of note, the patient says that she never had a colonoscopy
before because she has a h/o "twisted intestine."
In the ED, the patient had a CT abdomen that showed distal
colitis. The patient was started on cipro and flagyl and given
analgesia with good effect. Also on the CT, a 4cm pseudoaneurysm
was seen at the take-off of the aortofemoral bypass on the left.
Vascular was consulted and said not an acute issue.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
lactose intolerance, cholecystectomy, hysterectomy, aortic
aneurysm
repair, peripheral vascular disease, aortofemoral bypass
Social History:
The patient has lived at nursing facility x 1.5 years. She has a
son who lives in [**Name (NI) **] and a daughter who lives in [**Name (NI) 620**].
Family History:
nc
Physical Exam:
ON ADMISSION:
VITALS: 98.6, 146/56, 80, 16, 96% RA
GENERAL: NAD, appropriate
HEENT: PERRL, EOMI
LUNGS: CTAB listened anteriorlly
HEART: RRR, normal S1 S2, 2/6 systolic murmur at RUSB
ABDOMEN: Soft, exquisitely TTP in LLQ, can palpate firm mass in
LLQ, decreased bowel sounds, + guarding, no rebound. Patient
also has pulsatile mass in RLQ at site of pseudoaneurysm. +
bruit
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
ON DISCHARGE
VITALS: T 97.5 BP 160/64 HR 72 RR 18 O2 98 on RA
GENERAL: NAD, appropriate
HEENT: PERRL, EOMI
LUNGS: CTAB listened anteriorlly
HEART: RRR, normal S1 S2, 2/6 systolic murmur at RUSB
ABDOMEN: soft, some tendernes in LLQ on paplation. no rebound,
no guarding, no peritoneal sounds. Palpable pulsating mass in
RLQ. Normal BS
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3
Pertinent Results:
ON ADMISSION
[**2105-7-13**] 09:05PM URINE HOURS-RANDOM
[**2105-7-13**] 09:05PM URINE UHOLD-HOLD
[**2105-7-13**] 09:05PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2105-7-13**] 09:05PM URINE RBC-0 WBC-2 BACTERIA-MOD YEAST-NONE
EPI-0
[**2105-7-13**] 09:05PM URINE MUCOUS-RARE
[**2105-7-13**] 05:15PM GLUCOSE-103* UREA N-41* CREAT-1.4*
SODIUM-131* POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-19* ANION
GAP-16
[**2105-7-13**] 05:15PM estGFR-Using this
[**2105-7-13**] 05:15PM ALT(SGPT)-13 AST(SGOT)-18 ALK PHOS-110* TOT
BILI-0.5
[**2105-7-13**] 05:15PM LIPASE-14
[**2105-7-13**] 05:15PM ALBUMIN-2.8* CALCIUM-8.7 PHOSPHATE-4.7*
MAGNESIUM-1.6
[**2105-7-13**] 05:15PM WBC-17.5*# RBC-3.82* HGB-11.2* HCT-32.9*
MCV-86 MCH-29.5 MCHC-34.2 RDW-14.9
[**2105-7-13**] 05:15PM NEUTS-81.6* LYMPHS-9.4* MONOS-8.1 EOS-0.5
BASOS-0.3
[**2105-7-13**] 05:15PM PLT COUNT-212
ON DISCHARGE:
[**2105-7-22**] 08:00AM BLOOD WBC-10.0 RBC-3.21* Hgb-9.2* Hct-27.4*
MCV-85 MCH-28.6 MCHC-33.5 RDW-17.0* Plt Ct-387
[**2105-7-22**] 08:00AM BLOOD Glucose-107* UreaN-8 Creat-0.7 Na-141
K-4.2 Cl-111* HCO3-25 AnGap-9
Brief Hospital Course:
This is a [**Age over 90 **] yo female with a history of diverticulitis and PVD
who presents with LLQ pain, fevers, and leukocytosis concerning
for infection v ischemic colitis.
# Distal Colitis: She presented with exquisite tenderness in her
lower left quadrant and a history of no bowel movements for [**3-19**]
days. A CT abdomen was performed that showed distal colitis. The
CT exam on [**2105-7-13**] showed decreased flow through the superior
mesenteric artery. The differential included infectious vs.
ischemic colitis. She was started on cirpofloxacin IV and flagyl
IV. After arriving to the floor, the patient's blood pressure
dropped to 60s systolic and the patient was transferred to the
MICU. She did not require pressors as her BP responded to IV
fluids. Her lactate was within normal limits and continued to be
normal on 2 additional tests on [**2105-7-14**], arguing against
ischemic colitis. She also began moving her bowels there and was
guaiac negative. She was transferred back to the floor once her
blood pressures stabilized.
On the floor, the patient's pain continued to improve. On [**2105-7-19**]
she was switched to cipro PO and flagyl PO and the intravenous
antibiotics were discontinued. The patient's diet was advanced
slowly to the point where she was eating a regular diet by
[**2105-7-21**]. However She continues to have pain in her lower left
quadrant, but this has been consistently improving. On [**2105-7-21**],
an abdominal X-ray was performed which did not show any signs of
obstruction or free air
#alternating diarrhea/constipation. The patient had alternating
diarrhea and constipation, likely due to a combination of
resolving colitis vs. chronic history of IBS. This was managed
with loperamide and a bowel regimine, respectively. On the day
of discharge, the patient had 2 episodes of diarrhea.
#LLQ pain. secondary to colitis. ? additional components of IBS
and/or constipation. She received opiate analgesics on the day
of admission, but since then she was managed well with Tylenol
1000 mg PO Q8H standing. Tramadol 25 mg QHS:PRN pain was not
used during this admission but was added to her discharge orders
since she has used it in the past to manage pain. Tyelonol usage
can be decreased as her pain improves.
# [**Last Name (un) **]: On admission, her Cr was elevated to 1.4 from a baseline
<1. This improved with IVF and so was thought to be pre-renal.
On discharge her Cr was 0.7.
# Pseudoaneurysm: The CT of her abdomen during her initial
workup showed a 4cm pseudoaneurysm was seen at the take-off of
the aortofemoral bypass on the left. Vascular was consulted and
said not an acute issue, but would be happy to see her as an
outpatient. She is scheduled for a follow up appointment.
# Anemia: On admission, her Hct was 32 and trended down to the
25-26 level. It was suspected that the initial [**Location (un) 1131**] was due
to hemoconcentration as her records show a Hct range from 25-29.
On discharge her Hct was 27.4. There were no signs of hemolysis
in her lab work and her stools were guaiac negative.
#Depression: The patient endorses depression without SI and HI.
There were no acute issues but this should be followed up by her
primary care physician.
# HTN
Patient's antihypertensives were discontinued given concern for
ischemic colitis with goal SBPs 140-160. This should be
monitored upon discharge and antihypertensives resumed as
appropriate.
TRANSITION OF CARE
- HTN: monitor BP and resume antihypertensives as needed
- COLITIS: scheduled to complete cipro/flagyl on [**2105-7-27**]
Medications on Admission:
1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
2. Acetaminophen 650 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain/fever
4. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP HS
swish/spit
5. cyanocobalamin (vitamin B-12) *NF* 1,000 mcg/mL Injection
q28days
6. Loperamide 2 mg PO Q6H PRN diarrhea
7. starch *NF* 1 app Rectal [**Hospital1 **]
per rectal hemorrhoidal pain
8. Cholestyramine 4 gm PO DAILY
9. Amlodipine 10 mg PO HS
10. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
12. Creon *NF* (lipase-protease-amylase) 1 tab Oral TID
Creon 6
13. Lactinex *NF* (lactobacillus acidoph & bulgar) 1 tab Oral
[**Hospital1 **]
14. Nitroglycerin SL 0.4 mg SL PRN chest pain/angina
15. Tiotropium Bromide 1 CAP IH DAILY
16. Hydrochlorothiazide 25 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO DAILY
18. Artificial Tears 1 DROP BOTH EYES [**Hospital1 **] PRN dry eyes
19. HydrALAzine 50 mg PO BID
20. Multivitamins 1 TAB PO DAILY
21. Ondansetron 4 mg PO Q8H:PRN nausea
22. TraMADOL (Ultram) 25 mg PO DAILY AT 20:00
23. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H PRN GI
distress
24. Lactaid *NF* (lactase) 3,000 unit Oral at 0800 and 1700
25. Milk of Magnesia 30 mL PO DAILY PRN constipation
26. Lorazepam 0.5 mg PO Q6H:PRN anxiety
27. Clindamycin 600 mg PO DENTAL PROPHYLAXIS
for dental procedures
28. Polyethylene Glycol 17 g PO MONDAY, WEDNESDAY, FRIDAY AT
0830 PRN constipation
29. Docusate Sodium 100 mg PO DAILY
Monday, Wednesday, Friday only
30. calcium polycarbophil *NF* 625 mg Oral [**Hospital1 **]
31. Pantoprazole 20 mg PO Q12H
32. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
2. Artificial Tears 1 DROP BOTH EYES [**Hospital1 **] PRN dry eyes
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
5. Lorazepam 0.25 mg PO Q6H:PRN anxiety
6. Ondansetron 4 mg PO TID W/MEALS
please give before meals
7. Pantoprazole 40 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
10. Tiotropium Bromide 1 CAP IH DAILY
11. Ciprofloxacin HCl 500 mg PO Q12H
12. Creon *NF* (lipase-protease-amylase) 1 tab Oral TID
Creon 6
13. Clindamycin 600 mg PO DENTAL PROPHYLAXIS
for dental procedures
14. calcium polycarbophil *NF* 625 mg Oral [**Hospital1 **]
15. cyanocobalamin (vitamin B-12) *NF* 1,000 mcg/mL Injection
q28days
16. Lactaid *NF* (lactase) 3,000 unit Oral at 0800 and 1700
17. Lactinex *NF* (lactobacillus acidoph & bulgar) 1 tab Oral
[**Hospital1 **]
18. Loperamide 2 mg PO Q6H PRN diarrhea
19. Nitroglycerin SL 0.4 mg SL PRN chest pain/angina
20. Sodium Fluoride 1.1% (Dental Gel) 1 Appl TP HS
swish/spit
21. starch *NF* 1 app Rectal [**Hospital1 **]
per rectal hemorrhoidal pain
22. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
23. Multivitamins 1 TAB PO DAILY
24. Docusate Sodium 100 mg PO DAILY
Monday, Wednesday, Friday only
25. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
hold for confusion, somnolence, dizziness.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital for abdominal pain. You were
noted to have inflammation in your colon that was likely due to
a combination of low blood flow to your gut and an infection.
While you were here your blood pressure dropped very low and you
had to be monitored in the intensive care unit for some time.
Your blood pressure improved with fluid and with stopping your
blood pressure medications. We were initially concerned that
you were going to need surgery, but we were able to manage your
condition conservatively. You developed some diarrhea, which we
treated with loperamide, and you improved. We advanced your diet
slowly and now you are taking in a regular diet without nausea
or discomfort. On discharge, you continue to have some pain in
your lower left abdomen which is likely due to the resolving
infection in your colon, for which you will need to continue
taking antibiotics. Your primary doctor can restart your
antihypertensive medications in the future if your blood
pressures continue to remain stable. Your pain has been
controlled well with tylenol. Please decrease the amount of
tylenol you use as your pain decreases. We have added back your
home dose of Tramadol which you can take as well for pain.
MEDICATION CHANGES
-START ciprofloxacin
-START metronidazole
-STOP HydrALAzine
-STOP Amlodipine
-STOP Metoprolol
-STOP Hydrochlorothiazide
-STOP oxcodone
-STOP cholestyramine
-STOP milk of magnesia
-STOP Aluminum-Magnesium Hydrox.-Simethicone
Followup Instructions:
You will be evaluated by your primary care doctor upon return to
[**Hospital 100**] Rehab.
Department: GASTROENTEROLOGY
When: FRIDAY [**2105-7-24**] at 12:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 1391**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]
Department: Vascular Surgery
Address: [**Doctor First Name **] STE 5C, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1393**]
Appointment: Thursday [**2105-8-5**] 10:15am
Completed by:[**2105-8-4**]
|
[
"414.01",
"412",
"285.9",
"458.9",
"311",
"442.3",
"558.9",
"401.9",
"584.9",
"530.81",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10686, 10751
|
3939, 7504
|
234, 241
|
10803, 10803
|
2796, 3688
|
12518, 13331
|
1967, 1971
|
9249, 10663
|
10772, 10782
|
7530, 9226
|
10979, 12495
|
1986, 1986
|
3702, 3916
|
1483, 1637
|
179, 196
|
269, 1464
|
2000, 2777
|
10818, 10955
|
1659, 1786
|
1802, 1951
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,011
| 192,327
|
10115
|
Discharge summary
|
report
|
Admission Date: [**2166-2-12**] Discharge Date: [**2166-2-22**]
Date of Birth: [**2103-2-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Percodan / Morphine / Demerol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2166-2-12**] - Mitral Valve Replacement (27mm St. [**Male First Name (un) 923**] Mechanical
Valve)
History of Present Illness:
62 year old female with hypertension and hyperlipidemia,
congestive heart failure, DM who had an NSTEMI in [**2163**], now with
increasing shortness of breath. The patient was seen on [**12-3**] [**2165**] with complaints of right-sided chest pain. A chest
x-ray revealed right middle lobe pneumonia. On [**12-4**]
patient had an echocardiogram which revealed evidence of
moderate to severe mitral stenosis with a peak gradient of 32.0
mmHg. Patient states she has been very short of breath with
exertion for the past couple of months. Upon lying down to go to
bed she will experience shortness of breath and keeps a fan by
her bed to help her breath. She has a hospital bed and sleeps
with her HOB raised or will sleep on a chair. She has been
feeling palpitations or what she thinks are skipped beats and
constant fatigue and takes multiple naps on a daily
basis. She is referred for surgical consultation.
Past Medical History:
1) Hypertension
2) Hyperlipidemia
3) Diabetes (non-insulin dependent)
4) Anxiety disorder
5) S/P TAHBSO
6) Seasonal allergies
7) Mitral valve prolapse
8) S/P right foot surgery x 2 for osteomyletis
9) cholecystectomy
[**65**]) Rheumatic fever as a child
11) obesity
Social History:
Pt is a retired nurse. She lives with her husband. Pt has a
significant smoking history but quit smoking two years ago. She
denies any history of alcohol or drug abuse.
Family History:
Father had extensive cardiac history. Pt denies any history of
sudden death or premature cardiac disease in her family.
Physical Exam:
Admission Physical Exam:
Pulse: 74 Resp: O2 sat: 95%
B/P Right: 135/56 Left: 146/70
Height: 5'[**65**]" Weight: 255 lbs
General:obese,NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- 2/6 SEM, faint diastolic
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+, no HSM/CVA tenderness; healed midline scar
Extremities: Warm [x], well-perfused [x] Edema -none
Varicosities: BLE
Neuro: Grossly intact;MAE [**4-29**] strengths;nonfocal exam
Pulses:
Femoral Right:2+ Left:1+
DP Right: NP Left:NP
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit Right:none Left:? radiating murmur
Pertinent Results:
[**2166-2-12**] ECHO: Prebypass: The left atrium is dilated. No
mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Regional left ventricular wall motion is normal. There
is mild global left ventricular hypokinesis (LVEF = 50 %).
Overall left ventricular systolic function is mildly depressed
(LVEF= 50 %). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] 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 but aortic stenosis is not present. Moderate (2+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. The mitral valve shows characteristic
rheumatic deformity. There is moderate valvular mitral stenosis
(area 1.0-1.5cm2). Moderate to severe (3+) mitral regurgitation
is seen. Moderate [2+] tricuspid regurgitation is seen. There is
a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results on [**2166-2-12**] at 1000am.
Post bypass: Patient is A paced and receiving an infusion of
phenylephrine. Biventricular systolic function is unchanged.
Mechanical valve seen in the mitral position. It appears to be
well seated and the leaflets move well. Washing jets typical for
this type of valve seen. 2+ aortic insufficiency persists. Aorta
is intact post decannulation.
Poor transgastric views throughout the case.
[**2166-2-20**] CXR: Compared to the prior study, the size of the right
pleural effusion has decreased. There are bands of linear
density at the base of the right lung consistent with
atelectasis. Left lung is grossly clear. Heart and mediastinum
are not enlarged.
[**2166-2-22**] 05:00AM BLOOD WBC-9.6 RBC-4.07* Hgb-10.9* Hct-32.7*
MCV-80* MCH-26.8* MCHC-33.4 RDW-15.2 Plt Ct-476*
[**2166-2-22**] 05:00AM BLOOD PT-27.9* PTT-123.2* INR(PT)-2.7*
[**2166-2-22**] 05:00AM BLOOD Glucose-121* UreaN-27* Creat-1.2* Na-136
K-4.1 Cl-99 HCO3-23 AnGap-18
[**2166-2-18**] 03:00AM BLOOD Calcium-9.2 Phos-5.1* Mg-2.2
[**2166-2-12**] 02:16PM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
Mrs. [**Known lastname 33799**] was admitted to the [**Hospital1 18**] on [**2166-2-11**] for surgical
management of her mitral valve disease. She was taken to the
operating room where she underwent a mitral valve replacement
using a 27mm St. [**Male First Name (un) 923**] Mechanical valve. Cardiopulmonary Bypass
time= 80 minutes. Cross Clamp time= 63 minutes. Please see
operative note for details. She tolerated the procedure well and
was taken to the intensive care unit for monitoring. She later
awoke neurologically intact and was extubated without
difficulty. All lines and drains were discontinued in a timely
fashion. Beta-blocker/Statin/Aspirin and diuresis were
initiated. On postoperative day one, she was transferred to the
step down unit for further monitoring. Anticoagulation with
Coumadin was started for her mechanical mitral valve. She was
maintained on a Heparin drip until she was therapeutic on
Coumadin.
She will be followed for Coumadin dosing by Dr [**Last Name (STitle) **] and
first INR draw will be Monday [**2-24**] with INR goal 2.5-3.5 for
mechanical mitral valve. She was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for evaluation of her postoperative strength and mobility. The
remainder of her postoperative course was essentially
uneventful. She continued to progress and on POD #11 she was
discharged to home. All f/u visits were advised.
Medications on Admission:
ALPRAZOLAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet s) by mouth three times a day as needed
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 40 mg
Tablet - one Tablet(s) by mouth daily
BUPROPION HCL [WELLBUTRIN SR] - (Prescribed by Other Provider)
- 150 mg Tablet Sustained Release - 1 Tablet(s) by mouth twice a
day
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - 1,000 mcg/mL Solution - one monthly
DIPHENHYDRAMINE HCL - (Prescribed by Other Provider) - 25 mg
Capsule - one Capsule(s) by mouth daily as needed
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - (Prescribed by Other
Provider) - 145 mg Tablet - 1 Tablet(s) by mouth qam
FEXOFENADINE - (Prescribed by Other Provider) - 180 mg Tablet -
1 Tablet(s) by mouth qam
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - one
Tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth once a day as needed
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - (Prescribed by
Other Provider) - 100 unit/mL (70-30) Suspension - 72 units in
am and 54units in pm twice daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
9. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*1*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
11. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
12. potassium chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO Q12H (every 12 hours).
Disp:*120 Tablet Sustained Release(s)* Refills:*1*
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
14. insulin fixed dose and sliding scale ( see attached)
SC injections
15. warfarin 2 mg Tablet Sig: daily dosing per Dr.
[**Last Name (STitle) **];target INR 2.5-3.5 Tablets PO once a day: dose today
and tomorrow 5 mg ( take 2.5 tabs)only [**2-22**] and [**2-23**]; all
further daily dosing per Dr. [**Last Name (STitle) **];target INR 2.5-3.5 for
mechanical mitral valve.
Disp:*80 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Rheumatic mitral stenosis and mitralregurgitation s/p Mitral
Valve Replacement (27mm St. [**Male First Name (un) 923**] Mechanical Valve)
Past medical history:
Hypertension
Hyperlipidemia
Congestive heart failure
NSTEMI [**2163**]
Insulin-dependent Diabetes Mellitus type II
Anxiety Disorder
Rheumatic fever as a child
Obesity
Pernicious anemia
Bilateral lower lobe PNA in [**4-3**] Right middle lobe PNA [**12-4**]
Arthritis in hands and knees
Colonoscopy with polyp removal 10 yrs ago
Bilateral varicosities
Remote renal calculi
Bilateral lower extremity neuropathy
Lumbar disc disease
Bilateral Achilles tendon tears (wears braces)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) 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: [**Doctor Last Name **]: Phone:[**Telephone/Fax (1) 170**] [**2166-3-13**] 1:00
PCP/Cardiologist: [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] on [**2-19**] at 10:45am ([**Telephone/Fax (1) 33800**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mechanical MVR
Goal INR 2.5-3.5
First draw Monday [**2-24**]
Results to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 18658**] fax [**Telephone/Fax (1) 8719**]
Completed by:[**2166-2-22**]
|
[
"412",
"413.9",
"394.2",
"274.00",
"300.00",
"398.91",
"250.00",
"V15.82",
"416.8",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9911, 9974
|
5070, 6501
|
325, 428
|
10652, 10824
|
2828, 5047
|
11797, 12483
|
1859, 1980
|
7946, 9888
|
9995, 10133
|
6527, 7923
|
10848, 11774
|
2020, 2809
|
266, 287
|
456, 1367
|
10155, 10631
|
1672, 1843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,062
| 157,698
|
16190
|
Discharge summary
|
report
|
Admission Date: [**2142-7-20**] Discharge Date: [**2142-7-28**]
Date of Birth: [**2080-6-12**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Initially presented to [**Hospital Unit Name 196**] for atrial flutter ablation.
Transferred to ICU for hypotension.
Major Surgical or Invasive Procedure:
EP mapping
History of Present Illness:
61 yo male with CAD s/p inferior and anteroseptal MI '[**30**] s/p 3V
CABG (LIMA to LAD, SVG to OM, SVG to DM) and AVR (bovine) in
[**2-24**], CHF (EF40%, mod pulm htn, apical aneurysm), HTN, AF dx'd
[**6-6**] and failed CV on sotalol and amio, s/p DDD PM [**6-14**] for
post-CV bradycardia.
Presented to [**Hospital **] hospital with hypotension and atrial
fibrillation -> Aflutter. Amio started [**7-9**] and dig there and CV
[**2142-7-10**]. Converted to Aflutter [**7-14**]. [**7-18**] had VT/VF in setting
of K 6.6 and transferred to [**Hospital1 18**].
[**Hospital1 18**] Course: TEE/CV [**7-19**], pacer DDDR 70 with mode-switch, dig
stopped. Got 3 doses Coumadin (last [**7-22**]), and INR up to 5.1
[**7-25**], wbc climbing with lymphopenia. Waiting for INR to come down
(received 3 doses coumadin after amio started and INR went to
21) before flutter ablation. Over the past several days, BP
noted to be trending down. [**7-27**] hypotensive d/t ??infxn.
Transferred to MICU service for mgt of hypotension.
Past Medical History:
1. CAD
-Coronary artery disease status post inferior and
anteroseptal MI in [**2130**]
-status post three vessel CABG(LIMA to LAD, SVG to OM, SVG to
DM) and AVR (bovine) in [**2141-2-21**].
-ETT MIBI [**4-26**] on 8 min mod-[**Doctor First Name **] (7METS)57% PMHR-severe fixed
defect dital inf wall and septum
2. CHF
3. Hypertension.
4. Hypercholesterolemia.
5. Hypothyroidism.
6. Melanoma on left shoulder in [**2140-10-23**].
7. Erectile dysfunction.
8. History of erythema nodosum.
9. Community acquired pneumonia in [**2140-6-23**].
10.light chain multiple myeloma.
12. Multifactorial renal failure.
13. DM
14. Light chain nephropathy/proteinuria.
15. Restless leg syndrome.
16. Hypercholesterolemia.
17. Hypocalcemia.
Social History:
The patient is divorced and lives alone in
[**Location (un) 6691**], [**State 350**] in the Berkshires. He has two
children. He was working in produce at a market but had to
stop a week prior to admission because of shortness of breath
and edema. He smoked one cigar per day for 30 years. He
denies alcohol use.
Family History:
The patient's father had coronary artery
disease and was an alcoholic. The patient's mother had
diabetes mellitus and coronary artery disease. The patient's
sister has coronary artery disease and atrial fibrillation.
Physical Exam:
T96.7 BP110/72 P76 97%RA
Gen-very pleasant
HEENT-anicteric, no conjunctival pallor, no nasal findings, no
oral findings, neck supple, no LAD, infroorbital ecchymoses on
right eye, laceration on left forehead.
CVS-nl S1/S2, no S3/S4, 2/6 SEm at USB, no pedal edema, DP 1+
bilaterally, JVP 7cm.
resp-CTAB, no wheezes, no crackles
GI-nl BS, no tenderness
neuro-A+O X 3, move all 4 limbs
Pertinent Results:
[**2142-7-20**] 03:40AM GLUCOSE-120* UREA N-43* CREAT-4.8* SODIUM-140
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-18
[**2142-7-20**] 03:40AM CALCIUM-8.5 PHOSPHATE-6.3*# MAGNESIUM-1.8
[**2142-7-20**] 03:40AM DIGOXIN-1.2
[**2142-7-20**] 03:40AM WBC-16.9*# RBC-4.28*# HGB-13.5*# HCT-41.1#
MCV-96 MCH-31.5 MCHC-32.8 RDW-16.4*
[**2142-7-20**] 03:40AM PLT COUNT-169#
[**2142-7-20**] 03:40AM PT-12.7 PTT-26.4 INR(PT)-1.0
[**2142-7-21**] 06:35AM BLOOD WBC-10.6 RBC-4.15* Hgb-13.2* Hct-40.4
MCV-97 MCH-31.9 MCHC-32.7 RDW-16.2* Plt Ct-166
[**2142-7-22**] 08:20AM BLOOD WBC-10.5 RBC-4.23* Hgb-13.6* Hct-40.4
MCV-96 MCH-32.1* MCHC-33.7 RDW-16.1* Plt Ct-162
[**2142-7-23**] 06:10AM BLOOD WBC-12.1* RBC-4.31* Hgb-13.8* Hct-41.0
MCV-95 MCH-32.0 MCHC-33.7 RDW-16.2* Plt Ct-170
[**2142-7-24**] 04:00AM BLOOD WBC-16.7* RBC-4.50* Hgb-14.2 Hct-42.1
MCV-94 MCH-31.6 MCHC-33.9 RDW-16.2* Plt Ct-190
[**2142-7-24**] 09:21AM BLOOD WBC-17.0* RBC-4.49* Hgb-14.2 Hct-42.6
MCV-95 MCH-31.6 MCHC-33.3 RDW-16.3* Plt Ct-191
[**2142-7-25**] 06:20AM BLOOD WBC-12.7* RBC-4.24* Hgb-13.4* Hct-41.0
MCV-97 MCH-31.5 MCHC-32.6 RDW-15.9* Plt Ct-169
[**2142-7-26**] 06:35AM BLOOD WBC-16.7* RBC-4.35* Hgb-13.6* Hct-41.4
MCV-95 MCH-31.3 MCHC-32.8 RDW-16.1* Plt Ct-180
[**2142-7-26**] 08:20AM BLOOD WBC-15.0* RBC-4.09* Hgb-13.3* Hct-39.0*
MCV-95 MCH-32.4* MCHC-34.0 RDW-16.1* Plt Ct-173
[**2142-7-27**] 07:25AM BLOOD WBC-11.5* RBC-3.07* Hgb-9.7*# Hct-29.6*
MCV-97 MCH-31.6 MCHC-32.8 RDW-16.1* Plt Ct-145*
[**2142-7-27**] 11:06AM BLOOD WBC-9.6 RBC-2.88* Hgb-8.8* Hct-28.2*
MCV-98 MCH-30.6 MCHC-31.3 RDW-16.0* Plt Ct-155
[**2142-7-27**] 02:15PM BLOOD WBC-16.4*# RBC-3.47* Hgb-10.8* Hct-33.5*
MCV-96 MCH-31.1 MCHC-32.3 RDW-15.8* Plt Ct-189
[**2142-7-28**] 12:14AM BLOOD WBC-16.4* RBC-2.85* Hgb-9.1* Hct-26.8*
MCV-94 MCH-32.0 MCHC-34.0 RDW-15.9* Plt Ct-193
[**2142-7-24**] 04:00AM BLOOD Neuts-95.0* Bands-0 Lymphs-1.9* Monos-3.0
Eos-0.1 Baso-0
[**2142-7-27**] 11:06AM BLOOD PT-17.1* PTT-37.2* INR(PT)-1.8
[**2142-7-25**] 02:45PM BLOOD PT-29.1* PTT-43.1* INR(PT)-5.3
[**2142-7-24**] 09:40AM BLOOD PT-37.5* INR(PT)-8.9
[**2142-7-25**] 02:45PM BLOOD Fibrino-329 D-Dimer-995*
[**2142-7-20**] 03:40AM BLOOD Glucose-120* UreaN-43* Creat-4.8* Na-140
K-4.9 Cl-104 HCO3-23 AnGap-18
[**2142-7-21**] 06:35AM BLOOD Glucose-99 UreaN-61* Creat-5.9*# Na-138
K-5.3* Cl-102 HCO3-21* AnGap-20
[**2142-7-22**] 08:20AM BLOOD Glucose-119* UreaN-49* Creat-5.2* Na-138
K-5.0 Cl-101 HCO3-26 AnGap-16
[**2142-7-23**] 06:10AM BLOOD Glucose-152* UreaN-62* Creat-6.3*# Na-136
K-5.3* Cl-99 HCO3-22 AnGap-20
[**2142-7-24**] 04:00AM BLOOD UreaN-79* Creat-7.1* Na-137 K-5.6* Cl-98
HCO3-19* AnGap-26*
[**2142-7-24**] 09:21AM BLOOD Glucose-132* UreaN-86* Creat-7.4* Na-137
K-6.1* Cl-98 HCO3-19* AnGap-26*
[**2142-7-24**] 09:21AM BLOOD Glucose-132* UreaN-86* Creat-7.4* Na-137
K-6.1* Cl-98 HCO3-19* AnGap-26*
[**2142-7-25**] 06:20AM BLOOD Glucose-107* UreaN-62* Creat-5.8*# Na-139
K-5.6* Cl-101 HCO3-23 AnGap-21*
[**2142-7-26**] 06:35AM BLOOD Glucose-105 UreaN-86* Creat-6.9*# Na-138
K-6.0* Cl-98 HCO3-24 AnGap-22*
[**2142-7-26**] 08:20AM BLOOD Glucose-102 UreaN-85* Creat-7.1* Na-137
K-6.1* Cl-97 HCO3-25 AnGap-21*
[**2142-7-27**] 07:25AM BLOOD Glucose-111* UreaN-90* Creat-4.9*# Na-138
K-5.7* Cl-102 HCO3-23 AnGap-19
[**2142-7-27**] 11:06AM BLOOD Glucose-171* UreaN-66* Creat-3.2*# Na-141
K-3.7 Cl-114* HCO3-19* AnGap-12
[**2142-7-27**] 07:55PM BLOOD Creat-5.3*# K-6.2*
[**2142-7-28**] 12:14AM BLOOD Glucose-207* UreaN-116* Creat-5.5* Na-137
K-6.4* Cl-100 HCO3-23 AnGap-20
[**2142-7-24**] 09:21AM BLOOD ALT-16 AST-28 AlkPhos-99 TotBili-0.2
[**2142-7-27**] 11:06AM BLOOD LD(LDH)-243 CK(CPK)-43
[**2142-7-27**] 05:33PM BLOOD CK(CPK)-72
[**2142-7-27**] 09:32PM BLOOD CK(CPK)-66
[**2142-7-27**] 11:02PM BLOOD LD(LDH)-402* TotBili-0.2
[**2142-7-28**] 12:14AM BLOOD ALT-20 AST-26
[**2142-7-27**] 11:06AM BLOOD CK-MB-NotDone cTropnT-0.49*
[**2142-7-27**] 05:33PM BLOOD CK-MB-NotDone cTropnT-0.81*
[**2142-7-27**] 09:32PM BLOOD CK-MB-NotDone cTropnT-0.87*
[**2142-7-20**] 03:40AM BLOOD Calcium-8.5 Phos-6.3*# Mg-1.8
[**2142-7-21**] 06:35AM BLOOD Mg-2.1
[**2142-7-22**] 08:20AM BLOOD Mg-1.9
[**2142-7-23**] 06:10AM BLOOD Mg-2.6
[**2142-7-24**] 04:00AM BLOOD Mg-2.7*
[**2142-7-24**] 09:21AM BLOOD Albumin-3.0* Calcium-10.3* Phos-7.9*#
Mg-3.3*
[**2142-7-25**] 06:20AM BLOOD Calcium-8.5 Phos-5.6*# Mg-2.4
[**2142-7-26**] 06:35AM BLOOD Calcium-9.4 Phos-7.2*# Mg-2.9*
[**2142-7-26**] 08:20AM BLOOD Phos-7.2* Mg-2.7*
[**2142-7-27**] 07:25AM BLOOD Calcium-8.2* Phos-5.1*# Mg-2.2
[**2142-7-27**] 11:06AM BLOOD Calcium-4.8* Phos-3.1# Mg-1.5*
[**2142-7-27**] 02:15PM BLOOD Calcium-8.6
[**2142-7-28**] 12:14AM BLOOD Calcium-8.2* Phos-6.5*# Mg-3.1*
[**2142-7-27**] 11:02PM BLOOD Hapto-241*
[**2142-7-27**] 05:33PM BLOOD TSH-6.4*
[**2142-7-27**] 05:33PM BLOOD T3-26* Free T4-0.6*
[**2142-7-24**] 04:00AM BLOOD PTH-43
[**2142-7-27**] 11:02PM BLOOD Cortsol-29.3*
[**2142-7-27**] 09:32PM BLOOD Cortsol-25.5*
[**2142-7-27**] 07:55PM BLOOD Cortsol-22.9*
[**2142-7-20**] 03:40AM BLOOD Digoxin-1.2
[**2142-7-28**] 12:29AM BLOOD Type-ART pO2-175* pCO2-39 pH-7.38
calHCO3-24 Base XS--1 Intubat-NOT INTUBA
[**2142-7-27**] 08:04PM BLOOD Type-ART pO2-125* pCO2-45 pH-7.34*
calHCO3-25 Base XS--1 Intubat-NOT INTUBA
[**2142-7-27**] 06:16PM BLOOD Type-[**Last Name (un) **] pH-7.31*
[**2142-7-27**] 11:10AM BLOOD Lactate-2.1*
[**2142-7-27**] 06:16PM BLOOD Lactate-1.8
[**2142-7-27**] 08:04PM BLOOD Lactate-1.3
[**2142-7-28**] 12:29AM BLOOD Glucose-208* Lactate-1.4 K-6.0*
[**2142-7-27**] 06:16PM BLOOD freeCa-1.14
[**2142-7-27**] 08:04PM BLOOD freeCa-1.12
[**2142-7-28**] 12:29AM BLOOD freeCa-1.07*
[**7-27**] on transfer to the ICU:
EKG: Atrial paced rhythm
Right bundle branch block
Inferior infarct, age indeterminate
Anterior myocardial infarct, age indeterminate
Diffuse ST-T wave abnormalities - cannot exclude in part
ischemia
CXR: Worsening left retrocardiac opacity with adjacent moderate
sized pleural effusion. Pneumonia cannot be excluded.
CT abd/pelvis: 1. No evidence of retroperitoneal hematoma.
2. Standing in the subcutaneous tissues and small amount of free
fluid noted in the presacral space consistent with edema.
3. Moderate-sized bilateral pleural effusion with associated
atelectasis.
Brief Hospital Course:
61 yo M with MM, ESRD, CAD s/p V-tach arrest, CHF,
a-fib/flutter, awaiting INR to trend down for elective ablation,
when he subsequently became increasingly hypotensive and
confused/disoriented, so he was transferred to the ICU for
further management of ?sepsis vs.adrenal insufficiency. He was
under the care of the ICU team for only several hours before he
went into v-fib arrest, coded and was not able to be
resuscitated.
1)Hypotension: Likely sepsis vs adrenal insufficiency.
BCXs/fungal cx were sent in light of the recent steroid use.
Vanc and cefepime (for gram neg coverage) were started
empirically. As line infection was of high likelihood, the plan
was to d/c HD line when possible. He was started on IV stress
dose steroids Q8hrs empirically and cortisol stim test was sent.
Pressors were initiated with neo and levophed to maintain
MAP>60, and IVF boluses were given as needed. He was transfused
to HCT >30 and H/H chakcs proceeded Q6hours. CT was negative for
retroperitoneal bleed.
2) Renal: He was HD dependent and had been dialyzed the day
prior to transfer to the ICU.
3) Cor: He was on ASA and a statin, BP meds were held given
hypotension. On transfer to the ICU, EKG showed possible new
ischemia and cardiac markers trended upwards. However, in the
setting of his renal insuffuciency, level of elevation was not
clear. His potassium level was slowly creeping up. Kayexalate
was given and K followed. Prior to his subsequent K level at 6.4
and the third set of markers coming back, Mr.N went into v-fib
arrest. Code was called and CPR initiated. Despite 30 minutes
resus efforts, Mr.N was not able to be revived, code was stopped
and he was pronounced. His family was notified and they declined
autopsy.
[4) Thyroid: There was a question as to whether this was the
source of afib/flutter; however, TFT were normal. He was kept on
synthroid.
5) A-flutter: He was to undergo elective ablation after
stabilization of BP.
6) Heme: H/O multiple myeloma. Cont thalidomide, monitor HCT.
7) FEN: NPO
8) Code: FULL]
Medications on Admission:
1. Toprol-XL 50 mg po qd.
2. Trazodone 100 mg po qd.
3. Isosorbide mononitrate 30 mg ER qd.
4. Sinemet 10/100 mg qhs, prn, restless leg syndrome.
5. Lipitor 20 mg qd.
6. Synthroid 175 mcg qd.
7. Wellbutrin 100 mg [**Hospital1 **].
8. Aspirin 81 mg qd.
9. Glargine 20 units qhs.
10. Humalog sliding scale.
11. Calcium carbonate 500 mg tid.
12. Pamidronate 30 mg times one.
13. Zantac 300 mg qhs.
14. amiodarone 200mg [**Hospital1 **]
15. digoxin 0.125 QD
16. prednisone 50 on taper
17. clonasepam 2mg QHS
17. Thalidomide 400 [**Hospital1 **]
18. calcium acetate 1334
Discharge Medications:
None
Discharge Disposition:
Home with Service
Discharge Diagnosis:
1. Deceased
2. hyperkalemia
3. Atrial flutter
4. coronary artery disease post MI and CABG
5. CHF
6. Hypotension.
7. Hypothyroidism.
8.light chain multiple myeloma.
9.renal failure requiring hemodialysis
10. DM
Discharge Condition:
Deceased
Discharge Instructions:
None--deceased
Followup Instructions:
None-deceased
|
[
"427.31",
"427.5",
"V45.81",
"403.91",
"458.9",
"203.00",
"428.0",
"V43.3",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.95",
"99.60",
"88.72",
"38.91",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
12160, 12179
|
9479, 11514
|
453, 465
|
12433, 12443
|
3244, 9456
|
12506, 12522
|
2606, 2825
|
12131, 12137
|
12200, 12412
|
11540, 12108
|
12467, 12483
|
2840, 3225
|
297, 415
|
493, 1512
|
1534, 2260
|
2276, 2590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,206
| 192,461
|
37299
|
Discharge summary
|
report
|
Admission Date: [**2117-5-6**] Discharge Date: [**2117-5-11**]
Date of Birth: [**2053-12-31**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Talwin / Metaproterenol
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Tracheostomy
Major Surgical or Invasive Procedure:
Tracheostomy
Bronchoscopy
History of Present Illness:
The patient is a 63y/o gentleman with a PMH of COPD and
tracheomalacia s/p tracheostomy in [**2115**] admitted for T tube
placement. The patient had a bowel obstruction [**5-6**] leading to
ischemic bowel and perforation c/b septic shock. He was
intubated for an extended period of time and underwent
tracheostomy [**8-5**]. Trach was decannulated [**8-6**]. Her reported
improvement for one month after returning home then developed
dyspnea, sputum production and wheezing. He underwent a CT scan
which revealed narrowing of the trachea with a disruption of the
tracheal ring at that same site.
.
The patient underwent a flexible bronchoscopy [**2-7**] which
demonstrated a proximal trachea fracture and moderate
tracheomalacia. He is currently requiring O2 3L NC. The patient
is admitted for bronchoscopy with tracheostomy placement.
Past Medical History:
- COPD
- status post tracheostomy [**7-6**], decannulation [**2116-8-28**]
- Acute on chronic renal insufficiency (short term dialysis
during hospitalization 4/08-7-08)
- chronic low back pain, status post L5 (?) laminectomy
- Hypertension
- Ischemic bowel/perforation, status post subtotal colectomy,
now with ileostomy
- Peripheral vascular disease
- Sleep apnea but not using NIV
- Hypercholesterolemia
- BPH
- Anxiety/depression
- Seasonal allergies with chronic PND
Social History:
Married with 5 children. Former 90 pack/yr smoker, quit [**2113**]. No
EtOH.
.
Family History:
Mother deceased COPD. Father deceased stroke. Sister dies early
age from smoking related health problems.
Physical Exam:
Vital signs: T 98.2 HR 92 BP 131/82 RR 12 O2 98% 3L NC.
GEN: NAD, A&OX3
HEENT: MMM, oropharynx clear, no scleral icterus
Neck: Old tracheal stoma
CV: RRR,nl S1/S2 no MRG
RESP: + wheezing with expiration, decreased BS posteriorly
ABD: obese, soft, NT/ND, NABS, ostomy
EXT: no edema
.
Pertinent Results:
PERTINENT LABS:
[**2117-5-6**] WBC-9.4 HGB-11.7* HCT-34.8* MCV-88 MCH-29.8 PLT
COUNT-251
[**2117-5-6**] 07:10PM PT-11.3 PTT-29.1 INR(PT)-0.9
[**2117-5-6**] 07:10PM GLUCOSE-100 UREA N-37* CREAT-2.9* SODIUM-133
POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-31
.
[**2117-5-8**] WBC-13.4*
[**2117-5-11**] WBC-9.0
[**2117-5-11**] Glucose-93 UreaN-29* Creat-1.8* Na-139 K-4.1 Cl-99
HCO3-31
.
[**2117-5-8**] 8:33 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2117-5-11**]**
GRAM STAIN (Final [**2117-5-8**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2117-5-11**]):
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.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
BETA STREPTOCOCCI, NOT GROUP A. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
.
[**2117-5-10**] 8:03 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2117-5-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
.
.
IMAGING:
[**5-8**] CXR: No previous studies available for direct comparison.
There is a
tracheostomy tube with distal tip at the level of the clavicular
heads. There is diffuse pulmonary interstitial prominence,
particularly at the right base. This is suggestive of chronic
disease; however, comparison to old films would be more helpful
to establish interval change. There is cardiomegaly. There is
volume loss on the right side. The left lung is well aerated
without focal consolidation or pleural effusions.
.
[**5-10**] CXR: In comparison with the study of [**5-8**], there is little
change.
Tracheostomy tube remains in place. Continued hyperexpansion of
the lungs
with mild enlargement of the cardiac silhouette and prominence
of the
ascending aorta, raising the possibility of hypertension.
Diffuse prominence of interstitial markings is again consistent
with chronic lung disease. This is somewhat more prominent at
the right base, which could be a manifestation of superimposed
pneumonia.
.
Brief Hospital Course:
63 year old man with a PMH of COPD and tracheomalacia status
post tracheostomy [**2115**] admitted for bronchoscopy and
tracheostomy.
.
# Tracheomalacia: S/p rigid bronchoscopy in the OR with
tracheostomy placement. Pt with significant obstructive airways
disease. He was observed overnight in the MICU as per standard
protocol and then called back out to the floor. Pt tolerated
the procedure well and had no complications. He was started on
mucomyst and codeine-guafenesin to manage secretions. He will
follow-up with IP as an outpatient.
.
# Hospital-acquired pneumonia: Pt developed leukocytosis and low
grade fever after the procedure. This was felt to be possibly
inflammatory in setting of recent procedure, however CXR was
suspicious for a RLL infiltrate and the patient had a large
amount of tracheal secretions. He was treated with a 7-day
course of levofloxacin. WBC returned to [**Location 213**] and he had no
further fevers. Sputum culture was consistent with likely
oropharyngeal contamination.
.
# HTN: Continued HCTZ.
.
# Hyperlipidemia: Continued simvastatin.
.
# BPH: Continued terazosin.
.
# Anxiety/Depression: Continued Lexapro and trazodone.
.
Medications on Admission:
Trazadone 100 mg daily
Ascorbic acid
Ergocalciferol
ASA 81 mg po daily
MVI 1 tab po daily
Ablify 10 mg PO daily
Cyclobenzaprine 10 mg po daily
Lexapro 20 mg po daily
HCTZ 25 mg Po daily
Combivent (18 mcg/103 mcg( 90 mcg) /Actuation aerosol 2 puffs
QID
Nasonex 1 spray each nostril [**Hospital1 **]
Advair 500/50 1 puff [**Hospital1 **]
Prednisone 5 mg po daily
Propoxyphene 65 mg po BID
Ranitidine 150 mg PO daily
Simvastatin 20 mg Po daily
Terazosin 5 mh PO daily
.
Discharge Medications:
1. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
4. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for pain.
6. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation [**Hospital1 **] (2 times a day).
9. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
Nasal twice a day.
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Propoxyphene 65 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for pain.
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
15. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
22. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
23. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
24. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
25. Codeine-Guaifenesin 10-100 mg/5 mL Liquid Sig: [**1-30**] teaspoons
PO every six (6) hours as needed for cough/secretions.
Disp:*150 mL* Refills:*0*
26. Acetylcysteine 20 % (200 mg/mL) Solution Sig: [**2-7**] mL
Miscellaneous twice a day.
Disp:*QS mL* Refills:*2*
27. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every
other day for 5 days: dose on [**3-15**], [**5-16**].
Disp:*3 Tablet(s)* Refills:*0*
28. 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 or wheezing.
Disp:*QS mL* Refills:*1*
29. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*QS * Refills:*1*
.
Discharge Disposition:
Home With Service
Facility:
Visiting Nurses of Southern [**State 1727**]
Discharge Diagnosis:
Primary:
1. Tracheomalacia
2. Tracheostomy Placement
3. Hospital-acquired pneumonia
.
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 scheduled tracheostomy
procedure to treat the weakening of your trachea called
tracheomalacia. You were monitored in the ICU overnight after
your procedure. You are being discharged home to follow up with
the Interventional Pulmonology team for further consideration of
a T tube placement. Please maintain your scheduled follow up
listed below.
.
The following changes were made to your medications:
-START levofloxacin for pneumonia
-START mucomyst neb treatments twice a day until you see Dr.
[**Last Name (STitle) **] in clinic
-START codeine-guafenesin as needed for cough and secretions
.
Followup Instructions:
Interventional pulmonary will contact you to arrange a follow-up
appointment with Dr. [**Last Name (STitle) **] within the next 2-3 weeks.
.
You should follow-up with your PCP in the next 2 weeks.
.
|
[
"300.4",
"403.90",
"327.23",
"272.0",
"482.9",
"584.9",
"600.00",
"496",
"585.3",
"519.19",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
9469, 9544
|
5555, 6731
|
307, 335
|
9673, 9673
|
2245, 2245
|
10483, 10684
|
1819, 1927
|
7248, 9446
|
9565, 9652
|
6757, 7225
|
9825, 10460
|
1942, 2226
|
4482, 5532
|
255, 269
|
363, 1201
|
9688, 9801
|
2261, 4441
|
1223, 1707
|
1723, 1803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,383
| 135,931
|
49876
|
Discharge summary
|
report
|
Admission Date: [**2133-7-30**] Discharge Date: [**2133-8-4**]
Date of Birth: [**2092-4-2**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 41-year-old white
female status post gastric bypass surgery on [**7-2**] at [**Hospital 14852**] presenting with shortness of breath
and electrocardiogram changes at her primary medical doctor's
office on [**2133-7-30**].
The patient stated the sudden onset of shortness of breath,
swelling, dizziness, and urge to defecate at approximately
2 p.m. on [**2133-7-29**] after drinking a protein shake and
taking MiraLax (a laxative). The patient reports voiding a
large amount of soft stool but still feeling as if he were
having a "panic attack." The patient has no history of panic
attacks in the past. The patient called his primary medical
doctor's office where practice assistant advised her to
relax. The patient took a nap and felt better for a short
time, but later in the evening experienced weakness and
dyspnea on exertion on walking to her car.
The patient went to bed and had a usual night of sleep. She
was awake two times for urination and awoke feeling tired,
very easily became short of breath with light activity. The
patient went to her primary medical doctor's office where an
electrocardiogram was performed which showed changes, and the
patient was referred to the rule out pulmonary embolism. At
no time did the patient experience fevers, chills, chest
pain, diarrhea, or constipation. The patient did experience
a feeling of clamminess and palpitations during the initial
shortness of breath episode.
PAST MEDICAL HISTORY:
1. Obesity.
2. Status post gastric bypass surgery on [**2133-7-2**].
3. Spinal stenosis with left hip/thigh numbness which
requires chronic pain medication. Seen in Pain Clinic at
[**Hospital6 1708**].
4. Lupus; discoid type. Rash on leg and joint pains. No
history of renal involvement.
5. Deep venous thrombosis in left calf in [**2120**] while on oral
contraceptive pills; required Warfarin for six months.
ALLERGIES: COMPAZINE causes anaphylaxis.
MEDICATIONS ON ADMISSION:
1. [**Doctor Last Name 18928**] 120 mg p.o. b.i.d. (the same as time-released
morphine).
2. Zantac 150 mg p.o. b.i.d. (started after surgery)
3. Multivitamin one capsule p.o. q.d.
4. Caltrate one capsule p.o. q.d.
5. MiraLax 17 g p.o. q.d.
6. Percocet as needed.
FAMILY HISTORY: Grandfather with diabetes mellitus. Mother
with rheumatoid arthritis.
SOCIAL HISTORY: The patient is a social worker. She is
married with no children. She has a Yorkshire Terrier. No
history of tobacco, or alcohol, or illicit drug use.
EMERGENCY DEPARTMENT COURSE: Emergency Department course
revealed initial vital signs with a temperature of 96.7,
pulse was 89, blood pressure was 166/78, respiratory rate was
24, saturating 99% on 2 liters, weight was 325 pounds.
RADIOLOGY/IMAGING: Electrocardiogram showed a normal sinus
rhythm at 95 beats per minute, normal axis, T wave inversions
in II, III, and aVF, V3 through V6. Q wave in III, aVF as
compared to normal study of [**2133-6-29**].
A CT angiogram was performed which showed filling defects in
both the right main pulmonary artery and the left main
pulmonary artery, positive for pulmonary embolism.
The patient was given 162 mg of aspirin, Lopressor 5 mg
intravenously times two. Heparin was started per weight
based protocol. The patient was also given MS Contin 120 mg
times one, Zantac 150 mg times one, and oxygen per nasal
cannula 2 liters.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature was 96.7, pulse was 77, blood pressure was
129/81, respiratory rate was 12, pulse oximetry of 98% on 2
liters. In general, an obese female in no apparent distress.
Head, eyes, ears, nose, and throat revealed moist oral
mucosa. Neck was supple. No tracheal deviation. Pulmonary
revealed decreased breath sounds bilaterally. Cardiovascular
revealed a normal first heart sound, split second heart
sound. A regular rate and rhythm. No murmurs, rubs or
gallops. The abdomen was obese, soft, positive bowel sounds,
multiple laparoscopic scars. Extremities revealed no calf
vein tenderness, 1+ pitting edema over ankles and feet. Feet
were warm. Neurologically, alert and oriented times three.
No focal deficits were noted.
PERTINENT LABORATORY DATA ON PRESENTATION: Pertinent
laboratory results revealed the patient had a white blood
cell count of 7.7 (with 65.6% neutrophils), hematocrit
was 42.8. No elevated electrolytes on Chemistry-7. Initial
urinalysis showed a specific gravity of 1.035, negative
leukocyte esterase, negative nitrites, no red blood cells,
total protein, and ketones of above 80. Liver function tests
showed an alkaline phosphatase of 148, albumin was 4.4. The
patient had an initial set of cardiac enzymes which showed a
CK/MB of 9, a troponin I was 8.2, and a creatine
phosphokinase of 130.
HOSPITAL COURSE:
1. CARDIOVASCULAR: Elevated troponin and electrocardiogram
changes which were believed to be due to right heart strain
secondary to pulmonary embolism. However, cardiac enzymes
were cycled. The first set of cardiac enzymes revealed a
CK/MB of 9, troponin I was 8.2, and a creatine phosphokinase
was 130. The second set of cardiac enzymes revealed a CK/MB
was not done, troponin was 6, creatine phosphokinase was 64.
The third set revealed CK/MB was not done, troponin I
was 3.5, creatine phosphokinase was 64.
The patient had a transthoracic echocardiogram on [**7-31**]
which showed severe right heart strain, severe right heart
hypokinesis; at which point the Medical Intensive Care Unit
team was called for evaluation for thrombolytic therapy. The
patient was approved for thrombolytics.
Status post Medical Intensive Care Unit t-PA course, an
echocardiogram was performed on [**8-3**] which showed a left
ventricular ejection fraction of 55%, and mild right
ventricular hypokinesis; improved function as compared to
earlier study.
The patient's heart rate and blood pressure was stable at all
times. Telemetry course was significant only for infrequent
premature ventricular contractions.
2. PULMONARY: Status post bilateral pulmonary embolism, the
patient was started on heparin per weight based protocol.
The patient's oxygen saturations and respiratory rates were
monitored for further pulmonary embolism events, but were
always within normal limits.
The patient was evaluated by Medical Intensive Care Unit team
after transthoracic echocardiogram results and was given t-PA
therapy in the Medical Intensive Care Unit. Therefore, she
was there for approximately 30 hours. The patient returned
to the floor on a heparin drip. At no time did she
experience shortness of breath or tachypnea once on the
floor.
3. GASTROINTESTINAL: The patient was status post Roux-en-Y
gastric bypass surgery. The patient was given gastric bypass
level IV diet and on iron and Zantac prophylaxis while in the
hospital.
4. HEMATOLOGY: The patient found to have a left leg deep
venous thrombosis from midfemoral to popliteal vein on
[**7-31**]. Laboratory studies sent for hypercoagulability
workup including antiphospholipid antibody, protein C,
protein S, antithrombin, factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5244**], homocystine levels;
all the mentioned were pending. Homocystine, however, was
within normal limits.
The patient was continued on heparin and started on
Coumadin 5 mg p.o. q.h.s. When the patient was discharged
her INR was 2.2, and her heparin was stopped. The patient's
hematocrit was initially 42 on admission, but then dropped to
36.1, and had since risen to 36.5.
5. DERMATOLOGY: The patient was noted to have oval
erythematous scaling patch between skin folds at the left
pannus on [**2133-8-3**]. The patient was given miconazole
powder.
6. MEDICAL INTENSIVE CARE UNIT COURSE: The patient was
transferred to the Medical Intensive Care Unit on [**2133-7-31**] for t-PA administration. The patient received t-PA from
12 a.m. to 2 a.m. on [**2133-8-1**] without complications.
The patient had a subclavian central line placed in the
Medical Intensive Care Unit without complications. The
patient was observed in the Medical Intensive Care Unit for
approximately 30 hours and then was transferred back to the
floor.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: The patient was to be discharged to home
on regular home medications in addition to Coumadin 5 mg p.o.
q.h.s.
DISCHARGE FOLLOWUP: The patient was to follow up with her
primary care provider on Thursday, [**2133-8-6**] in the
morning for an INR check.
DISCHARGE DIAGNOSES:
1. Bilateral pulmonary embolism; status post thrombolytic
therapy.
2. Left leg deep venous thrombosis.
3. Status post gastric bypass surgery on [**2133-7-2**].
4. Morbid obesity.
5. Spinal stenosis.
6. Tenia corpora.
MEDICATIONS ON DISCHARGE:
1. Oxycodone/acetaminophen one to two tablets p.o. q.4h. for
breakthrough pain.
2. Morphine sulfate-SR 120 p.o. q.12h.
3. MiraLax 17 g p.o. q.d.
4. Multivitamin one capsule p.o. q.d.
5. Zantac 150 mg p.o. b.i.d.
6. Coumadin 5 mg p.o. q.h.s.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 101821**]
MEDQUIST36
D: [**2133-8-4**] 14:19
T: [**2133-8-11**] 13:03
JOB#: [**Job Number 34925**]
|
[
"415.19",
"724.00",
"272.4",
"453.8",
"V45.89",
"790.5",
"695.4",
"276.8",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
2435, 2507
|
8719, 8943
|
8969, 9482
|
2148, 2418
|
4977, 8375
|
8390, 8554
|
144, 166
|
8576, 8698
|
195, 1638
|
1660, 2122
|
2524, 4959
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,985
| 128,884
|
51211
|
Discharge summary
|
report
|
Admission Date: [**2111-6-2**] Discharge Date: [**2111-6-2**]
Date of Birth: [**2036-2-10**] Sex: M
Service:
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
male with multiple medical problems who was recently admitted
in [**2111-4-4**], to the Medical Intensive Care Unit for lobar
pneumonia, who presents to the Emergency Department with
acute shortness of breath. The patient was admitted at the
end of [**Month (only) 956**] with ischemic cerebrovascular accident which
was consistent followed by pneumonia. Sputum grew out E.
coli and Pseudomonas. The patient was subsequently treated
for these infections and discharged to rehabilitation with a
14 day course of Ceftazidine. The patient did well and was
sent home on Coumadin for his atrial fibrillation and
cerebrovascular accident. The Coumadin was discontinued
approximately one week ago and substituted with aspirin.
A follow-up transesophageal echocardiogram did not reveal
intra-cardiac thrombus.
The morning of admission, at approximately 5 a.m., the
patient acutely sat up in bed with sudden shortness of
breath. This improved with sitting up and upon arriving to
the Emergency Department the patient received Solu-Medrol 125
mg, Lasix 100 mg, morphine 2 mg, Levaquin 500 mg, Vancomycin
one gram and Ceftazidime one gram intravenously.
PAST MEDICAL HISTORY:
1. Lung cancer status post right pneumonectomy in [**2100**].
2. Chronic chronic obstructive pulmonary disease.
3. Atrial fibrillation with transesophageal echocardiogram
negative for thrombus on [**2111-4-3**].
4. The patient is status post cerebrovascular accident which
was in the right paraventricular area.
5. History of coronary artery disease status post myocardial
infarction times two; the last myocardial infarction in [**2106**].
6. Hypertension.
7. Colon cancer in [**2096**], status post colectomy with ostomy.
8. Abdominal aortic aneurysm in [**2110-8-4**] which was
measured to be 4.8 by 4.8 centimeters.
9. Congestive heart failure with preserved ejection
fraction.
10. Peptic ulcer disease.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has a 100 pack year history of
smoking with occasional alcohol use. He lives with his wife.
PHYSICAL EXAMINATION: On admission, vital signs were
temperature 97.9 F.; blood pressure 193/86 which rapidly
decreased to 137/69 in the Emergency Department; heart rate
of 110; respiratory rate 30; and the patient was saturating
94% on 100% nonrebreather and 98% on Bi-PAP with 100% FIO2.
General appearance is an elderly male in acute distress.
HEENT: Extraocular muscles are intact; question of icterus.
Oropharynx with no hemorrhages. Neck: Cannot assess jugular
venous distention given respiratory distress and retractions.
Pulmonary: Left coarse rales throughout without wheezes.
Cardiac: Regular rate and rhythm. Abdomen soft, nontender,
nondistended. Good bowel sounds. Extremities with two plus
edema, right greater than left.
LABORATORY: On admission included white blood cell count
27.4, hemoglobin 9.9, hematocrit 32.9, platelets 134. Chem 7
with sodium of 137, potassium 4.3, chloride 99, bicarbonate
26, BUN 28, creatinine 1.4 and glucose 121.
A chest x-ray was performed which showed left lower lobe
consolidation.
An electrocardiogram was performed which showed sinus
tachycardia with poor R wave progression and no Q waves but
ST depressions in leads I, II, V4 through V6.
Given the above the patient was sent for CT angiogram to rule
out pulmonary embolism. While in the CT scanner, the patient
had increasing respiratory distress and was intubated. The
patient was subsequently transferred to the Medical Intensive
Care Unit where he arrived at approximately 12:10 p.m.
The patient's family at this time was reconsidering the
patient's code status. While these decisions were being
made, the patient began to become more hypoxemic with
decreasing blood pressure, decreasing heart rate and bleeding
through his endotracheal tube.
The family decided that the aggressive nature of the
interventions required to sustain Mr. [**Known lastname 34143**] life exceeded
what he would want done. Therefore, they requested that he be
made comfort measures only. Mr. [**Known lastname 1637**] was given morphine
for pain control and subsequently died at 12:30 p.m.
He had no spontaneous respirations, no heart rate, no
response to painful stimuli and his pupils were unresponsive
to light.
The presumed cause of death was respiratory failure due
to combination of pulmonary hemorrhage and pneumonia which were
both evidenced on his CT angiogram
that had since been performed.
This was discussed with the patient's family and with his
primary care physician.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Name8 (MD) 234**]
MEDQUIST36
D: [**2111-6-2**] 19:24
T: [**2111-6-2**] 19:57
JOB#: [**Job Number 106256**]
|
[
"427.31",
"486",
"V10.05",
"401.9",
"518.81",
"V10.11",
"786.3",
"496",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2309, 5084
|
148, 171
|
201, 1382
|
1404, 2161
|
2179, 2285
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,281
| 183,651
|
17494+56864
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-11-21**] Discharge Date: [**2107-12-9**]
Date of Birth: [**2087-9-18**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins / Neurontin / Erythromycin / IV Dye,
Iodine Containing / Optiray 350 / Compazine
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Anaphylactoid reaction to IV contrast
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 22473**] is a 20 year-old female with history of
relapsing/remitting multiple sclerosis who presented to [**Hospital1 1535**] Emergency Department on [**2107-11-20**]
with left flank pain. She describes her pain as "achy"
discomfort which began approximately 10 days prior to admission,
wrapping around to her lower back, worse with movement, slightly
better with ibuprofen. She also notes that the discomfort is
worse with urination, mainly a "pressure" on the left side. She
denies associated hematuria/dysuria. She denies
N/V/diarrhea/abdominal pain/blood in stool/tarry colored stool.
She also reports left hip pain which developed over the same
time period for which she was seen by her PCP earlier this past
week and was diagnosed with probable bursitis. She reports that
the flank pain has progressively worsened over the past 10 days
so that her mother who works in the SICU at [**Hospital1 18**] referred her
to the ED for further evaluation.
.
In the ED, initial vitals were T 98.5 P 85 BP 102/66 RR 16
O2sat 100% RA. CBC, chemistries, and LFTs were normal and UA
was negative. She received 1mg IV morphine x2. Plan was made
for CT abdomen/pelvis to assess for possible kidney stone; if
stone was not present, then plan was to proceed with
administration of IV contrast to further assess for other
etiologies of her left flank pain.
After initial scan failed to demonstrate kidney stone, IV
contrast was administered. Within approximately one minute of
receiving IV contrast she reports feeling chest heaviness and
difficulty breathing. She also reports that her face became
swollen, she itched all over and that her throat was itchy. She
shouted "I can't breathe" while in the CT scanner and was
immediately removed from the scanner. She was treated
emergently for presumed life-threatening anaphylactoid reaction
to IV contrast; in this setting, she received 1 mL of 1:1000
epinephrine (1 mg) intravenously. She was then transferred back
to the Emergency Department and treated with solumedrol,
famotidine, benadryl, and bronchodilator nebulizers. She was
tachycardic to the 120s and hypotensive to systolic pressure in
the 70's, and received intravenous fluid resuscitation with 4
liters of normal saline. She then developed hypoxia and cough
with frothy pink sputum, requiring supplemental oxygen by
non-rebreather mask. EKG was notable for ischemic ST
depressions in the inferolateral leads. Her cardiac enzymes
(normal on presentation) were elevated (troponin of 0.43) when
measured after the anaphylaxis episode/epinephrine dose,
consistent with acute cardiac injury. She was then transferred
to the Medical Intensive Care Unit (MICU) for further evaluation
and treatment.
She was admitted to the MICU on [**2107-11-21**]. She was treated for
acute lung injury/pulmonary edema, volume-responsive shock, and
acute myocardial injury ultimately attributed to her
anaphylactoid reaction to IV contrast and subsequent
administration of 1 mg IV epinephrine at 1:1000 concentration
(note the standard dose of epinephrine for anaphylaxis is 0.3 mg
SC/IM at 1:1000 concentration). Echocardiogram on [**2107-11-22**]
demonstrated essentially normal cardiac function. Ms [**Known lastname 22473**]
noted the presence of continous substernal chest discomfort;
further evaluation did not demonstrate EKG or enzyme evidence of
ongoing cardiac injury. Her respiratory status and blood
pressure improved with supportive care, and she was transferred
from the MICU to the medical floor on [**2107-11-22**].
Past Medical History:
# Clinically definite multiple sclerosis, relapsing type, onset
[**5-/2102**], dx [**2-/2103**]
-18 prior attacks
-Tysabri infusions, [**2106-12-24**] and [**2107-1-24**]
-IV methylprednisolone (IVMP) [**2107-1-12**] for flare, then
hospitalized one week later for whole body numbness and loss of
temperature sense
-Lhermitte's phenomenon
-Double vision
-urinary retention
# Migraines
# Gastroparesis
Social History:
# Personal/professional: Criminal justice student at [**Last Name (un) 48848**]in [**Location (un) 3844**].
# Substance use: No smoking, occasional alcohol, no drug use.
Family History:
Noncontributory
Physical Exam:
VS (on admission to ICU): Temp: 97.3 BP: 93/46-->79/46 HR:104 ST
RR: 36 O2sat 91-94% NRB
GEN: Appears to have moderate increased WOB with tachypnea
HEENT: +facial swelling, pupils pinpoint and minimally reactive
to light, EOMI, anicteric, MMM, op without lesions, no
pharyngeal swelling
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: Course rales anteriorly as well as bilaterally posteriorly
CV: sinus tachy, S1 and S2 wnl, no m/r/g appreciated
ABD: nd, +b/s, soft, no masses or hepatosplenomegaly, left side
and low back tender to deep palpation, no rebound/guarding
EXT: no c/c/e, warm, palpable peripheral pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. CN II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTRs-patellar and
biceps on left, 1+ RUE DTR, hypoactive right patellar DTR.
Pertinent Results:
[**2107-11-20**]
WBC-5.7# RBC-4.99 HGB-13.3 HCT-39.7 MCV-80* MCH-26.6* MCHC-33.4
RDW-13.0
NEUTS-54.4 LYMPHS-36.1 MONOS-6.7 EOS-2.3 BASOS-0.5
PLT COUNT-325
GLUCOSE-72 UREA N-11 CREAT-0.6 SODIUM-137 POTASSIUM-3.7
CHLORIDE-102 TOTAL
CO2-27 ANION GAP-12
ALT(SGPT)-10 AST(SGOT)-20 CK(CPK)-68 ALK PHOS-79 AMYLASE-83 TOT
BILI-0.3
LIPASE-38
URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-
NEG UROBILNGN-1 PH-5.0 LEUK-NEG
.
[**2107-11-21**]
ABG: PO2-88 PCO2-39 PH-7.32* TOTAL CO2-21 BASE XS--5
WBC-13.9*# RBC-4.58 HGB-12.1 HCT-37.0 MCV-81* MCH-26.4*
MCHC-32.7 RDW-13.1
GLUCOSE-146* UREA N-6 CREAT-0.5 SODIUM-138 POTASSIUM-3.5
CHLORIDE-109*
TOTAL CO2-19* ANION GAP-14
.
Cardiac enzymes: troponin peak 0.43 on [**11-21**] at 1:00 am, trended
down thereafter. CK-MB peak 16 with MB index 10.6, total CPK
151.
.
CT abd/pelv: 1. No finding to explain patient's abdominal pain.
2. The patient appears to have experienced a severe
anaphylactoid reaction to intravenous contrast, as described in
the "Technique" section of this report. Note that this patient
had received intravenous contrast as recently as [**2106-12-16**] (for
CTPA), uneventfully.
.
CXR [**11-21**]: IMPRESSION: Right IJ tip is seen within the right
atrium. Recommend withdrawal by at least 2.5 cm. Bilateral
pulmonary edema. Small left effusion. No pneumothorax.
MRI Head:
1. Extensive periventricular and subcortical white matter
hyperintensities on T2/FLAIR imaging, few of which demonstrate
enhancement. Probable signal abnormalities involving the middle
cerebellar peduncles as well.
2. Enhancing lesion in the cervical spinal cord at the C2
level. However, the cervical spine is not completely evaluated
on the present study.
Compared to the prior study with contrast from [**2107-1-16**],
though the
extent of T2/FLAIR abnormality is stable, all of the enhancing
foci are new, suggestive of disease activity.
Brief Hospital Course:
Ms [**Known lastname 22473**] is a 20 year-old female with history of multiple
sclerosis who presented to the ED with L flank pain and suffered
severe anaphylactoid reaction to IV contrast with acute hypoxia
and hypotension while undergoing CT scan; in this setting she
received 1 mg 1:1000 IV epinephrine and developed acute lung
injury/pulmonary edema and acute myocardial injury for which she
was transferred to the Medical Intensive Care Unit as described
above. She was subsequently transferred to the medical floor on
[**2107-11-22**].
Once transferred to the medical floor, her supplemental oxygen
was progressively weaned off. Despite persistent symptoms of
central chest discomfort following her anaphylactoid event,
EKG/enzymes failed to demonstrate ongoing/residual cardiac
injury. Ms [**Known lastname 22473**] noted post-prandial nausea/vomiting for
several days s/p her ICU stay. She was treated with compazine
and zofran with minimal relief. With ongoing symptoms, she
received a second dose of compazine on [**11-27**]; approximately four
hours later, the patient developed facial contortion and left
hand spasm felt likely to represent an acute dystonic reaction
to the compazine. She was treated with benadryl, cogentin, and
valium. After approximately 8-12 hours, her left hand spasm
resolved, however Ms [**Known lastname 22473**] remained unable to open her jaw from
a closed position despite repeated dosing of benadryl, cogentin,
and valium. She was seen by the Neurology Consult Service and
also by Dr [**Last Name (STitle) 2866**] from Oral-Maxillofacial Surgery. Although
initially unable to speak because of concurrent inability to
move her tongue, after two days her tongue "loosened" and she
was able to communicate verbally despite persistent jaw closure.
It was uncertain whether her inability to open the jaw
represented trismus vs alternate complication of her dystonic
reaction. Ms [**Known lastname 22473**] was observed during sleep with persistent
closed jaw, arguing against conversion disorder. She was
maintained on IV fluid hydration and liquid diet by straw.
Consideration was given to administration of nerve block to
facilitate mechanical manipulation to open the jaw, however on
[**12-1**] her jaw was released from the closed position after 10 mg
IV valium and mechanical manipulation by her mother - once
released, Ms [**Name (NI) 22473**] was able to independently open/close her jaw,
eat, and speak without need for further mechanical intervention.
In terms of Ms [**Known lastname 48849**] original complaint of left flank pain,
Neurology Consult service felt that this most likely represented
a thoracic radiculopathy related to a herniated disc. Her
symptoms persisted, in waxing/[**Doctor Last Name 688**] intensity, throughout her
hospital course.
On [**12-4**], Ms [**Known lastname 22473**] notice that her right foot was "turning in"
(ankle inversion) when she walked; she notes that this is a
finding she relates to prior flares of her multiple sclerosis.
She also noted "clumsiness" of her right hand, most noticeable
in her hand-writing which has become less legible, as well as
right eye "blurry vision". A head MRI was obtained which
demonstrated new multiple sclerosis disease activity. Upon
consultation with Ms [**Known lastname 48849**] primary neurologist, Dr [**Last Name (STitle) 8760**], her
scheduled Tysabri dose was postponed and she was treated with a
3-day course of intravenous methylprednisolone at a dose of
250mg every 6 hours. Her next scheduled Tysabri dose was
arranged for [**2107-12-12**].
Repeat echocardiogram [**2107-12-9**] demonstrated essentially normal
cardiac function, without evidence of pericardial effusion or
focal wall motion abnormality.
Medications on Admission:
Tysabri 300 mg/15 mL, 1 IV infusion monthly
Discharge Medications:
1. Zovia 1/35E (28) 1-35 mg-mcg Tablet Sig: One (1) Tablet PO
daily ().
2. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every 6-8 hours
as needed for pain for 1 weeks.
Disp:*20 Tablet(s)* Refills:*0*
5. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia: as needed.
6. Ondansetron 4 mg Tablet every 8 hours as needed for nausea.
Disp:*10 Tablet(s)* Refills:*0*
6. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*15 Tablet(s)* Refills:*0*
7. Tysabri 300 mg/15 mL, 1 IV infusion monthly as directed by Dr
[**Last Name (STitle) 8760**] (Neurology)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Anaphylactoid reaction to IV contrast
2. Epinephrine overdose.
3. Acute lung injury.
4. Acute myocardial (heart) injury
4. Acute dystonic reaction and prolonged trismus (lock jaw)to
prochlorperazine (compazine)
5. Left flank pain, likely secondary to thoracic disc herniation
6. Multiple sclerosis, relapsing-remitting, with acute flare
Discharge Condition:
Heart and lung exams have returned to [**Location 213**]. Face, jaw, and
hand spasms, resulting from an adverse reaction to compazine,
have resolved. You are being discharged in stable condition,
but need close follow-up as an outpatient to ensure full
recovery from your complex hospital course.
Discharge Instructions:
You were evaluated in the Emergency Department for left-sided
flank pain. You had an abdominal CT scan to evaluate this pain,
and had a severe allergic "anaphylactoid" reaction to the
intravenous contrast used for the CT. You were given a high
dose of epinephrine, as well as steroids, famotadine, benadryl,
and intravenous fluids for treatment of this reaction. The
severe allergic reaction and high dose of epinephrine resulted
in injury to your heart and lungs. You were admitted and treated
for this reaction in the Intensive Care Unit for 2 days, and
once stable, transferred to the medicine floor.
You also developed a facial contortion and locked jaw (a
dystonic reaction) in response to a medication you took for
nausea, called Compazine. This resolved initially with
medications, except your jaw remained locked for 4 days. You
recieved benadryl, benztropine (Cogentin), and Valium. Higher
doses of valium in addition to manual manipulation of your jaw
was required to finally open the jaw.
You developed symptoms of right foot inversion, right hand
clumsiness, and right eye "blurring". An MRI of your head was
consistent with an active multiple sclerosis flare. You were
treated with high-dose steroids for three days, with mild
improvement.
Please remain at home for 1 week following discharge for further
monitoring, given the recent complicated hospital course
involving anaphylactic reaction, myocardial injury, acute lung
injury, and acute dystonic reaction.
Your back pain is likely from a bulging disc in your spine. You
can treat this with pain medication for now, and if it does not
resolve in [**1-17**] weeks, please see your primary care physician to
follow it up.
Please note that you are allergic to IV contrast, and had a
dystonic reaction to Compazine. These have been added to your
allergy list.
Please return to the ED or call your primary care physician if
you have symptoms similar to those you had in the CT scanner -
throat tightness, ichiness, or any other concerning symptoms.
Please do the same if your jaw locks again.
Followup Instructions:
You have been scheduled for Tysabri infusion at the pheresis
unit on at Monday [**2107-12-12**] at 2:15 PM. If you have any further
questions, please contact your neurologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8760**],
at ([**Telephone/Fax (1) 11088**] to schedule Tysabri infusion.
Please f/u with your primary care doctor in the next 1-2 weeks
to follow up on the multiple issues described above.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**0-0-0**] Name: [**Last Name (LF) 447**],[**Known firstname 9070**] E Unit No: [**Numeric Identifier 9071**]
Admission Date: [**2107-11-21**] Discharge Date: [**2107-12-9**]
Date of Birth: [**2087-9-18**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins / Neurontin / Erythromycin / IV Dye,
Iodine Containing / Optiray 350 / Compazine
Attending:[**First Name3 (LF) 758**]
Addendum:
Please see above for follow-up instructions with Dr [**Last Name (STitle) 7492**] in
Oral Maxillofacial Surgery.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Anaphylactoid reaction
2. Epinephrine overdose.
3. Acute lung injury.
4. Acute cardiac injury.
5. Acute dystonic reaction and trismus (lock jaw)
6. Left hip/back pain, possibly due to a herniated disc
7. Multiple sclerosis flare.
Discharge Condition:
Heart and lung exams have returned to [**Location 1867**]. Face, jaw, and
hand spasms, resulting from an adverse reaction to compazine,
have resolved. You are being discharged in stable condition,
but need close follow-up as an outpatient to ensure full
recovery from your complex hospital course.
Discharge Instructions:
You were evaluated in the Emergency Department for left-sided
flank pain. You had an abdominal CT scan to evaluate this pain,
and had a severe allergic "anaphylactoid" reaction to the
intravenous contrast used for the CT. You were given a high
dose of epinephrine, as well as steroids, famotadine, benadryl,
and intravenous fluids for treatment of this reaction. The
severe allergic reaction and high dose of epinephrine resulted
in injury to your heart and lungs. You were admitted and treated
for this reaction in the Intensive Care Unit for 2 days, and
once stable, transferred to the medicine floor.
You also developed a facial contortion and locked jaw (a
dystonic reaction) in response to a medication you took for
nausea, called Compazine. This resolved initially with
medications, except your jaw remained locked for 4 days. You
recieved benadryl, benztropine (Cogentin), and Valium. Higher
doses of valium in addition to manual manipulation of your jaw
was required to finally open the jaw.
You developed symptoms of right foot inversion, right hand
clumsiness, and right eye "blurring". An MRI of your head was
consistent with an active multiple sclerosis flare. You were
treated with high-dose steroids for three days, with mild
improvement.
Please remain at home for 1 week following discharge for further
monitoring, given the recent complicated hospital course
involving anaphylactic reaction, myocardial injury, acute lung
injury, and acute dystonic reaction.
Your back pain is likely from a bulging disc in your spine. You
can treat this with pain medication for now, and if it does not
resolve in [**1-17**] weeks, please see your primary care physician to
follow it up.
Please note that you are allergic to IV contrast, and had a
dystonic reaction to Compazine. These have been added to your
allergy list.
Please return to the ED or call your primary care physician if
you have symptoms similar to those you had in the CT scanner -
throat tightness, ichiness, or any other concerning symptoms.
Please do the same if your jaw locks again.
Followup Instructions:
You have been scheduled for Tysabri infusion at the pheresis
unit on at Monday [**2107-12-12**] at 2:15 PM. If you have any further
questions, please contact your neurologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9072**],
at ([**Telephone/Fax (1) 9073**] to schedule Tysabri infusion.
Please f/u with your PCP in the next 2-3 weeks regarding the
back pain.
Please call Dr [**Last Name (STitle) 7492**] (Oral Maxillofacial Surgery) to arrange
an appointment for further evaluation of your jaw.
[**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**] MD, [**MD Number(3) 765**]
Completed by:[**0-0-0**]
|
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icd9cm
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[
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[
"38.93"
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,368
| 149,570
|
52210
|
Discharge summary
|
report
|
Admission Date: [**2197-1-11**] Discharge Date: [**2197-1-17**]
Date of Birth: [**2122-6-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 yo female who is a longtime smoker with spirometry in [**2193**]
c/w moderate COPD who presents to the ED with shortness of
breath. The patient had been feeling unwell with SOB, chest
tightness, and cough x 1 week, so she was seen at an outside
clinic for workup on [**1-9**]. Before that visit, the patient says
that her SOB started abruptly over the weekend and was
associated with cough and phlegm. On [**1-9**], the patient was
placed on a 5 day course of Levofloxacin. She was given a
prescription for Albuterol HFA. Her O2 sat in the office was 99%
and a CXR was only significant for bilateral lower lobe
infiltrates and small BL effusions and flat diaphragms. On [**1-10**],
the patient continued to experience chest tightness, fatigue,
and cough. She re-presented to the office, where her O2 sat was
88%. The patient was kept on the levaquin and started n
prednisone 60mg. A home health aide visited her today and noted
hypoxia to high 80's. She received 3 nebs from EMS and was
brought to the hospital for further workup.
.
In the ED, initial VS were: 97.4 84 110/67 30 91% on neb at
100%. She presented with respiratory distress and was noted to
have diffuse wheezing on exam. She trigger for hypoxia upon
arrival. CXR revealed a potential RML infiltrate. She was given
solumedrol 125mg and levoquin 750mg. EKG revealed SR at [**Street Address(2) 108015**] depression 4 through 6. She was given aspirin 325mg and
started on a heparin gtt for NSTEMI management. She is
confirmed DNR/DNI so was started on noninvasive ventilation.
Vitals prior to transfer were afebrile, 73, 126/70, CPAP 8/5,
Fi02 100%.
.
On arrival to the MICU, she is in moderate resp distress and on
bipap, but can hold a conversation.
.
Of note, she has had her flu vaccine this year, and a pneumovax
after age 65.
Past Medical History:
COPD (chronic obstructive pulmonary disease)
Systemic lupus
Hypertension
h/o gastric ulcer
h/o GI bleed
h/o positive PPD
h/o colonic polyps
h/o diverticulosis
Depression
Fibrocystic breast changes
Social History:
Smoking: Current Everyday Smoker [**12-26**] ppd, 60 pack-year history
Smokeless Tobacco: Never Used
Alcohol: No
Adv Directives: DNR/DNI
Very active, lives at home, worked at [**Hospital1 **] as
behavioral counselor until this past summer. Now taking classes
at [**Hospital1 498**].
Family History:
Depression, breast cancer, alcoholism
Physical Exam:
Admission exam:
97.8 81 113/52 30 99% on 100%
General: Alert, oriented, on BiPAP
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, good air entry into bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, asymetric swellin in [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]>L
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam:
VS T 98.7 BP 122/55 (102-133/40-60) HR 60-70 RR 18 O2 96% RA
Walking O2 Sat 90-91% RA
Weight 51.4kg
Lungs clear to auscultation with good air movement, diminished
breath sounds at bilateral bases approximately 2 cm, otherwise
clear without crackles or wheezing
Exam otherwise stable
Pertinent Results:
Admission labs
WBC-12.0* RBC-3.50* Hgb-11.4* Hct-34.3* MCV-98 MCH-32.6*
MCHC-33.3 RDW-12.9 Plt Ct-209
Neuts-89.6* Lymphs-7.2* Monos-2.7 Eos-0.5 Baso-0
PT-15.1* PTT-28.1 INR(PT)-1.4*
Glucose-127* UreaN-22* Creat-0.7 Na-133 K-4.3 Cl-100 HCO3-23
AnGap-14
CK-MB-PND proBNP-5191*
Calcium-9.2 Phos-3.5 Mg-1.6
Lactate-1.7
Pertinent labs:
Troponin [**1-11**] 17:00- 0.37
Troponin [**1-12**] 00:45- 0.33
.
Microbiology:
Blood culture [**2197-1-11**]- no growth x 2
.
Imaging:
CXR [**2197-1-11**]-
1. Bilateral, right greater than left pleural effusions with
overlying atelectasis.
2. Additional ill-defined opacity in the right mid lung could be
due to consolidation from infection and/or aspiration.
.
Transthoracic Echocardiogram [**2197-1-11**]- The left atrium is normal
in size. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with inferolateral hypokinesis. The remaining
segments contract normally (LVEF = 45-50%). 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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
regurgitation is slightly eccentric, directed posteriorly and
likely arises from systolic tethering of the posterior leaflet.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction.
Moderate mitral regurgitation. Moderate pulmonary hypertension
Brief Hospital Course:
74 yo F with an extensive smoking history, COPD not on
medications, presenting with progressively worsening shortness
of breath and cough consistent with COPD exacerbation, and found
to have NSTEMI on admission.
.
# COPD exacerbation: appears to have been exacerbated by
possible PNA vs NSTEMI. Afebrile, no leukocytosis. Spirometry
shows FEV1/FVC = 65%, FEV1 61% predicted = Gold stage II. She
initially came to the MICU from the ED on BiPAP, which was
weaned on night of admission, and she was transferred to the
floor for further management. She completed a 5 day course of
azithromycin and 7 day steroid burst of 60mg prednisone (tapered
to 40mg for last 2 days). She was weaned from nasal cannula to
room air on the floor. Albuterol/ipratropium nebs were
transitioned to tiotropium, advair with as needed albuterol.
She was discharged on these medications. Her ambulatory O2 Sat
on the day of discharge was 90-91% on RA.
.
# Possible volume overload: She was ~4 lbs above dry weight on
admission (dry weight ~114lbs, came in 118lbs), and had some
vascular congestion on CXR. She was diuresed gently (she is
lasix naive) on the night of admission with lasix 10mg IVx1 and
put out 1L. This seemed to improved her breathing. TTE was
performed and showed mild regional left ventricular systolic
dysfunction (EF 45-50%), moderate mitral regurgitation, moderate
pulmonary hypertension. On transfer to the floor, she received
one additional dose of lasix given known bibasilar pleural
effusions, however, as she was oxygenating well on room air, no
further lasix was given and patient was not discharged on lasix.
Weight on discharge was 51.4.
.
# NSTEMI: Troponin bump to 0.37 on admission with ST
depressions in V4-V6. TIMI score was 5. She was put on a heparin
gtt, given ASA 325, metoprolol was started, high dose
atorvastatin started, ACEi held in acute setting. TTE did show
regional left ventricular systolic dysfunction with
inferolateral hypokinesis. Cardiology felt that this was most
likely demand ischemia. Following transfer to the floor,
cardiology felt that an outpatient stress test would be most
appropriate, and to continue medical management. She was
discharged on metoprolol 12.5mg [**Hospital1 **], atorvastatin 80mg and
aspirin 81mg.
.
# SLE: continued hydroxychloroquine
.
# Hypertension: Treated with amlodipine at home. Amlodipine
held on admission. Metoprolol initiated in setting of NSTEMI as
above.
.
# Depression: continued citalopram
.
# GERD: continued omeprazole
.
=================================
TRANSITIONAL ISSUES
# Discharge weight 51.4kg, patient will need daily weights and
may require lasix moving forward
# Ambulatory O2 saturation on day of discharge 90-91%
# Pulmonology follow-up not scheduled; patient will be called
with appointment
# New COPD medications include tiotropium and
fluticasone-salmeterol
# New cardiac medications include metoprolol, atorvastatin, and
aspirin
Medications on Admission:
-Prednisone 10 mg Oral Tablet TAKE 6-6-5-5-4-4-3-3-2-2-1-
1-([**12-26**])-([**12-26**]) TABLET(S) DAILY ON CONSECUTIVE DAYS. TAKE IN THE
MORNING WITH FOOD. OTHER MEDICATION, , home oxygen, 2 liters
continuous via nasal canula
-Ipratropium-Albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Inhalation
Solution for Nebulization use 1 vial EVERY FOUR TO SIX HOURS for
SHORTNESS OF BREATH and cough for copd
-Levofloxacin 750 mg Oral Tablet Take 1 tablet daily for 5 days
-Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA
Aerosol Inhaler Take 1-2 puffs every 4 to 6 hours as needed
-Hydroxychloroquine 200 mg Oral Tablet TAKE ONE TABLET DAILY
-Lorazepam (ATIVAN) 1 mg Oral Tablet TAKE 1 TO 2 TABLETS AT
BEDTIME AS NEEDED for insomnia
-Pravastatin (PRAVACHOL) 10 mg Oral Tablet one tab daily
-Amphetamine-Dextroamphetamine (AMPHETAMINE SALT COMBO) 10 mg
Oral Tablet TAKE 1 TABLET TWICE A DAY for add
-Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) TAKE 1
CAPSULE DAILY
-Citalopram 40 mg Oral Tablet TAKE ONE TABLET DAILY
-Amlodipine 5 mg Oral Tablet Take 1 tablet daily
-Alendronate 35 mg Oral Tablet take 1 tablet every week
Discharge Medications:
1. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
1. COPD exacerbation
2. Viral gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 6129**],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**].
You were admitted with shortness of breath and low oxygen levels
which were attributed to an exacerbation of your COPD. You
required supplemental oxygen for a period of times, in addition
to steroids and antibiotics to decrease lung inflammation. Over
time, the inflammation improved and you were doing well on room
air, even while walking. We will have a nurse come to your
home in the next few days to check your oxygenation when seated
and when walking to ensure that you are still doing well.
You also had diarrhea and vomiting which was due to a virus.
This improved with time and you were able to take in food at the
time of discharge.
The following changes were made to your medications:
- STOP prednisone
- START tiotropium inhaled once a day
- START advair inhaled twice a day
- CHANGE pravastatin to ATORVASTATIN
- CHANGE amlodipine (blood pressure medication) to METOPROLOL
twice daily
- START baby aspirin daily
Followup Instructions:
Name:[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 7716**], NP
Specialty: Primary Care
Location: [**Location (un) 2274**] [**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 20035**]
When:Tuesday, [**1-24**] at 10:20am
We are working on a follow up appointment in the Pulmonary
department at [**Hospital1 **] in the next two weeks. You will
be called at home with the appointment. If you have not heard
or have questions, please call [**Telephone/Fax (1) 38275**].
|
[
"410.71",
"799.02",
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"305.1",
"311",
"008.8",
"401.1",
"V49.86",
"710.0",
"416.8",
"V12.71",
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"414.01",
"V12.72",
"276.69",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10574, 10626
|
5429, 8358
|
312, 318
|
10718, 10718
|
3769, 4085
|
11949, 12508
|
2687, 2727
|
9540, 10551
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10647, 10697
|
8384, 9517
|
10869, 11926
|
2742, 3450
|
3466, 3750
|
265, 274
|
346, 2149
|
10733, 10845
|
4101, 5406
|
2171, 2369
|
2385, 2671
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,700
| 127,699
|
52116
|
Discharge summary
|
report
|
Admission Date: [**2184-6-26**] Discharge Date: [**2184-6-30**]
Date of Birth: [**2107-1-31**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77F with sleep apnea on home O2 recently discharged from [**Hospital1 2025**] s/p
treatment of LE cellulitis and increasing LE edema. CXR @ [**Hospital1 2025**]
revelaed worsening pulmonary edema, and she had a positive UA.
She received both CTX and Vancomycin. She also received bolus
fluids for hypotension. Patient discharged on Dicloxicillin on
[**2184-6-24**]
Patient returned to our ED on [**2184-6-25**] with change in mental
status. and increased LE pain, as noticed by family. Vitals on
admission were 96.6 72 112/58 20 100NRB (88 RA). CXR was
negative for any focal infiltrate. She was given Solumedrol 125
iv x 1 for presumed COPD exacerbation. ABG: 7.42/54/363.
Patient had facemask removed and transitioned to NC. She was
also given Vanc/Levo. Patient remained asleep for 4 hours
without internvention and sent to the floor. On the floor
patinet was somnolent and ABG was 7.31/65/135 and patinet was
transferred to the MICU for CPAP for presumed hypercarbic
respiratory failure.
Past Medical History:
HTN
Hyperlipidemia
Dm2
Afib on Coumadin
Gout
Sleep Apnea
Social History:
denies smoking, etoh use
Family History:
Noncontributory
Physical Exam:
Vitals - T:95.5 BP:110/60 HR:90 RR:18 02 sat: 88RA
GENERAL: somnolent
SKIN: bruise on L flank
HEENT: large neck, AT/NC, EOMI, PERRLA, anicteric sclera, pink
conjunctiva, patent nares, MMM, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: obese, +BS, nontender in all quadrants, no
rebound/guarding, no appreciable hepatosplenomegaly
M/S: lower extremity venous stasis changes, 2+ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: unable to assess
Pertinent Results:
Imaging:
CXR: IMPRESSION: Limited examination. Moderate cardiomegaly.
No pulmonary abnormality.
.
CT Head
FINDINGS: There is no hemorrhage, mass effect, shift of the
normally midline structures, or major vascular territorial
infarct. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
There is no hydrocephalus. Cysts are seen within the choroid
plexus. Osseous structures demonstrate mild upper hyperostosis
of the walls of the right maxillary sinus. The paranasal
sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. No hemorrhage or mass effect.
.
CT CHEST
CTA CHEST: There are coronary artery calcifications and
calcifications of the mitral and aortic annuli. Scattered
mediastinal lymph nodes do not meet CT criteria for enlargement.
While the examination is technically limited, there are no main
or segmental pulmonary artery emboli. There are small bilateral
pleural effusions and mild diffuse ground-glass opacity as well
as mild cardiomegaly, suggestive of mild pulmonary edema.
IMPRESSION:
1. Moderate cardiomegaly with small bilateral pleural effusions
and
ground-glass opacities suggestive of mild pulmonary edema.
Brief Hospital Course:
77F with known COPD on home O2 with possible COPD exacerbation
and resultant hypercarbin respiratory failure
Hypercarbic respiratory failure: Cause is unclear, though may
have had some element of CHF. Patient was found to have c02 in
the mid 60s and was somnolent and thus was taken to the MICU for
non-invasive ventilation. This intervention improved mental
status. Additionally was initially diuresed, but this was
complicated by hypotension. Cause was also likely secondary to
obesity hypoventilation given patient's habitus. As well
patient has OSA and was started on CPAP. Should increase CPAP
as tolerated and patient if possible should have a repeat sleep
study. Improved CO2 and mental status after CPAP. There is
very little evidence in chart that patient actually has COPD.
Night prior to discharge tolerated 10 CPAP. This should be
continued and a sleep consult should be done at some point.
Hypotension: Found to have SBPs in the 80s, however always able
to mentate and had adequate urine output. Hypotension was
likely a combination of difficulty in measuring, given habitus,
hypovolemia given diarrhea and high doses of diltiazem (thought
to be home doses, but possible patient was non-adherant). BPs
stable prior to discharge in the 100-130s range. Given that the
patient has baseline hypertension, suspect that diovan will
likely have to be restarted, as well as diltiazem.
C diff: diagnosed during this admission. Started on flagyl for
14 day course. Symptoms improved at time of diagnosis
Cellulitis - Patient recently discharged from [**Hospital1 2025**] s/p treatment
for cellulitis on dicloxacillin, on presentation was treated
wtih vancomycin. However, by HD # 2 was clearly improved and
antibiotics were discontinued.
Atrial fibrillation: had episodes of tachycardia and was started
on diltiazem at 1/2 home dose, was hypotensive (though as above,
difficult to get accurate BP) but also intermittently
tachycardic. Rate control was significantly improved with
digoxin load. The level of digoxin should be checked in [**11-25**]
days to ensure patient not toxic at time of steady state.
Coagulopathy: patient with increased INR during admission. This
is likely secondary to coumadin dosing at slightly higher (5 mg
versus 2.5 in some notes) as well as poor intake and diarrhea.
Additionally is on metronidazole that can increase it. This
level should be followed with coumadin restarted when level <3.
Though it is possible that the patient has developed another
cause for hypocoagulibility, it seems less likely in the setting
of previously normal coags. Nonetheless, if this should
continue to increase, mixing studies as well as hematology
evaluation may be necessary.
Medications on Admission:
Allopurinol 300 daily
Atorvastatin 10 daily
Diltiazem 360 daily
Gabapentin 300 [**Hospital1 **]
Valsartan 80 mg daily
Warfarin 5 mg daily
Lasix 100 mg [**Hospital1 **]
Glyburide 2.5 [**Hospital1 **]
Eucerin Cream
Nystatin Poweder
Dicloxacillin 250 mg q8h x 14 days (Day 1 [**2184-6-23**])
.
Discharge Medications:
1. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
7. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please check level [**7-1**] or [**7-2**].
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Hypercarbic respiratory failure
Obstructive sleep apnea
Atrial fibrillation
C diff
CAD
Discharge Condition:
improved
Discharge Instructions:
You were admitted with trouble breathing and recovering
infection. While you were here your breathing improved with the
use of CPAP. Additionally you now have c diff infection in your
bowels for which you should take antibiotics for 10 more days.
Please return to the ER if you have fever, chills, chest pain,
shortness of breath, vomiting, worsening diarrhea, abdominal
pain or any other concerning symptoms
Followup Instructions:
Please follow up with you primary care physician or with Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 1579**].
Additionally you should be seen by a pulmonologist. If you
would like to be seen by Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 513**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"491.21",
"272.0",
"274.9",
"682.6",
"250.00",
"427.31",
"511.9",
"327.23",
"008.45",
"272.4",
"599.0",
"V46.2",
"286.9",
"414.01",
"518.81",
"V58.61",
"785.2",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6921, 7000
|
3201, 5923
|
288, 294
|
7131, 7142
|
2002, 3178
|
7602, 8006
|
1464, 1481
|
6265, 6898
|
7021, 7110
|
5949, 6242
|
7166, 7579
|
1496, 1983
|
239, 250
|
322, 1326
|
1348, 1406
|
1422, 1448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,378
| 174,886
|
8488
|
Discharge summary
|
report
|
Admission Date: [**2108-6-13**] Discharge Date: [**2108-6-14**]
Date of Birth: [**2026-9-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81 year-old Russian speaking male with a history of HTN, HL, DM,
CAD s/p CABG/PCI, CHF, PVD, multiple CVAs, and CRF who presents
with acute dyspnea from [**Hospital 100**] Rehab. It is unclear when the
dyspnea started, but nursing found him short of breath at 4am
and called EMS. His O2sats were 70-80 on RA, and he was put on
a NRB and brought to our ED.
.
Initial vs in our ED were: T 101.8 (rectal), P 101, BP 145/54,
RR 20, O2sat 92% on NRB. He was noted to be agitated and
tachypneic with bilateral rales on exam. Labs notable for a WBC
of 15.4 (82 N, 4 bands). CK 255 with mildly elevated CK-MB 17
(MBI 6.7) but trop 0.41; Cr 2.6 up from baseline 1.8-2 but
previous trops in OMR peaked at 0.17. BNP 3798. CXR showed
bilateral infiltrates consistent with pulmonary edema with
possible superimposed RLL pneumonia. ECG showed ST depressions
in the precordial leads with a RBBB. Cardiology was called due
to his history of CAD but felt this was demand in the setting of
tachycardia and renal failure. ASA was given. He was noted to
have a GI bleed in [**2104**] but Hct stable from baseline and guaiac
negative so started on heparin gtt. He also was also given
vancomcyin, levofloxacin, flagyl, and tylenol. BPs remained in
the 100s and patient appearing better after starting positive
pressure ventilation. He was confirmed DNR/DNI per documentation
and discussion with family. On transfer, VS: P 93 BP 108/36, RR
22, O2sat 94% on CPAP 8/5, 50%.
.
On the floor, pt appears uncomfortable and complains of
restraints. With Russian interpreter present, he reports feeling
short of breath as well as vague chest pain. He denies fevers,
cough. However, obtainment of history is limited given
dysarthria. Of note, he was recently admitted in [**5-/2108**] for
evaluation of chest pain and dyspnea. He ruled out for MI and
was felt to have angina and decompensated CHF in the setting of
poorly controlled and treated for CHF thought secondary to
poorly controlled hypertension. He refused cardiac cath.
.
Review of systems:
As above, otherwise limited history. Denies fever, chills.
Denies headache. Denies cough. Denies nausea, abdominal pain.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Diabetes mellitus
- CAD s/p CABG (LIMA->LAD, SVG->OM, SVG->R-PDA) in [**12/2097**] and
BMS to SVG-PDA and DES to EIA and SVG-PDA ISR in [**12/2106**]
- CHF EF 45-50% in [**11/2106**], likely ischemic
- PVD s/p R fem-[**Doctor Last Name **] bypass, L fem-DP bypass, L SFA angioplasty
and patch
- History of multiple CVAs with right sided weakness, maintained
on aspirin and Plavix
- Chronic renal insufficiency
- Depression
- Anemia, melananic bleed in [**2104**] s/p negative EGD and
colonoscopy
- S/p appendectomy
- Previous ETOH abuse
- ?Gout, on allopurinol
Social History:
Per old d/c summary, patient is originally from [**Country 10363**].
Widowed. Has 4 children, 3 in [**Country 532**]/[**State 3908**] and one daughter in
U.S. Living at [**Hospital 100**] Rehab since [**2103**].
- Tobacco: 60 pack-year
- Alcohol: H/o EtOH abuse but none now
Family History:
Unable to elicit
Physical Exam:
On admission:
Vitals: T 98.2, BP 93/55, P 91, RR 20, O2sat 93% on 100% face
tent
General: Oriented to [**Hospital1 **] and [**Month (only) 116**], agitated, dysarthric,
tachypneic and using accessory muscles
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, unable to assess JVP
Lungs: Bilateral rales and coarse breath sounds, no wheezes
CV: Regular rate with no appreciable murmur butdifficult to
asuculate Abdomen: Soft, obese, non-tender, bowel sounds
present, no rebound tenderness or guarding
GU: Foley in place
Ext: Distal feet slightly cool, unable to palpate DP/TP pulses,
trace LE edema
Neuro: Pt responding to questions and simple commands but exam
limited by cooperation
.
On discharge:
General: appears comfortable, in NAD, AOx2, speech is dysarthric
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, thick
Lungs: Bibasilar rales and coarse breath sounds
CV: Regular rate, nl S1/S2
Abdomen: Soft, obese, non-tender, BS+ normoactive, no rebound
tenderness or guarding
GU: Foley in place
Ext: feet cool, pulses appreciated with doppler, trace LE edema
Neuro: awake, alert, speech dysarthric, AOx2
Pertinent Results:
Admission labs:
===============
[**2108-6-13**] 05:30AM BLOOD WBC-15.4*# RBC-3.60* Hgb-10.6* Hct-31.6*
MCV-88 MCH-29.4 MCHC-33.5 RDW-16.3* Plt Ct-214
[**2108-6-13**] 05:30AM BLOOD Neuts-82* Bands-4 Lymphs-8* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2108-6-13**] 05:30AM BLOOD PT-15.5* PTT-25.9 INR(PT)-1.4*
[**2108-6-13**] 05:30AM BLOOD Glucose-105* UreaN-61* Creat-2.6* Na-144
K-3.4 Cl-113* HCO3-19* AnGap-15
[**2108-6-13**] 06:10PM BLOOD Glucose-245* UreaN-64* Creat-3.2* Na-142
K-5.3* Cl-108 HCO3-17* AnGap-22*
[**2108-6-13**] 05:30AM BLOOD CK-MB-17* MB Indx-6.7* proBNP-3798*
[**2108-6-13**] 05:30AM BLOOD cTropnT-0.41*
[**2108-6-13**] 12:16PM BLOOD CK-MB-72* MB Indx-9.3* cTropnT-2.80*
[**2108-6-13**] 06:10PM BLOOD CK-MB-83* MB Indx-9.7* cTropnT-3.56*
[**2108-6-13**] 07:39PM BLOOD CK-MB-88* MB Indx-9.6* cTropnT-4.03*
[**2108-6-14**] 02:01AM BLOOD CK-MB-80* MB Indx-9.5* cTropnT-4.15*
[**2108-6-13**] 05:30AM BLOOD Calcium-8.7 Phos-0.7*# Mg-1.6
[**2108-6-13**] 05:58AM BLOOD Lactate-2.3*
.
Discharge labs:
===============
[**2108-6-14**] 02:01AM BLOOD WBC-28.3*# RBC-3.40* Hgb-10.0* Hct-30.3*
MCV-89 MCH-29.4 MCHC-32.9 RDW-16.2* Plt Ct-216
[**2108-6-14**] 02:01AM BLOOD Neuts-74* Bands-13* Lymphs-2* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-0
[**2108-6-14**] 02:01AM BLOOD PT-17.5* PTT-93.9* INR(PT)-1.6*
[**2108-6-14**] 02:01AM BLOOD Glucose-137* UreaN-72* Creat-3.5* Na-145
K-5.2* Cl-110* HCO3-19* AnGap-21*
[**2108-6-14**] 02:01AM BLOOD CK(CPK)-839*
[**2108-6-14**] 02:01AM BLOOD Calcium-8.7 Phos-5.6* Mg-2.6
[**2108-6-14**] 02:01AM BLOOD Vanco-9.2*
.
Imaging:
========
CXR [**6-13**]:
1. Findings concerning for recurrent chronic edema, with
possible superimposed infection at the right base.
2. Stable cardiomegaly.
.
CXR [**6-14**]:
As compared to the previous radiograph, there is no substantial
progression of the pre-existing severe pulmonary edema. Massive
cardiomegaly. No evidence of left pleural effusion, on the
right, the presence of mild-to-moderate pleural effusion cannot
be excluded. The lung parenchyma shows no evidence of newly
appeared focal parenchymal opacities suggesting pneumonia.
.
Brief Hospital Course:
81 year-old man with HTN, HL, DM, CAD, CHF, PVD, CVA, and CRF
p/w dyspnea and hypoxia with evidence of decompensated CHF,
pneumonia, and elevated troponins.
.
# Acute on chronic systolic CHF - pt has EF 40-45% (on TTE in
[**2106**]) and had significant pulmonary edema on admission with
elevated BNP. CXR showed pulmonary edema with possible RLL
opacity. Exacerbation of CHF likely in setting of pneumonia and
NSTEMI, as below. He was started on a lasix drip for diuresis
and Cr began to rise to 3.5 at time of discharge. We discussed
goals of care with the patient's family who did not want any
aggressive measures of care and lasix drip was continued for
comfort. His beta blocker was restarted on discharge given
improvement in blood pressure, but [**Last Name (un) **] continued to be held
given renal dysfucntion.
.
# Pneumonia - Patient had fever, leukocytosis with left shift,
and possible RLL opacity which was concerning for HCAP given
that he is a long-term facility resident with recent
hospitalization 1 month ago. Aspiration pneumonia also on
differential given he is s/p CVA, dysarthric, and found to be
aspirating on speech/swallow evaluation. Legionella was
negative. He was started on vancomycin, zosyn, and levofloxacin
for HCAP coverage including double coverage of pseudomonas.
Sputum sample was contaminated. His WBC was rising at time of
discharge but he was afebrile and breathing comfortably on
shovel mask (100%) which he wore intermittently. He should
complete an 8-day course of his antibiotic regimen (last day =
[**2108-6-20**]). Though patient did not pass speech/swallow evaluation,
he expressed desire to eat and was continued on feeding for
comfort, despite risk of aspiration. Should have CBC trended at
rehab.
.
# NSTEMI: Pt reported vague chest and left arm pain on admission
and had elevated troponins above previous baseline which
continued to rise (had not peaked at time of discharge). His ECG
showed diffuse ST depressions consisted with NSTEMI. Discussion
was held with his family who did not want any aggressive
measures (i.e. cardiac cath) for management of his ACS and he
was placed on heparin drip for 24 hrs, full dose ASA and plavix.
Simvastatin was changed to atorvastatin and beta blocker
restarted prior to discharge.
.
# Acute on chronic renal failure: Cr 2.6 on admission above most
recent baseline of 1.8, increased to 3.5. [**Month (only) 116**] be related to
decreased renal perfusion in setting of decompensated CHF which
is worsened given MI. We continued gentle diuresis with lasix
drip for comfort of breathing given significant pulmonary edema
and Cr should be trended on discharge. Antibiotics and other
medications should be renally dosed. Should have Chem 7 trended
at rehab.
.
# Goals of care: As per discussion with patient and family
patient does not want escalation of care and is DNR/DNI. Family
wanted to focus on making patient comfortable and there should
be discussion of avoiding further hospitalizations given patient
has clearly stated that he does not wish to be treated and feels
that he is being "tortured" by medical care. As above, despite
aspiration risk patient was continued on feeding for comfort.
.
# DM: Continude home Lantus 70 units daily and sliding scale
.
# s/p CVA: Continue ASA and plavix
.
# PAD: Continued ASA and plavix
.
Medications on Admission:
Allopurinol 100 mg daily
Oxycodone 10 mg [**Hospital1 **]
Clopidogrel 75 mg daily
Pantoprazole 40 mg daiy
Simvastatin 80 mg qhs
Aspirin 325 mg daily
Zolpidem 10 mg qhs
Artificial tears 1 gtt qhs
Bisacodyl 10 mg daily
Docusate 250 mg qhs
Tobramycin-dexamth 1 gtt qhs
Isosorbide mononitrate 90 mg daily
Glargine 70 units daily
NPH 15 units AC?
Regular SS
Torsemide 10 mg daily
Losartan 50 mg id
Acetamminophen 650mg q6h prn
Hydralazine 100mg tid
Metoprolol succinate 150 mg daily
Guaifenesin 600 mg tid prn
Discharge Medications:
1. furosemide 10 mg/mL Solution Sig: [**3-15**] ml/hour Injection
INFUSION (continuous infusion): please titrate for comfort of
breathing or ~100cc/hr.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. insulin aspart 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
8. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic HS (at bedtime).
9. tobramycin-dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic HS (at bedtime).
10. atorvastatin 80 mg Tablet Sig: One (1) ML PO DAILY (Daily)
as needed for cough.
11. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
12. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Imdur 60 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet
Extended Release 24 hrs PO once a day.
15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q48H (every 48 hours): last day = [**2108-6-20**].
16. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 g
Intravenous Q8H (every 8 hours): last day = [**2108-6-20**].
17. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: last day = [**2108-6-20**].
18. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
20. insulin glargine 100 unit/mL Solution Sig: Seventy (70)
units Subcutaneous once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Acute on chronic systolic heart failure
Health care associated pneumonia
NSTEMI
Acute on chronic renal failure
Secondary:
DM2
s/p CVA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 29901**],
You were admitted to [**Hospital1 18**] with an infection in your lungs which
may be due to aspiration of food. You were also found to have a
heart attack which likely worsened your heart failure and
resulted in fluid in your lungs, which made it difficult for you
to breathe. We gave you antibiotics and a medication to remove
fluid and your breathing imrpoved. We discussed with you and
your family that you did not want aggressive measures of care
and your heart attack was managed with medical therapy.
We have made the following changes to your medications:
- START lasix drip at the MACU (2-5mg/hour) for a goal urine
output of 100ml/hour to help your breathing. You can restart
your torsemide 10mg daily after you have enough fluid removed
with the lasix drip.
- START vancomycin, zosyn, and levofloxacin for a total of 8
days (last day = [**2108-6-20**])
- STOP your losartan until your kidney function improves
- DECREASE your allopurinol to 100mg every other day until your
kidney function improves
- DECREASE your metoprolol to 25mg [**Hospital1 **] until your blood pressure
improves
- STOP your hydralazine until your blood pressure improves
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You will follow up with the physicians at [**Hospital 100**] Rehab.
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2108-10-31**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], 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
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2108-6-14**]
|
[
"410.71",
"428.23",
"414.00",
"403.90",
"428.0",
"250.00",
"486",
"V45.81",
"780.79",
"272.4",
"438.89",
"585.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12569, 12635
|
6767, 10088
|
319, 325
|
12823, 12823
|
4613, 4613
|
14316, 14915
|
3428, 3447
|
10644, 12546
|
12656, 12802
|
10114, 10621
|
13008, 13581
|
5634, 6744
|
3462, 3462
|
4172, 4594
|
13610, 14293
|
2375, 2498
|
272, 281
|
353, 2356
|
4629, 5618
|
3476, 4158
|
12838, 12984
|
2520, 3117
|
3133, 3412
|
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